Quality of life: a research gap in teledermatology

An important outcome in healthcare, and in particular for dermatologic healthcare, is quality of life. Whereas the literature is well represented by quality of life assessments in dermatology, very little information is available that specifically addresses teledermatology's impact on quality of life. This gap in our knowledge of teledermatology is noteworthy precisely because of the importance that quality of life plays in dermatologic disease and healthcare delivery. The goal of this review is to briefly outline the concept of quality of life and its importance to dermatology, describe the different type of instruments that are used to assess quality of life, and to review studies that implemented teledermatology interventions and made quality of life assessments. The available literature has shown that teledermatology interventions do result in improved quality of life, and those changes correlate with improvements in disease severity and clinical course. Integrating quality of life assessments in future evaluations of teledermatology interventions would be valuable to provide a more comprehensive depiction of teledermatology's impact on patients receiving dermatology care via telemedicine.     

Pediatric teledermatology--a survey of current use

Abstract:  Demand for pediatric dermatologic care far exceeds the supply of pediatric dermatologists. Teledermatology has been proposed as a solution to improve access to care, however, data regarding teledermatology use for pediatric patients are lacking. Surveys assessing use and experience with teledermatology were administered to pediatric dermatologists attending the 2006 Society for Pediatric Dermatology Annual Meeting and to programs offering teledermatology identified in the American Telemedicine Association's 2003 Teledermatology Survey. Over half of the 76 pediatric dermatologists responding to the survey had previous experience with teledermatology and nearly half currently use some form of teledermatology. For most, this represents nonreimbursed, store-and-forward consultations. Respondents noted that teledermatology allows more accurate triage of dermatology patients, decreases travel and outpatient clinic visits, and provides an avenue for ongoing support and education for primary care physicians. While difficulties exist, overcoming obstacles to the use of pediatric teledermatology and reimbursement for such services could improve access to expert pediatric dermatologic care.     

Pediatric teledermatology: A review of the literature

Skin complaints are common among pediatric patients, yet as of 2020, fewer than 400 board‐certified pediatric dermatologists currently practice in the United States. Pediatric teledermatology may address barriers to dermatologic care in children, assisting with distant geographic locations and long wait times. A review of the literature was conducted to synthesize important features of teledermatology for pediatric dermatologists. We summarize types of telemedicine platforms, common dermatologic conditions seen by pediatric teledermatologists, diagnostic accuracy and concordance, and guidelines from the American Academy of Dermatology and the American Telemedicine Association regarding teledermatology. This report highlights the utility of pediatric telemedicine in both the outpatient and inpatient dermatology setting to increase access to high‐quality dermatologic care.     

Teledermatology in the times of COVID‐19 – a systematic review

The COVID‐19 pandemic restricts the care of dermatological patients in many ways. Teledermatology such as video consultation or “store‐and‐forward” teledermatology could at least partly compensate for this. This systematic review summarizes all published studies on teledermatology during the COVID‐19 pandemic. It is based on a MEDLINE search for articles from 2020 in English and German. Two surveys among dermatologists from the USA and India showed that more than 80 % offered teledermatology. Among German dermatologists 17.5 % of 480 respondents offered online video consultation, 11.3 % offline consultation (store and forward) and 10.0 % both. Five cohort studies on teledermatology during the pandemic were identified. Three of them investigated teledermatology in chronic dermatoses (acne, inflammatory skin diseases), one dealt with the care of oncological patients with dermatological complications, and one analyzed teleconsultation in suspected COVID‐19 cases. In all studies, teledermatology largely reduced the number of personal consultations. The results indicate that the limitations of personal dermatological care of patients with skin diseases during the COVID‐19 pandemic can be at least partially compensated by an extension of teledermatology. Findings from the use of teledermatology during the pandemic should be employed to improve the use and acceptance of teledermatology by patients and dermatologists.     

Pediatric consultative dermatology: A survey of the Society for Pediatric Dermatology workforce reveals shortcomings in existing practice models of pediatric dermatology consult services in the United States

The rate of pediatric hospitalization for cutaneous pathology has been increasing in recent years, often requiring the expertise of consulting pediatric dermatologists; however, the infrastructure of inpatient pediatric dermatology consultative services remains poorly characterized. We sought to assess the structure, consult volume, physician compensation, and utilization of teledermatology in pediatric dermatology inpatient services to better understand the current care model. Our survey of 118 pediatric dermatologists revealed that 89% of respondents see between 1 and 10 new consults per week, 39% perform all inpatient consults including evening and weekends without assistance from other providers, 71% do not have protected time during the week to provide inpatient consultations, and only 10% receive financial compensation via stipend. By highlighting both the high demand for pediatric consultative dermatology as well as the significant burden placed on these providers by existing practice models, we hope to encourage a reappraisal of the current infrastructure of pediatric inpatient dermatology to increase structural and financial support for this vital service.     

Practice guidelines for teledermatology in Australia

Despite the potential of teledermatology to increase access to dermatology services and improve patient care, it is not widely practised in Australia. In an effort to increase uptake of teledermatology by Australian dermatologists and support best practice, guidelines for teledermatology for the Australian context have been developed by The University of Queensland's Centre for Online Health in collaboration with The Australasian College of Dermatologists’ E-Health Committee. The guidelines are presented in two sections: 1. Guidelines and 2. Notes to support their application in practice, when feasible and appropriate. Content was last updated March 2020 and includes modalities of teledermatology; patient selection and consent; imaging; quality and safety; privacy and security; communication; and documentation and retention of clinical images. The guidelines educate dermatologists about the benefits and limitations of telehealth while articulating how to enhance patient care and reduce risk when practicing teledermatology.     

Geriatric teledermatology: store‐and‐forward vs. face‐to‐face examination

Background Telemedicine could be useful in countries like Italy to meet the needs of elderly patients and in particular in those in precarious general conditions, for whom travelling even short distances can pose considerable practical and economical difficulties. Objective The aim of this study was to determine the efficacy of store‐and‐forward teledermatology vs face‐to‐face consultations in elderly patients. Methods A total of 130 geriatric patients with skin diseases requiring dermatological examination were enrolled. The patients examined, consisting of 60 men (46.15%) and 70 women (53.85%), were aged between 66 and 97 years (mean age 80.58 years). Three dermatologists of the department, with equal experience took turns in face‐to‐face examination and teledermatology (store‐and‐forward). To compare face‐to‐face dermatological examinations with the asynchronous store‐and‐forward approach of teledermatology, we considered diagnostic agreement (ICD‐9 code), therapeutic agreement and concordance of diagnostic confidence. Results One hundred and fourteen of 130 patients were diagnosed with the same ICD‐9 code, making a total observed agreement of 87.7% with a Cohen’s κ estimated of 0.863. Agreement between therapies was 69.6% (Cohen’s κ = 0.640). As it concerns diagnostic confidence, dermatologists appeared generally slightly less certain of their diagnosis by telemedicine. Conclusions Store‐and‐forward teledermatology can improve diagnostic and therapeutic care for skin disease in elderly who lack easy and/or direct access to dermatologists.     

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offered pediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.     

Dermatologie in der Telemedizin Möglichkeiten und Grenzen

Telemedicine including teledermatology is the application of telecommunication technology for the purpose of diagnostics, planning and guiding of therapy and education. With the possibility to gain fast access to specialty knowledge, telemedicine makes it possible to deliver health care to patients at distant sites. By participating in telemedical consultations, patients receive accurate diagnosis in a rapid manner and save travel costs and time. Due to recent advances in computing and telecommunications technology, telemedicine will assume a more and more important role in future health care delivery. Telemedicine is utilized by almost all medical specialties but to varying degrees. Dermatology as a visually based specialty is predestined to use the various capabilities of telemedicine. The main applications so far include teledermatohistology and clinical teledermatology. The objective of this paper is to present the current status of teledermatology as part of telemedicine with a look toward future applications.     

Store-and-forward teledermatology: assessment of validity in a series of 2000 observations

Background and objectivesThe aim of this study was to assess the validity of store-and-forward teledermatology as a tool to support physicians in primary care and hospital emergency services and reduce the requirement for face-to-face appointments. Diagnostic validity and the approach chosen for patient management (face-to-face vs teledermatology) were compared according to patient origin and diagnostic group.Material and methodsDigital images from 100 patients were assessed by 20 different dermatologists and the diagnoses offered were compared with those provided in face-to-face appointments (gold standard). The proposed management of the different groups of patients was also compared.ResultsThe percentage complete agreement was 69.05% (95% confidence interval [CI], 66.9%–71.0%). The aggregate agreement was 87.80% (95% CI, 86.1%–89.0%). When questioned about appropriate management of the patients, observers elected face-to-face consultation in 60% of patients (95% CI, 58%–61%) and teledermatology in 40% (95% CI, 38%–41%). Diagnostic validity was higher in patients from primary care (76.1% complete agreement and 91.8% aggregate agreement) than those from hospital emergency services (61.8% complete agreement, 83.4% aggregate agreement) (p < 0.001) and teledermatology was also chosen more often in patients from primary care compared with those from emergency services (42% vs 38%; p = 0.003). In terms of diagnostic group, higher validity was observed for patients with infectious diseases (73.3% complete agreement and 91.3% aggregate agreement) compared to those with inflammatory disease (70.8% complete agreement and 86.4% aggregate agreement) or tumors (63.0% complete agreement and 87.2% aggregate agreement) (p <0.001). Teledermatology was also chosen more often in patients with infectious diseases (52%) than in those with inflammatory disease (40%) or tumors (28%) (p <0.001).ConclusionsStore-and-forward teledermatology has a high level of diagnostic validity, particularly in those cases referred from primary care and in infectious diseases. It can be considered useful for the diagnosis and management of patients at a distance and would reduce the requirement for face-to-face consultation by 40%.     

Preliminary results of DERMATEL: prospective randomized study comparing synchronous and asynchronous modalities of teledermatology

IntroductionThere is considerable variability in the results of studies that evaluate diagnostic reliability in teledermatology. There are only two studies that compare the synchronous and asynchronous modalities of teleconsult in the same sample. We present the results of the pilot project DERMATEL, a study of diagnostic concordance that aims to increase the evidence of these aspects.Material and methodsOne-hundred-fifty.nine patients referred by the general practitioner in the first consult were randomized (algorithm 3:2:1) in three arms: asyncronous teledermatology (store-and-forward or SAF), synchronous teldermatology (real-time or VTC), and conventional consult (CC). We used high-quality, fixed digital images in all cases. The patients on the VTC teledermatology arm were also evaluated by videoconference. Finally all patients attended a face-to-face consult, considered the gold standard of patient care. A second dermatologist evaluated the diagnostic and management concordance between the teleconsults and the face-to-face consults.ResultsOne-hundred.forty-seven patients completed the study as follows: 74 in the SAF teledermatology arm, 47 in the VTC teledermatology arm and 26 in the conventional consult (control group). The teledermatological (SAF and VTC) and face-to-face evaluations were identical in 100 of 121 patients (82.6 %). The errors were mild in 14 cases (11.6 %) and severe in 7 (5,8 %). The diagnostic concordance was very high (kappa = 0,813). The errors grouped by diseases were as follows: 6/54 (11 %) for tumors, 10/30 (33.3 %) for inflammatory conditions, 1/20 (5 %) for infectious diseases, 3/12 (25 %) for alopecia/acne and 1/5 (20 %) for others. There were 15 errors in the SAF teledermatology arm (20.3 %) and 6 in the VTC teledermatology arm (12.8 %); these differences were not statistically significant (χ² 1.12; p = 0.288).ConclusionThe reliability of dermatological teleconsult is very high, especially for tumoral or infectious diseases. The synchronous interaction with audio requires more resources, is difficult to coordinate and its diagnostic efficacy is not superior to SAF teledermatology.     

Teledermatology research review

Teledermatology consultations can be performed using either store-and-forward or real-time technology. The best-studied aspect of teledermatology is diagnostic reliability, also known as diagnostic agreement. A good level of diagnostic reliability is achieved by dermatologists using both store-and-forward and real-time modalities and is comparable to that found between clinic-based examiners. Less information is available regarding diagnostic accuracy. Current data suggest that teledermatologists reviewing store-and-forward consults achieve accuracy comparable to that of clinic-based dermatologists. When store-and-forward consult systems are used, approximately one in four in-person clinic appointments are averted. Real-time consult systems avoid the need to schedule approximately one in two clinic visits. Store-and-forward technology results in timelier interventions for patients when compared to a conventional referral process. To date, surveys of both store-and-forward and real-time teledermatology consult modalities suggest that patients, referring clinicians, and dermatologists are all highly satisfied with teledermatology consults. Very little has been published about the economic impact of store-and-forward teledermatology, whereas several studies have evaluated real-time modalities. Teledermatology has ranged from a cost-saving strategy to an intervention that incurs greater costs than conventional care, depending on the health care setting and economic perspective. Future research focusing on diagnostic accuracy, clinical outcomes using clinical course or disease status as outcome measures, development of reliable and valid teledermatology-specific survey instruments, and economic analyses that assess cost-effectiveness will help guide future teledermatology program assessments and policy.     

Teledermatology update: Mobile teledermatology

Mobile teledermatology is a relatively recent modification of teledermatology, which involves using mobile platforms like cellular phones to transmit images and data for the purpose of teleconsultations. With the rapidly improving quality of smart phone cameras combined with easier access to mobile internet, mobile teledermatology is emerging as a feasible and cost-effective method for teledermatology practice. Mobile teledermatology has shown good results in concordance studies comparing it to face-to-face consultations. Mobile teledermatology can be used for most types of clinical dermatology cases. Mobile teledermatology has been found to be useful in diagnosis, screening and triage of skin lesions including skin cancers. It is also useful as a tool to follow up patients with chronic dermatological problems like psoriasis and chronic wounds. The obvious advantage of mobile teledermatology is it’s cost-effectiveness and the fact that access to expert dermatology care is made easier for patients especially in remote areas. Further research is however required to standardize protocols for mobile teledermatology. Collaborative research among people working in this field would be very useful in this standardization and would help in optimizing the opportunities provided by this interesting tool. This article gives a brief overview of mobile teledermatology including definitions, tools involved, indications, limitations and future applications.     

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.     

Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project

Teledermatology is the practice of dermatology across distances (and time) and involves the transfer of electronic information. To be effective and safe, the teledermatology process needs to demonstrate an acceptable level of accuracy and reliability. Accuracy is reflected by the degree of concordance (agreement) between the teledermatology and face-to-face diagnoses. Reliability is dependent on how consistently a set of results can be reproduced across different operators. Mean concordance (primary diagnoses) achieved by four dermatologists studying 53 store-and-forward diagnostic cases, originating from 49 referred patients, was 79% (range 73-85%). When the differential diagnoses were taken into account, the variation across individual dermatologists narrowed further, with a mean of 86% (range 83-89%). In contrast, the mean general practitioner (GP; n=11) concordance (GP face-to-face vs reference dermatologist store-and-forward diagnoses) was 49%. An interim review of all 49 teledermatology patients showed no adverse outcome at the end of 3 months. The ability to request face-to-face visits by dermatologists, combined with GPs maintaining primary care of the referred patient, serve as additional safeguards for patients using a telemedicine system. Our results indicate that teledermatology management of referred skin complaints is both accurate and reliable.     

British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018

Lichen sclerosus (LS) is a chronic skin disease mainly affecting the anal and genital region. This article is a guideline, which means that the authors looked at all the available evidence about LS in scientific journals, and from this, put together up‐to‐date, evidence‐based recommendations for the management of the disease in adults (18+ years), children (0–12 years) and young people (13–17 years). The guideline was written by a committee of the British Association of Dermatologists, following strict criteria they have for assessing all the different studies on the subject. The guideline helps to guide doctors and nurses working in primary care (which means a patient's first port of call when they have a health problem, e.g. GP clinics, walk‐in centres) as well as in secondary care (meaning where GPs will send people for more specialist care, e.g. hospitals). The guideline covers a range of issues, from treatment options, to gaps in research that need to be addressed. From the guideline, an updated Patient Information Leaflet has been created and is available on the British Association of Dermatologists’ website ( www.bad.org.uk ). On the basis of these studies and expert consensus, 31 recommendations are made for the diagnosis and management of LS for both general practitioners and secondary care specialists. The recommended patient treatment pathways are presented as flow diagrams for men and women. All the evidence points to a potent topical steroid ointment as the most effective treatment for the condition. This is initially used for 3 months and then the frequency of treatment application is tailored to the individual patient to maintain good control of both symptoms and signs. Nine suggestions for future research studies are made to answer some outstanding questions and to fill gaps in current knowledge.     

Patient satisfaction with teledermatology is related to perceived quality of life

BACKGROUND: There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors. OBJECTIVES: To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service. METHODS: In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire. RESULTS: In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05). CONCLUSIONS: Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.     

Telemedicine in dermatology: findings and experiences worldwide – a systematic literature review

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross‐validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost‐effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under‐represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.     

Teledermatology in practice

Teledermatology has been the focus of much interest in recent years. Potential uses include a simple supporting role for primary care, more accurate triage of dermatology patients or an 'advice only' service reducing the need for dermatology patients to attend outpatient clinics. With the current under-provision of dermatology services in the UK and the waiting list targets set by government, teledermatology systems have been proposed as a possible solution. 'Store and forward' teledermatology systems are easy to set up and it has been shown that accurate diagnoses can be made using digital images attached to an E-mailed history. In an area of geographical isolation a store and forward teledermatology system has been used successfully to reduce patient waiting times. In Peterborough we have been using a store and forward teledermatology system for over 4 years. Our experience has demonstrated that for only a small number of selected patients was it possible to provide an advice-only service, but the majority of patients still need to be seen in the outpatient clinic. Despite the technical simplicity of these systems today there is still little evidence that teledermatology will have a significant impact on patient workload in the average dermatology clinic. It must be recognized that teledermatology is potentially a useful communication tool for selected patients in primary care but is unlikely to solve waiting list problems or replace the need for local dermatology services.     

Analyzing disparities in access to teledermatology compared with dermatology clinic visits before,during, and after COVID-19 quarantine

The COVID-19 pandemic has caused significant changes in dermatologic care, likely exacerbating health disparities for specific minority populations. The use of teledermatology has also become more prevalent during this period. The aim of this study was to determine if the proportion of teledermatology versus office-based visits varied significantly during three study periods of the COVID-19 pandemic. The secondary objective was to determine whether there are significant differences in the use of office-based dermatology versus teledermatology care across the following demographic subgroups: insurance type, race/ethnicity, age, and language during the same periods. A chart review of dermatology visits in electronic medical records at a tertiary referral center in Washington, DC, was conducted. The overall telehealth visit rate was 0% in the prequarantine period, 61.12% during the quarantine period, and 10.59% in the postquarantine period. After assessing telehealth utilization rates among the demographic subgroups, we noted that Medicaid users, Black patients, 64-year-olds or older, and English speakers may benefit the least from telehealth services. Teledermatology use necessitated by the COVID-19 pandemic may have promoted health care disparities for specific marginalized populations.