April Armstrong, MD, MPH
Keck School of Medicine, USC
Studio City, California, United States
Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy [published online ahead of print, 2020 May 26]. Brunasso AMG, Massone C. Dermatol Ther. 2020;e13495. doi:10.1111/dth.13695.
Nothing has thrust teledermatology more to the forefront of healthcare models than by the COVID-19 pandemic. Whether one loves it or hates it, many dermatologists are practicing teledermatology to manage patients with skin diseases during this pandemic.
Brunasso et al., described their teledermatology experience for chronic cutaneous autoimmune diseases during COVID-19 in a tertiary center in Italy. What is notable about this study is that the institution lacked a teledermatology platform. Thus, the dermatologists had to depend on phone calls and emails as ways of caring for their patients remotely. The dermatologists treated 126 patients with moderate-to-severe psoriasis, with over half of these patients on either oral or biologic agents. One hundred and ten (110) out of 126 patients continued their prior therapies during the pandemic, and 16 patients initiated new therapies, changed doses, or discontinued the therapies. I commend the authors for sharing how remote care of psoriasis patients was possible with telephone and email alone.
Having cared for psoriasis patients via teledermatology for more than 10 years prior to the pandemic, I recognize the benefits and limitations of teledermatology for managing psoriasis. I would like to share a few practice pearls.
First, be flexible about how you use communication technology. Various offices may have different resources to support synchronous technology (interactive video-based encounters or telephone) and/or asynchronous technology (store-and-forward methods). In general, when initiating systemic medications or managing psoriasis exacerbation, synchronous teledermatology (such as online video-based encounters) are preferred due to the opportunity for dialogue. If video-based technology is not available, telephone encounters are acceptable too to allow for dialogue, as was described by Brunasso et al. It is important to supplement those video or telephone encounters with still digital images of psoriasis lesions. This is because some online video-based technology does not provide images clear enough for diagnosis and/or management. Having the clearer digital images before the online visit will aid in management decisions and make the visit more efficient. For routine follow-up remote visits, either synchronous or asynchronous communication is acceptable. It is still preferable to have digital images available prior to the online synchronous visit whenever possible. Obtaining laboratory work up during the pandemic may be an issue for many patients, and it is important to carefully consider benefit/risk ratio of obtaining laboratory workup versus the potential risk of exposure to SARS-Cov2 at a healthcare facility.
Second, for special populations such as the elderly, it is helpful to have a family member test the teledermatology platform prior to the visit and be available to assist with the actual online visit. For children, evaluating their lesions over video-based encounters is a substantial challenge. Especially for young children, parents should take digital photographs of their skin lesions prior to the online visit.
Third, for special areas such as the scalp and intertriginous areas, it is best to obtain still digital images of those regions prior to the online visit. This is because trying to examine those areas in real-time via video-based encounters can be both physically challenging and awkward for patients.
Finally, no matter how good one’s teledermatology platform is, it is important to know the recommendations from professional dermatological societies regarding the management of psoriasis during the COVID-19 pandemic such that you can care for your patients based on the latest evidence.