Teledermatology: the way of the future?

Prior to the COVID-19 pandemic, the mere mention of teledermatology may have been met with confusion – or worse, flashbacks to blurry photos and pixilated videos. Yet with the rise of COVID-19, so has the application of telehealth within Australian dermatology practice. As we emerge into the post-pandemic years, its ongoing role in clinical practice is yet to be defined.

Teledermatology, a subset of telehealth, refers to where the dermatologist and patient are separated geographically, requiring information and communication technologies to bridge the separation. The main modes of delivering teledermatology are by store and forward (SAF), where images are transmitted for a clinician to review, and real-time video consultation (RTVC). Hydrid methods are most popular with Australian dermatologists and often involve a SAF method followed by RTVC, removing the potential challenges of poor-quality videos and limited internet connection.

Before the pandemic, teledermatology had well-documented evidence of its value and success. Yet almost 50 per cent of Australian dermatologists had never used teledermatology. In 2020, when the pandemic reached Australia, there was a 24-fold increase in telehealth services throughout Australia. With this, the proportion of dermatologists in Australian private practice utilising telehealth increased to 92.6 per cent.

Of particular benefit, this rise in teledermatology provision has enabled dermatologist access for Australians living in regional, rural and remote locations. In these areas, patients with dermatological conditions have historically had poorer outcomes. Australia has a vast geographic mass of 7.7 million square kilometres, where one-third of the population live outside of capital cities. Yet there are only about 550 practising dermatologists in Australia. Of these, only 10 per cent live and practice outside major metropolitan centres. Contrasting this, approximately one million Australians (four per cent) live with a chronic skin condition.

Beyond enabling access across a vast area, teledermatology has several other advantages. It has been purported to be of benefit in driving down public hospital dermatology waitlists and supporting local primary practitioner-led care. Of particular value is its role in triaging skin lesions, long-term follow-up of inflammatory conditions and monitoring of patients on biologic medications. Furthermore, patients benefit from reduction of travel requirements and associated costs, in addition to limited disruption to work and family commitments.

Yet teledermatology provision is not without challenges. It is not suitable for all patients or all visits. Gone is the diagnostic modality of palpating a rash or skin lesion, nor is dermoscopy available. Biopsies are often required for diagnosis and necessitate the scheduling of a face-to-face appointment. Procedures and hands-on therapies, such as narrow-band UV or light-emitting therapies, also require coordination. Within a complicated and evolving digital landscape, there is an onus on the practitioner for the protection of privacy and confidential storage of images. Specialised equipment is required for the production and storage of dermoscopic images. Additionally, the clinician must upskill and tailor the delivery of teledermatology to the needs of the patient and the clinical problem. For example, videoconferencing has limited utility for skin checks, yet SAF methods including macroscopic and dermoscopic images of lesions can be of significant value.

If there is one silver lining to the pandemic, it may be that patients in regional and remote locations are the unexpected beneficiaries of teledermatology. Now that teledermatology has been widely trialled, the impetus is on the medical profession to continue to drive change and carry on the provision of these services. As technology continues to evolve, so must the provision of dermatology.