The Africa Teledermatology Project: A retrospective case review of 1229 consultations from sub-Saharan Africa

The NLR SkinApp: Testing a Supporting mHealth Tool for Frontline Health Workers Performing Skin Screening in Ethiopia and Tanzania

Background: The prevalence of skin diseases such as leprosy, and limited dermatological knowledge among frontline health workers (FHWs) in rural areas of Sub-Saharan Africa, led to the development of the NLR SkinApp: a mobile application (app) that supports FHWs to promptly diagnose and treat, or suspect and refer patients with skin diseases. The app includes common skin diseases, neglected tropical skin diseases (skin NTDs) such as leprosy, and HIV/AIDS-related skin conditions. This study aimed to test the supporting role of the NLR SkinApp by examining the diagnostic accuracy of its third edition. Methods: A cross-sectional study was conducted in East Hararghe, Ethiopia, as well as the Mwanza and Morogoro region, Tanzania, in 2018-2019. Diagnostic accuracy was measured against a diagnosis confirmed by two dermatologists/dermatological medical experts (reference standard) in terms of sensitivity, specificity, positive predictive value, and negative predictive value. The potential negative effect of an incorrect management recommendation was expressed on a scale of one to four. Results: A total of 443 patients with suspected skin conditions were included. The FHWs using the NLR SkinApp diagnosed 45% of the patients accurately. The values of the sensitivity of the FHWs using the NLR SkinApp in determining the correct diagnosis ranged from 23% for HIV/AIDS-related skin conditions to 76.9% for eczema, and the specificity from 69.6% for eczema to 99.3% for tinea capitis/corporis. The inter-rater reliability among the FHWs for the diagnoses made, expressed as the percent agreement, was 58% compared to 96% among the dermatologists. Of the management recommendations given on the basis of incorrect diagnoses, around one-third could have a potential negative effect. Conclusions: The results for diagnosing eczema are encouraging, demonstrating the potential contribution of the NLR SkinApp to dermatological and leprosy care by FHWs. Further studies with a bigger sample size and comparing FHWs with and without using the NLR SkinApp are needed to obtain a better understanding of the added value of the NLR SkinApp as a mobile health (mHealth) tool in supporting FHWs to diagnose and treat skin diseases.

An mHealth App (eSkinHealth) for Detecting and Managing Skin Diseases in Resource-Limited Settings: Mixed Methods Pilot Study

BACKGROUND

In sub-Saharan Africa, the disease burden from skin diseases, including skin-related neglected tropical diseases (skin NTDs), is extremely high. These diseases often are overlooked due to limited access to health care stemming from, for example, remote geographical locations and a lack of experts. To address these gaps, we developed a mobile health app, eSkinHealth, which is a field-adapted platform to serve as a portable electronic patient chart and for teledermatology.

OBJECTIVE

The purpose of the study is to evaluate the usability and effectiveness of the app in rural Côte d'Ivoire for diagnosing and managing skin NTDs and other skin diseases.

METHODS

A 2-arm trial with local health care providers and patients with skin diseases was implemented over a 3-month period. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and 8 community health care workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, we evaluated our approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, our primary outcome was to evaluate the detection and management of 5 skin NTDs as our targeted diseases, namely, Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws, using the eSkinHealth app. Procedures of our methods were reviewed and approved by the institutional review board of the Ministry of Health and by Tulane University.

RESULTS

The mean age of our participants (providers) was 40.5 and 42.5 years for the intervention and control arms, respectively, and all were male (n=24). The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (SD 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including 4 dermatologists and program managers, were satisfied with the app. Especially community health care workers felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (P=.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (P<.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a "dermatosis." In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists.

CONCLUSIONS

The study provided evidence for the usability and effectiveness of the eSkinHealth app embedded into our surveillance approach to improve the detection and management of skin NTDs and other skin diseases in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin diseases in resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/NCT05300399.

Teledermatology in medical student, postgraduate trainee, and global dermatology education: A systematic review

Background

In the aftermath of the COVID-19 pandemic, medical students and residents in the U.S. and globally have gained more exposure to teledermatology, both for the purposes of clinical practice and education.

Objective

We conducted a systematic review to assess outcomes from teledermatology interventions for dermatology trainees in the U.S. and globally in accordance with Preferred Reporting Items for Systematic Reviews (PRISMA).

Methods

We searched MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL for articles written in English and published database inception to November 20, 2022.

Results

In total, 15 studies met the inclusion criteria. Outcomes reported ranged broadly from resident-provider concordance rates, diagnostic accuracy in comparison to control groups, number of patients seen, and self-reported satisfaction and improvement. Generally, studies indicated high satisfaction rates and improvement in educational outcomes among medical students, residents, and other trainees in the global health setting.

Limitations

Because of the heterogeneity of study design and outcomes reported, meta-analysis could not be performed.

Conclusion

Teledermatology can be successfully deployed for clinical care and education domestically and in the global health setting.

mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe

Background

mHealth can help with healthcare service delivery for various health issues, but there's a significant gap in the availability and use of mHealth systems between sub-Saharan Africa and Europe, despite the ongoing digitalization of the global healthcare system.

Objective

This work aims to compare and investigate the use and availability of mHealth systems in sub-Saharan Africa and Europe, and identify gaps in current mHealth development and implementation in both regions.

Methods

The study adhered to the PRISMA 2020 guidelines for article search and selection to ensure an unbiased comparison between sub-Saharan Africa and Europe. Four databases (Scopus, Web of Science, IEEE Xplore, and PubMed) were used, and articles were evaluated based on predetermined criteria. Details on the mHealth system type, goal, patient type, health concern, and development stage were collected and recorded in a Microsoft Excel worksheet.

Results

The search query produced 1020 articles for sub-Saharan Africa and 2477 articles for Europe. After screening for eligibility, 86 articles for sub-Saharan Africa and 297 articles for Europe were included. To minimize bias, two reviewers conducted the article screening and data retrieval. Sub-Saharan Africa used SMS and call-based mHealth methods for consultation and diagnosis, mainly for young patients such as children and mothers, and for issues such as HIV, pregnancy, childbirth, and child care. Europe relied more on apps, sensors, and wearables for monitoring, with the elderly as the most common patient group, and the most common health issues being cardiovascular disease and heart failure.

Conclusion

Wearable technology and external sensors are heavily used in Europe, whereas they are seldom used in sub-Saharan Africa. More efforts should be made to use the mHealth system to improve health outcomes in both regions, incorporating more cutting-edge technologies like wearables internal and external sensors. Undertaking context-based studies, identifying determinants of mHealth systems use, and considering these determinants during mHealth system design could enhance mHealth availability and utilization.

A Call to Action: Evidence for the Military Integration of Teledermoscopy in a Pandemic Era

Skin disease remains a common complaint among deployed service members. To mitigate the limited supply of dermatologists in the U.S. Military Health System, teledermatology has been harnessed as a specialist extender platform, allowing for online consultations in remote deployed settings. Operational teledermatology has played a critical role in reductions of medical evacuations with significant cost-savings. When direct in-person lesion visualization is unattainable, teledermoscopy can be harnessed as an effective diagnostic tool to distinguish suspicious skin lesions. Teledermoscopy has the versatile capacity for streamlined incorporation into the existing asynchronous telemedicine platforms utilized worldwide among deployed U.S. military healthcare providers. In terms of clinical utility, teledermoscopy offers a unique and timely opportunity to improve diagnostic accuracy, early detection rates, and prognostic courses for dermatological conditions. Such improvements will further reduce medical evacuations and separations, thereby improving mission readiness and combat effectiveness. As mission goals are safeguarded, associated operational budget costs are also preserved. This innovative, cost-effective technology merits integration into the U.S. Military Health System (MHS).

Early Detection and Case Management of Skin Diseases with a Mobile Health Application 'eSkinHealth': Protocol for a Mixed-Methods Pilot Study in Côte d'Ivoire

BACKGROUND

The prevalence of skin diseases is extremely high in sub-Saharan Africa, among which are skin neglected tropical diseases (skin NTDs) that could lead to life-long disabilities and deformities if not diagnosed and treated early. To achieve early detection and early treatment of these skin diseases, we developed a mobile health application (mHealth app): 'eSkinHealth.'

OBJECTIVE

This paper outlines a protocol for evaluating the effect of our eSkinHealth app in the early detection and effective management of skin diseases in Côte d'Ivoire.

METHODS

A mixed-methods pilot trial will be conducted in Côte d'Ivoire and will consist of 3 phases: phase 1, the development and improvement of the eSkinHealth app; phase 2, a pilot trial to evaluate the usability of the eSkinHealth app for local medical staff in Côte d'Ivoire; and phase 3, a pilot trial to evaluate the effectiveness of early detection and case management of targeted skin NTDs (Buruli ulcer, leprosy, yaws, and lymphatic filariasis) with the eSkinHealth app in Côte d'Ivoire. The pilot study will be implemented as a 2-arm trial with local healthcare providers and patients with skin NTDs over a 3-month follow-up period. The local healthcare providers will be assigned to an intervention group receiving the eSkinHealth app to be used in their daily practices or a control group. Training will be provided on the usage and implementation of the app and diagnostic pipeline to the intervention group only, while both groups will receive training on skin diseases. Our primary outcome is to evaluate the early detection and effective management of skin diseases using the eSkinHealth app in Côte d'Ivoire by number of cases diagnosed and managed. Additionally, we will evaluate the eSkinHealth app with validated questionnaires and in-depth interviews. Procedures of our methods have been reviewed and approved by the IRB of the Ministry of Health, Côte d'Ivoire and by Tulane University in 2021.

RESULTS

This study was funded in 2021. We started enrolment of patients in February 2022, and data collection is currently underway. We expect the first results to be submitted for publication in 2023.

CONCLUSIONS

Our 'eSkinHealth' is a field-adapted platform that could both provide direct diagnostic and management assistance to health workers in remote settings. The study will provide evidence for the usability and the effectiveness of the eSkinHealth app to improve the early detection and case management of skin NTDs in Côte d'Ivoire; and further, are expected to contribute to knowledge on mobile health approaches in the control of skin NTDs.

CLINICALTRIAL

2020-2054 (Clinicaltrials.gov).

Evaluation of WhatsApp as a Platform for Teledermatology in Botswana: Retrospective Review and Survey

Background

In emerging market countries in sub-Saharan Africa, access to specialty services such as dermatology is limited. Teledermatology is an innovative solution to address this issue; however, many initiatives have been tried without sustained success. Recently, WhatsApp has been used as a store-and-forward telemedicine communication platform for consultation and education in Botswana.

Objective

This study aims to describe the utilization of WhatsApp for teledermatology and the satisfaction levels of participating providers.

Methods

A 2-part pilot study was conducted. First, a retrospective review was performed of WhatsApp communications received by participating dermatologists in Gaborone, Botswana, from January 2016 to December 2019. Sender information, patient demographics and history, response time, diagnoses made, and follow-up recommendations were collected. Second, a 12-question cross-sectional survey was distributed to health care providers who utilized WhatsApp for teledermatology during this period. Descriptive statistics were then performed.

Results

There were 811 communication threads over the study period. The majority (503/811, 62%) of communications were consultations from providers inquiring about a specific patient, followed by multidisciplinary care coordination communications (90/811, 11%). Our in-depth analysis focused on the former. In 323 (64%) provider consultations, dermatologists responded within 1 hour. A diagnosis was made in 274 (55%) consultations. Dermatologists gave treatment recommendations remotely in 281 (56%) consultations and recommended an in-person dermatology visit in 163 (32%). Of the 150 health care providers surveyed, 23 (15%) responded. All respondents (100%) felt that there was a need for teledermatology and improved teledermatology education in Botswana. Moreover, 17 (74%) respondents strongly felt that the guidance received via WhatsApp was high quality, and 22 (96%) were satisfied with WhatsApp as a platform for teledermatology.

Conclusions

This retrospective review and survey demonstrated that WhatsApp is a quick, well-received, and sustainable method of communication between dermatologists and providers across Botswana. The app may offer a solution to the challenges providers face in accessing specialty referral systems, point-of-care education, and medical decision-making support for complex dermatologic cases in Botswana. The information gained from this pilot study can serve as the basis for future telemedicine studies to improve the implementation of teledermatology in Botswana and other resource-limited countries.

Teledermatology in the Control of Skin Neglected Tropical Diseases: A Systematic Review

Introduction

Neglected tropical diseases (NTDs) include a group of about 20 illnesses that have garnered relatively little attention, despite their ability to inflict significant suffering and disability. Skin neglected tropical diseases (sNTDs) are a subset of NTDs that present with cutaneous manifestations and are well known for their ability to generate stigma and promote poverty. Teledermatology (TD) represents a potential method to control sNTDs.

Objective

We sought to analyze the potential for TD to ease the burden of sNTDs.

Methods

We performed a systematic literature search using the Texas Medical Center Library One Search, which scans 167 databases, including Embase, PubMed, and Scopus. We included all original investigations published after 2011 that assessed the impact of TD intervention in the control of one or more sNTDs. We excluded studies not written in English and studies that did not perform any outcome analyses.

Results

Twenty studies met our search criteria, and 18 expressed positive attitudes towards TD. Overall, we found that TD may be a sustainable, cost-effective strategy for expanding access to care for individuals afflicted with sNTDs. However, poor image quality, lack of access to further diagnostic tests, and ethical, legal, and cultural issues pose as barriers to TD utilization.

Conclusion

TD may be helpful in achieving control of sNTDs but has its limitations. An integrated approach, which employs TD in conjunction with other strategies, represents a realistic path for alleviating sNTDs.

International Teledermatology Review

Purpose of Review

The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Improving technology and the recent COVID-19 pandemic have hastened its use internationally.

Recent Findings

Some barriers to the use of teledermatology have fallen considerably in the last year.

Summary

Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and variable use within countries. Many barriers remain to increasing the use of teledermatology.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

The Role in Teledermoscopy of an Inexpensive and Easy-to-Use Smartphone Device for the Classification of Three Types of Skin Lesions Using Convolutional Neural Networks

Background. The use of teledermatology has spread over the last years, especially during the recent SARS-Cov-2 pandemic. Teledermoscopy, an extension of teledermatology, consists of consulting dermoscopic images, also transmitted through smartphones, to remotely diagnose skin tumors or other dermatological diseases. The purpose of this work was to verify the diagnostic validity of images acquired with an inexpensive smartphone microscope (Nurugo^TM), employing convolutional neural networks (CNN) to classify malignant melanoma (MM), melanocytic nevus (MN), and seborrheic keratosis (SK). Methods. The CNN, trained with 600 dermatoscopic images from the ISIC (International Skin Imaging Collaboration) archive, was tested on three test sets: ISIC images, images acquired with the Nurugo^TM, and images acquired with a conventional dermatoscope. Results. The results obtained, although with some limitations due to the smartphone device and small data set, were encouraging, showing comparable results to the clinical dermatoscope and up to 80% accuracy (out of 10 images, two were misclassified) using the Nurugo^TM demonstrating how an amateur device can be used with reasonable levels of diagnostic accuracy. Conclusion. Considering the low cost and the ease of use, the Nurugo^TM device could be a useful tool for general practitioners (GPs) to perform the first triage of skin lesions, aiding the selection of lesions that require a face-to-face consultation with dermatologists.

COVID-19 and Teleneurology in Sub-Saharan Africa: Leveraging the Current Exigency

Africa has over 1.3 billion inhabitants, with over 60% of this population residing in rural areas that have poor access to medical experts. Despite having a ridiculously huge, underserved population, very few African countries currently have any form of sustained and organized telemedicine practice, and even fewer have dedicated tele-neurology services. The ongoing COVID-19 pandemic has proved to be one of the most significant disruptors of vital sectors of human endeavor in modern times. In the healthcare sector, there is an increasing advocacy to deliver non-urgent care via telemedicine. This paper examined the current state of tele-neurology practice and infrastructural preparedness in sub-Saharan Africa. Currently, there is over 70% mobile phone penetration in most of the countries and virtually all of them have mobile internet services of different technologies and generations. Although the needed infrastructure is increasingly available, it should be improved upon. We have proposed the access, costs, ethics, and support (ACES) model as a bespoke, holistic strategy for the successful implementation and advancement of tele-neurology in sub-Saharan Africa.

Telemedicine experience between two hospitals from Angola and Spain

OBJECTIVE

Telemedicine uses information and communication technologies to provide services in the field where the distance is a critical factor. The aim of the present study is to describe the experience of a synchronous telemedicine between two hospitals in Spain and Angola.

METHODS

This is a retrospective observational study of all synchronous telemedicine sessions conducted between the Hospital Nossa Senhora da Paz in Angola and the Vall d'Hebron University Hospital in Spain from January 2011 to December 2014.

RESULTS

Seventy-two cases were discussed in the telemedicine sessions. The average age of patients was 18.02 (SD 13.75) years and mostly women (54.38 percent). Reasons to discuss the cases were 46.47 percent doubts in the diagnosis and therapeutic management, 15.47 percent were purely formative cases, and only 8.45 percent treatment doubt. At the time of presentation, 29 percent of the patients were already diagnosed, 95 percent of whom with infectious disease diagnostic, and from the undiagnosed patients 36 percent presented a febrile syndrome.

CONCLUSION

This study shows the viability of synchronous telemedicine between European and African countries without an excessively sophisticated technology.

Novel Diagnostics for Kaposi Sarcoma and Other Skin Diseases in Resource-Limited Settings

In resource-limited settings, point-of-care diagnostic devices have the potential to reduce diagnostic delays and improve epidemiologic surveillance of dermatologic conditions. We outline novel-point-of care diagnostics that have recently been developed for dermatologic conditions that primarily affect patients living in resource-limited settings, namely, Kaposi sarcoma, cutaneous leishmaniasis, leprosy, Buruli ulcer, yaws, onchocerciasis, and lymphatic filariasis. All of the technologies described in this article are prototypes, and some have undergone field testing. These devices still require validation in real-world settings and effective pricing to have a major impact on dermatologic care in resource-limited settings.

[Artificial intelligence to support telemedicine in Africa]

Telemedizin findet seit Jahrzehnten Anwendung im Alltag von Dermatologen. Insbesondere in afrikanischen Ländern mit begrenzter medizinischer Versorgung, zu überbrückenden geografischen Distanzen und einem zwischenzeitlich relativ gut ausgebauten Telekommunikationssektor liegen die Vorteile auf der Hand. Nationale und internationale Arbeitsgruppen unterstützen den Aufbau von teledermatologischen Projekten und bedienen sich in den letzten Jahren zunehmend KI(künstliche Intelligenz)-gestützter Technologien, um Ärzte vor Ort zu unterstützen. Vor diesem Hintergrund stellen ethnische Variationen eine besondere Herausforderung in der Entwicklung automatisierter Algorithmen dar. Um die Genauigkeit der Systeme weiter zu verbessern und globalisieren zu können, ist es wichtig, die Zahl der verfügbaren klinischen Daten zu erhöhen. Dies kann nur mit der aktiven Beteiligung der lokalen Gesundheitsversorger sowie der dermatologischen Gemeinschaft gelingen und muss stets im Interesse des einzelnen Patienten erfolgen.

Position Statement on Atopic Dermatitis in Sub-Saharan Africa: current status and roadmap

BACKGROUND

The first International Society of Atopic Dermatitis (ISAD) global meeting dedicated to atopic dermatitis (AD) in Sub-Saharan Africa (SSA) was held in Geneva, Switzerland in April 2019. A total of 30 participants were present at the meeting, including those from 17 SSA countries, representatives of the World Health Organization (WHO), the International Foundation for Dermatology (IFD) (a committee of the International League of Dermatological Societies, ILDS www.ilds.org), the Fondation pour la Dermatite Atopique, as well as specialists in telemedicine, artificial intelligence and therapeutic patient education (TPE).

RESULTS

AD is one of the most prevalent chronic inflammatory skin diseases in SSA. Besides neglected tropical diseases (NTDs) with a dermatological presentation, AD requires closer attention from the WHO and national Departments of Health.

CONCLUSIONS

A roadmap has been defined with top priorities such as access to essential medicines and devices for AD care, in particular emollients, better education of primary healthcare workers for adequate triage (e.g. better educational materials for skin diseases in pigmented skin generally and AD in particular, especially targeted to Africa), involvement of traditional healers and to a certain extent also patient education, bearing in mind the barriers to effective healthcare faced in SSA countries such as travel distances to health facilities, limited resources and the lack of dermatological expertise. In addition, several initiatives concerning AD research in SSA were discussed and should be implemented in close collaboration with the WHO and assessed at follow-up meetings, in particular, at the next ISAD meeting in Seoul, South Korea and African Society of Dermatology and Venereology (ASDV) meeting in Nairobi, Kenya, both in 2020.

Recognition and management of congenital ichthyosis in a low-income setting

We report the case of a 3-week old girl in The Gambia who presented to hospital with an undiagnosed skin disorder evolving since birth. Using telemedicine to seek specialist dermatology advice abroad, she was diagnosed with and managed for suspected congenital lamellar ichthyosis. Poor early recognition and limited resources, for both acute and chronic care, created significant challenges to optimal management; these were overcome, in part, by adopting a common sense, back-to-basics approach to treatment and by empowering the parents to take ownership of their infant’s daily skin and eye care. This case highlights key global health issues associated with managing chronic, often debilitating, paediatric dermatological conditions in a low-income setting; namely, poor access to important diagnostic tools and medications, lack of experience and expertise in the management of severe skin disease and its associated complications, absence of long-term community support, alternative health beliefs and risk of sociocultural stigma.

The Development of a Mobile Application to Support Peripheral Health Workers to Diagnose and Treat People with Skin Diseases in Resource-Poor Settings

The high prevalence of skin diseases in resource-poor settings, where health workers with sufficient knowledge of skin diseases are scarce, calls for innovative measures. Timely diagnosis and treatment of skin diseases, especially neglected tropical diseases (NTDs) that manifest with skin lesions, such as leprosy, is crucial to prevent disabilities as well as psychological and socioeconomic problems. Innovative technological methods like telemedicine and mobile health (mHealth) can help to bridge the gap between the burden of skin diseases and the lack of capable staff in resource-poor settings by bringing essential health services from central level closer to peripheral levels. Netherlands Leprosy Relief (NLR) has developed a mobile phone application called the 'SkinApp', which aims to support peripheral health workers to recognize the early signs and symptoms of skin diseases, including skin NTDs, and to start treatment promptly or refer for more advanced diagnostic testing or disease management when needed. Further research is needed to determine how greatly mHealth in general and the SkinApp in particular can contribute to improved health outcomes, efficiency, and cost-effectiveness.

Long-Range Diagnosis of and Support for Skin Conditions in Field Settings

Skin diseases are a significant cause of morbidity and mortality worldwide; however, access to dermatology services are critically limited, particularly in low- to middle-income countries (LMIC), where there is an overall shortage of physicians. Implementation of long-range technological support tools has been growing in an effort to provide quality dermatology care to even the most remote settings globally. eHealth strategies can provide realistic healthcare solutions if implemented in a feasible and sensitive way, customizing tools to address the unique needs and resource limitations of the local setting. This article summarizes the various types of telemedicine and mobile health (mHealth) tools and their practical applications and benefits for patient care. The challenges and barriers of teledermatology are discussed, as well as steps to consider when implementing a new teledermatology initiative. eHealth arguably offers one of the most flexible and realistic tools for providing critically needed access to dermatology skills in underserved LMICs.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.

Skin disease prevalence study in schoolchildren in rural Côte d'Ivoire: Implications for integration of neglected skin diseases (skin NTDs)

Background

Early detection of several skin-related neglected tropical diseases (skin NTDs)–including leprosy, Buruli ulcer, yaws, and scabies- may be achieved through school surveys, but such an approach has seldom been tested systematically on a large scale in endemic countries. Additionally, a better understanding of the spectrum of skin diseases and the at-risk populations to be encountered during such surveys is necessary to facilitate the process.

Methods

We performed a school skin survey for selected NTDs and the spectrum of skin diseases, among primary schoolchildren aged 5 to 15 in Côte d’Ivoire, West Africa. This 2-phase survey took place in 49 schools from 16 villages in the Adzopé health district from November 2015 to January 2016. The first phase involved a rapid visual examination of the skin by local community healthcare workers (village nurses) to identify any skin abnormality. In a second phase, a specialized medical team including dermatologists performed a total skin examination of all screened students with any skin lesion and provided treatment where necessary.

Results

Of a total of 13,019 children, 3,504 screened positive for skin lesions and were listed for the next stage examination. The medical team examined 1,138 of these children. The overall prevalence of skin diseases was 25.6% (95% CI: 24.3–26.9%). The predominant diagnoses were fungal infections (n = 858, prevalence: 22.3%), followed by inflammatory skin diseases (n = 265, prevalence: 6.9%). Skin diseases were more common in boys and in children living along the main road with heavy traffic. One case of multi-bacillary type leprosy was detected early, along with 36 cases of scabies. Our survey was met with very good community acceptance.

Conclusion

We carried out the first large-scale integrated, two-phase pediatric multi-skin NTD survey in rural Côte d’Ivoire, effectively reaching a large population. We found a high prevalence of skin diseases in children, but only limited number of skin NTDs. With the lessons learned, we plan to expand the project to a wider area to further explore its potential to better integrate skin NTD screening in the public health agenda.

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. A common feature shared by several NTDs is skin involvement. Conditions within this group of NTDs have now been classified as skin NTDs to promote wider NTD integration. Several skin NTDs including leprosy, Buruli ulcer, yaws, and scabies are co-endemic in Côte d’Ivoire, West Africa. As children are vulnerable to these diseases, we carried out the first large-scale integrated, multi-skin NTD school survey in a rural district of this country. Our strategy of involving community healthcare workers and dermatologists effectively reached a large population. However, the detection of skin NTDs may have been limited because of the low schooling and attendance rate. We found a high prevalence of skin diseases among schoolchildren (26%), possibly due to poor socio-economic status and air pollution, which requires more attention. This high prevalence of skin diseases posed a challenge for our project as the need for medications and those with dermatological skills exceeded our capacity to reach our initial target population. Our study provides important lessons that will aid the framing of future school skin surveys in sub-Saharan Africa.

Tele-neurology in sub-Saharan Africa: A systematic review of the literature

BACKGROUND

The rapid advancement in telecommunications on the African continent has opened up avenues for improving medical care to underserved populations. Although the greatest burden of neurological disorders is borne by Low-and-Middle Income Countries (LMICs) including sub-Saharan Africa (SSA), there is a profound paucity of neurologists to serve the population. Telemedicine presents a promising avenue for effective mobilization and utilization of the few neurologists in Africa.

OBJECTIVE

To systematically review the published literature on the use of telemedicine for improved care and outcomes for patients with neurological disorders in SSA.

METHODS

We searched PubMed and Cochrane library from January 1, 1980 to April 30, 2017 using the following keywords: "Telemedicine neurology Africa", "Teleneurology Africa", "Telestroke Africa", "Telerehabilitation Africa", "Telemedicine for epilepsy", "Telemedicine for Parkinson's disease Africa", "Telemedicine for dementia Africa", "Telehealth neurology Africa". Our inclusion criteria were randomized controlled trials, or case series that reported the utilization of telemedicine for care/education of individuals with neurological disorders in sub-Saharan Africa.

RESULTS

This search yielded 6 abstracts. By consensus between two investigators, 1 publication met the criteria for inclusion and further review. The one study identified utilized telemedicine for the purpose of improving education/knowledge of 16 doctors and 17 allied health professionals in Parkinson's disease (PD) in Cameroon. The study noted feasibility and satisfaction of participants with telemedicine as well as improved knowledge base of participants after the educational course but noted access to healthcare by patients did not change. No studies have evaluated the use of telemedicine for care of patients with neurological disorders.

CONCLUSION

The indication is that teleneurology may be feasible in SSA and studies are needed to assess feasibility, acceptability, efficacy, cost-effectiveness of this promising discipline of neurology in these resource-limited settings. We propose the setting up of trans‑continental, inter-regional, intra-regional, and national networks of neurologists to utilize teleneurology platforms to improve the reach of neurology care in SSA.

A systematic review of satisfaction with teledermatology

Background The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live-interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction. Objective To systematically review all published studies of patient and provider satisfaction with SF and LI TD. Methods PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satisfaction with SF or LI TD between January 2000 and June 2016. Results Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction ( n = 24 and 17, respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed satisfaction (n = 9 and 6, respectively). Conclusion Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future programmes.

Teledermatology as a Means to Provide Multispecialty Care: A Case of Global Specialty Collaboration

Telemedicine can serve as a platform for specialty collaboration and potentially address the lack of specialized and subspecialized care globally. In this article we present a case in which the use of teledermatology facilitated global collaboration between multiple specialists and subspecialists, resulting in high-quality care of a child from a remote area of Botswana. We present the lessons learned and factors that should be considered when engaging in global specialty collaboration, especially between developed and developing countries. We also discuss the potential limitations of telemedicine when used within a global context. With these considerations in mind, global specialty collaboration facilitated by telemedicine can provide a potential solution to the lack of access to specialized and subspecialized care.