Using a mix of new technologies, teledermatology is changing how dermatologists provide care during the pandemic

• The pandemic has quickly illuminated teledermatology's specific applications.
• A hybrid approach may ensure the capture of high-quality images for evaluation.
• Advances in technology may expand the types of skin conditions assessed with teledermatology.

Increased reliance on teledermatology during the COVID-19 pandemic has not only helped patients avoid contracting infection but it's also given dermatologists a better understanding of how to best employ the technology in daily practice.

"Teledermatology has definitely become more important during the pandemic and has allowed us to keep delivering effective care to our patients while they are in the safe environment of their homes," Dr. Trilokraj Tejasvi, chair of the American Academy of Dermatology teledermatology task force, chair of the American Telemedicine Association special interest group for teledermatology, and associate professor of dermatology and director of teledermatology at the University of Michigan, said.

As the field scaled up teledermatology in March of 2020, dermatologists quickly learned that the technology has specific applications, Dr. Joseph C. Kvedar, chair of the ATA board of directors, professor of dermatology at Harvard Medical School, and senior advisor of virtual care at Mass General Brigham, said. Patient selection is critical to the success of teledermatology, as is knowing the limitations of some available technologies, he said.

When using teledermatology, understanding the typical workflow of patient care and adhering to HIPAA regulations are also key, Tejasvi said. He adds that professional societies such as the AAD and the ATA offer a variety of online teledermatology educational tools on these topics to their members.

Workflow and HIPAA compliance

Some appointments managed via teledermatology consist of an asynchronous approach with an initial online questionnaire or intake form about medical history and symptoms, Tejasvi said. Patients then take photos of their skin concerns with a smartphone and send images through the online patient portal.

A photo review by the dermatologist is followed by a video telehealth visit with the patient to collect more nuanced information and to provide a diagnosis and recommendations, Tejasvi said. Dermatologists may also prescribe necessary medications and give additional at-home care recommendations.

Video visits have gained popularity during the pandemic because of real-time interaction. However, with the lack of high-quality, static images available through video, a hybrid approach using synchronous and asynchronous elements is becoming the new normal, Tejasvi said.

"You need to use HIPAA-compliant software, whether it is through a system-wide portal or you're using some private party software," Tejasvi said. "Patient privacy is paramount."

Careful patient selection

Patients best suited for teledermatology include those with acne, eczema, psoriasis, or wounds, Kvedar said. These patients may occasionally need to go into a lab for blood work to monitor medications, with follow-up visits via telehealth.

In contrast, patients with skin cancer need in-person visits about every six months to a year, Dr. Kvedar said. Video conferencing apps on phones and laptops are not high enough resolution for this type of monitoring.

However, someone with a new skin growth might be initially evaluated via a teledermatology appointment using photos sent to the patient portal, Kvedar said. Dermatologists can then determine whether the patient needs immediate, in-person follow-up or can wait for a regularly scheduled appointment.

Mole mapping technology is advancing

While teledermatology currently isn't ideal for evaluating suspicious lesions, high-resolution digital photography has helped with mole mapping in the clinic, Dr. Adam Mamelak, a dermatologist in private practice in Austin, Texas, said. By using high-resolution photos to track moles over time, dermatologists can better recommend interventions, diagnostic testing, and treatment.

High-resolution, total body photography and dermoscopy, or microscopic examination of the skin surface, combined with artificial intelligence is an impressive advance in mole monitoring, Tejasvi said. However, the technology is cost-prohibitive because of the lack of reimbursement and may require more square footage than practices or institutions want to dedicate to the hardware required. Some patients with a history of melanoma or with more than 100 moles may want to pay out-of-pocket for these services.

Cloud-based systems and apps on smartphones can now run AI interpretations of moles and pigmented lesions, Mamelak said. In some cases, these apps can make patient self-evaluations more accurate, he said. Triage is one such example. "I predict that many of the larger hardware-heavy systems will become obsolete as the mobile apps become more developed," he said.

AI's application to dermatology will be manifold, but it will also help primary care doctors triage patients for dermatology referral, Kvedar said, who is an adviser to LuminDx, which is developing such a system. "I think that's the next phase of care we need to prepare for."