OFFICE BACK-UP

This patient was first seen in the office with a red scaly lesion on the arm that appeared to be a precancerous keratosis. It was treated with liquid nitrogen and the patient was instructed to return in six weeks if it hadn’t cleared. Instead the patient submitted this photo to our website. It appeared to be a scab and since the patient was on blood thinners, we thought it was probably ok being so large and dark. Fortunately he returned to the clinic two weeks later as instructed when the scab did not resolve. A biopsy was done and showed an ulcerated, amelanotic melanoma which is an extremely dangerous tumor. This was treated surgically and he has been well since the surgery eighteen months ago.

If this patient was not able to follow up promptly in the office for a biopsy, this life threatening skin cancer may have been much more advanced when finally treated. Practicing teledermatology without office back up should not be considered within the standard of care.

Possible skin cancer

TRIAGE

This photo is a recent case that was submitted to me. Notable features were the very dark pigmentation of these lesions and their irregular contours. They also appeared larger than most moles. The risk for a malignant melanoma was significant so we contacted the patient and had him in the office the next day for a biopsy. Fortunately, once in the office the pigment was not as dark as in the photo but one lesion was still suspicious so a biopsy was done. The pathology report revealed a benign nevus. This was a nice example of using teledermatology to get an expedited office visit and a biopsy.

Used with permission

OUTCOMES

The most recent issue of JAMA Dermatology had a study from a group at UC Davis that compared outcomes in patients with atopic dermatitis who were managed with regular office visits or online dermatology visits. In both groups there were significant improvements and the online patients did just as well as the patients who were seen in the office. What was notable is that this study was done in a rural area where patients travel large distances to see medical specialists. The travel burden for the online visitors was vastly less.

SPEED

I got this case on the weekend. The patient was able to get a photo that clearly showed these minute blisters grouped on a red area of skin. There also was a smaller group of blisters off to one side. These findings are consistent with shingles which is a reactivation of varicella-zoster virus. This is the virus that causes chicken pox. The important aspect here is that if a patient with shingles doesn’t receive treatment within 72 hours, the medication is ineffective and the person is subject to the potentially devastating effects of the virus. This patient was given valacyclovir within 24 hours of the initial outbreak and cleared without any problems.

Possible Shingles condition