Dermatology Online Journal

Clinically Relevant Dermatology Resources and the Internet: An Introductory Guide for Practicing Physicians
Brent D. Wainwright
Dermatology Online Journal 5(2): 8

Abstract

The number of dermatology sites on the Internet is growing rapidly and the resources they offer are of great benefit to dermatologists and physicians. The mainstay of dermatologic diagnosis is that of visual inspection and gross morphology, therefore, the use of improved imaging techniques, which allow for the rapid collection, electronic transmission, and indexing of images aids in the accurate recognition and interpretation of skin lesions. The graphic nature of the field of dermatology kindly lends itself to the use of the Internet. The enhanced ability to access information and share expert opinion worldwide will help lessen inappropriate treatment or delayed referral to an appropriate specialist and facilitate the accurate diagnosis of various dermatologic diseases.

Concerns about the quality of data are examined and an evaluation scheme proposed. An overview of available resources is presented along with links to additional resources to aid the reader in the identification of additional sites to explore. Sites were selected with the goal of identifying those that provide a broad range of information worthwhile to the dermatologist and general practitioner. Resources including, but not limited to, image atlases, electronic texts, drug databases, case study archives, laboratory testing, and clinical procedures are examined.

Introduction

The Internet is growing at an explosive rate with an estimated 100 million users on-line by the end of the century.[1] Since its early days as a Department of Defense project, the Internet (or åNet¹) has continued to evolve into a repository of global information linking individuals and institutions around the world. As the Internet is used increasingly for scientific publishing it is imperative that health professionals learn to access and utilize this information. With a reported 300f US physicians regularly using the Internet[2], (the rate at which physicians are getting online is increasing rapidly), it is clear that many are already positioned to take full advantage of this medium as a means to access the latest data and stay abreast of new developments.

A simple search using an Internet search engine reveals nearly 1.7 million references to sites classified as "Internet Resources for Physicians" and more than 500,000 indexed as "Dermatology Resources."[3] This plethora of sites is daunting but the resources they offer can be of great benefit to dermatologists and physicians in general because the information is current, readily accessible, and often organized in such a manner as to be useful to those without specific graduate training in dermatology.

This is not to say that access to quality images and information supplants the role of the dermatologist, however, changes in the area of health care management and the resultant need for specialist referral by a primary care physician (PCP) creates a need for increased familiarity with dermatology on the part of the PCP. The management of skin disorders by non-dermatologists can be a challenge and access to accurate and pertinent information will help lessen inappropriate treatment or delayed referral to an appropriate specialist which is of great importance since many asymptomatic skin lesions may be the sign of serious systemic illness.

The mainstay of dermatologic diagnosis is that of visual inspection and gross morphology, therefore, the use of improved imaging techniques, which allow for the rapid collection, electronic transmission, and indexing of images will aid in the accurate recognition and interpretation of skin lesions. Unfettered access to image databases and online dermatologic resources make the Internet a practical clinical tool that can improve patient care and education.

Problems with data

The shear abundance of dermatology sites on the Internet is not in itself a representation of the utility of the material. Locating accurate information and assessing its quality is a task in itself but an important consideration since anyone with access to the Internet can freely publish material without any sort of quality assurance or peer review. Physician concerns regarding the accuracy of Internet information can be evidenced by data which demonstrates that although 650f physicians surveyed agree that the Internet can enhance their access to clinical information, only 46% believe the information is likely to be of high quality.[4]

The reliability of medical information is not only an issue for clinicians but for policy makers as well since consumers frequently use the Internet to access health-related information. For example, of the estimated one million users of "Medscape," an on-line health information service, only 180,000 users are physicians, demonstrating the lay-person's fervent interest in on-line medical information.[5] It is worth noting that Medscape's editor-in-chief, Dr. George Lundberg, was the former editor of the Journal of the American Medical Association and his move adds an element of credibility to the electronic publishing efforts of the Internet.

The purpose of this article is not to debate the Internet's utility as a medical resource or to argue the quality of the information; suffice it to say that there are good resources and there are poor resources just as there are variations in the quality of data one sees in more traditional media. It is more important to be cognizant of such diversity and to use good judgement when appraising an Internet site just as one would any resource.

There are a number instruments used to rate Internet sites providing health information, but some have concluded that they have been incompletely developed, do not measure what they claim to assess, or employ "benchmarks" that are not in themselves a guarantee of quality.[6,7] Given the diversity of material on the Internet and the apparent deficits in current rating systems, the use of ill-defined or untested measures can misguide users. A more prudent technique is to adhere to the quality standards by which traditional print media are judged. This approach allows the reader to further develop and refine the skills needed to evaluate electronic resources on an independent basis.

Many of the standards used to evaluate traditional resources are readily adapted to the Net.[8] I propose an evaluation scheme based on the following core criteria which are in part based on those outlined in the literature:[6]

Authority - Authors and their credentials should be clearly identified along with those responsible for developing and maintaining the site.
Content - Considers the depth of material presented versus lists of links or repetitious information
Objectivity - Material should be free from commercial influence or if advertisements are present they should be separate from the informational content.
Attribution - References and ownership/copyright data should be identified.
Currency - Is the material dated and/or updated regularly?

There are a number of additional features that should be considered when judging on-line resources such as:

Overall Site Organization/Layout - Both of which are a reflection of the site's ease of use - Can one quickly access information?
Search Capabilities - Simple text searches versus combined or Boolean capabilities - Can you find what you are looking for?
Accessibility Can the site be accessed without charge? Are there registration requirements?
Images/Image Quality - Are photographs combined with text to aid in diagnosis? Good image resolution is of great importance especially for histopathology imaging.

This complexity of features combined with the dynamic nature of the Internet produce uncommon evaluation challenges. The use of a numerical ranking system was considered as a means to provide the reader with an idea of how well a site meets the core criteria, however, in the absence of a recognized systematic and widely supported rating system it is felt that a subjective assessment would best suit readers.

Site selection and evaluation

Sites were selected with the goal of identifying those which provide a broad range of information worthwhile to the dermatologist and general practitioner. Resources including, but not limited to, image atlases, electronic texts, drug databases, case study archives, laboratory testing, and clinical procedures were examined. Candidate sites were identified from those indexed by Internet search engines or discovered through a link from one site to another and subsequently researched and screened by the author. All of the sites examined as part of this study meet the core criteria identified above and can be accessed without cost or registration.

The sites presented below are a sampling of those providing high quality information suitable for dermatologists and physicians in general. There are numerous dermatology sites in addition to those discussed herein that provide quality information but are not reviewed as part of this discussion. For this reason a few sites that lack substantial content but offer somewhat exhaustive listings of dermatology links are presented to aid the reader in the identification of further sites to explore. The sites that follow have been sorted alphabetically, and as such, the order of presentation is in no way a reflection of rank or utility.

ADES: Advanced Dermatology Education Server (http://ades.tmc.edu.tw/english/default.htm): The purpose of ADES is to provide multimedia dermatological information for medical students, primary care physicians, and dermatologists. The content of the site is hosted by the Center for Biomedical Informatics at Taipei Medical College. At the time of writing the site was not fully functional but plans include a forum for dermatologists, monthly case reports, an introductory dermatology course, and a section with "simulated patients" designed with the goal of self-assessment. The section labeled "dermatology in primary care" focuses on educational material including definitions, etiology, clinical features, pathology, treatment, and differential diagnosis. When complete, the multimedia dermatology course will offer detailed illustrations of common skin disorders using digital photographs, pictures, videos, and animation which combined with the simulated patients will enable users to test their ability to make proper diagnoses and assign appropriate treatment. The site does not offer search capabilities but at present is not designed to be a searchable reference and is easily navigated without such utility.

Summary: Original content, frequently updated, and well organized. This site promises to make full-use of the Internet's multimedia capabilities but is presently not fully functional or comprehensive and lacks a search utility.

The Cutaneous Drug Reaction Database at Dartmouth (gopher://gopher.dartmouth.edu/1/Research/BioSci/CDRD): This comprehensive database of drug reactions with cutaneous manifestations is produced by Dr. Jerome Z. Litt. Although this site is not an true "web page" per se (i.e., it does not contain graphics or other multimedia features typical of the Internet/World Wide Web) it can be viewed using a standard web browser. The data is organized alphabetically by generic name, is updated annually, and can be searched using the site's search function which also allows trade name searches.

Summary: Comprehensive and updated regularly, this searchable database does a thorough job of organizing a great number of drug reactions and their cutaneous manifestations.

Dermatology Image Bank at the University of Utah School of Medicine (http://www-medlib.med.utah.edu/kw/derm/): The image collection at this location is the result of the work of Dr. John L. Bezzant, M.D., Brett Doxey, and the University's "Knowledge Weavers" team. Although its offerings are not as extensive as some of the other sites detailed herein, the site has a very clean and simple layout allowing for easy navigation. "Thumbnail" images are presented with links to corresponding full-size graphics and descriptive text. Once one has worked through the database, a quiz is available for self-assessment, making this a good resource for students and physicians interested in testing their knowledge of basic dermatology. One feature that makes this site unique is video - nine segments are available for download which demonstrate procedures such as spray freezing, punch and shave biopsies, and closure techniques. A link to articles offered as sources of information for the general practitioner is also available. Although this site does not have pharmaceutical company support, a CD-ROM version has been sponsored by Westwood Squibb.

Summary: Well-ordered layout is easy to navigate and includes a number of images, which are readily previewed by thumbnail. It is unclear as to how often the material is modified as the site only displays a 1997 copyright. The site offers original content, primarily geared towards non-specialists, but is incomplete in its content.

Dermatology Online Image Atlas (DOIA) (http://dermis.net/bilddb/index_e.htm): The DOIA was developed on the premise that dermatologic differential diagnosis is based on the recognition of clinical and histopathological features and that the availability of a comprehensive image database improves patient care and education.[9] The site is maintained by the University of Erlangen in Germany and provides a general overview of dermatologic diseases. Dermatology links as well as an interesting and informative list of publications related to the Internet and "Teledermatology" are available at this site. The DOIA contains thousands of high quality images combined with a search function which allows combined searches according to diagnosis, localization, and appearance of skin lesions. Images are also organized alphabetically by "diagnosis." For example, if one suspects a diagnosis of granuloma annulare, they would select the letter "G" and then "granuloma annulare" where they would find 26 images to aid the diagnosis. Included are images covering uncommon diagnoses which are infrequently available in conventional textbooks.

Summary: By far the most complete online image database. The atlas is well organized, fully indexed, and contains images with excellent resolution. The site is regularly updated and available on CD-ROM.

Dermatology Online Journal (http://dermatology.cdlib.org/DOJdesk/desk.html): The Dermatology Online Journal is a peer-reviewed electronic journal published by Arthur C. Huntley M.D. The journal is designed to take advantage of the multimedia nature of the Internet with the goal of making relevant material readily accessible to dermatologists. What makes this journal unique is its design - it is not simply an electronic copy of a paper based journal with a few digitized photographs added for effect but was designed to make full use of the Internet since its conception. Also worth a visit is Matrix Dermatology Resources (http://dermatology.cdlib.org), the parent site to the Journal which houses "Dermatology for Students" and "RxDerm." "Dermatology for Students" contains educational material used by medical students at the UC Davis Medical School. Besides presenting the basic science of skin, skin disease, and an introduction to the physical diagnosis of the skin, this section includes a melanoma tutorial and skin tumor atlas which are of benefit to physicians as well. RxDerm contains the archives of an on-line discussion group devoted to dermatologists which are indexed alphabetically from acanthosis nigricans to zoster; much of the dialogue is case related.

Summary:Original content, frequent updates, and excellent organization are strong points of this site. Material is far-reaching in its content with sections appropriate for both students and specialists. Includes a search function.

The Electronic Textbook of Dermatology (http://telemedicine.org/stamford.htm): The Electronic Textbook of Dermatology is produced by the Internet Dermatology Society (IDS) and edited by Rhett Drugge, M.D. The site is aimed at an audience of "trained clinical dermatologists" but is equally suited to non-dermatologists and medical students with an interest in the field of dermatology. The layout of the site allows for easy navigation although there is no automated search feature. The material presented is organized by topic and ranges from anatomy to therapeutics. There is some variation in the depth of the content presented. However, there is a broad range of subject matter covered including some unusual topics such as the cutaneous manifestations of biowarfare. In addition to the Textbook of Dermatology, the IDS site features the "Dermatology Knowledge Builder" which provides links to IDS Global Dermatology Grand Rounds (case reports with a search utility) and a number of off-site resources.

Summary: Broad content incorporating a number of unusual topics. Site layout facilitates navigation despite a deficient search function. Response to e-mail inquiries is unsatisfactory.

Martindale's Health Science Guide - Dermatology (http://www-sci.lib.uci.edu/~martindale/Medical1.html#Derm): This is a component of the massive 'Virtual' Medical Center created by James Martindale and hosted by the University of California. The section pertinent to dermatology contains an impressive number of links to online dermatology resources organized as "databases," "journals," "courses & textbooks," "tutorials & cases," and finally, "images." Although the site does not contain any original material, it is presented as an excellent starting point for those wishing to further explore online dermatology resources.

Summary: Constantly evolving and encyclopedic in it's content, this site contains links to an enormous variety of information including dermatology resources.

MedMark: Medical Bookmarks for Dermatology (http://www.medmark.org/derm): Designed by Ildo Shin, M.D., MedMark may well be the most comprehensive sources of dermatology links on the Internet but like the previous site does not contain any true content. There are several hundred links grouped into the following categories: Associations/Societies; Centers/Institutes/Labs; Departments/Divisions; Education/Training; Consumer; General; Hospitals/Clinics; Images/Atlases; Information Sources; Journals/News/Publications; Lists of Resources; and, Other Organizations. Links to electronic "bookmarks" for related resources such as infectious disease, immunology, and pathology can be accessed from MedMark's Home Page(http://www.medmark.org/derm/).

Summary: This site is periodically updated, well organized, and comprehensive in its listings. Although the site does not include any original content, it offers an excellent source of dermatology links.

University of Iowa, Department of Dermatology Home Page (http://tray.dermatology.uiowa.edu/home.html): The University's departmental site was created by Dr. Thomas Ray and serves as an index to a large number of local (i.e., University of Iowa based) and external dermatology resources including, but not limited to, societies and organizations, dermatology databases, and dermatology resources; external resources were not examined as part of this evaluation. Of interest to clinical dermatologists and students are the image database, an introduction to basic dermatology from the "Virtual Hospital®," the "DermPathTutor©," and "Dermatology Differential Diagnosis by Morphology©." The image database contains 337 images arranged alphabetically and is a useful supplement to the introduction to basic dermatology which was developed by Dr. Warren Piette. Both the image database and Dr.Piette's work contain high quality images and accompanying text. Histologic images are available through the DermPathTutor" which is an excellent tutorial in dermatopathology developed by Drs. Thomas Ray and Mary Stone. The tutorial includes a dictionary, dermatopathology images, and descriptive text. "Dermatology Differential Diagnosis by Morphology" is targeted at students and residents of dermatology with the goal of assisting learning differential diagnoses of skin disorders and diseases. Diagnoses are provided based on the clinical and morphologic features of skin lesions and can be revised by taking into consideration any added characteristics which may be present. The diagnoses provided are not comprehensive because they are limited, for practical reasons, to "characteristic, typical entities commonly presenting with a morphologic feature."[10] The overall site layout is good but is somewhat difficult to navigate due to the number of links, page multiplicity, and poor search feature. To initiate a search one must follow a number of links which can be confusing and makes a return to the dermatology home page tricky. However, the site is well-developed, offering a number of useful resources worth exploration.

University of Rochester Medical Center, Dermatology Laboratory Tests (http://www.urmc.rochester.edu/smd/dermdb/DermaHome.html): The University of Rochester Dermatology Laboratory Tests site provides current information on a number of infrequently used diagnostic tests for dermatologic diseases and is an excellent source of information concerning tests which are difficult to obtain. Tests are organized by technique (e.g., enzyme assay, PCR), disease, or can be located using the site's search utility. Analysis methods, specimen collection and shipping instructions, contact information and fee schedules are provided.

Summary: Original content, periodically updated, and well organized. This includes links to both on- and off-site material. The image atlas is indexed alphabetically and offers a variety of high-quality images of use for dermatologists and students alike.

Additional Resources

The extent and types of sites available are far-reaching. For this reason it was felt that an evaluation of a greater number of sites was beyond the scope of this paper. However, by proposing a scheme that encourages readers to develop Internet evaluation skills, readers should be readily able to critically examine additional sites independently. In order to balance out identified resources the following provide links to a sampling of major dermatology journal web sites, discussion groups, and a few "general" dermatology sites. These samples should aid the reader in the identification of additional sites worthy of further exploration.

Journals

• American Society of Laser Medicine and Surgery
• Archives of Dermatology
• Chronicle of Skin & Allergy
• European Journal of Pediatric Dermatology
• Journal of the American Academy of Dermatology
• Journal of Cutaneous Medicine & Surgery
• Journal of Dermatological Treatment
• Journal of Investigative Dermatology
• Skin Therapy Letter

Discussion Groups

• Academic Dermatology (acaderm-l@ucdavis.edu)
• Derm Chat (dermchat@ucdavis.edu)
• Derm Journal Club (dermijc@aslan.ucdmc.ucdavis.edu)
• Derm Therapy (rxderm-l@ucdavis.edu)
• RxDerm-L Archives

Dermatology and General Medical Sites

• American Society for Dermatologic Surgery
• Centers for Disease Control
• Dermatology in the Cinema
• Dermatology Lectures at Erlangen University
• Dermatology news in newspapers
• "DermWeb" at the University of British Columbia
• Doctor's Guide to the Internet
• eMedicine Online Dermatology Textbook
• Guide to Internet Clinical Medicine Resources
• Hardin Dermatology Resources
• Medscape
• Melanoma Statistics
• National Association of Physicians for the Environment
• New York University's "Tuesday Rounds"
• "PubMed" and "Medline" Access
• Skin Cancer Web Site
• University of British Columbia Dermatology

Conclusion

The Internet has become a valuable clinical tool which will continue to serve the medical community through enhanced access to biomedical information and increased communication among the health care community. Although the Internet's value as an educational instrument may be unproven, it continues to transform the way we access and assimilate medical information. In many ways the Internet is the ideal media through which to disseminate information in the rapidly changing field of medicine since it can be quickly updated, allows for rapid data access, is far-reaching, and is available 24 hours per day.

While the resources available on the Internet will not likely replace traditional journals or texts and can not substitute for clinical experience, they enhance the learning experience of both medical students and practicing physicians. The Internet offers users a variety of tools with which to keep up with the most current medical information and allow physicians to exchange information through electronic discussion groups.

It has been concluded that the availability of an online dermatology image database improves patient care. Unquestionably the graphic nature of the field of dermatology kindly lends itself to the use of the Internet and the enhanced ability to access information and share expert opinion worldwide will help facilitate the accurate diagnosis of various dermatologic diseases.

References

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2 Schieszer, J. Many Physicians Using Internet as Medical Library. Pediatric News. 1998;32(5):4.

3 Alta Vista [search engine online]. San Mateo, Calif: AltaVista. Available from: URL: http://www.altavista.com. Accessed April 2, 1999.

4 Brown, MS. What's up on the Internet: physician Internet use growing rapidly. Medical Practice Communicator. 1998;5(1):7.

5 Winslow, R. Former editor of JAMA finds Internet perch. Wall Street Journal. 1999 Feb 24;Sect. B:1 (col. 6).

6 Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA.1997;277(15):1244-1245.

7 Jadad AJ, Gagliardi A. Rating health information on the Internet - navigating to knowledge or to Babel? JAMA. 1998;279(8):611-614.

8 Tate M, Alexander J. Teaching critical evaluation skills for World Wide Web resources. Computers in Libraries. 1996;16(10):49-55.

9 Bittorf A, Krejci-Papa NC, Diepgen TL. Development of a dermatological image atlas with worldwide access for the continuing education of physicians. Journal of Telemedicine and Telecare. 1995;1: 45-53.

10 Ray TL. Dermatology differential diagnosis by morphology. Department of Dermatology, University of Iowa College of Medicine. 1996 Jun.



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