Accuracy of teledermatology for nonpigmented neoplasms

Erin M Warshaw, Frank A Lederle, Joseph P. Grill, Amy A. Gravely, AnnMarie 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, David B Nelson

Research output: Contribution to journalArticlepeer-review

81 Scopus citations


Background: Studies of teledermatology utilizing the standard reference of histopathology are lacking. Objective: To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. Methods: This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. Results: Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. Limitations: Non-diverse study population. Conclusions: Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Original languageEnglish (US)
Pages (from-to)579-588
Number of pages10
JournalJournal of the American Academy of Dermatology
Issue number4
StatePublished - Apr 2009

Bibliographical note

Funding Information:
Supported by the Department of Veterans Affairs Health Services Research and Development Service (grant IIR 01-072-2). During this study, Dr Warshaw was supported by a Veterans Affairs Cooperative Studies Clinical Research Career Development Award. Dr Warshaw had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Copyright 2009 Elsevier B.V., All rights reserved.


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