A 14-year review of a UK teledermatology service: experience of over 40 000 teleconsultations.

BACKGROUND: There is a paucity of published evidence of established teledermatology (TD) services in the UK. An in-house TD service using store-and-forward technology was set up at a large regional dermatology department in 2004. AIM: To review the TD service at our centre, including teleconsultation numbers, coding of diagnoses and patient outcomes. METHODS: Retrospective data were retrieved using the electronic patient database, from 31 July 2004 to 31 July 2018. More detailed information on patient outcomes was obtained from patient notes and histology records. A paper questionnaire was distributed to 100 patients to obtain patient feedback. RESULTS: In total, 40 201 teleconsultations were made over 14 years, and 64% of cases were coded (n = 25 555), of which 77% were lesions. The most common coded lesions were benign naevus (25%), seborrhoeic keratosis (22%) and basal cell carcinoma (19%). Of the total number of cases, 50% were discharged to their general practitioner with advice, 34% were booked for surgery and 16% were booked for a face-to-face appointment. In the survey, 82% of patients surveyed felt that the service was 'good' or 'very good'. A detailed study between 1 January 2015 and 1 January 2016 showed that there were 383 patients (10%) with no diagnosis made following teleconsultation, suggesting diagnostic uncertainty. Reasons for this included lack of diagnostic features, possibility of malignancy and service factors. Within this cohort, there was 68% diagnostic concordance. CONCLUSIONS: We have set up a successful TD service at a UK centre, which has prevented 16 282 face-to-face appointments over 14 years. Patient feedback has been very good. Review of cases with diagnostic uncertainty provides important information for service improvement and has not previously been documented.

Guidelines for topical PUVA: a report of a workshop of the British photodermatology group.

Psoralen photochemotherapy [psoralen ultraviolet A (PUVA)] plays an important part in dermatological therapeutics, being an effective and generally safe treatment for psoriasis and other dermatoses. In order to maintain optimal efficacy and safety, guidelines concerning best practice should be available to operators and supervisors. The British Photodermatology Group (BPG) have previously published recommendations on PUVA, including UVA dosimetry and calibration, patient pretreatment assessment, indications and contraindications, and the management of adverse reactions.1 While most current knowledge relates to oral PUVA, the use of topical PUVA regimens is also popular and presents a number of questions peculiar to this modality, including the choice of psoralen, formulation, method of application, optimal timing of treatment, UVA regimens and relative benefits or risks as compared with oral PUVA. Bath PUVA, i.e. generalized immersion, is the most frequently used modality of topical treatment, practised by about 100 centres in the U.K., while other topical preparations tend to be used for localized diseases such as those affecting the hands and feet. This paper is the product of a recent workshop of the BPG and includes guidelines for bath, local immersion and other topical PUVA. These recommendations are based, where possible, on the results of controlled studies, or otherwise on the consensus view on current practice.

Kaposi's sarcoma associated with immunosuppression for bullous pemphigoid.

Kaposi's sarcoma may occur in transplant recipients on immunosuppressive regimens, but is not well recognized in association with treatment for dermatological disease. We report two cases where multifocal Kaposi's sarcoma developed following iatrogenic immunosuppression with prednisolone and azathioprine for bullous pemphigoid. Both patients were HIV negative and, in one case, lesions regressed both clinically and histologically when immunosuppressive therapy was withdrawn.

Acrokeratosis paraneoplastica of Bazex in association with a metastatic neuroendocrine tumour.

Bazex syndrome is a rare cutaneous paraneoplastic phenomenon not previously reported in association with neuroendocrine tumours. We describe a patient who responded well to treatment with octreotide.

Hodgkin's disease presenting with digital ischaemia.

A 52-year-old man with primary Raynaud's disease developed increasingly severe Raynaud's phenomenon with digital ischaemia in all limbs, and gangrene in two digits of the left hand. He was subsequently found to have Hodgkin's disease. Cervical sympathectomy led to initial improvement in acute ischaemia, and chemotherapy was followed by further improvement in the general severity of Raynaud's phenomenon together with remission of the lymphoma.

Prostaglandin E1 as a screening vasodilator in primary pulmonary hypertension.

Pulmonary vasodilators are variably efficacious in primary pulmonary hypertension (PPH). None has consistently improved hemodynamics enough to obviate the need for complex and potentially hazardous testing of several vasodilators. Prostaglandin E1 (PGE1), a potent, short-acting pulmonary vasodilator, was administered to seven patients with PPH in order to determine whether PGE1 could accurately predict the hemodynamic and gas exchange effects of other commonly used vasodilators. Prostaglandin E1, nifedipine and hydralazine were administered to the patients while measuring pulmonary and systemic hemodynamics and arterial blood gases. Prostaglandin E1 was easily titrated but was inconsistent as a predictor of the effects of the other vasodilators with respect to pulmonary artery pressure, cardiac output and adverse effects on arterial oxygenation. This study suggests that patients with PPH must still receive carefully monitored trials of several vasodilators to determine whether there is a beneficial response and to select the appropriate treatment.