Henry L. Lee, MD, PhD

The world is still adjusting to the aftermath of the truly unprecedented pandemic caused by the coronavirus SARS-CoV-2. Time stood still during the height of the pandemic, and the world, including the field of medicine, is now forever changed. There are a few silver linings to the pandemic, including a welcome focus on healthcare access and outcomes disparity that was cruelly highlighted by the pandemic. Telemedicine, yet another positive development that was quickly embraced directly because of the pandemic, has revolutionized the practice of medicine, and my field of dermatology is no exception. Our department saw an explosion in video visits almost overnight, from essentially zero visits in 2019 to a height of over 9,000 visits in 2021, and has now settled to a stable 5,000-plus visits in 2023, accounting for approximately 7% of all visits. This trend reflects a broader shift, as telehealth usage in dermatology across the United States surged by 210 fold among Medicare Part B beneficiaries from 2019 to 2020 (Gronbeck et al., 2022).

Advantages of Teledermatology 

One of the primary advantages of telemedicine in dermatology is the convenience and access it offers patients. Through video visits, patients can access their dermatologists without the need to travel long distances or take time off of work. This is particularly beneficial in cases where patients need quick consultations or medication refills. A recent review examined 15 studies on patient and provider satisfaction with teledermatology and found overall satisfaction with the experience, quality of care and level of increased access (Miller et al., 2022). Additionally, in an era where appointment wait times can be lengthy, telemedicine provides a more immediate option for triaging patients, allowing dermatologists to prioritize those who need urgent in-person care.

For patients with established chronic diagnoses, telemedicine simplifies routine follow-up appointments. For example, individuals with acne who are on isotretinoin are required to have monthly medical visits, potentially with blood tests. Video visits coupled with laboratory visits from third-party laboratory facilities have eliminated the need for cumbersome monthly in-person visits, thereby reducing the burden on the healthcare system. In fact, the majority of my patients with chronic conditions—such as autoimmune blistering conditions, psoriasis, and atopic dermatitis—that require systemic medications like immunosuppressants can be managed primarily via video visits. Studies have shown that telemedicine can reduce no-show rates. One such study of a center in New York City revealed that the combination of both in-person and video visits led to nearly a 40% reduction in no-shows compared to providing solely in-person visits (Cline et al., 2021).

Another possible advantage of telemedicine is the potential cost savings it may provide to our already taxed health care system. Video visits clearly save patient lost work time and increase worker productivity. Several studies have set out to examine the potential cost-effectiveness of teledermatology versus face-to-face visits. An analysis of 8 such studies found that all eight studies demonstrated lower costs with teledermatology (Lopez-Liria et al., 2023). 

Limitations of Teledermatology

However, telemedicine in dermatology is not without its challenges. The quality of the video resolution can be a limiting factor, especially when evaluating skin conditions that require detailed visualization. To address this, many dermatology departments, including ours, request that patients submit high-resolution close-up and general photographs prior to their video visit. This augments the video consultation, providing the dermatologist with a clearer view of the patient’s skin condition.

Certain anatomical sites, such as the scalp, can be particularly difficult to assess via telemedicine. Hair loss, for instance, often requires a detailed examination that cannot often be adequately addressed via video visits. Through experience, our department has now developed a policy requiring that initial visits for hair loss be conducted in person. Similarly, the examination of sensitive areas like the genitals creates, at best, an awkward interaction and poses privacy-related challenges, which leads me to triage these visits to in-person visits.

Clearly, an obvious deficit of video visits is the inability to perform procedures. For example, an inflammatory rash requiring a simple skin biopsy would require a follow-up in-person procedure visit to perform the biopsy. I, however, have found this to not be a critical issue, as the expedited video visit and ensuing in-person biopsy lead ultimately to much more timely biopsy and medical care.

Technical difficulties, including issues with user interface navigation and internet connectivity, can also hinder the effectiveness of telemedicine. Additionally, current geographic restrictions require that patients be physically located in a state where the physician is licensed to practice—a regulation that complicates care delivery. During the height of the COVID-19 pandemic, these restrictions were temporarily lifted, allowing physicians to treat patients regardless of their location. However, the reimplementation of these geographic boundaries seems counterintuitive to our mission to treat and help our patients. The absurdity of these restrictions is highlighted by a recent visit in which my patient  was travelling on a private jet and was unsure of her current state airspace, raising logistical concerns about whether the consultation could proceed.

Conclusion 

Despite these limitations, telemedicine is an incredibly powerful tool for medicine and particularly dermatology. It has become an integral part of our department’s practice. When used for appropriate cases, it is an invaluable tool that enhances patient care and extends the reach of our dermatology services. Studies have shown that teledermatology can achieve diagnostic accuracy rates comparable to in-person visits, with one review, which examined 44 studies, reporting an 71% concordance rate between video visits and in-person visits for dermatologists (Bourkas et al., 2023). Looking forward, there is always the potential for further advancements, such as the development of photograph centers in primary care offices or pharmacies. These centers could provide high-resolution, in-focus images, and even dermoscopic images, which allow for a more detailed evaluation of the lesion and microstructures of the superficial skin that is not possible with the naked eye. Such innovations would further enhance the accuracy of teledermatology. Another technology platform is asynchronous photo-based visits, in which a photo is submitted and the dermatologist at a later time examines the photo and provides an assessment and plan. In our institution, such photo based visits are limited to consultations from other physicians. Ultimately, I would like to see patient initiated asynchronous photo-based visits covered by insurances and thus more aggressively utilized, thereby creating essentially a correspondence-based asynchronous “televisit.” The emergence of artificial intelligence (AI) coupled with incredible image databases also suggests the possibility of AI mediated image based diagnoses, potentially drastically reducing unnecessary dermatology consultations. In all of its iterations, technology-based non-in-person visits have extended the reach of dermatologists and have led to shortened wait times. We need to ensure that teledermatology, in its current and its future forms, is readily available and easily accessible to all of our patient populations, regardless of socioeconomic, education or racial background.  As we continue to refine telehealth and its accuracy and safety, society and insurances need to more aggressively embrace telemedicine in all of its forms, thereby increasing access to quality medical care and improving health-care equity.

1. 1. Gronbeck C., Grant-Kels J.M., Lu J., & Feng H. (2022). Increased Utilization of Teledermatology Among Medicare Part B Beneficaries During the COVID-19 Pandemic.Clin Dermatol, 40(6), 760-763.
   2. Miller J, Jones E. (2022). Shaping the future of teledermatology: a literature review of patient and provider satisfaction with synchronous teledermatology during the COVID‐19 pandemic. Clin Experimental Derm, 47(11), 1903–1909.  
   3. Cline A., Gao J.C., Berk-Krauss J., Kaplan L., Bienenfeld A., Desai A., Huang A., Bleicher B., Chopra R., Shukla S., Caleb J., Rodriguez B., James N., & Marmon S. (2021). Sustained Reduction in No-Show Rate with the Integration of Teledermatology in a Federally Qualified Health Center. J Am Acad Derm, 85 (5), e299-e301.
   4. Lopez-Lira, R., Valverde-Martinez, M.A., Lopez-Villegas, A., Bautista-Mesa, R., Vega-Ramirez, F.A., Peiro, S., & Leal-Costa, C. (2023). Teledermatology Versus Face-to-Face Dermatology: An Analysis of Cost-Effectiveness from Eight Studies from Europe and the United States. Int J environ Res Public Health, 19(4), 2534.
   5. Bourkas A.N., Barone N., Bourcas M.E.C., Fraser R.D.J., Lorincz A., Wang S.C., & Ramirez-GarciaLuna J.L. (2023). Diagnostic Reliability in Teledermatology: Systematic Review and a Meta-Analysis. BMJ Open, 13(8).

 

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