Using telemedicine to examine skin conditions
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Study Finds Issues with Dermatology Telemedicine

The Scoop

You’re probably familiar with the typical exam by a dermatologist using the dermatoscope to closely inspect moles, warts and such on your skin. But did you know some doctors use telemedicine for virtual dermatological exams? 

Telemedicine is the use of electronic communication tools such as laptops and smartphones by medical professionals to treat patients in another location. It’s convenient for patients who live far away from the nearest specialist or for those who prefer a doctor’s care from the comfort of their home. Take note: a recent study published by JAMA Dermatology1 suggests that if you have a skin condition, it may be best to consult with a doctor in person

Overview

  • Researchers posed as patients with skin conditions and contacted online telemedicine services.
  • Skin issues that required more than looking at a photo were often misdiagnosed. 
  • Prescriptions were issued without informing patients of risks or side effects.
  • Not all doctors were licensed to practice in the state where the researchers lived.

The Details

The study, headed by California-based dermatologist Dr. Jack Resneck, sought to evaluate the quality of online dermatology services. Researchers created six scenarios that included demographic information, a short history and description of symptoms, stock photos taken from the internet, and additional information to provide only if asked follow-up questions. 

Researchers documented 62 online visits with 16 telemedicine websites that offered services to California residents. They chose websites that specifically listed treatment for said they treated skin conditions. The interactions were not live; the patients entered information on website portals and in most cases received responses within a day or two. They did not use services that required video chats. 

The study participants were assigned to a practitioner in most cases, but a third of the time they were able to select who treated them. Clinicians included doctors, nurse practitioners, and physician assistants. 

About the practitioners 

  • 52% had backgrounds in dermatology.
  • 13% were located outside the United States and researchers found no evidence they were licensed in California. (All of the US clinicians were licensed in California.)
  • 74% asked for a list of current medications and allergies.
  • 32% advised patients of side effects when a prescription was issued.
  • 66% asked follow-up questions or for more information.
  • 94% asked to see photographs.
  • 77% provided a diagnosis while the others made a referral to a local physician.

The good news

Skin conditions that could be diagnosed based primarily on photographs were correctly identified in most cases. This included a patient with stasis dermatitis, a common inflammatory skin disease, and a patient with nodular melanoma, the most aggressive form of skin cancer. (Three of the 14 websites that reviewed this case said it was probably non-cancerous.)

The not so good news

For the remaining four cases, practitioners failed to ask the right questions, which resulted in missed diagnoses for the majority of patients. For example, 12 clinicians reviewed the case of the patient with polycystic ovarian syndrome. None dug deep enough to discover symptoms beyond the inflammatory acne she described. So she was treated for her acne but needed hormone therapy.

In another example, practitioners from nine websites reviewed the case of the patient with eczema herpeticum (a potentially life-threatening form of herpes); seven diagnosed her with regular eczema or an allergic reaction. Two of the websites gave her a prescription for prednisone, which would only have made her condition worse. 

The remaining two cases, which involved secondary syphilis and gram-negative folliculitis (a type of bacterial infection), were either misdiagnosed or referred to a local physician. 

Study conclusions

Researchers acknowledged that telemedicine can provide quality care. However, based on the results of this study, if a patient wants to use telemedicine for dermatology services, they recommend only using services provided by a practice where they are already an established patient.