Teledermatology: Case Selection and Consultation “Technology is Best when it Brings Patient–Physician Together.” : Clinical Dermatology Review

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Case Selection and Consultation “Technology is Best when it Brings Patient–Physician Together.”

Kanthraj, Garehatty Rudrappa

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Clinical Dermatology Review 7(1):p 3-9, Jan–Mar 2023. | DOI: 10.4103/cdr.cdr_23_22
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Dermatology is a visual specialty. The availability of clinical and histopathological images for diagnosis makes it an ideal choice for teledermatology consultation (TC). Transmission of electroencephalogram by Willem Einthoven[1] using telephone network in 1906 and providing psychiatry care between two hospitals in 1959, USA,[2] are the earlier telemedicine developments. There is a rapid progress to monitor astronaut’s heart rate, blood pressure, and electrocardiogram during 1960-1970.[3] In 1995, the term “teledermatology” was introduced by Perednia and Brown.[4] In 1997, Zelickson and Homan[5] demonstrated teledermatology in a nursing home setting. These are the milestones in telemedicine and its transformation to teledermatology.[1-5]

Teledermatology is a branch of dermatology involving the application of electronics, communications, and information technology to transmit the information between the patient and dermatologist and vice versa for practice and research to cater dermatology care.[4,6] TC is performed everywhere.[7-10] COVID-19 pandemic and lockdown have motivated dermatologists and patients to adopt TC as a medium to seek and provide patient care.

Transformation/Revolution of Teledermatology Consultation

Images were captured by ordinary camera, scanned, and sent through E-mail. Digital cameras transformed the art of TC. Images are easily transferred between computers using the Internet. Advances in technology resulted in an enhanced speed of the Internet. Transfer of images between mobile phones and personal digital assistants is made easy.[11-13] Advances in information technology, innovation in smartphones, android technology, and various mobile messenger applications (apps)[14,15] have revolutionized the TC and made it convenient for dermatologists and patients to communicate with each other [Figure 1]. Capture, transfer, and storage of the data are the steps involved between the patient and the dermatologist. Self-acquired patient images,[16,17] “selfies,” a mode to capture the images as an impact in patient-assisted TC. Patients participate actively[18] and directly send the image and receive advice from the dermatologist. Digitalization across the globe, with active participation by dermatologists and patients, resulted in the transmission of images through E-mail/web and social media[19] [Figure 1].

Figure 1:
The digital camera, Internet, personal digital assistants,[13] mobile phones,[11 , 12] android technology, selfie images,[16 , 17] and messenger apps[14 , 15] and social media[19] have revolutionized teledermatology consultation and provided easy patient and dermatologist access for clinical interaction. Capture and transfer of the data are made easy and simple

The Need for Teledermatology Consultation in COVID-19 Pandemic

A TC consultation is provided without exposing staff to viruses/infections in times of contagious disease outbreaks like the COVID-19 pandemic. Infectious disease transmission can be prevented by reducing the risks to both health-care workers and patients. COVID-19, a viral pandemic, is a well-suited scenario, in which dermatologists can evaluate and manage patients on a virtual platform.[20-22]

Scope and Purpose/Indications for Teledermatology Consultation

The various purposes or common applications of TC are: (1) diagnosis,[23-25] (2) triage[26-28] and counseling, (3) follow-up care,[29-39] and (4) investigation.[40-42] A dermatologist should identify the purpose before offering TC [Table 1]. The various indications[23-42] of TC are summarized in Table 1.

Table 1:
Various purposes/indications[23 - 44 , 58 - 62 , 69] for teledermatology consultation

Teledermatology Consultation and its Advantages

Feasibility studies[23-42] on TC applied for the purpose of triage, diagnosis, and follow-up care are analyzed. The selection of cases for TC depends on three of the following parameters: (i) clinical morphology and distribution pattern, (ii) course of the disease, and (iii) purpose/objective of dermatology care. The differences between TC for diagnosis and follow-up care are analyzed in Table 2.

Table 2:
The differences between diagnostic and follow-up care by teledermatology consultation

A TC reduces multiple visits for follow-up care and benefits the elderly, especially those coming from far-off places. It saves cost and time. TC is found to be cost-effective and reliable in reducing in-person visits, which saves time, and allows for the faster delivery of care. TC provides triage and reduces waiting time. Advantages of TC with respect to various purposes are:

  1. Diagnosis[23-25] – Instant diagnosis and treatment for cases presenting with characteristic morphology and distribution pattern
  2. Triage and counseling[26-28] – Prioritize for in-person examination and investigation or both
  3. Follow-up care[29-39] – The studies[29-39] reveal that store-and-forward (SAF) is appropriate for clinicians with established patients who require regular follow-up. Verified areas of care include treatment of chronic conditions, topical skin cancer therapy, wound monitoring,[29-32] and postprocedural[43,44] follow-up care. It minimizes/eliminates in-person follow-up visits and saves cost and time. Management of patients with established diagnoses. The chronic disorders that persist for a longer period may be characterized by remissions and exacerbations. Therefore, they need multiple visits for follow-up care to provide periodic assessments. Recently, follow-up care is delivered for chronic cutaneous autoimmune diseases[39] during the COVID-19 pandemic. In chronic disorders, TC has a significant impact on the elderly, especially those coming from far-off places. It saves cost and time. If the patient is not satisfied, he will be called for in-person examination
  4. Investigation [40-42] – involves interpretation of multiple patch test readings to diagnose and confirm allergic contact dermatitis. It minimizes in-person follow-up visits, saves cost and time, and is convenient to capture the serial images of the upper back and compare.

Teledermatology Consultation in Various Subspecialties

TC is applied widely in various dermatology fields: (a) cutaneous and esthetic surgery,[43,44] (b) geriatric care,[45-47] (c) pediatric care,[48-60] and (d) emergency dermatology care.[61-65] It is summarized in Table 3.

Table 3:
The subspecialties area for teledermatology consultation

Cutaneous and esthetic surgery

Cases can be triaged for priority in-person examination and posted for investigational procedures like skin biopsy. Presurgery/procedure counseling can be performed.[43] Follow-up care is easy and feasible in wound care[29-32]/postchemical peels, postcutaneous-esthetic surgeries, postacne procedures, and vitiligo surgeries. Studies[44] have revealed TC to be useful following postlaser procedures to provide follow-up care. Satisfactory follow-up care is provided by TC; it is continued; if it is not satisfactory, the patient is called for in-person examination.

Geriatric Care

Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in the elderly who lack easy and/or direct access to dermatologists.[45-47] It minimizes follow-up visits, cost, and time.

Pediatric care

Accurate triage and diagnosis of childhood dermatology cases decrease travel and outpatient clinic visits. It also provides an avenue for ongoing support and education for primary care physicians.[48-60]

Emergency dermatology

The skin emergency TC has proved to be successful to provide specialist dermatology services across Australia. The use of TC within the context of emergency-based care has achieved patient acceptance and confidence.[61-65] Newer generation mobile devices reduce the cost of video conferencing, increase the adaptability of teledermatology, and decrease general practitioner time.

Teledermatology consultation Diagnostic Agreement and Patient satisfaction:

The diagnostic accuracy is good when TC is compared to gold-standard in-person examination.[23] The diagnostic accuracy of SAF TC was good and comparable to video conference TC. Health-care providers need to plan for the appropriate utility of SAF-TC either alone or in combination with video conference TC to implement and deliver teledermatology care in India.[24] Messenger apps[14,15] (e.g., WhatsApp) are a medium for TC to capture and transfer of images.

The direct consult may increase patient satisfaction. Patient-assisted TC achieves a good patient satisfaction.[18] Patient satisfaction will play an integral role in the further growth, development, and implementation of TC.[66-70]

The Organization and Approach to a Case for Teledermatology Consultation

It comprises a basic model of SAF teledermatology, where a dermatologist interacts with the patients directly for regular cases or patients can directly send images to the dermatologist.[6,18] A dermatologist interacts in an online discussion forum to obtain a second opinion for the management of difficult-to-manage cases.[71]

Prerequisites for a Successful Teledermatology Consultation

Informed written consent for TC is a prerequisite. A dermatologist should obtain a proper history and observe the digital images for clinical findings. Consent form[72] and pro forma[72] for TC are prepared by the IADVL Academy and can be freely downloaded. A technical guideline for TC is prepared by the American Teledermatology Association.[73] Guidelines for telemedicine platforms are prepared by the National Medical Commission[74] and issued by the Ministry of Health and family welfare. A dermatologist should adhere to the regulations and practices to offer quality care.

The various feasibility studies using several teledermatology tools[75-93] involved to provide dermatology care are summarized in Table 4.

Table 4:
The various feasibility studies[75 - 93] using tools for teledermatology consultation

Limitations of teledermatology consultation

It is broadly divided into: (a) dermatological conditions and (b) technical factors that come in the way of TC.

Dermatological conditions

All cases may not be feasible with an objective of diagnosis in TC. These cases are not diagnosed by instant/spot examination. The various clinical situations a dermatologist may choose not to offer TC for diagnosis purposes[94] are: (i) nonspecific presentation, (ii) varied morphology, (iii) requires palpation, for example, skin tumors, (vi) multiorgan involvement, for example, Stevens–Johnson syndrome/Toxic epidermal necrolysis, (v) rare diseases –syndromes/genodermatoses (apart from skin examination, palpation for multisystem involvement may be needed), (vi) diseases that require criteria to diagnose, for example, atopic dermatitis, systemic lupus erythematosus, and Behcet’s disease, (vii) symptomatic presentation, for example, generalized itching, burning excessive sweating/hyperhidrosis (without any obvious lesion to capture the image and requires evaluation of the symptom/s by investigations, and (viii) represent a clinical entity due to various causes, for example, erythroderma, palmoplantar keratoderma, urticaria, and leg ulcer. In these situations, initial face-to-face examination needs to be performed, followed by follow-up care[29-39] using TC.

Technical factors

The various technology situations a dermatologist may choose not to offer TC for diagnosis purpose[94] are: (i) Poor quality of images, (ii) poor net connectivity, (iii) inability to palpate the lesions, (iv) lack of clinical data, (v) misinterpretation while transferring the information or while delivering the management, and (vi) lack of patient confidence in the technology. In these situations, initial face-to-face examination needs to be performed, followed by follow-up care[29-39] using TC.

A Protocol for Teledermatology Consultation

Mobile messenger apps provide a dermatologist to capture and transfer clinical images either in still (SAF) and motion (video) or both to offer quality care. Feasibility studies[14,15] have confirmed that using WhatsApp, TC can be provided. It is easy, technical feasibility, and cost-effective. WhatsApp groups make it possible for dermatologists and other specialties to discuss various dermatological diseases and their appropriate management. It is one of the easiest media to exchange knowledge and experience on a one-to-one basis. It is considered one of the safest instant messaging media due to encryption technology.

A dermatologist should screen the received clinical image from a general practitioner or self-acquired patient images (selfies[16,17]) and define the objective/purpose of dermatology care. If the case suits for diagnostic purpose, a treatment is offered. A clinician should be aware of the dermatological conditions where not to offer consultation for diagnostic purposes.[94] In these cases, a dermatologist can perform a face-to-face examination, investigate, analyze the case, offer treatment, and provide follow-up care by TC.[94]


TC serves best when it is used in specific situations. Studies have highlighted the importance of diagnostic purpose and follow-up care in TC. Patients and physicians know each other in follow-up care as they frequently interact with each other and achieve the best patient satisfaction. However, more studies are needed to analyze the role of follow-up care in individual dermatological conditions. In an Indian scenario, mobile teledermatology using messenger apps, for example, WhatsApp, can be used to provide follow-up care for chronic dermatological conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


We acknowledge the JSS Academy of Higher Education and Research-JSSAHER (Deemed-to-be University) for their constant academic encouragement and constructive suggestions in completing this project.


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                                                                                                    Teledermatology; case selection; consultation

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