demonstrate a great potential to expand the practice and delivery of dermatologic care.

Transcription

1 Research Original Investigation Ann Chang Brewer, MD; Dawnielle C. Endly, DO; Jill Henley, DO; Mahsa Amir, MD; Blake P. Sampson, MD; Jacqueline F. Moreau, MS; Robert P. Dellavalle, MD, PhD, MSPH IMPORTANCE With advancements in mobile technology, cellular phone based mobile applications (apps) may be used in the practice and delivery of dermatologic care. Invited Commentary page 1305 OBJECTIVE To identify and categorize the variety of current mobile apps available in dermatology for patients and providers. DESIGN, SETTING, AND PARTICIPANTS Dermatology-related search terms were queried in the online app stores of the most commonly used mobile platforms developed by Apple, Android, Blackberry, Nokia, and Windows. Applications were assigned to categories based on description. Popularity, price, and reviews were recorded and target audiences were determined through websites offering online mobile apps. MAIN OUTCOMES AND MEASURES Number, type, and price of mobile apps in dermatology. RESULTS A total of 229 dermatology-related apps were identified in the following categories: general dermatology reference (61 [26.6%]), self-surveillance/diagnosis (41 [17.9%]), disease guide (39 [17.0%]), educational aid (20 [8.7%]), sunscreen/uv recommendation (19 [8.3%]), calculator (12 [5.2%]), teledermatology (8 [3.5%]), conference (6 [2.6%]), journal (6 [2.6%]), photograph storage/sharing (5 [2.2%]), dermoscopy (2 [0.9%]), pathology (2 [0.9%]), and other (8 [3.5%]). The most reviewed apps included Ultraviolet ~ UV Index (355 reviews), VisualDx (306), SPF (128), isore (61), and SpotMole (50). There were 209 unique apps, with 17 apps existing on more than 1 operating system. More than half of the apps were offered free of charge (117 [51.1%]). Paid apps (112 [48.9%]) ranged from $0.99 to $ (median, $2.99). Target audiences included patient (117 [51.1%]), health care provider (94 [41.0%]), and both (18 [7.9%]). CONCLUSIONS AND RELEVANCE The widespread variety and popularity of mobile apps demonstrate a great potential to expand the practice and delivery of dermatologic care. JAMA Dermatol. 2013;149(11): doi: /jamadermatol Published online September 25, Author Affiliations: College of Medicine, University of Arizona, Phoenix (Brewer); Midwestern University College of Osteopathic Medicine, Glendale, Arizona (Endly, Henley); Department of Dermatology, School of Medicine, University of Colorado, Aurora (Amir, Dellavalle); School of Medicine, University of Washington, Seattle (Sampson); School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Moreau); Dermatology Service, Department of Veterans Affairs Medical Center, Denver, Colorado (Dellavalle); Department of Epidemiology, Colorado School of Public Health, Aurora (Dellavalle). Corresponding Author: Robert P. Dellavalle, MD, PhD, MSPH, Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont St, PO Box 165, Denver, CO (robert.dellavalle@ucdenver.edu). Advancements in mobile technology, along with the ubiquitous adoption of the smartphone, have had a profound effect on the practice of medicine. These devices are capable of running third-party software and use downloadable mobile applications (apps) to perform a seemingly endless variety of functions. Mobile apps have the ability to serve as diagnostic tools for physicians, educational resources for students, and health management programs for patients. In turn, many medically oriented mobile apps have been developed for patients and health care providers. In 2011, 84.5 million people in the United States owned a smartphone, and 41.6% of this population used downloadable mobile apps. 1 In recent years, smartphone and mobile app use among health care providers has mirrored that of the general population. In 2009, when approximately 64% of US physicians owned smartphones, ownership was predicted to reach 81% of providers by A 2012 survey of medical providers in Accreditation Council for Graduate Medical Education training programs 3 showed that this prediction may have been an underestimate. The survey revealed medical provider smartphone use of 85%, with more than half of providers using mobile apps. As recently as 2011, an estimated 38% of physicians with smartphones used medical-related apps on a daily basis. 4 Across specialties, mobile apps play an increasingly large role in providing reference material, educational aids, chronic disease management tools, and differential diagnosis builders. Smartphone apps are particularly useful in dermatology where a substantial amount of diagnosis and management is based on visual examination. Furthermore, the use of mobile devices in teledermatology may demonstrate benefit in the treatment of dermatologic problems in rural and underserved populations. 5,6 Mobile skin cancer screening has dem JAMA Dermatology November 2013 Volume 149, Number 11 jamadermatology.com

2 Original Investigation Research Table 1. Total Applications Category Android Apple Blackberry Nokia Windows Total, No. (%) Reference (26.6) Self-surveillance/diagnosis (17.9) Disease guide (17.0) Educational aid (8.7) Sunscreen/UV recommendation (8.3) Calculator (5.2) Teledermatology 1 7 a (3.5) Conference (2.6) Journal (2.6) Photograph storage/sharing (2.2) Dermoscopy (0.9) Pathology (0.9) Other (3.5) Total applications, No. (%) 78 (34.1) 129 (56.3) 14 (6.1) 2 (0.1) 6 (2.6) 229 (100.0) a Two additional Apple ios teledermatology applications were identified in a query of the term teledermatology during March 2013: HIV-Derm Algo Study (launched October 20, 2012) and SFGH Teledermatology pilot (launched November 12, 2012). onstrated diagnostic reliability and may become a practical substitution for in-person dermatologic consultations Additionally, chronic dermatologic diseases, such as psoriasis, have the potential to be effectively managed remotely using a mobile app interface. 11,12 Mobile technology, both versatile and practical, demonstrates great potential for augmenting dermatologic care. The primary purpose of this study was to identify and categorize the variety of current mobile apps available in the field of dermatology for patients and health care providers. Methods From July 12 to 13, 2013, we conducted a query of publicly available dermatology-related mobile apps within the app stores of mobile platforms developed by Apple, Android, Blackberry, Nokia, and Windows. These mobile platforms were chosen on the basis of popularity as evidenced by device sales in Dermatologic search terms were queried by term entry into the search field on each website for these app stores The Apple program itunes for Mac OS X was used to search for Apple-based applications; the search was performed within the App Store section of the itunes Store. 17 The following search terms were used: dermatology, psoriasis, rosacea, acne, skin cancer, melanoma, and eczema. Exclusion of apps included, but was not limited to, those pertaining to cosmetics, product advertisements, general medicine, private dermatology practices, entertainment, photograph alteration, or claims to cure skin diseases. From the remaining results, dermatology-related apps and the corresponding number of consumer reviews were recorded. If an app existed on multiple platforms, the total number of reviews was calculated as the sum of reviews from each platform. Based on the official description given for each unique app, the research team universally agreed on an assignment of each app to one of the following categories: general dermatology reference, disease guide, self-surveillance/diagnosis, educational aid, sunscreen/uv recommendation, calculator, teledermatology, journal, conference, photograph storage/ sharing, dermoscopy, pathology, and other. Additionally, based on the description of each app, we determined the target audience as patient, health care provider, or both. Applications were not purchased or downloaded. Because the presence of teledermatology apps was unanticipated in the initial query, an additional search for the term teledermatology was performed March 19, Two more teledermatology apps were identified on the Apple ios platform. These apps became publicly available in October and November 2012 and therefore would not have been identified in the initial query during July Results A total of 229 dermatology-related apps were identified (Table 1) in the following categories: general dermatology reference (61 [26.6%]), self-surveillance/diagnosis (41 [17.9%]), disease guide (39 [17.0%]), educational aid (20 [8.7%]), sunscreen/uv recommendation (19 [8.3%]), calculator (12 [5.2%]), teledermatology (8 [3.5%]), conference (6 [2.6%]), journal (6 [2.6%]), photograph storage/sharing (5 [2.2%]), dermoscopy (2 [0.9%]), pathology (2 [0.9%]), and other (8 [3.5%]). There were 209 unique apps, with 17 apps existing on multiple operating systems. Three apps existed on 3 operating systems. Fourteen apps were available on 2 operating systems. More than half of the apps were offered free of charge (117 [51.1%]). Paid apps (112 [48.9%]) ranged from $0.99 to $ (median, $2.99). The most expensive apps were medical textbooks. The market audiences included patient (117 [51.1%]), health care provider (94 [41.0%]), and both (18 [7.9%]). The largest number of apps fell within the category of general dermatology reference, with content ranging from a short list of common skin conditions for the general public jamadermatology.com JAMA Dermatology November 2013 Volume 149, Number

3 Research Original Investigation Table 2. Most Reviewed Applications Application No. of Reviews Category Platform Cost, $ Target Audience Ultraviolet ~ UV Index 355 UV recommendation Apple Free Patient VisualDx 306 Reference Android, Free Provider Apple SPF 128 UV recommendation Apple Free Patient isore 61 Reference Apple Free Patient SpotMole 50 Self-surveillance/diagnosis Android Free Patient Pocket Derm 46 Reference Apple 0.99 Provider Skin Scan a 41 Self-surveillance/diagnosis Apple 4.99 Patient Doctor Mole 36 Self-surveillance/diagnosis Android Free Patient What s My Rash? 36 Reference Apple 2.99 Patient Skin Conditions 35 Reference Android Free Patient a Name changed to Skin Vision in to a comprehensive dermatology reference guide for medical professionals. Additionally, several medical reference textbooks were available as apps. Self-surveillance/diagnosis apps varied in capabilities, with some allowing patients to document lesions, upload and receive dermatologist or algorithm-based feedback about the malignancy potential of lesions, follow diagnosis algorithms, log personal treatment regimens, and/or record symptoms to allergen exposures. Many apps were categorized as disease guides because they focused primarily on one disease, such as acne, rosacea, psoriasis, or eczema. Educational apps featured a variety of flashcards, multiple-choice questions, and board examination preparation materials for medical students, residents, and fellows. Applications included in the calculator category provided quick calculations for medication dosing, laser fluence levels, or dermatology-related indexes, such as the Psoriasis Area Severity Index. Several apps gave sunscreen recommendations based on skin type and weather conditions and were thus designated to the sunscreen/uv recommendation category. Many apps designated to the teledermatology category allowed for mobile consultation services. Conference apps offered useful maps and schedules for several dermatology conferences and annual meetings. Dermatology publication organizations have developed a few journal apps, which provide literature updates or bulletins. Photograph storage/sharing apps offered dermatology-specific photograph storage and sharing. Two dermoscopy apps were identified, both requiring the purchase of a proprietary dermoscope smartphone attachment. The pathology apps allowed users to obtain results of pathology tests via mobile phone. The apps that did not fall within any of the above categories comprised a dermatology patient support group, a product guide for contact allergens, and news. The 10 most reviewed mobile apps are listed in descending order in Table 2. Ultraviolet ~ UV Index (355 reviews, free), which provides sun protection recommendations based on one s location as determined by global positioning system (GPS), was the most reviewed app in our study. VisualDx (306 reviews, free) is a diagnostic reference and differential diagnosis builder for health care professionals; SPF (128 reviews, free) is another app that provides sun safety recommendations. isore (61 reviews, free) is a dermatology reference intended to be used by the general public. SpotMole (50 reviews, free) analyzes photos of moles for signs of melanoma using image processing and pattern-recognition techniques. Pocket Derm (46 reviews, $0.99) provides a basic reference intended to assist nondermatology providers in properly diagnosing dermatologic conditions. Skin Scan (41 reviews, $4.99) allows patients to photograph moles and uses an algorithm to classify moles as high risk, medium risk, or low risk. Doctor Mole (36 reviews, free) is another self-surveillance app that provides a risk assessment of each mole and saves images, allowing users to compare change over time. What s My Rash? (36 reviews, $2.99) provides a photograph gallery for patients to use as a reference for self-diagnosis. Skin Conditions (35 reviews, free) is a reference to gain basic information on various skin diseases. Discussion The recent growth and adoption of mobile apps have been rapid and widespread. Few dermatology apps have already been identified and reviewed for content and quality. 18,19 The present study documents the presence and variety of dermatologyrelated mobile apps designed for patients and/or medical providers. The results reveal that mobile apps may play a role in dermatology. Their growing popularity is evidenced by the fact that the 3 most prevalent dermatology-related apps had received a total of nearly 800 customer reviews. In comparison, popular medical applications, such as Medscape and Epocrates, have received more than and reviews, respectively. Widely popular nonmedical apps, such as Facebook (>6 million reviews) and Calorie Counter (nearly reviews), have a substantial number of reviews. 20 Although dermatology-related apps have a relatively small number of reviews in comparison with other medical and nonmedical apps, the number of users may be significant. These reviews provide a rough reflection of app use; however, they are likely a sizable underestimation, because app reviews represent only a fraction of the total downloads. The presence of several teledermatology apps within our survey suggests that mobile apps may be used in remote consultant services. Limited by poor image quality in the 1302 JAMA Dermatology November 2013 Volume 149, Number 11 jamadermatology.com

4 Original Investigation Research past, mobile smartphone image resolution has improved considerably and may no longer pose a limit to its use in teledermatology. 10 In fact, recent research found that an app that uses dermatologists to evaluate lesions in a store-andforward fashion had more than 98% sensitivity. 21 This technology, both efficient and practical, provides underserved communities with access to the clinical expertise of metropolitan dermatologists. 22,23 More than 75% of teledermatology patients are located in geographically isolated regions and live at or below 200% of the federal poverty level. 5 As the affordability of mobile technology improves, the implications for providing cost-effective specialty care to the economically and geographically underserved population are tremendous. Mobile apps also may provide a cost-effective and beneficial adjunct to traditional medical education for students, resident physicians, and practicing physicians. An Italian medical school 24 demonstrated improvement in academic performance among students in a 10-week dermatology course who were randomly assigned to a mobile smartphone incorporated learning model in comparison with students using a traditional lecture-based model. Another study 25 evaluated the role of smartphone-based learning at a remotely located residency training program and found that apps were used effectively by resident physicians in a resource-limited setting. Educational apps within our survey included free resources such as Dermatology Flashcards and paid apps such as Dermatology Physician Board Review Q and A ($8.99) and Dermoscopy: An Illustrated Self-assessment Guide ($94.99). The multitude of dermatology-related mobile apps may be used by health care professionals as an affordable and effective adjunct to traditional texts. Nearly half of dermatology-related apps targeted health care providers alone, and 51.1% of the identified apps targeted a patient audience. Patients and the general public may access health care apps to gain educational information, document personal skin disease, or even attempt selfdiagnosis. However, it is important that users recognize the potential risks of using mobile apps as resources for valid dermatology information. Previous surveys 19,26 of mobile apps within dermatology and other specialties have found a profound lack of academic reference or authorship by medical professionals. Of the apps identified in this study, few, such as Contact Allergen Replacement Database and UMSkinCheck, developed by Mayo Clinic and the University of Michigan, respectively, were clearly prepared by medical professionals. Several apps identified in our study claimed to be developed by dermatologists; however, authorship was not clearly stated or readily available within the description. Furthermore, most apps did not indicate design or development by medical personnel. In light of the recent expansion of the mobile app market, it has been proposed 19 that apps be held accountable for their content via authorship disclosure, regulatory approval, and external review. To date, the US Food and Drug Administration (FDA) has not released formal guidelines for mobile app developers. Currently, regulations under the FDA Safety and Innovation Act are limited to any app that meets the definition of device in section 201(h) of the Federal Food, Drug, and Cosmetic Act and is used as an accessory to a regulated medical device or transforms a mobile platform into a regulated medical device. 27 Considerable challenge exists for enforcement of these regulations because most apps do not constitute a medical device. However, efforts are under way to require companies with apps making medical claims to apply for FDA approval in a manner similar to that used for a medical device. 28 Already, in 2011 the US Federal Trade Commission outlawed a mobile app that touted an unsubstantiated acne cure. 29 We anticipate a formal set of FDA regulations to enforce safety, quality, and validity of content within the medical mobile app market. Further studies are needed to demonstrate the safety and efficacy of mobile apps as diagnostic tools in skin cancer screening. Numerous self-surveillance apps allow patients to log the location, color, and size of moles and even store photographs of moles to track changes. The University of Michigan developed UMSkinCheck, which allows users to compile a photographic library of moles and other lesions. Another app, SpotCheck, enables patients to upload photographs for a fee to be available to a board-certified dermatologist within 24 hours. Other apps allow the patient to assess cancer risk by following a skin cancer algorithm or by submitting a lesional photograph to a computer program. Computer algorithm software has demonstrated the potential to visually analyze pigmented skin lesions for melanoma with reasonably high sensitivity in the FDA-approved handheld imaging device MelaFind. 30 Similarly, imaging technologies may be used in mobile apps in the assessment of skin lesions. SkinMD, developed by students at the University of Pennsylvania, analyzes uploaded photographs using image-analysis algorithm software. These patient-oriented apps directed toward skin cancer screening may promote self-surveillance. However, patients and clinicians should maintain a healthy sense of skepticism because studies regarding the safety and accuracy of such apps are limited. Several smartphone applications that evaluate photographs of skin lesions and provide a malignancy risk assessment have demonstrated highly variable diagnostic accuracy. Skin Scan (the seventh most reviewed application identified in this study) uses fractal analysis to detect their categorization of high-, medium-, and low-risk nevi. In one study, 31 the app determined that 88.2% of biopsy-proven melanoma photographs were medium risk, and advised the users to simply monitor these lesions. A separate study 21 that evaluated 4 photograph-analysis applications using nearly 200 biopsy-confirmed melanomas found that test sensitivity ranged from 6.8% to 98.1% and specificity ranged from 30.4% to 93.7%; sensitivity was highest for the app that used a board-certified dermatologist for evaluation. The diagnostic inaccuracies of these apps may harm patients who substitute these relatively inexpensive tools for in-person medical care, by potentially delaying treatment for melanoma. In addition, mobile app analysis of skin lesions is limited by the user s judgment in choice of potentially malignant lesions. Application users may incorrectly choose skin lesions to assess, thereby delaying standard medical consultation and skin cancer screening. 32 jamadermatology.com JAMA Dermatology November 2013 Volume 149, Number

5 Research Original Investigation Conclusions Newmobileappsaredevelopeddaily,offeringawidearrayoftools for health care professionals, as well as for the general public. As our technological growth continues, the widespread use of mobile apps is likely to play an increasingly sophisticated role in dermatology. We have identified a variety of dermatology-related mobile apps and recognize both the potential benefit and inherentriskintheiruseforthemanagementofskindisease.additional investigation may be required to further elucidate the extent of mobile app use among dermatologists and patients. ARTICLE INFORMATION Accepted for Publication: May 19, Published Online: September 25, doi: /jamadermatol Author Contributions: Drs Brewer and Dellavalle had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Brewer, Henley, Sampson, Moreau, Dellavalle. Acquisition of data: Brewer, Endly, Henley, Amir, Sampson. Analysis and interpretation of data: Brewer, Endly, Henley, Sampson, Moreau, Dellavalle. Drafting of the manuscript: Brewer, Endly, Henley, Amir, Sampson. Critical revision of the manuscript for important intellectual content: Brewer, Endly, Sampson, Moreau, Dellavalle. Statistical analysis: Moreau. Administrative, technical, and material support: Endly. Study supervision: Brewer, Dellavalle. Conflict of Interest Disclosures: None reported. Disclaimer: The opinions expressed in this letter represent the views of the authors and not of the US government. REFERENCES 1. ComScore MobiLens Service. ComScore reports August 2011 U.S. mobile subscriber market share. /10/comScore_Reports_August_2011_U.S._Mobile _Subscriber_Market_Share. Published October 5, Accessed October 31, Manhattan Research. 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