First Derm Scientific Review in JAMA Dermatology

telemedicine jama study

Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease (JAMA Dermatol. Published online May 15, 2016)

We are happy to have had our service be reviewed as part of a “blind” study, that used images submitted using fake patient profiles to assess the performance of direct-to-consumer teledermatology websites. The study was conducted by Jack S. Resneck Jr et. al from the Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, testing 16 consumer dermatology services on offer in the state of California.

The research group sent each service 12 images of dermatology cases (two images per case) together with “patient” notes. In five cases they sent in an overview and a close up image. In one case, photos of two different moles were sent in. We looked into our database and we retrieved the cases that were part of the study: the photos submitted, questions asked, the time taken to provide an answer and finally the response provided by a dermatologist. The descriptions and questions submitted were reproduced in the published study, and we are re-posting them here, together with the photographs submitted as part of this research, and the responses posted by First Derm physicians. The study found that a significant proportion of the teledermatology results were inaccurate, though none of the First Derm results were inaccurate.

The study questioned First Derm’s use of physicians not licensed in California. Since First Derm offers an anonymous informational service rather than health care services, this is not an issue. As described more fully below, First Derm quality control procedures include screening its physician panel members and performing random audits of its reports.

 

What is First Derm?

First Derm has evolved from our own scientific research and a need in the 21st century for easy access to a dermatologist using today’s technology, for guidance on any skin issue a person is worried about and would like an opinion on what next steps to take. It is not a service that substitutes for a dermatologist visit; rather, it is a medical information service. In today’s connected world, 80% of people search the internet for their suspected medical conditions. A problem is that internet search engines are not optimized in regards to searching for skin issues, you cannot upload an image to a search engine and get an answer. This can lead to laypersons misinterpreting their condition, becoming more worried and taking the wrong steps.

The service is global, it is in 6 languages (English, Spanish, Swedish, French, Italian and Chinese). To date the service has responded to 17,000 cases from 160 countries. The service uses board-certified dermatologists distributed in USA, UK, Sweden, Spain, France, Italy and Australia to provide limited reactions to the images.

The dermatologists’ credentials are vetted, a background check is done and prospective panel members complete a screening test with images of various skin conditions. 20% of the cases are randomly audited by the advisory board. We have structured our approach with input from legal counsel, in order to ensure that the services offered are clearly informational, rather than health care services. Further detail may be found  Terms & Conditions as well as our privacy policy.

 

How it works

A user  submit two images via the website or one of our apps, together with a brief explanation of the condition, symptoms, other relevant information. At First Derm, we do not collect any personal information, such as e-mail addresses, phone numbers or other personal data. Anyone who would like to ask a dermatologist a question may do so, and have an answer within hours from our dermatologists with an informed perspective on what the image looks like and what to do next, e.g., try an over-the-counter cream or go see a doctor in person. We have 24 hour support to resolve any customer issues.

 

The idea that lead to First Derm

The founder Dr Alexander Börve created the concept with his dermatologist girlfriend after one evening, at a friend’s birthday party, she was annoyed by people asking her questions about their skin concerns. Many people want  to ask a specialist about skin issues and receive quick guidance on what to do next. This idea is not new; in the UK, there is NHS Direct and in Sweden there is 1177. A citizen can call in or e-mail and receive a “next step” answer from a nurse. This has been shown to be very cost-effective. As many as 50% of the cases do not need to see a healthcare professional in person, but can get better with just an over-the-counter, non-prescription medication. The other 50% are guided to the right level of healthcare.

 

Study cases that were sent in for a review with First Derm

Ask a Dermatologist

Anonymous, fast and secure!

telemedicine jama study syphilis
telemedicine jama study syphilis scalp

25 years old male
San Francisco

Question
I have a bad new rash. I saw my regular doctor and she said it is psoriasis, but the cream she gave me (Desonide) isn’t helping much. It all started about 3 weeks ago when it broke out on my back, my chest, my arms, my legs, and my feet. It doesn’t really itch that much but I look terrible. It’s even all in my scalp, and the desonide cream just makes a mess of my hair.

Received 2016-02-11 03:51
Given answer 2016-02-11 09:36

Answer
Based on the information and images submitted, this is possibly a PSORIASIS: Psoriasis is a chronic inflammatory disease of the skin which can present at any age. Red patches usually with white scales are seen on different skin areas such as elbows, knees, lower legs and/or scalp. Nevertheless, it can appear anywhere on the skin. A variable amount of itching can be experienced or none at all. Sometimes there are more family members with the condition. I recommend that you see a dermatologist or your family doctor in order to obtain prescriptions. Prescription treatment options include vitamin D-derived creams (e g Daivonex) with or without topical steroids (e g Daivobet), sun light or medical UV-therapy. In your case that don’t respond to this treatment, other systemic alternatives are available that you need to talk with your dermatologist about.

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

telemedicine jama study acne
telemedicine jama study acne 2

28 years old female
San Francisco

Question
I’ve had acne since my teen years but now I’m 28 and I’m getting tired of it. I tried a bunch of prescription creams and ointments (like clindamycin and retin-A) that didn’t work, and an antibiotic pill (I’m not sure which kind) I took for a few months a couple of years ago made it halfway better. What can I do t get clearer skin?

Received 2016-02-28 01:14
Given answer 2016-02-28 01:54

Answer
Based on the information and images submitted, possibly ACNE NODULOCYSTICA: Red raised spots (papules), pus-filled spots (pustules) and deeper inflamed cysts, which may be painful, are typical findings. It can affect the face, but also the chest and/or back. This type of acne may lead to scarring. Oral treatment with an antibiotic (eg Doxycycline) plus a topical treatment with benzoyl peroxide combined with a topical retinoid may help. For severe, resistant, scarring acne isotretinoin may be considered. An immediate over the counter option to start with is topical benzoyl peroxide wash, but due to the acne severity, an office visit with a dermatologist is needed for full evaluation and prescription based treatments. Due to the severity AND persistent nature of your acne, an open discussion about isotretion is suggested. Isotretion gets a lot of bad press, but for those with severe acne, it’s worth a discussion with a dermatologist. A large percentage of people are acne free for 10 years!! Good luck!

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

telemedicine jama study acne man
telemedicine jama study acne man 2

20 years old male
San Francisco

Question
I’ve had acne since I was 12. Two years ago, my dermatologist started me on pills (doxycycline) and it was awesome. It was so much better for a long time. I’m still on the pills, but my acne has been getting bad again on my lips and chin with some new pus bumps for 2 months. Why isn’t it working anymore? What else can I use?

Received 2016-02-08 22:58
Given answer 2016-02-09 14:09

Answer
Based on the information and images submitted, possibly ACNE / INFLAMMATORY ACNE: Red raised spots (papules), pus-filled spots (pustules) and deeper inflamed cysts, which may be painful, are typical findings. It can affect the face, but also the chest and/or back. This type of acne may lead to scarring. Oral treatment with an antibiotic (eg Doxycycline) plus a topical treatment with benzoyl peroxide combined with a topical retinoid may help. Success in the past with doxycycline is great, but sometimes changing to another oral antibiotic like minocycline may help. Also adding over the counter benzoyl peroxide wash and a topical prescription retinoid is helpful. For persistent inflammatory acne, a re-visit with the dermatologist is advised to discuss other options including isotretinoin.

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

telemedicine jama study Eczema herpeticum
telemedicine jama study Eczema herpeticum woman

19 years old female
San Francisco

Question
I’ve had eczema since I was a little kid. It’s been pretty bad at times. But I was getting better over the last year or two. My creams had been working pretty well. Over the last 10 days, my skin on my face and neck got way more itchy and irritated and my rash got worse. Do I need a stronger cream? Should I start on Atarax pills again?

Received 2016-03-07 02:06
Given answer 2016-03-07 07:59

Answer
Based on the information and images submitted, this is possibly a ECZEMA ATOPICUM. Atopic eczema usually starts in childhood , and sometimes coincide with asthma and hay fever. People with eczema atopicum usually have dry skin, and daily use of moisturizor is recommended to decrease the risk of eczema. When eczema is present a topical steroid creme is needed. In your case from the images your eczema is infected and you need to see your doctor to get a prescription for antibiotic and exclude other infection for example herpes simplex. Your eczema will not be improved by a stronger cortison cream if you have an infection. Another suggestion for treatment after the infection is gone is tacrolimus which will require a prescription from your dermatologist or family doctor.

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

telemedicine jama study mole
telemedicine jama study mole 2

35 years old male
San Francisco

Question
There are two moles that I wanted you to check. Do I need to get them taken off? The first picture is of a mole on my right cheek, and the second picture is of a mole in the middle of my back. I think they both showed up about 5 years ago, but I’m not sure. They both seem to have grown some this year, but they don’t hurt or itch or anything.

Received 2016-02-05 02:30
Given answer 2016-02-05 03:28

Answer
Based on the information and images submitted, possibly SEBORRHEIC KERATOSIS (back) and ATYPICAL NEVUS (cheek): A seborrhoeic keratosis is a benign wart-like lesion (not contagious) that is very common in adults. They are usually brown in color, often slightly raised and may have a waxy or scaly surface. Potential treatments include curettage (scraping) or cryotherapy (freezing with liquid nitrogen). However, since seborrheic keratoses are benign, often if asymptomatic (no bleeding, no itching), they can be left on the skin. An office visit is indicated by a dermatologist for examination of nevus (mole) on cheek (size, appears different than other moles). A skin biopsy (small in office procedure) may be performed and/or a dermatologist may use a dermatoscope (hand-held device to examine moles) to check for benign or concerning features. Your history matters (history of blistering sunburns, personal or family history of skin cancers). Concerning mole features that should prompt an immediate full skin examination include: 1. Asymmetry- If you draw an imaginary line down the center of your mole, one side does not look like the other side 2. Border- The borders are not smooth. 3. Color- There is more than one color within the mole or if a mole has lost color it once had. 4. Diameter- Moles larger than the size of an eraser head (6 millimeters); although some malignant (cancerous) moles, if caught early may be detected at a size smaller than millimeters. 5. Evolving Moles- If a mole starts to look different in anyway over time (change in size, shape, color, pain, itching, bleeding) This message is provided as general information only.

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

telemedicine jama study stasis eczema
telemedicine jama study stasis eczema leg

60 years old male
San Francisco

Question
These red splotches on my legs have been there a couple of months, and this week they turned brighter red and got all irritated. My wife thinks it has started to get bigger. Is this an infection? Do I need antibiotics?

Received 2016-02-28 06:58
Given answer 2016-02-28 15:54

Answer
Based on the information and images submitted, this is possibly a ECZEMA HYPOSTATICUM also known as VENOUS ECZEMA, a common form of dermatitis that affects one or both lower legs in association with venous insufficiency. Venous eczema occurs when the valves in the leg veins do not work properly, reducing drainage of blood from the legs. This leads to an increase in the pressure inside the leg veins, which then causes damage to the overlying skin. The exact reason why the resulting skin changes occur is unclear, but is likely to be due to leakage of blood and blood products into the surrounding tissue. This then triggers inflammation in the skin. Being overweight can make the problem worse because of increased pressure on the leg veins. Immobility, leg swelling, varicose veins, previous clots in the leg (venous thrombosis) and previous cellulitis are other possible contributory factors. Venous eczema occurs on the lower legs and is often very itchy and sometimes painful. It can vary in severity from changes in skin coloring and dryness of the skin to areas of inflamed eczema with red spots, scaling, weeping and crusting. Swelling of the legs may also be present. It is often associated with varicose veins. Cornerstones in the treatment of this disease are reduce swelling in the legs and treatment of the eczema. Simple measures are very important in helping to reduce venous pressures and the risk of further complications. These include losing weight and keeping active, don’t forget to take regular walks! Venous eczema can be made worse by standing or sitting with the legs down for long periods, for example sleeping in a chair; it is recommended when at rest that you raise your legs as high as possible for at least part of the day, ideally above the level of your heart by lying down. Care also needs to be taken to avoid damaging the skin on the leg, for example it is important to avoid knocking or hitting the leg on hard objects (such as supermarket shelves, trolleys, doors of kitchen cupboards, etc.). Compression socks or stockings are another simple measure that helps to reduce the pressures in the leg veins and should be worn at all times during the day in order to support the veins. Fitted moderate to high compression socks can be obtained from a surgical supplies company. Light compression using travel socks may be adequate, and these are easy to put on. They can be bought at pharmacies, travel and sports stores. More compression is obtained by wearing two pairs. However, compression stockings should not be used if you have an arterial disease in the legs. Your dermatologist or family physician can advise you about this and a simple test measuring your leg circulation is often performed before using compression stockings. Topical emollients or moisturizers should be used at least twice daily for all the skin on the lower leg, whether affected or not; these make the skin more supple and can help to prevent the skin breaking down. A steroid cream is often added to moisturizing treatment to treat the eczema and it should be applied to the affected patches of skin only: start with applying Hydrocortisone 1% cream (available over-the-counter without a prescription) twice daily for a week, then once daily a couple of weeks, later once every other day and end up with applications 1-2 times a week. In general, the responses to the above measures are good if they are used every day on a long-term basis.

This message is provided as general information only. It does not create a physician-patient relationship, and is not a diagnosis or treatment plan, for which you should consult your personal physician.

 

 

 

Ask a Dermatologist

Anonymous, fast and secure!

logo
1 (415) 234-4124
Support
Share This