Telemedicine in Dermatology

Abstract

Telemedicine is known as the practice of diagnosing and treating patients by medical professionals from a distant location. In dermatology, telemedicine offers a transformative approach to healthcare services, particularly in remote or rural areas. Telemedicine allows patients to access medical care conveniently, ensuring both doctor and patient’s safety. Multiple advantages of telemedicine have been described, including lowering the necessity for expensive hospital trips and enabling remote consultations. Dermatology is a specialized field that is not universally accessible in all regions as ideally required. Therefore, telemedicine serves as a useful tool to facilitate access to evaluations for various dermatological conditions. However, despite its benefits, telemedicine in dermatology also encounters certain obstacles. In this chapter, we explore the dynamic and impact of telemedicine, specifically in the field of dermatology.

1. Introduction

Telemedicine, known as the practice of diagnosing and treating patients from a distant or rural location, has become increasingly important within modern healthcare practices. This approach has shown notable benefits, including improved healthcare access, enhanced quality of care, increased patient satisfaction, and decreased administrative expenses and costs. In dermatology, we talk about “Teledermatology,” and it has emerged as a vital tool in healthcare services, particularly in rural areas or during times when in-person consultations are challenging, such as COVID-19. This innovative approach utilizes telecommunications technology to facilitate remote diagnosis, treatment, and management of various dermatological conditions. In this chapter, we aim to explore the current landscape of telemedicine in dermatology, discussing its applications, benefits, challenges, and future directions.

2. What is telemedicine?

Telemedicine involves health services supported by telecommunication and electronic technologies [1]. It is defined by the World Health Organization (WHO) as “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” [2].

The evolution of telemedicine spans many years, starting from the creation of the telegram, which served as a communication medium in its time, followed by the emergence of radio and telephone, both of which played significant roles in medical telecommunications. This journey includes the visionary concept of Hugo Gernsback, a renowned science fiction writer, who foresaw the potential of radio in providing remote medical care, as depicted in his work “The Radio Doctor – Maybe” [3, 4]. Additionally, figures like Gerson Cohen contributed to this evolution with innovations such as teleradiology, as described in his publication detailing a three-year experience of transmitting radiographs using commercial telephone lines between a clinic in Atlantic City and a county hospital in Philadelphia [5, 6].

Described in 1999 as “the use of telecommunications and computer technology to offer medical information and services remotely” [7], telemedicine has been studied over the years and is recognized as a method of delivering healthcare services via the Internet, typically utilizing the video conferencing technology [8].

From 2000 to the present day, there has been a rapid evolution in technology, including hardware such as smartphones, tablets, and telemedicine devices, as well as software like mobile applications, and improved connectivity through cellular and broadband networks. This technological progress has led to the development of various telemedicine devices, making remote care more accessible. The widespread adoption of smartphones has enabled consumers to access healthcare services conveniently through portable devices [1, 4, 9].

Furthermore, telemedicine’s applications extend to various other areas, such as virtual medical appointments, remote chronic disease management, and telepharmacy services.

2.1 Teledermatology

Teledermatology utilizes telecommunications and information technologies to diagnose, monitor, treat, prevent, conduct research, and provide education remotely [3], involves remote consultation and treatment of patients with skin diseases by healthcare providers, and has become more acknowledged as a vital aspect of healthcare provision.

The majority of teledermatology research has been conducted particularly during the COVID-19 pandemic [10, 11]. Since then, numerous reviews and studies have been developed on this topic. In one such study conducted by Kennedy J. et al., it was revealed that 96.9% of the 591 dermatologists surveyed provided virtual consultations in 2020 [12].

There are four primary teledermatology practice models [13, 14]:

• Consultation: refers to the process where the referring physician seeks advice or guidance from the dermatologist concerning the patient’s skin condition.

• Triage: where doctor can determine the priority of management and referrals.

• Direct care: doctor directly interacts with patients, either through video conferences or by patients sharing images of their skin lesions.

• Follow-up: where doctor can monitor the progress of the skin condition and how it responds to treatment over time.

Telemedicine, evolving within the field of dermatology, includes three primary applications: synchronous, asynchronous, and hybrid platforms [15, 16].

• Synchronous: utilizes real-time audio/video conferencing for direct interactions between patients and dermatologists and was the predominant approach during the pandemic [17]. This method provides a more personalized interaction similar to in-person consultations, enabling dermatologists to promptly gather information about patient symptoms and medical history [13].

• Asynchronous: involves patients forwarding clinical history and images directly to dermatologists through intermediary referring providers. It does not involve live teleconferencing and is often used for triaging, consultations, or follow-ups. A key advantage of this model is its flexibility for both dermatologists and patients, eliminating the need to schedule a specific time for communication, especially useful across different time zones [3, 13].

• Hybrid models: incorporate both approaches, enabling direct synchronous interactions for gathering patient history and providing education, while also facilitating the asynchronous transmission of high-quality images to ensure precise evaluation. It helps to solve problems with both methods by giving dermatologists a quick chat with the patient or doctor and also a clear picture of the skin problem [11, 13].

Each approach has its own characteristics and advantages, addressing the specific needs of both patients and dermatologists (Table 1).

Type	Advantages	Disadvantages
Synchronous	Real-time communication between the doctor and the patient. Experience more similar to face-to-face consultation. There is no separation in time.	Needs prior arrangement to agree to an appointment-convenient time. Requires high-speed internet access – connectivity issues The quality of videos may not match that of static images
Asynchronous	The patient has the option to capture a static image of the skin disease. Gives flexibility to the doctor and patients. It does not require appointments or specific times. Enables doctor to examine the image at a later time without disrupting their workflow.	There is no real-time communication; so, the doctor may be unable to resolve any unclear details in the patient’s medical history. Delays in communication.
Hybrid	Offering to the doctor a time-efficient consultation with the patient. Can offer high-quality image of the dermatological disease.	It can become expensive when multiple platforms are needed.

Table 1.

Advantages and disadvantages of each type of teledermatology.

The main features evaluated in teledermatology are accessibility, accuracy, cost-effectiveness, informed consent, and data security [13]. Accessibility is vital, facilitating patients to receive diagnosis and monitoring at home, while reducing exposure risks [18, 19]. Accuracy is comparable to face-to-face consultations, with studies demonstrating high diagnostic precision as we will talk about later [20]. Teledermatology proves cost-effective by reducing inpatient visits, transportation expenses, and lost productivity, particularly during the pandemic [21, 22]. Informed consent is essential, requiring patients to understand teledermatology features and data security policies, although debates persist on the method of obtaining consent [23, 24]. Data security measures, including pseudo anonymization and encryption, are crucial to safeguard patient privacy [13].

The accessibility and convenience offered by telemedicine have revolutionized the delivery of dermatological care, breaking down geographical barriers and improving patient access to specialists. Patients can now receive timely consultations and follow-ups without the need for travel, reducing both costs and logistical challenges associated with traditional healthcare delivery.

2.1.1 Teledermatology in specific diseases

Existing evidence confirms the diagnostic precision of teledermatology and its effectiveness in treating conditions, such as acne, atopic dermatitis, psoriasis, hair disorders, and even skin cancer [15].

In the context of acne, teledermatology has been extensively studied, especially using synchronous and asynchronous telemedicine [15, 25]. During the pandemic, teledermatology in acne management played a significant role, with a majority of visits conducted remotely. Studies have indicated a strong correlation between in-person and digital diagnosis of acne severity, demonstrating positive clinical outcomes with teledermatology. Prescription of isotretinoin via teleconsultations yielded mild adverse effects, with outcomes comparable to in-person visits [26, 27].

Another area of focus in teledermatology is atopic dermatitis (AD), showing promising results in the management of AD, with high diagnostic concordance rates and positive clinical outcomes observed across various studies [10, 15, 28]. Research indicates that both asynchronous and synchronous teledermatology approaches are effective in diagnosing and monitoring AD, with equivalent improvements in disease severity and patient-reported outcomes compared to in-person visits [29, 30]. Additionally, teledermatology has been recommended by leading medical organizations for its utility in therapeutic education, severity monitoring, and facilitating patient communication in AD management.

Moreover, telemedicine has been recognized as a valuable alternative for psoriasis follow-ups, particularly synchronous and asynchronous teledermatology [31, 32]. Studies have shown that teledermatology yields similar or superior efficacy in improving Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) scores compared to traditional in-person consultations [33]. Additionally, teledermatology has been associated with greater improvements in patient-physician relationships and treatment compliance [34]. Overall, teledermatology serves as a beneficial tool for monitoring systemic therapies, enhancing treatment adherence and improving clinical outcomes in psoriasis.

Despite the extensive exploration of teledermatology in managing various dermatological conditions such as those named before, a few studies have explored telemedicine’s role in alopecia. A systematic review was conducted [35], analyzing 11 studies comprising 9622 patients, the majority of whom suffered from androgenetic alopecia (AGA), with telemedicine showing high diagnostic accuracy and positive outcomes. Notably, tele-trichology evaluation, coupled with telemedicine, aids in diagnosis and treatment initiation, particularly for alopecia areata (AA) and patients with AA undergoing specific treatments with Janus kinase (JAK) inhibitors [35]. Although teledermatology offers accessible care, its utilization for alopecia remains relatively low compared to other conditions.

In summary, teledermatology has demonstrated its effectiveness in diagnosing and managing a wide range of dermatological conditions. The utilization of synchronous and asynchronous telemedicine during the pandemic has highlighted its importance in providing remote care, with positive clinical outcomes observed across various studies.

2.2 Benefits and challenges of teledermatology

As mentioned before, teledermatology has positively transformed dermatology consultations by providing patients worldwide with increased access to specialized healthcare services. This form of consultation not only benefits patients in rural areas but also reduces waiting times for appointments with specialists such as a dermatologist [36]. It is well known that, for rural patients, it is expensive to assist for consultation in urban areas where most of the dermatologists are placed, so teledermatology could help reduce transportation, alimentation, and accommodation costs for these patients and their families. On the contrary, it would prevent patients or their families from wasting time traveling to medical appointments, which sometimes lead to them being absent from work, sometimes worsening their economic condition [37]. There is evidence to confirm where it was found that, by increasing telemedicine services, the coverage of patients who, due to mobility problems or lack of money, could not access in-person appointments expanded, which led insurance companies to include telemedicine in their plans [38].

It has been demonstrated that when using teledermatology, you could not only decrease time to diagnosis and treatment but also make patient follow-up timely and safe [37]. When holding medical meetings where difficult cases are evaluated, we could have dermatologists from different parts of the world to participate in important decisions, especially when it comes to diagnoses and treatments that would benefit patients. Barbieri JS et al. concluded in their study that teledermatology is a potential triage tool to classify cases into nonurgent versus emergent cases requiring immediate in-person consultation [39].

Regarding the barriers to teledermatology, they are still present in both developing and developed countries. Among them is the limitation of having equipment in good condition, with internet networks that cover all national territories and specifically speaking of dermatology, it would be having good image quality to properly evaluate each patient, especially when evaluating pigmented lesions [36]. Clemens Scott Kruse et al. made a systematic review where they evaluated barriers to adopting telemedicine worldwide, and they found about 33 barriers that they grouped in: organizational barriers, patient-related barriers, and staff and program barriers [40]. Also, it is important for countries to stablish some regulations and public policies to ensure medicolegal responsibilities and privacy issues when making consultations via telemedicine to increase the safety of the patient and the treating doctor.

Regarding the privacy and security of doctors as well as patients, it is important that medical consultations are carried out via applications that are encrypted and that they are applications that are only used as a medical communication tool, thus avoiding access to information to third parties, which would allow both doctors and patients to have peace of mind when making consultations via telemedicine [40].

Additionally, countries and medical insurance companies should make regulations to ensure the privacy of both doctors and patients during medical consultations. This includes prohibiting the use of patient images, videos, and personal information for purposes other than the consultation itself. It must implement secure equipment for data transmission, which should undergo continuous evaluation and include encrypted systems with restricted access to information. In the article by P. J. Gómez Arias et al., fair measures for telemedicine use in Spain are described. Changes to the codes of ethics were made to facilitate appropriate telemedicine practices. Patients are required to sign informed consent allowing virtual evaluation [41].

Finally, we summarize in Table 2 the advantages and disadvantages of teledermatology.

Advantages

Disadvantages

Faster and cost-effective Increases patient access to specialized health services such as dermatology Useful for patient triage High patient and physician satisfaction High diagnostic accuracy Collaboration with other colleagues Eliminates geographical barriers, facilitating access for patients to dermatologists worldwide Tool to help educate patients and health workers Minimize traveling of patients

Requires good access to internet and good equipped technology Not a full-body examination, so it can lead to miss incidental lesions Cannot palpate lesions Reimbursement is poor Poor quality images sent by patients Dermoscopy cannot be used Fraud and abuse Cases of misdiagnosis Confidentiality Patient privacy Lack of regulations and public policies for telemedicine

Table 2.

Advantages and disadvantages of teledermatology.

2.3 Future trends in teledermatology

Recent developments in telemedicine technology leverage artificial intelligence (AI) to enhance physicians’ efficiency [1]. AI refers to a machine’s ability to independently solve problems, while machine learning (ML) employs algorithms to derive desired output data by identifying patterns and relationships within input data. Data can be provided to algorithms in two main ways: supervised learning, where both input and output data are labeled, and unsupervised learning, which involves training algorithms with unlabeled data. In dermatology, supervised learning is predominantly used due to its image-centric nature, where recognizing structures within images is predominant [42].

Studies comparing dermatologists to machine-learning algorithms showed computer algorithms were superior to clinicians in diagnostic accuracy for pigmented skin lesion [43]. Phillips et al. conducted a study on a deep learning algorithm for identifying melanoma. Their results showed that the AI achieved better recognition of melanoma compared to dermatologists and significantly outperformed primary care physicians [44]. These new advances will make it possible to help dermatologists with the monitoring and diagnosis of tumors such as melanoma.

As is known, skin lesions can vary depending on the skin phototype and can sometimes confuse the dermatologist when making diagnoses, but, with the help of artificial intelligence this could be minimized since in the study carried out by Groh, Matthew et al. where they concluded that well-designed physician-machine partnerships can enrich the diagnostic precision of physicians [45]. Moreover, mobile applications are also improving telemedicine, and in a study made in Colombia by Juan Pablo Sáenz et al., the authors concluded that the adoption of a teledermatology approach utilizing mobile applications and a domain-specific ontology-driven knowledge base aims to offer prompt support to healthcare professionals such as a general practitioner who answers dermatological consultations in rural areas where dermatologists are not available [9].

For instance, Mohammed Saleh Al-Dhubaibi et al. detail a case of cutaneous larva migrans in a 35-year-old female patient who presented with a serpiginous skin lesion on her left ankle, where clinical suspicion led to the diagnosis and albendazole treatment was prescribed, all of these using the “AskUrDr-For-Doctors” online medical application (Figure 1) [46].

Figure 1.

Screenshot of the mobile application “AskUrDr-For-Doctors” only available in the country of application development.

Another study on teledermatology and applications, conducted by Tassilo Degel et al., systematically evaluated mobile applications available in German or English for patients with chronic wounds. Out of 118 identified applications, 10 were patient-oriented. Following exclusion criteria, three applications underwent evaluation, with WUND APP (Figure 2) emerging as the top-rated option [47].

Figure 2.

Screenshot of the mobile application.

In conclusion, the implementation of new applications with teledermatology together with AI could screen large numbers of patients, sending those with distressing lesions to a dermatologist on time and discharging those with benign lesions earlier, decongesting the health system and thus giving priority to those who truly need a priority assessment with specialists like dermatologist [42].

3. Conclusions

Telemedicine is an expanding field that utilizes technology to facilitate the provision of healthcare services remotely to a wide variety of individuals in various locations. Within this domain, teledermatology stands out as a valuable tool for diagnosing and managing a wide spectrum of dermatological conditions. Furthermore, teledermatology serves as a potential triage mechanism, distinguishing between nonurgent cases and emergent cases necessitating immediate in-person consultation. Moreover, teledermatology holds promise in reducing costs for patients and their families while also overcoming geographical barriers, thereby enhancing patient access to dermatologists worldwide. Integrating teledermatology with artificial intelligence (AI) could further speed up the process by screening large volumes of patients and promptly referring those with concerning lesions to dermatologists for rapid assessment. In summary, teledermatology represents a powerful resource with the potential to revolutionize the delivery of dermatological services, making care more accessible, efficient, and impactful for a broader population.

Conflict of interest

The authors declare no conflict of interest.