11 GENERAL INTRODUCTION conditions themselves in their practice with a wait-and-see policy or medical treatment. Fourteen percent of patient complaints in GP practice are related to the skin [36]. It is estimated that GPs manage or treat 86% of these skin conditions themselves and that they refer 14% of the patients to a dermatologist [37]. With more than 34 referrals per 1000 enrolled patients per year (in 2022), dermatology is the largest referral specialism of GPs [38]. The top-3 International Classification of Primary Care (ICPC) codes for dermatology referrals from 2022 showed that most of these GP referrals were related to “Skin disease, other” (S99), “Nevus/mole” (S82), or “Malignant neoplasm of skin” (S77) [38]. Patients wait on average 35 days for a scheduled consultation appointment in the outpatient dermatology department and 18 days for a consultation in case of a suspicious lesion (September 2023) [39], while GPs receive a diagnosis and advice by a TD about a patient’s skin lesion within 2 working days. Furthermore, the incidence of skin cancer is increasing worldwide due to excessive sun exposure (Ultraviolet (UV) light) on tropical holidays and leisure activities, the growing and aging population, and patients’ awareness of skin cancer [40]. GPs experience an increase in patients who request assessments of nevi and other skin lesions [40]. This growing need for dermatology care and the rise in suspicious lesions combined with the aging population further enlarges the pressure on Dutch healthcare [41,42]. As the pivot of primary care, GPs experience high work pressure and have little consultation time for each patient [1]. In the fixed consultation time of 10-15 minutes, the GP has to identify the patient’s purpose of consultation and original request for help, take an anamnesis, perform a physical examination, discuss diagnosis and treatment management policy with the patient, start a referral or prescribe medication, and write a report in the GP Information System (Dutch: Huisarts Informatie Systeem (HIS)) [40]. In addition, for skin neoplasms, the GP needs to decide whether the skin condition is benign or malignant. However, GPs experience challenges in diagnosing skin disorders, especially in discriminating (pre) malignant and benign skin lesions, and diagnosing skin cancer [40,43-45]. This results not only in referrals of patients with malignant skin lesions to a dermatologist, but also of patients with mild benign skin lesions (for example, seborrheic keratosis, vascular lesions, and benign nevus) [42-44]. Teledermatology could thus support GPs in this patient referral process for low-complex dermatology questions so that mainly patients with complex or severe skin lesions or patients that require specialized care outside the scope of the GP are referred to the dermatologist. Teledermatology is therefore an example of a digital dermatology intervention that can be used in addition to standard care to support GPs in diagnosing skin lesions in primary practice and improve GP’s diagnostic accuracy by TD advice. 1
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