What if dermatologists could peek into the lives of their patients outside of the office or clinic? This concept is not as far-fetched as it might sound. With the meteoric rise of teledermatology, physicians have already gotten a taste of how technology can influence medicine. Extending the practice into the patient’s home provides an opportunity to make health care more accessible, and a number of studies have shown the potential benefits of virtual visits for a variety of settings and diseases.
“As the COVID-19 crisis hit the United States and as lockdowns became mandatory across the country, doctors and patients alike realized that there was still a need to continue dermatologic care,” said Andrew Weinstein, MD, MPH, a board-certified dermatologist and fellow of American Academy of Dermatology at Boynton Beach Skin in Boynton Beach, FL. “But dermatology is a visual and tactile specialty, so providing care required some compromises. Technology can be a useful adjunct to care.”
Teledermatology is not the only end product of years of research and development. Technology is beginning to integrate into other aspects of medical practice, from patient-directed tech to artificial intelligence and more.
Patient Apps and Products
The patient’s perspective is the most important tool dermatologists should use when making a diagnosis. “Even in modern medicine, listening to the patient is still key to making an accurate diagnosis and forming an appropriate treatment plan,” said Dr Weinstein. He highlighted that medical students continue to learn to take a history of the patient’s chief compliant before even learning how to perform a physical examination. A long-term history of cutaneous changes, not just of the acute presentation, is ideal.
“As dermatologists are aware, monthly self-skin checks can make a difference when it comes to outcomes. This is where a patient directed app can be of value to your patients and your practice,” said Dr Weinstein. “Patient-generated images help patients to track their concerning lesions. Generating a photolog of these lesions helps to decrease personal recall bias. Since the images are available to their dermatologist, either in the context of screening visits or as a prompt for an early appointment, these apps can truly help patients and physicians alike make the most of skin-self exams.”
Patient-facing apps and products have the potential to elucidate gaps in care plans or adherence as well as empower patients to take a more active role in their disease management. A variety of apps are currently available, ranging from measuring exposures and behaviors to monitoring lesions. These apps can provide a central location to monitor skin and individual moles. For skin cancer, apps such as UMSkinCheck, MoleMapper, Miiskin, and MoleScope2 can provide a cost-effective and data-safe option for patients to record their skin changes. In addition, this method helps keep the patient’s skin health more private, preventing any accidental and embarrassing reveals when scrolling through the camera roll of their mobile phone.
“The added bonus,” explained Dr Weinstein, “is any patient-taken images of their lesions or concerns can help track changes over a period. Patients can monitor moles or other areas more closely and lessen their personal recall bias.”
Similarly, these apps can give patients an outlet to track their overall health and progression. Rijsbergen et al found that an e-diary app ensured proper treatment administration, concluding that it may be valuable for frequent and reliable monitoring of patient-reported outcomes. Additional applications, such as EczemaWise, have multiple tracking capabilities, allowing patients to monitor quality-of-life factors such as sleep and itch to provide a more holistic look of their disease. This information, when organized, can be an incredible useful tool in collecting patient history. Another useful function of patient apps is their utility in acting as a reminder. Studies have shown that use of an app can have a beneficial effect in therapeutic adherence.
Despite the overall usability, dermatologists need to be aware of the limitations in such patient-facing apps. A recent study showed that patients who used a skin monitoring app were neutral on whether they felt the app helped them manage their skin. A literature review regarding the remote monitoring of post-surgical wound healing emphasized that many patients still lack technological competence, which may greatly affect the reliability of the collected data.
Digital tools are not just for patients. In fact, dermatologists can integrate technology in new ways. Largely, these tools are geared toward education, and some of the currently available options include VisualDx, YouDermoscopy, MyDermPath, and UpToDate. These tools, particularly over the past year, have been integral to the education of dermatology’s next generation. The breadth of knowledge and interactivity allow residents, young professionals, and trainees to review their diagnostic skills or narrow down their diagnosis options by selecting components found on physical examination.
Chan and Markowitz9 recommend caution with physician-facing health-related apps. While these applications are widely used, these apps have not been approved by the three main governing bodies that regulate mobile medical apps, including the FDA, Federal Trade Commission, and the Office for Civil Rights.
A newer avenue of research into digital dermatology is artificial intelligence (AI). “AI, and devices that use it, are under development as decision-making aids. These use computer algorithms to create a ‘magic bullet’ to save us time and to save patients from unnecessary procedures and costs,” said Dr Weinstein. “However, I do not believe that AI-supported decision-making is ready for wide use in dermatology just yet. While medicine will continue to benefit from advances in computing and image capture, the practiced eye of a dermatologist is still the best tool we have in the fight against skin cancer.”
The literature seems to support this statement. Chung et al demonstrated poor automated risk assessment of a mobile app for the evaluation of skin cancer when compared with a dermatologist. Likewise, teledermoscopy did not increase sensitivity of skin cancer detection vs the naked-eye skin self-examination. Though the specificity of diagnosing skin cancer is much lower in smartphone apps than that of a dermatologist, these apps may be useful in the pre-evaluation of pigmented moles by patients.
Dermatology, and medicine in general, continues to navigate these new digital ventures. While teledermatology and technology cannot replace the clinical utility of in-office appointments, these tools can serve as great adjuncts to care in and out of the practice. No matter what tech is used, said Dr Weinstein, dermatologists should never be afraid to bring a patient in for additional examination. The future of the field may look more digitized, but dermatologists will continue to be the experts in providing human care.
1. Beer J, Hadeler E, Calume A, Gitlow H, Nouri K. Teledermatology: current indications and considerations for future use. Arch Dermatol Res. Published online October 19, 2020. doi:10.1007/s00403-020-02145-3
2. Galan N. How effective are skin cancer apps for early detection? MedicalNewsToday. Published August 21, 2019. Accessed January 29, 2021. https://www.medicalnewstoday.com/articles/285751
3.Rijsbergen M, Niemeyer-van der Kolk T, Rijneveld R, et al. Mobile e-diary application facilitates the monitoring of patient-reported outcomes and a high treatment adherence for clinical trials in dermatology. J Eur Acad Dermatol Venereol. 2020;34(3):633-639. doi:10.1111/jdv.15872
4. Mateja L. Empower your patients to monitor their eczema symptoms. The Dermatologist. 2020;28(12):28. Accessed January 29, 2021. https://www.the-dermatologist.com/article/eczemawise-1220
5. Joergensen KM, Vestergaard C, Joergensen MS, et al. Memory buttons in combination with mobile application-induced objective and subjective effects in patients with atopic dermatitis. Dermatol Res Pract. 2020;2020;8915893. doi: 10.1155/2020/8915893
6. Glines KR, Haidari W, Ramani L, Akkurt ZM, Feldman SR. Digital future of dermatology. Dermatol Online J. 2020;26(10):13030/qt75p7q57j
7. Hampton P, Richardson S, Brown S, Goodhead C, Montague K, Olivier P. Usability testing of MySkinSelifie: a mobile phone application for skin self-monitoring. Clin Exp Dermatol. 2020;45(1):73-78. doi:10.1111/ced.13995
8. Wang SC, Au Y, Ramirez-GarciaLuna JL, Lee L, Berry GK. The promise of smartphone applications in the remote monitoring of postsurgical wounds: a literature review. Adv Skin Wound Care. 2020;33(9):489-496. doi:10.1097/01.ASW.0000694136.29135.02
9. Chan CX, Markowtiz O. APPlying knowledge: evidence for and regulation of mobile apps for dermatologists. Cutis. 2020;106(2):76-78. doi:10.12788/cutis.0036
10. Chung Y, van der Sande AAJ, de Roos KP, et al. Poor agreement between the automated risk assessment of a smartphone application for skin cancer detection and the rating by dermatologists. J Eur Acad Dermatol Venereol. 2020;34(2):274-278. doi:10.1111/jdv.15873
11. Janda M, Horsham C, Vagenas D, et al. Accuracy of mobile digital teledermoscopy for skin self-examinations in adults at high risk of skin cancer: an open-label, randomised controlled trial. Lancet Digit Health. 2020;2(3):e129-e137. doi:10.1016/S2589-7500(20)30001-7.
12.Wolf JA, Moreau JF, Patton TJ, Winger DG, Ferris LK. Prevalence and impact of health-related internet and smartphone use among dermatology patients. Cutis. 2015;95(6):323-328.
13. Maier T, Kulichova D, Schotten K, et al. Accuracy of a smartphone application using fractal image analysis of pigmented moles compared to clinical diagnosis and histological result. J Eur Acad Demratol Venereol. 2015;29(4):663-667. doi:10.1111/jdv.12648