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telemedicine is the practice of healthcare using interactive audio , visual , and data communication ; this includes healthcare delivery , diagnosis , consultation , and treatment , as well as education and transfer of medical data .
telemedicine may be as simple as two health professionals discussing a case over the telephone or as complex as using satellite technology and videoconferencing equipment to conduct a real - time consultation between medical specialists in two different countries .
telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care .
teledermatology as an application of telemedicine was developed in 1995 : it turns out to be a gradually more ordinary mean of delivering dermatologic healthcare worldwide and will almost certainly have a greater medical function in the future . during the last years , teledermatology has gained a lot of interest among scientific community .
it can deeply revolutionize the delivery of dermatology services , providing equitable services to remote areas and allowing primary care physicians to refer patients to well - equipped dermatological services at a distance .
teledermatology uses telecommunication technologies to transfer information to patients via mobile phone and images of skin lesions to clinicians via the internet .  
nowadays , a reduction of morbidity and mortality of nonmelanoma and melanoma skin cancer is the most important challenge for dermatology : teledermatology can be considered a new tool that allows preventing and diagnosing skin cancers .
because solar irradiance is the reason of many dermatologic effects , a certain number of studies have tried to evaluate different methods to calculate a daily parameter of sun irradiance .
these studies have tried to correlate the daily parameter with human photoexposure in order to avoid sunburns and other sun risks [ 47 ] . nevertheless , sunscreen use is often recommended in order to prevent certain types of skin cancers and sunburns [ 8 , 9 ] . from a national canadian questionnaire ,
it has been estimated that only a few part of population ( about 20% ) uses sunscreen regularly . a major cause of nonadherence to sunscreen use is oversight , but also the misunderstanding about sunscreen uses and its benefit .
in order to avoid the risks of sun exposure , many educational programs are in progress to inform people about preventive measures .
many scientific agencies have calculated , under the leadership of who ( world health organization ) , a daily index of sun irradiance to detect the cut - off value to avoid sunburn and sun risks .
sun light composes of a very wide range of electromagnetic waves of which the human eye is able to perceive light radiations .
it knows that med ( minimal erythemal dose ) is defined as the quantity of uvb able to elicit an erythemal response .
nevertheless , to calculate skin sensitivity , a new noninvasive method is a multiband spectrophotometer ( skin analyzer ) with two reflectance measures , and other magnitudes which can be directly correlated to them ( e.g. , absorbance ) , a calculation unit and a data storage unit for calculating the corresponding med .
this sensitivity varies from individual to individual and can be determined with different methods [ 6 , 11 , 12 ] . in 2006 ,
monitored sun radiation to obtain bioclimatic parameters useful for evaluating climatic changes in order to get an adequate sun protection map , set up an experimental photodermatology service , and promote preventive devices through a system of customized uv teledosimetry using information technology such as mobile phones .
a total of 450 tourists were selected in capri town , and   they filled a questionnaire containing personal information as sex , age , hair colour , eye colour , phototype , sunscreen used , and sunbathing time .
the med was measured by the skin analyser q tan , and , after the examination , the team of dermatologists compiled   a card for each of them with information about their photosensitivity .
the tourists selected in this project before sun exposure were informed by smss through their mobile phones or through   a light board about the optimal uv dose for their skin and about an estimate of the residual exposure time considering the uv irradiance .
more exactly , in the study , the authors correlated the uvi to the phototype of the subjects studied , thus obtaining an estimate of the maximum exposure time expressed in minutes to avoid sunburn .
a software instantaneously calculates the exposure time to avoid sunburn on the basis of the effective erythemal dose ( de ) expressed in med / h using the following algorithm st = 60/de .
therefore , in a typically sunny august day with a uvi equal to 6 ( 2.6 med / h ) , a phototype i or ii at his / her first sun exposure would develop a sunburn after about 20 minutes , while in a moderately pigmented subject this would take some hours .
half of them received daily sms reminders through their mobile phones for 6 weeks , and the other half did not receive reminders .
the smss reminder consisted of two components : a  hook  text detailing daily local weather information and a  prompt  text reminding users to apply sunscreen .
this methodology showed that a simple daily reminder could maintain adherence to sunscreen application ; in fact the participants who received the sms reminders were nearly twice as adherent to a regimen of daily sunscreen application respect with control participants who did not receive sms reminders .
previous studies that had just examined the use of text messaging in health care have found that text - message reminders improve outpatient clinic attendance [ 1519 ] , encourage weight loss , and provide support to diabetic patients .
the results of these studies confirm that text messages or smss can promote behavioural changes .
in fact , smss can be used to promote preventive health behaviours or help individuals adhere to medication regimens for several reasons .
the mobile phone renders the people readily available , and the sms is a simple , low cost , and immediate method of delivering reminders without using the computers , but the point more important is that text messaging may be attractive to younger people , an important target population for development of positive preventive health habits . despite numerous recommendations , people have yet to understand the problems related to excessive sun exposure and the importance of using sunscreen .
the results of these studies suggest that text - message reminders reach a large number of people at low cost .
introduction of a program that incorporates text - message reminders to a large population may be an innovative preventive health measure against the development of skin cancer .
dermoscopy is a noninvasive , in vivo technique and has the potential to improve up to 49% the diagnostic accuracy for melanoma and nonmelanoma skin cancer , if used by experts [ 2224 ] . in 1998 , provost et al .
made the first step in the creation   of an international teledermoscopy network , using a store - and - forward technology with dermoscopic images .
the feasibility of teledermoscopy reveals a 91% consensus between the face - to - face diagnosis and the remote diagnosis .
the consensus netmeeting of dermoscopy ( a virtual meeting of experts from all over the world ) was another evident example of the practical applicability of the use of dermoscopy via the internet . in 2003 ,
a pilot study of the dermoscopic - pathologic approach using telediagnosis for melanocytic skin neoplasms revealed that the diagnostic accuracy reached 83% versus gold standard ( conventional histopathologic diagnosis by experts ) .
a 2-step teledermatologic approach may be feasible in managing individuals with multiple pigmented skin lesions .
teleconsultations were sent from general practitioners to the pigmented skin lesion clinic of the department of dermatology , university of seville , in seville , spain , and 49% of the patients were referred to the ftf clinic .
there was agreement among the teleconsultants for both the diagnosis ( k = 0.91 ) and for the management options ( k = 0.92 ) .  
regard , tan et al . evaluated if teledermoscopy could be considered as a triage tool of patients referred to a skin lesion clinic .
two - hundred patients referred to a dermatology skin lesion clinic were recruited , and a total of 491 lesions were seen .
digital and dermoscopic photographs were taken of skin lesions of concern , and the patients were then seen independently face - to - face by two out of three dermatologists .
the digital images were evaluated 4 weeks later , as a teledermoscopy consultation , by two of these dermatologists .
there was excellent agreement between teledermoscopy and face - to - face diagnosis with only 12.3% of lesions having disparate diagnoses of clinical significance .
only 12 of 491 lesions appeared to have been underreported by teledermoscopy when compared with face - to - face diagnosis .
however , when histopathology became available , only one malignant lesion had been missed ( a basal cell carcinoma diagnosed as solar keratosis ) by teledermoscopy .
importantly , 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face - to - face by a dermatologist .
also investigated the feasibility of teleconsultation using a new generation of cellular phones in pigmented skin lesions .
18 patients were selected consecutively in the pigmented skin lesions clinic of the department of dermatology , medical university of graz , graz ( austria ) .
the face - to - face ( ftf ) diagnoses ( 16 benign lesions and 2 melanomas ) were made in each case .
clinical and dermoscopic images were acquired using a sony ericsson k 750i with a built - in two - megapixel camera and a pocket dermoscopy device with a 25 mm 10x lens ( dermlite ii pro hr ( 3gen , llc 
two teleconsultants reviewed the images on a specific web application where images had been uploaded in jpeg format .
compared to the face - to - face diagnoses , the two teleconsultants obtained a score of correct telediagnoses of 89% and of 91.5% reporting the clinical and dermoscopic images , respectively . anyway , in a nhs r&d technology assessment , patients referred to a 2-week wait clinic were invited to have a series of digital photographs , with and without dermoscopy , immediately before their face - to - face consultation . a surprisingly high proportion ( 33% ) of referrals proved to have a cutaneous malignancy or a severely dysplastic lesion , with
almost 22% having a malignant melanoma or squamous cell carcinoma , possibly reflecting the rise in incidence of skin cancers reported elsewhere .
if the highest level of clinician confidence had been applied , no cancers would have been missed , but only 20% of patients would have avoided an outpatient appointment .
it was concluded that it is unlikely that this approach can dramatically reduce the need for conventional clinical consultations while still maintaining patient safety .
unfortunately , according to previous observations , teledermoscopy of hypopigmented or nonpigmented lesions can not always significantly improve diagnostic accuracy .
fabbrocini et al . focused on 44 not very common lesions in the clinical practice , characterized by poor and/or absent pigmentation , absence of regular network , and a diameter < 5  mm . the 44 lesions examined by the two observers consisted of 39 melanocytic lesions ( 12 spitz naevi , 9 melanomas , 8 melanomas in situ , 7 clark naevi , 2 dermal naevi , and 1 spitzoid melanoma ) and 5 nonmelanocytic lesions ( 2 seborrheic keratosis , 1 dermatofibroma , 1 haeman - gioma , and 1 bowen papulosis ) .
they chose these kinds of lesions with high diagnosis complexity either clinically or dermoscopically to evaluate the reliability of using teledermoscopy for the diagnosis of rare and atypical lesions .
the pattern analysis and the 7-point checklist were applied to all 44 skin lesions for the early detection of melanoma .
the interobserver agreement and the agreement between face - to - face diagnosis and telediagnosis were assessed .
the agreement was investigated using cohen 's k statistics . with respect to the pattern analysis
, it was observed that some features , such as leaf - like areas , milia - like cysts / comedo - like openings , blue - white structures , and blotches , are detected with the same frequency in face - to - face and teledermoscopic observations .
regarding pigment network , regression structures , and diffuse pigmentation , the results showed that they were more evident in teledermoscopic observation , whereas vascular pattern , radial streaks , and dots / globules had lower detection frequency .
with respect to the 7-point checklist , it was noticed that irregular pigmentation and regression structures had a higher frequency in teledermoscopic observation ; all other criteria were better detected in face - to - face observation . a significant difference in total score derived from 7-point checklist analysis was evident between face - to - face observation and teledermoscopic observation ; lesions with a score equal or superior to 3 were found mostly in face - to - face observation .
the agreement , evaluated through cohen 's k , between the 1st and the 2nd observer on clinical diagnosis was very low ( k = 0.362 ) .
moderate agreement ( k = 0.435 ) was detected between the 1st and the 2nd observer on dermoscopic diagnosis ; this suggested that dermoscopy improved clinical diagnosis .
these data showed that telediagnosis , compared with face - to - face diagnosis , presented a lower diagnostic accuracy .
it can deeply revolutionize the delivery of dermatology services , providing equitable services to remote areas and   allowing primary care physicians to refer patients to well - equipped dermatological services at a distance .
images can be transmitted via a virtual private network to the teledermoscopists , and   those ones can be made mobile as the technology is portable , overcoming geographical barriers , and delivering service to remote areas [ 3537 ] .
in particular , teledermatology can aid in the prevention and diagnosis of nonmelanoma and melanoma skin cancer .
patients seem to accept teledermatology , considering it as an excellent mean to obtain healthcare , particularly in those areas with no expert dermatologists available
. the use of innovative mobile technology can improve prevention campaign , reaching young people too .
clinicians have also generally reported affirmative experiences with teledermatology , excluding for the diagnosis of  pink  lesion .
further studies focusing on cost effectiveness , intrinsic limits , and patient and clinician satisfaction will facilitate to delineate the potential of teledermatology as a mean of dermatologic healthcare delivery .
telemedicine is a rapidly developing application of clinical medicine where medical information is transferred through interactive audiovisual media for the purpose of consulting remote medical procedures or examinations , reducing the time of consultation for patients . 
 teledermatology as an application of telemedicine was developed in 1995 : it turns out to be a gradually more ordinary mean of delivering dermatologic healthcare worldwide and will almost certainly have a greater medical function in the future . in particular 
 , teledermatology can aid in the prevention and diagnosis of nonmelanoma and melanoma skin cancer ; telemedicine and teledermatology offer the opportunity to make available consultations with experts also by long distance . 
 overall , patients seem to accept teledermatology , considering it as an excellent mean to obtain healthcare , particularly in those areas with no expert dermatologists available . 
 clinicians have also generally reported affirmative experiences with teledermatology in the skin cancer field . 
 further studies focusing on cost effectiveness , patient outcomes , and patient and clinician satisfaction will facilitate to delineate the potential of teledermatology as a mean of prevention and diagnosis of nonmelanoma and melanoma skin cancer .