Evidence-based consensus recommendations for everyday clinical practice

Teledermatology has gained increasing importance in German-speaking countries as well as internationally. As a strongly visual subject, dermatology is very well suited for telemedicine applications. The S2k guideline creates a scientifically sound basis for teledermatological applications and is thus an important step towards the implementation of modern procedures in everyday care.

The guideline recommendations refer to various teledermatology procedures for defined diseases [1]. The focus is on teledermatological care for psoriasis, atopic dermatitis and skin cancer, as well as acute and chronic wounds. In addition, the guideline provides recommendations for further dermatological application areas of telemedicine. It should be noted that implementation of the recommendations in specific clinical situations should be considered in light of individual patient-relevant circumstances (e.g., comorbidities, comedication, contraindications). The following is an excerpt from the S2k guideline [1]:

Psoriasis

A total of six controlled studies have been published on teledermatological care of psoriasis. In summary, they show that the accompanying teledermatological care of patients with psoriasis, in particular also the progress controls via photos or videos, are effective and beneficial. Questions about patient counseling and testing adherence and compliance also received positive responses. Overall, the above studies thus suggest a benefit of supportive teledermatological care in psoriasis. In the future, the focus will also be on progress monitoring of system therapies as well as patient counseling and support.

Strong consensus (100%)*:

• Initial diagnosis of psoriasis based solely on teledermatologic findings should not be made.
• Supportive counseling of the diagnosis in the course of a B2B** connection can be provided.
• Psoriasis can basically be assessed with store-and-forward or real-time technology during the course of the disease, once the diagnosis has been made by means of a presence examination.
• Morphologic progression of psoriasis using teledermatology and collection of patient-reported outcomes such as DLQI and pruritus may be recommended.
• Teledermatologic determination of PASI cannot be performed because of the inability to assess induration.
• Determination of the affected body surface area (BSA) and the components “erythema” and “desquamation” from the PASI can be performed telemedically.
• The transmission of the SAPASI (self-assessed PASI) can be used for telemedical follow-up.
• Supplementary counseling of the patient about measures in the course of therapy can be recommended both in the form of the store-and-forward method and in the real-time mode.

* 2 abstentions
** B2B = business-to-business connection between two medical experts

Atopic dermatitis and other eczema diseases.

Similar to psoriasis, the controlled studies (4 in total) on atopic dermatitis suggest that reporting of findings and thus follow-up is possible and valid in a teledermatology setting. A key question is the utility and cost-effectiveness of patient counseling in the course of online video consultations. There have been no studies on this to date.

Strong consensus (100%^)*:

• Initial diagnosis of atopic dermatitis based solely on teledermatologic findings should not be made.
• The clinical and anamnestic criteria of atopic skin diathesis, including atopic stigmata (except dermographism), can be collected by teledermatological means.
• Atopic dermatitis, once diagnosed by a presence examination, can generally be assessed with a store-and-forward method or real-time technology as it progresses.
• Morphologic progression of atopic dermatitis using teledermatology and collection of patient-reported outcomes such as DLQI and pruritus may be recommended.
• The determination of the body surface area (BSA) and the parameters “erythema”, “lichenification” and “excoriation” can be done teledermatologically.
• “Edema” cannot be adequately assessed teledermatologically, thus the collection of the SCORAD and EASI cannot be done appropriately.
• Supplementary counseling of the patient about measures in the course of therapy can be recommended in the store-and-forward method as well as in the real-time mode.

* 2 abstentions
 

Skin cancer

On melanocytic lesions and skin cancer, there is by far the largest publication base in digital dermatology among all dermatological indications, with 52 published papers [2]. There is sufficient data for the validity and practicality of sending and analyzing appropriate, good quality findings, as well as for mobile and even web-based use [3,4]. However, according to a comprehensive meta-analysis, presence diagnostics were superior to digital reporting in some of the studies [5]. The indication must therefore be differentiated and adapted to the situation.

Strong consensus (100%^)*:

• Primary diagnosis of melanocytic lesions based on teledermatologic findings may be considered if the morphologic findings are clinically unequivocal and the necessary additional history and clinical information can be obtained. If the findings are clinically unclear, a dermatoscopic examination should be performed. This can be performed teledermatologically or as a presence examination
• Primary diagnosis of melanocytic lesions based on AI solutions alone should not be performed.
• The primary diagnosis of non-melanocytic lesions incl. of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) detection based on teledermatologic findings may be considered if the morphologic findings are clinically unequivocal and the necessary additional history and clinical information can be obtained. If the findings are clinically unclear, a dermatoscopic examination should be performed. This can be performed teledermatologically or as a presence examination
• Primary diagnosis of non-melanocytic lesions based on KI solutions alone should not be performed.

* 2 abstentions

Chronic and acute wounds

Next to skin tumors, the best data in the international literature is found for chronic wounds [6]. The concordance between morphological findings obtained by telemedicine and the presence findings is so high that, at least in the care of existing patients, support by teledermatological findings may be useful and unobjectionable. The focus here is on the assessment of progression and the early detection of complications. Several controlled studies show that digital documentation and assessment of wound findings is not inferior to face-to-face documentation and analysis. In these studies, the diagnostic quality of digital findings was equated to those of direct findings. While the practical benefit of telemedical wound treatment in the homecare setting was still described as moderate in an early study [7], a more recent randomized care trial in patients with leg ulcers in Denmark found a significantly higher healing rate when supportive teledermatological care was provided from the clinical center beyond routine outpatient treatment [8]. These findings suggest that, given the infrastructure (a) introduce teledermatology into the course of care for existing patients; and b) to make preparations already guided by teledermatology in the run-up to the presence contacts in a specialized center, such as the planning of diagnostic measures.

Strong consensus (>75%^)‡:

• The primary diagnosis of acute and chronic wounds by teledermatological methods can be recommended if the necessary clinical, apparative-diagnostic and anamnestic data for a diagnosis are available
• The primary diagnosis of acute and chronic wounds by teledermatological methods can be recommended if the necessary clinical, apparative-diagnostic and anamnestic data for a diagnosis are available
• The follow-up of wounds in the course of initiated therapy with real-time technology can be recommended if the quality of the image findings is assured. The same applies to the progress control of the quality of dressings and bandages
• Telemedical quality control and education in the application of dressings and compression systems by nursing staff can be recommended as a supportive measure.

Other dermatological applications

Given the extremely large number of different skin diseases, it is not surprising that systematic studies on the efficacy and benefits of telemedicine have generally not been implemented for rare diseases. On the other hand, given the often small number of dermatologic specialists and the frequent overtaxing of primary care physicians, diagnostic concepts in particular have a potentially important role to play. The study by Heidenheim from Denmark/Faroe Islands [9], which showed the added value of suspicious diagnosis by dermatologists in primary care, can be considered as examples of appropriate support for family physicians and general practitioners in rare diseases. Subject to possible legal limits, however, the earliest possible, appropriate and systematic diagnosis with the aid of teledermatological technologies is of benefit to care.

Strong consensus (100%^)‡:

• Teledermatologic store-and-forward care can be recommended for those dermatoses that are suitable for it based on primarily morphologic diagnosis in conjunction with anamnestic and clinical information. These include, for example, infectious skin diseases, acute and chronic eczema, and benign skin tumors, insofar as they can be clearly assigned. Further necessary diagnostics such as histological examinations and clinical laboratory should not be delayed by this.
• In dermatological diagnostics, teledermatological real-time care of visible dermatoses usually has no discernible advantages over the store-and-forward technique and should only be used when communication with the patient and/or co-treating physicians on site is the primary concern.
• Real-time teledermatologic care of visible dermatoses may be recommended in therapeutic care for existing patients during the course.
• Teledermatological treatment in store-and-forward and real-time modes can be recommended in the follow-up of surgical findings and in the evaluation of scars, insofar as additional information on the clinic and patient well-being is also collected.

^{‡  3}abstentions

Literature:

1. Augustin M, Strömer K, et al: S2k guideline Teledermatology 2020, www.awmf.org/leitlinien/detail/ll/013-097.html, (last accessed 25.05.2021).
2. Trettel A, Eissing L, Augustin M: Telemedicine in Dermatology: Findings and Experiences Worldwide – A Systematic Literature Review. J Eur Acad Dermatol Venereol 2018; 32 (2): 215-224.
3. Markun S, et al: Mobile teledermatology for skin cancer screening: A diagnostic accuracy study. Medicine (Baltimore) 2017; 96: e6278 .
4. Ferrándiz L, et al: Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: A randomized teledermoscopy trial. J Am Acad Dermatol 2017; 76: 676-682.
5. Finnane A, et al: Teledermatology for the Diagnosis and Management of Skin Cancer: A Systematic Review. JAMA Dermatol 2017; 153: 319-327.
6. Augustin M, et al: Practice of teledermatology. Guideline of German-speaking dermatologists. J Dtsch Dermatol Ges 2018; 16 (Suppl. 5): 6-57.
7. Terry M, et al: Feasibility study of home care wound management us-ing telemedicine. Adv Skin Wound Care 2009; 22: 358-364.
8. Zarchi K, et al: Expert advice provided through telemedi-cine improves healing of chronic wounds: prospective cluster controlled study. J Invest Dermatol 2015; 135: 895-900.
9. Le Bryld, et al: The Atlantic Experience. In: Soyer HP, Binder M, Smith AC: Telemedicine in Dermatology; Berlin Heidelberg: Springer, 2012, 9-14.

DERMATOLOGIE PRAXIS 2021; 31(3): 47-48