Poor Image Quality May Limit Televulvology Care

Jake Remaly

November 17, 2020

Seeing patients with vulvar problems via telemedicine can lead to efficient and successful care, but there are challenges and limitations with this approach, doctors are finding.

Image quality is one key factor that determines whether a clinician can assess and manage a condition remotely, said Aruna Venkatesan, MD, chief of dermatology and director of the genital dermatology clinic at Santa Clara Valley Medical Center in San Jose, Calif. Other issues may be especially relevant to televulvology, including privacy concerns.

"Who is helping with the positioning? Who is the photographer? Is the patient comfortable with having photos taken of this part of their body and submitted, even if they know it is submitted securely? Because they might not be," Venkatesan said in a lecture at a virtual conference on diseases of the vulva and vagina, hosted by the International Society for the Study of Vulvovaginal Disease.

When quality photographs from referring providers are available, Venkatesan has conducted virtual new consultations. "But sometimes I will do a virtual telemedicine visit as the first visit and then figure out, okay, this isn't really sufficient. I need to see them in person."

Melissa Mauskar, MD, assistant professor of dermatology and obstetrics and gynecology at the University of Texas Southwestern Medical Center, Dallas, described a case early on during the COVID-19 pandemic that illustrates a limitation of virtual visits.

A patient sent in a photograph that appeared to show lichen sclerosus. "There looked like some classic lichen sclerosus changes," Mauskar said during a discussion at the meeting. "But she was having a lot of pain, and after a week, her pain still was not better."

Mauskar brought the patient into the office and ultimately diagnosed a squamous cell carcinoma. "What I thought was a normal erosion was actually an ulcerated plaque," she said.

Like Venkatesan, Mauskar has found that image quality can be uneven. Photographs may be out of focus. Video visits have been a mixed bag. Some are successful. Other times, Mauskar has to tell the patient she needs to see her in the office.

Certain clinical scenarios require a vaginal exam, Venkatesan noted. Although some type of assessment may be possible if a patient is with a primary care provider during the telemedicine visit, the examination may not be equivalent. Doctors also should anticipate where a patient might go to have a biopsy if one is necessary.

Another telemedicine caveat pertains to patient counseling. When using store-and-forward telemedicine systems, advising patients in a written report can be challenging. "Is there an easy way ... to counsel patients how to apply their topical medications?" Venkatesan said.

Excellent Care Is Possible

Vulvology is a small part of Venkatesan's general dermatology practice, which has used telemedicine extensively since the pandemic.

In recent years, Venkatesan's clinic began encouraging providers in their health system to submit photographs with referrals. "That has really paid off now because we have been able to help provide a lot of excellent quality care for patients without them having to come in," she said. "We may be able to say: 'These are excellent photos. We know what this patient has. We can manage it. They don't need to come see us in person.' " That could be the case for certain types of acne, eczema, and psoriasis.

In other cases, they may be able to provide initial advice remotely but still want to see the patient. For a patient with severe acne, "I may be able to tell the referring doctor: 'Please start the patient on these three medicines. It will take 2 months for those medicines to start working and then we will plan to have an in-person dermatology visit.' " In this case, telemedicine essentially replaces one in-person visit.

If photographs are poor, the differential diagnosis is broad, a procedure is required, the doctor needs to touch the lesion, or more involved history taking or counseling are required, the patient may need to go into the office.

Beyond its public health advantages during a pandemic, telemedicine can improve access for patients who live far away, lack transportation, or are unable to take time off from work. It also can decrease patient wait times. "Once we started doing some telemedicine work … we went from having a 5-month wait time for patients to see us in person to a 72-hour wait time for providing some care for patients if they had good photos as part of their referral," Venkatesan said.

Telemedicine has been used in inpatient and outpatient dermatology settings. Primary care providers who consult with dermatologists using a store-and-forward telemedicine system may improve their dermatology knowledge and feel more confident in their ability to diagnose and manage dermatologic conditions, research indicates.

In obstetrics and gynecology, telemedicine may play a role in preconception, contraception, and medical abortion care, prenatal visits, well-woman exams, mental health, and pre- and postoperative counseling, a recent review suggests.

Image Quality Is Key

"Quality of the image is so critical for being able to provide good care, especially in such a visual exam field as dermatology," Venkatesan said.

To that end, doctors have offered recommendations on how to photograph skin conditions. A guide shared by the mobile telehealth system company ClickMedix suggests focusing on the area of importance, capturing the extent of involvement, and including involved and uninvolved areas.

Good lighting and checking the image resolution can help, Venkatesan offered. Nevertheless, patients may have difficulty photographing themselves. If a patient is with their primary care doctor, "we are much more likely to be able to get good quality photos," she said.

Venkatesan is a paid consultant for DirectDerm, a store-and-forward teledermatology company. Mauskar had no relevant disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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