Telemedicine in Dermatology

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).

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.

2.2 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.

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].

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].

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].