Teledermatology in Atopic Dermatitis: A Systematic Review

Abstract

Telemedicine use has been increasing especially during the COVID-19 pandemic. Various studies have outlined benefits of telemedicine including improving health equity, reducing wait times, and cost-effectiveness. Skin diseases such as atopic dermatitis (AD) may potentially be managed via telemedicine. However, there are no evidence-based recommendations for best practices in telemedicine for assessing AD patients. The objective of this review is to assess and summarize current evidence on telemedicine modalities for AD. This review will assess patient outcomes from various telemedicine models for AD. A review protocol was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Two reviewers independently screened potential studies and extracted data. Studies were included if they evaluated any telemedicine assessment for AD. Of 2719 identified records, 5 reports were included. Two reports used the direct-access online model, 1 used web-based consultation, 1 used e-health through a personal eczema portal, and 1 used an online platform and mobile application. All models were variations of the asynchronous, store and forward model. In all the included reports, teledermatology for the follow-up of patients with AD was effective and equivalent when compared to in-person appointments or standard treatment for their respective key outcome measures. However, it is unclear what the most effective teledermatology model is due to significant heterogeneity between studies. Teledermatology may serve as an important tool for triaging and follow-up of patients with AD. More studies are needed to determine which teledermatology models are most effective for virtual assessment of AD.

Introduction

Telemedicine is an evolving field that uses technology to facilitate remote healthcare service delivery to various populations in different settings. It improves access to healthcare for several groups including those experiencing a shortage of medical professionals, individuals with barriers to attending in-person medical appointments and those who prefer the convenience of virtual care.^1,2 In addition, telemedicine improves health equity between rural and urban areas and has shown to increase care quality, accessibility, and patient satisfaction. ³ Moreover, a systematic review of the literature in 2015 highlighted the potential that telemedicine improves cost-effectiveness of healthcare delivery by reducing administrative costs. ⁴

In times of crises, conventional medical practices must adapt to emergent circumstances to promote patient safety and well-being. In 2020, the COVID-19 pandemic imposed critical measures to limit the spread of the virus. ⁵ In particular, public health efforts focused on minimizing patient and healthcare professionals’ interactions for non-life threatening conditions. ⁶ As a consequence of the pandemic, telemedicine emerged as a crucial tool in maintaining healthcare delivery.^7-9 Telemedicine usage reduced in-person consultations as clinicians started screening, triaging, and following their patients remotely.^7,8 This change in practice demonstrated a reduction in the risk of COVID-19 infection, while simultaneously minimizing wait times and enabling management and follow-up of chronic diseases.^6-8,10

Skin diseases affect almost one-third of the world’s population and are the fourth most common cause of all human disease. ¹¹ Of the skin diseases, atopic dermatitis (AD) affects 20% of children and 10% of adults in high-income countries. ¹² It is ranked as the skin disease with the highest global burden as measured by the disability-adjusted life years. ¹² Management of AD can pose a challenge to patients, and the healthcare system, especially in underserved areas or during crises. ¹³ Patients suffering from AD, require ongoing care to adjust and monitor treatment plans, prevent complications, and ultimately enhance quality of life. Telemedicine can be beneficial in managing these conditions.^14-16 It has been shown to be a clinically and cost-effective tool for daily routine patient management,^17,18 and has been well-received by both patients and healthcare providers. ¹⁹

Despite all of the presumed advantages, there are no evidence-based recommendations or a gold standard for best practices in telemedicine for supporting patients with AD.^20,21 The 3 primary methods for delivering teledermatologic care are synchronous (live video or telephone evaluation), asynchronous (store and forward), and hybrid (combination of the two). ²² Clinicians are currently using various approaches and various electronic applications (eg, mobile apps, online portals, Zoom, Google Meet, etc.) to manage their AD patients with no clear recommendations on the most effective approach. ¹⁸ The objective of this systematic review is to assess and summarize current evidence on different telemedicine modalities, and evaluate several patient outcomes for AD.

Methods

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement were followed (see Supplementary Figure S1). ²³

Search Strategy and Data Sources

Team members (LV, TT, and LD) created a list of telemedicine and AD keywords, and then a health sciences librarian (LD) conducted searches in Medline (Ovid MEDLINE(R) ALL), Embase (Ovid interface) Cochrane trials, and Scopus on August 12, 2023 (see Appendix 1 materials for the full search strategy). The search included all studies from 1946 to August 11, 2023. Conference abstracts and editorials were excluded. No language or date restrictions were applied.

Study Selection and Outcome Measures

Two reviewers (LV and TT) independently screened titles and abstracts of retrieved studies to identify potentially relevant ones. They completed full-text review independently using pre-defined inclusion/exclusion criteria. Studies were included if they evaluated any telemedicine assessment for primary AD. There was no limitation on the age of study participants. Studies which involved other dermatologic conditions were excluded. Disagreements were first resolved between the 2 reviewers and then by discussion among the research team.

Data Extraction and Analysis

Two reviewers (TT and LV) independently extracted data. Details extracted include study characteristics (ie, study date, authors, title, study design), population characteristics, telemedicine model, model description, outcome measures (eg, Eczema Area and Severity Index). We conducted a descriptive analysis, the findings of which we summarized in tables. A meta-analysis was not feasible due to the heterogeneity of identified studies and the inconsistent outcome measures.

Results

After reviewing 2719 title and abstracts, 108 were screened for inclusion in the full-text review phase; 103 were then excluded (9 had no full-text available, 82 did not describe a telemedicine model, 12 did not include AD-specific data). Overall, we included 5 studies in this systematic review: 4 were randomized controlled trials (RCTs),^17,24,26 and 1 a retrospective cohort study ²⁷ (see Supplementary Table S1 for a summary of the included studies). Of note, Armstrong et al ²⁵ and Kornmehl 2017 et al ¹⁷ shared the same patient group for their respective studies.

All 5 of the included studies used an asynchronous (store and forward) teledermatology model, but implementation of the model and outcome measures differed as discussed below.

Armstrong et al ²⁵ used a patient-oriented eczema measure and investigator global assessment to compare effectiveness of a direct-access online model with in-person office visits for the follow-up of dermatologic care in pediatric and adult patients with AD. They found that patients whose disease was managed through the direct-access online model achieved equivalent improvements in disease severity as compared with those whose disease was managed through in-person visits.

Kornmehl et al ¹⁷ assessed the same direct-access online model as Armstrong et al; ²⁵ however, they differed in their key outcome measure. They used Dermatology Life Quality Index, Children’s Dermatology Life Quality Index, and the 12-Item Short Form Survey questionnaire to assess quality of life in the intervention and control groups. Their study showed that adult and pediatric AD patients managed through the direct-access online model had equivalent quality of life outcomes as those seen in-person. ¹⁷

Bergmo et al ²⁴ assessed the effect of web-based consultations for parents of children with AD on self-management behaviours, health outcomes, health resources use, and family costs compared to standard treatment without specialist care. ²⁴ The standard treatment group was encouraged to seek treatment through usual channels such as primary care and hospital visits. Both groups first took part in a 30-minute individual face-face education session prior to intervention, which discussed AD and self-management skills. The intervention group was then permitted to use a secure messaging system to send photos and a description of the child’s condition to the specialist who responded with treatment advice. They were also encouraged to submit a pre-designed form to classify and rate the severity of eczema. Self-management behaviour was measured using a form where parents noted which kind of treatment they currently use (eg, moisturizers, emollients, baths, wet-wraps, antiseptics, topical steroids, and phototherapy) and frequency of use. The severity of AD was measured using the SCORing Atopic Dermatitis (SCORAD) tool. Self-reported numbers of general practitioner visits, outpatient consultations, emergency visits, hospital admissions, visits to complementary therapists and personal expenses for moisturizers, special clothing, and diets were used to assess whether web consultations affected costs and resource use. ²⁴ This study showed that web consultations are non-inferior to standard treatment in terms of improving self-management behaviour, health outcomes, health resource use, and family costs. However, both groups received a 30 minutes educational session prior to intervention. The web-based consultation group did have fewer visits to practitioners offering complementary therapies compared to the control group.

van Os-Medendorp et al ²⁶ compared follow-up of AD patients using an e-health portal with in-person follow-up. They assessed several outcomes measures including disease-specific quality of life, self-reported data on skin status, symptoms of itching along with direct costs of care, costs of e-health service, outpatient visits and days taken off work by adult patients and the parents of children with AD. ²⁶ They concluded that teledermatology, after initial diagnosis and treatment, for patients with mild-to-moderate AD is as effective as face-to-face care with regards to quality of life and severity of disease. Their cost minimization analysis showed a 73% probability that teledermatology reduces indirect costs by a reduction of absenteeism from work. ²⁶

A retrospective cohort study by Giavina-Bianchi et al ²⁷ evaluated the proportion of AD patients who could be managed by their primary care provider with specialist teledermatology support and the accuracy of AD diagnosis via an online portal and mobile application. They showed that primary care physicians were able to manage 72% of AD patients using teledermatology services, whereas 28% needed to be referred to in-person dermatologists. Also, the proportion of teledermatologists’ diagnoses of AD that matched the final diagnosis made by the in-person dermatologist was 84.4%. ²⁷

Discussion

In this systematic review, we identified and summarized the literature pertaining to various teledermatology modalities and their effectiveness in triaging, diagnosing, and treating AD. There was a scarcity in data pertaining to this topic, and as such, both pediatric and adult studies were included in our final analysis. All of the included studies used a variation of the asynchronous, store and forward method, which involves uploading health information to a secure portal or application. The asynchronous design allows a specialist or member of the specialist’s team to review the information at a suitable time. However, design of the store and forward platforms and type of information collected differed significantly between studies. Studies included used secure messaging platforms, online portals, and mobile applications. It is unclear, which form of the store and forward model is most effective. However, the studies demonstrated that teledermatology through a store and forward modality is clinically effective and equivalent when compared to in-person appointments or standard treatment for their respective key outcome measures in AD. This parallels the authors’ personal experience, in which we have found that the store and forward model is the most used and accepted teledermatology model for triage and management of AD patients.

Teledermatology has emerged as a valuable tool for triaging AD patients, allowing for remote assessment and prioritization of care. Giavina-Bianchi et al demonstrated that virtual platforms are effective in triaging individuals with lesions suspicious for AD, and determining which patients require an in-person appointment with a dermatologist. ²⁷ This finding is crucial, as it implies that teledermatology may be effective as a screening tool to determine which patients require in-person assessment, and to which healthcare provider the case should be referred. Through streamlining the referrals, teledermatology can decrease the overall backlog to see a dermatologist in the community. More importantly, it may also allow increased accessibility to dermatologic care, particularly in remote cities where specialists are scarcer. In fact, the International Foundation of Dermatology estimates that 3 billion people in 345 developing countries lack access to dermatologists. ²⁸ Even in developed countries such as Canada, the median wait time to see a dermatologist is 92 days. ²⁹ In our province of Alberta, there are several teledermatology services utilized for triage including ConsultDerm and eReferral, which are asynchronous, store and forward platforms. These teledermatology services have been successfully integrated in underserved populations. This was supported in the study by Olteanu et al, ³⁰ which analyzed referrals received on ConsultDerm. ConsultDerm allows referring physicians to upload patient history and photos to obtain management advice including if an in-person dermatologic assessment is necessary. They identified that 48% of dermatologic consults arose from regions with a population less than 30,000, and the approximate time from receipt of the referral to completion of the consult was 5.6 days, further supporting teledermatology’s role in serving smaller underserved regions. Although it appears to be an efficient method to provide specialist care to underserved communities, further Canadian-specific data regarding concordance of virtual diagnosis with in-person assessment is required as well as AD-specific data.

Teledermatology can be used for both diagnosis and follow-up care of AD patients. However, there are some differences in the approach and benefits of using teledermatology for diagnosis versus follow-up. Diagnosis can be more challenging, especially with the inability to conduct a full physical examination, which may be necessary for accurate diagnosis and assessment of AD. This is true for patients with more complex or atypical cases of AD. For follow-up care, teledermatology can be beneficial for monitoring the patient’s condition over time and adjusting treatment plans as necessary. This can reduce the need for in-person visits and potentially improve patient adherence with treatment plans. Teledermatology for follow-up care can also be particularly helpful for patients who have achieved control over their AD, reducing the need for frequent in-person visits. Armstrong et al, ²⁵ highlighted that teledermatology was effective in managing AD in a follow-up setting. They also pointed to the potential cost-saving benefit for patients who can avoid travelling to see their dermatologist for follow-up appointments. Their results are relevant to Canadians as the study included patients in underserved communities within a large region in the United States, which parallels many regions in Canada. The true cost-saving benefit of teledermatology is currently unclear as there appears to be variations depending on the dermatologic condition being treated. A study by Snoswell et al, ³¹ in Australia concluded that teledermatology is more costly than in-person visits for skin cancer, but due to improved wait times to seek specialist attention, allowed for treatment and resolution of skin cancers 26 days earlier than their trial cohort. In addition, the cost of implementation of a teledermatology system is typically frontloaded, and therefore any cost savings are seen after a period of time. ³¹ It is also important to highlight that teledermatology for follow-up care can be limited by the potential for missed or delayed diagnosis of new or worsening symptoms. Therefore, dermatologists should be cautious and teledermatologic consultations should include patient education to mitigate that risk.

Despite reassuring findings, our analysis of the benefit of teledermatology was limited by the small number of papers which met our inclusion criteria. The evidence presented in this paper suggests that teledermatology may serve as an important tool for the screening, diagnosis, and follow-up of patients with AD. Although the asynchronous, store and forward model was used in all our included studies, due to the heterogeneity between the interventions studied, we are unable to provide specific recommendations regarding the most effective modality. In addition, there was an absence of studies which analyzed synchronous and hybrid models for AD patients that met our inclusion criteria. Our team recommends that future cohorts conduct RCTs to determine which platforms are most effective for virtual assessment of AD.

Supplemental Material

sj-docx-1-cms-10.1177_12034754231223694 – Supplemental material for Teledermatology in Atopic Dermatitis: A Systematic Review

Supplemental material, sj-docx-1-cms-10.1177_12034754231223694 for Teledermatology in Atopic Dermatitis: A Systematic Review by Luvneet Verma, Tarek Turk, Liz Dennett and Marlene Dytoc in Journal of Cutaneous Medicine and Surgery

Supplemental Material

sj-docx-2-cms-10.1177_12034754231223694 – Supplemental material for Teledermatology in Atopic Dermatitis: A Systematic Review

Supplemental material, sj-docx-2-cms-10.1177_12034754231223694 for Teledermatology in Atopic Dermatitis: A Systematic Review by Luvneet Verma, Tarek Turk, Liz Dennett and Marlene Dytoc in Journal of Cutaneous Medicine and Surgery

Supplemental Material

sj-docx-3-cms-10.1177_12034754231223694 – Supplemental material for Teledermatology in Atopic Dermatitis: A Systematic Review

Supplemental material, sj-docx-3-cms-10.1177_12034754231223694 for Teledermatology in Atopic Dermatitis: A Systematic Review by Luvneet Verma, Tarek Turk, Liz Dennett and Marlene Dytoc in Journal of Cutaneous Medicine and Surgery

Supplemental Material

sj-docx-4-cms-10.1177_12034754231223694 – Supplemental material for Teledermatology in Atopic Dermatitis: A Systematic Review

Supplemental material, sj-docx-4-cms-10.1177_12034754231223694 for Teledermatology in Atopic Dermatitis: A Systematic Review by Luvneet Verma, Tarek Turk, Liz Dennett and Marlene Dytoc in Journal of Cutaneous Medicine and Surgery