The doctor will “see” you now: Teledermatology in the era of COVID-19

The COVID-19 pandemic has transformed healthcare delivery across the world. Headlines about shortages of lifesaving resources and personal protective equipment have dominated our attention. But patients and doctors are also facing quieter challenges. Social distancing measures and concerns about transmission of the virus have significantly reduced the number of patients coming into hospitals and doctors’ offices for non-COVID-related health concerns — sometimes at a significant detriment to their health — due to delays in diagnosis or treatment.

In response, hospitals and clinics are increasingly turning to telemedicine — appointments by phone call or videoconference — as a way to safely treat patients during this public health crisis. And telemedicine visits are increasingly being covered by insurance. Dermatology is one of many medical specialties now “seeing” their patients virtually.

Dermatology is well suited to telemedicine

Dermatology is a highly visual field that is particularly well-suited for telemedicine in the current era where smartphones, tablets, and laptops are nearly ubiquitous, and can be easily used to take and send photos or to teleconference in real time. Even before the COVID-19 pandemic, studies found that teledermatology diagnoses can be accurate, result in high patient satisfaction, and allow for better access to dermatologists in areas where their numbers are limited or wait times are high.

Put your best face forward

Poor image quality can reduce the usefulness of teledermatology, but there are steps you can take to make these visits more productive.

For a start, try to send photos to your dermatologist ahead of your visit, even if your telemedicine visit will be conducted through real-time videoconferencing. Videoconferencing relies heavily on internet connectivity, bandwidth, and video quality (of both the physician and the patient), which can significantly impact image quality.

When taking photos, choose a solid, nonreflective background with diffuse, fluorescent lighting. Use macro mode, which is better for close-ups, if possible. Flash photograph has its pros and cons, but if there is good lighting overall, then turn off the flash, which can change the color and white balance of the photo. If you are taking a picture of a lesion, such as a mole, include a ruler, or another object for size reference, in the photo.

For videoconferencing, try to make sure you have stable internet connectivity and sufficient bandwidth before the session. Sit in a location with sufficient lighting (though it’s better if your back is not to a window), and in front of a camera that is in focus, stably positioned, and adjustable (in case the physician asks for both distant and close-up views). Depending on the part of the body in question, you may want to find a sufficiently private space for your appointment. Also remember to dress in a way that will allow easy viewing of the area of the body that the doctor needs to see.

Limitations of teledermatology may make it less useful in certain cases

Certain types of cases warrant special consideration due to the limitations of teledermatology, including image quality and lack of access to certain tools. In these cases, teledermatology is often best used as a tool for triage. The dermatologist can gather a thorough history and use the available visual information to formulate a plan for whether and when the patient should be seen in person.

One such case is the evaluation of pigmented lesions, which include freckles and moles, often in the context of whether such a lesion is cancerous. When evaluating these lesions in person, dermatologists often use a device called a dermatoscope, which illuminates and magnifies lesions so that finer details are visible. Pigmented lesions can be diagnostically challenging over telemedicine because dermoscopy is rarely available.

Hair-bearing areas such as the scalp can also be difficult to visualize well, and may need to have hair parted or removed, and photographed with special lighting. Mucosal surfaces, such as the inside of the mouth, can be similarly hard to fully visualize, and need special lighting and exposure. And while many dermatology patients can expect to have a full body skin check in the office, this is very difficult to do in a thorough and meaningful manner over telemedicine.

Finally, skin concerns that may involve a procedure, such as a skin biopsy or a medication injection, cannot be done via telemedicine. In these cases, a telemedicine visit can help guide the decision for whether the procedure is needed and how urgently.

As we continue to adjust to the effects of COVID-19, hospitals and clinics will likely be employing a hybrid strategy of telemedicine and in-person visits in order to provide the best medical care for patients in the safest environment.

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