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Dermatology, telemedicine and the pandemic: can skin diagnosis be done from a distance?

Yale Medicine Magazine, 2022 Issue 168 More than skin deep
by Ken Byron

Telemedicine was already in use by Yale dermatologists pre-pandemic – but a new study showed telemedicine services can be expanded successfully, with real benefits for patients with skin conditions.

In the spring and summer of 2020, as the COVID-19 pandemic was taking root, most medical disciplines had shifted some in-person visits to telemedicine. The ability to see a provider at a distance has transformed how people can access health care, especially when it comes to superficial conditions—those that are visible on the surface of the body. Not every specialty benefited equally from the advantages telemedicine offered, but physicians practicing dermatology quickly embraced the technology’s potential while mitigating its shortcomings.

Are In-Person Visits Vital to Diagnosing Dermatological Conditions?

It may seem obvious that dermatology is a specialty that is particularly reliant on in-person patient examinations. Dermatologists have long been wary of missing critical information and skeptical of technology’s ability to offer meaningful live imagery. The pandemic, however, has changed that.

“Dermatology is a high-volume practice, and it was not safe to have [patients] come into the office. At that same time, we still had patients whom we needed to see, and they were quite satisfied,” said Sara Perkins, MD, assistant professor of dermatology.

Yale School of Medicine’s Department of Dermatology has 24 doctors and four clinical sites in the Greater New Haven area. Before the pandemic, the doctors saw about 1,200 patients a week. Some of those patients were evaluated through telemedicine, but it was not a significant part of the practice.

When the dermatology department closed its offices on March 16, 2020, however, telemedicine became the only option. The department quickly trained its staff, which included giving them detailed scripts for calling patients and advising them about switching to telehealth appointments. In the first week, the practice had 224 telemedicine visits with patients; in the third week, that number grew to 500. By that point, with only a few exceptions, the department eliminated in-person appointments.

The Pandemic Brought Important Changes

As the pandemic waned in Connecticut, the dermatology department moved back to in-person visits, and Perkins said that during the summer of 2021, most visits were in person. Even so, modern videoconferencing tools, including state-of-the-art encrypted software and high-resolution cameras on modern smartphones, impressed physicians with what they are able to see from afar.

Patients also had to adapt to the new way of doing things. That included learning how to take pictures of a skin condition for doctors to evaluate and uploading the pictures onto a website where they could be viewed before the appointment. A patient taking a picture of a skin lesion was instructed to put a penny next to it so the doctor could see the size of the lesion, Perkins said.

Some conditions, like acne, lend themselves well to telemedicine, Perkins noted. But in many cases, a doctor will still have to see a patient in person even if the initial evaluation was done via a telehealth appointment.

Telemedicine has also been important in keeping patients in the hospital safe during the pandemic, said Caroline Nelson, MD, assistant professor of dermatology at Yale and director of the inpatient consultative service for dermatology at Yale New Haven Hospital. While telemedicine has an ongoing potential to be useful in the inpatient setting, it also has important limitations that require caution.

Telemedicine: an Effective Tool for Dermatology

Good-quality images are essential when using telemedicine to make an evaluation. However, Nelson said, obtaining them can be challenging even with training. Hospital primary care teams have their hands full treating urgent medical problems. “Taking photographs can be a burden,” Nelson said. Moreover, “in the absence of a full-body exam, you are not able to palpate the patient’s skin.” Finally, bedside diagnostic tools, while often helpful, are unavailable with telemedicine.

A case in point was a man admitted to Yale New Haven Hospital with COVID-19. The hospital primary care team saw blisters that a dermatologist needed to evaluate. Nelson said at first glance the images sent to her team looked like a case of shingles. To further evaluate, Nelson and her team decided to see the patient in person, so they donned masks, gowns, and other personal protective equipment. Full-body examination and bedside diagnostics revealed that the patient had a fungal infection mimicking shingles that required a different treatment.

Perkins, Nelson, and other department physicians described their success with telemedicine during the pandemic in a paper that was published in the Journal of the American Academy of Dermatology in July 2020.

Perkins said that for dermatology, telemedicine will remain an option for visits going forward. “Patients like it; they value the convenience and access,” she said. Rather than debating the merits of telemedicine, the clinicians’ focus will be on improving the service. “As we get better at at-home diagnostics and imaging, I can envision a scenario in which the patient takes a picture of the skin condition, does a self-administered test, and the doctor can use that to make an evaluation,” Perkins said. “We are working on options for telemedicine that the patient initiates, and [we] can give them an answer in 24 to 48 hours.”