Teledermatology

Issues of Concern

Real-time teledermatology involves a live video consultation with the patient. In contrast, in store-and-forward teledermatology, the patient's images are transmitted to the teleconsultant as the first step, followed by the consultant giving a relevant plan of action regarding diagnosis or management. Hybrid teledermatology combines elements of "real-time" and "store-and-forward" teledermatology. Teledermatology using mobile phones is referred to as mobile-teledermatology. Extensions of teledermatology include teledermoscopy, in which doctors consult on dermoscopic images transmitted electronically, and teledermatopathology, or telecytology, in which dermatopathology or cytology images are transmitted.

Teledermatology has grown in potential over the last 2 decades. The inherent visual nature of dermatology makes it ideal for the practice of telemedicine. The US Department of Defense has been 1 of the pioneers in developing teledermatology protocols adapted to develop civilian programs.

Systematic literature reviews have shown that teledermatology is most commonly used for patient management, patient consultation in remote locations, or medical support in nursing homes and home care settings. Based on published data, the practice of teledermatology is the highest in North America and Europe. Countries with a lower physician-to-patient ratio seem to be underrepresented in teledermatology practice. In general, telemedicine is considered cost-effective, although systematic reviews have suggested that more rigorous studies are required to study the economic aspects of telemedicine.

Related Concepts

Telepathology and Telecytology 

Telepathology and Telecytology combine clinical data with high-quality, supporting pathology and cytology data to improve the diagnostic capability of teledermatology. Teledermatopathology has become more feasible and effective because of advances in digitizing histopathology slides and the development of robot-assisted microscopy.

Teledermoscopy

Dermoscopic patterns are well-established for many dermatological conditions, especially skin malignancies. The combination of clinical teledermatology with teledermoscopy has been shown to improve the effectiveness of teledermatology consultations. Teledermoscopy enhances the triage of teleconsultations involving a possible diagnosis of malignancy. Direct, patient-initiated teledermoscopy is also acceptable and effective in triage and early detection of skin cancers.

Teledermatology in the context of aesthetic medicine

The advantage of using teledermatology in the context of aesthetic medicine is that it usually involves conditions that are not emergencies or life-threatening situations. Teledermatology can be used for the initial diagnosis of aesthetic conditions and follow-up with aesthetic patients, especially postprocedure, such as monitoring patients who have undergone laser resurfacing.

Smartphone teledermatology/mobile teledermatology

One of the limitations of teledermatology during the early years of practice was the relatively cumbersome and expensive equipment required to exchange data. Technology has improved the quality of image capture, storage, and transmission of clinical images using smartphones. Smartphones can also be easily connected to internet networks. Smartphone-based teledermatology and teledermoscopy are effective in diagnosing and triaging dermatological conditions, including malignancies. The ease of use also makes smartphone teledermatology the ideal tool for patient-initiated teledermatology. An extension of the practice of teledermatology using smartphones is the use of social media platforms to discuss dermatology cases. The advantage of these platforms is that more doctors can view and comment on clinical cases in both the context of diagnosis and management.[3][4][5][6][7]

Effective teledermatology requires good infrastructure on both sides of the consultation. Often, remote areas have poor infrastructures and lack image capture devices and internet connectivity, reducing clinical data quality. All practitioners involved in teledermatology must have basic training related to dermatological imaging and dermatology nomenclature. A proper electronic medical record system, including linked image storage, is integral to teledermatology. The practice and extent of maintaining electronic medical records show significant variations worldwide. Standardizing dermatological imaging and related electronic medical records would be an important part of improving the quality and effectiveness of teledermatology practices.

Clarity regarding the legal and ethical issues, especially related to the confidentiality of patient data, must be established globally. The referring site should obtain informed consent to take images and take the time to explain to the patients how the images are used thoroughly.[8][9][10]

Clinical Significance

Studies have shown good patient satisfaction and diagnostic concordance for teledermatology compared to face-to-face consultations. Teledermatology can be an effective triage tool, reducing referral times, even in cutaneous malignancies, especially in combination with teledermoscopy. While teledermatology classically involves outpatient dermatology, studies have shown that it can also be an effective and useful tool in inpatient dermatology. Teledermatology has also been useful in treating chronic skin diseases, including chronic ulcers.[11][12]

The basic concepts of teledermatology have been used effectively in dermatology teaching and residency programs. Effective use of telemedicine can help get expert faculty involved in cost-effective teaching programs. Teledermatology provides educational benefits to participants like primary care providers and dermatologists. Teledermatology has also been effective in other procedures, such as reading patch tests.

Patient-Initiated Teledermatology

At present, the 4 common types of business models used in teledermatology practice include (1) standard fee-for-service reimbursement from insurance, (2) capitated service contracts, (3) per-case service contracts, and (4) direct-to-consumer. Patient-initiated teledermatology, which provides direct consultation and the ability of physicians to follow up on dermatology patients, has become increasingly popular; however, research and evidence for the effectiveness of these are limited. Patient-initiated teledermatology also enables patients to get more involved, actively managing their health through direct communication with dermatologists. As the quality of image-capture devices, especially smartphones, increases, the effectiveness of patient-initiated teledermatology should improve. Recent studies have shown that patients themselves can take accurate, high-quality dermoscopic images at home, enabling them to combine skin self-examination with patient-initiated teledermoscopy. This, in turn, can improve the quality of the teledermatology consults; however, standard protocols for imaging must be explained to the patients for this to be effective. The development of business models related to patient-initiated teledermatology must consider issues related to financial reimbursement for the consultants and legal and ethical issues.[13]

Strong evidence shows that teledermatology is effective in earlier diagnosis and triage of skin diseases. Still, practitioners need to consider regional legal frameworks while practicing teledermatology.[6][14][15][12]