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. 2018 Dec 4;12(12):CD013193.
doi: 10.1002/14651858.CD013193.

Teledermatology for diagnosing skin cancer in adults

Naomi Chuchu  1 , Jacqueline Dinnes, Yemisi Takwoingi, Rubeta N Matin, Susan E Bayliss, Clare Davenport, Jacqueline F Moreau, Oliver Bassett, Kathie Godfrey, Colette O'Sullivan, Fiona M Walter, Richard Motley, Jonathan J Deeks, Hywel C Williams; Cochrane Skin Cancer Diagnostic Test Accuracy Group
Affiliations

Teledermatology for diagnosing skin cancer in adults

Naomi Chuchu et al. Cochrane Database Syst Rev. .

Abstract

Background: Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time.

Objectives: To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis.

Search methods: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

Selection criteria: Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician.

Data collection and analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration.

Main results: The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions.

Authors' conclusions: Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.

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Conflict of interest statement

NC: nothing to declare. JD: nothing to declare. YT: nothing to declare. RNM: "my institution received a grant for a Barco NV commercially sponsored study to evaluate digital dermoscopy in the skin cancer clinic. My institution also received Oxfordshire Health Services Research Charitable Funds for carrying out a study of feasibility of using the Skin Cancer Quality of Life Impact Tool (SCQOLIT) in non melanoma skin cancer. I have received royalties for the Oxford Handbook of Medical Dermatology (Oxford University Press). I have received payment from Public Health England for the "Be Clear on Cancer" skin cancer report. I have no conflicts of interest to declare that directly relate to the publication of this work." SB: nothing to declare. CD: nothing to declare. JM: nothing to declare. OB: nothing to declare. KG: nothing to declare. CO: nothing to declare. FW: nothing to declare. RM: nothing to declare. JJD: nothing to declare. HCW: I am director of the NIHR HTA Programme. HTA is part of the NIHR which also supports the NIHR systematic reviews programme from which this work is funded.

Figures

1
1
Sample photograph of superficial spreading melanoma(left), basal cell carcinoma (centre) and squamous cell carcinoma (right). Copyright © 2012 Dr Rubeta Matin: reproduced with permission.
2
2
Current clinical pathway for people with skin lesions.
3
3
PRISMA flow diagram.
4
4
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.
5
5
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study.
6
6
Forest plot of tests for the detection of any skin cancer (any). CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
7
7
Summary receiver operating characteristic plot of teledermatology using photographic images versus histology for the detection of any skin cancer (any).
8
8
Forest plot of tests for the detection of invasive melanoma or atypical intraepidermal melanocytic variants. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive; VI: visual inspection.
9
9
Summary receiver operating characteristic plot of teledermatology using clinical and dermoscopic images for the detection of invasive melanoma or atypical intraepidermal melanocytic variants.
10
10
Forest plot of tests for the detection of invasive melanoma. CI: confidence interval; FN: false negative; FP: false positive; MM: malignant melanoma; TN: true negative; TP: true positive; VI: visual inspection.
11
11
Forest plot of tests for the detection of basal cell carcinoma (BCC). CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
12
12
Receiver operating characteristic plot teledermatology using photographic images alone versus histology for the detection of basal cell carcinoma.
13
13
Forest plot of tests for the detection of cutaneous squamous cell carcinoma (cSCC). CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive; VI: visual inspection.
14
14
Forest plot of tests for referral accuracy (expert in‐person diagnosis as reference standard). CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
1
1. Test
Teledermatology – photographic image vs histology (any).
2
2. Test
Teledermatology – dermoscopic image vs histology (any).
3
3. Test
Teledermatology – photographic + dermoscopic image vs histology (any).
4
4. Test
Expert face‐to‐face (visual inspection (VI) + dermoscopy) vs histology (any).
5
5. Test
Teledermatology – photographic image vs histology (invasive melanoma or atypical intraepidermal melanocytic variantsi).
6
6. Test
Teledermatology – dermoscopic image vs histology (invasive melanoma or atypical intraepidermal melanocytic variants).
7
7. Test
Teledermatology photographic + dermoscopic image vs histology (invasive melanoma or atypical intraepidermal melanocytic variants).
8
8. Test
Expert face‐to‐face (VI + dermoscopy) (invasive melanoma or atypical intraepidermal melanocytic variants).
9
9. Test
Teledermatology – photographic + dermoscopic image vs histology (invasive melanoma).
10
10. Test
Expert face‐to‐face (VI + dermoscopy) vs histology (invasive melanoma).
11
11. Test
Teledermatology – dermoscopic image vs histology (acral melanoma).
12
12. Test
Teledermatology – photographic image vs histology (basal cell carcinoma (BCC)).
13
13. Test
Teledermatology – dermoscopic image vs histology (BCC).
14
14. Test
Teledermatology – photographic + dermoscopic image vs histology (BCC).
15
15. Test
Expert face‐to‐face (VI + dermoscopy) vs histology (BCC).
16
16. Test
Teledermatology – photographic image vs histology (cutaneous squamous cell carcinoma (cSCC)).
17
17. Test
Teledermatology – dermoscopic image vs histology (cSCC).
18
18. Test
Expert face‐to‐face (VI + dermoscopy) vs histology (cSCC).
19
19. Test
Teledermatology – photographic image vs face‐to‐face clinical diagnosis (immediate action).
20
20. Test
Teledermatology – photographic image vs face‐to‐face clinical diagnosis (of malignancy).
21
21. Test
Teledermatology – photographic image vs face‐to‐face clinical diagnosis (immediate action or follow‐up).
22
22. Test
Teledermatology – photographic image vs face‐to‐face clinical diagnosis (immediate action; registrar data).
23
23. Test
Teledermatology – photographic/dermoscopic image vs face‐to‐face clinical diagnosis (immediate action).
24
24. Test
Teledermatology – live link vs face‐to‐face clinical diagnosis (diagnosis of any skin cancer).
25
25. Test
Teledermatology – live link vs face‐to‐face clinical diagnosis (definitely/probably malignant).
26
26. Test
Teledermatology – live link vs face‐to‐face clinical diagnosis (biopsy decision).
See this image and copyright information in PMC

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    1. Harrison PV, Kirby B, Dickinson Y, Schofield R. Teledermatology ‐ high technology or not?. Journal of Telemedicine and Telecare 1998;4(Suppl 1):31‐2. - PubMed
Heffner 2009 {published data only}
    1. Heffner VA, Lyon VB, Brousseau DC, Holland KE, Yen K. Store‐and‐forward teledermatology versus in‐person visits: a comparison in pediatric teledermatology clinic. Journal of the American Academy of Dermatology 2009;60(6):956‐61. - PubMed
Hicks 2003 {published data only}
    1. Hicks LL, Boles KE, Hudson S, Kling B, Tracy J, Mitchell J, et al. Patient satisfaction with teledermatology services. Journal of Telemedicine and Telecare 2003;9(1):42‐5. - PubMed
High 2000 {published data only}
    1. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low‐cost store‐and‐forward teledermatology consultation. Journal of the American Academy of Dermatology 2000;42(5):776‐83. - PubMed
Hue 2016 {published data only}
    1. Hue L, Makhloufi S, Sall N'Diaye P, Blanchet‐Bardon C, Sulimovic L, Pomykala F, et al. Real‐time mobile teledermoscopy for skin cancer screening targeting an agricultural population: an experiment on 289 patients in France. Journal of the European Academy of Dermatology & Venereology 2016;30(1):20‐4. - PubMed
Hwang 2014 {published data only}
    1. Hwang JS, Lappan CM, Sperling LC, Meyerle JH. Utilization of Telemedicine in the U.S. Military in a Deployed Setting. Military Medicine 2014;179(11):1347‐53. - PubMed
Ishioka 2009 {published data only}
    1. Ishioka P, Tenorio JM, Lopes PR, Yamada S, Michalany NS, Amaral MB, et al. A comparative study of teledermatoscopy and face‐to‐face examination of pigmented skin lesions. Journal of Telemedicine and Telecare 2009;15(5):221‐5. - PubMed
Kahn 2013 {published data only}
    1. Kahn E, Sossong S, Goh A, Carpenter D, Goldstein S. Evaluation of skin cancer in Northern California Kaiser Permanente's store‐and‐forward teledermatology referral program. Telemedicine Journal and E‐health 2013;19(10):780‐5. - PubMed
Knol 2006 {published data only}
    1. Knol A, Akker TW, Damstra RJ, Haan J. Teledermatology reduces the number of patient referrals to a dermatologist. Journal of Telemedicine and Telecare 2006;12(2):75‐8. - PubMed
Krupinski 1999 {published data only}
    1. Krupinski EA, LeSueur B, Ellsworth L, Levine N, Hansen R, Silvis N, et al. Diagnostic accuracy and image quality using a digital camera for teledermatology. Telemedicine Journal 1999;5(3):257‐63. - PubMed
Lamel 2012 {published data only}
    1. Lamel SA, Haldeman KM, Ely H, Kovarik CL, Pak H, Armstrong AW. Application of mobile teledermatology for skin cancer screening. Journal of the American Academy of Dermatology 2012;67(4):576‐81. - PubMed
Lamminen 2000 {published data only}
    1. Lamminen H, Tuomi ML, Lamminen J, Uusitalo H. A feasibility study of realtime teledermatology in Finland. Journal of Telemedicine and Telecare 2000;6(2):102‐7. - PubMed
Lesher 1998 {published data only}
    1. Lesher JL Jr, Davis LS, Gourdin FW, English D, Thompson WO. Telemedicine evaluation of cutaneous diseases: a blinded comparative study. Journal of the American Academy of Dermatology 1998;38(1):27‐31. - PubMed
Lewis 1999 {published data only}
    1. Lewis K, Gilmour E, Harrison PV, Patefield S, Dickinson Y, Manning D, et al. Digital teledermatology for skin tumours: a preliminary assessment using a receiver operating characteristics (ROC) analysis. Journal of Telemedicine and Telecare 1999;5(Suppl 1):S57‐8. - PubMed
Loane 1998a {published data only}
    1. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Gore HE, Mathews C, et al. Patient satisfaction with realtime teledermatology in Northern Ireland. Journal of Telemedicine and Telecare 1998;4(1):36‐40. - PubMed
Loane 1998b {published data only}
    1. Loane MA, Corbett R, Bloomer SE, Eedy DJ, Gore HE, Mathews C, et al. Diagnostic accuracy and clinical management by realtime teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. Journal of Telemedicine and Telecare 1998;4(2):95‐100. - PubMed
Loane 2000 {published data only}
    1. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al. A comparison of real‐time and store‐and‐forward teledermatology: a cost‐benefit study. British Journal of Dermatology 2000;143(6):1241‐7. - PubMed
Loane 2001a {published data only}
    1. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Evans C, Hicks N, et al. A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective. Journal of Telemedicine and Telecare 2001;7(2):108‐18. - PubMed
Loane 2001b {published data only}
    1. Loane MA, Oakley A, Rademaker M, Bradford N, Fleischl P, Kerr P, et al. A cost‐minimization analysis of the societal costs of realtime teledermatology compared with conventional care: results from a randomized controlled trial in New Zealand. Journal of Telemedicine and Telecare 2001;7(4):233‐8. - PubMed
Lowitt 1998 {published data only}
    1. Lowitt MH, Kessler II, Kauffman C, Hooper FJ, Siegel E, Burnett JW. Teledermatology and in‐person examinations: A comparison of patient and physician perceptions and diagnostic agreement. Archives of Dermatology 1998;134(4):471‐6. - PubMed
Lyon 1997 {published data only}
    1. Lyon CC, Harrison PV. A portable digital imaging system in dermatology: Diagnostic and educational applications. Journal of Telemedicine and Telecare 1997;3(1_suppl):81‐3. - PubMed
Martinez‐Garcia 2007 {published data only}
    1. Martinez‐Garcia S, Boz‐Gonzalez J, Martin‐Gonzalez T, Samaniego‐Gonzalez E, Crespo‐Erchiga V. Teledermatology. Review of 917 teleconsults. Actas Dermo‐Sifiliograficas 2007;98(5):318‐24. - PubMed
Massone 2007 {published data only}
    1. Massone C, Hofmann‐Wellenhof R, Ahlgrimm‐Siess V, Gabler G, Ebner C, Soyer HP. Melanoma screening with cellular phones. PloS One 2007;2(5):e483. - PMC - PubMed
May 2008 {published data only}
    1. May C, Giles L, Gupta G. Prospective observational comparative study assessing the role of store and forward teledermatology triage in skin cancer. Clinical and Experimental Dermatology 2008;33(6):736‐9. - PubMed
McGraw 2009 {published data only}
    1. McGraw TA, Norton SA. Military aeromedical evacuations from central and southwest Asia for ill‐defined dermatologic diseases. Archives of Dermatology 2009;145(2):165‐70. - PubMed
McManus 2008 {published data only}
    1. McManus J, Salinas J, Morton M, Lappan C, Poropatich R. Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments. Prehospital & Disaster Medicine 2008;23(3):210‐6. - PubMed
Moreno‐Ramirez 2006 {published data only}
    1. Moreno‐Ramirez D, Ferrandiz L, Galdeano R, Camacho FM. Teledermatoscopy as a triage system for pigmented lesions: a pilot study. Clinical and Experimental Dermatology 2006;31(1):13‐8. - PubMed
Moreno‐Ramirez 2007 {published data only}
    1. Moreno‐Ramirez D, Ferrandiz L, Nieto‐Garcia A, Carrasco R, Moreno‐Alvarez P, Galdeano R, et al. Store‐and‐forward teledermatology in skin cancer triage: experience and evaluation of 2009 teleconsultations. Archives of Dermatology 2007;143(4):479‐84. - PubMed
Moreno‐Ramirez 2009 {published data only}
    1. Moreno‐Ramirez D, Ferrandiz L, Ruiz‐de‐Casas A, Nieto‐Garcia A, Moreno‐Alvarez P, Galdeano R, et al. Economic evaluation of a store‐and‐forward teledermatology system for skin cancer patients. Journal of Telemedicine and Telecare 2009;15(1):40‐5. - PubMed
Ndegwa 2010 {published data only}
    1. Ndegwa S, Prichett‐Pejic W, McGill S, Murphy G, Severn M. Teledermatology services: rapid review of diagnostic, clinical management, and economic outcomes. Ottawa: Canadian Agency for Drugs and Technologies in Health (CADTH), 2010.
Nordal 2001 {published data only}
    1. Nordal EJ, Moseng D, Kvammen B, Løchen ML. A comparative study of teleconsultations versus face‐to‐face consultations. Journal of Telemedicine and Telecare 2001;7(5):257‐65. - PubMed
Oakley 1997 {published data only}
    1. Oakley AM, Astwood DR, Loane M, Duffill MB, Rademaker M, Wootton R. Diagnostic accuracy of teledermatology: results of a preliminary study in New Zealand. New Zealand Medical Journal 1997;110(1038):51‐3. - PubMed
Oakley 2006 {published data only}
    1. Oakley AM, Reeves F, Bennett J, Holmes SH, Wickham H. Diagnostic value of written referral and/or images for skin lesions. Journal of Telemedicine and Telecare 2006;12(3):151‐8. - PubMed
Oztas 2004 {published data only}
    1. Oztas MO, Calikoglu E, Baz K, Birol A, Onder M, Calikoglu T, et al. Reliability of Web‐based teledermatology consultations. Journal of Telemedicine and Telecare 2004;10(1):25‐8. - PubMed
Pak 1999 {published data only}
    1. Pak HS, Welch M, Poropatich R. Web‐based teledermatology consult system: preliminary results from the first 100 cases. Studies in Health Technology and Informatics 1999;64:179‐84. - PubMed
Pak 2002 {published data only}
    1. Pak HS. Teledermoscopy: a specific application of teledermotology. Skinmed 2002;1(1):18‐9. - PubMed
Pak 2003a {published data only}
    1. Pak HS, Harden D, Cruess D, Welch ML, Poropatich R. Teledermatology: an intraobserver diagnostic correlation study, part I. Cutis 2003;71(5):399‐403. - PubMed
Pak 2003b {published data only}
    1. Pak HS, Harden D, Cruess D, Welch ML, Poropatich R. Teledermatology: an intraobserver diagnostic correlation study, part II. Cutis 2003;71(6):476‐80. - PubMed
Pak 2007 {published data only}
    1. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Store‐and‐forward teledermatology results in similar clinical outcomes to conventional clinic‐based care. Journal of Telemedicine and Telecare 2007;13(1):26‐30. - PubMed
Pak 2009 {published data only}
    1. Pak HS, Datta SK, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Cost minimization analysis of a store‐and‐forward teledermatology consult system. Telemedicine Journal and E‐health 2009;15(2):160‐5. - PubMed
Patro 2015 {published data only}
    1. Patro B, Tripathy J, De D, Sinha S, Singh A, Kanwar AJ. Diagnostic agreement between a primary care physician and a teledermatologist for common dermatological conditions in North India. Indian Dermatology Online Journal 2015;6(1):21‐6. - PMC - PubMed
Perednia 1998 {published data only}
    1. Perednia DA, Wallace J, Morrisey M, Bartlett M, Marchionda L, Gibson A, et al. The effect of a teledermatology program on rural referral patterns to dermatologists and the management of skin disease. Studies in Health Technology and Informatics 1998;52(Pt 1):290‐3. - PubMed
Phillips 1997 {published data only}
    1. Phillips CM, Burke WA, Shechter A, Stone D, Balch D, Gustke S. Reliability of dermatology teleconsultations with the use of teleconferencing technology. Journal of the American Academy of Dermatology 1997;37(3):398‐402. - PubMed
Piccolo 1999 {published data only}
    1. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann‐Wellenhof R, Dell'Eva G, et al. Face‐to‐face diagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study. Archives of Dermatology 1999;135(12):1467‐71. - PubMed
Piccolo 2002 {published data only}
    1. Piccolo D, Peris K, Chimenti S, Argenziano G, Soyer HP. Jumping into the future using teledermoscopy. Skinmed 2002;1(1):20‐4. - PubMed
Rashid 2003 {published data only}
    1. Rashid E, Ishtiaq O, Gilani S, Zafar A. Comparison of store and forward method of teledermatology with face‐to‐face consultation. Journal of Ayub Medical College, Abbottabad 2003;15(2):34‐6. - PubMed
Ribas 2010 {published data only}
    1. Ribas J, Graça Souza Cunha M, Schettini AP, Barros da Rocha Ribas C. Concordância entre diagnósticos dermatológicos obtidos por consulta presencial e por análise de imagens digitais. Anais Brasileiros de Dermatologia 2010;85(4):441‐7. - PubMed
Romero 2010 {published data only}
    1. Romero G, Sanchez P, Garcia M, Cortina P, Vera E, Garrido JA. Randomized controlled trial comparing store‐and‐forward teledermatology alone and in combination with web‐camera videoconferencing. Clinical and Experimental Dermatology 2010;35(3):311‐7. - PubMed
Romero 2014 {published data only}
    1. Romero Aguilera G, Cortina de la Calle P, Vera Iglesias E, Sánchez Caminero P, García Arpa M, Garrido Martín JA. Interobserver reliability of store‐and‐forward teledermatology in a clinical practice setting. Actas Dermo‐sifiliograficas 2014;105(6):605‐13. - PubMed
Seidenari 2004 {published data only}
    1. Seidenari S, Pellacani G, Righi E, Nardo A. Is JPEG compression of videomicroscopic images compatible with telediagnosis? Comparison between diagnostic performance and pattern recognition on uncompressed TIFF images and JPEG compressed ones. Telemedicine Journal and E‐health 2004;10(3):294‐303. - PubMed
Senel 2013 {published data only}
    1. Senel E, Baba M, Durdu M. The contribution of teledermatoscopy to the diagnosis and management of non‐melanocytic skin tumours. Journal of Telemedicine and Telecare 2013;19(1):60‐3. - PubMed
Shin 2014 {published data only}
    1. Shin H, Kim DH, Ryu HH, Yoon SY, Jo SJ. Teledermatology consultation using a smartphone multimedia messaging service for common skin diseases in the Korean army: a clinical evaluation of its diagnostic accuracy. Journal of Telemedicine and Telecare 2014;20(2):70‐4. - PubMed
Tait 1999 {published data only}
    1. Tait CP, Clay CD. Pilot study of store and forward teledermatology services in Perth, Western Australia. Australasian Journal of Dermatology 1999;40(4):190‐3. - PubMed
Tan 2010a {published data only}
    1. Tan E, Oakley A, Soyer HP, Haskett M, Marghoob A, Jameson M, et al. Interobserver variability of teledermoscopy: an international study. British Journal of Dermatology 2010;163(6):1276‐81. - PubMed
Tan 2010b {published data only}
    1. Tan E, Yung A, Jameson M, Oakley A, Rademaker M. Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial). British Journal of Dermatology 2010;162(4):803‐11. - PubMed
Tandjung 2015 {published data only}
    1. Tandjung R, Badertscher N, Kleiner N, Wensing M, Rosemann T, Braun RP, et al. Feasibility and diagnostic accuracy of teledermatology in Swiss primary care: process analysis of a randomized controlled trial. Journal of Evaluation in Clinical Practice 2015;21(2):326‐31. - PubMed
Taylor 2001 {published data only}
    1. Taylor P, Goldsmith P, Murray K, Harris D, Barkley A. Evaluating a telemedicine system to assist in the management of dermatology referrals. British Journal of Dermatology 2001;144(2):328‐33. - PubMed
Tucker 2005 {published data only}
    1. Tucker WF, Lewis FM. Digital imaging: a diagnostic screening tool?. International Journal of Dermatology 2005;44(6):479‐81. - PubMed
van der Heijden 2013 {published data only}
    1. Heijden JP, Thijssing L, Witkamp L, Spuls PI, Keizer NF. Accuracy and reliability of teledermatoscopy with images taken by general practitioners during everyday practice. Journal of Telemedicine and Telecare 2013;19(6):320‐5. - PubMed
Vano‐Galvan 2011 {published data only}
    1. Vano‐Galvan S, Hidalgo A, Aguayo‐Leiva I, Gil‐Mosquera M, Rios‐Buceta L, Plana MN, et al. (Store‐and‐forward teledermatology: assessment of validity in a series of 2000 observations). Actas Dermo‐Sifiliograficas 2011;102(4):277‐83. - PubMed
Warshaw 2009a {published data only}
    1. Warshaw EM, Lederle FA, Grill JP, Gravely AA, Bangerter AK, Fortier LA, et al. Accuracy of teledermatology for pigmented neoplasms. Journal of the American Academy of Dermatology 2009;61(5):753‐65. - PubMed
Warshaw 2009b {published data only}
    1. Warshaw EM, Lederle FA, Grill JP, Gravely AA, Bangerter AK, Fortier LA, et al. Accuracy of teledermatology for nonpigmented neoplasms. Journal of the American Academy of Dermatology 2009;60(4):579‐88. - PubMed
Warshaw 2010a {published data only}
    1. Warshaw EM, Gravely AA, Bohjanen KA, Chen K, Lee PK, Rabinovitz HS, et al. Interobserver accuracy of store and forward teledermatology for skin neoplasms. Journal of the American Academy of Dermatology 2010;62(3):513‐6. - PubMed
Warshaw 2015 {published data only}
    1. Warshaw EM, Gravely AA, Nelson DB. Reliability of store and forward teledermatology for skin neoplasms. Journal of the American Academy of Dermatology 2015;72(3):426‐35. - PubMed
Watson 2010 {published data only}
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Weingast 2013 {published data only}
    1. Weingast J, Scheibböck C, Wurm EM, Ranharter E, Porkert S, Dreiseitl S, et al. A prospective study of mobile phones for dermatology in a clinical setting. Journal of Telemedicine and Telecare 2013;19(4):213‐8. - PubMed
Weinstock 2002 {published data only}
    1. Weinstock MA, Nguyen FQ, Risica PM. Patient and referring provider satisfaction with teledermatology. Journal of the American Academy of Dermatology 2002;47(1):68‐72. - PubMed
Weinstock 2009 {published data only}
    1. Weinstock MA. Evaluation of in‐person dermatology versus teledermatology. Journal of the American Academy of Dermatology 2009;61(5):902‐3. - PubMed
Whited 1999 {published data only}
    1. Whited JD, Hall RP, Simel DL, Foy ME, Stechuchak KM, Drugge RJ, et al. Reliability and accuracy of dermatologists’ clinic‐based and digital image consultations. Journal of the American Academy of Dermatology 1999;41(5):693‐702. - PubMed
Whited 2002 {published data only}
    1. Whited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, et al. Teledermatology's impact on time to intervention among referrals to a dermatology consult service. Telemedicine Journal and E‐health 2002;8(3):313‐21. - PubMed
Whited 2003 {published data only}
    1. Whited JD, Datta S, Hall RP, Foy ME, Marbrey LE, Grambow SC, et al. An economic analysis of a store and forward teledermatology consult system. Telemedicine Journal and E‐health 2003;9(4):351‐60. - PubMed
Whited 2004 {published data only}
    1. Whited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, et al. Patient and clinician satisfaction with a store‐and‐forward teledermatology consult system. Telemedicine Journal and E‐health 2004;10(4):422‐31. - PubMed
Whited 2006 {published data only}
    1. Whited JD. Teledermatology research review. International Journal of Dermatology 2006;45(3):220‐9. - PubMed
Whited 2010 {published data only}
    1. Whited JD. Economic analysis of telemedicine and the teledermatology paradigm. Telemedicine Journal and E‐health 2010;16(2):223‐8. - PubMed
Whited 2016 {published data only}
    1. Whited JD. Diagnosis and management of pigmented skin lesions using teledermatology. Current Dermatology Reports 2016;5(2):90‐5.
Williams 2001 {published data only}
    1. Williams T, May C, Esmail A, Ellis N, Griffiths C, Stewart E, et al. Patient satisfaction with store‐and‐forward teledermatology. Journal of Telemedicine and Telecare 2001;7(Suppl 1):45‐6. - PubMed
Williams 2007 {published data only}
    1. Williams CM, Qureshi A, Geller A, Kvedar J. Skin cancer education program via teledermatology: Is it effective?. Journal of the American Academy of Dermatology 2007;56(2):AB100.
Wootton 2000 {published data only}
    1. Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost‐benefit analysis. BMJ 2000;320(7244):1252‐6. - PMC - PubMed
Zelickson 1997 {published data only}
    1. Zelickson BD, Homan L. Teledermatology in the nursing home. Archives of Dermatology 1997;133(2):171‐4. - PubMed

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