Report The role of dermatopathology in conjunction with teledermatology in resource-limited settings: lessons from the African Teledermatology Project Matthew W. Tsang1, MD, MSt, and Carrie L. Kovarik2, MD 1Department of Dermatology, University Abstract of Minnesota, Minneapolis, MN, USA, Background Access to dermatology and dermatopathology services is scarce in 2 and, Departments of Dermatology and sub-Saharan Africa. Teledermatology provides consultations for healthcare providers in Internal Medicine, University of resource-limited settings where specialty medical services are difficult to obtain, and the Pennsylvania, Division of Infectious Diseases, Philadelphia, PA, USA African Teledermatology Project has helped to bridge the gap in dermatological care in Africa. This program also allows for biopsy specimens to be sent to the USA for processing Correspondence in cases where the clinical diagnosis is difficult and definitive diagnosis has implications for Carrie Kovarik, MD patient management. This study characterizes conditions diagnosed through clinicopatho- Assistant Professor logical correlation in conjunction with photos and tissue submitted to the African Dermatology, Dermatopathology, and Infectious Diseases Teledermatology Project. University of Pennsylvania Materials and methods Retrospective case review of tissue specimens submitted over 2 Maloney Building three years. 3600 Spruce Street Results Fifty-five biopsy specimens met inclusion criteria and represent cases of Philadelphia, PA 19104 malignancy (35%), infection (7%), suspected infection (15%), lichenoid tissue reaction E-mail: [email protected] (5%), dermatitis (15%), and other various conditions (18%). Three biopsy specimens were Funding sources: None. non-diagnostic (5%). Clinicopathological concordance between submitting clinician and Disclosures: The authors have no biopsy results occurred in 32 out of 55 cases (58%). Clinical and pathological diagnoses conflict of interest to declare. differed in 21 out of 55 cases (38%). Kaposi sarcoma (KS) represents the clinical diagnosis Dr. Tsang’s research time was most often suspected in the evaluated biopsy specimens (42%) and was correctly supported by the American Society of Dermatopathology Mentorship Award. recognized clinically in 13 out of 23 cases (57%). Conclusion Clinical images may not provide sufficient information to definitively diagnose certain infectious and malignant dermatological conditions submitted through telemedicine consultation. Microscopic examination of skin biopsy specimens is an important adjunct for accurate diagnosis of disease and determination of appropriate treatment strategies. The African Teledermatology Project was initiated Introduction through a collaboration between the Departments of Nations of the developing world face significant physi- Dermatology at the University of Pennsylvania, USA, and cian shortages, particularly specialists such as dermatolo- the Medical University of Graz, Austria, with additional gists. Sub-Saharan Africa is among the world’s most collaboration from Mbarara University of Science and underdeveloped and resource-poor regions, with as few Technology and Makerere University in Uganda, the as 10 physicians per 100,000, and no dermatologists in Botswana-UPenn Partnership, the Baylor International many areas.1–3 The availability of dermatopathology Pediatric AIDS Initiative (BIPAI), the American Academy services is even rarer, with only 14% of sub-Saharan of Dermatology, and the University of Queensland in African nations reporting the presence of a dermato- Brisbane, Australia, in 2007. Participating African medi- pathologist in their country.4 In areas where access to cal centers in Botswana, Eritrea, Kenya, Lesotho, Liberia, dermatology and dermatopathology is scarce, general Malawi, Mozambique, Nigeria, South Africa, Swaziland, clinicians rely heavily on clinical judgment and are Tanzania, and Uganda have submitted approximately 700 rarely able to submit skin biopsies for histological inter- clinical cases for review since the project began in 2007. 150 pretation. Clinical photographs along with patient history are posted International Journal of Dermatology 2011, 50, 150–156 ª 2011 The International Society of Dermatology Tsang and Kovarik Role of dermatopathology in conjunction with teledermatology in resource-limited settings Report 151 on the web-based application (http://africa.telederm. were also sent to the USA for analysis and definitive diagnosis. org) for secure internet review by teledermatologists who All biopsy specimens originating as consultations from Africa in provide feedback and suggestions on management and the University of Pennsylvania Department of Dermatology, diagnosis.1,2 Division of Dermatopathology, were evaluated. This includes all The use of teledermatology consultation for second tissue specimens sent for processing and subsequent opinion service has been shown to be useful as a means pathological consultation in the three-year period from 2007 to of generating discussion and confirmation of diagnosis, as 2009. well as management decisions.5 The African Telederma- The age, gender, and country of origin (Fig. 1) of each patient tology Project has demonstrated the usefulness of a tele- were recorded. The clinical history outlined in the dermatology network in improving the provision of care teledermatology consultation and the corresponding pathology for skin disease in resource-limited settings. In most cases, report, as well as the histological diagnoses rendered, were diagnosis and management decisions can be reached with evaluated by both authors. In cases where two or more biopsy the clinical history and clinical photographs alone. How- specimens were taken from a single patient, each biopsy was ever, in certain situations, such as dermatoses of the counted separately if the corresponding diagnoses were different. immunosuppressed, histology provides information imper- In settings where the diagnosis of both specimens was identical, ative to determining definitive diagnosis and safe treat- the biopsies were aggregated and counted once, as they ment strategies. Anecdotal evidence and case reports represented two samples of an identical process. Based upon the highlight the protean manifestations of human immuno- biopsy site and microscopic description, biopsies were excluded deficiency virus (HIV)-associated dermatoses and under- if they did not include skin as part of the specimen. Biopsies were score the value of histopathological confirmation of not excluded because of patient age, race, or economic status. diagnosis prior to the initiation of treatment strategies.6–8 Treatment courses for antimicrobial and malignant condi- Results tions are complex in this patient population, and if the incorrect empiric therapy is initiated, the underlying dis- Fifty-nine cases were identified for review and, of these ease process can worsen.6 cases, 55 met both the inclusion and exclusion parame- The African Teledermatology Project has helped to ters. The biopsy specimens represent 22 females and 31 bridge the gap in access to dermatological specialty care males (one female and one male each with two biopsies). in Africa through store and forward teledermatology con- The diagnoses rendered in the 55 cases can be divided sultation services. This teledermatology program also into seven general categories: malignancy; infection; sus- allows for biopsy specimens to be performed and sent to pected infection; lichenoid tissue reaction; dermatitis; the USA for processing in cases where the clinical diagno- other; and non-diagnostic biopsies (Table 1). Kaposi sar- sis is difficult and definitive diagnosis has implications for coma (KS) represents 79% of malignant biopsies (15/19) management of the patient. This study seeks to character- and 27% of all biopsy specimens (15/55). Infections rep- ize the conditions diagnosed through clinicopathological resent 22% (12/55) of biopsy specimens, including con- correlation in conjunction with photos and tissue submit- firmed infections based upon organism identification in ted to the African Teledermatology Project. We will cate- four specimens and suggestive histology despite negative gorize the diagnoses rendered; determine the timeliness of stains in eight specimens. Infections include filariasis, specimen acquisition and diagnosis; evaluate the concor- fungal infections, and leprosy. Dermatitis represents 15% dance of the clinical diagnosis of the submitting clinician of biopsy samples (8/55), and includes eczema, dermatitis and histological diagnosis; and determine the possible not otherwise specified (NOS), folliculitis, psoriasis, and clinical impact of such information on the ultimate course lichen simplex chronicus. Other diagnoses represent 18% of patient care and treatment recommendations. The of biopsy specimens and include: congenital ichthyosiform types of specimens sent represent clinically challenging erythroderma; a suspected immunobullous disorder; con- situations where tissue examination is imperative to deter- nective tissue disorder; vasculitis; pyogenic granuloma; mining the safest and best course of treatment for skin gout; normal lymph node; scar; and cysts. diseases, and the African Teledermatology Project pre- Only 5% of biopsies were non-diagnostic (3/55). Of sents a unique solution for the definitive diagnosis of diffi- these biopsies, one represented a superficial sample of cult dermatology cases in resource-limited settings. mostly epidermis. The clinically suspected