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Background and objectives Understanding the origin and referral routes of patients seen in teledermatology and in-person dermatology consultations in Spain is of interest from the perspective of health care management. The objective of this study was to describe the referral routes and the frequency and characteristics of teledermatology consultations in Spain. Material and methods We performed a descriptive cross-sectional study of data collected over 6 days from the DIADERM study sample, which included the outpatients diagnosed by 80 Spanish dermatologists, selected by means of stratified random sampling. We studied the source and destination of patients based on funding, type of consultation, and age of the patients. We reported the frequency of teledermatology consultations, their origin and destination, type of funding, age of the patients, and most common diagnoses, and compared them with the same characteristics for in-person consultations. Results In private consultations, most patients were direct clients, whereas the most frequent source in public consultations was primary care and the dermatologist. Sixty-six percent of patients were referred to dermatology and 27% were discharged. No differences in these percentages were found between public and private consultations. The ratio of follow-up to initial visits was 0.8 for public consultations and 0.2 for private consultations. Teledermatology accounts for 1% of consultations. Eighty percent of these come from primary care and 17% are direct visits. Thirty-three percent of these visits are referred to primary care —a greater proportion than in in-person consultations. Galicia, Andalusia, and Catalonia are the regions with the highest percentage of consultations. Conclusions The results suggest that dermatologists in Spain have a considerable ability to resolve cases. Teledermatology accounts for a small percentage of consultations and access to these consultations is direct in a large percentage of cases.

Resumen Antecedentes y objetivos El conocimiento de las rutas de origen y derivacion de los pacientes atendidos en consulta dermatologica presencial y de teledermatologia en Espana tiene interes desde el punto de vista de la gestion sanitaria. El objetivo de este estudio es describir las rutas de derivacion y la frecuencia y caracteristicas de la teledermatologia en Espana. Material y metodos Estudio transversal descriptivo sobre la muestra del estudio DIADERM, que recogio la actividad de 80 dermatologos espanoles, seleccionados mediante muestreo aleatorio estratificado, durante 6 dias. Se estudiaron el origen y destino de los pacientes en funcion de la financiacion, el tipo de consulta y la edad de los pacientes. Se describio la frecuencia de las consultas por teledermatologia, su origen y destino, el tipo de financiacion, la edad de los pacientes y los diagnosticos mas frecuentes, comparandolos con la consulta presencial. Resultados El origen mas frecuente en la consulta privada es el directo, mientras que en la publica es la atencion primaria y el propio dermatologo. Un 66% de los pacientes se derivan a dermatologia y un 27% son dados de alta. No existen diferencias en estos porcentajes entre consulta publica y privada. El indice sucesivas/primeras fue de 0,8 para la consulta publica y de 0,2 para la privada. La teledermatologia representa un 1% de las consultas. El 80% procede de atencion primaria y el 17% tiene origen directo. Se deriva a atencion primaria el 33%, en mayor proporcion que en consulta presencial. Galicia, Andalucia y Cataluna son las regiones donde representa un mayor porcentaje de consultas. Conclusiones Los resultados sugieren una alta capacidad resolutiva de las consultas de dermatologia en Espana. La teledermatologia representa un porcentaje pequeno de las consultas, y el acceso a ella se da en un porcentaje relevante de pacientes por via directa.

Adalimumab (ADA) is a recombinant human monoclonal antibody indicated for the treatment of psoriasis that specifically inhibits tumor necrosis factor. Until recently we only had the presentation of 40 mg of ADA, being the standard dose in adults an initial administration of 80 mg, followed by 40 mg every 2 weeks. Newly the presentation of 80 mg of ADA has been commercialized, allowing the administration of the standard dose or a higher dose, with fewer injections. In this study, we retrospectively studied 11 patients with psoriasis who have received treatment with the presentation of 80 mg of ADA in two dermatology departments of two hospitals in Spain since its commercialization until June 2019. At the end of the study, an improvement in the mean final Psoriasis Area Severity Index (PASI) of all patients was observed, without any patient presenting any adverse effects. This study shows the efficacy and safety of 80 mg of ADA in a sample of 11 patients with psoriasis.

Management of facial extensive recurrent basal cell carcinoma can be a challenge for dermatologists. Although the preferred technique is usually Mohs surgery, sometimes the patient's condition or predicted aggressive surgery make other options advisable.We describe a case of a giant recurrent basal cell carcinoma in the face of an old woman successfully treated by combined therapy with MAL-photodynamic therapy and topical 5%.The patient remains well and with no sign of the tumor, with very good cosmetic result two years after treatment.Management of extensive facial basal cell carcinoma with combined therapies, as photodynamic therapy followed by topical imiquimod, can be an option for selected cases such as ours.

Clustered or agminated juvenile xanthogranuloma (JXG) is an unusual form of JXG characterized by multiple reddish-brown or yellowish papules and nodules in a coalescent pattern. We report a case of clustered JXG involving the left lower back of a 5-month-old boy.

Nino varon de siete anos con prurito del cuero cabelludo de reciente aparicion tras volver de un campamento de verano. La madre traia la almohada del nino, manchada con multiples hemorragias puntiformes (fig. 1). Estos hallazgos y la clinica relatada orientaron el diagnostico de Pediculosis capitis. La exploracion minuciosa del cabello de este paciente y el estudio del cabello mediante peinado con el pelo mojado demostro tanto la presencia de liendres eclosionadas como liendres con parasitos vivos en su interior; el diagnostico de infestacion activa se establecio al observar los parasitos adulto, como se ve en esta imagen de microscopia optica (fig. 2).

Received May 30, 2012, Revised July 11, 2012, Accepted for publication September 20, 2012 Corresponding author: Francesc Messeguer, Deparment of Dermatology, Instituto Valenciano de Oncologia, Mateo Pueyo nr.6, 5 CP:46800, Xativa-Valencia, Spain. Tel: 34-685-529-231, Fax: 34-961-114-342, E-mail: francescmb@comv.es This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Fig. 1. Patient lesions in January 2011, erythematous scaly plaques over 80% of her total body surface (SCORing atopic dermatitis [SCORAD]: 23). Severe Refractory Atopic Dermatitis in an Adolescent Patient Successfully Treated with Ustekinumab