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Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.

Background Store-and-forward teledermatology is an emerging means of access for patients with skin disease lacking direct access to dermatologists. Objectives We sought to examine the patient demographics, diagnostic concordance, and treatment patterns in teledermatology for patients younger than 13 years. Methods We conducted a descriptive retrospective cohort study involving 429 patients. Results Diagnoses were concordant in 48% of cases, partially concordant in 10%, and discordant in 42%. Management recommendations were concordant in 28% of cases, partially concordant in 36%, and discordant in 36%. Primary care providers tended to underuse topical steroids and overuse topical antifungals and systemic antibiotics. Only 1.4% and 6.0% of patients required repeated teledermatology consultation and in-person dermatology consultation, respectively. Limitations Limitations were the inability to generalize the data from the population studied and the chances of error and bias in teledermatology diagnoses. Conclusions Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in children who lack direct access to dermatologists.

The ATA assembled a group of experts to develop practice guidelines for teledermatology. This document represents the body of work that this distinguished group assembled. It was approved by the ATA Board of Directors and is presented here in its entirety.

Epidermal expression of the two isoforms of the prostaglandin H-generating cyclooxygenase (COX-1 and COX-2) was evaluated both by immunohistochemistry performed on human and mouse skin biopsy sections and by Western blotting of protein extracts from cultured human neonatal foreskin keratinocytes. In normal human skin, COX-1 immunostaining is observed throughout the epidermis whereas COX-2 immunostaining increases in the more differentiated, suprabasilar keratinocytes. Basal cell carcinomas express little if any COX-1 or COX-2 immunostaining whereas both isozymes are strongly expressed in squamous cell carcinomas deriving from a more differentiated layer of the epidermis. In human keratinocyte cultures, raising the extracellular calcium concentration, a recognized stimulus for keratinocyte differentiation, leads to an increased expression of both COX-2 protein and mRNA; expression of COX-1 protein, however, shows no significant alteration in response to calcium. Because of a recent report that failed to show COX-2 in normal mouse epidermis, we also looked for COX-1 and COX-2 immunostaining in sections of normal and acetone-treated mouse skin. In agreement with a previous report, some COX-1, but no COX-2, immunostaining is seen in normal murine epidermis. However, following acetone treatment, there is a marked increase in COX-1 expression as well as the appearance of significant COX-2 immunostaining in the basal layer. These data suggest that in human epidermis as well as in human keratinocyte cultures, the expression of COX-2 occurs as a part of normal keratinocyte differentiation whereas in murine epidermis, its constitutive expression is absent, but inducible as previously published.

Background Teledermatology programs in the United States have evolved over the past several decades. No systematic survey of teledermatology programs in the United States is available in peer-reviewed literature. Objective To provide up-to-date information regarding the state of teledermatology programs in the United States. Methods Active U.S. teledermatology programs were surveyed in 2011 with regards to practice models, clinical volume, and payment methods. These findings were compared with those from 2003. Results By January 2012, 37 teledermatology programs were active in the United States. Store-and-forward teledermatology was the most frequent delivery modality offered by 30 (81%) of the programs. The majority of the programs were based at academic institutions (49%), followed by Veterans Administration hospitals (27%), private practice (16%), and health maintenance organizations (HMOs) (8%). The majority of programs (67%) provided services to their home state only, whereas the rest also served additional U.S. states or abroad. The median number of consultations per program was 309 (range, 5-6500) in 2011. The most frequent payer sources were private payers, followed by self-pay, Medicaid, Medicare, and HMOs. Since 2003, with the confirmed discontinuation of 24 previously active programs, the total number of active teledermatology programs in 2011 was 60% of that in 2003. However, the annual consult volume per program nearly doubled for the sustainable programs in 2011. Limitations Itemized billing information was not uniformly available from all programs. Conclusion The turnover in teledermatology programs is relatively constant, with an increase in consult volume for sustainable programs. Store-and-forward is the dominant modality of delivery, while hybrid technology model is emerging.

The concentration of extracellular calcium appears critical to the initiation of keratinocyte differentiation. Prostaglandins (PGs) have also been implicated in cell differentiation. Consequently, the participation of endogenous eicosanoids in calcium-induced differentiation of human keratinocytes was evaluated in vitro. Our results demonstrate that: (1) exogenously introduced PGE2, the major keratinocyte-derived eicosanoid, but not prostaglandin I2 (PGI2) or its stable metabolite 6-keto-PGF1α, enhances calcium-induced cornified envelope formation, an established marker of keratinocyte differentiation; (2) increasing extracellular calcium increased endogenous PGE2 synthesis by cultured keratinocytes; (3) blocking endogenous PGE2 synthesis with indomethacin significantly suppresses calcium-induced formation of the cornified envelope; and (4) adding back PGE2 to indomethacin-treated keratinocytes is able to re-establish the control level of cornified envelope formation following stimulation by calcium. These data document the participation of endogenously generated PGE2 in the modulation of calcium-induced differentiation by human keratinocytes.

In this study we have demonstrated that noradrenaline increases the levels of prostaglandin E2 and prostaglandin I2 (detected as the stable metabolite 6-keto-prostaglandin F1 alpha) synthesized by homogenates of superior cervical ganglia from the adult rat. This noradrenaline-induced prostaglandin production was further characterized: (a) Selective destruction of adrenergic sympathetic postganglionic neurons in the ganglia using 6-hydroxydopamine abolished both basal and stimulated prostaglandin production. (b) Elimination of preganglionic cholinergic sympathetic nerve terminals in the ganglia had no effect. (c) Mepacrine (a phospholipase inhibitor) and indomethacin (a cyclooxygenase inhibitor) attenuated both basal and stimulated prostaglandin production. (d) Yohimbine, but not prazosin, suppressed the noradrenaline dose-response curve for prostaglandin production. The results of these experiments show that, in vitro, noradrenaline stimulates de novo synthesis of prostaglandin E2 and prostaglandin I2 by sympathetic postganglionic neurons. This stimulation by noradrenaline appears to result from action at an alpha 2-adrenergic receptor.

Prostaglandins (PGs) were measured in perfusate from the lumbar intrathecal (IT) space of pentobarbital anaesthetized rats. The level of PGE2, but not of PGF2 alpha or 6-keto PGF1 alpha, was increased by immersion of a hindpaw in water at a noxious temperature (50 degrees C). No increase in PGE2 was produced by non-noxious thermal stimulation (35 degrees C water). The noxious stimulus-evoked increase in PGE2, and increases in PGE2 during norepinephrine infusion (10 micrograms/ml), were significantly decreased in rats pretreated with intrathecal 6-hydroxydopamine. These data suggest that noxious stimuli induce an increase in the production of spinal PGE2 and that this production derives from, or requires the presence of noradrenergic terminals in the spinal cord.

he Residency Review Committee of the Accredita-tion Council for Graduate Medical Education now requirespsychiatric residents to demonstrate “competency” in fiveforms of psychotherapy: brief, cognitive behavior, andsupportive therapies; long-term psy-chodynamic therapy; and combinedpsychotherapy and pharmacotherapy(1). The field has been struggling withthe implications of this graduation re-quirement since its promulgation in2001 (2). During training, residentsfrequently choose a particular treat-ment for a particular patient based ontheir caseloads, training needs, andsupervisory availability, with the rareopportunity to see how patients mightrespond to different psychotherapies.As a theoretical exercise, such an ex-perience would clarify the differences and similaritiesamong different psychotherapeutic orientations, includ-ing their theoretical assumptions, technical interventions(3), and the process of differential therapeutics that psy-chiatrists must undertake in evaluating patients and de-veloping treatment plans (4, 5).We simulate that experience by presenting a suitablepatient to experts from the disciplines of cognitive behav-ior therapy, interpersonal psychotherapy, and long-termpsychodynamic psychotherapy. Each expert will describehow his treatment might proceed. As we shall see, thetreatments differ conceptually and technically. Other ther-apies, including time-limited brief dynamic therapy(which has its own conceptual basis and technical ap-proach), are beyond the scope of this presentation.

12-O-Tetradecanoylphorbol-13-acetate (TPA) induces prostaglandin E2 (PGE2) synthesis in mouse keratinocytes and is associated with the induction of keratinocyte proliferation as well as accelerated differentiation. In human keratinocytes, TPA has been reported not to induce the release of either 3H-labeled arachidonic acid or 3H-labeled prostaglandins, even though cell differentiation is stimulated. Because PGE2 has been associated with the modulation of cell differentiation and because of technical problems inherent in evaluating arachidonic acid metabolism using only radiolabeled substrates, we evaluated the ability of TPA to induce endogenous PGE2 generation by cultured human keratinocytes using a specific and sensitive enzyme immunoassay. With this technique, TPA was found to induce a dose-dependent (1.6 x 10(-12)-1.6 x 10(-8) M) increase in PGE2 generation. These results are consistent with observations made not only in mouse keratinocytes but in other mammalian and human cell types. Documenting the ability of TPA to stimulate PGE2 production in human keratinocytes is very relevant to current theories regarding the role of PGE2 in keratinocyte differentiation as well as to establishing parallels between the murine and human skin models.

We wished to assess both diagnostic accuracy and concordance among dermatologists when evaluating digital images of skin disease presented using a low-cost asynchronous (store-and-forward) format. Each of eight board-certified dermatologists reviewed 50 clinical cases presented in digital format on a 15-inch computer monitor. For each case, the teleconsultants made a primary diagnosis and differential diagnosis and indicated whether or not a biopsy should be performed both before and after reviewing a brief history of each case. Diagnostic accuracy was calculated for each teleconsultant on the basis of biopsy, culture, or wet mount results. Concordance was determined by comparing primary and differential diagnoses made by the teleconsultants on all 50 cases with those made by the dermatologists who originally examined the patients in person. For eight skin cancers, the diagnostic accuracy for the inperson dermatologist was 88% versus 90% (range, 75-100%) for the teleconsultants. For the 25 cases (including the 8 skin cancers) confirmed by either biopsy (20), culture (1), or wet mount (4), the in-person accuracy was 84% compared to 73% (range, 65-88%) for the teleconsultants. The concordance between the in-person and teleconsultant diagnoses were in agreement 77% of the time (90% if differential diagnoses were included). After evaluating the accompanying history, teleconsultants changed their primary diagnosis in 11% of the cases (range, 2-22%). Biopsy rates were not significantly different between teleconsultants (45%) and in-person dermatologists (40%). An asynchronous software application can provide levels of diagnostic accuracy and concordance equivalent to those reported using live teleconsultation.

Peroxisomal deficiency has been described in a number of syndromes characterized by chondrodysplasia punctata, including the Conradi-Hünermann (C-H) syndrome. Because of overlapping clinical features of X-chromosome inheritance, ichthyosis, and limb-reduction defects in C-H and CHILD (congenital hemidysplasia with ichthyosiform erythroderma and limb defects) syndromes, we examined peroxisomal content using diaminobenzidine cytochemistry and peroxisomal functions in fibroblasts from involved vs uninvolved skin of CHILD syndrome.Fibroblasts from involved skin of a patient with CHILD syndrome accumulated cytoplasmic lipid, visualized with the fluorescent probe, nile-red. Ultrastructurally, fibroblasts of involved skin of CHILD syndrome accumulated lamellated membrane and vacuolar structures. By diaminobenzidine ultracytochemistry, fewer peroxisomes were present. Moreover, the activities of two peroxisomal enzymes, catalase and dihydroxyacetone phosphate acyltransferase, were decreased (approximately 30% of normal). However, peroxisomal oxidation of very-long-chain and branched-chain fatty acids was preserved. Moreover, plasma very-long-chain fatty acids, plasma phytanic acid, and erythrocyte plasmalogen content were normal.The CHILD, C-H, and rhizomelic chondrodysplasia punctata syndromes are all characterized by ichthyosis, chondrodysplasia punctata, and limb defects, as well as peroxisomal deficiency. Thus, these syndromes may be related pathogenically. Because peroxisomes are involved in prostaglandin metabolism, peroxisomal deficiency may directly contribute to the previously reported alterations in prostaglandin metabolism in fibroblasts of involved skin of fibroblasts.

The contribution of exocytosis to norepinephrine-stimulated prostaglandin release from sympathetic postganglionic neurons was evaluated in homogenates of adult rat superior cervical ganglia. Incubation of ganglion homogenates with norepinephrine (1 mM) for 30 min caused an increased release of prostaglandin E 2 and prostaglandin I 2 (measured as the stable metabolite, 6-keto-PGF 1a ). Neither tetrodotoxin (10 mM), K + (120 mM), nor EDTA in Ca 2+ -free buffer affected prostaglandin generation under basal and norepinephrine-stimulated conditions. These results suggest that the increase in prostaglandin production by sympathetic neurons after norepineprhine administration is not through the release of previously synthesized intracellular stores. Instead, the increase in prostaglandins in response to norepinephrine appears to be explained by de novo synthesis.

Skin can be considered as a two-compartment tissue consisting of an overlying epidermis and an underlying dermis separated by a selectively permeable basement membrane. Studies on the communication between these skin compartments have shown that the keratinocyte, which is the constitutive cell of the epidermis appears susceptible to modulation by dermally derived influences. In tissue recombinant experiments, Billingham and Silvers (1967) found that regional epidermal histomorphology in guinea pigs (e.g. sole versus ear) was determined by the origin of the dermal component. Melbye and Karasek (1973) and Mackenzie and Fusenig (1983) further found that facilitation of epidermal proliferation may depend on diffusable, dermally-derived factors.