Recognizing the haystack is the task of the primary care physician.

In a reply to our letter Ferrandiz and colleagues wondered why dermoscopy experts did not already fully embrace teledermoscopy (TD) for suspicious pigmented skin lesions.(1) Our study showed that the structure of the health systems that were investigated differed, with countries where primary care physicians (PCP) hold a gate keeper function and others with direct access to a dermatologist. Significant differences in waiting time and travel distance were observed.(2) Since we believe that there is enough evidence that the addition of high quality dermoscopic pictures to a teleconsultation leads to higher accuracy of the diagnosis we did not investigate this question in our survey.