Dermatology Online Journal

Internet advice in dermatology and allergy: 1 year analysis of telerequests and answers
Bernadette Eberlein-König,¹ Reinhard Engst,² Dietrich Abeck,³ Johannes Ring⁴
Dermatology Online Journal 7(2): 3

1-4. Department of Dermatology and Allergy Biederstein, Technical University Munich

---

Abstract

The purpose of this study was to analyze the content and objectives of questions asked by internet users who accessed the homepage of the Department of Dermatology and Allergy Biederstein at the Technical University of Munich. Users were offered the opportunity to ask free questions on the Web site. The results of lay and medical individuals seeking advice were collected over a 12 month period and the answers given were reviewed. We received inquiries from 279 laypersons and 31 physicians. The majority of questions (53.8%) asked by non-medical users dealt with dermatology-related problems. Inquiries related to hair (13.3%) and acne or rosacea (11.3%) were most common. 46.2% of e-mail requests were allergy-related. Most of the interest focused on food allergy and adverse food reactions (22.5%) or hay fever and perennial rhinoconjunctivitis (19.4%). Previous consultation of a physician was reported in 40.9%. 13.6% had consulted an allergist or dermatologist. The majority of questions asked by physicians concerned allergy-related topics (64.6%). Most questions were answered by a short letter giving advice and encouraging the non-medical user to visit a dermatologist and/or allergist (72.4%). In 27.6% we felt that the inquiries were answered completely. Our website offer to answer dermatology-related and allergy-related questions for free was well accepted and shows that many patients seek additional, reliable information regarding their diseases. The purpose of such an offer is not to replace the traditional physician-patient contact, but to assist non-medical users to better understand their health problems and to guide them to seek additional medical help when required.

---

Introduction

There exists an enormous amount of medical information on the internet providing non-medical individuals and professional users with information of varying quality. In the dermatological and allergological areas there are many useful Web site addresses for physicians, some of which provide the opportunity to ask individual questions [1,2,3,4]. For laypersons there rarely exist sites where individual questions will be answered by experts free of charge. In contrast many unsolicited e-mails sent to dermatologists or allergologists are either not answered or answered with a standard e-mail saying that teleadvice cannot be provided. [5,6]

In order to study the usefulness of providing individualized expert advice to German speaking users of the world wide web from a university department of dermatology and allergology, we created in our homepage the opportunity to ask individual questions related to dermato-allergological topics.

Methods

In April 1997 the Department of Dermatology and Allergy Biederstein Technical University Munich installed a homepage in the German language (www.derma-allergie.med.tu-muenchen.de). The Web sites included information about the department, physicians, specialty fields, research activities, publications, information about lectures, postgraduate education, congresses etc. and the opportunity to ask free questions*. No special information for laypersons in the area of dermatologic and allergologic diseases was included. In a form we asked for the inquirer's address since most responses were sent by letter. Questions without addresses were answered by e-mail. There was one form for patients ("Dear patient, you may ask about skin diseases or allergological problems. We are trying to answer your question as soon as possible. Please leave your address.") and one for physicians ("Dear colleague, you can ask a question pertaining to our field of work. We are trying to answer your question competently as soon as possible. Please leave your adress.")

For this study all e-mails sent between April 15, 1998 and April 15, 1999(one year) were collected and analysed. Use of the web sites was measured by a statistical program (RENT-A-GURU, Heidelberg, Darmstadt, Germany). During the study period, the questions were answered in almost all cases by one experienced physician and undersigned by one or two senior physicians from our clinic. A descriptive, statistical analysis was used.

Results

During the period of one year (April 15th 1998 to April 15th 1999) we received a total of 310 questions by e-mail from non-medical individuals (90%) and physicians (10%).

Age and sex

The age of laypersons asking questions (n=279) via internet was given by 34 individuals (12.2%) and ranged between 20 and 60 years (mean: 31 years). Of these writers, 153 (54.8%) were males, 105 (37,7%) were females. In 21 cases (7.5%) the sex was not stated. Physician inquiries accounted for 31 (10%) of the e-mails (24 males, 4 females, 3 not stated).

Country and state of origin

The country of origin of all writers was in most cases Germany (n=251; 81%). Within Germany 57 (23%) came from Bavaria, 194 (77%) from other regions. Only 39 e-mails had their origin in other countries: 19 (48.7%) came from Austria, 3 (7.7%) from Switzerland and the rest from other countries (n=17, 43.6%; Scotland: n=1; South Africa: n=1; Norway: n=2, United States of America: n=2; Netherlands: n=2; France: n=2; Turkey: n=2; United Kingdom: n=2; Belgium: n=1; Spain: n=1; Slovenia: n=1). In 20 cases (6.5%) the country of origin could not be determined exactly. In order to get this information we asked for the complete address of the writers. Their current address including phone number was provided by 231 (74.5%).

Length of the e-mail demand

The length of the e-mail sent was smaller than five sentences in 192 cases (61.9%), between five and ten sentences in 95 cases(30.6%), and longer than 10 sentences in 23 cases(7.4%).

Topics

Inquiries of patients and consumers contained an allergological topic in 46.2% (n=129) and a dermatological topic in 53.8% (n=150). Physician inquirers posed questions pertaining to allergy in 64.6% (n=20). The remaining questions from physicians pertained to dermatology.

The distribution of different topics within these two categories are shown in table 1. Allergy-related questions about food intolerances (22.5%) and hay fever/rhinoconjunctivitis (19.4%) were most often asked. Among dermatological problems, questions about hair problems (13.3%) and acne/rosacea (11.3%) were most common.

Type of question

There were different types of questions. Questions for general information were asked by 184 persons (59.4%). Fifteen (4.8%) wanted a recommendation for a specialist. Many asked for a therapy recommendation (n=103 ,33.2%), and 19 (6.1%) particularly asked for a newly-introduced therapy. Diagnosis-related questions were asked for in 22 cases(7.1%).

Diagnosis

The diagnosis was mentioned or regarded as clear due to the description in 240 (77.4%) cases.

Duration of disease

In 100 e-mails(32.3%) the duration of the disease was mentioned: 75 persons had been suffering from the disease longer than 6 months, 25 shorter than 6 months.

Previous consultations of a physician

Less than half of the non-medical writers (40.9%) had already contacted a physician, a dermatologist or allergist in 13.6% (n=38). Only 3 (1.1%) mentioned explicitly that they had not seeked for medical advice before. In all other cases this point was not clear or not applicable to the question.

Person who asked

A majority of questions pertained to an individual case (197,70%). Many asked for themselves (128, 65%), 40 (20.3) for their child or children and 29 (14.7%) for another person.

Previous therapies

An already attempted therapy was mentioned in 84 (27.1%) cases. In 212 cases (68.4%) no statement was made about this point and 14 (4.5%) reported that they had no therapy so far.

Answering the questions

Most questions (if an address was given) were answered by a letter with the signature of a senior physician. Written letters were provided for reasons of patient confidentiality. This letter contained the name of the contact person with fax and telephone number. When the address was not given, the question was answered by e-mail. In urgent cases a telephone call was performed.

According to our opinion it was possible to answer 77 questions (27.6%) completely and sufficiently with a few sentences. 168 questions of patients or consumers (60.2%) were answered by giving advice and encouraging the person to contact a dermatologist or allergist. In 20 cases (7.2%) only the consultation of a dermatologist or allergist was recommended. In a total of 20 cases (6.5%) documents (copies of textbook pages, diet sheets, patients´ information leaflets etc.) were sent.

About 10 times we received an additional query from a person after they had received our response.

Topics	Frequency (n)
Food allergy and intolerances	29
Hay fever/respiratory atopy	25
Hairs	20
Acne/Rosacea	17
Urticaria/Quincke-edema	12
Atopic eczema	12
Contact dermatitis	11
Palmoplantar eczema	8
Psoriasis	7
Vitiligo	6
Scleroderma	4
Hyperhidrosis	4
Mastocytosis	3
Herpes	3
Scars	3
Nevi	3
Insect venom allergy	3
Other allergological topics	29
Other dermatological topics	80
Total	279
Table: Distribution of dermatological and allergological topics asked by laypersons.

Conclusion

This study analyzed 310 e-mails from patients, consumers or physicians seeking information about dermatological and/or allergological problems through the homepage of our department.

It was surprising that nearly half of the questions dealt with allergological problems underlining the importance of this field in the general population. This may be due on the one hand to the high prevalence of these diseases, or on the other hand, to dissatisfaction with the available treatments. In contrast, other very common diseases like psoriasis were rarely addressed. This may also reflect the composition of internet users, mainly consisting of younger persons with university education [7], who tend to have more allergological problems [8,9]. However, the sample size was too small to draw detailed conclusions of this nature.

The main topics in the allergy field were food intolerances and rhinoconjunctivitis. This may demonstrate problems with adequate diagnosis and/or therapy. In the dermatological field, hair problems and acne/rosacea were the main topics reflecting the need for information about new therapies (e.g. finasteride) and showing that people do not always visit a dermatologist for treatment of "common" dermatological diseases (e.g. acne). Compared to the ten predominant diseases treated in our department during the last ten years (atopic eczema, psoriasis, tinea, acne, tumor, contact dermatitis, urticaria, verruca, nevus, herpes), it seems that very common diseases such as psoriasis and tinea were underrepresented. Furthermore, malignant dermatological diseases were only rarely the topic of the questions, suggesting that older people suffering from these diseases may not use this type of platform and prefer the direct patient-physician contact.

It is possible that the anonymity of e-mail encourages frustrated patients or patients who are afraid to ask questions of their physicians. [5] However, in our study the majority (about 75%) did not remain anonymous and looked for individual advice. This was underlined by the fact, that only 14.5% of the writers did not give their telephone number.

The mean age and sex of the patients who did indicate these facts, correspond to the main internet user groups [7] and are in accordance with a previously published study [5]. In this study 209 unsolicited e-mails sent by patients (or relatives of friends of patients) to a physician of a dermatologic hospital in Germany were analyzed.

Some similarities and some differences with that study were also seen for the number of physicians who were contacted before (56% vs. 40.9% in our study), the types of requests (general information: 34% vs. 59.4%; therapy: 30% vs. 33.2%; specialist: 15% vs. 4.8%; new therapy: 12% vs. 6.1%; diagnosis : 11% vs. 7.1%), and the person for whom the information is sought (for himself: 44% vs. 64%, for other persons: 30% vs. 35%). In contrast, whereas we were able to determine the country of origin in 93.5% (88.1% from Germany or other German speaking countries, 23% from our home-state of Bavaria), the prior study was only able to identify the country of origin in 34% and most senders were probably from the United States.[5]

It is known that answering questions by e-mail presents problems of confidentiality, liability and licensing. Therefore standards have been suggested as guides to the assessment of medical information on the internet [10,11,12,13,14,15,16]. In order to solve some of these problems, we answered (if an address was given) all questions individually by an official short letter of our department undersigned by at least two physicians (at least one senior staff member) or by e-mail. As many questions dealt with chronic diseases (at least 75%) the delay by answering this way was regarded as irrelevant. In very urgent cases a telephone call was made followed by a letter. As the letter contained the complete address of our department, the name of a contact person, a fax and telephone number, the origin of the response was clearly stated and further contact was possible. In order to avoid wrong conclusions from the limited data the patients provided, we advised and encouraged the person to contact a dermatologist or allergist in more than 60% of the cases.

It was suggested that a teleadvice service, which is easily accessible and offered for free, is prone to be excessively used by information-seeking patients [5]. A significantly larger volume of queries would have been difficult to handle satisfactorily. However, in our experience this did not happen. Our Web site can be found by the usual search engine services and the offer for the medical advice is on the first Web site. In our response letters there is information for further contact. Nevertheless our advice service was not overused (about 6 questions per week) and only 7.4% were longer than 10 sentences. Only after publishing our teleadvice in a popular magazine in July 1998 the number of questions clearly increased for two to three weeks. This and the fact that more than 40% had already contacted a physician shows that most people are aware that getting teleadvice via internet is only one method to get further medical information. It seemed that most of them did not expect to get advice that would replace the direct contact with a physician, especially for acute problems as was suggested by a study with a fictitious question about an acute dermatological problem. [6]

Most of the people from whom we received an additional communication after getting our response, thanked us for our advice which had enabled them to take appropriate steps to solve their medical problems.

Therefore we see the sense of answering these questions in our medical fields, not to solve the patients' problems completely or to replace the traditional physician-patient contact, but to help them proceed rationally to find their diagnosis and worthwhile therapy. We assume that this approach could help to reduce inappropriate consultations and increase efficiency by directing appropriate patients more quickly to specialists and subspecialists. We hope this may contribute to reduced costs of health care and improved medical care.

Finally, since liability issues and standards differ among countries, physicians interested in setting up a similar website should thoroughly investigate their legal liability beforehand.

References

1. Huntley AC. Internet resources for dermatology. J Am Acad Dermatol. 31: 474-484, 1994.

2. Diepgen TL, Bittorf A, Schuler G, Krejci-Papa NC. Dermatologie und Internet - Nutzen für Klinik und Forschung. Hautarzt 48: 373-378, 1997.

3. Krejci-Papa NC, Bittorf A, Diepgen T, Huntley A. Dermatology on the Internet. A source of clinical and scientific information. J Dermatol Sci. 13: 1-4, 1996.

4. Sitaru C. Dermatology resources on the Internet: a practical guide for dermatologists. Int J Dermatol. 37: 641-647, 1998

5. Eysenbach G, Diepgen TL. Patients looking for information on the internet and seeking teleadvice. Motivation, expectations and misconceptions as expressed in e-mails sent to physicians. Arch Dermatol. 135: 151-156, 1999

6. Eysenbach G, Diepgen TL. Evaluation of cyberdocs. Lancet 352: 1526, 1998.

7. http://www.electronic-commerce.org/marktbarometer/ daten/demogra.html

8. Ring J. Allergy and modern society. Does ´Western life style`promote the development of allergies? Int Arch Allergy Immunol. 113: 7-10, 1997. 9. Schäfer T, Vieluf D, Behrendt H, Krämer U, Ring J. Atopic eczema and other manifestation of atopy: Results of a study in East and West Germany. Allergy 51: 532-539, 1996.

10. Adelhard A, Obst O. Evaluation of medical internet sites. Meth Inform Med 38: 75-70, 1999.

11. Kim P, Eng TR, Deering MJ, Maxfield A. Published criteria for evaluating health related web sites: review. BMJ 318: 647-649, 1999.

12. Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the world wide web. JAMA 280: 1333-1335, 1998.

13. Jadad AR, Gagliardi A. Rating health information on the internet. Navigating to knowledge or to babel? JAMA 279: 611-614, 1998.

14. McLellan F. ìLike hunger, like thirst": patients, journals, and the internet. Lancet 352: sII39-SII43, 1998.

15. Lindberg DAB, Humphreys BL. Medicine and health on the internet. The good, the bad and the ugly. JAMA 280: 1303-1304, 1998

16. Hwang MY, Glass RM, Molter J. How to find reliable online health information and resources. JAMA 280: 1380, 1998.

© 2001 Dermatology Online Journal