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Warshaw E, Greer N, Hillman Y, et al. Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic Review of the Evidence [Internet]. Washington (DC): Department of Veterans Affairs (US); 2010 Jan.

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Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic Review of the Evidence [Internet].

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APPENDIX EEVIDENCE TABLE: OVERVIEW OF STUDIES FOR KEY QUESTIONS 1 AND 2

Diagnostic Accuracy, Diagnostic Concordance, Management Accuracy, Management Concordance

Study Country Study design Funding# Subjects # ConditionsPopulation and Study CharacteristicsTeledermatology CharacteristicsOutcomes EvaluatedQuality Rating
A. Store and forward systems studies (n=41)
Warshaw 20095

United States, US armed service personnel/veterans

Repeated Measure

Funding: Department of Veterans Affairs Health Services R&D Service


542

542
Mean age (range): 66 years (23–94)
Gender: female 4%, male 96%
Race/ethnicity: white 97%

Condition characteristics:
Benign Neoplasm:267
Keratinocyte Carcinoma:84
Dysplastic Nevus: 155
Melanoma:36

Inclusion criteria: PSL
Exclusion criteria: Skin tags, previously biopsied lesions

Study duration (months): 3
Nikon Coolpix 4500, 3Gen Dermlite, Minolta X370 with Heine dermphot (TDSC)

Photographer: Support staff

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: Yes

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Warshaw 20096

United States, US armed service personnel/veterans

Repeated Measure

Funding: Department of Veterans Affairs Health Services R&D Service


728

728
Mean age (range): 71 years (21–94)
Gender: female 2%, male 98%
Race/ethnicity: white 99%

Condition Characteristics:
Keratinocyte Carcinoma - 385
Actinic Keratosis - 81
Benign Neoplasm - 258
Other - 4

Inclusion criteria: Non-pigmented neoplasms
Exclusion criteria: Skin tags, previously biopsied lesions

Study duration (months): 34
Nikon Coolpix 4500 3Gen Dermlite (TDSC)

Photographer: Support staff

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: Yes

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Edison 20087

United States

Repeated Measure Both SAF and LI

Funding: Federal Office for the Advancement of Telehealth, Health Resources and Services Administration


110

110
Mean age (range): 42 (7–92)
Gender: female 69%, male 31%
Race/ethnicity: white 85%, black 12%, Asian 2%, Hispanic 1%

Condition Characteristics (Only reported for 70):

Actinic Keratosis - 10
Acneiform - 12
Benign Neoplasm - 19
Dysplastic nevus - 1
Infectious - 7
Eczematous - 8
Other – 13

Inclusion criteria: New pts on study days
Exclusion criteria: NR

Study duration (months): 18
Camera: NR

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Fabbrocini 20088

Italy

Repeated Measure

Funding: NR


NR

44
Age: NR
Gender: NR
Race/Ethnicity: NR

Condition characteristics:
Melanoma - 22
Benign Neoplasm - 15
Dysplastic nevi - 7

Inclusion criteria: Non-pigmented, absence of regular network, or diameter <5 mm
Exclusion criteria: NR

Study duration (months): NR
Nikon 4500 Coolpix, Wild M650 Steromicroscope

Photographer: Dermatologist

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 8/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 1/3
 Data analysis: 1/2
Di Stefani 20079

Italy

Repeated Measure

Funding: NR


18

465
Mean age (range): 28.4 years (10–55)
Gender: female 39%, male 61%
Race/ethnicity: NR

Condition characteristics: PSL
Inclusion criteria: ≥3 clinically atypical nevi on back
Exclusion criteria: NR
Nikon 990 (macro), Videocap digital videodermoscopy

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Ferrandiz 200710

Spain

Repeated Measure

Funding: Instituto Carlos III


134

134
Mean age: 70.3 years
Gender: female 39%, male 61%
Race/ethnicity: NR

Condition characteristics:
Keratinocyte Carcinoma - 95
Actinic keratosis - 14
Melanoma - 1
Other - 3
Benign Neoplasm - 17

Inclusion criteria: Non-melanoma skin cancer or fast-growing vascular tumor
Exclusion criteria: “Lesions expected to require major reconstruction”, melanoma

Study duration (months): 12
Nikon Coolpix 4300

Photographer: NR

Time between photograph and gold standard (days): mean 26 days
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 0/2
Moreno-Ramirez11 2007

Spain

Repeated Measure

Funding: Instituto Carlos III


882

890
Mean age: 41.5 years
Gender: female 59%, male 41%
Race/ethnicity: NR

Condition characteristics:
Benign Neoplasm - 548
Keratinocyte Carcinoma - 119
Actinic keratosis - 102
Melanoma - 18
Infectious - 9
Papulosquamous/Other - 15
Other Malignant Neoplasm - 3
Dysplastic nevus - 76

Inclusion criteria: Circumscribed lesions
Exclusion criteria: NR

Study duration (months): 15
Nikon Coolpix 4300

Photographer: NR

Time between photograph and gold standard (days): <31

76
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 2/2
Bowns 200612

United Kingdom

Randomized controlled trial;
Data extracted from TD arm

Funding: National Health Service R&D grant
92

92
Mean age: intervention 43.6 years, Gender: female 63%, male 37%
Race/ethnicity: NR
Condition characteristics:

Malignancy- 3
Benign Neoplasm –5
Infectious - 4
Eczematous – 11
Papulosquamous/Other - 62
Acneiform - 7

Inclusion criteria: ≥ 16 years old, had not seen dermatologist in last year
Exclusion criteria: genital lesions

Study duration (months): NR
Nikon Coolpix 900

Photographer: Primary care staff, often general practitioner

Time between photograph and gold standard (days): mean 60
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 4/7
 Reference test: 2/3
 Data analysis: 2/2
Bowns 200613

United Kingdom

Repeated Measure

Funding: National Health Service R&D grant


256

256
Mean age: NR
Gender: female 53%, male 47%
Race/ethnicity: NR

Condition characteristics:
Keratinocyte Carcinoma – 54
Actinic keratosis-15
Dysplastic nevus-3
Melanoma-24
Benign neoplasm-159
Other-1

Inclusion criteria: Suspected skin cancer

Exclusion criteria: NR

Study duration (months): NR
Camera: NR

Photographer: Medical Photography Department

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 2/2
Moreno-Ramirez 200614

Spain

Repeated Measure

Funding: Instituto Carlos III


61

61
Mean age (range): 39 years (1–73)
Gender: female 71%, male 29%,
Race/ethnicity: NR

Condition characteristics:
Keratinocyte Carcinoma - 2
Benign Neoplasm - 54
Melanoma - 1
Dysplastic Nevus - 1

Inclusion criteria: PSL

Exclusion criteria: Pts who did not show to CD

Study duration (months): 2
Nikon Coolpix 4500 DermLite (TDSC)

Photographer: General practitioner

Time between photograph and gold standard (days): <30
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 1/2
Oakley 200615

New Zealand

Repeated Measure

Funding: NR


73

109
Mean age (range): 59 years (16–93)
Gender: female 64%, male 36%
Race/ethnicity: NR

Condition characteristics:
Keratinocyte Carcinoma - 43
Actinic keratoses - 17
Melanoma - 8
Benign neoplasms - 37
Papulosquamous/Other - 4

Inclusion criteria: New pts with skin growth
Exclusion criteria: Inflammatory dermatoses, infections, resolved lesions, poor quality images

Study duration (months): NR
Nikon Coolpix 955

38 TD (6 were trainee dermatologists)

Photographer: medical student

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Baba 200517

Turkey

Repeated Measure Both SAF and LI

Funding: NR


228

242
Mean age (range): 35 years (2–82)
Gender: female 63%, male 37%
Race/ethnicity: NR

Condition characteristics:
Acneiform - 41
Infectious - 54
Pre-malignant/Malignant- 2
Eczematous - 46
Benign Neoplasms - 45
Papulosquamous/Other - 54

Inclusion criteria: New dermatology pts
Exclusion criteria: None

Study duration (months): 2.3
Canon Powershot S10

Two dermatologists with 3 to 5 years experience.

Photographer: Nurse

Time between photographing and gold standard test (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Mahendran 200516

United Kingdom

Repeated Measure

Funding: NR


163

163
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Benign Neoplasm - 81
Keratinocyte Carcinoma - 48
Actinic keratoses - 10
Melanoma - 5
Infectious - 3
Papulosquamous/Other - 10
Dysplastic nevus - 6

Inclusion criteria: Pts with suspected skin cancer, informed consent
Exclusion criteria: Pts who did show to CD (number NR)

Study duration (months): 18
Nikon Coolpix 950

2 different dermatologists and a 3rd year trainee dermatologist viewed all the cases as well

Photographer: General practitioner

Time between photograph and gold standard (days): <14
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 8/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 5/7
 Reference test: 2/3
 Data analysis: 1/2
Moreno-Ramirez 200518

Spain

Repeated Measure

Funding: Grant from Instituto Carlos III


108

108
Mean age (range): 43 years (2 to 84
Gender: female 65%, male 35%
Race/ethnicity: NR

Condition characteristics (for 57 biopsied PSL):
Keratinocyte Carcinoma - 23
Benign Neoplasm - 12
Dysplastic Nevi -16
Melanoma - 6

Inclusion criteria: changing, new, symptomatic or concerning pigmented lesions

Exclusion criteria: NR

Study duration (months): 3
Nikon Coolpix 4300

Photographer: General practitioner

Time between photograph and gold standard (days): mean 8 days (range 5–14)
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 2/3
 Data analysis: 0/2
Tucker 200519

United Kingdom

Repeated Measure

Funding: NR


75

84
Mean age: NR
Gender: female 64%, male 36%
Race/ethnicity: NR

Condition characteristics: NR

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 1
Fujifilm MX-1700

Photographer: dermatologists

Time between photograph and gold standard (days): 0
Diagnostic Accuracy : No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 2/2
Ferrara 200421

Italy

Repeated Measure

Funding: NR


12

12
Median age (range): 41 years (14–71)
Gender: female 17%, male 83%
Race/ethnicity: NR

Condition characteristics: PSL
Benign Neoplasm - 5
Melanoma - 7

Inclusion criteria: NR
Exclusion criteria: NR
Study duration (months): NR
TDSC: Heine Dermaphot Molemax Videocap

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 0/2
Oztas 200420

Turkey

Repeated Measure

Funding: NR


125

125
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Infectious - 50
Tumors (not further defined) -12
Eczematous - 10
Acneiform - 8
Papulosquamous/Other - 39
Benign Neoplasm - 6

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): NR
Canon Powershot 70

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Piccolo 200422

Italy

Repeated Measure

Funding: NR
73

77
Mean age (range): 28 years (4–77)
Gender: female 53%, male 47%
Race/ethnicity: NR

Condition characteristics:
Acral PSL
Benign - 71
Melanomas - 6

Inclusion criteria: Acral melanocytic lesions
Exclusion criteria: NR

Study duration (months): NR
TDSC: Molemax II, Heine Dermaphot

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 2/3
 Data analysis: 0/2
Shapiro 200423

United States

Repeated Measure

Funding: University of Pennsylvania Department of Dermatology
49

49
Mean age: NR
Gender: female 46%, male 54%
Race/ethnicity: NR

Condition characteristics: Skin growths

Inclusion criteria: Skin growth referred by general practitioner

Exclusion criteria: Previous dermatology evaluation

Study duration (months): NR
Olympus D-600L

Photographer: General practitioner

Time between photograph and gold standard (days): <16
Diagnostic Accuracy: No

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 2/2
Coras 200324

Germany

Repeated Measure

Funding: NR
NR

45

Age, gender, and race/ethnicity: NR

Condition characteristics: PSL
Benign Neoplasm - 24
Dysplastic Nevus - 5
Melanoma - 16

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 16
Dermogenius ultra

Photographer: Clinic dermatoscopic examiner

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Du Moulin 200325

Netherlands

Repeated Measure

Funding: University Hospital Maastricht and Ministry of Economic Affairs
106

106
Mean age: 47 years
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Malignant/Premalignant - 6
Benign Neoplasms - 12
Eczematous 28
Infectious- 15
Acneiform - 13
Papulosquamous/Other - 22

Inclusion criteria: Pts referred from general practitioner
Exclusion criteria: Dermatologic referral clearly indicated

Study Duration (months): 11
Ricoh 5000

Photographer: General practitioner

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Pak 2003 (Part I27 and Part II26)

United States, 100% army veterans, or relatives

Repeated Measure

Funding: Walter
Reed Army Medical Center
404

404
Mean age (range): 59 years (18–92)
Gender: female 43%, male 57%
Race/ethnicity: white 82%, black 13%, Asian/Hispanic 5%

Condition characteristics:
Infectious - 31
Premalignant/Malignant - 54
Acneiform - 28
Benign neoplasm - 115
Eczematous - 44
Papulosquamous/Other - 132

Inclusion criteria: Adult new pts
Exclusion criteria: Medical emergencies

Study duration (months): 4
Olympus D-600L Nikon Coolpix 900

Photographer: Nurse

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Rashid 200328

Pakistan

Repeated Measure

Funding: NR

33

33
Age, gender, and race/ethnicity: NR

Condition characteristics:
Keratinocyte Carcinoma - 1
Infectious - 9
Eczematous - 4
Benign Neoplasm - 3
Papulosquamous/Other - 16

Inclusion criteria: NR
Exclusion criteria: Common conditions such as acne and melasma

Study duration (months):NR
Kodak DC-210

Photographer: “Trainee doctor”

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Oliveira 200229

Brazil

Repeated Measure

Funding: NR
92

NR
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics: NR

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): NR
Kodak DC265

Photographer: nurse

Time between photograph and gold standard (days): <7
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 1/2
Jolliffe 200130

United Kingdom

Repeated Measure

Funding: National Health Service R&D grant
138

144
Age range: 15–94 years
Gender: female 66%, male 34%
Race/ethnicity: NR

Condition characteristics: PSL

Inclusion criteria: PSL
Exclusion criteria: NR

Study duration (months): NR
Sanyo HiFi video

Photographer: Dermatologist

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Jolliffe 200131

United Kingdom

Repeated Measure

Funding: National Health Service Executive London R&D grant
611

819
Age range: 8 to 94 years
Gender: female 76%, male 24%
Race/ethnicity: NR

Condition characteristics: PSL
Benign Neoplasm - 635
Keratinocyte Carcinoma - 20
Dysplastic Nevi - 112
Actinic keratoses - 13
Melanoma - 9
Infectious - 10
Acneiform - 5
Rash/Other - 13
Eczematous - 2

Inclusion criteria: PSL
Exclusion criteria: Genital lesions, mental impairment, fear of technical equipment

Study duration (months): NR
Sanyo HiFi video

Photographer: Dermatologist

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 1/2
Lim 200132

Australia

Repeated Measure

Funding: Australian Dermatology Research and Education Foundation
23

27
Age: NR
Gender: NR
Race/ethnicity: NR

Condition Characteristics:
Eczematous - 18
Benign Neoplasm - 9
Infectious - 12
Keratinocyte Carcinoma - 3
Acneiform - 6
Paulosquamous/Other - 5

Inclusion criteria: new skin condition
Exclusion criteria: wart or acne

Study duration (months): 3
Kodak DC265

Photographer: Dermatologist

Time between photograph and gold standard (days): ≤7
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 1/3
 Data analysis: 0/2
Taylor 200133

United Kingdom

Repeated Measure

Funding: NR
188

NR
Age: NR
Gender: NR
Race/ethnicity: “42% of the conditions from pigmented pts”

Condition characteristics (most common diagnoses in 127):
Eczematous - 21
Keratinocyte carcinoma - 9
Papulosquamous/Other - 15
Benign Neoplasm - 69
Acneiform - 8
Infectious - 5

Inclusion criteria: New dermatology pts
Exclusion criteria: NR

Study duration (months): 3
NR

Photographer: Nurse

Time between photograph and gold standard test: NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 13/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 2/2
Barnard 200034

United States

Repeated Measure

Funding: NR
50 “cases”Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics: 8 skin cancer cases

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): NR
Nikon Fujix DS505, Nikon SLR

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Braun 200035

Switzerland

Repeated Measure

Funding: NR
51

55
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics: PSL
Benign Neoplasm - 37
Dysplastic Nevus - 3
Melanoma - 9
Keratinocyte Carcinoma - 4
Other -2

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 6
TDSC: Mitsubishi CCD

Photographer: 6 dermatologists

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 2/3
 Data analysis: 1/2
High 200036

United States

Repeated Measure

Funding: Mayo Clinic and Foundation, Minnesota Academy of Family Physicians
92

106
Mean age (range): 39.7 years (10 months – 81 years)
Gender: female 48%, male 52%
Race/ethnicity: NR

Condition characteristics:
Benign Neoplasm - 35
Keratinocyte Carcinoma - 6
Actinic keratoses -2
Melanoma - 1
Infectious - 12
Acneiform - 8
Papulosquamous/Other - 25
Eczematous - 17

Inclusion criteria: NR
Exclusion criteria: None

Study duration (months): 1.5
Sony DCS-F1

Photographer: Medical student

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Piccolo 200037

Italy

Repeated Measure

Funding: Osterreichische Krebshilfe Steiermark, Graz, Austria
40

43
Mean age (range): 39.5 years (3–91)
Gender: female 47.5%, male 52.5%
Race/ethnicity: NR

Condition characteristics: PSL
Keratinocyte carcinoma - 3
Melanoma - 11
Benign Neoplasm - 29

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 3
TDSC: video camera and stereomicroscope

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: No

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Krupinski 199938

United States

Repeated Measure

Funding: USDA Rural Utilities Service, US Dept. of Commerce, Health and Human Services
308

308
Age, gender, and race/ethnicity: NR

Condition characteristics:
Melanoma - 4
Actinic keratoses - 20
Keratinocyte Carcinoma - 49
Dysplastic nevus - 16
Benign Neoplasm - 106
Infection - 20
Eczematous - 36
Papulosquamous/Other - 57

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): NR
Canon Powershot 600

Photographer: Medical students

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 2/3
 Data analysis: 0/2
Lewis 199939

United Kingdom

Repeated Measure

Funding: NR
56 casesAge: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics: NR

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 7
Kodak DC40

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 8/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 5/7
 Reference test: 3/3
 Data analysis: 0/2
Piccolo 199940

Italy

Repeated Measure

Funding: NR
66

66
Mean age (range): 41.2 years (8–82)
Gender: female 52%, male 48%
Race/ethnicity: NR

Condition characteristics: PSL
Melanocytic- 57
Nonmelanocytic-9

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 0.75
TDSC: video camera and stereomicroscope

Photographer: NR

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Tait 199941

Australia

Repeated Measure

Funding: NR
30

NR
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics: NR

Inclusion criteria: Visible skin lesion
Exclusion criteria: NR

Study duration (months): NR
Ricoh RDC 300

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Whited 199942

United States, US armed service personnel/veterans

Repeated Measure

Funding: Veterans Affairs Health Service R&D
129

168
Mean age (range): 61 years (22 to 82)
Gender: female 2%, male 98%
Race/ethnicity: white 80%, black 20%

Condition characteristics: NR

Inclusion criteria: Diagnostic uncertainty
Exclusion criteria: Previous dermatology evaluation

Study duration (months): NR
Fujix DS-515

Photographer: Research assistant

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Whited 199843

United States, VA pts

Repeated Measure

Funding: NR
12

13
Age: NR
Gender: NR
Race/ethnicity: NR

Condition Characteristics:
Benign neoplasm - 2
Keratinocyte carcinoma - 7
Actinic keratoses – 1
Other – 1
No biopsy - 1

Inclusion criteria: Suspected skin cancer
Exclusion criteria: NR

Study duration (months): NR
Fujix DS-515 digital camera, 1280x1000 pixels

Photographer: NR

Time between photograph and gold standard test (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Kvedar 199744

United States

Repeated Measure

Funding: Massachusetts General Hospital Dermatology Service
116

123
Mean age (range): 40 years (18–84)
Gender: NR
Race/ethnicity: NR

Condition characteristics: NR

Inclusion criteria: NR
Exclusion criteria: Acne or warts cases

Study duration (months): 2
Kodak DCS 420

Photographer: Non- dermatologists

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 13/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Lyon 199745

United Kingdom

Repeated Measure

Funding: NR
100

100
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Eczematous - 12
Acneiform - 3
Infectious - 5
Other - 20
Benign Neoplasm - 41
Keratinocyte Carcinoma - 19
Actinic keratoses - 5

Inclusion criteria: Dermatology referral
Exclusion criteria: NR

Study duration (months): NR
DC-40 Kodak

Photographer: Dermatology resident

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 8/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 4/7
 Reference test: 3/3
 Data analysis: 0/2
Zelickson 199746

United States

Repeated Measure

Funding: NR
29

30
Age: NR
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Rash-18
Lesion-12

Inclusion criteria: Nursing home resident with a skin condition
Exclusion criteria: NR

Study duration (months): NR
Sony CCD-TR400 video

Photographer: Nurse

Time between photograph and gold standard (days): <2
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
B. Live interactive studies (n=10)
Edison 20087

United States

Repeated Measure Both SAF and LI

Funding: Federal Office for the Advancement of Telehealth, Health Resources and Services Administration
110

110
Mean age (range): 42 (7–92)
Gender: female 69%, male 31%
Race/ethnicity: white 85%, black 12%, Asian 2%, Hispanic 1%

Condition Characteristics for 70:
Actinic Keratosis - 10
Acneiform - 12
Benign Neoplasm - 19
Dysplastic nevus - 1
Infectious - 7
Eczematous - 8
Other – 13

Inclusion criteria: New pts on study days
Exclusion criteria: NR

Study duration (months): 18
Camera: NR

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 1/2
Baba 200517

Turkey

Repeated Measure SAF +LI

Funding: NR
228

242
Mean age (range): 35 years (2–82)
Gender: female 63%, male 37%
Race/ethnicity: NR

Condition characteristics:
Acneiform - 41
Infectious - 54
Pre-malignant/Malignant- 2
Eczematous - 46
Benign Neoplasms - 45
Papulosquamous/Other - 54

Inclusion criteria: None
Exclusion criteria: None

Study duration (months): 2.3
Mustek camera

Photographer: Nurse

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Nordal 200147

Norway

Repeated Measure

Funding:
112

112
Mean age (range): 40 years (17–82)
Gender: female 51%, male 49%
Race/ethnicity: NR
Condition characteristics:
Eczematous - 7
Acneiform - 1
Papulosquamous/Other - 6
Benign neoplasm - 1

Inclusion criteria: New dermatologic conditions
Exclusion criteria: Surgical treatment, emergency cases and most nevi

Study duration (months): NR
Sony CCD DXC 930P video

Photographer: General practitioner

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 13/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 6/7
 Reference test: 3/3
 Data analysis: 2/2
Gilmour 199848

United Kingdom

Repeated Measure

Funding: National Health Service
126

155
Age range: 3 month -83 years
Gender: female 51%, male 49%
Race/ethnicity: NR

Condition characteristics:
Eczematous - 55
Papulosquamous/Other - 37
Infection - 23
Acneiform - 12
Tumor - 20

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): 12
Camera NR

Photographer: General practitioner or trained assistant

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Lesher 199849

United States

Repeated Measure

Funding: Tele- medicine Center of Medical College of Georgia
60

68
Age: ≥ 18 years of age
Gender: NR
Race/ethnicity: NR

Condition characteristics:
Eczematous - 17
Benign Neoplasm -12
Keratinocyte Carcinoma - 3
Actinic keratosis - 6
Infectious - 4
Acneiform - 11
Papulosquamous/Other -15

Inclusion criteria: Adults with skin condition
Exclusion criteria: NR

Study duration (months): NR
VC TK-1280U, Panasonic WV-E550

Photographer: NR

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 11/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Loane, 199850

United Kingdom

Repeated Measure

Funding: National Health Service
351

427
Mean age (range): 41 years (5 months-89 years)
Gender: female 55%, male 45%
Race/ethnicity: NR

Condition characteristics (preliminary results):
Tumor - 78
Eczema - 54
Infection - 28
Benign Neoplasm - 21
Acneiform - 13
Papulosquamous/Other - 42

Inclusion criteria: Dermatology referral
Exclusion criteria: NR

Study duration (months): 18
VC7000 video, KY-F55B JVC video

Photographer: General practitioner

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Lowitt 199851

United States, US armed service personnel/veterans

Repeated Measure

Funding: Baltimore Research and Education Foundation
102

130
Median age (range): 65 (range 23 to 85)
Gender: male 95%, female 5%
Race/ethnicity: white 60%, black 40%

Condition characteristics:
Acneiform - 17
Eczematous - 33
Infectious - 9
Papulosquamous/Other -17
Benign Neoplasm - 36
Premalignant Tumor - 16
Malignant Neoplasm - 6

Inclusion criteria: consecutive dermatology outpts
Exclusion criteria: Pts transported by stretcher

Study duration (months): 2
3-CCS JVC video

Photographer: Nurse escort

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: Yes

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 12/14
Sources of bias identified by QUADAS
 Selection: 2/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Phillips 199852

United States

Repeated Measure

Funding: NR
51

107
Mean age: 47
Gender: female 84%, male 16%
Race/ethnicity: NR

Condition characteristics:
Benign Neoplasm - 81
Keratinocyte Carcicnoma - 5
Melanoma - 1
Premalignant - 14
Dysplastic Nevi - 5

Inclusion criteria: NR
Exclusion criteria: NR

Study duration (months): NR
Panasonic video, Canon video

Photographer: Dermatologist

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: Yes
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Oakley 199753

New Zealand

Repeated Measure

Funding: Waikato Information Services Department of Health
104

135
Age range: 2–86 years,
Gender: female 60%, male 40%
Race/ethnicity: NR

Condition characteristics:
Eczematous - 17
Benign Neoplasm - 24
Malignant Neoplasm - 25
Actinic Keratosis - 15
Infectious - 7
Acneiform - 13
Melanoma - 4
Papulosquamous/Other -30

Inclusion criteria: New dermatology pts
Exclusion criteria: NR

Study duration (months): NR
Canon VC-C1 video, Vtel system

Photographer: Dermatologist

Time between photograph and gold standard (days): 0
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 9/14
Sources of bias identified by QUADAS
 Selection: 1/2
 Index test: 6/7
 Reference test: 2/3
 Data analysis: 0/2
Phillips 199754

United States

Repeated Measure

Funding: NR
60

79
Mean age (range): 37 years (1–68)
Gender: female, 60%, male 40%
Race/ethnicity: white 73%, black 25%

Condition characteristics:
Eczematous - 14
NMSC - 4
Actinic keratosis - 5
Acneiform - 9
Infection - 8
Melanoma - 1
Benign Neoplasm - 26
Papulosquamous/Other -12

Inclusion criteria: Referral
Exclusion criteria: NR

Study duration (months): NR
Picture-Tel System 4000 video, Elmo model MN401X dc

Photographer: trained nurse

Time between photograph and gold standard (days): NR
Diagnostic Accuracy: No

Diagnostic Concordance: Yes

Management Accuracy: No

Management Concordance: No
Overall QUADAS score: 10/14
Sources of bias identified by QUADAS
 Selection: 0/2
 Index test: 7/7
 Reference test: 3/3
 Data analysis: 0/2
Bookshelf ID: NBK49166

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