|Year : 2020 | Volume
| Issue : 5 | Page : 3-10
Teledermatology practice in the COVID-19 pandemic
Garehatty Rudrappa Kanthraj, Jayadev B Betkerur
Department of Dermatology, Venereology and Leprosy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
|Date of Submission||01-May-2020|
|Date of Decision||01-May-2020|
|Date of Acceptance||02-May-2020|
|Date of Web Publication||04-Jun-2020|
Garehatty Rudrappa Kanthraj
Department of Dermatology, Venereology and Leprosy, JSS Hospital, JSS Academy of Higher Education and Research, Mahatma Gandhi Road, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Pandemics like influenza and plague have posed a great threat to humanity in the past. Recent outbreak of COVID-19, a viral pandemic, has motivated the global community for social distancing and enforcement of lockdown. Teledermatology practice (TP) is an effective, safe, and fast medium to reach one who is difficult to reach. It is a medium for a dermatologist to cater the needy patients. Store-and-forward (SAF) teledermatology mobile apps (e.g., WhatsApp) perform to capture, transfer, and store the clinical images. This overview provides an insight to TP. In an Indian scenario, SAF TP meets the technical requirement, economical, and easy to practice. Spotters, pediatric, geriatric, and chronic cases are managed with TP. The Indian Association of Dermatologists, Venereologists, and Leprologists in view of COVID-19 situation encourages its members to perform TP and provide care. The members may practice TP after observing all conditions as in telemedicine guidelines prepared by the National Medical Council with due caution.
Keywords: COVID-19, messenger apps, online discussion forum, teledermatology practice
|How to cite this article:|
Kanthraj GR, Betkerur JB. Teledermatology practice in the COVID-19 pandemic. Int J Health Allied Sci 2020;9, Suppl S1:3-10
|How to cite this URL:|
Kanthraj GR, Betkerur JB. Teledermatology practice in the COVID-19 pandemic. Int J Health Allied Sci [serial online] 2020 [cited 2020 Aug 6];9, Suppl S1:3-10. Available from: http://www.ijhas.in/text.asp?2020/9/5/3/285967
| History of Telemedicine|| |
In 1906, Wilhelm Einthoven discovered telecardiogram and was successful in the transmission of electrocardiogram using a telephone network. The Nebraska Project, USA, in 1959, used videoconference for psychiatry patients which was conducted between two hospitals within a distance of 150 km. Between 1960 and 1970, research to monitor astronaut's heart rate, blood pressure, and electrocardiogram was conducted. The term teledermatology was introduced by Perednia and Brown. Teledermatology in a nursing home setting was first demonstrated by Zelickson and Homan.
Teledermatology practice (TP) is performed everywhere including as far as South Pole, as remote as Faroe Islands, rural India, USA, Africa, and in austere environments. Teledermatology is a branch of dermatology involving application of electronics, communications, and information technology to transmit the information between the patient and dermatologist and vice versa for research and practice to cater dermatology care.,
Similar to radiology, dermatology is a visual specialty; availability of clinical and histopathological images for diagnosis makes it an ideal choice for TP.
A TP consultation is provided without exposing staff to viruses/infections in the times of contagious disease outbreaks like COVID. TP can prevent the transmission of infectious diseases, reducing the risks to both health-care workers and patients. Unnecessary and avoidable exposure of the people involved in delivery of health care can be avoided using TP. COVID-19, a viral pandemic, is a well-suited scenario, in which dermatologists can evaluate and manage patients.
The aim of TP is to reach the one who is difficult to reach. For dermatology care in remote geographic regions or needy population in situ ations like serious pandemics like COVID-19 where the population is under lockdown, early care is provided and difficult to manage cases that are not neglected.
| Scope and Purpose/indications|| |
TP reduces multiple visits for follow-up care and benefits elderly, especially those coming from far-off places. It saves cost and time. A TP applies to diagnosis, treatment, and follow-up of skin disorders and education. Teledermatology was found to be cost-effective and reliable in reducing in-person visits, saves time, and allows for the faster delivery of care. TP provides triage and reduces waiting time. The various indications,,,,,,,,,,,,, are summarized in [Table 1].
|Table 1: Summarizes the various indications for teledermatology practice|
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| Teledermatology for 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.
| Teledermatology for Paediatric Care|| |
Accurate triage and diagnosis of childhood dermatology cases decrease travel and outpatient clinic visits and provide an avenue for ongoing support and education for primary care physicians.
| Teledermatology for Emergency Conditions|| |
The Skin Emergency Telemedicine Service has proved to be a successful, sustainable, and valuable addition to the specialist dermatology services provided across Queensland, Australia. The use of teledermatology within the context of emergency-based care has gained a high degree of patient's acceptance and confidence. New-generation mobile devices reduce the cost of videoconferencing, increase the adaptability of teledermatology, and decrease general practitioner time.,,
| Teledermatology and Diagnostic Agreement|| |
Systematic reviews by Levin and Warshaw showed that there is a good diagnostic agreement when comparing a teledermatology diagnosis and in-person clinical diagnosis or histopathology with traditional face-to-face consultations. The diagnosis concordance between dermatologists and teledermatologists increased from 92% to 98% (95% confidence interval [CI]: 87%–100%) when overlaps between differential diagnoses were considered as partial agreements. The diagnostic accuracy of store-and-forward (SAF) TP was good and comparable to videoconference TP. Health-care providers need to plan for appropriate utility of SAF-TP either alone or in combination with videoconference TP to implement and deliver teledermatology care in India. Messenger apps (e.g. WhatsApp) are a medium for TP.
| Teledermatology and Patient Satisfaction|| |
One of the main areas of patient dissatisfaction for both live video and SAF teledermatology revolved around the lack of follow-up. Therefore, the referring physician plays a pivotal role in conveying the dermatologist's recommendations to the patient, which can have a major impact on patient satisfaction in the field. Patient satisfaction will play an integral role in the further growth, development, and implementation of teledermatology. Direct consult may increase patient satisfaction.
| Teledermatology and Cost–-Effectiveness|| |
Teledermatology is cost-effective in terms of significantly decreasing the need for in-person visits. Real-time interactive teledermatology has been found to be time-consuming than store-and-forward dermatology. Video call is mostly used to counsel the patient.
| The Organization of Teledermatology Practice|| |
The organization of TP for a self-practicing dermatologist is illustrated in [Figure 1]. It comprises a basic model SAF teledermatology where a dermatologist interacts with the patients directly for regular cases (spotters) along with online discussion forum to obtain a second opinion on management of difficult-to-manage cases.,
|Figure 1: Illustration of the organization and process involved in teledermatology practice for a dermatologist to manage regular case (to use store and forward teledermatology practice) as well as difficult-to-manage cases (to use online discussion forum) and deliver care (modified with permission from Kanthraj GR. J Eur Acad Dermatol Venereol 2010;24:961-6. and Kanthraj GR. Indian J Dermatol Venereol Leprol 2011;77:276-87)|
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| Prerequisites for Teledermatology Practice|| |
- A dermatologist should obtain a proper history
- Patient should be able to provide electronic images of the skin disorder. Landow summarizes the requirements for a successful TP as: (1) image quality; (2) preselection of patients (tumoral conditions are the simplest; nevi evaluation should not exceed 1–2 lesions at most; multiple nevi patients should be excluded; and hair conditions are difficult to photograph and diagnose); and (3) a dermoscopic image is a requirement for pigmented and tumoral lesions; and good internet connectivity is a necessity.
| Store-And-Forward Teledermatology|| |
Static images of clinical and histopathological data are accessed anytime and anywhere. They are transferred from a general practitioner to a specialist to deliver the management. Dermatology cases that can be diagnosed by face-to-face examinations (spotters) have a good diagnostic accuracy by SAF TP. A diagnosis agreement of 89% has been documented. SAF TP is cheap and easy to set up and practice. It is the most common teledermatology tool as most of the cases are dealt and often regarded as a basic model for a TP.
| Videoconference|| |
It is a live or interactive teledermatology. General practitioner, patient, and specialist interact with one another using live/motion images. Various feasibility studies, have confirmed good diagnostic accuracy when videoconference is compared to face-to-face consultation.
| Hybrid Teledermatology|| |
This is a combination of both videoconference and SAF TP to overcome the shortcomings faced when either of them is used individually.
| Store-And-Forward Teledermatology Versus Videoconference|| |
Good patient and physician satisfaction along with good diagnostic accuracy is achieved in all. The simultaneous presence of a health-care professional is required in videoconference and hybrid teledermatology and his or her presence may not be required in SAF TP. SAF TP is the most cost-effective and convenient compared to videoconference. The time taken for consultation is least for SAF TP and more in videoconference and hybrid teledermatology. Motion images are used in videoconference, still images are used in SAF TP, and both the types of images are used in hybrid teledermatology. A hybrid system with audio is no better than SAF TP alone. However, in the current context of mobile messenger apps -whatsapp consultation for example, still images and videos can be stored and forwarded. It has emerged as a widely used medium for TP.
| Mobile Teledermatology|| |
The term mobile teledermatology represents the transmission of images via mobile phones, as well as through personal digital assistants. Motion and still images are transferred. Advanced net-work technology along with the mobile messenger apps has revolutionized TP. Android technology and apps find an application medium to capture, transfer, and store the images.,
| Teledermatopathology|| |
Transmission of histopathological images of the skin using information technology for expert opinion is called teledermatopathology. Teledermatopathology is achieved by (i) video-image (dynamic) analysis; (ii) SAF (static); and (iii) web-based virtual slide system. A virtual slide system is a recently developed technology where a robotic microscope is used; any field of the specimen is selected for better digitalization at any required magnification at the discretion of the dermatopathologist.
| Teledermoscopy|| |
Pigmented skin lesions and melanoma are analyzed based on the dermoscopic criteria that depend on characteristic changes in the epidermis and dermis. Dermoscopy images are transmitted for expert opinion using routine TP tools like SAF TP or tertiary TP for the second opinion. If these images are transferred using mobile technology, it is called mobile teledermoscopy. Pigmentary skin lesions are screened using mobile teledermoscopy.,,,,
| Online Discussion Forums|| |
Difficult to manage cases is a challenge to the health-care system. An online discussion forum is formed with a group of dermatologists who share constructive suggestions,, for a submitted case. Feasibility studies have confirmed 81% concordance with face-to-face consultation. Members of academic societies such as the Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL) have formed an online discussion forum at ACAD_IADVL@googlegroups.com (an e-mail group) and participate in regular academic discussions. Telederm.org, Rxderm, Virtual Grand Rounds in Dermatology, and Black Skin Dermatology Online are the examples of online discussion forums. Experts may be unavailable for an instant case or dermatologists and allied research workers who might have carried out research involving an online discussion forum may not have registered at the site and at times consensus may not be reached for a case without these experts are the limitations of online discussion forum.,,,,
The various teledermatology tools and health-care professionals involved to provide dermatology care are summarized in [Figure 2].
|Figure 2: Summarizes the various teledermatology tools used for patient care (reproduced with permission from Kanthraj GR. Indian J Dermatol Venereol Leprol 2015;81:136-43)|
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Poor net connectivity, poor image quality, and lack of referral pro forma data can limit TP. All cases may not be feasible with an objective of diagnosis in TP. The cases that are not diagnosed by spot examination are summarized in [Table 2].
|Table 2: Summarizes the various clinical situations a dermatologist may choose not to offer teledermatology practice for diagnosis purpose|
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The requirements for real-time videoconferencing (synchronous encounters) and SAF teledermatology have been specified by the American Telemedicine Association. Monitors for viewing images shall have a minimum of 1024 × 768 pixel resolution, minimum contrast ratio of 500:1, minimum luminance of 250 cd/m, and minimum dot pitch of 0.19.
In India, till now, there was no legislation or guidelines on the practice of telemedicine through video-, phone-, and internet-based platforms (web/chat/apps etc.). Recently, the board of governors (BoGs) of the Medical Council of India (MCI) along with NITI Aayog have prepared the guidelines for telemedical practice. The detailed guidelines about the role of patient, health-care provider, and technology platform are highlighted. Each patient will be identified by a unique and universal patient identifier so that one central patient information record can be assimilated, comprehensive medical databases can be built, or if the patient wants, he/she can move across multiple providers without losing data. The same principles apply irrespective of the mode (video, audio, and text) used for a telemedicine consultation.
Guidelines for technology platforms enabling telemedicine prepared by the board of governors of medical council of India along with NITI Aayog
This specifically covers those technology platforms which work across a network of Registered Medical Practitioners (RMPs) and enable patients to consult with RMPs through the platform.
- Technology platforms (mobile apps, websites, etc.) providing telemedicine services to consumers shall be obligated to ensure that the consumers are consulting with RMP duly registered with Ntional Medical Councils (NMCs) or respective state medical council and comply with relevant provisions
- Technology platforms shall conduct their due diligence before listing any RMP on its online portal. Platform must provide the name, qualification, registration number, and contact details of every RMP listed on the platform
- In the event some noncompliance is noted, the technology platform shall be required to report the same to BoGs, in supersession to the MCI who may take appropriate action
- Technology platforms based on artificial intelligence/machine learning are not allowed to counsel the patients or prescribe any medicines to a patient. Only a RMP is entitled to counsel or prescribe and has to directly communicate with the patient in this regard. While new technologies such as artificial intelligence, Internet of things, and advanced data science-based decision support systems could assist and support a RMP on patient evaluation, diagnosis, or management, the final prescription or counseling has to be directly delivered by the RMP
- Technology platform must ensure that there is a proper mechanism in place to address any queries or grievances that the end-customer may have
- In case any specific technology platform is found in violation, BoG, MCI, may designate the technology platform as blacklisted, and no RMP may then use that platform to provide telemedicine.
| Teledermatology and Law|| |
There is no definite legislation addressing the TP. One cannot take shelter on the pretext of teledermatology consultation. A medicolegal principle of traditional consultation applies to TP. All prescriptions need to be signed duly by a RMP as per the Drugs and Cosmetic Rules 1945. The physician is responsible for the issues related to security, privacy, and confidentiality of patient data. The American Telemedicine Association Guidelines recommend that each health-care provider and patient should have a unique identifier and the images are stored confidentially in secured data base. Encryption for storage of patient data and for transmitting medical information should be inbuilt.
Use a disclaimer which may read as “the medical opinion is only based on records available without direct contact with the patient and hence, this advice is only to guide the referring doctor and cannot equate face-to-face consultation.”
| Medical Ethics, Data Privacy, and Confidentiality|| |
Principles of medical ethics including professional norms for protecting patient privacy and confidentiality as per the Indian Medical Council (IMC) Act shall be binding and must be upheld and practiced. RMP would be required to fully abide by the IMC (Professional conduct, Etiquette, and Ethics) Regulations, 2002, and with the relevant provisions of the IT Act, data protection and privacy laws or any applicable rules notified from time to time for protecting patient privacy and confidentiality and regarding the handling and transfer of such personal information regarding the patient. This shall be binding and must be upheld and practiced.
RMP will not be held responsible for breach of confidentiality if there is a reasonable evidence to believe that patient's privacy and confidentiality has been compromised by a technology breach or by a person other than RMP. The RMPs should ensure that reasonable degree of care is undertaken during hiring such services.
| Teledermatology and Education|| |
TP plays a vital role in education. Resident training, exchange of knowledge and opinion between different dermatologists, and learning of dermatological diseases from different parts of the world are the roles of tele-education.,,,
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-on-one basis. It is considered to be one of the safest instant messaging media because of encryption technology. Dermatology residents feel more confident at handling various disorders with additional TD learning. TD can reduce the residents' empathetic nature toward patients and reduce the patient–physician relationship and loss of integral approach rather than focusing on single lesions.,
| Teledermatology and Reimbursement|| |
Reimbursement policies for teledermatology services are rather new and vary significantly from place to place. The Netherlands offers full reimbursement for services and has completely integrated teledermatology into its health-care system. However, in the United States, reimbursement remains a major challenge in telemedicine and continues to evolve in recent years. Currently, all states and the District of Columbia have defined telemedicine law, regulations and Medicaid policies. In USA reimbursement varies from state to state. Reimbursement for live video teledermatology far exceeds the reimbursement for SAF teledermatology. Many states restrict reimbursement coverage to live video teledermatology only and exclude SAF teledermatology.
In the Indian context as per the recent NMC guideline, telemedicine consultations should be treated the same way as in-person consultations from a fee perspective: RMP may charge an appropriate fee for the telemedicine consultation provided. An RMP should also give a receipt/invoice for the fee charged for providing telemedicine-based consultation.
| A Protocol for Teledermatology Practice|| |
According to a survey completed by Armstrong et al., most teledermatology programs have shifted from live interaction video to the SAF modality due to its technological flexibility and lower cost of service delivery. A dermatologist should screen the received clinical image from a general practitioner or self-acquired patient images, (selfies) and define the objective/purpose of dermatology care [Figure 3]. 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 purpose [Table 2]. In these cases, a dermatologist can perform face-to-face examination, investigate, analyze the case, offer treatment and provide follow-up care by TP [Figure 3].
| Conclusion|| |
In an Indian scenario, mobile teledermatology using messenger apps, for example, WhatsApp, can be used with good diagnostic accuracy and patient satisfaction. Mobile messenger apps provide a dermatologist to capture and transfer the clinical images either in still (SAF) and motion (video) or both. Recently, the BoGs (MCI) have proposed guidelines for telemedical practice. The IADVL in view of COVID-19 situation encourages its members to perform TP and provide care. The members may practice teledermatology after observing all conditions as in telemedicine guidelines prepared by NMC with due caution.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stanberry B. Telemedicine: Barriers and opportunities in the 21st
century. J Intern Med 2000;247:615-28.
Zundel KM. Telemedicine: History, applications, and impact on librarianship. Bull Med Libr Assoc 1996;84:71-9.
Cipolat C, Geiges M. The history of telemedicine. Curr Probl Dermatol 2003;32:6-11.
Perednia DA, Brown NA. Teledermatology: One application of telemedicine. Bull Med Libr Assoc 1995;83:42-7.
Zelickson BD, Homan L. Teledermatology in the nursing home. Arch Dermatol 1997;133:171-4.
Sun A, Lanier R, Diven D. A review of the practices and results of the UTMB to South Pole teledermatology program over the past six years. Dermatol Online J 2010;16:16.
Jemec GB, Heidenheim M, Dam TN, Vang E. Teledermatology on the Faroe Islands. Int J Dermatol 2008;47:891-3.
Feroze K. Teledermatology in India: Practical implications. Indian J Med Sci 2008;62:208-14.
] [Full text]
Vallejos QM, Quandt SA, Feldman SR, Fleischer AB Jr., Brooks T, Cabral G, et al
. Teledermatology consultations provide specialty care for farmworkers in rural clinics. J Rural Health 2009;25:198-202.
Kaddu S, Soyer HP, Gabler G, Kovarik C. The Africa teledermatology project: Preliminary experience with a sub-Saharan teledermatology and e-learning program. J Am Acad Dermatol 2009;61:155-7.
McManus J, Salinas J, Morton M, Lappan C, Poropatich R. Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments. Prehosp Disaster Med 2008;23:210-6.
Kanthraj GR. Newer insights in teledermatology practice. Indian J Dermatol Venereol Leprol 2011;77:276-87.
] [Full text]
Hofmann-Wellenhof R, Salmhofer W, Binder B, Okcu A, Kerl H, Soyer HP. Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers. J Telemed Telecare 2006;12 Suppl 1:15-7.
Bianciardi Valassina MF, Bella S, Murgia F, Carestia A, Prosseda E. Telemedicine in pediatric wound care. Clin Ter 2016;167:e21-3.
Koller S, Hofmann-Wellenhof R, Hayn D, Weger W, Kastner P, Schreier G, et al
. Teledermatological monitoring of psoriasis patients on biologic therapy. Acta Derm Venereol 2011;91:680-5.
Frühauf J, Schwantzer G, Ambros-Rudolph CM, Weger W, Ahlgrimm-Siess V, Salmhofer W, et al
. Pilot study using teledermatology to manage high-need patients with psoriasis. Arch Dermatol 2010;146:200-1.
Armstrong AW, Parsi K, Schupp CW, Mease PJ, Duffin KC. Standardizing training for psoriasis measures: Effectiveness of an online training video on Psoriasis Area and Severity Index assessment by physician and patient raters. JAMA Dermatol 2013;149:577-82.
Trindade MA, Wen CL, Neto CF, Escuder MM, Andrade VL, Yamashitafuji TM, et al
. Accuracy of store-and-forward diagnosis in leprosy. J Telemed Telecare 2008;14:208-10.
Watson AJ, Bergman H, Williams CM, Kvedar JC. A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne. Arch Dermatol 2010;146:406-11.
Singer HM, Almazan T, Craft N, David CV, Eells S, Erfe C, et al
. Using network oriented research assistant (NORA) technology to compare digital photographic with in-person assessment of acne vulgaris. JAMA Dermatol 2018;154:188-90.
Ivens U, Serup J, O'goshi K. Allergy patch test reading from photographic images: Disagreement on ICDRG grading but agreement on simplified tripartite reading. Skin Res Technol 2007;13:110-3.
Grey KR, Hagen SL, Hylwa SA, Warshaw EM. Utility of store and forward teledermatology for skin patch test readings. Dermatitis 2017;28:152-61.
Moreno-Ramírez D, Ferrándiz L. A 10-year history of teledermatology for skin cancer management. JAMA Dermatol 2015;151:1289-90.
Massone C, Maak D, Hofmann-Wellenhof R, Soyer HP, Frühauf J. Teledermatology for skin cancer prevention: An experience on 690 Austrian patients. J Eur Acad Dermatol Venereol 2014;28:1103-8.
Moreno-Ramirez D, Ferrandiz L, Nieto-Garcia A, Carrasco R, Moreno-Alvarez P, Galdeano R, et al
. Store-and-forward teledermatology in skin cancer triage: Experience and evaluation of 2009 teleconsultations. Arch Dermatol 2007;143:479-84.
Kanthraj GR. Teledermatology: Its role in dermatosurgery. J Cutan Aesthet Surg 2008;1:68-74.
] [Full text]
Rubegni P, Nami N, Cevenini G, Poggiali S, Hofmann-Wellenhof R, Massone C, et al
. Geriatric teledermatology: Store-and-forward vs. face-to-face examination. J Eur Acad Dermatol Venereol 2011;25:1334-9.
Fieleke DR, Edison K, Dyer JA. Pediatric teledermatology – A survey of current use. Pediatr Dermatol 2008;25:158-62.
Finnane A, Siller G, Mujcic R, Soyer HP. The growth of a skin emergency teledermatology service from 2008 to 2014. Australas J Dermatol 2016;57:14-8.
Jünger M, Arnold A, Lutze S. Teledermatology for emergency patient care: Two-year experience with teledermatological emergency care. Hautarzt 2019;70:324-8.
Duong TA, Cordoliani F, Julliard C, Bourrat E, Regnier S, de Pontual L, et al
. Emergency department diagnosis and management of skin diseases with real-time teledermatologic expertise. JAMA Dermatol 2014;150:743-7.
Levin YS, Warshaw EM. Teledermatology: A review of reliability and accuracy of diagnosis and management. Dermatol Clin 2009;27:163-76, vii.
Kanthraj GR. A longitudinal study of consistency in diagnostic accuracy of teledermatology tools. Indian J Dermatol Venereol Leprol 2013;79:668-78.
] [Full text]
Williams TL, Esmail A, May CR, Griffiths CE, Shaw NT, Fitzgerald D, et al
. Patient satisfaction with teledermatology is related to perceived quality of life. Br J Dermatol 2001;145:911-7.
Whited JD. Teledermatology. Current status and future directions. Am J Clin Dermatol 2001;2:59-64.
Landow SM, Mateus A, Korgavkar K, Nightingale D, Weinstock MA. Teledermatology: Key factors associated with reducing face-to-face dermatology visits. J Am Acad Dermatol 2014;71:570-6.
Loane MA, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al
. A comparison of real-time and store-and-forward teledermatology: A cost-benefit study. Br J Dermatol 2000;143:1241-7.
Kanthraj GR. Authors' willingness for second-opinion teledermatology in difficult-to-manage cases: An online survey. J Eur Acad Dermatol Venereol 2010;24:961-6.
Pasquali P, Sonthalia S, Moreno-Ramirez D, Sharma P, Agrawal M, Gupta S, et al
. Teledermatology and its current perspective. Indian Dermatol Online J 2020;11:12-20.
] [Full text]
High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776-83.
Baba M, Seçkin D, Kapdaǧli S. A comparison of teledermatology using store-and-forward methodology alone, and in combination with Web camera videoconferencing. J Telemed Telecare 2005;11:354-60.
Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al
. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. BMJ 2000;320:1252-6.
Edison KE, Dyer JA. Teledermatology in Missouri and beyond. Mo Med 2007;104:139-43.
Romero G, Sánchez P, García M, Cortina P, Vera E, Garrido JA. Randomized controlled trial comparing store-and-forward teledermatology alone and in combination with web-camera videoconferencing. Clin Exp Dermatol 2010;35:311-7.
Braun RP, Vecchietti JL, Thomas L, Prins C, French LE, Gewirtzman AJ, et al
. Telemedical wound care using a new generation of mobile telephones: A feasibility study. Arch Dermatol 2005;141:254-8.
Massone C, Lozzi GP, Wurm E, Hofmann-Wellenhof R, Schoellnast R, Zalaudek I, et al
. Cellular phones in clinical teledermatology. Arch Dermatol 2005;141:1319-20.
Massone C, Lozzi GP, Wurm E, Hofmann-Wellenhof R, Schoellnast R, Zalaudek I, et al
. Personal digital assistants in teledermatology. Br J Dermatol 2006;154:801-2.
Pecina JL, Wyatt KD, Comfere NI, Bernard ME, North F. Uses of mobile device digital photography of dermatologic conditions in primary care. JMIR Mhealth Uhealth 2017;5:e165.
Moreno-Ramírez D, Argenziano G. Teledermatology and mobile applications in the management of patients with skin lesions. Acta Derm Venereol 2017;Suppl 218:31-5.
Massone C, Soyer HP, Lozzi GP, Di Stefani A, Leinweber B, Gabler G, et al
. Feasibility and diagnostic agreement in teledermatopathology using a virtual slide system. Hum Pathol 2007;38:546-54.
Massone C, Brunasso AM, Campbell TM, Soyer HP. State of the art of teledermatopathology. Am J Dermatopathol 2008;30:446-50.
Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L, et al
. Teledermoscopy – Results of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6:132-7.
Massone C, Hofmann-Wellenhof R, Ahlgrimm-Siess V, Gabler G, Ebner C, Soyer HP. Melanoma screening with cellular phones. PLoS One 2007;2:e483.
Carli P, de Giorgi V, Chiarugi A, Nardini P, Weinstock MA, Crocetti E, et al
. Addition of dermoscopy to conventional naked-eye examination in melanoma screening: A randomized study. J Am Acad Dermatol 2004;50:683-9.
Dahlén Gyllencreutz J, Paoli J, Bjellerup M, Bucharbajeva Z, Gonzalez H, Nielsen K, et al
. Diagnostic agreement and interobserver concordance with teledermoscopy referrals. J Eur Acad Dermatol Venereol 2017;31:898-903.
Soyer HP, Hofmann-Wellenhof R, Massone C, Gabler G, Dong H, Ozdemir F, et al
. telederm.org: Freely available online consultations in dermatology. PLoS Med 2005;2:e87.
Huntley AC, Smith JG. New communication between dermatologists in the age of the Internet. Semin Cutan Med Surg 2002;21:202-4.
Lozzi GP, Soyer HP, Massone C, Micantonio T, Kraenke B, Fargnoli MC, et al
. The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory, neoplastic skin diseases: A best practice model in dermatology? J Eur Acad Dermatol Venereol 2007;21:30-4.
Hu SW, Foong HB, Elpern DJ. Virtual grand rounds in dermatology: An 8-year experience in web-based teledermatology. Int J Dermatol 2009;48:1313-9.
Ezzedine K, Amiel A, Vereecken P, Simonart T, Schietse B, Seymons K, et al
. Black skin dermatology online, from the project to the website: A needed collaboration between North and South. J Eur Acad Dermatol Venereol 2008;22:1193-9.
Kanthraj GR. Patient-assisted teledermatology practice: What is it? When, where, and how it is applied? Indian J Dermatol Venereol Leprol 2015;81:136-43.
] [Full text]
McKoy K, Antoniotti NM, Armstrong A, Bashshur R, Bernard J, Bernstein D, et al
. Practice Guidelines for Teledermatology. Telemed J E Health 2016;22:981-90.
Telemedicine Telemedicine Practice Guidelines –Ministry of Health and Family Welfare –MoHFW. Available from: http://www.mohfw.gov.in'pdf'
. [Last accessed on 2020 Apr 10].
Eedy DJ, Wootton R. Teledermatology: A review. Br J Dermatol 2001;144:696-707.
Thomas J, Kumar P. The scope of teledermatology in India. Indian Dermatol Online J 2013;4:82-9.
] [Full text]
Hogan SC, van Hees C, Asiedu KB, Fuller LC. WhatsApp platforms in tropical public health resource-poor settings. Int J Dermatol 2019;58:228-30.
Yeung H, Sargen MR, Luk KM, Berry EG, Gurnee EA, Heuring E, et al
. Teledermatology and teledermatopathology as educational tools for international dermatology: A virtual grand rounds pilot curriculum. Int J Dermatol 2018;57:1358-62.
Williams CM, Kedar I, Smith L, Brandling-Bennett HA, Lugn N, Kvedar JC. Teledermatology education for internal medicine residents. J Am Acad Dermatol 2005;52:1098-9.
Tensen E, van der Heijden JP, Jaspers MW, Witkamp L. Two decades of teledermatology: Current status and integration in national healthcare systems. Curr Dermatol Rep 2016;5:96-104.
Armstrong AW, Wu J, Kovarik CL. State of teledermatology program in the United States. J Am Acad Dermatol 2012;67:939-44.
Hogan K, Cullan J, Patel V, Rajpara A, Aires D. Overcalling a teledermatology selfie: A new twist in a growing field. Dermatol Online J 2015;21. pii: 13030/qt84x5d2gg.
Damanpour S, Srivastava D, Nijhawan RI. Self-acquired patient images: The promises and the pitfalls. Semin Cutan Med Surg 2016;35:13-7.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]