10.5826/dpc.1203a124
Background: In the new circumstances of Coronavirus disease 2019 pandemic, teledermatology and teledermoscopy have become more important in daily practice for departments which visuality is at the forefront as dermatology and plastic and reconstructive surgery.
Objective: In this study, it is aimed to determine diagnostic accuracy and treatment approaches of non-melanocytic skin lesions between two clinics by store and forward teledermatology method and to evaluate the contribution of teledermoscopy to the diagnostic accuracy of dermatologists.
Methods: A total of 26 patients with non-melanocytic skin lesions were included to the study. Clinical images of the lesions were sent by email to three plastic surgeons and three dermatologists. The accuracy of the diagnoses were evaluated by comparing teledermatology with histopathology. Diagnosis and treatment approaches were recorded for both clinics. Dermatologists also defined their diagnosis with teledermoscopic images.
Results: The mean percentage of diagnostic accuracy among dermatologists’ was 74.3% and among plastic surgeons’ was 61.5%. There was no significant difference in diagnostic accuracy between departments (p=0.625). There was a statistically significant difference between the departments for diagnostic and treatment approaches (p values respectively p=0.002, p&lt;0.001). Plastic surgeons prefered to confirm their pre-diagnosis histopathologically more than dermatologists. Plastic surgeons recommended surgical procedures for 25 lesions (96.2%) while dermatologists for 14 (53.8%) lesions. Teledermoscopy increased the rate of diagnostic accuracy of dermatologists from 74,3% to 82%.
Conclusions: Teledermatology is an effective method for non-melanocytic skin lesions with high diagnostic accuracy. Adding dermoscopy to teledermatology increases diagnostic accuracy of dermatologists on non-melanocytic skin lesions.
text/xml
2160-9381
1814
en
Ozge Gunduz
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
telemedicine, teledermatology, teledermoscopy, non-melanocytic skin lesion, diagnostic accuracy
Evaluation of Diagnostic Accuracy and Therapeutic Approach of Dermatologists and Plastic Surgeons to Non-Melanocytic Skin Lesions by Using Telemedicine: Diagnostic Accuracy and Therapeutic Approach of Dermatologists and Plastic Surgeons
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-05-29
2022-07-28
2022-09-13
e2022124
Dermatol Pract Concept
Background: In the new circumstances of Coronavirus disease 2019 pandemic, teledermatology and teledermoscopy have become more important in daily practice for departments which visuality is at the forefront as dermatology and plastic and reconstructive surgery.
Objective: In this study, it is aimed to determine diagnostic accuracy and treatment approaches of non-melanocytic skin lesions between two clinics by store and forward teledermatology method and to evaluate the contribution of teledermoscopy to the diagnostic accuracy of dermatologists.
Methods: A total of 26 patients with non-melanocytic skin lesions were included to the study. Clinical images of the lesions were sent by email to three plastic surgeons and three dermatologists. The accuracy of the diagnoses were evaluated by comparing teledermatology with histopathology. Diagnosis and treatment approaches were recorded for both clinics. Dermatologists also defined their diagnosis with teledermoscopic images.
Results: The mean percentage of diagnostic accuracy among dermatologists’ was 74.3% and among plastic surgeons’ was 61.5%. There was no significant difference in diagnostic accuracy between departments (p=0.625). There was a statistically significant difference between the departments for diagnostic and treatment approaches (p values respectively p=0.002, p&lt;0.001). Plastic surgeons prefered to confirm their pre-diagnosis histopathologically more than dermatologists. Plastic surgeons recommended surgical procedures for 25 lesions (96.2%) while dermatologists for 14 (53.8%) lesions. Teledermoscopy increased the rate of diagnostic accuracy of dermatologists from 74,3% to 82%.
Conclusions: Teledermatology is an effective method for non-melanocytic skin lesions with high diagnostic accuracy. Adding dermoscopy to teledermatology increases diagnostic accuracy of dermatologists on non-melanocytic skin lesions.
Ozge Gunduz
2022/07/28
10.5826/dpc.1203a124
e2022124
Midnorth Coast Dermatology, 31 Wyandra Crescent Port Macquarie 2444 NSW, Australia
2160-9381
telemedicine, teledermatology, teledermoscopy, non-melanocytic skin lesion, diagnostic accuracy
en
e2022124
Evaluation of Diagnostic Accuracy and Therapeutic Approach of Dermatologists and Plastic Surgeons to Non-Melanocytic Skin Lesions by Using Telemedicine: Diagnostic Accuracy and Therapeutic Approach of Dermatologists and Plastic Surgeons
https://dpcj.org/index.php/dpc/article/download/1814/1652
                    Dermatology Practical & Conceptual


 Evaluation of Diagnostic Accuracy and Therapeutic
 Approach of Dermatologists and Plastic Surgeons
     To Non-Melanocytic Skin Lesions By Using
                   Telemedicine
         Burcu Tugrul1, Basak Yalici-Armagan2, Hatice Gamze Demirdag3, Ozge Gunduz4


1. Ankara City Hospital, Department of Dermatology, Ankara, Turkey.
2. Hacettepe Univercity, Faculty of Medicine, Department of Dermatology, Ankara, Turkey.
3. Private Practice, Hatice Gamze Demirdag Dermatology Clinic, Ankara, Turkey.
4. Midnorth Coast Dermatology, 31 Wyandra Crescent Port Macquarie 2444 NSW, Australia.



Key words: telemedicine, teledermatology, teledermoscopy, non-melanocytic skin lesion, diagnostic accuracy
Citation: Tugrul B, Yalici-Armagan B, Demirdag HG, Gunduz O. Evaluation of diagnostic accuracy and therapeutic approach of
dermatologists and plastic surgeons to non-melanocytic skin lesions by using telemedicine. Dermatol Pract Concept. 2022;12(3):e2022124.
DOI: https://doi.org/10.5826/dpc.1203a124
Accepted: November 1, 2021; Published: July 2022
Copyright: ©2022 Tugrul et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Burcu Tugrul, MD, Ankara City Hospital, Department of Dermatology, Bilkent, Çankaya, 06800, Ankara, Turkey,
E-mail address: burcutugrul@yahoo.com




 ABSTRACT              Introduction: In the new circumstances of coronavirus disease 2019 pandemic, tele-dermatology and
                       tele-dermoscopy have become more important in daily practice for departments for which visuality is
                       at the forefront as dermatology and plastic and reconstructive surgery.
                       Objectives: This study was aimed to determine diagnostic accuracy and treatment approaches of
                       non-melanocytic skin lesions between 2 clinics by store and forward tele-dermatology method and to
                       evaluate the contribution of tele-dermoscopy to the diagnostic accuracy for dermatologists.
                       Methods: A total of 26 patients with non-melanocytic skin lesions were included in the study. C
                                                                                                                     ­ linical
                       images of the lesions were sent by email to 3 plastic surgeons and 3 dermatologists. The accuracy
                       of the diagnoses was evaluated by comparing tele-dermatology with histopathology. Diagnosis and
                       treatment approaches were recorded for both clinics. Dermatologists also defined their diagnosis with
                       tele-dermoscopic images.
                       Results: The mean percentage of diagnostic accuracy among dermatologists was 74.3% and among
                       plastic surgeons was 61.5%. There was no significant difference in diagnostic accuracy between depart-
                       ments (P = 0.625). There was a statistically significant difference between the departments for diagnostic
                       and treatment approaches (P values respectively P = 0.002, P < 0.001). Plastic surgeons preferred to con-
                       firm their pre-diagnosis histopathologically more than dermatologists. Plastic surgeons ­recommended



Original Article | Dermatol Pract Concept. 2022;12(3):e2022124                                                                       1
                      surgical procedures for 25 lesions (96.2%) while dermatologists for 14 (53.8%) ones. Tele-dermoscopy
                      increased the rate of diagnostic accuracy of dermatologists from 74.3% to 82.0% (P = 0.02).
                      Conclusions: Tele-dermatology is an effective method for non-melanocytic skin lesions with high
                      diagnostic accuracy. Adding dermoscopy to tele-dermatology increases diagnostic accuracy of derma-
                      tologists on non-melanocytic skin lesions.




Introduction                                                      contribution of the TDS method to the diagnostic accuracy
                                                                  of dermatologists.
Telemedicine (TM), defined as practicing medicine at a dis-
tance, has grown in popularity over the past ten years [1].       Methods
As social distancing becoming the new standard in the era of
Coronavirus disease 2019 (COVID-19) pandemic, TM emerges          Patients who applied to the dermatology unit of a tertiary
as a key tool in medicine. It can be performed with live in-      oncology hospital in Turkey and were performed a diagnos-
teraction technology via videoconferencing equipment or with      tic skin biopsy between April 2018 and March 2019 were
store-and-forward methods via transmitting digital images or      included in the study. Patients who were under 18 years old,
photographs of the lesions with patient clinical history [2,3].   pregnant and not volunteers were not involved. Informed
    TM has a particular value in specialties which have a         consent was taken from each patient and the protocol was
strong visual aspect, such as dermatology and plastic and         approved by a local research and ethics review committee.
reconstructive surgery (PRS) [4]. TM applications among              Lesions of the patients were examined and recorded by
plastic surgeons was observed particularly in the manage-         the same dermatologist (BT) who took clinical and dermo-
ment of various conditions such as acute trauma, burns, and       scopic pictures of the lesions by using her same mobile phone
postoperative monitoring [5-8]. Tele-dermatology (TD) has         (iPhone 7s, Apple Inc) and dermoscopy device with connec-
been used since 1995 as an example of TM [9]. TD is a use-        tion kit (DermLite DL3N, 3Gen Inc). Lesions with clinical
ful alternative where specialized dermatological assistance is    and dermatoscopic photographs which required histopatho-
not available and has been used successfully to support health    logic examination for differential diagnosis were included
professionals worldwide, in either an asynchronous store-and-     in the study. Histopathologic examination was accepted as
forward format or a real-time video conferencing format [10].     gold standard for diagnostic accuracy in the present study.
The majority of TD studies were related to skin cancers in        Age, gender, duration and localization of the lesions, clinical
the literature [11-14]. Dermoscopy is a non-invasive tool for     and histopathological diagnoses, clinical and dermoscopic
originally developed for diagnosing and detecting skin cancer.    images were recorded. The evaluation was performed using
It has been shown that dermoscopy can be used in the diag-        TD with SAF method. Clinical images and a brief clinical
nosis of pigmented and non-pigmented skin lesions over time.      history were sent by email to 6 physicians, namely 3 plastic
Tele-dermoscopy (TDS) is a currently defined method that          surgeons and 3 dermatologists. Each physician was 8 to 15
aims to increase diagnostic accuracy by adding dermoscopic        years experienced within his/her specialty. All dermatologists
images to TD [15]. Most of the research with TDS focuses on       had completed a dermoscopy course before the study.
melanocytic skin lesions including melanoma and melanocytic          Physicians were asked to record their clinical diagnosis,
nevus. There have been only a few reports with TD and TDS         which was then compared with the histopathological diag-
to diagnose non-melanocytic skin lesions (NMSLs) [2,11,15].       nosis. It was also questioned whether they need to confirm
    Face to face (FTF) comparisons of diagnostic accuracy         the diagnosis with histopathology and which treatment ap-
and therapeutic approaches between dermatologists and             proaches such as excision, cryotherapy, electrotherapy or
plastic surgeons have controversial results [16-18]. To the       laser therapy would prefer. Excision was classified as a surgi-
best of our knowledge there is no study in English-language       cal procedure while other procedure were non-surgical ones.
literature comparing the diagnostic accuracy and differences      Plastic surgeons were asked if they request a dermatology
in treatment approach for NMSLs between dermatology and           consultation before treatment decision.
PRS departments by using TD.                                         Accuracy was defined as the ability of a test to deter-
                                                                  mine disease correctly by comparison with a reference/gold

Objectives                                                        standard [11]. The accuracy of TD for diagnosis was estab-
                                                                  lished by comparison with histopathological examination.
The aim of this study was to evaluate diagnostic accu-            Physicians were asked to record their clinical diagnoses after
racy rates and treatment approaches of dermatologists             the evaluation of the pictures and clinical information, and
and plastic surgeons in NMSLs by using TM and the                 then clinical diagnoses were compared with the histological



2                                                                     Original Article | Dermatol Pract Concept. 2022;12(3):e2022124
diagnoses. TD diagnoses were accepted as correct if they were         accuracy of the physicians were compared by McNemar or
same with the histopathological diagnoses. The percentage             Cochran Q test as appropriate. A P value less than 0.05 was
of correct diagnosis was defined as the accuracy of TD. In            considered as significant.
order to determine the diagnostic accuracy between depart-
ments, at least two out of three physicians from the same
                                                                      Results
department were required to make the correct diagnosis.
    Dermatologists were asked if they requested to evaluate           The clinical characteristics of patients and duration, local-
dermoscopic images of the lesions to confirm their clinical           ization, and the histopathological diagnoses of lesions are
diagnosis made by TD. Regardless of the answer, to deter-             summarized in Table 1. According to the diagnostic accu-
mine the effect of TDS on the diagnosis, dermatologists eval-         racy, there was no statistically significant difference within
uated tele-dermoscopic images of all lesions after clinical           the physicians of the same department. The P value for der-
images and were asked to make a diagnosis, too.                       matologists was 0.41 and for plastic surgeons was 0.07. The
    Statistical analyses were performed with the IBM SPSS             percentages of physicians diagnostic accuracy in the same
for Windows Version 23.0. Numerical variables were sum-               department were demonstrated on Figure 1. The average
marized as mean ± standard deviation or median (min-                  percentage of diagnostic accuracy among dermatologists
imum-maximum). Categorical variables were given as                    was 74.3% and among plastic surgeons was 61.5%. There
frequencies and percentages. Categorical variables were               was not statistically difference in diagnostic accuracy be-
compared by chi square or Fisher exact test. Diagnostic               tween departments (P = 0.625).



      Table 1. Clinical characteristics of patients, features and histopathologic diagnoses of lesions

             Clinical characteristics                                                                          N (%)
 Age, years
 Median (min-max)                                    47 (18-83)
 Gender, N (%)
 Male                                                13 (50)
 Female                                              13 (50)
 Duration of lesions
                                                     Since childhood                                          3 (11.5)
                                                     <1 month                                                 3 (11.5)
                                                     <1 year                                                   5 (19)
                                                     1-5 years                                                 6 (23)
                                                     >5 years                                                  9 (35)
 Localization of lesions
                                                     Scalp                                                     13 (50)
                                                     Face                                                      1 (3.8)
                                                     Upper extremity                                          4 (15.4)
                                                     Lower extremity                                           1 (3.8)
                                                     Torso                                                     7 (27)
 The histopathologic diagnoses
                                                     Seborrheic keratosis                                         3
                                                     Verruca vulgaris                                             2
                                                     Epidermal cyst                                               2
                                                     Dermatofibroma                                               3
                                                     Fibroma                                                      3
                                                     Sebaceous adenoma                                            1
                                                     Bowen disease                                                1
                                                     BCC                                                          3
                                                     SCC                                                          3
Min = minimum; Max = maximum; BCC = basal cell carcinoma; SCC = squamous cell carcinoma



Original Article | Dermatol Pract Concept. 2022;12(3):e2022124                                                                    3
                                        90%
                                              80.8%
                                        80%                                                            76.9%
                                                      73.1%
                                                              69.2%
                                        70%
              DIAGNOSTIC ACCURACY (%)
                                        60%
                                                                                            53.8%                 53.8%

                                        50%

                                        40%

                                        30%

                                        20%

                                        10%

                                        00%

                                                                      1   2     3


          Figure 1. The frequencies of each dermatologist (the left columns) and plastic surgeon’s (the right columns)
          diagnostic accuracy.



    Dermatologists preferred surgical procedures for 14                       lesions [2]. Similarly, in another study, the diagnostic rate of TD
(53.8%) lesions and nonsurgical procedures for 12 (46.2%)                     was found 59.0% for non-pigmented neoplasms [11]. Şenel et
lesions. Plastic surgeons preferred nonsurgical procedures                    al reported that diagnostic accuracy of non-melanocytic skin
for one lesion (3.8%) whereas surgical procedures for 25                      tumors by TD was 85.0% and 88.0% for 2 different dermatol-
lesions (96.2%). There was a statistically significant dif-                   ogists [15]. Diagnostic agreement rates were reported to be be-
ference between the departments for treatment approaches                      tween 47.7% to 87.3% for non-pigmented lesions by Warshaw
(P < 0.001) (Figure 2).                                                       et al [11], Giavina-Bianchi et al also studied diagnostic accuracy
    The need of dermoscopic images in addition to clinical                    of TD for both pigmented and non-pigmented skin lesions. They
pictures was an average of 80.7% of the lesions for der-                      reported accuracy rates of 75.0%, 71.0%, 64.0% and 50.0%
matologists. Diagnostic accuracy of TDS was 82% for all                       for basal cell carcinoma, squamous cell carcinoma, cysts, and
lesions which were confirmed by histopathologically. TDS                      warts/seborrheic keratosis or lipomas, respectively [20].
increased the rate of mean diagnostic accuracy of TD from                           Although there are studies which were performed with
74,3% to 82% among dermatologists (P = 0.02) (Table 2).                       plastic surgeons about efficacy of TM in various conditions
    Among plastic surgeons, the average percentage of re-                     such as wound and burn management, trauma, free flap
questing a dermatology consultation before treatment deci-                    care, cleft lip/palate repair, there is not any report about di-
sion was 28.2% (Table 2).                                                     agnostic accuracy of NMSLs diagnosis with TM method [1].
                                                                              FTF studies demonstrated that the overall diagnostic accu-
                                                                              racy of skin lesions for plastic surgeons was around 60.0%
Conclusions
                                                                              to 89.0% [17,21-23]. Clinical diagnosis matched with the
In the current digital and locked-down world related to                       pathological diagnosis was considered as a correct diagno-
COVID-19 pandemic, TM helps physicians for diagnosis                          sis in these studies. Sönmez et al [17] reported correct di-
and management of the patients. The diagnostic accuracy                       agnosis rate for PRS clinic as 61.4% and Matteucci et al
and therapeutic approach to NMSLs by using TD was eval-                       [22] reported an overall diagnostic accuracy of malignant
uated between dermatology and PRS departments in the                          lesions of 83.0%. Basal cell carcinomas were diagnosed with
current study. While there was no difference between the 2                    the highest degree of accuracy with 89.0%, whereas squa-
departments in diagnostic accuracy, a significant difference                  mous cell carcinomas were with a lower level of diagnostic
was found in treatment approach in favor of the surgical                      accuracy with 33.0% [22]. The correct diagnostic rate for
approach among plastic surgeons.                                              basal cell carcinoma was 68.0% in the study by Stone et al
    Diagnostic reliability and accuracy of TM among dermatol-                 [21]. In Hallockstudy, overall diagnostic accuracy was 65%
ogists was found to vary from 47.7% to 88.0% in the literature                in 2000 excised skin tumors [23]. Our diagnostic accuracy
[2,11,15,19,20]. Fabbrocini et al reported a correct diagnosis                rates for dermatologists and plastic surgeons in the diagnosis
rate of 52.0% for dermatologists using TDS for difficult pink                 of NMSLs were compatible with previous studies.



4                                                                                   Original Article | Dermatol Pract Concept. 2022;12(3):e2022124
                                                                                                96.2%
                                          100%


                                          80%


                 TREATMENT APPROACH (%)   60%
                                                                  53.8%
                                                         46.2%
                                          40%


                                          20%

                                                                                                             3.8%
                                          00%
                                                          DERMATOLOGIST                        PLASTIC SURGEON

                                                          SURGICAL PROCEDURES     NON-SURGICAL PROCEDURES


             Figure 2. The frequencies of the treatment approaches of dermatologists and plastic surgeons (p <0.001)



                                            Table 2. The response rates of dermatologists and plastic surgeons

                                                                                      D1                D2            D3
                                                                                   n/N (%)         n/N (%)          n/N (%)      Average %
 In how many lesions did dermatologists request dermoscopic                         24/26           26/26            13/26          80.7
 images to confirm their diagnosis?                                                 (92.3)          (100)             (50)
 In how many lesions was teledermoscopic pre-diagnosis                              23/26           21/26            20/26          82.0
 histopathologically compatible? (Diagnostic accuracy of TDS)                       (88.5)          (80.8)           (76.9)
                                                                                    n/ND            n/ND             n/ND             %
                                                                                     (%)             (%)              (%)
 For how many lesions that required dermoscopic                                     10/24           17/26             8/13           563
 confirmation were also requested histopathological                                 (41.7)          (65.4)           (61.5)
 confirmation?
                                                                                     P1              P2               P3         Average %
                                                                                    n (%)           n (%)            n (%)
 Requesting dermatology consultation                                                   2              11               9            28.2
                                                                                     (7.7)          (42.3)           (34.6)
D1 = Dermatologist-1; D2 = Dermatologist-2; D3 = Dermatologist-3; P1 = Plastic surgeon-1; P2 = Plastic surgeon-2; P3 = Plastic surgeon-3;
N = Total number of lesions; ND = total number of lesions that required dermoscopic image; TDS = Tele-dermoscopy



    Although there is no data comparing diagnostic accuracy                     et al, which compared the diagnoses rates for various skin
for various skin lesions between dermatologists and plas-                       lesions for dermatology and PRS departments, overall cor-
tic surgeons by using TM in the scientific literature, there                    rect diagnosis rate of biopsied skin lesions was 64.0% for
are some reports with FTF methods [16-18,21]. Sellheyer                         the dermatology clinic and 61.4% for the PRS clinic and did
and Bergfeld reported that dermatologists accurately diag-                      not differ significantly between the 2 clinics [17]. Similar to
nosed neoplastic and cystic skin lesions nearly 2 times more                    the Sönmez et al study, the diagnostic accuracy rate did not
(75%) than non-dermatologist physicians (40%) or plastic                        differ between the 2 departments in the current study. Our
surgeons (45%) [18]. Similarly, Stone et al reported higher                     findings suggest that the TM method has similar results to
positive predictive value for basal cell carcinoma (as one of                   FTF in terms of comparing diagnostic accuracy for derma-
malignant NMSLs) diagnosis of dermatologists (85%) than                         tology and PRS departments.
plastic surgeons (68%) [21]. In another study, similar diag-                       With the use of dermoscopy, correct clinical diagnosis
nostic rates for basal cell carcinoma were reported among                       especially for the pigmented lesions and benign neoplastic
dermatologists and plastic surgeons which were higher than                      lesions increased in recent years [17]. The efficacy of contri-
other physicians [16]. In a retrospective study by Sönmez                       bution of dermoscopy to TD has been investigating recently.



Original Article | Dermatol Pract Concept. 2022;12(3):e2022124                                                                               5
A study evaluating 1000 lesions suggested that TD and TDS          time-saving technique in the evaluation and management
might be valid and reliable tools for the diagnosis of actinic     [19]. Matteucci et al emphasized the importance of special-
keratosis [24]. Additionally, TDS was reported to be superior      izing, especially in lesions with predicted as low malignancy
to FTF dermoscopy and to TD only for detecting early actinic       risk [22]. Our results support the idea that e-consultation
keratoses [24]. Braun et al reported that diagnostic accuracy      of the skin lesions to a dermatologist via TM may be an ef-
of NMSLs with TDS was higher than traditional dermo-               fective method to prevent unnecessary surgery for a plastic
scopic approach with the exception of Kaposi sarcoma [25].         surgeon.
Senel et al reported that TD was a reliable technique for the         Our study had some limitations. There were no predeter-
diagnosis of nonmelanocytic skin tumors and TDS increased          mined categories for clinical diagnosis of NMSLs and num-
the reliability and the accuracy of TD. The accuracy of the        ber of lesions was small. With higher number of physicians
diagnoses was significantly increased by the addition of der-      and different kinds of lesions, requirements of TD between
moscopic images from 85% to 94% and from 88% to 95%                clinics can be determined.
for 2 different tele-dermatologists [15]. On the other hand, it       In conclusion, TM is an easy method for NMSLs diag-
is also reported that TDS had an advantage for only biopsied       nosis with up to 75% of diagnostic accuracy. Adding TDS
pigmented lesions [19]. Fabbrocini et al evaluated difficult       to TD increases diagnostic accuracy for dermatologists on
pink lesions and reported lower correct diagnosis rate for         NMSLs diagnosis. The difference in treatment approach be-
TDS than FTF examination and they discussed that this re-          tween departments can be reduced through the effective use
sult might be cause of the absence of typical criteria of pink     of TD and TDS via e-consultation.
lesions [2]. In the present study, dermatologists had agreed
that TDS was helpful to confirm their clinical diagnoses in
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Original Article | Dermatol Pract Concept. 2022;12(3):e2022124                                                                                 7
