Response: “Distinguishing Stevens-Johnson syndrome/toxic epidermal necrolysis from clinical mimickers during inpatient dermatologic consultation—A retrospective chart review”

Abstract

Institutional Review Board approval. Store-andforward teledermatology consults are submitted through a shared electronic medical record, and a response is generated #24 hours by our team of teledermatology consultants. Among these, a subcohort was identified with ''Stevens Johnson syndrome,'' ''SJS,'' ''toxic epidermal necrolysis,'' or ''TEN'' in the referring differential diagnosis.Owing to the inability of dermatology to meet the skin burden of hospitalized patients, 4 inpatient teledermatology consultation at hospitals without a dermatologic consultant may prevent misdiagnosis of SJS/TEN, limit some unnecessary expenses related to transfer costs and inappropriate therapeutics, and permit an earlier time to discharge.Among 73 patients with a referring differential diagnosis of SJS/TEN, 71 (97%) were given a different diagnosis (Table I). The teledermatology consultant diagnostic impression in 26 patients (36.6%) was ''morbilliform'' or ''exanthematous drug rash.'' In addition, 1 patient with drug rash with eosinophilia and systemic symptoms was identified and treated remotely. Of 71 patients, 15 (21%) were receiving systemic steroids and 16 (23%) intravenous antibiotics. The eDermatology consultant recommended stopping steroids or antibiotics 60% and 81% of the time, respectively. All 71 patients were discharged in good condition an average of 11.8 days later.Two of the 73 patients were given a consultant diagnosis of SJS/TEN, both with consistent histopathology. These patients were transferred to a higher level of care (Fig 1).No., Number; SD, standard deviation. *The eDermatology consultant diagnoses in 71 of 73 patients were not consistent with SJS/TEN. y Transfer was recommended for 1 patient with of diffuse immunobullous disease, 1 patient with of erythema multiforme major, and 2 patients with SJS/TEN.

Accuracy and Cost-effectiveness of a Telemedicine Triage Initiative for Patients With Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

“…The present results suggest that telemedicine improves triage for SJS/TEN and is associated with a reduction in the number of patients transferred without need for burn unit care. Others have demonstrated that telemedicine consultation is associated with cost savings and is useful for differentiating SJS/TEN from other non–life-threatening skin disorders among inpatients . The study’s limitations include sparse documentation on patients not transferred, which precluded the calculation of the triage system’s sensitivity.…”

Inpatient Teledermatology: a Review

“…Even where teledermatologic consultations are not perfectly accurate, they are substantially better than if patients were to receive no dermatology consultation at all, as supported by the frequent diagnostic, management substitution and accretion when patients are referred to the care of dermatologists after first being evaluated by non-dermatology physicians [ 36 , 37 ]. Patients with complex medical dermatologic conditions and severe adverse cutaneous reactions can receive appropriate diagnostic, therapeutic management and appropriate triage (i.e., burn unit) from IPTD without a live interaction [ 19 ••, 38 – 40 , 41 •]. Live consultative dermatologists agree more frequently with inpatient teledermatologists than they do with hospitalists, and multiple studies have demonstrated that teledermatology concurs with the gold standard diagnosis and treatment of face-to-face dermatology between 81 and 88% of the time [ 15 , 17 , 35 ].…”

“…These can be extrapolated to ITPD, but studies are lacking. However, Georgesen et al [ 19 ••] demonstrated that antibiotic misuse occurred in 76% of inpatients initially thought to have cellulitis (no monetary savings discussed) and that the use of inpatient teledermatology consulted for SJS/TEN saved $32,000 by avoiding unnecessary ambulance transfer to academic burn centers due to incorrect hospital team diagnosis [ 41 •].…”

“…As summarized in Table 2 , teledermatology has unique advantages and disadvantages. Because it does not require the patient and provider to be physically present or concurrently available, teledermatology provides faster and more cost-effective care [ 19 ••, 41 •]. It increases access to dermatologic expertise for hospitals without or with dermatologic hospitalists and, as previously mentioned, can be useful for patient triage [ 11 , 15 , 19 ••, 20 , 59 ].…”