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Research Letters |

Pilot Study Using Teledermatology to Manage High-Need Patients With Psoriasis FREE

Julia Frühauf, MD, MSc; Gerold Schwantzer, MSc; Christina M. Ambros-Rudolph, MD; Wolfgang Weger, MD; Verena Ahlgrimm-Siess, MD; Wolfgang Salmhofer, MD; Rainer Hofmann-Wellenhof, MD
[+] Author Affiliations

Author Affiliations: Department of Dermatology (Drs Frühauf, Ambros-Rudolph, Weger, Ahlgrimm-Siess, Salmhofer, and Hofmann-Wellenhof) and Institute for Medical Informatics, Statistics and Documentation (Mr Schwantzer), Medical University of Graz, Graz, Austria.


Arch Dermatol. 2010;146(2):200-201. doi:10.1001/archdermatol.2009.375.
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Patient empowerment has been found to be a key factor for achieving improved health outcomes in psoriasis.1 Telemedicine has revolutionized some aspects of health care delivery by transforming relationships between patients and physicians, shifting the power of consultation so that patients may become more informed and assertive.2 However, the greater confidence of dermatologists when making the diagnosis by in-person examinations3 may have impeded the routine use of teledermatology until now. The present study provides baseline data on the feasibility of teledermatology services for high-need patients with psoriasis, preparing the way for further effectiveness studies.

After approval was granted by the institutional review board at the Medical University of Graz, Austria, and informed written consent was obtained, patients with psoriasis who met the inclusion criteria (men or women, age ≥18 years, eligible for etanercept treatment,4 and able to use mobile phones) were prospectively enrolled in the 12-week pilot study. Etanercept treatment was administered according to standard protocol.4

Patients were given and trained on a general packet radio services/universal mobile telecommunications system (GPRS/UMTS)–enabled Smartphone (Nokia 6630; Nokia, Helsinki, Finland) with a 1.3-megapixel camera and special software that integrated both a section for capturing images and a section for the input of historical information, including occurrence of adverse effects or skin lesions in regions inaccessible to the camera (eg, the scalp) or not usually photographed (eg, the genitalia). Patients photographed their skin lesions according to the anatomic areas of Psoriasis Area and Severity Index (PASI) or Palmoplantar PASI (PASI/PPPASI).5 The data were transmitted through GPRS/UMTS to a Web server at weeks 0, 1, 2, and every 2 weeks thereafter. Treatment instructions were sent via e-mail-to–short message service techniques to the patients' phones within 24 hours.

Data from routine outpatient consultations at weeks 0, 1, 6, and 12 were compared with those obtained by 2 teledermatologists (TD1 and TD2) with particular attention to the accuracy of PASI/PPPASI scores and therapeutic outcome assessments (≥50% reduction from baseline PASI/PPPASI scores [PASI/PPPASI 50] at week 12).4 Based on the face-to-face assessments (FTF), PASI/PPPASI 50 responders were continued on etanercept treatment regimens.

All eligible patients (6 men and 4 women; median age, 40 years; age range, 25-67 years) agreed to participate in the study. Eight patients had plaque psoriasis, and 2 presented with palmoplantar psoriasis. Each of the 10 patients transmitted 8 “mobile visits” (total, 80 visits) including 32 to 64 images each (total, 486). Image quality was very good for an average of 86% of the images (range, 66%-95%); satisfactory for 12% (range, 5%-28%); and poor for 2% (range, 0%-6%).

The PASI/PPPASI scores correlated significantly between the FTF and the 2 teledermatologists (r = 0.71-0.96 for TD1 and r = 0.78-0.98 for TD2) (Table) as well as between the 2 teledermatologists (r = 0.93) (P < .001). The interrater variability (mean PASI/PPPASI deviation from FTF) was very low for both teledermatologists, with values ranging from 0.86 to 3.39. For patient outcomes, TD1 agreed 8 of 10 times with FTF (κ = 0.52), and TD2 agreed with FTF 9 of 10 times (κ = 0.78). Therapeutic outcome marginally differed in 2 patients. In one case, FTF assessed a PASI/PPPASI 50, while the teledermatologists found a 44% (TD1) and 24% (TD2) PASI/PPPASI improvement from baseline to week 12. In the other case, TD1 calculated a PASI/PPPASI 50, while TD2 found a 47% and FTF a 44% PASI/PPPASI improvement. Palmoplantar psoriasis ratings were completely concordant.

Table Graphic Jump LocationTable Comparison and Correlation of Disease Severity Measurements Obtained by FTF Consultation and 2 Teledermatologists in 10 High-Need Patients With Psoriasis Receiving Etanercept

For the first time, to our knowledge, we have assessed the feasibility of a patient-driven mobile home-monitoring system for high-need patients with psoriasis, which actively integrates them into their treatment process. We have demonstrated a strong correlation between severity measurements obtained by an FTF physician and teledermatologists (Table) and a good concordance of PASI/PPPASI 50 assessments and management decisions. Because severity scorings differed mainly in diverse estimations of the involved area and induration of the lesions, one may speculate that the divergence might have resulted from the inability of the teledermatologists to see the entire body and to palpate the lesions, or it might have resulted from some flaws of the PASI scoring system for which an interrater variability of up to 8.1 PASI scores has been described.5

In our study, the interrater variability was very low (Table), indicating that mobile teledermatology is a feasible method for monitoring disease severity in patients with psoriasis. Larger controlled studies are required to evaluate the impact of remote follow-up care on patient empowerment and its influence on the therapeutic outcome.

Correspondence: Dr Frühauf, Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, Austria (juliafruehauf@mac.com).

Author Contributions: Drs Frühauf and Hofmann-Wellenhof and Mr Schwantzer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Frühauf. Acquisition of data: Weger, Ahlgrimm-Siess, and Salmhofer. Analysis and interpretation of data: Schwantzer, Ambros-Rudolph, and Hofmann-Wellenhof. Drafting of the manuscript: Frühauf. Critical revision of the manuscript for important intellectual content: Schwantzer, Ambros-Rudolph, Weger, Ahlgrimm-Siess, Salmhofer, and Hofmann-Wellenhof. Statistical analysis: Frühauf and Schwantzer. Study supervision: Hofmann-Wellenhof.

Financial Disclosure: None reported.

Additional Contributions: We are indebted to Joanneum Research (research institution in Austria).

Richards  HLFortune  DGGriffiths  CE Adherence to treatment in patients with psoriasis. J Eur Acad Dermatol Venereol 2006;20 (4) 370- 379
PubMed Link to Article
Finch  TLMort  MMair  FSMay  CR Future patients? telehealthcare, roles and responsibilities. Health Soc Care Community 2008;16 (1) 86- 95
PubMed Link to Article
Whited  JD Teledermatology research review. Int J Dermatol 2006;45 (3) 220- 229
PubMed Link to Article
Nast  AKopp  IBAugustin  M  et al. Deutsche Dermatologische Gesellschaft (DDG); Berufsverband Deutscher Dermatologen (BVDD), Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007;5 ((suppl 3)) 1- 119
PubMed Link to Article
Langley  RGEllis  CN Evaluating psoriasis with Psoriasis Area and Severity Index, Psoriasis Global Assessment, and Lattice System Physician's Global Assessment. J Am Acad Dermatol 2004;51 (4) 563- 569
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable Comparison and Correlation of Disease Severity Measurements Obtained by FTF Consultation and 2 Teledermatologists in 10 High-Need Patients With Psoriasis Receiving Etanercept

References

Richards  HLFortune  DGGriffiths  CE Adherence to treatment in patients with psoriasis. J Eur Acad Dermatol Venereol 2006;20 (4) 370- 379
PubMed Link to Article
Finch  TLMort  MMair  FSMay  CR Future patients? telehealthcare, roles and responsibilities. Health Soc Care Community 2008;16 (1) 86- 95
PubMed Link to Article
Whited  JD Teledermatology research review. Int J Dermatol 2006;45 (3) 220- 229
PubMed Link to Article
Nast  AKopp  IBAugustin  M  et al. Deutsche Dermatologische Gesellschaft (DDG); Berufsverband Deutscher Dermatologen (BVDD), Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007;5 ((suppl 3)) 1- 119
PubMed Link to Article
Langley  RGEllis  CN Evaluating psoriasis with Psoriasis Area and Severity Index, Psoriasis Global Assessment, and Lattice System Physician's Global Assessment. J Am Acad Dermatol 2004;51 (4) 563- 569
PubMed Link to Article

Correspondence

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