WHEN CAN’T YOUR DOCTOR BE WRONG

When you visit your doctor about a problem, your doctor needs to make sure that problem does not represent some sort of life threatening issue like cancer. When a physician evaluates a patient on the internet, there are not as many clues to go on to make that judgement so patients and physicians need to know when it is ok to make an educated guess and when you have to be sure of the diagnosis. A growth or a mole can always represent a skin cancer however a localized rash is rarely indicative of a serious medical condition.

The photo below was submitted by a young woman who thought she had ringworm. The doctor thought it looked more like nummular dermatitis but couldn’t be sure just from the photos. He reasoned that a trial of therapy with a topical steroid would not pose a risk of serious harm to the patient. If things didn’t clear, bringing the patient to the office for a KOH test could then be done. The rash cleared with triamcinolone 0.1% ointment.

Used with permission

WHEN SKIN CANCER IS EVEN MORE DANGEROUS

Squamous cell carcinoma (SCC) is usually a mild form of skin cancer that can be very dangerous in certain situations.

This patient noticed a sudden growth of this crusted red nodule on a frequently sun exposed area of his arm that resembled an SCC. Of note, the patient had a kidney transplant several years before. To prevent rejection of his transplanted kidney, the patient takes several medications that suppress his immune system. These immunosuppressive medications can make skin cancers more frequent and aggressive. As a result, anyone using these medications, even for other conditions, has a higher chance of dying from skin cancer. Patients on these medications have to be careful with the sun and should be followed closely by a dermatologist.

Squamous cell carcinoma

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

DIAGNOSTIC ACCURACY

To formulate a diagnosis, the physician relies on both subjective evidence obtained by speaking with the patient and objective evidence gained by examining the patient. Historically this process required a face to face visit with the physician.

Photos transmitted over the internet now allow physicians to examine their patients from afar and render diagnoses and treatment recommendations without an office visit. This novel approach to healthcare prompted multiple studies that examined the diagnostic accuracy of these internet evaluations. The results showed good but not perfect correlation between internet diagnoses and face to face exams. However, even though the diagnoses were not always the same, there was almost always agreement on initial treatment or whether to biopsy a lesion.