Telederm Dermatology Manual

TELE-DERM 2015
A RESOURCE FOR LEARNING
ABOUT SKIN CANCER MEDICINE
AND DERMATOLOGY
1 CONTENTS
1) TELE-DERM PROGRAM CONCEPT
p3
2) THE TELE-DERM WEBSITE
p4
3) GP COLLEGE DERMATOLOGY CURRICULAR
p4
4) USING THE RRMEO TELEDERM WEBSITE
p5-9
a) How to login to Telederm via RRMEO
p5
b) How to submit a case to Telederm
p6-7
c) Suggested templates for case submission
p8
d) QRME Telederm consent form
p9
5) DL1 DERMATOSCOPE QUICK-USER GUIDE
p10
6) DERMOSCOPY AND THE THREE-POINT CHECKLIST p11-13
7) USEFUL DERMATOLOGY RESOURCES
p14-15
Textbooks, websites, guidelines, courses, prevention
8) RRMEO usernames and TEMPORARY passwords
p16-17
USEFUL CONTACTS
Dr Claire Palmer: [email protected] or 0488387778
ACRRM RRMEO (Telederm website problems): [email protected] or
(07) 3105 8200
2 1) TELE-DERM PROGRAM CONCEPT
•
•
•
•
!
QRME registrar surveys indicate that the majority of GP registrars consider
their prior training in dermatology to be poor.
According to BEACH data, skin-related problems make up ~12% of all GP
presentations in Queensland.
Queenslanders have the highest rates of skin cancer in Australia, and
Australians among the highest in the world. This holds for both melanoma and nonmelanoma skin cancer (NMSC).
It is more difficult for rural Australians to access dermatology specialist services.
RURAL MEDICAL PRACTITIONERS NEED TO BE SKILLED IN THE PREVENTION,
DIAGNOSIS AND MANAGEMENT OF SKIN CANCERS AND SKIN CONDITIONS.
Training in early detection and management of skin cancer has been included in the Rural
Medical Education Program provided by QRME. In addition to the rural practice-based
training and small group learning, QRME provides an additional resource for learning about
skin cancer medicine and dermatology, called the Telederm program.
The clinical course and survival outcomes of skin cancers, particularly melanoma, are altered
by early detection and intervention. One key skill for early detection of melanoma is
dermoscopy, a diagnostic technique that uses light and magnification to see more details
within the skin layers. With training, dermoscopy can assist in the early diagnosis of
melanoma and aid in the diagnosis of NMSC. There are many dermoscopic algorithms for
screening pigmented skin lesions for melanoma. One basic dermoscopy algorithm we would
like registrars to learn is the Three-point checklist.
QRME would like rural registrars to learn how to use teledermatology resources to submit
patient cases online for advice. The teledermatology resource being used by QRME is
Telederm National via the ACRRM RRMEO website. In order to make full use of these webbased resources, in-practice clinical photography and dermoscopy are required.
In order to take dermoscopic and macroscopic photographs of skin lesions and rashes, and
submit patient cases to Telederm National, QRME have provided registrars with the following:
1. A DL1 dermatoscope with adapters
This is a compact dermatoscope that can be used on its own or can be adapted to
digital photography. Adapters are available for iPhones, iPads, and galaxy phones.
You will be given adapters for both iPhone and iPad mini. Others can be purchased
from Docstock online. www.dockstock.com.au/
2. A Dermoscopy textbook: Johr, Soyer and Argenziano, “Dermoscopy the Essentials”.
This can be accessed on an iPad mini via the web using expertconsult (see inside
textbook cover for details) and https://expertconsult.inkling.com/redeem/ OR on your
iPad using the “inkling” app downloaded from iTunes. Inkling is an app used to read
Interactive Books, eBooks and Textbooks on iPad, iPhone, Mac and PC. More info
at: https://itunes.apple.com/au/app/inkling-read-interactive-books/id379351586?mt=8
3. Access to the ACRRM RRMEO Telederm website (with a QRME subgroup)
RRMEO usernames and passwords are shown in section 8 on p16-17. If you are
already an ACCRM member your login will be the same. If you are not an ACCRM
member, QRME have created a login username and temporary password for you.
3 2) THE TELE-DERM WEBSITE
Telederm National is a teledermatology case advice service provided by the Australian
College of Rural and Remote Medicine (ACRRM) via the Rural and Remote Medical
Education Online (RRMEO) website. Telederm has tools and resources that can help
registrars learn more about skin cancer medicine and dermatology.
One key feature of Telederm is the ability to submit patient cases along with clinical photos
to a dermatologist, for review and practical advice. This is known as store-and-forward
telemedicine. Telederm National educational resources include:
• Access to all cases submitted to Dr Jim Muir for advice
• Alphabetical bank of 600+ cases
-­‐ Case studies with discussions and photos
-­‐ Dermoscopy atlas of cases
• Other resources
-­‐ Jims tips, Video vault
-­‐ Useful web links to dermatology resources
-­‐ Dermatology Therapeutic guidelines
QRME Telederm 2015 Subgroup
There is a subgroup within Teledem National for QRME registrars called “QRME Telederm
2015”. This subgroup is only accessible to QRME registrars who are in their GPT1/PRR
terms. GP registrars should learn how to use a dermatoscope and how to navigate the
Telederm website.
We hope that QRME registrars will use the Telederm website;
1. TO SUBMIT PATIENT CASES FOR ADVICE with clinical photos, using the
QRME Telederm 2015 subgroup. Registrars can submit as many cases as they
need. Once a case has been submitted Dr Benjamin Carew and/or Dr Jim Muir
(dermatologists) will give online feedback/advice on the case within 24-48 hours.
2. AS A PLATFORM FOR LEARNING ABOUT SKIN CANCER MEDICINE AND
DERMATOLOGY to complement practice-based and small group learning.
There will be learning modules posted on Telederm with a “pigmented case of the month”.
Learning modules are optional and based in the GP College curricular. The pigmented case
of the month demonstrates the application of the dermoscopic Three-point checklist using a
clinical case with dermatoscopic photos.
3) GP COLLEGE DERMATOLOGY CURRICULUM
Both ACRRM and RACGP GP training colleges have a dermatology curriculum.
• RACGP
Below is a link to the 2011 RACGP curriculum. The dermatology curriculum can be
found on page 255 of this document: http://www.racgp.org.au/curriculum
• ACRRM
Below is a link to the ACRRM website. Click on the Dermatology section at:
http://www.acrrm.org.au/primary-curriculum
4 4) USING THE RRMEO TELE-DERM WEBSITE
a) HOW TO LOG ON TO TELE-DERM via RRMEO
Section 8 of this handbook (p16-17) has a list of RRMEO username and temporary
passwords to access Telederm via the RRMEO website.
1. Go to www.rrmeo.com/
2. Log in with your username and password. See below:
If you have not been given a username or password, please contact QRME. If you have
forgotten or lost them, you can contact ACRRM by clicking on the “contact RRMEO” button at
the top of the login page and they can email them to you. If you have your username but have
forgotten your password, you can click on password reminder and your password will be sent
to you via email.
3. Click on “Telederm National” in the My RRMEO Module Enrolment box. See below:
4. Click on “QRME Telederm 2015” in the Subgroup Membership box. See below.
5 5. Once in the QRME Telederm 2015 subgroup, the right side of the screen (as shown
below) has two main sections to become familiar with; “Discussion Forums” and the
“Latest File Uploads”.
b) HOW TO SUBMIT A CASE TO TELE-DERM
A case can be submitted under “Discussion Forums” by clicking on “Submit a Case”.
Click onto “Submit a case” and a window (see below) with a Disclaimer and CONSENT
FORM (printable if required) will appear. Consent can be verbal or written and should be
documented in clinical notes. Click on “Agree” at the bottom left to continue.
6 On the next screen you can either:
1. Look at cases which have already been submitted by others, by clicking on the case
description, OR
2. Go to the top left of the page and click on “ADD THREAD” to enter your case details.
The case submission page is shown below:
Put in a brief case description
at the top, e.g. 54 year-old
male with lesion left leg. Enter
the history in the “Body” as
provided. Images and results
can be attached by clicking on
“Browse”. A maximum of three
images of up to 5MB each can
be posted per case. If you
have more you can attach
them as a “reply” later.
Making a comment or “reply” to a case.
Any member of the subgroup can reply or make comments about any cases that are posted.
From the list of cases, click onto the relevant case description. The “Add reply” button is on
the bottom right hand corner of a case. You can type in your comments or add an image.
7 c) SKIN LESION: SUGGESTED TEMPLATE FOR CASE SUBMISSION
Brief case description:
Patient Initials:
Age:
Gender:
HISTORY
• History of Complaint
-­‐ Site (s), Size (s), Duration, Progression
• Treatments to date
• Previous skin cancers
• Past medical/surgical history
• Medications (esp. immunosuppressant or prev. cancer therapy)
• Smoking history
• Occupation(s)
• Sun Exposure
• Family History of skin cancer
EXAMINATION
Dermoscopy features:
CLINICAL PICTURES (can be attached)
DIAGNOSIS
HISTOLOGY
MANAGEMENT PLAN
SKIN RASH/GENERAL DERM: SUGGESTED TEMPLATE FOR CASE
SUBMISSION
Brief case description:
Patient Initials:
Age:
Gender:
HISTORY
• History of Complaint
-­‐ Site (s), Size (s), Duration, Progression,
-­‐ Associated symptoms e.g. itch, fever, arthralgia, malaise
• Treatments to date
• Previous skin complaints
• Past Medical history
• Medications (incl. herbs, natural)
• Smoking history
• Alcohol and drug history
• Occupation(s)
• Exposures: (animal, chemicals etc.)
• Overseas travel
• Family History skin complaints:
EXAMINATION
CLINICAL PICTURES (can be attached)
HISTOLOGY (if done can be attached)
DIAGNOSIS
• Provisional
• Differential
CURRENT MANAGEMENT PLAN
8 d) CONSENT FORM
PATIENT CONSENT FORM FOR MY DOCTOR TO USE MY INFORMATION FOR
MEDICAL EDUCATION AND/OR TO SEEK AN OPINION BY A DERMATOLOGIST VIA
TELE-DERM
I, ………………………….…………………….(patient name) acknowledge that my doctor, as
part of his/her vocational education through Queensland Rural Medical Education, is seeking
information and guidance on the diagnosis and management of my condition from a qualified
dermatologist and/or is using my information for education and teaching purposes. This
involves transmission of details of my case, including images over the Internet. I have
checked with my doctor that no details or images sent can reveal my identity. I acknowledge
that the internet is not a totally secure medium and third parties may be able to gain
unauthorised access to my TELE-DERM consultation. I realise that a face-to-face
consultation with a dermatologist is less likely to result in an error of diagnosis or
management.
I understand that I can instead be referred to a dermatologist for a face-to-face consultation if
I wish.
I understand that dermatologists at TELE–DERM are merely giving my doctor information and
guidance. They will not be responsible for the diagnosis and management of my condition.
I understand that all decisions on the diagnosis and management of my condition will be
made by my doctor, ……..………………………………… (referring doctors name).
I understand that I may still need to see a specialist face-to-face if my condition cannot be
managed by my doctor after consultation with a TELE–DERM dermatologist.
I consent to my case being posted on the TELE–DERM web site for educational purposes.
I acknowledge that my doctor is currently completing vocational general practice education
through Queensland Rural Medical Education. I also acknowledge that the TELE-DERM
service is hosted by the Australian College of Rural and Remote Medicine (“ACRRM”) and
funded by the Commonwealth Government as represented by its Department of Health and
Ageing. Queensland Rural Medical Education, the Department and ACRRM, and their
respective directors and other officers and employees, partners, agents and sub-contractors
make no representations or warranties and do not accept any liability from any person for the
information or guidance (or the use of such information or guidance) which is provided on the
TELE-DERM web site or as part of the TELE-DERM service.
This Consent may be relied upon by the Doctor, Queensland Rural Medical Education,
Queensland Division of General Practice, the TELE – DERM dermatologists, the
Commonwealth Government and ACRRM (including their directors and other persons
mentioned above).
Signed…………………………………….(patient)
Date ………………
Witness signature ……………………………………(referring doctor)
9 5) EQUIPMENT QUICK USER GUIDE: DL1 Dermatoscope
There is a video on how to assemble the DL1 in the QRMEonline resources and
in QRME Telederm 2015 subgroup under the “Latest file uploads” section.
DL 1 dermatoscope with spacers and iPhone adapter
•
•
•
•
•
•
•
iPad mini adapter
Compact with 4 white LEDs
10 times magnification, (then can zoom in with mobile device)
Can be used with Cross-polarisation (cancels out reflected light) or non-polarisation
(for fluid immersion)
Glass faceplate (E) with 10 mm scale
Lithium battery recharges from any laptop or PC via USB cable or apple charger
o 60 min user time
o Charge for 2 hour initially
o Red indicator light means it is charging
o Green light means is charged; flashing means 25% charge left
Takes images with your mobile device
5 year warranty
Your DL1: can be used with a Crosspolarised or Non-polarised Spacer Unit
(B) or a Cross-polarising Clip (H). Slide
either the spacer Unit or clip onto the
DL1 until it snaps securely into place.
The spacer unit should be placed
directly on the skin.
Push the power button (C) at the right
side of the unit to activate the light. To
turn OFF, simply push the power
button.
For use with a mobile device, attach
the Dermlite mobile device
case/adapter (A) to your mobile device
then attach your DL1 to the case.
DL1 will turn off automatically after 2
minutes.
To remove the glass faceplate (E) for
cleaning or non-contact dermoscopy,
rotate the bayonet ring (D)
counterclockwise and remove. Handle
with care.
10 6) DERMOSCOPY AND THE THREE-POINT CHECKLIST
Dermoscopy (also known as epiluminescence microscopy) is the examination of skin lesions
with a dermatoscope.
Dermoscopy is a diagnostic technique that uses light and magnification to visualise colour
and structure in the epidermis, dermoepidermal junction, and papillary dermis of the skin.
The Three-point checklist is a validated, dermoscopic, screening tool for analyzing
pigmented skin lesions. It is very useful for dermoscopy beginners. With training 96.3% of
melanomas can be classified correctly using the Three-point checklist. The goal of the
checklist is to determine whether a pigmented lesion is benign or suspicious. If it is
suspicious it will need excision.
The main aim of the checklist is to ensure that no patient leaves the clinic with an
undiagnosed melanoma.
The checklist is based on three dermoscopic features found to be important in distinguishing
melanomas from other benign pigmented lesions:
1. Asymmetry of colour and/or structure (see below for an explanation)
2. Atypical pigment network; and
3. Blue-white structures
Interpretation
-­‐ One point is given for each feature if present. Presence of 2 or 3 features indicates a high
likelihood of melanoma and excision is recommended.
! A lesion scoring 0 or 1 is likely to be benign
! A lesion scoring 2 or 3 should be excised.
More information about the Three-point checklist can be found at
1.
2.
3.
4.
Dermoscopy; The Essentials Textbook.
http://www.dermnetnz.org/doctors/dermoscopy-course/3-point-checklist.html
http://www.dermoscopy-ids.org/discussion/docs/3pt_tutorial.pdf
https://www.youtube.com/watch?v=mZpa6BBbEec
If you are interested in dermoscopy and skin cancer medicine you could use some of your
education funding to complete the UQ Certificate in Primary Care Skin Cancer Medicine.
11 PIGMENTED SKIN LESION: Is it benign or suspicious?
THREE-POINT CHECKLIST- screening test
1
Asymmetry in
colour and/or
structure
Symmetrical
Asymmetrical
Typical network
Atypical network
2
Atypical
Network
3
Blue-white
structures
One point for each feature that is present
Score 0 or 1 BENIGN LESION E.g. naevus Score 2 or 3 SUSPICIOUS E.g. Melanoma > Excise/biopsy 12 AN EXPLANATION OF SYMMETRY/ASYMMETRY
SYMMETRICAL LESIONS
ASYMMETRICAL LESIONS
Asymmetry of colour Asymmetry of internal structures Outline irregular but asymmetrical due to asymmetry of colour and structure 13 7) OTHER USEFUL DERMATOLOGY RESOURCES
TEXTBOOKS
The first two textbooks are recommended for the Certificate of Primary Care Dermatology
• Skin Disease and Diagnosis and Treatment, by Thomas Habif. Publisher Elsevier.
• Surgery of the Skin: procedural dermatology, by June Robinson.
rd
• Dermoscopy: An Atlas. 3 Ed, by Menzies, Crotty, Ingvar and McCarthy. Publisher
McGraw Hill.
• Therapeutic Guidelines Dermatology. 2009. (eTG available on the QRMEonline)
WEBSITES
http://dermnetnz.org/
This is an excellent website especially to refer to in your GP practice and for
studying for exams. It has an alphabetical index of topics, a list of skin diseases,
conditions and their treatments, online courses, and links to other websites.
http://www.aad.org/education-and-quality-care/medical-student-core-curriculum
This is the American Academy of Dermatology and they have put together
some excellent PowerPoint presentations on dermatology topics for primary care
doctors and medical students (all you could possibly need). They are REALLY good
summaries with great photos and treatment regimens. Especially good for quick
exam study. Stats are American but otherwise all appropriate to Australian practice.
http://thinkgp.com.au/
FREE Online Medical Education. It has very succinct modules on Prevention and
early detection of skin cancer, Biopsy techniques, Diagnosis and Management of
NMSC and Diagnosis and Treatment of Melanoma, Chronic ulcers and dressings,
SLE
http://www.dermnet.com/
This has a great skin disease atlas with a lot of images, major topic reviews and
videos. It is an American website.
http://www.acne.org.au/
Is great for learning about acne and educating your patients.
http://www.australiandoctor.com.au/
“How To Treat” section has good reviews of various dermatology topics.
http://www.dva.gov.au/service_providers/resources/Documents/wdcaremd.pdf
Department of Veteran Affairs has a very good booklet on ulcers and wound care
GUIDELINES
•
Melanoma management guidelines
http://www.nhmrc.gov.au/guidelines/publications/cp111
•
Cancer Council Non Melanoma Skin Cancer (NMSC) guidelines and summary
documents which are a useful GP guide (have been rescinded but still useful).
http://www.cancer.org.au/Healthprofessionals/clinicalguidelines/skincancer.htm
•
There are useful NMSC management guidelines from America which can be found at
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site
14 COURSES (ONLINE AND FACE-TO-FACE)
A number of organisations offer further training in Dermatology and Skin Cancer Medicine.
Some options include:
•
University of Queensland
UQ offers excellent certificate courses and masters programs.
There are many short courses to choose from including Certificate in
Primary care Skin Cancer Medicine, Certificate in Advanced Dermoscopy,
Certificate in Primary Care Skin Cancer Surgery and the Advanced Skin Cancer
Surgery workshop.
http://healthcert.com.au/courses.htm
•
Certificate of Primary Care Dermatology
This is a collaboration between the RACGP, ACRRM and the Australasian
College of Dermatologists. It has mostly online format with 25 modules purchased as
completed. 23 modules are online and 2 practical modules involve procedural
workshops ad a clinical attachment. There are online discussion groups and
required case submissions. The first 6 modules are dedicated to the
management of skin cancer.
http://www.racgp.org.au/education/courses/dermatology/ OR
http://www.acrrm.org.au/dermatology-certificate-in-primary-care
•
Skin Cancer College of Australia and NZ
This organization has developed a fellowship program that involves components of
the UQ and ACD certificate course. They offer face-to-face courses including
Certificate of Skin Cancer Medicine, Diploma of Skin Cancer Medicine, Advanced
Diploma of Skin Cancer Medicine and Surgery, Dermoscopy workshops and a
Diploma of Dermoscopy.
SKIN CANCER PREVENTION RESOURCES FOR YOU & YOUR PATIENTS
•
Cancer Council of Australia
http://www.cancer.org.au/cancersmartlifestyle/SunSmart/Preventingskincancer.htm
•
QLD Cancer Council
http://www.cancerqld.org.au/page/prevention/skin_cancer/
•
The Victorian Cancer Council website is excellent.
It has a GP section that can be selected from the top of the page with great education
resources.
http://www.sunsmart.com.au/default.asp
15 8) RRMEO USERNAMES AND PASSWORDS FOR QRME TELEDERM via
rrmeo.com/
All registrars have been added/enrolled into the Telederm National subgroup entitled “QRME
Telederm 2015” within the ACCRM RRMEO website.
For registrars who are ACRRM members or who have an existing RRMEO username
and password, they remain the same, and if forgotten can be retrieved from the RRMEO
website login page or by contacting ACRRM.
For registrars who are not ACRRM registrars or have not ever had a RRMEO username
and password, QRME have created one for you and it is listed below. You MUST CHANGE
THE PASSWORD when you login for the first time.
Registrar Name
RRMEO
username
RRMEO
password
Marlina Ab Rahman
Prabali Adhikari
Dorcas Ajose
Angela Allsopp
Danielle Andreussi
Myo Thuzar (Myo) Aung
Andrew Baird
Hollie Berghofer
Archana Bhandarker
Sheelagh Buttanshaw
Jiun-Horng (Paul) Chang
Timothy Charles
Tyng Cheng
Andrew Choo
Nadim Cody
Brooke (Brooke) Davies
Rebecca (Rebecca) Devereaux
Eric donaldson
Ruth Ducommun
Ayeza (Isa) Durrani
Sean (Sean) Dwyer
David Eviston
Katie Fletcher
Rebecca Fletcher
Usman Gul
Motssim Halawani
Gregory Hammond
Gwynne Hannay
Tahsina (Tina) Haque
Simon Ho
Simon Howell
Deanne Hummelstad
Kyle Johnston
Rajshree (Raj) Kharia
William Yi Ching Kuo
Hong-Way (Frank) Lin
David Little
Khin Thet Thet Lwin
Sally McKenzie
Lei Min
Debraj Mukherjee
Susan Mullen
Yashanthini (Yasha) Nadarajah
mrahman
padhikari
existing username
existing username
existing username
mtaung
abaird
existing username
abhandarker
existing username
existing username
tcharles
tcheng
achoo
ncody
existing username
existing username
edonaldson
rducommun
existing username
existing username
deviston
existing username
rfletcher
ugul
mhalawani
existing username
existing username
thaque
existing username
showell
dhummelstad
existing username
rajkharia
wkuo
flin
existing username
existing username
existing username
lmin
existing username
existing username
existing username
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16 Registrar Name
RRMEO
username
RRMEO
password
Hozefa Nooruddin
Jonathan Ong
Joanna Pappas
Anthony Pass
Tapan Paul
Kent Perkins
Michelle Porter
Cobie Powell
Brendan Purcell
Ramkumar (Ram) Rajasekaran
Sweta Rani
Alan Richardson
Erin Ridler
Kathryn Robson
Christine Ross
Rakhee Saxena
Amay Singh
Deborah (Deb) Smith
Tobias (Toby) Smith
James Sprouster
Deeba (Deepa) Sriramulu
Bin (David) Sun
Faisal Syed
Nitin (Nitin) Tandon
Desiree Tee
Kok Chuan (KC) Tee
Christopher (Chris) Tomsett
Jeanne-Marie van der Westhuizen
Kirsten Van Wunnik
Anna Vanderstaay
Jordan Whicker
Adam Whipps
Hannah Woodall
Grant Wooldridge
Nathalie Worth
Mohamad Faiz Yaman
Alisa Yocom
hnooruddin
jong
existing username
existing username
tpaul
existing username
existing username
existing username
existing username
rrajasekaran
srani
existing username
existing username
existing username
existing username
rsaxena
asingh
existing username
tobysmith
jsprouser
dsririamulu
existing username
fsyed
ntandon
dtee
ktee
existing username
jvanderwesthuizen
existing username
avanderstaay
existing username
adamwhipps
existing username
gwooldridge
existing username
myaman
ayocom
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This handbook was written for the QRME Telederm Education Program by:
Dr Claire Palmer
General Practitioner
Medical Educator
290 Hume Street
PO Box 2076, Toowoomba, QLD 4350
T. 0488387778
E. [email protected]
www.qrme.org.au
17