by: Brian Chau, MS3

The clinical process of evaluating suspicious skin lesions is often taught in medical school through the ABCDE method.

Student physicians are taught to evaluate said lesions based on Asymmetry, irregular Borders, multiple Colors, Diameters > 6mm, and Enlarging lesion.

Dermoscopy is a non-invasive, clinical examination of skin lesions with the aid of a dermatoscope. This process utilizes a liquid medium between a magnifier, a transparent plate, and a polarized light source to allow physicians to better visualize lesions.

It’s an important technique, used by dermatologists to aid in distinguishing between a benign growth and a malignant lesion. For students and residents interested in learning more about this process, Dermoscopy: An Illustrated Self-Assessment Guide app is an attractive option on the iOS.

Developed by Usatine Media, from Richard Usatine, MD, Dermoscopy: An Illustrated Self-Assessment Guide is based on the textbook with the same name from McGraw-Hill, by Robert H. Johr, MD, (Clinical Professor of Dermatology, Associate Clinical Professor of Pediatrics, Pigmented Lesion Clinic, University of Miami School of Medicine) and Wilhelm Stolz, MD (Director, Clinic of Dermatology, Allergology and Environmental Medicine, Hospital München Schwabing, Professor of Dermatology, Faculty of Medicine, Ludwig-Maximilians-Universität, Munich, Germany).

It’s important to note that this Dermoscopy app is not a tool to be used as a diagnostic app. There are several “photo” skin lesion diagnostic apps on the market already, such as MelApp.

Instead, this Dermoscopy app is designed to teach the basics of dermoscopy to students and residents, through an introductory text and practice cases.

Dermoscopy: An Illustrated Self-Assessment Guide is divided into 5 core chapters. The first chapter is an incredibly useful introduction to dermoscopy, with a lengthy section entitled “The Two-Step Algorithm.” This portion covers the process behind analyzing a skin lesion with dermoscopy, core principles and criteria involved in this process. Everything is presented in a very clear-cut, high-yield manner.

Throughout this first chapter, dermoscopy images are shown which correspond to the dermatological concept being discussed. At the end of the first chapter is a multiple-choice quiz over the diagnostic process for different lesions. Browsing this first chapter had me feeling like I was reading a textbook, just with a better layout (especially for the quiz) and sharper images.

After the first chapter, users will find the remaining chapters to be organized as case question sets, by anatomical region, from head to toe, 191 cases total. Some regions have more cases than others (Trunk/Extremities with 113 cases, Palm/Nose/Nails with 31 cases).

I felt the cases were well laid out, with a presenting history, associated dermoscopy images, and questions following. Most of the questions are true/false, but the final question for each case asks users to rate the risk level of the lesion and select the correct diagnosis from a list. Also, users must choose a disposition–that is, what sort of intervention the patient will require, if any at all.

The introductory text and subsequent cases are really the key features of Dermoscopy: An Illustrated Self-Assessment Guide. There’s a basic search feature, which helps in quickly locating specific cases, plus a preface and foreword from the textbook.

Overall, I was very impressed with Dermoscopy: An Illustrated Self-Assessment Guide. For me, it served as a very eye-opening guide to the process dermatologists use in evaluating suspicious skin lesions. Not many medical students choose to pursue a career in dermatology, but I feel it’s important to at least have a basic understanding of the complexity involved in such skin lesion analysis. The introductory text was perfect for this purpose and the cases were quite comprehensive. The solid, high-yield feel of a good textbook hasn’t been lost with the transition of this app from text to iOS. The quiz portions load with ease and the images are remarkably detailed.

Dermoscopy: An Illustrated Self-Assessment Guide is available for $94.99, through iTunes. This app requires iOS 3.1.3 or later and runs on the iPod Touch, iPhone and iPad. There is also an Android version available of Dermoscopy: An Illustrated Self-Assessment Guide, along with the previously-mentioned textbook version.

Likes:

• Superb introduction to dermoscopy on the iOS
• Excellent layout for easy navigation
• Detailed dermoscopy images
• Massive selection of cases

Dislikes:

• Price may drive some users away, but it’s on par with the textbook version
• Doesn’t offer cases for some scabies and a few other parasites

Conclusion:

• Dermoscopy: An Illustrated Self-Assessment Guide is a great example of an excellent textbook-to-app port
• This app is easy to navigate, covers high-yield material, and offers a large selection of important clinical cases with detailed dermoscopy imagery

Links:

Developer
iTunes

There has been a recent growth in the range of medical and surgical treatments available in cosmetic dermatology.

The second edition of Color Atlas of Cosmetic Dermatology was originally written to provide a succinct yet broad overview of cosmetic therapy using a range of illustrations and photographs – an area where devices like the iPhone and iPad really shine.

Targeted at a niche group of healthcare providers, this app certainly gets the job done. Valuable information covering consultation, management, treatment and side effects of cosmetic procedures has not been lost in this transfer from physical book to electronic app.

From the contents page of this universal app, it is possible to access information related to 64 specific conditions/diseases which come under various headings including disorders of various glands, hair follicles, pigmentation, photoaging, vascular alterations and benign/malignant growths. This comprehensive reference is well designed ensuring relevant information can be found quickly and efficiently.

Each particular condition is consistently presented in the same fashion and includes important information such as pathogenesis, pathology, examination, key consultative questions, management and treatment options amongst many other sections. Each section is well presented and accompanied by a wide range of pictures including many illustrating before and after treatment.

Key details on the set-up of each procedure, and a review of the necessary equipment are also provided.

The developers have made an excellent effort to improve the readers experience and this is reflected in an excellent user interface. There are many useful features including a detailed search function, bookmark ability, note-taking and the built in ability to ‘jump’ to a particular section. This ensures that the key information is never more than a couple of taps away-a key point for any detailed reference texts such as the Color Atlas of Cosmetic Dermatology.

The color photographs have also been ‘tagged’ so they also show up in search results which is useful as dermatology is so reliant on visual inspection and examination. Color Atlas of Cosmetic Dermatology contains over 450 high resolution color photographs which can be manipulated using standard touch gestures.

One particular strength of this app is the inclusion of detailed bibliographies at the end of each section. These correspond to the end of chapters in the physical text and it is nice to see the inclusion of these in the app. This allows the end user to review the evidence for themselves and assess the risks and benefits of various treatments.

Price:

• $139.99

Likes:

• Lots of detailed color photos
• Excellent user interface for a textbook
• Evidence based references
• No internet access required
• Universal app

Dislikes/Future Updates I’d Like To See:

• It would be fantastic if the detailed references at the end of each section were linked to PubMed or Google so it would be easier to access the original papers.

Overall Rating:

• Color Atlas of Cosmetic Dermatology is an excellent reference resource for dermatologists who are looking for a complete yet concise guide to a wide range of cosmetic disorders
• The user interface is focused and presents information covering diagnosis, treatment, and procedures in an easily accessible format
• Whilst expensive, the price is comparable to the physical version.

iTunes link

Programs that deliver specialty care to underserved areas utilizing telemedicine are being launched all over the world. However a recent study published in the British Journal of Dermatolgy raises some questions about the limitations of this technology, particularly some unintended consequences that appear to have adverse patient outcomes.

The study looked at a series of dermatolgy referrals for suspicious skin lesions, gathering data on 400 patients within a VA site. What they found was that for many of those patients these visits led to important diagnoses – but not always for the lesion for which they were actually referred.

As described in a great piece in Medscape News by Dr. Laurie Barclay, who also does a great analysis of the study, the results were surprising to say the least.

The dermatologist identified 149 malignant lesions in 98 patients, but only 88 lesions (59.1%) corresponded to the index lesion. The consulting dermatologist performed a biopsy on 111 incidental lesions, of which 61 (55.0%) were additional skin cancers. Of these 61 incidental cancers, 12 (19.7%) were in patients in whom the index lesion was clinically benign and which the dermatologist did not perform a biopsy of the lesion.

So in short, 40% of the malignant lesions found by the dermatologist were the result of a complete skin exam that incidentally identified suspicious lesions. The implication here for teledermatology programs – where a dermatologist would review whatever lesions are highlighted by the referring physician – is these lesions would be missed.

Some care is better than none, so this is certainly not an argument against all telemedicine programs. For example, teledermatology programs in areas where dermatologists aren’t available would certainly be valuable. However, in areas where such teledermatology services may be utitlized as a lower-cost alternative to in-person dermatologic evaluation, this study should give us pause. It’s findings clearly suggest that these kinds of programs are not replacements for in-person evaluations and the physical exam – a notion which has implications well beyond dermatology.

By: Darwin Wan, MS II

Since dermatology is not always emphasized in most medical schools’ curriculums, I was pretty excited to try Pocket Derm. The concept of the app is similar to Shelley’s 77 Skins, a set of flash cards that  claims to cover 95% of “what you need to know” with its 77 skin conditions. While Pocket Derm does not make  such a claim, I was nonetheless looking forward to having information at my fingertips on many of the skin conditions that I might encounter.

Pocket Derm is a very simple app. There is a list of diagnoses from which to pick, covering a variety of skin conditions, from acne to condyloma accuminata to melanoma. The app has a large number of skin conditions, though by no means comprehensive. Interestingly, there is a tab available for users to request diagnoses that they wish to see included in the app.

Each skin condition includes a brief definition, a link to a glossary for medical terms used in the definition, and photographic examples of the condition (usually just one photo).

While I found it handy to have a list of all these skin conditions, I did find the content for each skin condition a bit sparse. Pocket Derm’s clinical utility appears to be limited to providing a quick reference for medical students seeking to familiarize themselves with common skin conditions. I imagine it could be hard to diagnose conditions based on a single photo and brief definition. Including sections for history, etiology, differential, complications and management, or even including a link for internet search would have greatly enhanced the app’s clinical utility. As it stands, Pocket Derm’s core function feels a bit like a light version of the dermatology portion of Epocrates Essentials.

Pocket Derm also includes a glossary section for dermatologic terms. I actually find this section very useful. As a medical student often faced with deciphering a heap of new terms daily, I often glaze over terms for which I only know the approximate meaning. The glossary section was very useful for quickly defining terms and understanding the difference between dermatology terms such as nodules versus papules.

Overall, Pocket Derm is a simple but useful app for the beginning dermatology learner. Its use is mainly in helping students familiarize themselves with common dermatologic conditions and terms. Its clinical utility is limited due to the sparse content for each disease, and the app would greatly benefit  even from including a  link to a Google search or Wikipedia page (not that I endorse Wikipedia as a source for clinical decision-making, but links to it are simple to add).

Likes

• Good overview and reference for common dermatologic conditions
• Simple and quick to navigate

Dislikes

• Relatively sparse content limits clinical utility

Conclusion

Pocket Derm is a nice, simple app for people interested in learning about some common skin conditions. If you have access or a subscription to a more robust disease database app, you may not need this app.

iTunes link, Price $ 0.99

Darwin Wan, B.Sc(Kin) is a second year medical student at the University of Alberta, and currently servies as the Information Technology Officer for the student body.

Getting a new medication or medical device approved in the United States requires embarking on path so nightmarish it makes Dante’s Inferno look like the yellow brick road. And while most clinicians and bureaucrats would agree that we need to find a better way, its not hard to imagine how we ended up with such a complex regulatory structure. Going back over 2,000 years to the Hippocratic Oath, the practice of medicine has rested largely on two principles – beneficence and non-maleficence. The latter refers to the idea that we, as clinicians, first do no harm while the former requires that we act foremost in the best interest of the patient. In attempting to uphold these principles, we have created an enormous regulatory structure intended to act as a sieve allowing only those interventions of proven benefit to reach the general public.

I don’t claim its anywhere close to a perfect system. And as there are enormous amounts of money at stake, often involving a very vulnerable group of people, its our responsibility to stay vigilant against those who attempt to manipulate the system as well as treatments that are of questionable value. And there are a small group of app developers whose apps may fall into the latter category with claims to treat acne with light – well, that is unless a patient is willing to hold their iPhone to their face for the next 100 years.

Acne is an incredibly common condition which can significantly degrade quality of life. Up to 10% of Americans experience forms severe enough to leave permanent physical and psychological scars. While many therapies exist, escalation of therapy often involves significant risk. One emerging therapy is in phototherapy – basically using specific wavelengths of light to treat the skin. With a minimal side effect profile, results are promising. A recent review in the British Journal of Dermatology describes a number of small trials that show lesion reduction after treatment with phototherapy. For example, one trial found a blue-red light combination treatment to be more effective than a common topical treatment. Another found no difference between blue light treatment and a topical antibiotic. Its important to note that these trials were small and often poorly controlled, so the best conclusion that can be drawn is that these therapies are promising and warrant further study.

However, at least two app developers have decided to go ahead and bring this therapy to market – FunVid Apps with Acne Light Waves and Archibald Industries with Acne Away Premium. For $2 or $5, respectively, they claim that acne sufferers can watch their acne disappear in as little as 3 days simply by holding their iPhones to the affected area for as little as 1 minute twice a day. Wow!

When I first saw these apps, I was skeptical but decided to give them the benefit of the doubt. Surely, they would back up these claims with some evidence suggesting it works. Unfortunately, the website links on iTunes just go to the developer pages where the apps are not even mentioned. No luck here.

Then I thought maybe the developers had almost stumbled onto a low-cost, effective treatment for acne and further study would vindicate these apps. So I decided to compare the phototherapy these apps provided with that provided in one of the clinical trials. Unfortunately, the dosing of light in these trials is measured in irradiance (J/m2) and the only description of light output I could find for the iPhone was in illuminance (llux/umens) – the key difference between the two is that illuminance is more a measure of what our eyes perceive while irradiance is more a measure of the energy carried by the light. So at best, there is currently no way to show that the iPhone is even capable of delivering the doses of light that have been shown to have some effect in our small trials. At worst, based on my calculations, it would take over 100 years to achieve the same dosage of energy used in a single treatment in one trial of blue light phototherapy (see below for details on calculations).

So where does that leave us? Phototherapy is an unproven but promising medical therapies aimed at managing a condition with potentially severe physical and psychological consequences. I suspect these apps are likely cheap knockoffs of potentially beneficially therapy while providing no supporting evidence of their own.

Knowing that some medical therapies of acne make skin photosensitive, these apps are potentially harmful to patients who use them without a physicians knowledge. In addition, they more than likely provide no benefit to a patient suffering from acne. While these developers do not claim to be medical professionals, they do claim to treat a medical condition and should be held to the same Hippocratic standards that we hold all others in the medical field.

As such, I hope that one of two things would happen here. My preference would be that someone, preferably the developers, prove me wrong – give me some reason to believe that a reasonable argument could be made that these apps are effective. I promise I’d happily recant everything I’ve said. Otherwise, I hope someone – the developers themselves or Apple – pull these apps out of the app store, thereby preventing vulnerable patients on wasting their money on what is likely just a glorified mood light.

Appendix: What follows is the result of my attempt to convert the 207 lux output of the iPhone into an estimate of its irradiance. I include it only in the hopes that someone with a stronger physics background will either confirm or correct my calculations. At 207 lux and a screen area of 0.00425 m2, the illuminance of the iPhone screen is 0.87975 lumens. Using the phototopic luminosity function value of 0.1 at a wavelength of 420 nm, which is used in at least one trial of blue light, the conversion factor for a narrow band light would be 6830 lm/(W/m2). The irradiance would therefore be 0.00012881 W/m2 or 0.000000012881 W/cm2. So to reach the 40 J/cm2 per treatment that was used in the above referenced trial, it would take 126 years.

How many of your patients, inpatient or outpatient, have skin lesions?  How do you approach these skin lesions?  With befuddlement, with a frantic search of Up-to-Date articles, with an almost reflexive dermatology consult?  Now there’s a point-of-care resource that promises to allow clinicians to generate a “visual differential diagnosis” for any skin condition we see.  Here we review VisualDx Mobile from Logical Images, Inc, a “visual diagnostic decision support system”

First and foremost, with any point-of-care tool, reliability is key and in addition to all of these This app is from a reputed developer that employs over 100 practicing physicians on its editorial board to update its digital medical image collection, which numbers over 18,000 on this app. Logical Images, Inc (Rochester, NY) is a reputed medical technology company that has developed the world’s largest digital medical image library that includes over 60,000 images of visually presenting diseases (18,000 on this app).  We previously featured a conversation with Dr. Art Papier, Co-Founder and Chief Scientific Officer of Logical Images (posted March 4, 2010).  As mentioned in this conversation, the NIH has awarded Dr. Papier a $2 million grant to develop a standardized lexicon for dermatology.  Moreover, VisualDx boasts of customers such as the Military Health System, Delaware Division of Public Health, Wyoming Department of Health, and many more. Long story short – we trust them.

As for the app itself, it is rather intuitive to use: the home screen (shown above) features two functions, aptly named “Build a Differential” and “Find a Diagnosis.”

With “Build a Differential,” the user can input as much specific data about a patient’s presentation as he/she desires: the entry fields include neonate/infant vs child vs adult vs elder, drug eruptions, single vs multiple lesions, lesion morphology, body location, “key findings” (patient appearance, time course), and “other findings” (exposures, labs, medical history, occupation, social history, travel, etc.).  The app takes the entered information and presents a differential diagnosis ranked by likelihood (on how many patient findings match) and displayed via titled high-quality images—the so-called “visual differential diagnosis.”

Upon finding and clicking on a condition in the differential (shown above), the user can access an image bank of the condition, as well as the ICD-9 and information such as diagnostic pearls, differential diagnosis, best tests, management pearls, therapy, and associated findings. All of this information is grouped together into one screen and indexed on the right side of the screen, allowing for easy navigation between sections.

The other function on the home screen is the “Find a Diagnosis” function (shown below), which allows a user to browse or easily search for one of over 1000 diagnoses to see the associated bank of images and reach the aforementioned information about the condition.

As a fourth-year medical student and soon-to-be internal medicine resident, I was very impressed with this app’s clinical utility, as it makes for a infinitely useful tool both in outpatient and inpatient settings.  It is quick-loading, intuitive to use, and can prove to be a powerful source of help for identifying the many skin lesions that one is bound to see in any setting.  The most useful facet of the program is, not surprisingly, the “Build a Differential” function that shines when one encounters a skin lesion.  Though I did not come across any unknown skin lesions this week (unusual), I employed it several times on patients of mine with known dermatologic conditions and was pleased to discover that it included the correct diagnosis among the first several conditions on its generated differentials. From there, the images were high-quality and helpful in proper diagnosis.  Moreover, it has great potential for patient teaching or interaction, especially for warning about drug eruptions or assessing transient or historical skin lesions.  Unfortunately, the differential diagnosis resets if one exits the app.  Nonetheless, I absolutely plan to use this app as a resident, especially for the many clinic patients I will undoubtedly see with dermatologic complaints.

Pricing: Current VisualDx subscribers can download this app at no cost. A free trial (of 15 days’ duration) is available for clinicians who are new to VisualDx.  After that, a one-year subscription to VisualDx costs $199 (or $49 on student pricing) for the Clinician Package, or $99 (or $29 on student pricing) for the Pediatrics Package, which limits the features to neonate/infant/child lesion(s).

Likes:

Ease of use, powerful visual differential diagnoses

Tremendous quality and quantity of images (over 18,000)

Breadth of dermatologic diagnoses, over 1000 at last count

Dislikes/Future Updates I’d Love to See:

If your institution does not subscribe to VisualDx, the high cost

Differential diagnosis is lost if user exits the app

No way to e-mail a visual differential diagnosis or illness information and images for a patient

Conclusion: A powerful app, almost a must-have in my opinion, with a tremendous user-friendly interface, for a medical student or resident to help evaluate dermatologic lesions in both inpatient and outpatient settings.

Amit Patel is a fourth-year medical student at Washington University in St. Louis, MO. He is a graduate of Duke University and will be entering an Internal Medicine residency this July. We are thrilled to have Amit aboard!

[website]

[itunes]

This article is part of our HIMSS 2010 coverage. It includes a brief review of the iPhone medical app from Logial Images – Visual Dx Mobile – and a conversation with Dr. Art Papier, Co-Founder and Chief Scientific Office of Logical Images.

Although an unimaginable array of technology was demonstrated in the hangar-like exhibition spaces at HIMSS, one of the most impressive uses of technology from a physician’s perspective was in a small booth in far off corner. In it, the voluble and passionate co-founder and Chief Scientific Officer of Logical Images (www.logicalimages.com), Dr. Art Papier demonstrated a web and mobile based application that magically produces a sequence of high quality diagnostic images in response to user queries. Since Dr. Papier is Associate Professor of Dermatology at the University of Rochester School of Medicine, the application was originally dedicated to presenting high-quality images of dermatologic conditions.

This is fortunate in two respects. First, the most important findings in dermatology are visible to the naked eye and thus to a camera, second few clinicians (except for dermatologists) have more than the slightest familiarity with dermatologic conditions whereas skin conditions, according to Dr. Papier, account for 15% of visits to PCPs. The application has since also expanded to include radiology. An iPhone and iPod Touch version  was announced at HIMSS this week.

What Visual Logic has pioneered is a sophisticated structured search that allows the physician to sequentially enter more specific information about the patient’s presentation and be presented with a “visual” differential diagnosis. For example, a physician could enter that the patient is a veterinarian, has fevers and has a rash, and with each entry, the panoply of images on the screen would decrease in number until a match is made by the physician. For radiology, a mouse-over the chest xray conveniently highlights the abnormal portions of the lungs on the image. Dr. Papier has also been awarded a $2 million grant from the NIH to create a standardized lexicon for the field of dermatology.

The ten-year old web application has over 60,000 medical images collected from physicians and institutions showing that show dermatologic diseases along with their variations with age, stage, and skin color. The more than 100 editors of the collection include some of the distinguished academicians in dermatology, according to Dr. Papier. The textual medical content is obtained from peer-reviewed literature and includes treatment recommendations. There is also a consumer oriented version of the database at skinsight.com. In addition to dermatology,  Dr. Papier adds dentistry, endoscopy and pathology as other fields that are amenable to visual diagnosis.

Announced formally at HIMSS is the iPhone version of Visual Logic, appropriately named Visual Dx Mobile, contains over 18,000 images as well as text information such as next steps in management, diagnostic pearls, recommended tests, and ICD-9 codes. In the demonstration of the iPhone app, the image and text display could be seen to be smooth and rapid (see video). One cannot help but marvel at the impressive volume of clinical information now available in a small hand-held device (I wonder if the American Dermatology Association has pondered the implications of launching a small army of amateur dermatologists). The software is generally licensed by institutions but physicians can also buy it as modules, for example the pediatric module would cost $120 per year. According to the company, VisualDx is already in use at more than 1,300 clinical sites, including hospitals, public health organizations, government agencies, medical groups, and medical schools. Current VisualDx subscribers can download VisualDx Mobile for free at Apple’s App Store. Nonsubscribers can request a free trial or purchase a VisualDx subscription in order to access the app.

Dr. Papier emphasizes that the goal is to help physicians make a diagnosis. Much of where health IT intervenes in the clinical process has to do with treatment, such as clinical decision support systems that help physicians select the best or most cost-effective treatment. All of these resources are of little use if the diagnosis is wrong. This is especially relevant the treating physician may not be familiar with the patient’s condition, as is often the case with dermatology.  Even more relevant is that, while every disease has a “classic” or “textbook” presentation, in reality every disease also has innumerable variations. The ER physician, PCP or pediatrician cannot possibly memorize every variation, this is the advantage of specialization and the result of unconscious accrual of pattern recognition. The availability of large atlases is also of limited benefit, since they are invariably organized by diagnosis, which is of little help if you do not already know the diagnosis. With wider availability of sophisticated diagnostic tools such as VisualDx Mobile at the point of care, hopefully more patients can receive quicker and more accurate diagnoses in the future.