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2020&#41; in the Autonomous Community of Madrid&#46; These patients had been referred from primary care or other specialties&#46; A total of 16 dermatologists&#44; all of whom were staff physicians from the Dermatology Department of HULP&#44; participated in the study&#46; We excluded patients with appointments for specialist treatment &#40;laser&#44; pigmentation treatment&#44; ultrasound&#44; patch testing&#44; high-resolution anoscopy&#44; and pediatric hospital consultations&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Inclusion Criteria</span><p id="par0085" class="elsevierStylePara elsevierViewall">To be included&#44; patients had to have an appointment at HULP or a PSC&#44; present with skin lesions at the time of the study&#44; and sign the informed consent document&#46; In the case of patients aged &#60;18 years&#44; the parents or guardians signed the informed consent document&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Exclusion Criteria</span><p id="par0090" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients who did not sign an informed consent document&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patients for whom it was not possible to obtain a photograph of their skin condition&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients who had been seen elsewhere &#40;e&#46;g&#46;&#44; emergency department&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Teledermatology Platform</span><p id="par0110" class="elsevierStylePara elsevierViewall">The teledermatology system used was based on the application MyDoctor App&#44; which was tailored specifically to this project&#46; The app makes it possible to send images and videos between patients and physicians from 35 specialties&#46; During lockdown&#44; the app was combined with the &#8220;Qu&#233;date en casa&#8221; &#40;&#8220;Stay home&#8221;&#41; initiative and was free of charge&#46; In order to prevent patients from outside our clinic from having access to dermatologists from HULP&#44; we opened 16 private appointment schedules&#44; which corresponded to consultations with the dermatologists with whom the patient had an appointment&#46; The patient received an email with a link to download the app&#59; therefore&#44; the consultation was forwarded directly to the patient&#8217;s dermatologist&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The model used was a hybrid dermatology model&#44; with a first store-and-forward stage&#44; in which the patient sent an image via the app&#44; followed by a second phase&#44; in which the dermatologist contacted the patient by telephone in real time&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Design</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Visits</span><p id="par0120" class="elsevierStylePara elsevierViewall">Visit 1 &#40;day 0&#41;&#58; The patient is informed about the study by telephone&#46; The inclusion&#47;exclusion criteria are evaluated&#46; If the patient agrees to participate&#44; he&#47;she is sent an email with a link to download the app&#46; It is stressed that images should be well focused and taken under good lighting conditions&#44; with at least one close-up image and another taken from a distance&#46; The informed consent is signed electronically via the app&#46; The patient takes the photographs that he&#47;she considers appropriate and sends them&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Visit 2 &#40;days 1-7&#41;&#58; The dermatologist contacts the patient by telephone&#44; either from home &#40;via virtual private network&#41; or from the clinic&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The visit followed the usual format&#58; history&#44; request for&#44; and evaluation of additional tests and treatment via the hospital computer network&#47;virtual private network&#46; The clinical history was obtained using the computer network of HULP&#46; Additional images were requested if the dermatologist considered it appropriate&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As for safety measures&#44; discharge with referral to primary care was only considered in the case of a mild dermatologic condition and a definitive diagnosis&#46; A condition was considered mild when&#44; in the dermatologist&#8217;s opinion&#44; it did not imply a significant impairment of the patient&#8217;s quality of life &#40;e&#46;g&#46;&#44; mild acne&#44; seborrheic keratosis&#44; or pityriasis versicolor&#41;&#46; The patient was provided with a contact number for the return to the consultations&#46; The app sent a satisfaction survey to the patient 24&#8239;hours later and to the physician at the end of the study&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Variables</span><p id="par0140" class="elsevierStylePara elsevierViewall">Age&#44; sex&#44; race&#44; skin phototype&#44; university education&#44; COVID-19 risk factors&#44; diagnosis&#44; diagnostic category&#44; suspected cancer&#44; dermatologic emergency&#44; dermatologist&#8217;s confidence in the diagnosis on a scale of 1-10 &#40;1&#44; no confidence&#59; 10&#44; definitive diagnosis&#41;&#44; diagnostic capacity &#40;definitive&#44; probable&#44; not possible&#41;&#44; reasons for impossibility of diagnosis&#44; image quality &#40;sufficient&#47;insufficient&#41;&#44; need for continued specialist care according to the dermatologist &#40;at 1&#44; 3&#44; and 6&#8239;months&#41;&#44; treatment prescribed by telephone&#44; inclusion on the surgical waiting list&#44; patient&#8217;s degree of satisfaction&#44; and dermatologist&#8217;s degree of satisfaction &#40;Likert scale&#41; &#40;Annex 1&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The diagnostic category included cancer-precancer &#40;including actinic keratosis&#44; skin cancer&#44; nonmelanoma skin cancer&#44; melanoma&#41;&#44; melanocytic disease &#40;typical and atypical nevi&#41;&#44; inflammation&#44; infection&#44; pediatric conditions&#44; and other conditions &#40;including benign tumors&#44; alopecia&#44; and ungual involvement&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical Analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of all the clinical and analytical variables studied using SPSS Version 12 &#40;SPSS Inc&#46;&#41;&#46; Qualitative variables are expressed as absolute and relative frequencies&#59; quantitative variables are expressed using the main measures of dispersion &#40;mean &#91;SD&#93;&#44; median&#44; minimum&#44; maximum&#44; interquartile range &#91;IQR&#93;&#44; 95&#37; CI&#41;&#46; Likert scales were used to measure confidence in the diagnosis&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">From the Admissions Department of HULP&#44; we telephoned 2316 patients&#44; all of whom had been scheduled for appointments as new patients at HULP and the PSCs&#46; Patients were gradually called from the date the study was approved by the local ethics committee on April 20&#44; 2020 until May 4&#44; 2020&#46; A total of 1497 &#40;64&#46;6&#37;&#41; patients agreed to participate&#46; In the email inviting patients to download the app&#44; we provided the telephone number of the Dermatology Office&#44; as well as the email of the app helpdesk&#46; Patients who did not wish to participate or could not participate were offered the option of making an appointment that would become active once the face-to-face appointment schedule was opened&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The reasons for not participating in the study among the remaining 819 patients were not having a smartphone &#40;9&#37;&#44; n&#8239;&#61;&#8239;73&#41;&#44; not having email &#40;24&#37;&#44; n&#8239;&#61;&#8239;193&#41;&#44; not having visible lesions on the skin &#40;23&#37;&#44; n&#8239;&#61;&#8239;185&#41;&#44; or simply not wishing to participate &#40;45&#37;&#44; n&#8239;&#61;&#8239;368&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Of the 1497 who agreed to participate&#44; 896 patients completed the registration process&#44; although only 452 completed a remote consultation with their dermatologist &#40;30&#37;&#41;&#46; Of these&#44; 374 attached an image &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Demographic Characteristics</span><p id="par0170" class="elsevierStylePara elsevierViewall">We analyzed data from patients who completed their visit by attaching an image &#40;n&#8239;&#61;&#8239;374&#41;&#46; Mean age was 42&#8239;&#40;19&#46;5&#41; years&#44; and 62&#37; were women&#46; Whites accounted for 91&#46;5&#37; of the patients&#46; The Fitzpatrick skin phototype&#8212;according to the patient&#8212;was I in 2&#46;5&#37;&#44; II in 58&#37;&#44; III in 35&#46;5&#37;&#44; and IV in 4&#37;&#46; Patients were educated to university level in 44&#37; of cases&#44; and 7&#37; presented risk factors for COVID-19 &#40;&#62;&#8239;70 years&#44; comorbidity&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diagnosis</span><p id="par0175" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; the diagnostic categories were as follows&#58; melanocytic lesions&#44; inflammation&#44; infection&#44; cancer-precancer&#44; pediatric disease&#44; and other&#46; The cancer-precancer category included 34 patients&#44; of whom 18 &#40;4&#46;8&#37;&#59; 95&#37; CI&#44; 2&#46;6&#37;-7&#37;&#41; were considered to have cancer&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the most frequent diagnoses&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> provides a few examples&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">One case was classified as a dermatologic emergency and involved an atopic patient who presented with erythroderma&#46; Additional tests &#40;ordered online&#41; were required in 105 patients &#40;28&#46;3&#37;&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diagnostic Performance</span><p id="par0190" class="elsevierStylePara elsevierViewall">Of the patients who sent an image &#40;n&#8239;&#61;&#8239;374&#41;&#44; a diagnosis could be made in 87&#46;1&#37; &#40;95&#37; CI&#44; 83&#46;7&#37;-90&#46;5&#37;&#41;&#59; in the dermatologist&#8217;s opinion&#44; this was probable in 48&#46;6&#37; &#40;95&#37; CI&#44; 43&#46;5&#37;-53&#46;6&#37;&#41; and definitive in 38&#46;5&#37; &#40;95&#37; CI&#44; 33&#46;5&#37;-43&#46;4&#37;&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Confidence in the diagnosis made was evaluated subjectively by each dermatologist&#44; with a score&#8239;&#8805;&#8239;7&#47;10 in 290 cases &#40;77&#46;5&#37;&#44; 95&#37; CI&#44; 73&#46;2&#37;-81&#46;7&#37;&#41;&#46; Image quality was considered sufficient in 52&#46;1&#37; &#40;95&#37; CI&#44; 47&#37;-57&#46;1&#37;&#41; of cases&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In contrast&#44; diagnosis was not possible in 12&#46;8&#37; &#40;95&#37; CI&#44; 9&#46;4&#37;-16&#46;1&#37;&#41; of cases &#40;n&#8239;&#61;&#8239;49&#41; for the following reasons&#58; the image was not consistent with the consultation &#40;58&#46;3&#37;&#41;&#44; image quality was poor &#40;22&#46;9&#37;&#41;&#44; and additional testing was necessary &#40;18&#46;7&#37;&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Diagnostic performance and confidence in the diagnosis differed by area &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Impact on Consultations</span><p id="par0210" class="elsevierStylePara elsevierViewall">Of the 374 patients who provided an image for their consultation&#44; 17&#37; &#40;95&#37; CI&#44; 13&#46;1&#37;-20&#46;8&#37;&#41; &#40;n&#8239;&#61;&#8239;64&#41; were referred for follow-up in primary care&#46; Continued care was necessary in 309 patients&#59; this was considered a priority &#40;under 1 month&#41; in 15&#37; &#40;95&#37; CI&#44; 11&#46;3&#37;-18&#46;6&#37;&#41; &#40;n&#8239;&#61;&#8239;56&#41;&#46; The face-to-face visit was delayed 3 months in 50&#37; &#40;n&#8239;&#61;&#8239;190&#41; of patients and up to 6&#8239;months in 17&#37; &#40;95&#37; CI&#44; 13&#46;1&#37;-20&#46;8&#37;&#41; &#40;n&#8239;&#61;&#8239;64&#41;&#46; Therefore&#44; face-to-face visits were avoided for at least 3 months in 85&#37; &#40;95&#37; CI&#44; 81&#46;2&#37;-88&#46;6&#37;&#41; of patients &#40;n&#8239;&#61;&#8239;318&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Treatment was prescribed by telephone in 101 patients &#40;27&#37;&#59; 95&#37; CI&#44; 22&#46;5&#37;-31&#46;5&#37;&#41;&#44; and 8 patients were included directly on the surgical waiting list&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Patients scored their satisfaction with the online visit on a scale of 1 to 5&#46; The average score obtained by the 16 dermatologists was 4&#46;5&#47;5&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The dermatologists scored their satisfaction according to the items consulted &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0230" class="elsevierStylePara elsevierViewall">The main objective of the present study was to determine the percentage of face-to-face consultations that could be avoided using teledermatology during lockdown&#46; In the sample studied here&#44; we were able to completely avoid face-to-face consultations with a specialist in 17&#37; of cases and to postpone face-to-face consultations by at least 3 months in an additional 68&#37; of patients&#46; Furthermore&#44; we prioritized care for those patients who needed it&#44; even when required within 24&#8239;hours&#44; as occurred in the case of a patient with erythroderma&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">According to data from the DIADERM study&#44; the percentage of discharges with check-ups by primary care and check-ups by a dermatologist are 6&#37; and 65&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The same percentages for teledermatology are 33&#37; and 42&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In both cases&#44; the need for continued care is considerable&#44; albeit to a lesser extent than in our study &#40;82&#37;&#41;&#46; Very different data were reported from a recent store-and-forward teledermatology study carried out in Germany that included 1364 patients and where 64&#37; of face-to-face consultations were avoided&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> These data contrast with those of our study&#44; although the difference can be explained by the fact that&#44; in our protocol&#44; we established that only patients with a confirmed diagnosis and trivial disease would be discharged for follow-up in primary care&#59; the remainder were given appointments for check-ups with the same specialist&#46; While this protocol was designed in this way to ensure patient safety &#40;given the lack of experience with teledermatology in our center&#41;&#44; it prevents us from drawing reliable conclusions on the efficacy of teledermatology as a screening tool&#46; It is also important to remember that direct store-and-forward teledermatology data are usually inferior to those obtained by indirect store-and-forward teledermatology&#44; where images and the associated use of dermoscopy guarantee better diagnostic performance&#44; thus avoiding up to 58&#37; of face-to-face consultations&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Nevertheless&#44; our diagnostic performance was high&#58; we were able to make a diagnosis for 87&#46;1&#37; of patients with a considerable degree of confidence&#46; These results are similar to those reported by Sondermann et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> who were able to diagnose 90&#46;3&#37; of patients remotely&#46; Consistent with data form other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;16</span></a> we found that confidence in the diagnosis was higher for the categories infection&#44; cancer-precancer&#44; and inflammation and lower in melanocytic lesions and pediatric diseases&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The most frequent diagnoses were melanocytic nevus&#44; acne&#44; eczema&#44; actinic keratosis&#44; seborrheic keratosis&#44; and basal cell carcinoma&#46; These diagnoses are illustrative of the most common main diagnoses in dermatology in the PSCs and are similar to those reported elsewhere&#44; such as in DIADERM&#44; where the most common diagnoses were actinic keratosis &#40;8&#46;2&#37;&#41;&#44; basal cell carcinoma &#40;8&#46;1&#37;&#41;&#44; and melanocytic nevus &#40;7&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;15</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Image quality was considered adequate for diagnosis in 52&#46;1&#37; of cases&#44; which is consistent with data reported from a recent study on teledermatology based on WhatsApp&#44; where 54&#46;3&#37; of dermatologists considered image quality sufficient for diagnosis&#46; However&#44; this is lower than the 81&#37; recorded for indirect store-and-forward teledermatology&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> O&#8217;Connor et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> reported the results of a pediatric study that compared the diagnostic accuracy of teledermatology in 2 groups&#44; i&#46;e&#46;&#44; with and without previous instructions on imaging&#46; The authors reported no significant differences between the groups&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The results of the survey completed by dermatologists from HULP showed that the overall level of satisfaction was considered good by 68&#46;7&#37;&#46; It is worthy of mention that 81&#46;25&#37; agreed&#47;totally agreed with a high degree of confidence in the diagnosis&#44; 74&#37; agreed&#47;totally agreed that teledermatology had a positive impact on the running of their department&#44; and 87&#46;2&#37; would apply this approach to new areas of therapy&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">As for patient satisfaction&#44; the average score given to the 16 dermatologists was 4&#46;5&#47;5&#44; that is&#44; slightly higher than in a recent study of 243 teledermatology consultations&#44; where the average score was 4&#46;38&#47;5&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This finding supports publications that show a high index of patient satisfaction with direct-to-consumer telemedicine systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Online technology is well implemented in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> as seen in the high number of smartphone users in our study&#46; Nevertheless&#44; only 1 in every 4 patients recruited finally sent an image as part of their consultation&#59; of these&#44; 44&#37; were educated to university level&#46; We did not perform a structured analysis of the reasons why this high percentage of patients did not manage to complete a visit&#44; although according to the data gathered from the telephone calls to the dermatology office and the app helpdesk&#44; the main reasons were technological difficulties&#44; lack of trust in the security of the process&#44; and resolution of the skin disease&#46; We believe that these data may have improved if we had used a system that opened the patient&#8217;s camera directly by means of an SMS&#44; without the need to download an app&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Another limitation of our study is that we did not analyze diagnostic agreement in the application of teledermatology&#46; Therefore&#44; we cannot guarantee the diagnostic reliability of the approach&#46; However&#44; Sondermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> performed a random assessment of diagnostic agreement in 100 patients and found it to be 97&#37;&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Very few studies report the diagnostic performance of direct store-and-forward teledermatology&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17&#44;21</span></a> and we were unable to find studies performed during the COVID-19 lockdown&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In conclusion&#44; teledermatology is an effective tool that enables the practice of dermatology to continue during a pandemic in a way that is satisfactory for both patients and physicians&#46; Implementation of this form of teledermatology could complement face-to-face care activity&#44; especially in patients undergoing follow-up&#46; However&#44; the development of an efficient teledermatology system necessarily implies integration of digital imaging into medical information systems&#59; therefore&#44; we must ensure the necessary infrastructure for secure storage and transmission of images&#44; without unnecessarily increasing the workload of clinicians&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Acknowledgments"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-08-12"
    "fechaAceptado" => "2020-11-16"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1354292"
          "palabras" => array:6 [
            0 => "Teledermatology"
            1 => "Telemedicine"
            2 => "Store and forward"
            3 => "Asynchronous"
            4 => "Remote"
            5 => "COVID-19"
          ]
        ]
      ]
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          "identificador" => "xpalclavsec1354291"
          "palabras" => array:6 [
            0 => "Teledermatolog&#237;a"
            1 => "Telemedicina"
            2 => "Store and forward"
            3 => "As&#237;ncrona"
            4 => "Virtual"
            5 => "COVID-19"
          ]
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dermatologic care was halted because of the coronavirus disease 2019 pandemic&#44; prompting us to study the usefulness of direct-to-patient teledermatology via a mobile application&#46; We aimed to evaluate the service as a tool for avoiding face-to-face consultations&#44; describe the main conditions diagnosed&#44; and assess levels of patient and physician satisfaction&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and method</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prospective descriptive study of new patients who met the inclusion criteria&#46; Descriptive statistics for all variables were analyzed with SPSS&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Of the 1&#44;497 patients who agreed to participate in the study&#44; 25&#37; &#40;n &#61; 374&#41; sent an image to a consultant dermatologist through the mobile application&#46; Sixty-four patients &#40;17&#37;&#41; were discharged directly and referred to primary care for follow-up&#46; A face-to-face consultation was avoided for at least 3 months in 85&#37; of patients &#40;n &#61; 318&#41;&#59; 87&#46;1&#37; &#40;n &#61; 325&#41; received a diagnosis and the dermatologist&#39;s level of confidence in this diagnosis was 7 or higher in 77&#46;5&#37; of cases &#40;n &#61; 290&#41;&#46; The quality of the images sent was considered sufficient in 52&#46;1&#37; of cases&#46; Patients rated their satisfaction with a score of 4&#46;5 out of 5&#46; Eleven of the 16 dermatologists rated their satisfaction as good overall&#46; The most common conditions were inflammatory and melanocytic lesions&#46; The main diagnoses were nevi&#44; acne&#44; and eczema&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Direct-to-patient store-and-forward teledermatology is an effective means of evaluating new patients&#46; Both clinicians and patients expressed high levels of satisfaction with the service&#46; Systems enabling the addition of digital images to patient records are necessary to ensure the efficiency of teledermatology&#46;</p></span>"
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            "identificador" => "abst0010"
            "titulo" => "Background"
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            "identificador" => "abst0015"
            "titulo" => "Material and method"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Como consecuencia de la pandemia por la COVID-19 ces&#243; la actividad dermatol&#243;gica asistencial&#44; por lo que iniciamos un estudio para evaluar la utilidad de la teledermatolog&#237;a &#40;TD&#41; directa entre paciente y dermat&#243;logo a trav&#233;s de una App&#46; El objetivo fue evaluar el impacto de esta herramienta para evitar consultas presenciales&#44; as&#237; como describir los principales diagn&#243;sticos y la satisfacci&#243;n de pacientes y m&#233;dicos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todo</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo prospectivo&#46; Se incluyen pacientes nuevos que cumplen criterios de inclusi&#243;n&#46; Se realiz&#243; un an&#225;lisis descriptivo de todas las variables mediante el programa estad&#237;stico SPSS&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De los 1&#46;497 pacientes que aceptaron participar el 25&#37; &#40;n &#61; 374&#41; enviaron una consulta virtual con imagen&#46; De entre ellos el 17&#37; &#40;n &#61; 64&#41; fueron dados de alta de forma directa para control por atenci&#243;n primaria&#46; En un 85&#37; &#40;n &#61; 318&#41; de los pacientes se logra evitar la consulta presencial durante al menos 3 meses&#46; Se emiti&#243; un diagn&#243;stico en el 87&#44;1&#37; &#40;n &#61; 325&#41; de los pacientes&#44; siendo la confianza en el diagn&#243;stico &#8805; 7&#47;10 en el 77&#44;5&#37; &#40;n &#61; 290&#41;&#46; La calidad de la imagen fue suficiente en el 52&#44;1&#37;&#46; La satisfacci&#243;n del paciente fue de 4&#44;5&#47;5&#46; Once de 16 dermat&#243;logos consideraron la TD &#250;til globalmente&#46; La afecci&#243;n m&#225;s frecuente fue la inflamatoria y melanoc&#237;tica&#44; siendo los diagn&#243;sticos m&#225;s habituales nevus&#44; acn&#233; y eccema&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La TD directa as&#237;ncrona es una herramienta eficaz para valorar pacientes nuevos&#44; con un alto grado de satisfacci&#243;n para m&#233;dicos y pacientes&#46; El desarrollo de un sistema de TD eficiente implica la integraci&#243;n de la imagen digital en los sistemas de informaci&#243;n m&#233;dicos&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sendagorta E&#44; Servera G&#44; Nu&#241;o A&#44; Gil R&#44; P&#233;rez-Espa&#241;a L&#44; Herranz P&#46; Estudio piloto de la teledermatolog&#237;a directa durante el estado de alarma por la pandemia COVID-19 en un &#225;rea sanitaria de Madrid &#40;Estudio EVIDE-19&#41;&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;345&#8211;353&#46;</p>"
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            "apendice" => "<p id="par0295" class="elsevierStylePara elsevierViewall">For each item&#58; totally agree&#47;agree&#47;neutral&#47;disagree&#47;totally disagree&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8208;</span><p id="par0300" class="elsevierStylePara elsevierViewall">I am confident about the diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8208;</span><p id="par0305" class="elsevierStylePara elsevierViewall">The tool is useful at the general level&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8208;</span><p id="par0310" class="elsevierStylePara elsevierViewall">I felt comfortable with the procedure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8208;</span><p id="par0315" class="elsevierStylePara elsevierViewall">I have improved my ability to manage my agenda&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8208;</span><p id="par0320" class="elsevierStylePara elsevierViewall">I believe that this intervention has a positive impact on my patients&#8217; health&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8208;</span><p id="par0325" class="elsevierStylePara elsevierViewall">I believe that this intervention has a positive impact on the overall management of my department&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8208;</span><p id="par0330" class="elsevierStylePara elsevierViewall">I believe that this intervention could be applied to new areas of therapy&#46;</p></li></ul></p>"
            "etiqueta" => "Annex 1"
            "titulo" => "Physician survey"
            "identificador" => "sec0095"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient recruitment flowchart&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients in each diagnostic category&#46;</p>"
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        "etiqueta" => "Figure 3"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Images sent via the app&#46; A&#44; Pityriasis rosea&#46; B&#44; Scabies&#46; C&#44; Pigmented lesion requiring assessment by dermoscopy&#46; D&#44; Impetigo&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic ability and degree of confidence on a scale of 1 to 10 in the diagnosis made according to the diagnostic categories&#46;</p>"
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        "etiqueta" => "Figure 5"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Continuity of care&#46; Percentage of discharges and check-up visits at 1&#44; 3&#44; and 6&#8239;months&#46;</p>"
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        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Likert scale for satisfaction according to the disease&#46; TA indicates totally agree&#59; A&#44; agree&#59; N&#44; neither agree nor disagree&#59; D&#44; disagree&#59; TD&#44; totally disagree&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Nevus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;15&#46;9&#37;-24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acne&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;6 &#40;6&#46;6&#37;-12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Eczema&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;7 &#40;5&#37;-10&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Seborrheic keratosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;9 &#40;4&#46;3&#37;-45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;7 &#40;1&#46;7&#37;-5&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Original Article
Direct-to-Patient Teledermatology During COVID-19 Lockdown in a Health District in Madrid, Spain: The EVIDE-19 Pilot Study
Estudio piloto de la teledermatología directa durante el estado de alarma por la pandemia COVID-19 en un área sanitaria de Madrid (Estudio EVIDE-19)
E. Sendagorta
Corresponding author
, G. Servera, A. Nuño, R. Gil, L. Pérez-España, P. Herranz
Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
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our activity was restricted to the management of dermatologic emergencies and interdepartmental consultations&#46; In this context&#44; the United States Centers for Disease Control and Prevention and other public bodies stated that telemedicine should be considered part of the health system response to COVID-19&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Teledermatology is defined as the clinical evaluation of skin lesions by dermatologists using telemedicine techniques&#46; Teledermatology can be asynchronous &#40;store-and-forward&#41;&#44; synchronous &#40;real-time&#41;&#44; or hybrid &#40;an asynchronous phase and a synchronous phase&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is generally indirect&#44; between primary care and dermatology&#44; with or without associated dermoscopic images&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The direct-to-patient store-and-forward modality involves a direct digital consultation between the patient and the dermatologist based on images captured using the patient&#8217;s smartphone&#46; This modality has the disadvantage that both the image quality and the information necessary for appropriate history taking are poor&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The advantages of teledermatology have been demonstrated in multiple studies and comprise the ability to reduce the waiting list&#44; act as a triage system&#44; and enable remote access to a dermatologist&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;5</span></a> Spain is among the countries that publishes most articles on teledermatology&#44; which is well established in more than 25&#37; of all Spanish public dermatology departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Platforms such as WhatsApp and email were used during lockdown&#44; although sending images via insecure platforms is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a> Therefore&#44; we performed a pilot study to evaluate the application of direct hybrid teledermatology for the care of new patients&#46; We examined appointments scheduled during the period running from the declaration of the state of emergency to the initial easing of restrictions&#44; with the entry of phase 0 in the Autonomous Community of Madrid&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was approved by the Clinical Research Ethics Committee of HULP on April 20&#44; 2020&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objectives</span><p id="par0035" class="elsevierStylePara elsevierViewall">To evaluate the impact of a teledermatology program as a tool for avoiding face-to-face consultations during the study period&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Primary&#58; To determine the percentage of new patients for whom a face-to-face appointment is avoided over 1&#44; 3&#44; and 6&#8239;months&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Secondary&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">To determine the percentage of online consultations in which&#44; according to the dermatologist&#44; a diagnosis is made or not and to report the reason why the diagnosis could not be made&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">To determine the percentage of patients who can start treatment or be included on the surgical waiting list&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">To determine the percentage of patients with suspected cancer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">To determine the percentage of dermatologic emergencies &#40;requiring care in 24&#8239;hours&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">To report differences in the impact of the program in the following care areas&#58; cancer-precancer&#44; melanocytic lesions&#44; inflammation&#44; infection&#44; pediatrics&#44; and other areas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">To evaluate patient and dermatologist satisfaction&#46;</p></li></ul></p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><p id="par0080" class="elsevierStylePara elsevierViewall">The patients invited to participate in the study were those given an appointment as new patients in the general appointment schedule of HULP and peripheral specialist centers &#40;PSCs&#41; whose appointment had been cancelled between the start of lockdown &#40;March 14&#41; and the start of phase 0 &#40;May 4&#44; 2020&#41; in the Autonomous Community of Madrid&#46; These patients had been referred from primary care or other specialties&#46; A total of 16 dermatologists&#44; all of whom were staff physicians from the Dermatology Department of HULP&#44; participated in the study&#46; We excluded patients with appointments for specialist treatment &#40;laser&#44; pigmentation treatment&#44; ultrasound&#44; patch testing&#44; high-resolution anoscopy&#44; and pediatric hospital consultations&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Inclusion Criteria</span><p id="par0085" class="elsevierStylePara elsevierViewall">To be included&#44; patients had to have an appointment at HULP or a PSC&#44; present with skin lesions at the time of the study&#44; and sign the informed consent document&#46; In the case of patients aged &#60;18 years&#44; the parents or guardians signed the informed consent document&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Exclusion Criteria</span><p id="par0090" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients who did not sign an informed consent document&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patients for whom it was not possible to obtain a photograph of their skin condition&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients who had been seen elsewhere &#40;e&#46;g&#46;&#44; emergency department&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Teledermatology Platform</span><p id="par0110" class="elsevierStylePara elsevierViewall">The teledermatology system used was based on the application MyDoctor App&#44; which was tailored specifically to this project&#46; The app makes it possible to send images and videos between patients and physicians from 35 specialties&#46; During lockdown&#44; the app was combined with the &#8220;Qu&#233;date en casa&#8221; &#40;&#8220;Stay home&#8221;&#41; initiative and was free of charge&#46; In order to prevent patients from outside our clinic from having access to dermatologists from HULP&#44; we opened 16 private appointment schedules&#44; which corresponded to consultations with the dermatologists with whom the patient had an appointment&#46; The patient received an email with a link to download the app&#59; therefore&#44; the consultation was forwarded directly to the patient&#8217;s dermatologist&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The model used was a hybrid dermatology model&#44; with a first store-and-forward stage&#44; in which the patient sent an image via the app&#44; followed by a second phase&#44; in which the dermatologist contacted the patient by telephone in real time&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Design</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Visits</span><p id="par0120" class="elsevierStylePara elsevierViewall">Visit 1 &#40;day 0&#41;&#58; The patient is informed about the study by telephone&#46; The inclusion&#47;exclusion criteria are evaluated&#46; If the patient agrees to participate&#44; he&#47;she is sent an email with a link to download the app&#46; It is stressed that images should be well focused and taken under good lighting conditions&#44; with at least one close-up image and another taken from a distance&#46; The informed consent is signed electronically via the app&#46; The patient takes the photographs that he&#47;she considers appropriate and sends them&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Visit 2 &#40;days 1-7&#41;&#58; The dermatologist contacts the patient by telephone&#44; either from home &#40;via virtual private network&#41; or from the clinic&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The visit followed the usual format&#58; history&#44; request for&#44; and evaluation of additional tests and treatment via the hospital computer network&#47;virtual private network&#46; The clinical history was obtained using the computer network of HULP&#46; Additional images were requested if the dermatologist considered it appropriate&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As for safety measures&#44; discharge with referral to primary care was only considered in the case of a mild dermatologic condition and a definitive diagnosis&#46; A condition was considered mild when&#44; in the dermatologist&#8217;s opinion&#44; it did not imply a significant impairment of the patient&#8217;s quality of life &#40;e&#46;g&#46;&#44; mild acne&#44; seborrheic keratosis&#44; or pityriasis versicolor&#41;&#46; The patient was provided with a contact number for the return to the consultations&#46; The app sent a satisfaction survey to the patient 24&#8239;hours later and to the physician at the end of the study&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Variables</span><p id="par0140" class="elsevierStylePara elsevierViewall">Age&#44; sex&#44; race&#44; skin phototype&#44; university education&#44; COVID-19 risk factors&#44; diagnosis&#44; diagnostic category&#44; suspected cancer&#44; dermatologic emergency&#44; dermatologist&#8217;s confidence in the diagnosis on a scale of 1-10 &#40;1&#44; no confidence&#59; 10&#44; definitive diagnosis&#41;&#44; diagnostic capacity &#40;definitive&#44; probable&#44; not possible&#41;&#44; reasons for impossibility of diagnosis&#44; image quality &#40;sufficient&#47;insufficient&#41;&#44; need for continued specialist care according to the dermatologist &#40;at 1&#44; 3&#44; and 6&#8239;months&#41;&#44; treatment prescribed by telephone&#44; inclusion on the surgical waiting list&#44; patient&#8217;s degree of satisfaction&#44; and dermatologist&#8217;s degree of satisfaction &#40;Likert scale&#41; &#40;Annex 1&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The diagnostic category included cancer-precancer &#40;including actinic keratosis&#44; skin cancer&#44; nonmelanoma skin cancer&#44; melanoma&#41;&#44; melanocytic disease &#40;typical and atypical nevi&#41;&#44; inflammation&#44; infection&#44; pediatric conditions&#44; and other conditions &#40;including benign tumors&#44; alopecia&#44; and ungual involvement&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical Analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of all the clinical and analytical variables studied using SPSS Version 12 &#40;SPSS Inc&#46;&#41;&#46; Qualitative variables are expressed as absolute and relative frequencies&#59; quantitative variables are expressed using the main measures of dispersion &#40;mean &#91;SD&#93;&#44; median&#44; minimum&#44; maximum&#44; interquartile range &#91;IQR&#93;&#44; 95&#37; CI&#41;&#46; Likert scales were used to measure confidence in the diagnosis&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">From the Admissions Department of HULP&#44; we telephoned 2316 patients&#44; all of whom had been scheduled for appointments as new patients at HULP and the PSCs&#46; Patients were gradually called from the date the study was approved by the local ethics committee on April 20&#44; 2020 until May 4&#44; 2020&#46; A total of 1497 &#40;64&#46;6&#37;&#41; patients agreed to participate&#46; In the email inviting patients to download the app&#44; we provided the telephone number of the Dermatology Office&#44; as well as the email of the app helpdesk&#46; Patients who did not wish to participate or could not participate were offered the option of making an appointment that would become active once the face-to-face appointment schedule was opened&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The reasons for not participating in the study among the remaining 819 patients were not having a smartphone &#40;9&#37;&#44; n&#8239;&#61;&#8239;73&#41;&#44; not having email &#40;24&#37;&#44; n&#8239;&#61;&#8239;193&#41;&#44; not having visible lesions on the skin &#40;23&#37;&#44; n&#8239;&#61;&#8239;185&#41;&#44; or simply not wishing to participate &#40;45&#37;&#44; n&#8239;&#61;&#8239;368&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Of the 1497 who agreed to participate&#44; 896 patients completed the registration process&#44; although only 452 completed a remote consultation with their dermatologist &#40;30&#37;&#41;&#46; Of these&#44; 374 attached an image &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Demographic Characteristics</span><p id="par0170" class="elsevierStylePara elsevierViewall">We analyzed data from patients who completed their visit by attaching an image &#40;n&#8239;&#61;&#8239;374&#41;&#46; Mean age was 42&#8239;&#40;19&#46;5&#41; years&#44; and 62&#37; were women&#46; Whites accounted for 91&#46;5&#37; of the patients&#46; The Fitzpatrick skin phototype&#8212;according to the patient&#8212;was I in 2&#46;5&#37;&#44; II in 58&#37;&#44; III in 35&#46;5&#37;&#44; and IV in 4&#37;&#46; Patients were educated to university level in 44&#37; of cases&#44; and 7&#37; presented risk factors for COVID-19 &#40;&#62;&#8239;70 years&#44; comorbidity&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diagnosis</span><p id="par0175" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; the diagnostic categories were as follows&#58; melanocytic lesions&#44; inflammation&#44; infection&#44; cancer-precancer&#44; pediatric disease&#44; and other&#46; The cancer-precancer category included 34 patients&#44; of whom 18 &#40;4&#46;8&#37;&#59; 95&#37; CI&#44; 2&#46;6&#37;-7&#37;&#41; were considered to have cancer&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the most frequent diagnoses&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> provides a few examples&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">One case was classified as a dermatologic emergency and involved an atopic patient who presented with erythroderma&#46; Additional tests &#40;ordered online&#41; were required in 105 patients &#40;28&#46;3&#37;&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diagnostic Performance</span><p id="par0190" class="elsevierStylePara elsevierViewall">Of the patients who sent an image &#40;n&#8239;&#61;&#8239;374&#41;&#44; a diagnosis could be made in 87&#46;1&#37; &#40;95&#37; CI&#44; 83&#46;7&#37;-90&#46;5&#37;&#41;&#59; in the dermatologist&#8217;s opinion&#44; this was probable in 48&#46;6&#37; &#40;95&#37; CI&#44; 43&#46;5&#37;-53&#46;6&#37;&#41; and definitive in 38&#46;5&#37; &#40;95&#37; CI&#44; 33&#46;5&#37;-43&#46;4&#37;&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Confidence in the diagnosis made was evaluated subjectively by each dermatologist&#44; with a score&#8239;&#8805;&#8239;7&#47;10 in 290 cases &#40;77&#46;5&#37;&#44; 95&#37; CI&#44; 73&#46;2&#37;-81&#46;7&#37;&#41;&#46; Image quality was considered sufficient in 52&#46;1&#37; &#40;95&#37; CI&#44; 47&#37;-57&#46;1&#37;&#41; of cases&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In contrast&#44; diagnosis was not possible in 12&#46;8&#37; &#40;95&#37; CI&#44; 9&#46;4&#37;-16&#46;1&#37;&#41; of cases &#40;n&#8239;&#61;&#8239;49&#41; for the following reasons&#58; the image was not consistent with the consultation &#40;58&#46;3&#37;&#41;&#44; image quality was poor &#40;22&#46;9&#37;&#41;&#44; and additional testing was necessary &#40;18&#46;7&#37;&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Diagnostic performance and confidence in the diagnosis differed by area &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Impact on Consultations</span><p id="par0210" class="elsevierStylePara elsevierViewall">Of the 374 patients who provided an image for their consultation&#44; 17&#37; &#40;95&#37; CI&#44; 13&#46;1&#37;-20&#46;8&#37;&#41; &#40;n&#8239;&#61;&#8239;64&#41; were referred for follow-up in primary care&#46; Continued care was necessary in 309 patients&#59; this was considered a priority &#40;under 1 month&#41; in 15&#37; &#40;95&#37; CI&#44; 11&#46;3&#37;-18&#46;6&#37;&#41; &#40;n&#8239;&#61;&#8239;56&#41;&#46; The face-to-face visit was delayed 3 months in 50&#37; &#40;n&#8239;&#61;&#8239;190&#41; of patients and up to 6&#8239;months in 17&#37; &#40;95&#37; CI&#44; 13&#46;1&#37;-20&#46;8&#37;&#41; &#40;n&#8239;&#61;&#8239;64&#41;&#46; Therefore&#44; face-to-face visits were avoided for at least 3 months in 85&#37; &#40;95&#37; CI&#44; 81&#46;2&#37;-88&#46;6&#37;&#41; of patients &#40;n&#8239;&#61;&#8239;318&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Treatment was prescribed by telephone in 101 patients &#40;27&#37;&#59; 95&#37; CI&#44; 22&#46;5&#37;-31&#46;5&#37;&#41;&#44; and 8 patients were included directly on the surgical waiting list&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Patients scored their satisfaction with the online visit on a scale of 1 to 5&#46; The average score obtained by the 16 dermatologists was 4&#46;5&#47;5&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The dermatologists scored their satisfaction according to the items consulted &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0230" class="elsevierStylePara elsevierViewall">The main objective of the present study was to determine the percentage of face-to-face consultations that could be avoided using teledermatology during lockdown&#46; In the sample studied here&#44; we were able to completely avoid face-to-face consultations with a specialist in 17&#37; of cases and to postpone face-to-face consultations by at least 3 months in an additional 68&#37; of patients&#46; Furthermore&#44; we prioritized care for those patients who needed it&#44; even when required within 24&#8239;hours&#44; as occurred in the case of a patient with erythroderma&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">According to data from the DIADERM study&#44; the percentage of discharges with check-ups by primary care and check-ups by a dermatologist are 6&#37; and 65&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The same percentages for teledermatology are 33&#37; and 42&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In both cases&#44; the need for continued care is considerable&#44; albeit to a lesser extent than in our study &#40;82&#37;&#41;&#46; Very different data were reported from a recent store-and-forward teledermatology study carried out in Germany that included 1364 patients and where 64&#37; of face-to-face consultations were avoided&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> These data contrast with those of our study&#44; although the difference can be explained by the fact that&#44; in our protocol&#44; we established that only patients with a confirmed diagnosis and trivial disease would be discharged for follow-up in primary care&#59; the remainder were given appointments for check-ups with the same specialist&#46; While this protocol was designed in this way to ensure patient safety &#40;given the lack of experience with teledermatology in our center&#41;&#44; it prevents us from drawing reliable conclusions on the efficacy of teledermatology as a screening tool&#46; It is also important to remember that direct store-and-forward teledermatology data are usually inferior to those obtained by indirect store-and-forward teledermatology&#44; where images and the associated use of dermoscopy guarantee better diagnostic performance&#44; thus avoiding up to 58&#37; of face-to-face consultations&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Nevertheless&#44; our diagnostic performance was high&#58; we were able to make a diagnosis for 87&#46;1&#37; of patients with a considerable degree of confidence&#46; These results are similar to those reported by Sondermann et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> who were able to diagnose 90&#46;3&#37; of patients remotely&#46; Consistent with data form other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;16</span></a> we found that confidence in the diagnosis was higher for the categories infection&#44; cancer-precancer&#44; and inflammation and lower in melanocytic lesions and pediatric diseases&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The most frequent diagnoses were melanocytic nevus&#44; acne&#44; eczema&#44; actinic keratosis&#44; seborrheic keratosis&#44; and basal cell carcinoma&#46; These diagnoses are illustrative of the most common main diagnoses in dermatology in the PSCs and are similar to those reported elsewhere&#44; such as in DIADERM&#44; where the most common diagnoses were actinic keratosis &#40;8&#46;2&#37;&#41;&#44; basal cell carcinoma &#40;8&#46;1&#37;&#41;&#44; and melanocytic nevus &#40;7&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;15</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Image quality was considered adequate for diagnosis in 52&#46;1&#37; of cases&#44; which is consistent with data reported from a recent study on teledermatology based on WhatsApp&#44; where 54&#46;3&#37; of dermatologists considered image quality sufficient for diagnosis&#46; However&#44; this is lower than the 81&#37; recorded for indirect store-and-forward teledermatology&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> O&#8217;Connor et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> reported the results of a pediatric study that compared the diagnostic accuracy of teledermatology in 2 groups&#44; i&#46;e&#46;&#44; with and without previous instructions on imaging&#46; The authors reported no significant differences between the groups&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The results of the survey completed by dermatologists from HULP showed that the overall level of satisfaction was considered good by 68&#46;7&#37;&#46; It is worthy of mention that 81&#46;25&#37; agreed&#47;totally agreed with a high degree of confidence in the diagnosis&#44; 74&#37; agreed&#47;totally agreed that teledermatology had a positive impact on the running of their department&#44; and 87&#46;2&#37; would apply this approach to new areas of therapy&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">As for patient satisfaction&#44; the average score given to the 16 dermatologists was 4&#46;5&#47;5&#44; that is&#44; slightly higher than in a recent study of 243 teledermatology consultations&#44; where the average score was 4&#46;38&#47;5&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This finding supports publications that show a high index of patient satisfaction with direct-to-consumer telemedicine systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Online technology is well implemented in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> as seen in the high number of smartphone users in our study&#46; Nevertheless&#44; only 1 in every 4 patients recruited finally sent an image as part of their consultation&#59; of these&#44; 44&#37; were educated to university level&#46; We did not perform a structured analysis of the reasons why this high percentage of patients did not manage to complete a visit&#44; although according to the data gathered from the telephone calls to the dermatology office and the app helpdesk&#44; the main reasons were technological difficulties&#44; lack of trust in the security of the process&#44; and resolution of the skin disease&#46; We believe that these data may have improved if we had used a system that opened the patient&#8217;s camera directly by means of an SMS&#44; without the need to download an app&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Another limitation of our study is that we did not analyze diagnostic agreement in the application of teledermatology&#46; Therefore&#44; we cannot guarantee the diagnostic reliability of the approach&#46; However&#44; Sondermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> performed a random assessment of diagnostic agreement in 100 patients and found it to be 97&#37;&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Very few studies report the diagnostic performance of direct store-and-forward teledermatology&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17&#44;21</span></a> and we were unable to find studies performed during the COVID-19 lockdown&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In conclusion&#44; teledermatology is an effective tool that enables the practice of dermatology to continue during a pandemic in a way that is satisfactory for both patients and physicians&#46; Implementation of this form of teledermatology could complement face-to-face care activity&#44; especially in patients undergoing follow-up&#46; However&#44; the development of an efficient teledermatology system necessarily implies integration of digital imaging into medical information systems&#59; therefore&#44; we must ensure the necessary infrastructure for secure storage and transmission of images&#44; without unnecessarily increasing the workload of clinicians&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dermatologic care was halted because of the coronavirus disease 2019 pandemic&#44; prompting us to study the usefulness of direct-to-patient teledermatology via a mobile application&#46; We aimed to evaluate the service as a tool for avoiding face-to-face consultations&#44; describe the main conditions diagnosed&#44; and assess levels of patient and physician satisfaction&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and method</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prospective descriptive study of new patients who met the inclusion criteria&#46; Descriptive statistics for all variables were analyzed with SPSS&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Of the 1&#44;497 patients who agreed to participate in the study&#44; 25&#37; &#40;n &#61; 374&#41; sent an image to a consultant dermatologist through the mobile application&#46; Sixty-four patients &#40;17&#37;&#41; were discharged directly and referred to primary care for follow-up&#46; A face-to-face consultation was avoided for at least 3 months in 85&#37; of patients &#40;n &#61; 318&#41;&#59; 87&#46;1&#37; &#40;n &#61; 325&#41; received a diagnosis and the dermatologist&#39;s level of confidence in this diagnosis was 7 or higher in 77&#46;5&#37; of cases &#40;n &#61; 290&#41;&#46; The quality of the images sent was considered sufficient in 52&#46;1&#37; of cases&#46; Patients rated their satisfaction with a score of 4&#46;5 out of 5&#46; Eleven of the 16 dermatologists rated their satisfaction as good overall&#46; The most common conditions were inflammatory and melanocytic lesions&#46; The main diagnoses were nevi&#44; acne&#44; and eczema&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Direct-to-patient store-and-forward teledermatology is an effective means of evaluating new patients&#46; Both clinicians and patients expressed high levels of satisfaction with the service&#46; Systems enabling the addition of digital images to patient records are necessary to ensure the efficiency of teledermatology&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Como consecuencia de la pandemia por la COVID-19 ces&#243; la actividad dermatol&#243;gica asistencial&#44; por lo que iniciamos un estudio para evaluar la utilidad de la teledermatolog&#237;a &#40;TD&#41; directa entre paciente y dermat&#243;logo a trav&#233;s de una App&#46; El objetivo fue evaluar el impacto de esta herramienta para evitar consultas presenciales&#44; as&#237; como describir los principales diagn&#243;sticos y la satisfacci&#243;n de pacientes y m&#233;dicos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todo</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo prospectivo&#46; Se incluyen pacientes nuevos que cumplen criterios de inclusi&#243;n&#46; Se realiz&#243; un an&#225;lisis descriptivo de todas las variables mediante el programa estad&#237;stico SPSS&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De los 1&#46;497 pacientes que aceptaron participar el 25&#37; &#40;n &#61; 374&#41; enviaron una consulta virtual con imagen&#46; De entre ellos el 17&#37; &#40;n &#61; 64&#41; fueron dados de alta de forma directa para control por atenci&#243;n primaria&#46; En un 85&#37; &#40;n &#61; 318&#41; de los pacientes se logra evitar la consulta presencial durante al menos 3 meses&#46; Se emiti&#243; un diagn&#243;stico en el 87&#44;1&#37; &#40;n &#61; 325&#41; de los pacientes&#44; siendo la confianza en el diagn&#243;stico &#8805; 7&#47;10 en el 77&#44;5&#37; &#40;n &#61; 290&#41;&#46; La calidad de la imagen fue suficiente en el 52&#44;1&#37;&#46; La satisfacci&#243;n del paciente fue de 4&#44;5&#47;5&#46; Once de 16 dermat&#243;logos consideraron la TD &#250;til globalmente&#46; La afecci&#243;n m&#225;s frecuente fue la inflamatoria y melanoc&#237;tica&#44; siendo los diagn&#243;sticos m&#225;s habituales nevus&#44; acn&#233; y eccema&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La TD directa as&#237;ncrona es una herramienta eficaz para valorar pacientes nuevos&#44; con un alto grado de satisfacci&#243;n para m&#233;dicos y pacientes&#46; El desarrollo de un sistema de TD eficiente implica la integraci&#243;n de la imagen digital en los sistemas de informaci&#243;n m&#233;dicos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sendagorta E&#44; Servera G&#44; Nu&#241;o A&#44; Gil R&#44; P&#233;rez-Espa&#241;a L&#44; Herranz P&#46; Estudio piloto de la teledermatolog&#237;a directa durante el estado de alarma por la pandemia COVID-19 en un &#225;rea sanitaria de Madrid &#40;Estudio EVIDE-19&#41;&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;345&#8211;353&#46;</p>"
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Article information
ISSN: 15782190
Original language: English
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