COMMENTARY

Teledermatology in the COVID-19 Era: No Turning Back

Graeme M. Lipper, MD

Disclosures

December 14, 2020

Teledermatology vs In-office Visits: How to Triage

Teledermatology can be used for consultations, initial visits, follow-ups, and prescription renewals. Obviously, some conditions are more amenable to remote assessment and treatment than others. We have the most data on use of teledermatology — primarily through store-and-forward visits — for atopic dermatitis, psoriasis, acne, and skin cancers.

We have data supporting the conclusion that teledermatology is highly effective and complements face-to-face visits for follow-up care of common inflammatory skin conditions.

One randomized clinical trial (RCT) of over 150 children and adults with atopic dermatitis comparing in-person and teledermatology (store-and-forward) visits for follow-up care found that both groups showed similar improvement over the course of 1 year.

Another RCT of 300 patients with psoriasis found comparable results with remote and in-person follow up care.

Teledermatology also offers a convenient and effective way to follow acne patients. An RCT of 69 patients with severe acne treated with isotretinoin found excellent and comparable clinical outcomes in those receiving either remote or in-person follow up. And patients like it. In one observational study of over 50 patients with acne who were switched to remote visits owing to the pandemic, almost three quarters (71%) said they were highly satisfied with their care. Virtually all (96%) were happy enough that they planned to continue to receive care from the same dermatologist.

The role of teledermatology in skin cancer screening or evaluation of suspicious skin lesions is less clear. A recent Cochrane review of 22 studies reported on the diagnostic accuracy of teledermatology (primarily store-and-forward) for the detection of skin cancer. Although the authors noted that the studies were generally small and heterogeneous and methodological quality was difficult to judge, they concluded that teledermatology can correctly identify the majority of malignant lesions. Inclusion of dermoscopic images improved sensitivity, especially in the case of pigmented lesions. However, the investigators warned against drawing any firm conclusions from these data and noted that sensitivities were more variable for the detection of invasive melanomas or atypical intraepidermal melanocytic lesions.

A Convenient Tool, but Not a Replacement

Like it or not, teledermatology is here to stay. It appears to be ideally suited for some aspects of dermatologic care in our "contactless" society. Follow-up for stable chronic inflammatory skin conditions can be done safely and effectively through remote visits, with the added benefit that these remote visits are more convenient for our patients, less disruptive to their schedules, and easily integrated into a hybrid schedule that includes in-person visits.

But teledermatology has obvious limits. Patients with acute skin concerns, such as infection (cellulitis, abscesses, ruptured and inflamed follicular cysts), rapidly growing cutaneous lesions, and suspicious pigmented lesions, are best evaluated in-person. Maybe one day, we will be able to program drones to fly to our patients' homes and perform diagnostic procedures, such as skin biopsies. But until then, some problems will always need a hands-on approach.

Graeme M. Lipper, MD, is a clinical assistant professor at the University of Vermont Medical College in Burlington, Vermont, and a partner at Advanced DermCare in Danbury, Connecticut.

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