Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

Teledermatology for Diagnosis and 

Management of Skin Conditions: 

A Systematic Review of the Evidence 

Department of Veterans Affairs

Health Services Research & Development Service

January 2010

Prepared for: 

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & 

Development Service

Washington, DC 20420 

Prepared by:

VA Evidence Synthesis Program

Center for Chronic Disease 

Outcomes Research

Minneapolis VA Medical Center

Minneapolis, MN 

Principal Investigator:

Erin Warshaw, MD, MS

Research Associates

Nancy Greer, PhD

Yonatan Hillman, BA

Emily Hagel, MS

Roderick MacDonald, MS

Indulis Rutks, BS

ESP Program Director 

Timothy J. Wilt, MD, MPH
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

PREFACE

VA’s Health Services Research and Development (HSR&D) Service works to improve the cost, 

quality, and outcomes of healthcare for our nation’s veterans. Collaborating with VA leaders, 

managers, and policy makers, HSR&D focuses on important healthcare topics that are likely to 

have significant impact on quality improvement efforts. One significant collaborative effort is 

HSR&D’s Evidence-based Synthesis Program (ESP). Through this program, HSR&D provides 

timely and accurate evidence syntheses on targeted healthcare topics. These products will 

be disseminated broadly throughout VA and will: inform VA clinical policy, develop clinical 

practice guidelines, set directions for future research to address gaps in knowledge, identify the 

evidence to support VA performance measures, and rationalize drug formulary decisions.

HSR&D provides funding for four ESP Centers. Each Center has an active and publicly 

acknowledged VA affiliation and also serves as an Evidence Based Practice Center (EPC) 

supported by the Agency for Healthcare Research and Quality (AHRQ). The Centers will each 

generate three evidence syntheses annually on clinical practice topics of key importance to VHA 

leadership and policymakers. A planning committee with representation from HSR&D, Patient 

Care Services (PCS), Quality Enhancement Research Initiative (QUERI), Office of Quality 

and Performance (OQP), and the VISN Clinical and Quality Management Officers, has been 

established to identify priority topics and key stakeholder concerns and to ensure the quality of 

final reports. Comments on this evidence report are welcome and can be sent to Nicole Floyd, 

ESP Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Warshaw E, Greer N, Hillman Y, Hagel E, MacDonald R, Rutks I and 

Wilt TJ. Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic 

Review of the Evidence. VA-ESP Project #09-009; 2009
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

This information is distributed solely for the purposes of pre-dissemination peer review. 

It has not been formally disseminated by the Department of Veterans Affairs. It does 

not represent and should not be construed to represent a Department of Veterans Affairs 

determination or policy.

Financial disclosure: No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, grants 

or patents received or pending, or royalties) that conflict with material presented in the 

report.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

TABLE OF CONTENTS

EXECUTIVE SUMMARY ...................................................................................................................1

Background.....................................................................................................................................1

Methods ..........................................................................................................................................2

Results ...........................................................................................................................................2

Future Research Recommendations................................................................................................7

Conclusions.....................................................................................................................................8

INTRODUCTION AND BACKGROUND .......................................................................................9

METHODS .............................................................................................................................................11

Topic Development, Technical Expert Panel................................................................................11

Search Strategy .............................................................................................................................11

Data Abstraction ...........................................................................................................................12

Quality Assessment.......................................................................................................................13

Data Synthesis...............................................................................................................................14

Peer Review ..................................................................................................................................14

RESULTS................................................................................................................................................15

Literature Flow .............................................................................................................................15

KEY QUESTION #1 ....................................................................................................................15

KEY QUESTION #2 ....................................................................................................................20

KEY QUESTION #3 ....................................................................................................................35

KEY QUESTION #4 ....................................................................................................................42

KEY QUESTION #5 ....................................................................................................................48

SUMMARY AND DISCUSSION.......................................................................................................53

Conclusions...................................................................................................................................53

Future Research Recommendations..............................................................................................54

REFERENCES ......................................................................................................................................56
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

TABLES

Table 1. Definitions of Outcomes.................................................................................................13

Table 2. Summary of Study Characteristics for Teledermatology Studies (KQ1, KQ2)..............22

Table 3. Diagnostic Accuracy Using Histopathology/Lab Tests (KQ1a) .....................................24

Table 4. Diagnostic Concordance -Teledermatology & Usual Care

(In-Person Dermatology) (KQ1b)....................................................................................27

Table 5. Management Accuracy Using Histopathology/Lab Tests (KQ2a)..................................32

Table 6. Management Concordance -Teledermatology & Usual Care

(In-Person Dermatology) (KQ2b)....................................................................................32

Table 7. Clinical Course Outcome (KQ3).....................................................................................35

Table 8. Patient Satisfaction and Preference (KQ3) .....................................................................37

Table 9. Time to Treatment/Dermatological Visits Avoided (KQ3) .............................................41

Table 10. Cost Outcomes (KQ4)...................................................................................................44

Table 11. Key Elements for Success / Barriers to Implementation (KQ5)...................................52

FIGURES

Figure 1. Reference Flow Chart....................................................................................................16

Figure 2. Quality of Store and Forward Teledermatology Studies...............................................23

Figure 3. Quality of Live Interactive Teledermatology Studies ...................................................23

Figure 4a. Aggregated Diagnostic Accuracy: Store and Forward ................................................26

Figure 4b. Primary Diagnostic Accuracy: Store and Forward......................................................26

Figure 5a. Aggregated Diagnostic Concordance: Store and Forward ..........................................30

Figure 5b. Primary Diagnostic Concordance: Store and Forward................................................30

Figure 6a. Aggregated Diagnostic Concordance: Live Interactive...............................................31

Figure 6b. Primary Diagnostic Accuracy Concordance: Live Interactive ....................................31

Figure 7a. Management Concordance: Store and Forward ..........................................................34

Figure 7b. Management Concordance: Live Interactive ..............................................................34

APPENDIX A. Search Strategy.............................................................................................................63

APPENDIX B. Data Extraction Form...................................................................................................64

APPENDIX C. Peer Review Comments and Responses .....................................................................69

APPENDIX D. Abbreviations...............................................................................................................72

APPENDIX E. Evidence Table: Overview of Studies for Questions 1 and 2.......................................73
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

INTRODUCTION AND BACKGROUND

Telemedicine uses telecommunication technology to transfer medical information. Due to the 

visual nature of a skin examination, telemedicine, specifically, teledermatology, is a potentially 

valuable tool in the diagnosis and management of dermatologic diseases for patients in rural 

areas (including rural Veterans Affairs Medical Centers [VAMCs] and Community Based 

Outpatient Clinics [CBOCs]) where a dermatologist may not be available. Teledermatology 

may also be useful in primary care settings to triage cases and limit unnecessary dermatology 

clinic referrals as well as to assist with follow-up care or monitoring after an in-person 

dermatology visit. Two particular types of teledermatology are commonly employed. Store 

and forward (SAF) uses asynchronous still digital image technology for communication, similar 

to an email system. Participants are typically separated by both time and space. Real-time or 

live interactive (LI) uses video-conferencing technology. Participants are separated by space, 

not by time. Both systems have advantages and disadvantages. SAF requires less technological 

sophistication and lower cost equipment than LI, permits the referring provider to submit the 

consultation with accompanying image(s) to the dermatologist for review at a later time, and 

does not require the dermatologist to be immediately available or on-call to urgently review the 

teleconsult while the patient is in the primary care clinic. In contrast, LI permits a more dynamic 

assessment of the skin condition and allows the dermatologist to obtain a real-time history from 

both the patient and the referring provider, to make an immediate initial diagnosis, and to provide 

a management plan. Owing partly to the technological simplicity of SAF and the fact that SAF 

allows the dermatologist to review the telemedicine consult either outside of normal clinic hours 

or bundled into separate time slots within an existing clinic, SAF is the more widely used form 

of teledermatology in the VA. An informal, unpublished survey of VA dermatology chiefs in 

December 2009 found that 44% (19/43) of responding VA dermatology services are utilizing 

teledermatology; 17 VAs are using SAF, one is using LI, and one is using both methodologies. 

The diagnostic and management accuracy (match of teledermatology diagnosis or in-person 

dermatology diagnosis with a gold standard of histopathology or other laboratory test) and 

concordance (agreement between teledermatology and in-person dermatology) of these 

technologies, their cost-effectiveness, and their impact on clinical management and patient 

outcomes (including satisfaction) are not well understood. Although research demonstrating that 

teledermatology is accurate and cost-effective is essential, it is not sufficient. Lessons learned 

from mature, functioning teledermatology systems in the United Kingdom and New Zealand 

include that “initial concerns about the ability to diagnose and manage patients by telemedicine 

have turned out to be less important that the practical issues of implementation.”1 Incorporating 

research findings into clinical practice requires identifying and removing structural and process 

barriers as well as enhancing critical components to success. Based on the work of Rogers2 and a 

systematic review of empirical research studies, Greenhalgh et al. developed a conceptual model 

for considering the determinants of diffusion, dissemination, and implementation of innovations 

in health service delivery and organization.3 Greenhalgh et al. concluded that adoption of any 

health care technology increases to the degree that such technology is perceived as possessing 

the following qualities in relation to existing practice: relative advantage (the new technology 

is better than current processes); compatibility (consistency with existing values, behaviors and 

past experiences); low complexity (easy to understand and use); trialability (can be modified and 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

experimented with on a limited basis), and observability (results of the change are visible).3

We conducted an evidence synthesis report to systematically review and summarize the scientific 

literature addressing: 1) teledermatology for the diagnosis of skin conditions, 2) teledermatology 

for the management of skin conditions, 3) clinical outcomes when teledermatology is used, 4) the 

cost of teledermatology compared with usual care (in-person dermatology), and 5) key elements 

of and barriers to successful implementation of teledermatology. We addressed the following 

key questions:

1a. How does the accuracy of teledermatology compare to usual care (in-person dermatology) 

for the diagnosis of skin conditions?

1b. How does the concordance of teledermatology compare to usual care (in-person 

dermatology) for the diagnosis of skin conditions?

 2a. How does the accuracy of teledermatology compare to usual care (in-person dermatology) 

for clinical management of skin conditions?

2b. How does the concordance of teledermatology compare to usual care (in-person 

dermatology) for clinical management of skin conditions?

3. How do clinical outcomes (clinical course, satisfaction, quality of life, visits avoided) of 

teledermatology compare to usual care (in-person dermatology) for skin conditions?

4. How does the cost of teledermatology compare to usual care (in-person dermatology)?

5. What are the key structural and process elements associated with successful implementation 

of teledermatology and what are the barriers?
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

METHODS

Topic Development, Technical Expert Panel

This topic was nominated by the Center for Chronic Disease Outcomes Research, Minneapolis 

VA Medical Center in consultation with the VA Evidence Synthesis Program. Robert Dellavalle, 

MD, PhD; Dennis Oh, MD; and John Whited, MD, MHS agreed to serve on the Technical Expert 

Panel (TEP) for the project. The TEP and the VA Department of Health Services Research and 

Development (HSR&D) collaborated with the Minneapolis VA Evidence Synthesis Program 

(ESP) to identify and refine key questions including populations, interventions, comparisons, 

outcomes, and settings of relevance. 

Search Strategy

We searched MEDLINE (OVID) and PubMed for clinical trials, systematic reviews, cost studies, 

and implementation papers from 1990 to June, 2009 using standard search terms. We chose 1990 

as the start date for the search based on consensus from the TEP members that studies prior to 

1990 would likely not be relevant to current practice. We limited the search to articles involving 

human subjects and published in English language. Search terms included: remote consult/

consultation, electronic mail, telecommunications, telemedicine, telepathology, dermatology, and 

teledermatology. (Appendix A)

Study Selection

Titles and abstracts identified from the search were reviewed by physicians and research 

associates trained in the critical analysis of literature to identify peer-reviewed articles likely 

related to one or more of the key questions. 

Specific inclusion criteria were as follows:

1. Controlled trial (questions 1 and 2)

2. Store and forward (SAF) or live interactive (LI) teledermatology

Specific exclusion criteria included:

1. Teledermatology involving mobile phones

2. Non-teledermatology settings (e.g., imaging analyses, telemedicine studies other than 

teledermatology, videomicroscopy studies, basic science, imaging techniques)

3. Dermatopathology studies

4. Reviews, teledermatology program descriptions, and history of teledermatology (unless 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

relevant to questions 3, 4 or 5)

5. Studies of computer-aided diagnoses only (e.g., pigmented lesions)

6. Survey studies addressing outcomes other than those defined in questions 1-5

7. Teledermatology as an educational tool for primary care physicians or residents

8. Technology assessment only

9. Remote monitoring of known diagnoses (e.g., leg ulcers, post-operative wounds)

10. Teledermatology involving patient generated photos and/or history (without a referring 

provider)

11. Non-English language

12. Case series with no control group (questions 1 and 2 only)

13. Commentaries, editorials or meeting abstracts (unless relevant to question 5)

14. Studies involving one diagnosis only (e.g., leprosy) or only acne and warts; studies of one 

category of skin conditions (e.g., pigmented lesions which could have multiple diagnoses) 

were included

15. Duplicate publications; if both preliminary and final reports were published, the final data 

analysis was utilized

16. Pediatric population only (as this would not be relevant to VA population); studies involving 

both adults and children were included.

For key questions 1 and 2 we included clinical trials of teledermatology with an in-person 

dermatology control group if they provided information related to diagnostic and management 

accuracy or concordance. For key question 3, we extracted data related to patient satisfaction 

and preferences. For key question 4 we obtained articles and evaluated past reviews assessing 

cost analyses of teledermatology programs with an emphasis on studies applicable to practice in 

the United States. For key question 5 we conducted a narrative review of identifiable information 

related to structural and process elements associated with successful implementation of 

teledermatology as well as barriers to implementation framing the section around the conceptual 

model developed by Greenhalgh et al.3

Data Abstraction

Two research associates (YH, NG) extracted data on study design, patient characteristics, lesion 

type(s), intervention(s), comparison(s), and outcome(s) from each included study for questions 1 

to 4 (Appendix B – Data Extraction Form). The principal investigator verified all extracted data 

for these outcomes and also summarized data on implementation issues (question 5). Our main 

outcomes were diagnostic and management accuracy and concordance as defined in Table 1.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Table 1. Definitions of Outcomes

Outcome

 (Statistics Reported) Definition

ACCURACY

Match of TD (teledermatology) or CD (clinical dermatology) 

with Gold Standard of Histopathology or other Laboratory 

Test

	 Diagnostic Accuracy – CD

	(% Correct, Kappa statistic, 

Sensitivity/Specificity)

Match of the CD diagnosis and histopathology/other lab test

 Aggregated: Match of any of the CD diagnoses (primary or

differential diagnoses) with histopathology/lab diagnosis

 Primary: Match of the primary CD diagnosis with

histopathology/lab diagnosis

	 Diagnostic Accuracy – TD

	(% Correct, Kappa statistic,

Sensitivity/Specificity)

Match of the TD diagnosis and histopathology/ other lab test

 Aggregated: Match of any of the TD diagnoses (primary or

differential diagnoses) with histopathology/lab diagnosis

 Primary: Match of the primary TD diagnosis with

histopathology/lab diagnosis

	 Management Accuracy – CD

	 (% Correct)

Match of the CD management plan with management based on

histopathology/other lab test

	 Management Accuracy – TD

	 (% Correct)

Match of the TD management plan with management based on

histopathology/other lab test

CONCORDANCE Agreement between TD and CD 

	 Diagnostic Concordance

	 (% Agreement, Kappa statistic)

Agreement between the TD diagnosis and the CD diagnosis

 Aggregated: Agreement of any of the TD diagnoses (primary

or differential diagnoses) with any of the CD diagnoses

(primary or differential diagnoses)

 Primary: Agreement of the primary TD diagnosis with the

primary CD diagnosis

	 Management Concordance

	 (% Agreement, Kappa statistic)

Agreement between the TD management and the CD

management

Quality Assessment 

We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) instrument to

assess for study quality for studies pertaining to key questions 1 and 2.4QUADAS is the first

standardized, systematically developed, Delphi derived instrument used to assess methodological

quality of studies of diagnostic tests. The QUADAS tool includes 14 questions that assess

potential outcome bias. Items are scored as “yes,” “no,” or “uncertain” and can be grouped under

4 main domains: subject selection, index test, reference test, and data analysis. A summary score

is not a recommended final metric of quality though we arbitrarily reported on the number of

studies scored with a “yes” on at least 10 of 14 items as well the individual “yes” scores for

each of the 4 domains. We believe such reporting can assist the reader in determining potential

sources of study bias and encourage future researchers to adhere to these quality measures. Two

extractors (EW, YH) independently reviewed all studies for quality. A third investigator (TW)

resolved scoring discrepancies through review and discussion.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Data Synthesis

We reported results from each study separately for each outcome and method of outcome 

reporting (e.g., percent correct, kappa statistic, sensitivity/specificity, and concordance). Results 

were stratified according to whether the intervention was SAF or LI. We evaluated studies 

according to sample size, type of dermatological conditions studied, and whether they enrolled 

users of, and assessed outcomes in, the VA health care system. Due to considerable heterogeneity 

in study design, patient and lesion characteristics, and outcome reporting methods results 

were rarely pooled and instead displayed graphically according to teledermatology technology 

and sample size. If appropriate, weighted mean differences based on study sample sizes were 

calculated for the percentage of correct diagnoses for TD and usual care. Most pooled estimates 

were only possible using data from a subsample of eligible studies; caution is recommended in 

interpreting these pooled findings. 

Peer Review

A draft report was sent to TEP members and peer reviewers identified by VA HSR&D. 

Reviewer comments and author responses are summarized in Appendix C. 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

RESULTS

Literature flow

The OVID MEDLINE search yielded 559 references with 3 duplicates for a total of 556 unique 

references. The PubMed search yielded 587 references. When the results from these searches 

were combined, 486 duplicate references were eliminated resulting in 657 titles and abstracts 

for review. From the 657 titles and abstracts, 473 references were excluded. The full text of 

184 references was then reviewed and another 100 references were excluded. One additional 

reference (a recent publication) was added resulting in a total of 85 studies included in the report. 

Figure 1 details the exclusion criteria and the number of references related to each of the key 

questions. 

KEY QUESTION 1

1a. How does the accuracy of teledermatology compare to usual care (in-person 

dermatology) for the diagnosis of skin conditions?

1b. How does the concordance of teledermatology compare to usual care (in-person 

dermatology) for the diagnosis of skin conditions?

Summary of Studies for Key Questions 1 and 2 (Table 2 and Appendix E) 

The study design, population and study characteristics, teledermatology characteristics, outcomes 

evaluated, and the quality rating for each of the included studies are presented in Appendix E.

Description of store and forward studies 

Study design and location

Forty-one unique store and forward studies (reported in 42 publications) enrolling between 12 

and 882 subjects met inclusion criteria for Key Questions 1 and 2.5,6,7,8,9,10,11,12,13,14.15,16,17,18,19,20,2

1,22,23,24,25,26,27,28,29.30,31,32,33,34,35.36,37,38,39,40,41,42,43,44,45.46 The majority of these studies each evaluated 

fewer than 200 subjects. All studies utilized a repeated measure study design with the exception 

of one randomized, controlled trial (RCT).12 Based on location, most of the studies were 

conducted in the United States (n = 12),5,6,7,23,25,26,34,36,38,42,43,44,46 followed by the United Kingdom 

(n = 9),12,13.16,19,30,31,33,39,45 Italy, (n = 6),8,9,21,22,37,40 Spain (n = 4),10,11,14,18 Australia/New Zealand (n 

= 3),15,32,41 Turkey (n = 2),17,20 and one study each from Germany,24 Netherlands,25 Pakistan,28

Brazil,29 and Switzerland.35
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Figure 1. Reference Flow Chart 

*Search results from OVID MEDLINE (556) and PubMed (587) were combined, removing duplicate entries (486)

**Manuscript reference list includes additional references cited for background and methods plus Web sites relevant to KQ5

***Total ≠ 85; many studies addressed more than one key question

Excluded = 473 references

Not teledermatology= 278

Not English language = 59 

Comments, editorials, history, study 

descriptions only, surveys not on outcomes 

of interest, reviews, pathology, or meeting 

abstracts = 46

Technology evaluation only = 46

Case series with no, or inadequate, control 

group = 23

Pediatric subjects only = 10

Computer-aided dermatology = 6

Teledermatology for education purposes 

only =3

Teledermatology utilizing mobile phone = 2

Included studies = 84 + 1 recent 

publication = 85 references**

Pulled for full text review = 184 

references

Search results = 657 references* 

Excluded = 100 references

Comments, editorials, duplicate publications, study 

framework, surveys no on outcomes of interest, reviews, 

pathology, or meeting abstracts = 55

Not teledermatology = 24

Technology evaluation only = 8

Case series with no, or inadequate, control group = 9

Teledermatology for education purposes only = 1

Remote monitoring = 1

No outcomes of interest = 2

Q4 (costs) = 10 

references***

Q3 (outcomes) = 

26 references***

Q1/Q2 (diagnosis & management) 

= 50 references***

Q5 (implementation) 

= 13 references***
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Patient and skin condition characteristics

Five studies (six publications) involved U.S. military personnel and/or veterans.5,6,26,27,42,43 The 

study by Pak also included beneficiaries of U.S. military personnel.26,27 Fewer than half (19/41, 

46.3%) of the studies reported mean age; of those reporting, mean age was 53 years (range of 

means 28 to 71 years). Thirteen studies included subjects less than 18 years of age, in addition 

to adults.7,9,14,15,17,18,21,22,30,31,36,37,40 In 21 studies reporting gender, most of the subjects were male 

(57% overall, range 29% to 98%). Only 5 studies, all conducted in the United States, reported 

racial or ethnic characteristics.5,6,7,26,27,42 The majority of subjects in those 5 studies were 

Caucasian (93%). 

Fourteen studies included patients with a variety of skin conditions including rashes 

(e.g., papulosquamous, eczematous) as well as circumscribed lesions (isolated skin 

growths).7,12,17,20,25,26,27, 28,32,33,36,38,42,45,46 Twenty-two studies evaluated only patients with 

circumscribed lesions (suspected skin cancer and/or isolated skin growths); of these, twelve 

studies exclusively evaluated subjects with pigmented skin lesions5,9,14,18,21,22,24,30,31,35,37,40 and 

two studies enrolled only subjects with non-pigmented skin lesions.6,8 The remaining eight 

studies only included subjects with circumscribed lesions but did not specify pigmentation 

status.10,11,13,15,16,23,34,43 Five studies did not provide details on types of skin conditions 

included.19,29,39,41,44 

Description of live interactive studies

Study design and location

Ten unique live interactive, repeated measure studies enrolling between 51 and 351 subjects 

met inclusion criteria for Key Questions 1 and/or 2.7,17,47,48,49,50,51,52,43,54 Two of the studies also 

had a store and forward component.7,17 One-half of the studies were conducted in the U.S. (n 

= 5).7,49,51,52,54 Two studies were performed in the United Kingdom,48,50 and one study each was 

completed in Turkey,17 Norway,47 and New Zealand.53

Patient and skin condition characteristics

One live interactive study involved U.S. veterans.51 For the six studies reporting average 

age,7,17,47,50,52,54 the mean age (40 years; mean range 35 to 47 years) was younger and less varied 

compared to the store and forward studies. Seven studies included children or adolescent 

subjects in addition to adults.7,17,47,48,50,53,54 Three U.S. studies reported racial or ethnic 

characteristics,7,51,54 overall, the majority of subjects in these three studies were Caucasian (72%), 

although the study by Lowitt included a significant number of African-American participants 

(40%).51 Nearly all studies reported gender (n=9), with women comprising the majority of 

subjects (54%; mean range 5 to 84%). 

Nine studies included patients with a variety of skin conditions including rashes (e.g., 

papulosquamous, eczematous) as well as circumscribed lesions (isolated skin growths).7,17,47,48,49,5

0,51,53,54 One study evaluated only patients with circumscribed lesions (suspected skin cancer and/

or isolated skin growths).52 No live interactive studies focused specifically on either pigmented 

or non-pigmented lesions.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Quality assessment

Most included studies assessing accuracy and concordance (Key Questions 1 and 2) utilized 

methods to reduce sources of bias, particularly related to appropriate use of index and 

reference tests. However, the majority of studies using store and forward technology did not 

clearly address patient selection biases such as enrolling a representative spectrum of general 

dermatological patients or clearly describing exclusion criteria. Both store and forward and live 

interactive studies generally did not account for all patients at the end of the study or include 

patients with uninterpretable results (Figures 2 and 3). Among individual studies, 11 of 41 SAF 

and 3 of 10 LI publications adequately reported on least 10 of 14 quality assessment items; most 

lower quality studies failed to adequately describe or enroll a representative spectrum of patients 

or account for all originally enrolled patients in data analysis.

QUESTION 1a: Diagnostic Accuracy (Table 3, Figures 4a and 4b)

Overall Comparisons: Twenty studies (19 SAF, 1 LI) reported diagnostic accuracy defined 

as matching of teledermatology diagnosis with histopathology diagnosis or other lab test. 

Results were reported as percent match between the primary diagnosis and/or aggregated 

diagnoses (primary plus differential) and histopathology, kappa statistic, and/or sensitivity 

and specificity. Fifteen studies also reported diagnostic accuracy of usual care (in-person 

dermatology diagnoses), allowing for direct comparisons of accuracy rates between these two 

methods of care. Ten of these 15 studies found that diagnostic accuracy for usual care (in-person 

dermatology visit) was better than teledermatology,5,6,8,15,24,34,37,38,40,42 3 studies reported better 

diagnostic accuracy for teledermatology,30,35,51 and 2 reported mixed results.26,27,43 The three 

studies which reported higher diagnostic accuracy rates for teledermatology were comprised 

of smaller sample sizes (n=11,51 n=51,35 n= 13830). In the small pilot study by Lowitt51 the 

difference between accuracy rates was the result of one lesion, a difference likely due to chance. 

In the study by Braun35 involving 55 pigmented skin lesions in 51 patients, diagnoses were 

compared between six general dermatologists in private practice (usual care) with a dermatoscopic 

expert at a university pigmented skin lesion clinic (teledermatologist). The better diagnostic 

accuracy of the teledermatologist in this study was likely due to dermatoscopic expertise; the six 

general dermatologists had “different levels of experience” whereas the teledermatologist was a 

dermatoscopic expert. In the larger study by Jolliffe31 involving 144 pigmented skin lesions in 138 

patients, the same dermatologist who saw the patient in clinic (and likely followed up on biopsy 

results) served as teledermatologist (several months later), possibly resulting in recall bias. 

Pooled Comparisons: Statistical pooling of the six SAF studies reporting aggregated diagnostic 

accuracy rates found that the weighted mean absolute difference was 19% better for usual care 

than teledermatology.5,6,26,27,34,42,43 For the 11 SAF studies5,6,15,24,26,27,30,35,37,40,42,43 which reported 

primary diagnostic accuracy rates, the weighted mean absolute difference was 11% better for 

usual care than teledermatology. Similarly, the weighted mean absolute difference for primary 

diagnostic accuracy for six pigmented skin lesion studies was also better (5%) for usual care 

than teledermatology.5,24,30,35.37,40 A recent unpublished analysis of teledermatology data from 

1514 biopsied skin neoplasms found that teledermatology was significantly less accurate for 

eleven common skin neoplasms including melanoma, squamous cell carcinoma, and basal cell 

carcinoma.55
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Value of Teledermatoscopy: Four studies evaluated teledermatology with standard macro images 

and teledermatoscopy.5,6,8,14 In general, teledermatology accuracy rates improved up to 15% 

(absolute difference) with teledermatoscopy. A recent unpublished analysis found that diagnostic 

accuracy significantly improved with polarized light teledermatoscopy specifically for squamous 

cell carcinoma and basal cell carcinoma.55

Conclusion: The evidence shows that diagnostic accuracy of usual care (in-person dermatology) 

is better than teledermatology (aggregated diagnostic accuracy absolute difference 19%; 

primary diagnostic accuracy absolute difference 5% and 11%). When dermatoscopy-trained 

teledermatologists are available, teledermatoscopy may be beneficial for isolated skin lesions.

QUESTION 1b: Diagnostic Concordance (Table 4, Figures 5a, 5b, 6a and 6b)

Overall Comparisons: Thirty-seven (27 SAF; 9 LI; 1 SAF+LI) studies reported diagnostic 

concordance (simple agreement without verification by histopathology or laboratory test) 

between usual care (in-person dermatology) and teledermatology. Thirty-five studies (25 

SAF, 9 LI, 1 SF+LI) reported concordance as percent agreement for exact diagnosis (primarysee figures 5b and 6b, aggregated-see figures 5a and 6a, and/or not specified,7,45,46 malignant/

benign status,13,29,39 or diagnostic category.51 Seven studies in six publications reported kappa 

statistics7,11,18,29,52,53 and three studies reported sensitivity and specificity.13,29,39

Percent Concordance - SAF Lesion Study Results: Aggregated diagnostic agreement was 

assessed in 4 studies (Table 4, Figure 5a). Two medium-sized studies, both of which evaluated 

circumscribed skin lesions, found similar aggregated diagnostic concordance rates of 64% 

(n=10915) and 65% (n=16316). Two smaller lesion studies found higher aggregated diagnostic 

concordance rates, 90% (n=5034) and 95% (n=1043). Weighted average aggregated diagnostic 

concordance of these four lesion studies was 64.4% (230/358). Primary diagnostic concordance 

(Table 4, Figure 5b) was assessed in one pigmented lesion study40 and five skin lesion 

studies;13,15,16,34,43 concordance ranged from 48% to 91%. Weighted average for these six studies 

was 62.3% (443/708).

Percent Concordance - SAF General Study Results: Nineteen studies involving a range of 

dermatologic conditions (lesions and rashes) evaluated diagnostic concordance (Table 4, Figures 

5a and 5b). Aggregated diagnostic agreement was assessed in ten of these studies and ranged 

from 60-100%. The three highest rates were from studies in which the same dermatologist 

served as both clinic dermatologist and teledermatologist and did not appear to be blinded to 

index results (91%,26,27 96%,32 and 100%41). Excluding those three studies, the weighted average 

aggregated diagnostic agreement rate was 65.3% (703/1077). Primary diagnostic agreement was 

assessed in 14 studies and ranged from 46% to 88%. Excluding the three studies where the same 

dermatologist served as both clinic dermatologist and teledermatologist (70%,26,27 88%,32 and 

83%41), the weighted average primary diagnostic concordance rate was 66.3% (1227/1851).

Percent Concordance - LI Studies: Six LI studies reported aggregated diagnostic concordance 

rates ranging from 78 to 99% (Figure 6a); excluding three studies in which the same 

dermatologist served as both clinic dermatologist and teledermatologist for >50% of cases 

(78%,48 82%,53 82%50), the weighted average aggregated diagnostic concordance was 86.5% 

(268/310). Eight LI studies reported primary diagnostic concordance rates ranging from 57-
20

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

78% (Figure 6b); excluding three studies in which the same dermatologist served as both clinic 

dermatologist and teledermatologist (67%,48 75%,53 67%50), the weighted average primary 

diagnostic concordance rate was 70.5% (258/366).

Kappa, Sensitivity, Specificity 

SAF Studies: Kappa values ranged from 0.71 to 0.93 for the four SAF teledermatology studies 

reporting this statistic.7,11,18,29 Excluding the one study with likely bias (same dermatologist 

served as both clinic dermatologist and teledermatologist, k=0.9318), kappa values varied by 16 

points and values indicated substantial agreement (k=0.71,7 k=0.81,11 k=0.8729). Sensitivity and 

specificity was reported in three studies (utilizing the clinic dermatologist’s assessment as the 

gold standard); all three evaluated only agreement for benign or malignant status, not specific 

diagnosis. Sensitivity ranged from 0.88 to 1.0 and specificity ranged from 0.39 to 0.98. 

LI Studies: Three LI studies reported kappa values of 0.32,52 0.62,53 and 0.79.7 The study by 

Phillips52 had the lowest kappa value (k=0.32); this study employed a live interactive system 

which may not have been able to provide the detail required for the individual skin lesions 

evaluated. No LI studies evaluated sensitivity or specificity.

LI+SAF Study Results: Only one study evaluated a combination of SAF and LI 

teledermatology.17 In that study, primary diagnostic accuracy concordance was 82%, higher than 

the weighted average concordance rate of SAF studies (66.3%) and LI studies (70.5%).

Conclusion: Based on the data above, the weighted mean aggregated diagnostic concordance 

rates for SAF teledermatology were similar for lesion studies (64%) and general studies 

(65%); the rate for LI (87%) was higher, but this was based on significantly fewer patients 

(approximately 300 vs. >1,000). The weighted mean primary diagnostic concordance for SAF 

teledermatology was also similar for lesion studies (62%) and general studies (66%); the rate for 

LI studies was higher (71%) but based on fewer patients. In summary, diagnostic concordance 

of SAF is good and may be better for LI, possibly due to the ability to obtain additional history in 

the LI setting.

KEY QUESTION 2

QUESTION 2a. How does the accuracy of teledermatology compare to usual care (inperson dermatology) for clinical management of skin conditions? (Table 5)

Only two studies assessed management accuracy (expert panel consensus of management based 

on histopathologic diagnosis) of usual care and teledermatology.5,6 Both were large, utilized 

SAF teledermatology, were completed at the same VA, enrolled primarily older, Caucasian, men, 

and involved circumscribed skin lesions. In both studies, overall management was equivalent 

(defined as a ±10% difference) for usual care and teledermatology (macro images as well as 

two types of dermatoscopic images). Although the overall management accuracy rates were 

not significantly different, further unpublished analysis of this data provided by the lead author 

of this evidence report found that nine melanomas were mismanaged with teledermatology 

as compared to two with usual care, and management accuracy of usual care was superior to 

teledermatology (macro images or dermatoscopic images) not only for melanoma but also for 
21

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

basal cell carcinoma, squamous cell carcinoma, and premalignant actinic keratoses.55

Conclusion: While overall rates of management accuracy were equivalent (±10%), for malignant 

and premalignant lesions, rates for teledermatology and teledermatoscopy were inferior to 

usual care; caution is recommended when using teledermatology in these cases. Because only 

two studies reported management accuracy, these results may be difficult to generalize to other 

populations and study settings.

QUESTION 2b. How does the concordance of teledermatology compare to usual care (inperson dermatology) for clinical management of skin conditions? (Table 6, Figures 7a and 

7b)

SAF Studies: Fourteen SAF teledermatology studies reported management concordance (percent 

agreement n=13, kappa n=3, sensitivity and specificity n=2).7,9,10,12,13,15,16,23,26,31,42,43,45,46 Two studies 

evaluated concordance of the triage management decision of “refer or not refer” for pigmented 

skin lesions31 or skin lesions;13 percent concordance was 80%31 and 61%13 for these two studies 

yielding a weighted average of 75.3% (809/1075). Three studies (in four publications) evaluated 

concordance for the diagnostic procedure decision “biopsy or no biopsy” and found concordance 

rates of 100%23 and 95%43 for skin lesions (weighted average of 98.5%, 68/69) and 76% for 

a variety of skin conditions.26.27 Several studies did not describe management options but 

reported percent concordance rates of 55% to 94% (Figure 7a).7,12,15,16,45,46 Two studies evaluated 

concordance rates for three different management options; these rates were 96%9 and 72%.42

Three studies reported the following kappa statistics: k=0.69 for three management options for 

265 pigmented skin lesions in 18 patients;9 k=0.75 for planned surgical technique for 134 skin 

lesions;10 and k=0.62 for 110 skin conditions.7 Sensitivity/specificity ranged from 0.69/0.82 (refer 

or not refer31) to 1.0/1.0 (biopsy or no biopsy23).

LI Studies: Four LI teledermatology studies reported management concordance.7,48,52,56 A study 

of 107 skin lesions in 51 patients found a concordance rate of 86% (k=0.47) for the decision 

“biopsy or no biopsy.”52 Three other studies involving a wide variety of skin conditions found 

concordance rates of 64%,56 72%,48 and 75%.7 No LI studies reported sensitivity/specificity.

Conclusion: Concordance rates for management were moderate to very good for both SAF and LI 

teledermatology.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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Table 2. Summary of Study Characteristics for Teledermatology Studies (KQ1 and KQ2) 

Store and Forward (N=41) Live Interactive (N=10)

Characteristic Mean and/or 

Range

Number of 

Studies

Reporting

Mean and/or 

Range

Number of 

Studies

Reporting

Number of Subjects:

Repeated measure studies

12 to 882

(NR in 3) 40 51 to 351 10

 Randomized controlled trials (TD arm only) 92 1 NA 0

Studies involving US Military Personnel or Veterans:

 Number of subjects 129 to 728 5 102 1

Age of Subjects in Years:

 All studies, weighted mean (mean range)

53 

(28 to 71) 19

40 

(35 to 47) 6

 Studies with children/adolescents (<18 years of age) in 

addition to adults NR 13 NR 7

Gender:

 Female: mean % (mean range)

43 

(2 to 71) 21

54 

(5 to 84) 9

Race:

 Caucasian: mean % (mean range)

93 

(80 to 99) 5

72 

(60 to 85) 3

 Black: mean % (mean range) 5 

(12 to 20) 5

27 

(12 to 40) 3

 Other: mean % (mean range) 2

(<1 to 5) 5

1

(0 to 3) 3

Study Location in U.S:

 Number of subjects per study 12 to 728 12 51 to 131 5

Skin Condition Characteristics:

 Rashes and lesions

 number of subjects per study

23 to 404 14 60 to 351 9

 Lesions only

 number of subjects per study

12 to 882

(NR in 2) 22 51 1

 Pigmented lesions only 

 number of subjects per study

12 to 611

(NR in 1) 12 NA 0

 Non-pigmented lesions only

 number of subjects per study

728

(NR in 1) 2 NA 0

Outcomes Assessed:

 Diagnostic accuracy

 number of subjects per study

12 to 728 19 102 1

 Diagnostic concordance

 number of subjects per study 12 to 882 27 51 to 351 10

Management accuracy

 number of subjects per study 542 to 728 2 NA 0

Management concordance

 number of subjects per study 12 to 882 14 51 to 351 4
23

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Figure 2. 

Figure 3. 
24

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Table 3. Studies Reporting Diagnostic Accuracy using Histopathology/Lab Tests as Gold Standard (KQ1a) 

(See Appendix D for abbreviations)

Study

Diagnostic Accuracy - 

Teledermatology 

 % Correct, Kappa, or Sensitivity/Specificity

Diagnostic Accuracy - 

Usual Care

 % Correct, Kappa, or 

Sensitivity/Specificity

Mean Absolute 

Difference, 

% Correct

A. Store and forward pigmented skin lesion studies (n=10)

Warshaw 20095

VA

542 Pts

542 PSL

 Aggregated: 

 52% (282/542)

 65% (352/542) PLD

 67% (363/542) CID

Primary: 

 50% (271/542)

 47% (255/542) PLD

 57% (309/542) CID

Aggregated: 

80% (434/542)

Primary: 

59% (320/542) 

-28%

-9%

Moreno-Ramirez 200614

61 Pts

No. PSL NR

k=0.91 

(95% CI 0.82, 1.00)

k=0.94 TDSC 

(95% CI 0.88, 1.00) 

NR NA

Moreno-Ramirez 200518

No. Pts NR

57 PSL

k=0.79

(95% CI 0.70, 0.89) NR NA

Ferrara 200421

12 Pts

12 PSL

Primary: 83% (10/12) TDSC

NR NA

Piccolo 200422

73 Pts 

77 PSL

Mean Sensitivity for 11 TDs:

0.91 (SD 0.09)

 (Range 0.83-1.00)

Mean Specificity for 11 TDs:

 0.95 (SD 0.04)

 (Range 0.92-1.00)

NR NA

Coras 200324

No. Pts NR

45 PSL

Primary: 89% (40/45) TDSC

For Malignant vs. Benign:

 Sensitivity: 0.86

 Specificity: 0.92

Primary: 91% (41/45) DSC

For Malignant vs. Benign:

 Sensitivity: 0.86

 Specificity 0.96

-2%

Jolliffe 200130

138 Pts

144 PSL

Primary: 47% (68/144)

 (95% CI 39%, 55%)

TD also served as CD

Primary: 43% (63/144)

 (95% CI 35%, 51%)

TD also served as CD

4%

Braun 200035

51 Pts

55 PSL

Primary: 75% (41/55) TDSC Primary: 64% (35/55) DSC 11%

Piccolo 200037

40 Pts

43 PSL

Primary: 87% avg for 6 derms TDSC 

(range 81%-95%)

Primary: 91% (39/43) DSC -4%

Piccolo 199940

66 Pts 

66 PSL

Primary 86% (57/66) TDSC Primary 92% (61/66) DSC -6%

B. Store and forward skin lesion studies (n=6)

Warshaw 20096

VA

728 Pts

728 SL 

Aggregated: 

 56% (408/728)

 65% (473/728) PLD

Primary: 

 43% (313/728)

 47% (342/728) PLD

Aggregated: 

76% (553/728)

Primary:

56% (408/728) 

-20%

-13%
25

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Fabbrocini 20078

No. Pts NR

44 SL

k=0.44 

k=0.45 CID

k=0.52 

k=0.70 CID NA

Ferrandiz 200710

134 Pts

No. SL NR (73% NMSC)

Primary: 85% (110/130)

k=0.86 (95% CI 0.83, 0.89) NR NA

Oakley 200615

No. of Pts NR

29 SL

Primary: 71% (34/48) 

(95% CI 56, 83)

38 TDs including 6 residents

Primary: 72% (21/29) 

(95% CI 53, 87%)

5 CDs including 2 plastic 

surgeons

-1%

Barnard 200034

25 “cases”

Aggregated: 73% avg for 8TDs 

(range 54%-80%)

Aggregated: 84% -11%

Whited 199843

VA

9 SL

Aggregated average: 84%

Aggregated (2 TDs):

89% (8/9)

78% (7/9)

Primary average: 59%

Primary (2 TDs):

78% (7/9)

22% (2/9)

Aggregated: 78% (7/9)

Primary: 67% (6/7)

6%

-8%

C. Store and forward general studies (n=3)

Pak 2003 (part II)26

DoD

119 Pts

119 Conditions

Aggregated: 78% (No. NR)

Primary 19%

Aggregated: 60%

Primary: 73%

18%

-54%

Krupinski 199938

104 Pts

104 Conditions

Primary: 76% Avg for 3 TDs Primary/Aggregated: 89% Avg 

for 3 CDs

(Combo 58% Primary; 42% 

Aggregated)

-13%

Whited 199942

VA

No. Pts NR

79 Conditions

Aggregated average: 77%

Aggregated (3 TDs):

68% (95% CI 58%, 78%)

78% (95% CI 69%, 87%)

85% (95% CI 77%, 93%)

Primary average: 59%

Primary (3 TDs):

53% (95% CI 42%, 64%)

63% (95% CI 52%, 74%)

62% (95% CI 51%, 73%)

Aggregated: 85% (95% CI 77%, 

93%)

Primary: 59% (95% CI 48%, 

70%)

-8%

0

Weighted mean difference for aggregated diagnosis studies 

(range of mean differences; # studies) -19% (-28 to 18%; 6 studies)5,6,26,34,42,43

Weighted mean difference for primary diagnosis studies (range 

of mean differences; # studies) -11% (-54 to 11%; 11 studies)5,6,15,24,26,30,35,37,40,42,43

Weighted mean difference for primary diagnosis pigmented skin 

lesion studies (range of mean differences; # studies) -5% (-9 to 11%; 6 studies)5,24,30,35,37,40

D. Live interactive studies (n=1)

Lowitt 199851

VA

No. Pts NR

11 Conditions

Aggregated: 73% (8/11) Aggregated: 64% (7/11) 9%
26

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Figure 4a

Figure 4b.
27

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Table 4. Studies for Reporting Diagnostic Concordance between Teledermatology and Usual Care 

(In-Person Dermatology) (KQ1b)*

Study 

No. of subjects

No. of skin conditions

Percent concordant Kappa statistic Sensitivity and Specificity

A. Store and forward pigmented skin lesion studies (n=2)

Moreno-Ramirez 200518

108 Pts

No. PSL NR

NR k=0.93

(95% CI 0.87, 0.98)

TD = CD

NR

Piccolo 199940

66 Pts

66 PSL

Primary: 91% (60/66) DSC 

NR NR

B. Store and forward skin lesion studies (n=6)

Moreno-Ramirez 200711

882 Pts 

882 SL 

NR k=0.81 

(95% CI 0.78, 0.84)

NR

Bowns 200613

256 Pts

256 SL

Primary: 69% (159/230) agreement on 

specific diagnosis

TDSC: 75% (193/256) agreement on benign 

or malignant 

NR

TD:

Sensitivity=0.98 (95% 

CI 0.92, 0.99)

Specificity= 0.39 

(95% CI 0.32, 0.47)

TDSC: Sensitivity=0.98 

(95% CI 0.92, 0.99)

Specificity=0.43

(95% CI 0.36, 0.51) 

Oakley 200615

73 Pts

109 SL

Aggregated: 64%, No. NR

Primary: 53% (100/189) 

 (95% CI 46, 60%)

TD=38 dermatologists including residents

CD=3 dermatologists and 2 plastic surgeons

NR NR

Mahendran 200516

163 Pts

163 SL

Aggregated: 65% (106/163) 

Primary: 48% (78/163) 

 

NR NR

Barnard 200034

50 “cases”

Aggregated: 90%, No. NR (range for 8TDs 

86-96%)

Primary: 77%, No. NR (range for 8 TDs 

67%-84%)

NR NR

Whited 199843

VA

12 Pts

10 SL

2TDs - Aggregated:

 90% (9/10)

100% (10/10) 

Primary:

 80% (8/10) 

 60% (6/10)

NR NR

C. Store and forward general studies (n=19)

Edison 20087

110 Pts

110 Conditions

Primary: 73% (80/110)

(95% CI 64, 81%)

k=0.71

(95% CI 0.67, 0.76) NR

Bowns 200612

92 Pts

92 Conditions

Primary: 55% (51/92)

NR NR
28

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Baba 200517

228 Pts

242 Conditions

Primary:

 TD also served as CD: 81% (197/242)

 TD not the same as CD: 75% 

(181/242)

NR NR

Tucker 200519

75 Pts

84 Conditions

Aggregated: 68% (57/184)

Primary: 56% (47/84) NR NR

Oztas 200420

125 Pts

125 Conditions

Primary: 70% (88/125) Average of 3 TDs 

NR NR

Du Moulin 200325

106 Pts

106 Conditions

Aggregated: 63% (67/106)

Primary: 54% (57/106) NR NR

Pak 200327

DoD

404 Pts

404 Conditions

Aggregated: 91% (366/404)

Primary: 70% (283/404) 

TD also served as CD (included 

residents)

NR NR

Rashid 200328

33 Pts

33 Conditions

Aggregated: 81% (27/33) NR NR

Oliveira 200229

92 Pts

No. Conditions NR

98% (88/90) for benign vs. malignant k=0.87 Sensitivity=1.00

Specificity=0.98

Lim 200132

23 Pts

27 Conditions

Aggregated: 96%, No. NR

Primary: 88%, No. NR

TD also served as CD

NR NR

Taylor 200133

188 Pts

No. of Conditions NR 

Aggregated: 60%, No. NR

Primary: 50%, No. NR NR NR

High 200036

92 Pts

106 Conditions

Aggregated:

 85% (84/99)

 64% (49/77)

 77% (76/99)

Primary:

 70% (69/99)

 64% (49/77)

 77% (76/99)

NR NR

Krupinski 199938

308 Pts

308 Conditions

3 TDs (some also served as CD)

Primary: 

 81%, No. NR

 84%

 85%

Average of all 3: 83%

NR NR

Lewis 199939

56 Cases

93% No. NR 

(likelihood of benign vs. malignant on 1-5 

scale)

NR

Sensitivity=0.88 

Specificity=0.80

(benign vs. malignant)

Tait 199941

30 Pts

No. of Conditions NR

Aggregated: 100% (30/30)

Primary: 83% (25/30)

TD also served as CD

NR NR

Whited 199942

VA

129 Pts

168 Conditions

3 TDs - Aggregated: 

 84% (95% CI 79%, 90%)

 83% (95% CI 78%, 89%)

 95% (95% CI 92%, 98%)

Primary:

 41% (95% CI 34%, 49%)

 44% (95% CI 36%, 52%)

 52% (95% CI 45%, 60%)

Average = 46%

NR NR
29

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Kvedar 199744

No. of Pts NR

123 Conditions

2 TDs - Aggregated:

 70%

 67%

Primary:

 61%

 64%

NR NR

Lyon 199745

100 Pts

100 Conditions

93% (93/100)

TD staff; CD resident

NR NR

Zelickson 199746

29 Pts

30 Conditions

88% (53/60) 

Combination of 2-3 TDs

NR NR

D. Live interactive studies skin lesion studies (n=1)

Phillips 199852

51 Pts

107 SL

Primary: 59% (63/107) k=0.32 NR

E. Live interactive general studies (n=8)

Edison 20087

110 Pts

110 Conditions

80% (88/110)

(95% CI 73%, 88%)

k=0.79

95% CI 0.75, 0.83)

NR

Nordal 200147

112 Pts

112 Conditions

Aggregated: 86% (97/112)

Primary: 72% (81/112) NR NR

Gilmour 199848

126 Pts

155 Conditions

Aggregated: 78% (121/155)

Primary: 57% (88/155)

TD also served as CD in 51% (79/155) of 

cases 

NR NR

Lesher 199849

60 Pts

68 Conditions

Aggregated: 99% (67/68)

Primary: 78% (53/68) NR NR

Loane 199850

351 Pts

427 Conditions

Aggregated: 82% (352/427)

Primary: 67% (285/427) 

TD also served as CD in 63% (226/427) 

of cases

NR NR

Lowitt 199851

VA

102 Pts

130 Conditions

Aggregated: 80% (104/130) 

Agreement for diagnostic category

NR NR

Oakley 199753

104 Pts

135 Conditions

Aggregated: 82% (110/135)

Primary: 75% (101/135) 

TD also served as CD in 79% of cases

k=0.62 (TD not the 

same as CD)

k=0.91 (TD also 

served as CD)

NR

Phillips 199754

60 Pts

79 Conditions

Primary: 77% (61/79) NR NR

F. Live interactive and store and forward studies (n=1)

Baba 200517

228 Pts

242 Conditions

Primary: 

90% (218/242) TD also served as CD

 82% (199/242) TD not the same as CD

NR NR

*Results for staff dermatologists unless otherwise reported.
30

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Figure 5a.

Figure 5b.
31

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Figure 6a.

Figure 6b.
32

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Table 5. Studies Reporting Management Accuracy using Histopathology/Lab Tests as the Gold Standard 

(KQ2a)

Study 

TD Management Accuracy, 

% Correct

CD Management Accuracy, 

% Correct

 Absolute Mean

Difference,

% Correct

A. Store and forward studies

Warshaw 20096

VA

728 Pts

728 SL 

79% (574/728)

80% (581/728) PLD

84% (608/728)

84% (609/728) PLD

-5%

-4%

Warshaw 20095

VA

542 Pts

542 PSL

71% (383/542)

70% (380/542) PLD

74% (401/542) CID 

66% (356/542)

66% (356/542) PLD

66% (357/542) CID

5%

4%

8%

Weighted mean difference for studies (range of mean differences; No. studies) -0.6% (-5 to 5%; 2 studies)5,6

Weighted mean difference for PLD studies (range of mean differences; No. studies) -0.2% (-4 to 4%; 2 studies)5,6

B. Live interactive studies

No studies

Table 6. Studies Reporting Management Concordance between Teledermatology and Usual Care (In-Person 

Dermatology) (KQ2b)

Study Percent concordant Kappa statistic

Sensitivity and

Specificity

A. Store and forward pigmented skin lesion studies (n=2) 

Di Stefani 20079

18 Pts

465 PSL

TD1 96% TDSC

TD2 96% TDSC

Denominator: # of lesions

For 3 Management Options (Annual 

follow-up, Short term follow-up, Biopsy)

TD1 k=0.68

TD2 k=0.70 NR

Joliffe 200131

611 Pts

819 PSL

80% (652/819) 

Concordance for refer or not refer NR

Sensitivity=0.69

Specificity=0.82

Calculated on 82% 

of refer or not refer

B. Store and forward skin lesion studies (n=5) 

Ferrandiz 200710

134 SL

(73% NMSC)

NR

k=0.75

(95% CI 0.71, 0.79)

Agreement on planned 

surgical technique

NR

Bowns 200613

256 Pts

256 SL

61% (157/256) 

Concordance for refer or not refer NR NR

Mahendran 200516

163 Pts

163 SL

55% (90/163) NR NR
33

Teledermatology for Diagnosis and Management of Skin Conditions: 

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Shapiro 200423

49 Pts

49 SL

100% (49/49) 

Concordance for biopsy vs. no biopsy NR

Sensitivity=1.0

(95% CI 0.87, 1.00)

Specificity=1.0 

(95% CI 0.85, 1.00)

Whited 199843

VA

12 Pts

10 SL

TD1 100% (10/10)

TD2 90% (9/10)

Concordance for biopsy or no biopsy

NR NR

C. Store and forward general studies (n=7)

Edison 20087

110 Pts

110 Conditions

66% (73/110) 

(95% CI 58%, 75%)

k=0.62

(95% CI 0.55, 0.69) NR

Bowns 200612

92 Pts

92 Conditions

55% (51/92) NR NR

Oakley 200615

73 Pts

109 Conditions

82% (208/252) TDSC

Denominator: # of responses from up to 

38 TDs and 5 CDs, including 2 plastic 

surgeons

NR NR

Pak 200326

DoD

404 Pts

404 Conditions

76% (307/404) 

Concordance for biopsy or no biopsy

NR NR

Whited 199942

VA

129 Pts

168 Conditions Denominators for Management 

Types NR

3 TDs

Medical Therapy:

Aggregated: 71%, 75%, 80%

 Primary: 67%, 68%, 69%

Clinical Procedures:

 Aggregated: 64%, 73%, 74%

 Primary: 64%, 73%, 74%

Diagnostic Tests:

 Aggregated: 70%, 69%, 69%

 Primary: 67%, 66%, 68%

NR NR

Lyon 199745

90 Pts

90 Conditions

94% (85/90) 

CD=resident TD=staff NR NR

Zelickson 199746

29 Pts

30 Conditions

90% (54/60) 

Combination of 2-3 TDs NR NR

D. Live interactive studies (n=4)

Edison 20087

110 Pts

110 Conditions

75% (82/110) 

(95% CI 66%, 83%)

k=0.71

(95% CI 0.64, 0.78) NR

Gilmour 199848

61 Pts

61 Conditions

72% (44/61) NR NR

Loane 199856

214 Pts

252 Conditions

64% (160/252) 

TD also served as CD in 44% of cases NR NR

Phillips 199852

51 Pts

107 SL

86% (92/107)

Concordance for biopsy or no biopsy

k=0.47 

Biopsy or no biopsy NR
34

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Figure 7a.

Figure 7b.
35

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

KEY QUESTION 3

How do clinical outcomes (clinical course, satisfaction, quality of life, visits avoided) of 

teledermatology compare to usual care (in-person dermatology) for skin conditions? (Tables 7, 

8, and 9)

Clinical Outcomes: We identified three studies that reported clinical course for patients 

evaluated with either teledermatology or usual care (in-person dermatology) (Table 7).57,58,59 

Although two of the studies suggested that clinical course is more favorable following 

teledermatology, the three studies used different methods for determining clinical course and 

assessed clinical course at different time points.

Eminovic et al.57 reported a notable difference in the percentage of patients improved at one 

month after referral in the teledermatology group (20%) compared to the usual care group (4%). The 

assessment was done by a dermatologist during an in-person dermatology consultation. However, it is 

important to note that the teledermatology group was treated during the one month period, as needed, 

based on the results of the teledermatology consultation while the usual care group had yet to see a 

dermatologist. In the Pak et al.58 study involving DOD and veterans, the assessment was done for 

both groups at four months after the initial visit (either teledermatology or in-person dermatology) 

using photographic images. There was no significant difference in clinical course rating (improved, no 

change, or worse) between the two groups. Granlund et al.59 assessed outcomes at six months using 

a questionnaire. The response rate was 60%. A significantly higher percentage of teledermatology 

patients reported that their condition had resolved (63% vs. 23%, p=0.03).

Table 7. Clinical Course Outcome for Teledermatology Studies (KQ3) 

Study

Country

Number of Subjects for Clinical Course Outcome/Total Number of Subjects

Design 

Intervention Clinical Course

 Teledermatology Usual 

Care

A. Store and forward systems studies (n=2)

Eminovic 200957

Netherlands

N=369 evaluable (total N=605 pts)

RCT; general practitioners randomized to TD or UC

Clinical outcome assessed at time of CD appointment

Teledermatology group: SAF TD 

followed by CD visit at 1 month

Usual care group: referred for CD 

visit (approximately 1 month waiting time)

40/200 (20%) 

judged to not 

need CD visit 

because condition 

had improved

7/169 (4%) 

judged to not 

need CD visit because condition 

had improved

Pak 200758

United States

VA and DoD

N=508/698

Clinical outcome assessed by photographs (baseline compared to four months) 

Teledermatology group: baseline 

SAF TD with repeat imaging at 4 

months

Usual care group: CD visit (baseline) with imaging for outcome 

assessment only; repeat imaging at 

4 months 

64% improved

33% no change

4% worse

n=272

65% improved

32% no change

3% worse

n=236

(p=0.57)

B. Live interactive studies (n=1)

Granlund 200359 

Finland

N=29/48

Non-randomized; same dermatologist for TD 

and UC

Clinical outcome assessed via questionnaire at 

six months (29 of 48 pts responded)

Patients from first clinic had TD 

consultation

Patients from second clinic had CD 

consultation

Both groups: follow-up as needed 

after initial consultation

63% ”still suffer 

from disease”

63% “resolved” 

n=16

85% “still suffer 

from disease”

23% “resolved” 

n=13

(p=0.03)
36

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Patient Satisfaction: Seven SAF and four LI studies reported patient satisfaction (Table 8). 

Assessment tools ranged from a single question to surveys with over 50 items. As a result of the 

wide discrepancy in assessments used, we focused our report on overall satisfaction measures 

rather than satisfaction with specific elements of teledermatology or usual care (in-person 

dermatology). 

SAF Studies: In the four SAF studies that included both teledermatology and usual care groups, 

satisfaction ratings were comparable with a mean satisfaction rating of 3.8 out of 5,57 or greater 

than 75% of patients reporting satisfaction with both teledermatology and usual care.12,18,60 In 

the three studies with no comparison group, teledermatology was rated as “excellent” or “good” 

by 42% of the patients;61 93% reported they were “happy” with teledermatology;62,63 and at 4 to 

6 weeks after teledermatology, 64% reported they were satisfied.64 Three of the studies included 

VA or DoD populations.60,61,64

LI Studies: Four LI studies reported patient satisfaction. In the one study that included 

teledermatology and usual care groups (non-randomized), a significantly greater number of 

patients (96% vs. 83%, p=0.03) reported they were satisfied with teledermatology than with 

usual care.59 The median satisfaction rating (on a scale of 0 to 10) was also higher for the 

teledermatology group (9.6 vs. 9.0, p=0.03). Of the three studies without a comparison group, 

the reported satisfaction ratings were 44%,47 88%,65 and 92%.66 Only one of these studies was 

completed in the United States.65

Overall: Of the five studies that included both teledermatology (either SAF or LI) and usual 

care groups, patients expressed comparable levels of satisfaction in three of the studies (all of 

which were randomized, controlled trials; one included a veteran population).12,57,60 One nonrandomized study reported greater satisfaction with teledermatology.59 One repeated measures 

study reported greater satisfaction with usual care, however, the usual care patients in that 

study had already been seen via SAF teledermatology.18 Response rates for the satisfaction 

assessments ranged from 58% to 100%.

Patient Preference: Four SAF and eight LI studies reported patient preference (Table 8). A total 

of four of these studies (2 SAF, 2 LI) were conducted in the United States.

SAF Studies: With the exception of one study that reported that 76% of patients preferred 

teledermatology over waiting for a usual care appointment,12 preferences for teledermatology or 

usual care were similar. In one VA study, 42% preferred teledermatology over usual care while 

37% preferred usual care over teledermatology.60 A study from the United Kingdom reported that 

40% preferred usual care over teledermatology with 68% responded that teledermatology was 

“as good as” usual care.62,63 A DoD-based study reported that 42% preferred teledermatology and 

38% preferred usual care when asked 4 to 6 weeks after their initial appointment.64

LI Studies: In one study, patients experienced both SAF and LI sessions. Although 85% 

“accepted” SAF teledermatology, 82% of those patients felt that the LI session was also needed.17

Reported preferences for teledermatology ranged from 69%65 to 38%.47,48 Reported preferences 

for usual care ranged from 28%47 to 43%.67 In two studies, approximately one-third of the 

patients surveyed expressed no preference.47,53 In two studies, teledermatology was rated “as 

good as” usual care by 54%53 and 66%67 of patients. 
37

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Overall: Preference for teledermatology ranged from 38% to 86%. One study reported slightly 

higher satisfaction with usual care but 76% of the patients preferred teledermatology over 

waiting to see a dermatologist.12 A VA study reported that patients were more likely to respond 

“strongly agree” to statements about satisfaction with usual care and more likely to respond 

“agree” to statements about satisfaction with teledermatology yet “most” patients preferred a 

teledermatology appointment rather than driving 2 hours to see a dermatologist.51 It appears 

that other factors, such as waiting time for a in-person dermatology appointment and the need 

to travel long distances (involving both expense and time off from work), influence patient 

preference for usual care or teledermatology.

Table 8. Patient Satisfaction and Patient Preference for Teledermatology Studies (KQ3) 

Study

Country

Satisfaction Assessment 

Number of Patients for this Outcome

Preference

Patient Satisfaction

 Teledermatology Usual Care

Preference

A. Store and forward systems studies (n=7)

Eminovic 200957 

Netherlands 

RCT - GPs randomized to TD or UC

20/43 items from short-form Patient Satisfaction 

Questionnaire III (mean score, 5 point scale - 5 

indicating greatest satisfaction)

N=350/605 (57.8% response rate)

3.8 

n=191

3.8 

n=159

NR

Bowns 200612

United Kingdom

RCT

51 items from Patient Satisfaction Questionnaire 

 III plus 9 items specific to SAF 

N=147/208 (70.7% response rate)

satisfied overall: 84%

n=80

satisfied overall: 87%

n=67

(p=0.59)

preferred TD over 

waiting for UC: 76%

Moreno-Ramirez 200518

Spain, Pigmented Lesions

Repeated measure design

Question “Are you satisfied with this way of being 

attended by a specialist?”

N=219 TD; 108/219 “selected” for additional UC

very satisfied: 86%

n=219

very satisfied: 98%

n=108 (all had TD 

before UC)

NR

Whited 200460

United States; Durham, NC VAMC

RCT

Telephone Survey

 UC: Visit-Specific Satisfaction Questionnaire

 TD: Related questions plus specific TD items

 BOTH: 5 point scale (Excellent to Poor) 

N=194/275 (70.5% response rate) 

excellent or very good: 

79% 

n=101

excellent or very good: 

78%

n=93

preferred TD over 

UC: 42%

preferred UC over 

TD: 37%
38

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Weinstock 200161

United States; Togus, Maine VAMC

TD Cohort

Telephone Survey (10 questions)

 5 point scale (Excellent to Poor)

 Mean 14 months after TD (range 2.5-30.5)

N=100/148 (67.6% response rate) randomly 

selected

 from 1030 consults

excellent or good: 

42%

ability of TD to treat 

skin disease:

good/excellent 

41%

fair/poor 46%

no comparison group NR

Williams 200162,63

United Kingdom

TD Cohort

Survey of 15 items developed for SAF TD 

 5 point scale (strongly disagree to strongly 

agree) 

N=123/141 (87.2% response rate)

“happy” with TD: 

93%

no comparison group prefer UC to TD: 

40%

believed TD as good 

as UC: 68%

Pak 199964

United States, DoD

TD Cohort

Survey (details NR) at baseline and 4-6 weeks 

N=77/100 (baseline; 77% response rate)

N= 55/100 (4-6 week; 55% response rate)

baseline:

satisfied with TD: 

“most” 

4-6 weeks:

satisfied with TD: 

64%

 

no comparison group at 4-6 weeks: 

prefer UC: 38%

prefer TD to waiting for 

UC: 42%

B. Live interactive studies (n=9)

Granlund 200359

Finland

Open, non-randomized TD vs. UC

Survey of 5 questions:

 Completed after encounter and 6 months

 5 point scale (very good to very bad)

Linear analog scale of 0 to 10

 Completed after encounter and 6 months

N=48 immediately after encounter 

N=29 at 6 months 

satisfied with TD: 

96%

n=23

Linear analog scale:

Median=9.6 after 

consultation

Mean=7.4 at 6 

months

n=16

satisfied with UC: 83% 

n=25 (p=0.03)

Linear analog scale:

Median=9.0 after 

consultation

 (p=0.03)

Mean=6.6 at 6 

months 

(p>0.05)

n=13

NR

Baba 200517

Turkey

Combined SAF + LI Cohort

Questions: 

 1) Acceptance of TD or UC

 2) Need for LI in addition to SAF

N=228 

overall satisfaction NR no comparison group would accept TD: 

85% (of these, 82% 

felt LI+SAF was 

needed rather than 

just SAF)

Hicks 200365

United States

TD Cohort

Survey of 8 questions:

 Completed after each visit, >1 survey per pt

 7-point scale (very unsatisfied to very satisfied)

N=321 TD pts

very satisfied or satisfied: 88%

n=258

no comparison group felt TD much better/

better than UC: 69% 

n=255
39

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Nordal 200147

Norway

Repeated measures design

Survey of 9 items:

 4 point scale (very satisfied to unsatisfied)

N=116/121 (95.9% response rate)

very satisfied with TD: 

44% 

unsatisfied with TD: 

10%

no comparison group for a future dermatology consult:

prefer TD: 38%

prefer UC: 28% 

indifferent: 34%

general preference:

prefer TD: 18%

prefer CD: 16% 

indifferent: 66%

Lamminen 200066

Finland

TD Cohort

Survey (details NR) 

N=25

TD “excellent or 

good”: 92%

no comparison group NR

Gilmour 199848

United Kingdom

Repeated measures design

Survey of 16 items:

 5 point scale (strongly disagree to strongly 

agree)

N=122/126 (96.8% response)

overall satisfaction NR no comparison group prefer TD: 38%

prefer UC: 42%

TD as good as UC: 

43%

Lowitt 199851

United States, Baltimore VAMC

Repeated measures design

Survey of 7 items:

 4 point scale (strongly disagree to strongly 

agree) 

N=124/139 (89.2% response rate)

overall satisfaction NR overall satisfaction NR

more “strongly agree” 

responses for UC vs. 

more “agree” responses 

for TD (p=0.001)

“most” prefer TD 

close to home rather 

than UC 2 hours 

away 

Loane 199867

Northern Ireland

Repeated measures design

Survey of 15 items:

 5 point scale (strongly disagree to strongly 

agree)

N=292/334 (87.4% response rate)

overall satisfaction NR overall satisfaction NR prefer TD: 41%

prefer UC: 43%

TD as good as UC: 

66%

Oakley 199753 

New Zealand

Repeated measures design

Survey (details NR):

 5 point scale (strongly disagree to strongly 

agree)

N=98/104 (94.2% response rate)

overall satisfaction NR overall satisfaction NR TD as good as UC: 

54%

undecided: 31%

Time to Treatment: Four SAF studies and no LI studies addressed the question of time to 

treatment (Table 9). One study included both time to treatment and time to teledermatology 

results; one additional study included only time to teledermatology results.

In all four studies, the time to treatment was shorter for patients who were initially seen by 

teledermatology. Time from general practitioner consult to dermatology clinic (or opinion) 

was significantly shorter for teledermatology patients compared to usual care patients in the 

three studies that reported this outcome11,12,68 with the difference ranging from 44 days to 76.3 

days (all p<0.001). Time to biopsy was 19 days shorter (p=0.03).68 Time to surgery or definitive 

intervention was significantly shorter in the three studies that reported this outcome.10,68,69 The 

difference ranged from 21 to 86 days (all p<0.01). Two of these studies68,69 were conducted 
40

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

at VA medical centers. It is important to note that although times to treatment experienced by 

teledermatology patients in the VA studies were shorter than those for usual care patients, the 

reported times are not reflective of current VA practices; all veterans now are scheduled within 

30 days. Two studies reported time to teledermatology results. Mean times were 61.1 hours11 and 

44 hours.18

Clinic Dermatology Visits Avoided: The number of in-person dermatology visits avoided 

was reported in 11 SAF and 3 LI studies (Table 9). Two SAF studies reported the number of 

dermatology visits required. Teledermatology patients required a mean of 0.98 visits in one 

study68 and 1 visit in another study.10 In the same two studies, usual care patients required a mean 

of 1.13 or at least 2 visits, respectively.

Two SAF studies reported the percentage of patients who did not require a dermatology clinic 

visit (“preventable” visits) following teledermatology compared to usual care patients. The 

differences between groups were 20.7% (39% teledermatology vs. 18.3% usual care)57 and 28% 

(66% teledermatology vs. 38% usual care).12 Two live interactive studies reported a similar 

outcome with a difference of 14% (44% teledermatology vs. 30% usual care) in one study70 and a 

difference favoring usual care of 1% (54% teledermatology vs. 55% usual care).71

Seven additional SAF studies and one additional LI study reported visits avoided with no 

comparison group. The percentage of visits avoided ranged from 12.8% to 72%.11,16,18,33,64,66,69,72

The study that reported 12.8% clinic dermatology visits avoided also reported that 33.1% 

required clinic dermatology surgery.16

Conclusions: There was insufficient evidence to conclude whether teledermatology had an 

effect on clinical course, although a VA/DoD study with over 500 patients reported comparable 

outcomes. Patient overall satisfaction with and preference for teledermatology or usual care 

were comparable in VA/DoD and other studies. Patients noted waiting time for an appointment 

and travel time/distance as factors when considering preference. Time to treatment was 

significantly shorter and clinic dermatology visits can be avoided when patients have an initial 

teledermatology visit.
41

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Table 9. Time to Treatment and Clinic Dermatology Visits Avoided for Teledermatology Studies (KQ3) 

Study Time to Treatment (Average) CD Visits Avoided*

A. Store and forward systems studies (n=11)

Eminovic 200957

Netherlands

Cluster RCT

N=369/605

NR

CD visits “preventable” for: 

TD 39.0% (N=200)

UC 18.3% (N=169)

Difference 20.7% (95% CI 8.5, 32.9)

Hsiao 200868

United States

Retrospective review of veterans 

treated for skin cancer

N=149/169 

46% UC, 54% TD

Consult to (days):

Opinion (TD or CD): 

 TD 4 vs. UC 48 (p<0.001)

Biopsy: 

 TD 38 vs. UC 57 (p=0.034) 

Surgery: 

 TD 104 vs. UC 125 (p=0.006)

Mean number of CD visits: 

TD 0.98 vs. UC 1.13 (p=0.02) 

NOTE: 14% of TD did not require 

any CD visits prior to surgery; all UC 

required >1 visit

Ferrandiz 200710

Spain

Pilot study of SL needing regular 

surgical excision

N=226 (134 TD compared to random 

sample of 92 UC

Consult to surgery (days):

 TD 26.1 vs. UC 60.6 

(p<0.001)

TD: 1 CD visit needed

UC: > 2 CD visits needed

Difference: ≥ 1 visit

Moreno-Ramirez 200711

Spain

Repeated Measure, Historical 

Control

N=2539 (2009 TD compared to 530 

UC

Consult to CD clinic (days):

 TD 12.3 vs. UC 88.6 

(p<0.001)

Time for TD results 61.1 hrs

NOTE: N unclear for this outcome

51.2% (n=1029) of TD did not need 

CD visit 

Bowns 200612

United Kingdom

RCT

N=165/208

Consult to opinion (days):

 TD 13 (n=85) vs. UC 67 (n=72)

 p<0.0001

No follow-up visits needed: 

TD 66% vs. UC 38% 

(p=0.0003)

Knol 200672

Netherlands

N=306 intent to refer consultations

and 505 TD 

No comparison group

NR 53.3% (n=163) did not need CD 

Mahendran 200516

United Kingdom

Repeated Measure

N=163

NR

12.8% (n=21) did not need CD 

(reassurance only)

33.1% (n=54) did not need CD 

consult visit but did need CD surgery

Moreno-Ramirez 200518

Spain

Cohort, PSL

N=219 

Time for TD results 44 hrs 51% (n=111) did not need CD 

Whited 200269

United States

RCT of Veterans

N=275 (TD=135, UC=127)

Consult to definitive intervention (days, 

median):

 Intent to Treat:

 TD 41 vs. UC 127 p=0.0001

 Actual Visit:

 TD 50 vs. UC 137.5 p=0.0027

18.5% of TD did not need CD 

Taylor 200133

United Kingdom

TD Reliability Study

N=188/194 NR

31% of TD did not need CD (based 

on 376 assessments, 188 cases X 

2 consultants)

NOTE: CD diagnosis differed from 

TD diagnosis in 14% of these 

188 cases 
42

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

Pak 199964

United States

Department of Defense

Cohort, no comparison group

N=100 

NR 45% did not need CD

B. Live interactive studies (n=3)

Loane 200170

United Kingdom

RCT TD vs. UC

N=274 (126 TD, 148 UC)

NR 44% of TD and 30% of UC did not need 

follow-up visit

Wooton 200071

United Kingdom

RCT TD vs. UC

N=204 ( 102 TD, 102 UC)

NR 54% of TD and 55% of UC did not need 

follow-up visit

Lamminen 200066

Finland

Cohort, TD

N=25

NR 72% did not need follow-up visit

*Does not include TD visit(s). Number of CD visits avoided 

KEY QUESTION 4

How does the cost of teledermatology compare to usual care (in-person dermatology)? 

(Table 10)

Cost data were reported in three studies involving SAF teledermatology, six studies of LI 

teledermatology, and one study that included both SAF and LI teledermatology (Table 10). Due 

to differences in factors included in cost assessments and the various perspectives (societal, 

health service, or patient), it was difficult to summarize these findings.

SAF Studies: Whited et al.73 used a micro-costing approach with a VA perspective and found 

that teledermatology was cost-effective but not cost-saving for decreasing time to initial 

definitive dermatologic care. It was assumed that VA centers had both on-site primary care and 

dermatology clinics. Definitive care was achieved in 50 days using teledermatology compared to 

138 days with usual care. The long-duration to achieve definitive dermatologic care, particularly 

for the usual care population, is no longer consistent with current VA practice (appointments 

within 30 days) and may result in an overly favorable estimate of teledermatology. Pak et 

al.,74 based on a DoD population, reported cost savings of $32 per patient if lost productivity 

was considered. Moreno-Ramirez et al.75 reported that teledermatology was cost-effective for 

patients referred to a skin cancer clinic.

SAF and LI Study: A comparison of SAF and LI teledermatology found store and forward to be 

less expensive but less efficient clinically than live interactive teledermatology.

80 This analysis 

considered the educational benefit to general practitioners obtained during the live interactive 

sessions.

LI Studies: Six studies assessed LI versus usual care including two studies conducted in the 

United States. Studies had marked differences in design and settings. Most indicated that 
43

Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

teledermatology either cost less or was cost efficient compared to usual care, particularly if 

patients had to travel long distances or certain criteria were met for referral volume and costs.

Conclusions: Cost studies were limited by variations in parameters included and perspectives 

chosen for the analyses. The majority of studies (including both SAF and LI technologies) found 

teledermatology to be cost effective if certain critical assumptions were met; the most important 

included patient travel distance, teledermatology volume, and costs of usual care.
44

nd Management of Skin Conditions: 

ence Evidence-based Synthesis Program

ies Reporting Cost Outcomes (KQ4)

ParticipantsAge, race, genderSkin Conditions

SitesProvidersAssumptions

Cost Outcomes/Utilization Outcomes

(US$, except as noted)

 (N=3)

N=275 (135 TD, 140 UC)age: NRrace: NRgender: NRConditions: NR

On-site primary care clinic and onsite dermatology clinic Providers: primarily dermatology residentsMicro-costing approach,VA perspective 

-Average cost ($) per pt (base-case):

TD: 36.40 UC: 21.40Incremental cost per pt: 15.00 

(sensitivity analysis range: 10.50 to 15.00)

-Median time to initial definitive intervention:

TD: 50.0 days UC: 137.5 daysIncremental effectiveness: 87.5 daysIncremental cost-effectiveness ratio for TD: $0.17 per pt per

day (sensitivity analysis range: $0.12 to $0.17)

Conclusion: TD not cost-saving but was cost-effective for decreasing time to initial definitive dermatological care

r

N=698 (351 TD, 347 UC)age: NRrace: NRgender: NRConditions: NR

Military primary care and dermatology clinicsProviders: NRCost-minimization,DoD perspective

-Costs ($, average per pt) TD UC  Total Direct 103,043 (294) 98,365 (283) Lost Productivity 16,359 (47) 30,768 (89) Total Cost 119,402 (340) 129,133 (372)Conclusion: TD cost-saving, if lost productivity is considered



N=4018 (2009 TD, 2009 UC)age: NRrace: NRgender: NRConditions: suspected skin cancer

12 primary care clinics/ 1 central skin cancer clinicProviders: NRSocietal perspective

-Waiting interval for skin cancer clinic:

TD: 12.3 days UC: 88.6 daysIncremental effectiveness 76.3 days

-Unit cost ($) per pt: 

TD: 119.67 UC: 194.06 (p<0.005)Incremental cost savings of TD $74.39

-Cost-effectiveness: $0.98 saved per waiting day avoided by TDConclusion: SAF TD is cost-effective for referrals to skin cancer clinic
45

nd Management of Skin Conditions: 

ence Evidence-based Synthesis Program

ive (N=1)

N=96 /102 randomized to TD (see Wootton 2000)age: mean=38.9 years race: NRgender: 47% maleConditions: Most common - eczema, psoriasis, acne, and tumors

4 primary care centers (2 rural, 2 urban) and 2 dermatology centersProviders: 2 dermatologists (1 for SAF and 1 for LI) 

-Dermatologist consultation time (mean):

SAF: 1.6 min LI: 15.7 min

-Total pt time (wait, consult, travel) (mean):

SAF: 41.5 min LI: 52.2 min

-Variable costs per pt SAF LI Dermatologist £4.00 £39.25 GP £9.50 £29.83 Pt time off work £4.76 £5.99 Pt travel (all local) £1.89 £1.89 Total £20.15 £76.96-Fixed costs SAF: £6.75 LI: £124.92-Savings with LI (20% non-referral savings): £9.74-Benefits with LI (GP training): £60.04-Net societal costs SAF: £29.90 LI: £132.10Conclusion: SAF cheaper, but less clinically efficient, than LI

6)

N=87 (119 visits)age: NRrace: NRgender: NRConditions: dermatitis, infectious, acneiform, papulosquamous, tumors

2 rural primary care centers and university dermatology clinicProviders: 1 dermatologist

-Total Costs $ (per Pt) Primary care* TD  Provider 8,848 (102) 5,236 (60) Diagnostic evaluation 9,367 (108) 3,031 (35) Medication 7,388 (85) 3,969 (46) Total 25,603 (294) 12,236 (141) *cost of care for pt prior to TD consultationConclusion: TD can decrease costs of dermatological care

N=169/204 (102 TD, 102 UC)age: mean=38.6 yrsrace: NRgender: 42% maleConditions: NR

4 primary care centers (2 rural, 2 urban) and 2 dermatology centersProviders: NR

-Costs per Pt TD UC Variable costs £76.96 £48.73 Fixed costs £124.92 £0.00  Savings £9.74 £0.00 Benefits £60.04 £0.00  Net societal cost £132.10 £48.73Conclusion: TD not cost-effective in setting evaluated (average distance to dermatology clinic 26km); TD would be cost- effective if distance >78km 
46

nd Management of Skin Conditions: 

ence Evidence-based Synthesis Program

N=203 (109 TD, 94 UC) age: mean=41 yrs  (14% minors/in school)race: NRgender: 48% maleConditions: NR

2 rural primary care centers and 1 dermatology departmentProviders: NRSocietal perspective

-Costs ($): TD UC  Fixed Costs 7974.05 0.00 Variable Costs 7481.45 13,536.60 Total 15,455.50 13,536.60 Unit Cost 125.65 127.71 Conclusion: From societal perspective, TD more cost-efficient than UC 

N=375 TD pts (actual workload for 1 yr) age: NRrace: NRgender: NRConditions: NR

1 primary care clinic and 1 central dermatology clinicProviders: NRAssumed health outcomes for TD = UC Societal and health-care sector perspective

-Fixed Costs ($)

TD: 43,866.35 Pt Travel/Visiting: 35,052.60 Pt Travel: 0 Local Dermatologist: 105,452.60

-Variable Costs ($) per Pt

TD: 21.12 Pt Travel/Visiting: 66.33 for 1st 240 pts* Pt Travel: 479.60 Local Dermatologist: 0*Maximum workload for visiting dermatologist - 240 pts;

remaining pts travel to clinic at cost of $339.90 per ptConclusion: TD was less costly than the three alternatives if >195 pts per year

N=274 pts (126 TD, 148 UC)254/413 (62%) questionnaires completedage: mean=39.7 yearsrace: NRgender: 44% maleTD pts: 61% urban, 39% ruralUC pts: 71% urban, 29% ruralConditions: NR

1 urban and 1 rural primary care clinic and 1 dermatology departmentProviders: General practitioners and dermatologistsHealth service and pt perspectives

-Total Costs/Benefits($): Urban Rural

TD UC TD UC

 Variable 7025 7226 4747 3062  Fixed 10527 0 8605 0

Total 17552 7226 13352 3062

 Savings 1084 0 459 0 Societal* 16468 7226 12893 3062 Marginal** 77 69 88 71 Unit*** 214 69 263 71 *(Fixed+Variable)-(Savings)  **(Variable-Savings)/(#Pts) ***(Societal)/(#Pts)Conclusion: Overall, total costs higher for TD than UC Sensitivity analysis found that for rural areas, TD costs < UC
47

nd Management of Skin Conditions: 

ence Evidence-based Synthesis Program

N=451 TD visits (301 new, 150 followup) and 47,434 UC visitsage: NRrace: NRgender: NRConditions: Top 5 conditions: actinic keratosis, eczema, acne, benign neoplasm, viral infection

1 Primary care center and 1 dermatology clinicProviders: 1 nurse practitioner (trained in dermatologic procedures); 1 dermatologistProvider perspective; cost-minimization 

-Costs ($) per hour TD UC TD equipment 4.75 0.00 Facility and personnel 143.88 193.04 Physician compensation 125.00 153.00 Total 273.63 346.04 Conclusion: Hourly costs higher for UC than TDOne-way Sensitivity Analyses found TD = UC costs if:

a. technology cost $44/hr b. physician compensation was $197/hrc. clinic space cost was $57/hr (rather than $12.50-TD 

and $100-UC) Reimbursement for TD: per visit=$122, per hour=$487

 and chronic dermatitis. 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

KEY QUESTION 5

What are the key structural and process elements associated with successful implementation of 

teledermatology and what are the barriers? (Table 11)

As summarized above, most research in teledermatology has focused on the accuracy and 

reliability to diagnose and manage skin conditions in a research setting. However, lessons 

learned from mature, functioning teledermatology systems include “...that the successful 

implementation of teledermatology as a routine service requires understanding of and paying 

great attention to the interplay between social and technical aspects of teledermatology.”81 Finch 

and colleagues conducted a longitudinal qualitative study based on in-depth semi-structured 

interviews of dermatologists, nurses, administrators, patient advocates, primary care providers 

and technologists in 12 teledermatology services in the UK and concluded that “the original...

vision of how teledermatology would be utilized, as a technological fix for long waiting lists and 

consultant shortages, failed to be realized.”82

Several publications have described key elements for successful implementation of 

teledermatology.83,84,85,86,87,88,89 We summarized these recommendations in Table 11. We attempted 

to categorize success facilitators using the definitions of Greenhalgh et al.3 We categorized 

implementation barriers according to administrative, clinical, patient and technical factors. We 

emphasized factors likely to play a role in VA specific settings. Detailed information on specific 

equipment, training in photography, and computerized medical record applications are beyond the 

scope of this review and are available on the World Wide Web.90,91,92 Because store and forward is 

the method used almost exclusively for dermatology in the VA system (informal survey December, 

2009), we focused on this form of teledermatology in this section. Readers interested in lessons 

learned from live interactive teledermatology programs are referred to Oakley et al.1 The following 

summary of key elements of facilitators and barriers to implementation are based on a review of the 

literature and the authors’ experience with teledermatology within the VA. 

Evaluate the Implementation Setting:

Prior to implementing a teledermatology program, a thorough evaluation of organizational 

issues for the specific VA setting is critical. Most Veterans Integrated Service Networks (VISNs) 

have at least one larger medical center with dermatology services whereas smaller VAMCs 

and Community Based Outpatient Clinics (CBOCs) usually do not have on-site dermatology 

services. There are three likely scenarios for implementing teledermatology in a VA setting:

Intrasite Service: Teledermatology services for a site which already has an onsite VA 

dermatology service. The main purpose of this type of service is usually triaging dermatology 

consults.

Intersite Service: Teledermatology services for a site which has no onsite VA dermatology 

services but a VA with a dermatology clinic is within reasonable driving distance. 

New Service: Teledermatology services for a site which has no VA dermatology services. In this 

scenario, dermatology services are usually either provided by community dermatologists (fee 

basis or contract), by other VA specialties (surgery, ophthalmology, plastics, infectious diseases, 

etc), or by primary care without specialty support.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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Define Objectives:

The objectives for these three VA scenarios may be very different. As described by Pak,83

common objectives of teledermatology programs include: to improve access to dermatology, 

to optimize dermatology resources, to reduce dermatology costs, and/or to improve quality of 

health care (including educating primary care physicians). Identifying specific objectives will 

help determine the type of teledermatology service best suited for the program’s goals. Because 

new systems require significant effort, it is crucial that key players (dermatologists, primary care 

providers, and administrators) perceive that the benefits outweigh the effort and commitment to 

learning a new system. In the framework of Rogers2 this would be considered determining the 

relative advantage of teledermatology versus existing services.

Understand Organizational Issues:

Understanding how the VISN or specific medical center delivers dermatological care is 

important. This is consistent with the Greenhalgh et al.3 recommendation that implementation 

of teledermatology must be compatible with medical center’s existing values, behaviors and 

past experiences. Lessons learned from teledermatology in the United Kingdom include that 

teledermatology is “not a quick nor simple fix for long waiting times in dermatology.”82 Revenue 

models for Intrasite and Intersite situations are relatively simple as the main dermatology 

service already provides dermatology care. In these situations, the main goal is often to decrease 

waiting times and eliminate unnecessary visits to the dermatology clinic; physician workload 

generally remains stable for dermatology but may increase for primary care. For the New Service 

scenario, workload for both the dermatology hub site and remote primary care site increase. In 

this situation, fee basis/consultation costs for the remote site generally decrease; if the two sites 

have different operating budgets, there will need to be some type of transfer of funds to support 

the extra workload by the dermatology service. It is also important to realize that not all skin 

conditions are treatable via teledermatology, so some fee basis/consultation by the referring 

site to community dermatologists will continue in the New Service scenario and therefore, it is 

unlikely that these costs will be completely eliminated.

Evaluate and Provide Required Resources: 

It is important to evaluate the resources (primary care, dermatology, and other specialty 

resources) at each site. For the Intrasite and Intersite situations, resources are usually a minor 

concern because any services not available in primary care are usually available in dermatology, 

which is either on site (Intrasite) or within driving distance (Intersite). There may be some 

simple resources needed in primary care (e.g., liquid nitrogen for treatment of warts and actinic 

keratoses) that will enhance management of common skin conditions in primary care without 

requiring a dermatology visit. If these additional resources are not created, teledermatology 

will simply function as a triage tool, eliminating only consultations for straightforward 

benign growths or treatment for simple skin rashes.73 For the New Service scenario and the 

Intersite scenario, additional manpower will be needed for follow-up of teledermatology 

recommendations at the referring site. Often this is a primary care physician, physician assistant, 

or nurse practitioner who serves as a “local dermatology champion,” someone who is willing 

to perform skin biopsies, microscopic examinations for fungus, bacteria and scabies, and other 

relatively minor procedures. If this creates extra workload for that individual, it is important that 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

this be recognized, and if needed, adjustments made to their schedule. Because approximately 

50% of VA dermatology visits are related to skin neoplasms, it is important to identify surgical 

specialties at the referring site for excisions of biopsy-proven skin cancers (e.g., ophthalmology, 

plastics, general surgery, ear/nose/throat). A key component is whether the implementation 

scenarios developed are of relatively low complexity and easy to understand and use for both the 

dermatology and the referring primary care services. In an informal survey of VA dermatology 

service chiefs in December 2009, three sites volunteered information regarding reasons why 

they discontinued providing teledermatology services which included that teledermatology: 

was an ineffective use of physician time, resulted in suboptimal images, and that most patients 

ultimately needed to come to the dermatology clinic (unpublished).

Conduct Cost Analysis and Assess Alternatives to Teledermatology

One of the most common mistakes in planning teledermatology programs is to focus primarily on 

the cost of teledermatology equipment. Store and forward teledermatology equipment generally 

consists of an off-the-shelf, moderate quality digital camera. Personnel, not equipment costs, are 

the most important costs in a teledermatology program and all alternatives to teledermatology 

should be explored. In the New Service scenario, the major alternative is outsourcing (fee 

basis, consultation). Other common options include hiring a part-time dermatologist or a 

physician extender with dermatology training. Cost comparisons of teledermatology with 

these alternatives should include evaluation of the number of consults, number of dermatology 

visits typically required per patient, average cost per consultation, and the types of services 

typically provided by community dermatologists. For example, if the major services provided 

by community dermatologists are procedures, teledermatology is unlikely to yield cost savings 

because these procedures cannot be performed remotely unless a VA provider is hired or trained 

to perform these procedures.

Prepare a Business Model

The business model needs to incorporate support at the remote site for both obtaining and 

uploading photographs and dermatologic-specific medical history and for follow-up of 

teledermatology recommendations. This “teledermatology technician” is often a nurse 

practitioner, physician assistant, nurse, or other medical personnel. While one study found 

that it took an average of 12 minutes for a primary care physician to take pictures, upload the 

images, and subsequently implement advice,93 for consistency of photo quality and efficiency 

of physician time, we do not advocate that primary care physicians function as imagers and/

or technicians. Collins and colleagues94 collected data from 36 general practitioners (who were 

responsible for obtaining photographs and uploading information) participating in a randomized 

controlled trial of SAF teledermatology in the United Kingdom; 47% stated that they were not 

satisfied with teledermatology (21% were satisfied and 32% were unsure) and 50% identified 

increased workload as a key problem. In his review of teledermatology in the military, Pak 

stated that “teledermatology has not been embraced by primary care providers because it 

requires additional resources at the referring site (although less total resources for the higher 

organization). Most clinics were short on personnel and primary care providers did not have time 

to take photos.”85 Implementation is more likely to succeed if the teledermatology technician 

is not the referring provider and has flexible duties so that he/she is available to perform 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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teledermatology services when needed so that the patient does not have to return for imaging. 

Alternatively, patients can be scheduled at a later time into a teledermatology clinic at the remote 

site for imaging by the teledermatology technician.

A process for follow-up of teledermatology patients is also critical. In some situations, the 

teledermatology technician also serves as a coordinator, notifying patients of teledermatology 

recommendations, coordinating medication recommendations, suggested procedures and 

appropriate follow-up visits. In all three scenarios (Intersite, Intrasite, and New Service), 

teledermatology involves a shift from a dermatology referral model to a co-managed/consult 

model and more workload for primary care providers. Unless support for this increased 

workload is provided, the system is likely to fail. 

Obtain Organizational Support

It is important to obtain support from key opinion leaders at both the referring site and the 

dermatology site. Medical center leadership, primary care, surgical subspecialties, dermatology, 

and pharmacy are important. If the referring site does not perceive a need for teledermatology, 

there will be minimal incentive to allocate space and resources. For the Intersite and New 

Service scenarios, the remote pharmacy may need to stock additional dermatology-specific 

medications and create quick pharmacy orders in the VA Computerized Patient Record System 

(CPRS). “Marketing” teledermatology to both dermatologists and primary care providers also 

requires creativity. As emphasized above, if workload increases for either or both services, 

incentives and support are critical for success. Benefits to primary care providers are often 

greatest in the New Service scenario. Providing education and quick consultative services to rural 

primary care physicians can be important motivators. Dermatologists and primary care providers 

must be involved in program planning from the outset to provide insight on the business model 

and workflow issues. It is also important to incorporate teledermatology into regular clinic 

procedures. For example, one teledermatology program failed, in part, simply because it took 

the dermatologist 15 minutes each way to walk to the telemedicine area.86

Provide Teledermatology Specific Training

The teledermatologist often provides hands on training for the teledermatology technician. 

Several helpful resources are available on dermatology-specific photography and recommended 

medical histories for teledermatology.83,90,91,92 It is ideal if the teledermatology technician and 

local dermatology champion learn basic dermatology terminology, common skin conditions, 

and criteria for appropriate teledermatology consults. Periodic refresher training should also be 

included.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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Table 11. Key Elements for Success and Barriers to Implementation 

Facilitators for Implementation 

Determine Relative Advantage

Define objectives

Evaluate alternatives to teledermatology

Clarify if relative risk of implementation is manageable

Conduct initial cost analysis and estimate

Assess Compatibility

Involve all parties in the planning and implementation process 

Understand organization layout

Obtain buy-in from key players 

Research resources available (primary care, specialty care, community)

Design Low Complexity System

Create easy to use system

Provide onsite technology support 

Provide support at referring site (technician/consult manager)

Provide support for additional workload at dermatology site 

Incorporate teledermatology into usual processes 

Minimize patient waiting time

Ensure Trialability

Reconceptualize professional roles/duties and ensure high levels of flexibility

Provide training and feedback for teledermatology technician/consult manager

Analyze business process and refine

Demonstrate Observability

Determine if objectives are met, disseminate findings and evaluate improvement steps 

Barriers to Implementation

Administrative:

Lack of initial administrative support 

Lack of ongoing support 

Clinical:

Insufficient training of primary care and dermatology in use of teledermatology

Single person trained who may not be available

Inertia among potential users (patients, primary care, dermatology) 

Increased workload for primary care and dermatology without additional support

Lack of clinical follow-up

System does not fit objectives of the site

Emphasis on technology rather than practical implementation and ongoing support

Patient:

Patient inconvenience

Lack of education of participants (patients and providers)

Patient preference to see “in-person” dermatologist

Technical:

Software problems

Purchase of general teledermatology equipment rather than standard digital camera

Poor photo quality

Lack of standardization
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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SUMMARY AND DISCUSSION

This report summarizes a large body of evidence regarding: 1) teledermatology for the 

diagnosis of skin conditions, 2) teledermatology for the management of skin conditions, 3) 

clinical outcomes when teledermatology is used 4) the cost of teledermatology, and 5) key 

elements of and barriers to successful implementation of teledermatology. Differences in study 

settings, skin conditions, trial methodology, and outcomes weaken the strength of the evidence. 

When appropriate, we calculated weighted pooled estimates for similar studies. Summarized 

evidence indicates that diagnostic accuracy of usual care (in-person dermatology visit) is 

5 to 19% (average absolute difference) better than teledermatology. When dermatoscopytrained teledermatologists are available, teledermatoscopy improves diagnostic accuracy of 

circumscribed skin lesions, although generally not to a level exceeding usual care. We found 

that diagnostic and management concordance of usual care (in-person dermatology visit) and 

teledermatology is good for SAF and may be better for LI, likely due to the ability to obtain 

additional history in the LI setting. Limited data from two SAF studies, both from the same 

VA medical center, show that while overall management accuracy rates are equivalent for SF 

teledermatology and usual care, teledermatology is significantly less accurate for malignant skin 

lesions including squamous cell carcinoma, basal cell carcinoma, and melanoma. While this 

finding needs to be confirmed in other settings and in other study populations, awareness of this 

potential limitation of teledermatology in a VA population is important. 

Our search found very little evidence on clinical course, an important limitation also noted 

in a 2006 report from the Agency for Healthcare Research and Quality (AHRQ).95 Studies 

evaluating visits avoided uniformly showed that teledermatology can decrease the number of 

dermatology clinic visits. While studies of patient satisfaction were generally positive, factors 

such as distance to the dermatology clinic and wait times for an in-person appointment play 

important roles in patient satisfaction. Cost analyses were limited by broad variations in cost 

assessment parameters and perspectives. The majority of studies found teledermatology to be 

cost effective if certain critical assumptions were met; the most important included patient travel 

distance, teledermatology volume, and costs of usual care.

While evaluation of accuracy and reliability of a new technology is important, many more 

factors become important in evaluating clinical outcomes. Especially for SAF teledermatology, 

if recommendations are not communicated to the patient or not implemented by the referring 

provider, patient outcome is likely to be poor, despite a highly accurate and reliable technology. 

Because teledermatology involves a shift in workload, ongoing support (i.e., funding for a 

teledermatology technician, training for primary care physicians, additional dermatology staff) 

is critical. Barriers to implementation and key factors for success are highly dependent on the 

intended setting. Identifying site-specific barriers is critical to successful implementation.

Conclusions

In general, diagnostic accuracy of usual care (in-person dermatology care) is better than SAF 

teledermatology. Both SAF as well as LI teledermatology appear to have acceptable diagnostic 

and concordance compared to clinic dermatology. SAF is currently more widely used in the VA. 

Little information exists on the impact of teledermatology on clinical outcomes and management 

compared to management provided by in clinic dermatologists. This may be particularly 
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Teledermatology for Diagnosis and Management of Skin Conditions: 

A Systematic Review of the Evidence Evidence-based Synthesis Program

important for dermatologic conditions with potentially serious outcomes (e.g., malignant and 

premalignant lesions). Patient satisfaction with teledermatology is relatively high though there 

are individuals who have strong beliefs for a particular approach and little information exists 

from non-research settings regarding patient satisfaction. Cost analysis studies are limited in 

number and relevance to current VA practice. Identifying and removing barriers to successful 

implementation is essential. Studies are needed to compare teledermatology with primary care 

to inform decision making about the best way to provide dermatology in areas without reliable 

access to in-person dermatology (e.g., rural areas). Given the results of this review, the potential 

benefits of teledermatology (e.g., decreased patient travel, shorter time to intervention, primary 

care provider education) need to be evaluated in the context of its limitations including inferior 

diagnostic accuracy and management accuracy, especially for malignant skin neoplasms.

Future Research Recommendations

Additional research is needed to determine the long-term effectiveness, feasibility, satisfaction, 

and cost-effectiveness of teledermatology (especially store and forward methodologies) 

integrated into primary care settings with outcomes related to the impact of teledermatology on 

patient management and clinical outcomes. Standardized reporting of diagnostic, management, 

and outcome accuracy and concordance are needed. Future studies should attempt to distinguish 

between lack of concordance between two in-person dermatologists and lack of concordance 

between teledermatology and in-person dermatology. Studies that blind assessors to the patient/

lesion are preferred to reduce bias in outcome assessment. Additional outcomes could assess 

the impact on primary care practice, referring provider satisfaction, and follow-up patterns. 

Barriers to successful implementation need to be identified that incorporate differences in 

patient populations, lesion severity, and acuteness; distance traveled and availability of local 

dermatologists; and other clinical setting issues in order to determine the relative feasibility and 

effectiveness of different teledermatology strategies in different settings (e.g., Intrasite, Intersite, 

New Site). 

Importantly, while this review suggests that diagnostic accuracy of teledermatology is inferior 

to in-person dermatologic care, teledermatology may still be superior to dermatologic care 

provided by a non-dermatologist; studies are needed to compare teledermatology with primary 

care. Additional research is needed to determine the long-term outcomes and cost-effectiveness 

of teledermatology (especially store and forward methodology) in the VA setting. We are aware 

of one randomized controlled study in progress (Impact of Teledermatology on Health Services 

Outcomes in the VA HSRD IIR05-278, PI John Whited) which will assess quality of life and 

nine-month clinical course outcomes in two VA SAF teledermatology programs. 

We recommend prioritizing studies which address the following outcomes:

1. Comparison of teledermatology with dermatologic care by a VA primary care provider or 

a dermatology trained nurse practitioner: This study setting is very relevant to remote/

inaccessible locations where no in-person dermatologist is available (e.g., Hawaii, Alaska, 

remote rural clinics). Relevant outcomes include diagnostic accuracy and concordance, 

management accuracy and concordance, long-term outcomes, cost-effectiveness, and patient/

provider satisfaction.
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Teledermatology for Diagnosis and Management of Skin Conditions: 

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2. Comparison of teledermatology with in-person care by a dermatologist in a VA setting: 

Long-term clinical outcomes, patient and provider satisfaction, and cost analyses are needed. 

Additional outcomes should assess the impact of teledermatology on primary care practice 

and follow-up patterns. Barriers to successful implementation need to be identified that 

incorporate differences in patient populations, skin condition severity and acuteness, distance 

traveled, and availability of on-site dermatologists.

3. Comparison of specific imaging techniques to enhance teledermatology accuracy: More 

research is needed to understand the limitations of teledermatology (e.g., malignant skin 

neoplasms) and whether specific techniques (e.g., polarized light dermatoscopy, contact 

immersion dermatoscopy, and confocal microscopy) can overcome these limitations.

4. Evaluation of teledermatology to provide follow-up dermatologic care: Clinical outcomes, 

feasibility, and cost analyses are needed to evaluate chronic skin conditions which require 

frequent monitoring such as leg ulcers, post-operative wound care, and chronic dermatitis. 
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