Analysis of live interactive teledermatologic consultations for prisoners in Korea for 3 years

Abstract

Introduction

Teledermatology has contributed to the enhanced accessibility of underserved populations. This study investigated the prevalence and clinical outcomes of dermatologic diseases in prisoners in Korea through live interactive teledermatology (LITD)

Method

The medical records of patients in a Busan prison, who interacted with a dermatologist using LITD from July 2013 to August 2016, were reviewed retrospectively.

Results

The mean age of the 406 patients enrolled in the study was 39.0 years and 91.4% were male. Infectious disease (42.8%) was the most common type of disease, followed by eczematous disease (29.4%) and diseases of the skin appendages (14.5%). Among the 187 (38.2%) patients who had a follow-up consultation, 162 (86.7%) showed clinical improvement, whereas 21 showed either no change or a worse clinical outcome. Twenty patients were diagnosed with different types of dermatologic disease at follow-up consultations.

Discussion

LITD can contribute to a favourable clinical outcome and may thus be an effective alternative to face-to-face consultation in prisoners and other underserved populations.

Keywords

Prison skin disease teledermatology

Introduction

A previous study showed that prisoners sought medical consultations for their medical problems three times more often than the general population, with dermatological conditions being the fifth most common medical issue.¹ Although the importance of specialist management of dermatologic problems in prisons has received increasing attention,^2,3 there have been only a few investigations of dermatologic disease in inmate populations. In addition, face-to-face consultations between dermatologists and prisoners are often challenging. Teledermatology has been introduced as a useful alternative to face-to-face dermatologic consultations for underserved populations, such as those in rural areas, the armed services, and prisons.^4-6 Among the various teledermatology techniques, store and forward teledermatology (SFTD), which uses captured images, is the most common.⁷ Khatibi et al.⁸ reported the results of SFTD-based teledermatologic consultations done in a prison population. However, to our knowledge, the efficacy of live interactive teledermatology (LITD), which uses real-time video communication, has yet to be tested in this setting. Thus, the present study is a retrospective analysis of LITD in Korean prisoners.

Methods

Teledermatologic consultations were held once a week, beginning in March 2013. The LITD equipment in both the hospital and the prison consisted of a monitor connected to a 720-pixel-resolution camera with an LED illumination system (YouNaCare Lite; U-Shin C&C, Ansan, Republic of Korea). The videoscope installed in the prison for LITD enabled an up to 16-fold enlargement of skin lesion images.

Prisoners with skin problems could obtain an appointment for a teledermatologic consultation with a dermatologist via the prison officer. At consultation, the dermatologist diagnosed the disease and recommended treatment based on real-time consultation and visual inspection using the LITD equipment. When laboratory tests or a dermatologic examination were required, the patient visited the hospital after receiving permission from the prison officer.

This study was a retrospective review of the medical records of patients in a Busan prison who sought LITD-based consultation with a dermatologist from Busan Paik Hospital from July 2013 to August 2016. The collected data included sex, age, description of the skin lesion, diagnosis, treatment, and clinical course.

Dermatologic diseases were categorized as described elsewhere.⁹ The distribution of dermatologic diseases at the first consultation was assessed. For patients with more than one consultation, the clinical outcome was analysed according to the second consultation. The clinical outcome was evaluated according to the diagnosis made at the first consultation. For patients diagnosed with more than one dermatologic disease, the outcomes were evaluated separately. If the interval between consultations was <6 months, the clinical outcome was classified as improved, no change, or aggravated based on an overall assessment of the skin lesion and related symptoms done by the dermatologist. Recurrence was defined when a patient sought a consultation >6 months after the previous consultation for the same condition. Data from patients who made use of LITD for a new-onset, different skin problem at the follow-up consultation were also evaluated. Patient management proceeded according to the diagnosis made at the first consultation, and the numbers of drugs prescribed according to disease category were calculated. This study was approved by the Institutional Review Board of Busan Paik Hospital.

Results

Demographic information

The 406 patients enrolled in this study received a total of 490 diagnoses at the first consultation. The mean age of the largely male (91.4%) study population was 39.0 years, ranging from 17 to 76 years. Demographic details are provided in Table 1.

Table 1.

Demographic information of the patients.

Patient information	No. (%)
Sex
Male	371 (91.4)
Female	35 (8.6)
Age group	Mean age: 39.0
≤19	19 (4.7)
20–29	85 (20.9)
30–39	121 (29.8)
40–49	97 (23.9)
50–59	73 (18.0)
≥60	11 (2.7)
Number of diagnosis at 1^st consultation	Total number of diagnoses: 490
1	329 (81.0)
2	70 (17.2)
3	7 (1.8)
Number of consultation	Total number of consultations: 697
1	254 (62.6)
2	84 (20.7)
3	38 (9.3)
4	15 (3.7)
5 or more	15 (3.7)

Distribution of dermatological diseases at first consultation

Most of the diagnosed dermatologic diseases were confined to six categories (infectious disease, eczematous disease, diseases of the skin appendages, papulosquamous disease, drug eruption/erythema/urticaria, and pruritic dermatosis). Disease categories including less than five cases were grouped as “others”.

Infectious disease (42.8%) was the most common type of disease, followed by eczematous disease (29.4%), diseases of the skin appendages (14.5%), and papulosquamous disease (4.3%) (Table 2). Among the infectious diseases, dermatomycosis (33.8%) was the most common, followed by folliculitis (33.3%) and scabies (24.8%). Among the eczematous diseases, contact dermatitis (58.3%) was the most common, followed by seborrheic dermatitis (23.6%) and atopic dermatitis (8.3%). Acne vulgaris (77.5%) was the most common skin appendage disease, followed by alopecia (9.8%) and rosacea (9.8%).

Table 2.

Classification of dermatologic diseases at the first consultation.

Category	Disease	No. (%)
Infectious disease		210 (42.8%)
	Dermatomycosis	71
	Folliculitis	70
	Scabies	52
	Viral infection	11
	Cellulitis	4
	Syphillis	2
Eczematous disease		144 (29.4%)
	Contact dermatitis	84
	Seborrheic dermatitis	34
	Atopic dermatitits	12
	Nummular eczema	8
	Hand eczema	5
	Stasis dermatitis	1
Disease of skin appendage		71 (14.5%)
	Acne vulgaris	55
	Alopecia	7
	Rosacea	7
	Hidradenitis suppurativa	1
	Osmidrosis	1
Papulosquamous disease		21 (4.3%)
	Psoriasis	18
	Exfolicative dermatitis	1
	Pityriasis lichenoides	1
	Pityriasis alba	1
Drug eruption/ erythema/ urticaria		17 (3.5%)
	Urticaria	13
	Drug eruption	3
	Toxic erythema	1
Pruritic dermatosis		17 (3.3%)
	Pruritus	6
	Lichen simplex chronicus	5
	Prurigo	5
Others		11 (2.2%)
	Vasculitis	3
	Scar	2
	Callus	2
	Burn	1
	Miliaria rubra	1
	Postinflammatory hyperpigmentation	1
	PUPPP	1

PUPPP: Pruritic urticarial papules and plaques of pregnancy

Follow-up consultation

The majority (n = 254, 62.6%) of the prisoner patients sought a consultation only once, while the remainder (n = 152, 37.4%) sought two or more consultations (Table 1). According to the disease category, the rate of re-consultation was highest in patients with pruritic dermatosis (43.7%), diseases of the skin appendages (40.8%), infectious disease (38.6%), and papulosquamous disease (38.1%) (Table 3).

Table 3.

Rate of follow-up consultations by disease category, as diagnosed at the first consultation.

	No.	Follow-up consultation No. (%)
Category	No.	(+)	(–)
Total	490	187 (38.2)	303 (61.8)
Infectious disease	210	81 (38.6)	129 (61.4)
Eczematous disease	144	52 (36.1)	92 (63.9)
Disease of skin appendage	71	29 (40.8)	42 (59.2)
Papulosquamous disease	21	8 (38.1)	13 (61.9)
Drug eruption/ erythema/ urticaria	17	6 (35.3)	11 (64.7)
Pruritic dermatosis	16	7 (43.7)	9 (56.3)
Others	11	4 (36.4)	7 (63.6)

Management

The different approaches to disease management according to disease category are summarized in Table 4. Laboratory tests were recommended for two patients with suspected syphilis. One patient was tested at another hospital and had a positive result. The other patient was not tested.

Table 4.

Drugs prescribed to the prison patients at the first consultation.

Category	AH	AN	TCS	SCS	TCI	TR	TAF	SAF	TAB	SAB	TAV	SAV	IC	Other
Infectious disease	106	4	11	14	–	2	73	49	59	49	1	6	51	3 (SA)
Eczematous disease	94	–	130	52	3	–	16	2	3	16	–	–	–	1 (TR)
Disease of skin appendage	28	–	8	10	4	16	8	–	38	51	–	–	–	–
Papulosquamous disease	11	–	20^#	2	–	–	1	1	2	–	–	–	–	3 (CS)
Drug eruption/ erythema/ urticaria	17	–	6	8	–	–	–	–	–	–	–	–	–	–
Pruritic dermatosis	13	–	14	3	–	–	–	–	–	1	–	–	–	–
Others	2	1	3	1	–	–	–	–	1	–	–	–	–	2
Total number of prescription	276	5	192	90	7	18	98	52	103	117	1	6	51	9

AH: Antihistamine; AN: Analgesic; TCS: Topical corticosteroid; SCS: Systemic corticosteroid; TCI: Topical calcineurin inhibitor; TR: Topical retinoid; TAF: Topical antifungal; SAF: Systemic antifungal; TAB: Topical antibiotic; SAB: Systemic antibiotic; TAV: Topical antiviral; SAV: Systemic antiviral; IC: Insecticide; SA: Salicylic acid; TR: Trental; CS: Cyclosporin

^#Eleven of 20 patients received topical steroid which is combined with vitamin D analogue

Clinical outcome at the second consultation

The clinical outcomes of patients who sought a second consultation are summarized in Table 5. Among the 15 patients showing no change in their condition, acne vulgaris (four patients) was the most common disease, followed by two cases each of seborrheic dermatitis and dermatomycosis, and one case each of scabies, folliculitis, atopic dermatitis, nummular eczema, stasis dermatitis, alopecia, and prurigo. Six patients had aggravated conditions: two cases each of contact dermatitis and atopic dermatitis, and one case each of scabies and tinea. Recurrence was seen in two patients with scabies, one patient with folliculitis, and one with urticaria.

Table 5.

Comparison of clinical outcomes at the second consultation according to dermatologic disease category, as diagnosed at the first consultation.

Category	Clinical outcomes at 2^nd consultation No. (%)
Category	Improved	No change	Aggravated	Recurred
Total	162 (86.7)	15 (8.0)	6 (3.2)	4 (2.1)
Infectious disease	72 (88.9)	4 (4.9)	2 (2.5)	3 (3.7)
Eczematous disease	43 (82.7)	5 (9.6)	4 (7.7)	0 (0.0)
Disease of skin appendage	24 (82.8)	5 (17.2)	0 (0.0)	0 (0.0)
Papulosquamous disease	8 (100.0)	0 (0.0)	0 (0.0)	0 (0.0)
Drug eruption/ erythema/ urticaria	5 (83.3)	0 (0.0)	0 (0.0)	1 (16.7)
Pruritic dermatosis	6 (85.7)	1 (14.3)	0 (0.0)	0 (0.0)
Others	4 (100.0)	0 (0.0)	0 (0.0)	0 (0.0)

Newly diagnosed dermatologic diseases at follow-up consultation

At the follow-up consultation, 20 patients complained of new-onset skin lesions that differed from their pre-existing lesions. Scabies, the most common condition, developed in seven patients, followed by dermatomycosis (5), contact dermatitis (3), acne vulgaris (3), and viral infection (2). Twelve patients were diagnosed at a second consultation, four at a third, two at a fourth, and one each at fifth and sixth consultations.

Scabies

At the first consultation, 52 patients were diagnosed with scabies. Two patients initially diagnosed with contact dermatitis showed an aggravated condition at the second consultation and were re-diagnosed with scabies. Seven other patients with skin problems different from those at the previous consultation were diagnosed with scabies at the follow-up consultation. Thus, in this study, 61 patients were clinically diagnosed with scabies. Among the 52 patients already diagnosed with scabies at the first consultation, 28 did not seek a further consultation, whereas the others sought two or more consultations. One patient each had no change or showed disease aggravation at the second consultation. They stopped insecticide (lindane) use at the second consultation and were instead started on a topical corticosteroid based on a clinical impression of contact dermatitis.

Discussion

The use of teledermatologic consultations is expanding worldwide.¹⁰ For diseases involving the skin, teledermatologic consultations provide easy access to dermatologists, especially for geographically isolated patients, such as those who live in rural areas or on islands, or who are imprisoned. Because dermatologic disorders usually show characteristic gross findings, in terms of colour, shape, and distribution, they are especially suited for telemedicine.¹¹ There are currently two types of teledermatologic techniques, SFTD and LITD. In SFTD, the skin disease is diagnosed after the physician has obtained information about the patient, as well as images of the lesion. In LITD, the patient and physician communicate with each other directly through real-time video consultation.¹² White⁷ analysed the diagnostic reliability, accuracy, and clinical outcomes of patients evaluated by teledermatologic consultation and showed that both SFTD and LITD have considerable accuracy compared with conventional face-to-face consultations. Although LITD is more time-consuming for physicians than SFTD, it may save time over the long term by allowing the physician’s questions to be clarified immediately via real-time imaging and communication.⁷

The importance of health care in prisons has been increasingly recognized. Skin diseases are a common health problem among prisoners¹ because of certain environmental factors that are commonly present, such as cohabitation, overcrowding, and humid and hot conditions; together with poor personal hygiene, these factors may favour disease development.¹³ Previous studies of the distribution of dermatologic diseases diagnosed by face-to-face consultations in prisons identified infectious disease and non-specific dermatitis as being the most common,^13–15 in agreement with our results. This convergence can be explained by the similar environmental and demographic features of the evaluated populations.

The effectiveness of teledermatologic consultations for prisoners was verified by the improved clinical outcome seen in the majority of patients (86.7%) who had a follow-up consultation, even though the follow-up rate was not particularly high (38.2%). The low follow-up rate may have been due to the specific environment of the prison, or to financial difficulties (where the prisoners were expected to pay for their own both teledermatologic and onsite consultation). Nonetheless, given the favourable results seen in patients having a follow-up consultation, the lack thereof was not necessarily negative. However, it may be necessary to increase the follow-up rate to overcome the limitations of teledermatologic consultations. In addition, this study showed that LITD enabled the detection of new-onset dermatologic problems and differentiated them from previously diagnosed conditions.

The unfavourable clinical response in the 21 patients with aggravated or unchanged conditions might have been related not only to natural disease progression, but also to the limitations of LITD, such as misdiagnosis and limitation in the selection of treatment. Misdiagnosis can arise from insufficient examination, for example the absence of palpation or potassium hydroxide smear.^16,17 In addition, indirect inspection done via a monitor, rather than direct assessment of a lesion, may result in subtle differences in the brightness or tint of a skin lesion and thus may influence the diagnostic process, especially for atypical lesions. Combining new methods, such as teledermoscopy, with teledermatologic consultation may reduce misdiagnosis. Dermoscopy is useful in the diagnosis of scabies and dermatomycosis, two diseases with a high prevalence in prisons, and its introduction in this setting holds promise. The clinical outcomes of patients with acne vulgaris, the most common disease in the “no change” group in this study, may have been improved if treatments such as surgical acne extraction had been allowed.

Despite these limitations, our study suggests that teledermatologic consultation for prisoners is an effective and reliable substitute for face-to-face consultations that overcomes the spatial constraints associated with this isolated population. The effectiveness of teledermatologic consultation is almost similar with that of onsite consultation in the same expense. To consider the risk of transportation for prisoners and the cost of transit workers to surveil them, teledermatologic consultation could be a safer and more cost-effective way to provide medical service than onsite consultation.

Finally, of the patients from the general population who visited our clinic during the same period, scabies was diagnosed in only 1.3% of cases. The higher incidence of scabies (1.3% vs. 12.8%, p < 0.001, relative risk 9.8) in the prison population than in the general population likely reflected prison-specific environmental factors, as discussed above, as well as a poor understanding among prisoners of the clinical characteristics of scabies. Early detection of scabies is important to prisoner health, and teledermatology could play a role in early detection and prevention of dissemination.

In summary, while the number of patients in our study was not sufficient to allow for assessment of the prevalence of skin diseases in the prison setting, or the reliability of teledermatologic consultations, most of the patients evaluated in follow-up consultations had a good outcome. Thus, teledermatology seems to be a good method to overcome time and space constraints in healthcare provision, and is a satisfactory technique for providing medical consultations for underserved patients, such as those in prisons.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by 2017 Inje University Busan Paik Hospital research grant.

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