• Erin M Warshaw, Frank A Lederle, Joseph P Grill, Amy A Gravely, Ann K Bangerter, Lawrence A Fortier, Kimberly A Bohjanen, Karen Chen, Peter K Lee, Harold S Rabinovitz, Robert H Johr, Valda N Kaye, Sacharitha Bowers, Rachel Wenner, Sharone K Askari, Deborah A Kedrowski, and David B Nelson.
• Minneapolis Veterans Affairs Medical Center, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA. erin.warshaw@med.va.gov
• J. Am. Acad. Dermatol. 2009 Nov 1;61(5):753-65.

BackgroundAccurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma.ObjectiveWe sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology.MethodsWe conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed.ResultsWe enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology.LimitationsNondiverse study population and relatively small number of melanomas were limitations.ConclusionsIn general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

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