Pros and cons of teledermatology

| Melissa Leavitt

When people travel to the East African nation of Uganda, they often hope to snap a photo of an elusive mountain gorilla. For some, spotting a majestic silverback can be a life-changing experience.

When Dr. Jules Lipoff, a dermatologist at the University of Pennsylvania, traveled to Uganda, he took pictures of something else. In his case, it was a life-changing experience for the ones being photographed.

Lipoff completed part of his medical training in rural Uganda where, he said, there are high rates of HIV and skin diseases. To ensure his new neighbors got the best care possible, he began taking pictures of their skin disorders and emailing them to his dermatology professors back home.

What Lipoff was doing — using photographs and the web to get medical care from a dermatologist in another location — is called teledermatology. A branch of telemedicine, teledermatology is an increasingly common way for patients to communicate with their providers and for doctors to communicate with each other.

When used as an extension of ongoing, in-person care, teledermatology helps ensure that everyone, regardless of where they live, has access to the trained skin specialists they need.

“You don’t necessarily have to work halfway across the world to see problems with access to care and how we can make it work for people at home,” said Lipoff, who is now a member of the American Academy of Dermatology’s Telemedicine Task Force.

Teledermatology can take many different forms, explained Dr. April Armstrong, a dermatologist at the University of Southern California in Los Angeles and a member of the National Psoriasis Foundation Medical Board.

Primary care providers can use it to communicate with a dermatologist about a patient’s skin problem and get a recommendation on the best approach. Or a patient can use it to communicate directly with a dermatologist when time, distance or cost make an in-person appointment difficult. Armstrong, who has extensively studied this patient-to-provider form of teledermatology, calls it “direct care.”

Some dermatologists offer direct care through email, texts or other services. People can also obtain direct care teledermatology through web-based platforms not associated with a brick-and-mortar clinic.

“Traditionally, we’ve applied the model to patients who live far away because geographically, they’re at a disadvantage in terms of receiving quality derm care on a consistent basis,” said Armstrong, adding that some of her patients take multiple buses through Los Angeles traffic to see her.

But distance isn’t the only barrier to in-person care.

Dr. Mark Seraly, a dermatologist near Pittsburgh, Pennsylvania, said that teledermatology can also be helpful for people who can’t afford in-person care, or who don’t have the flexibility to take time off from work or school.

Seraly is the founder of DermatologistOnCall, a web-based teledermatology platform that provides direct care. DermatologistOnCall launched a partnership with NPF’s Patient Navigation Center in August 2016.

A picture-perfect fit for psoriasis?

In many ways, telemedicine was made for dermatology. Making diagnoses based on photographs has always been part of the dermatologist’s routine.

“We’re trained by looking at things, looking at images; we take our board [exams] that way,” said Seraly.

When it comes to psoriasis, research indicates that teledermatology has a particularly good track record.

“Studies have shown that people can assess psoriasis images in photographs quite well, and assess the degree of severity and make clinical decisions quite well,” Armstrong said.

Armstrong was lead author on a study, published in June 2012 in the Journal of the American Academy of Dermatology, comparing the quality of care given to psoriasis patients seeing their dermatologist for follow-up exclusively online to quality of care for patients having in-person follow-up.

Results indicated that patients in both groups experienced similar improvements in skin and quality of life, with no significant differences between the groups.

For a chronic condition like psoriasis, which requires frequent check-ups, communicating online with your doctor between appointments can be particularly helpful. Armstrong said the online option actually encourages patients to have more regular check-ins with their doctor.

I can't remember what my doctor said!

Melissa Withem Voss, of Lake County, Illinois, developed psoriasis in her 20s.

She has regular in-person appointments with her dermatologist but likes using her doctor’s online portal to touch base between visits. When she emails her dermatologist, she hears back within 24 hours.

For her, that beats trying to reach her care team by phone. She uses email to ask questions she didn’t have time for during the appointment. That way, she can gather her thoughts and make sure she’s getting the information she needs.

“When you’re in an appointment, you can be rushed, because the doctors are behind — or you’re in a rush because they’ve taken too long to get to you,” Voss said.

But aside from convenience, there’s another reason Voss uses teledermatology — she’s almost completely deaf, which makes it difficult for her to process comprehensive information during a quick conversation.

“I’m more apt to send an email to the physician just because understanding them back is less difficult,” she said.

Over the past few months, online communication has become an essential part of her treatment plan. She’s been dealing with severe psoriasis for decades. “I have been, at times, covered on 97 percent of my body,” she said.

But that changed in December 2016, when she tried a biologic called Taltz (ixekizumab) that gave her clear skin.

The change is so dramatic that, for the first time in decades, she’s feeling sensations on her skin — different textures, for instance, like the silky feeling of fur when her dog brushes past her — that her thick plaques prevented her from feeling before.

It’s important to her do everything she can to make sure she stays on top of her treatment. That would be a lot harder without teledermatology.

Voss said that, perhaps because Taltz is a new medication, her pharmacy can’t always answer questions about potential side effects or the way Taltz might interact with other medicines she takes. She emails questions to her doctor instead.

“I like to send messages back and forth trying to figure out, ‘OK, is it safe to take a Tums if I have heartburn?’” she said.

She also emailed a picture when her skin started to improve. Before she started her new treatment, her back was completely covered in plaques. But after she began taking Taltz, her psoriasis came to resemble an hourglass, with her skin clearing toward the edges of the middle of her back.

That’s a tough image to describe. But a picture was worth a thousand words.

“[My doctor’s office] contacted me back, and they were like, ‘This is fantastic! We’re anxious to see how far it gets by the time we get to your three-month appointment,’” Voss recalled.

Helping patients manage medication is one of the most beneficial uses of teledermatology. A team of researchers in Austria developed a teledermatology system specifically for psoriasis patients who take a biologic. The system helped doctors monitor for side effects and track changes in disease severity.

A few days before patients were scheduled for a dose of the drug, the system sent a questionnaire asking about the status of their disease and other health concerns. Patients answered the questionnaire and uploaded a photo of their skin.

Results from the study, which involved 19 patients, were published in August 2011 in the journal Acta Dermato-Venereologica.

On average, it took a little more than a day for doctors to review the data and send recommended changes to treatment. Most of the people involved in the study found the services to be helpful and said they would recommend them to a friend.

Why face-to-face is still preferred

For many people, getting medical care online is a natural extension of their everyday use of technology. Taking high-quality photos is easier than ever, and web applications are revolutionizing the way we get services.

“There are a lot of paradigms that have been overthrown through tech — like Netflix changing the way we get our movies, or Uber changing how we get on-demand rides,” said Lipoff.

But the comparisons between teledermatology and these services can only go so far, he added.

As people with psoriasis explore teledermatology options with their provider, it’s important to remember that, in many situations, teledermatology simply can’t provide the same quality of care as in-person visits.

Scalp psoriasis is one example. “It’s very difficult to image scalp lesions, no matter how good a photographer you may be. Estimating the severity in the scalp is very difficult,” Armstrong said. Skin cancer screenings should also be conducted in person, she added.

No matter the situation, teledermatology is most useful when it’s only one component of an ongoing relationship with your doctor. Teledermatology services should never disrupt that relationship.

“We consider teledermatology not as a replacement but as an adjunct to other existing modes of delivering care,” Armstrong said.

That’s especially important to remember if you’re considering using a web-based teledermatology platform that doesn’t include your usual health care team. Getting an accurate diagnosis from someone who doesn’t know your medical history, or who hasn’t seen you in person, isn’t easy.

A group of researchers pretending to be patients with skin diseases tried several web-based platforms. They evaluated the quality of the diagnoses and treatment recommendations they received, and published the results in the May 2016 issue of the journal JAMA Dermatology.

When a photograph alone was enough to evaluate the “patient,” most providers made an accurate diagnosis, according to the findings. But when it was necessary to learn more about the patient’s medical history, the providers performed less well.

(DermatologistOnCall was one of the teledermatology platforms included in the study, but the study did not report outcomes from specific platforms.)

Armstrong calls having a face-to-face visit with your provider when you begin working together the optimal approach. That way you can establish a relationship with your doctor in person and feel confident in your diagnosis. After that, teledermatology is one way to check in with each other.

“While teledermatology can be very convenient in many cases, it has limitations, and sometimes an in-person conversation needs to occur,” Armstrong said.

Even though teledermatology has been a big help to Voss, there’s still one conversation she wants to have with her dermatologist in person. It’s that “ta-da” moment when she’ll get to tell — and show — her doctor that her skin is clear.

She said she doesn’t want to send in a picture for that. “I want to walk in and say, ‘Here you go!’” she laughed.

Ready for your close-up? 5 tips for perfect pictures

Teledermatology makes it possible for patients to get quality skin care from their doctors using photographs and online communication. Here are tips from the experts on taking quality photos for your doc.

1.    Be clear.

“We want clear images,” said Armstrong. “If the patient notices that the image is blurry, I would advise the patient not to even send it. Discard it and take another photo.”

2.    Don’t be shy.

Take close-up pictures and photograph areas where your psoriasis is. “What’s most helpful is if [patients are] able to image their skin in a systematic fashion, so we can see all of these areas that are involved,” Armstrong said.

3.    Dare to compare.

Don’t ignore skin where you don’t have psoriasis, said Lipoff. “Sometimes people will only show us where the problem is, but we actually need to compare,” he said. “What do the two hands look like compared to each other?”

4.    Follow directions.

Whatever teledermatology service you’re using, get clear instructions on how to take a good photograph. “The system should be set up so that it can’t fail,” said Lipoff.

5.    Know when a picture isn’t worth a thousand words.

There are times when a doctor needs more information than a photo can convey. Armstrong advises patients to describe their symptoms, such as itching and pain, in addition to sending a photo. “Oftentimes I know from my patients that they may not have very severe psoriasis on a visual inspection, but what brings them into the clinic is the itch, for example.”

 


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