eMedicine Specialties > Dermatology > Technology & Dermatology

Store-and-Forward Teledermatology

Hon Pak, MD, Assistant Professor, Department of Dermatology, Uniformed Services University of Health Sciences; Consulting Staff, Department of Dermatology, Brooke Army Medical Center
Günter Burg, MD, Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland

Updated: May 30, 2008

Introduction

Teledermatology is best defined as the practice of dermatology using available communication and information technology. Given its visual nature, dermatology is well suited for telemedicine, and with advances in digital imaging technology and the availability of the Internet, the full potential of teledermatology (ie, improved patient access, more cost-effective medicine, expanded continuing medical education and distance learning) seems more within reach. However, teledermatology cannot replace a traditional face-to-face dermatology evaluation in every instance.

To date, studies on diagnostic agreement between teledermatology evaluations and in-person evaluations have reported a rate of 41-95% for store-and-forward (S&F) teledermatology and a rate of 54-99% for real-time teledermatology. This is mainly reported as an interobserver diagnostic correlation rate because the field of dermatology has no real "gold standard." The variability in diagnostic correlation rates is due to differences in methodologies and how agreements are defined and measured. For example, some studies report simple agreement versus disagreement, while others include partial agreements. In addition, some studies focus on specific skin conditions such as cutaneous malignancies, while others focus on general skin conditions.

Prior research has demonstrated that S&F teledermatology results in acceptable levels of reliability and accuracy compared with clinic-based evaluations. Until recently, no study had definitively demonstrated the impact of teledermatology on clinical outcome. Using a randomized clinical trial study design, Pak et al^1,2 demonstrated that S&F teledermatology results in an equivalent clinical course compared with a conventional clinic-based consultation process. Clinical-course assessments were made by serial digital imaging performed at baseline and at 4 months after enrollment. This was the first study to comprehensively address the impact of S&F teledermatology on clinical course. The authors are not aware of a similar large clinical outcomes study with real-time teledermatology.

Based on the literature, S&F teledermatology appears to be as clinically effective as real-time teledermatology. Each modality has distinct benefits and disadvantages, and a combined hybrid modality is now being used with greater frequency. Although teledermatology has been very successful in certain regions and organizations, widespread adoption of teledermatology has been limited, not because of technology, but because of fundamental flaws in the current US health care model and the change in the workflow and responsibilities among nurses, referring physicians, and specialists.

The eMedicine article Teledermatology may be of interest.

S&F Versus Live Video Teleconference Teledermatology

The 2 methods of teledermatology are S&F teledermatology and live video teleconference (VTC) teledermatology. VTC teledermatology uses a synchronous video and audio transmission to allow a live, interactive consultation between a patient and a remote physician (usually a specialist). S&F teledermatology is a method of sharing information in a manner independent of time (asynchronous) and place using digital images and clinical information received via the Internet for consultation with a remote dermatologist.

Each mode has its advantages and disadvantages; however, most dermatologists tend to favor S&F teledermatology because it is less expensive and more practical. The major advantage of VTC teledermatology is that it most closely mimics the traditional face-to-face evaluation and allows a live interaction between the dermatologist and the patient. However, its distinct disadvantages are its higher cost, higher bandwidth, and, most importantly, requirement for coordination. On the other hand, S&F teledermatology is less expensive because it uses the widely available Internet and readily available commercial, off-the-shelf equipment (eg, digital camera). More importantly, S&F teledermatology does not require coordination between the physician and the patient, thereby saving valuable time.

Early Evolution of Digital Imaging and Teledermatology

The evolution of S&F teledermatology parallels the advances in digital imaging and the Internet, whose rapid growth has allowed fast and efficient transmission of digital information. Pioneering work by several dermatologists and other advances in technology are responsible for the current state of teledermatology.

Using 180 digitized slides of various dermatologic diseases at 3 different resolutions, Perednia et al³ reported that color slides and their digitized images (574 X 489 pixels at 24-bit color) were statistically similar. Using the multiple-choice receiver operating characteristic analysis, they found that this similarity was true even when stratified by difficulty of diagnosis. In 1997, Bittorf et al⁴ reported that images at 768 X 512 pixels at 24-bit color were perceived equivalent to images at higher resolutions.

In an attempt to determine the effectiveness of imaging as a replacement for physical examination, Harrison et al⁵ used conventional photographic prints of skin tumors from 210 patients to make a diagnosis and compared the results with the criterion standard of histologic diagnosis. They reported 71% diagnostic accuracy for the images studied by a dermatologist (histologic diagnosis after physical examination) compared with 49% accuracy for those studied by referring physicians (via prints).

To test digital imaging in a real-world setting, Provost et al⁶ digitized and compressed (joint photographic E G [JPEG]-10-16:1 compression) conventional and dermatoscopic photo transparencies of 31 pigmented lesions (ie, 22 atypical melanocytic nevi, 9 biopsy-proven early malignant melanomas), sent them via the Internet, and then had dermatologists evaluate them via a color computer monitor. He determined an overall 87% rate of diagnostic agreement for clinical images and 92% agreement for dermatoscopic images. Although the dermatologists' performances in the diagnostic assessment of digitized images appear to not be affected by the level of compression (up to 40X), Sneiderman et al⁷ reported in 1994 that ratings of image quality for compressed images are significantly lower than for uncompressed images and for original photographic slides.

With the reduction of image quality, Herrmann et al⁸ report that the reliability of the diagnosis is reduced. In 2005, Yagi and and Gilbertson⁹ and Brauchli et al¹⁰ report that new scanning technologies allow telepathological, entire-slide image analysis and conferencing in superior quality.

Reliability, Confidence, Biopsy Rate, Limitations, Outcome, and Satisfaction

This section reviews and summarizes the key findings in the literature. For a thorough analysis of the literature in the area of reliability, see the following 2 articles (also referenced in the Bibliography):

• Whited JD.¹¹ Teledermatology research review. Int J Dermatol. Mar 2006;45(3):220-9.
• Eminovic N, de Keizer NF, Bindels PJ, Hasman A.¹² Maturity of teledermatology evaluation research: a systematic literature review. Br J Dermatol. Mar 2007;156(3):412-9.

Reliability

Although recognized that a dermatologist's diagnosis based on a face-to-face evaluation cannot be 100% accurate, most studies addressing the reliability of teledermatology have compared interobserver diagnosis (teledermatology vs face-to-face consultation) to determine its effectiveness. 
 
Interobserver reliability

Interobserver reliability rates between teledermatologists and clinic-based dermatologists, when using S&F technology, has varied from 41-95%. One study assessed interobserver reliability in the context of the baseline agreement found among different clinic-based examiners. The patient sample was examined by multiple clinic-based dermatologists and multiple teledermatologists. Interobserver reliability between (1) clinic-based examiners and teledermatologists and (2) teledermatologists and teledermatologists was compared with the level of reliability found between different clinic-based examiners. 
 
Comparable reliability was found among all groups, as evidenced by the overlapping 95% confidence intervals (CIs). The kappa statistic is a chance-corrected measure of agreement that is often used in reliability assessments. Although somewhat arbitrary, a kappa of 0.61 or higher is considered a substantially higher level of agreement than would be expected by chance alone and is generally accepted as a benchmark of high reliability.
 
Intraobserver reliability

Intraobserver agreement is measured between an examiner reviewing a patient in a clinic setting and the same examiner reviewing that patient's teledermatology consultation. Pak et al^1,2 reported the first diagnostic correlation study of an S&F teledermatology consultation system that used strictly an intraobserver comparison. This intraobserver study was an attempt to evaluate a teledermatology consultation system without taking into account the diagnostic variability among the dermatologists. Diagnostic agreement rates using S&F technology have been reported to be 61-91%. Variations in the results from these studies are due, in part, to sample size, the definition of agreement, interobserver variability, and the exclusion of certain types of skin conditions. Although researchers found no statistical difference in the disagreement rate between a face-to-face evaluation and a teledermatologist evaluation, a different study reported that teledermatologists tended to give more broad differentials rather than a single diagnosis.

Contrary to Kvedar et al,¹³ who reported that no specific disease category was more or less difficult to diagnose, Pak et al¹⁴ found that papulosquamous conditions, as a category, had the lowest rate of complete agreement (59%). This is consistent with the findings of Zelickson and Homan,¹⁵ who determined that eruptions were more difficult to diagnose than lesions. Loane et al¹⁶ also reported that eczematous conditions accounted for more than one third of all inappropriate management decisions. Although not completely clear, this lower diagnostic correlation and higher uncertainty may occur for several reasons, such as the inability to perform in-office tests (eg, potassium chloride preparations) or to palpate the lesions. Perhaps more important is the potential sampling error, in which the contributing or referring physicians submit images that are not representative of the patient's true skin condition.

Diagnostic confidence level

Confidence has been measured most commonly for dermatologists answering the consultation, and results vary slightly from study to study. However, in general, the confidence level is generally high. For example, Krupinski et al¹⁷ reported in 1999 (n = 308) that the confidence among dermatologists was "very definite to definite" 62% of the time. In a study by Kvedar et al,¹³ the diagnostic certainty level (diagnostic confidence) correlated well with the type of diagnostic agreement. However, the literature reveals that the confidence level is slightly lower for teleconsultations compared with face-to-face evaluations.

Pak et al¹⁴ found the diagnostic certainty level of new teledermatologists to be generally lower in the teledermatology group (confidence level = 7) compared with the in-person evaluation group (confidence level = 9). In a multicenter, longitudinal, 4-phase, descriptive and evaluation study (n = 2009), Moreno-Ramirez et al¹⁸ rated diagnostic confidence on a 3-point scale, with 3 indicating an absolutely confident clinical diagnosis and 1 indicating an absolutely uncertain diagnosis. They reported a mean confidence level for teleconsultation of 2.59 (95% CI, 1.98-3.00), lower than that of a face-to-face evaluation at 2.84 (95% CI, 2.45-3.00). In a separate study, Moreno-Ramirez et al¹⁹ reported that the confidence level increased when teledermoscopy was added to the teleconsultations (4.75 vs 4.14, P <.05).

Not surprisingly, High et al²⁰ showed that the high confidence level did correlate with higher diagnostic concordance between face-to-face dermatology evaluation and teledermatology.

The authors hypothesize that the lower diagnostic confidence levels are due to multiple reasons, including a lack of confidence in the new computer technology, an inability to obtain additional history, an inability to perform in-office tests, and a lack of training in teledermatology.

Procedure rates/biopsy rates

In an earlier study by Pak et al,^1,2 teledermatology evaluations recommended biopsies more often (10% more often vs in-person evaluations). However, most reports to date indicate no differences in the recommendation for biopsy between in-person evaluations and teledermatologist evaluations. Shapiro et al²¹ reported no difference in the rate of biopsy between a face-to-face evaluation and teledermatology (n = 49). Hockey et al²² reported a biopsy rate of approximately 16% in their study in Australia.

In analyzing the economic data from the published teledermatology clinical outcomes study (n = 504), Pak et al found no difference in the clinical outcome or the biopsy/procedure rate between the control group (face to face) and S&F teledermatology. This result will be submitted for publication soon.

Of note, anyone starting a teledermatology program may see a slight transient increase in the biopsy rate, which will likely normalize as training improves and dermatologists become more familiar with teledermatology.

Limitations

S&F teledermatology has certain inherent limitations compared with a traditional dermatology visit. Much of the limitation is based on the shift in responsibility/work from dermatologists to primary care providers. In addition, a new role (consult manager/technician/imager) is introduced into the workflow. Furthermore, the success of any teledermatology program depends on the quality of the image, the skill of the photographer, and the quality of the patient. Other limitations include lack of interaction with the patient, an inability to palpate lesions, and the inability to perform simple laboratory tests such as potassium hydroxide or scabies preparations.

Many of these limitations can be minimized by improving the technology (better digital camera) and training (standards based, workflow), while others (workload shift to referring site) cannot be corrected. Although S&F teledermatology is not interactive, it does not preclude it. After reviewing a consult with ambiguous history or inconsistencies, one of the authors of this article has called patients prior to completing his reports.

The limitation for S&F teledermatology as it is currently being used (technology) is its inability to perform total body imaging. In the authors' opinion, varying body habitus, extent of hair growth, and folds prevent consistent total body mapping. This will likely change as technology improves and is capable of producing total cutaneous surface mapping.

Outcomes data

Only 2 prior studies have made any attempt to evaluate clinical outcomes, both using retrospective data analytic techniques. Krupinski et al¹⁷ reported a clinical course rating on 7 of 100 subjects at 6 months from the date of referral. One hundred percent (3 of 3) of the teledermatology patients were rated as having an "improved" clinical course, compared with 3 (75%) of 4 usual-care patients. A second study by Marcin et al²³ noted that 74 (58.3%) of 127 patients undergoing a teledermatology consultation were rated as achieving a "clinical improvement." This study did not have a comparable group undergoing conventional clinic-based care to use as a comparator.

Bowns et al²⁴ reported an outcomes study in 2006 (n = 208), but they had difficulties in recruitment and had potential biases introduced by selective loss of patients and a delay in obtaining a valid second opinion in the study group. They concluded that no valid conclusions could be drawn regarding the clinical performance of this model of S&F telemedicine.

Pak et al¹⁴ conducted the largest clinical outcomes study to date in teledermatology. The goal was to determine if S&F teledermatology results in comparable clinical outcomes compared with a conventional clinic-based consult process. Subjects were randomized to either usual care (a conventional clinic-based dermatology appointment) or an S&F teledermatology consultation. All subjects received baseline digital imaging and re-imaging performed 4 months later. The image sets from both study arms were used to make clinical outcome assessments between baseline and 4 months.

Blinded to randomization assignment, a dermatologist rated the clinical outcomes using a 3-point clinical course rating scale. Clinical course was rated as improved, no change, or worse. For usual care, 65.3% were rated as improved, 32.2% were rated as no change, and 2.5% were rated as worse. For teledermatology, 63.6% were rated as improved, 32.7% were rated as no change, and 3.7% were rated as worse (see below). The results of this study indicate that S&F teledermatology consultations result in comparable clinical outcomes compared with conventional referral processes and clinic-based evaluations.

The consult modality and clinical course rating, with results, are as follows:

• Usual care
• Improved and/or no change - 97.5%
• Worse - 2.5%
• Teledermatology
• Improved and/or no change - 96.3%
• Worse - 3.7%

Satisfaction
 
A large body of evidence indicates that patients have been largely satisfied with teledermatology and welcome it as a way to improve access to dermatologists. In some cases, patients expressed discomfort with not having a personal interaction with a dermatologist. However, according to a study by Huston and Burton²⁵ from 1997, only 16% of patients would prefer to see the specialist in person. The biggest source of dissatisfaction among patients was the long waiting times for follow-up after a consultation.
 
Weinstock et al²⁶ reported that both patients and providers considered this a useful program and would recommend it to a friend or colleague. Their greatest concern was their lack of direct contact with their dermatologist. Other common concerns were waiting time and follow-up. Privacy concerns were not commonly mentioned. Providers expressed greater satisfaction than their patients. Their greatest concerns involved the inability of the program to handle the demand.
 
Referring clinicians generally perceive that they receive educational benefits from the teledermatology consultation process. Whether this translates into a measurable gain of knowledge has not been validated. Anecdotal evidence shows that the volume of consultations generally decreases with time in a given stable population of referring providers, which thought to be due to the educational aspect. Referring clinicians express misgivings about the time requirements and consultation burden that teledermatology may impose on their practice.
 
As part of a randomized clinical trial that compared the clinical and economic outcomes of S&F teledermatology with a conventional referral process, Whited et al²⁷ conducted satisfaction assessments among participating patients, referring primary-care clinicians, and consultant dermatologists. A majority of referring clinicians (92%) and dermatologist consultants (75%) reported overall satisfaction with the teledermatology consultation process. Ninety-five percent of referring clinicians reported that teledermatology resulted in more timely referrals for their patients. This finding was validated by the observation that teledermatology patients reached a point of initial intervention significantly sooner than did patients in usual care (41 d vs 127 d; P = .0001).
 
Teledermatology patients reported satisfaction with the outcome of their teledermatology consultation 82% of the time. However, patients did not express a clear preference for a consultation method. A total of 41.5% of patients preferred teledermatology, 36.5% preferred usual care, and 22% were neutral. The authors have demonstrated a high level of satisfaction among all users of an S&F teledermatology consultation system, and, in some cases, survey results could be validated with observed clinical outcomes.

S&F Teledermatology Systems

The simplest S&F telemedicine systems use e-mail with images included as attachments. An example is the US Army's secure Army Knowledge Online (AKO) Teleconsultation system, through which deployed troops have teleconsultation support 24 h/d, 7 d/wk. The program has received almost universal acceptance by deployed providers, many of whom are repeat users. US Navy, Marine Corps, and Air Force providers serving in the most dangerous parts of the combat zone comprise greater than 21% of all teleconsultations generated.

Note the following statistics: 

• Fourteen specialties with contact groups
• Over 40 months (April 2004 to July 2007), 2824 teleconsultations performed
• Fifty-five known evacuations prevented
• Eighty-eight known evacuations facilitated following consultant's recommendation
• Eight hundred seventy-three different referring health care professionals
• Three hundred eighty-two teleconsultations performed on non-US patients
• Average reply time of 5.4 hours

More common are World Wide Web–based or client/web applications that allow consult history and images to be loaded onto a central server and routed to dermatologists. Many systems are used throughout the world; many were developed noncommercially (eg, Dermanet, PATH, Telederm), and others were the product of commercial development (eg, TeleDerm Solutions, Second Opinion). Each has benefits and limitations, and selection should be based on need and setting.

The use of hybrid systems has increased. Hybrid systems combine S&F technology (high-resolution still images) with the real-time VTC systems. In particular, the University of Missouri has been using this hybrid approach in the last few years and has found it very successful. Several surveys have been completed to assess volume, reimbursements, and modality (ie, live interactive vs S&F).

Obstacles to Telemedicine

The development and use of teledermatology has several obstacles, as follows:

• Malalignment of incentives: Fragmentation of reimbursement systems (eg, lack of Medicare reimbursement for S&F telemedicine) is a hindrance.
• Current health care system based on disease management rather than wellness
• Restrictions with interstate medical licensing (United States): This results in higher overhead to maintain multistate licenses.
• Issues of medicolegal liability: This has not been an issue. Teledermatologists, as consultants, make recommendations through the consultation system, and the referring physician ultimately must decide whether or not to accept the recommendations. In cases of a misdiagnosis, whether either or both physicians are liable remains unclear. To protect the physician, a disclaimer should state that the consulting physician is not responsible for misinterpretations due to a technical or conceptual weakness in the teledermatological consultation system used. Of note, the availability of malpractice insurance is lacking for private practice (ie, nonfederal, nonuniversity) dermatologists who want to perform only teledermatology. Most current teledermatologists have a dermatology practice in addition to the teledermatology section.
• Change in health care business model: The workload shifts from the dermatology office to the nurse and primary care providers at the referring site.

Given these obstacles to S&F teledermatology, successful implementation depends on a clear understanding of the issues and the development of a risk-mitigating strategy. Specifically, some or many of these issues may not be relevant for a given organization.

Reimbursement

Federal 

Center for Medicare/Medicaid Services (CMS)/Medicare reimburses for real-time teleconsultations in the United States, limited to designated nonmetropolitan statistical areas. Reimbursement for S&F teledermatology has been limited to federal demonstration project sites only in Alaska and Hawaii. The gathering  of data from this CMS demonstration project is ongoing.

State
 
Medicaid reimburses for real-time teleconsultations in most states. In addition, California, Arizona, Minnesota, and South Dakota also reimburse for both real-time and S&F teleconsultations.

• Thirty-eight programs in 25 states currently receive reimbursements from private payers.
• Three of the programs receive reimbursement for S&F teleconsultations.
•  Private payers appear to follow the leadership of Blue Cross & Blue Shield more than Medicare or Medicaid
•  More than 100 payers were identified, and Blue Cross & Blue Shield reimburse in 21 States.

Reimbursement data from the 16 most active teledermatology programs, as reported from the 2003 survey mentioned in Future Prospects, is as follows:

• Medicaid/Medicare/third party - 8
• Correctional contract - 3
• Grants only - 2
• Medicaid only - 1
• Medicare only - 1
• Medicaid/Medicare - 1
• Medicare/third party - 1
• Medicare/other government - 1
• Other - 1

Starting a Teledermatology Program

Although teledermatology has been beneficial and cost effective in some settings, the authors' experiences indicate that many teledermatology programs have failed, not because of the technology, but because teledermatology was implemented in isolation. A thorough understanding of an organization's business process and business model is crucial to the successful integration of teledermatology. In fact, unless teledermatology is integrated into the current business process and model, the chance for success is greatly reduced. Information is available on how to determine if teledermatology is right for an organization. Guides provide step-by-step instructions on implementation, including recommendations on a standardized imaging protocol for all teledermatology consultations. For more details, refer to this article: Pak HS.²⁸ Implementing a teledermatology programme. J Telemed Telecare. 2005;11(6):285-93.
 
Medscape's Medical Practice Management Resource Center and the Medical Malpractice and Legal Issues Resource Center may be of interest.

Future Prospects

Telemedicine enables physicians to use modern telecommunications technology to gain access to specialists promptly and conveniently, with satisfactory reliability and diagnostic accuracy.

In the near future, telemedicine will become an integral part of the health care system. Much greater transmission bandwidth will be readily available, and advances in digital imaging technology along with advances in cell phone/personal digital assistant (PDA) devices will allow patients to directly access dermatologists. Given the advances in telepathology, especially as it relates to automated scanning of slides, teledermatopathology will become part of daily practice.

Automated or assisted diagnostic devices such as Melafind will begin to fundamentally change how melanomas are diagnosed, and these types of diagnostic imaging technologies will become more commonplace.  Furthermore, with advances in microfluidics, nanotechnology, and other "labs on chips" combined with systems biology, teledermatology may even become the conduit to deliver dermatologic care.

Standards for telemedical referral has been devised for (1) content (eg, determining what specific information is required by the teledermatologist to make an accurate diagnosis) and (2) data structure (eg, Health Level 7 [HL-7]–compatible, Digital Imaging and Communications in Medicine [DICOM] for images), but the standards must be widely adopted to ensure patient safety while optimizing quality of care.

Although some issues remain unresolved (eg reimbursement), teledermatology will clearly enhance the delivery of dermatologic care to patients.

• Thirty-six states have telehealth programs that provide dermatology services.
• At least 62 programs in those states actively provide teledermatology services.
• Teledermatology using real-time mode is more common than programs using S&F technologies (34 vs 17).
• At least 7 programs use both real-time and S&F technologies to provide dermatology services.
• The number of real-time encounters in 2002 ranged from 11-1040, with an average of 295 per program.
• The number of S&F encounters in 2002 ranged from 12-1500, with an average of 545 encounters per program.

Multimedia

Media file 1: The Dermanet equipment.

Media file 2: The Dermanet equipment in use.

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Keywords

store and forward teledermatology, S&F teledermatology, video teleconferencing dermatology, Internet diagnosis, telemedicine, VTC dermatology, remote-access diagnosis, multispecialty interactive teleconsultation, multi-specialty interactive teleconsultation, telemedicine network, telecare, teledermatology consult system, teledermatology consultation system, telemedical activity, telemedical diagnosis, Dermanet, e-mail diagnosis, teledermatology evaluation, teledermatologist

Contributor Information and Disclosures

Author

Hon Pak, MD, Assistant Professor, Department of Dermatology, Uniformed Services University of Health Sciences; Consulting Staff, Department of Dermatology, Brooke Army Medical Center
Hon Pak, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: TeleDerm Solutions Ownership interest Board membership; American Telemedicine Association None Board membership

Coauthor(s)

Günter Burg, MD, Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland
Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association
Disclosure: Nothing to disclose.

Medical Editor

Harold S Rabinovitz, MD, Clinical Professor, Department of Dermatology, University of Miami School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Amanda Oakley, ChB, FRACP, MB, Clinical Director, Clinical Associate Professor, Department of Dermatology, Waikato Hospital, Hamilton, New Zealand
Amanda Oakley, ChB, FRACP, MB is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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