Face-to-Face vs Teledermatology for the Diagnosis of Potential Skin Cancers

Doctor on the computer laptop screen.
Doctor on the computer laptop screen. Telemedicine or telehealth concept.
Investigators examined the effectiveness of diagnosing skin cancer by teledermatology and face-to-face interaction.

Use of teledermatology workflows — that is, a dermatoscopic-fitted digital camera, a picture archiving and communication system, and image retrieval to a large, high-resolution computer monitor — is associated with excellent detection of skin cancer, fewer visits to a dermatology clinic, and reduced wait times, according to study results published in the Journal of the American Academy of Dermatology.

The investigators sought to compare the risks for biopsy and skin cancer diagnosis among 2 face-to-face workflows — direct referral and roving dermatologist — and 4 teledermatology workflows. A retrospective cohort was conducted at Kaiser Permanente Northern California.

Outcomes of the study included the probabilities of biopsy, cancer diagnosis, and a dermatology visit that did not result in a skin cancer diagnosis. Per the null hypothesis, the risks for outcomes were the same for each of the 4 teledermatology workflows and the 2 face-to-face workflows, with this knowledge being important for optimizing implementation of teledermatology.

A total of 59,279 health plan members age 18 to 89 years who had a primary care provider (PCP) encounter for a skin lesion (alone or with a rash) between January and June 2017 were identified. PCP encounters comprised both face-to-face visits and patient portal messages. Each patient was counted only 1 time, and the date of visit to the PCP or the date of upload to the patient portal was defined as the date of entry into the study. Of the total participants, 25,041 received teledermatology encounter, 21,911 had a direct referral to dermatology, and 12,327 had a referral to a roving dermatologist. Overall, one-third of the participants were ≥65 years of age, 57% were women, 26% were nonwhite, and 9% had a history of skin cancer.

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Compared with direct referral, the teledermatology workflow was associated with a 9% greater likelihood of cancer detection (95% CI, 2%-16%), 4% lower probability of biopsy (relative risk, 0.96; 95% CI, 0.93-0.99), and 39% fewer face-to-face visits (relative risk, 0.61; 95% CI, 0.57-0.65). Other workflows were shown to be less effective.

A major limitation of the study is the fact that differing proficiencies across teledermatology workflows and selection of patients for direct referral could have resulted in bias. The investigators concluded that implementation is key to the effectiveness of teledermatology. They intend to support further adoption of dermoscopy, to increase training and thus help improve image quality, and to enhance consideration of the value linked to viewing images on a larger computer monitor.

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Marwaha S, Fevrier HB, Alexeeff SE, et al. Comparative effectiveness study of face-to-face and teledermatology workflows for diagnosing skin cancer [published online February 1, 2019]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2019.01.067.