key: cord-0989483-4h925or1
authors: Loh, C. H.; Tam, Y. C.; Oh, C. C.
title: Teledermatology in the COVID-19 pandemic: a systematic review
date: 2021-08-02
journal: JAAD Int
DOI: 10.1016/j.jdin.2021.07.007
sha: 89f9901d504c50205603db167143437afdcc10ac
doc_id: 989483
cord_uid: 4h925or1

Background Teledermatology (TD) has emerged as a critical way of delivering care remotely in the COVID-19 pandemic. Objective We conducted a systematic review to assess how TD has been implemented worldwide. Methods We searched PubMed, SCOPUS, EMBASE, Web of Science and Google Scholar for articles on the use of TD for patient care, written in English and published from December 1st 2019 to October 15th 2020. Results 27 studies were included, involving 16,981 patients. There was significant uptake of TD during the pandemic. Synchronous TD appeared to be more commonly implemented than asynchronous TD. Common ambulatory dermatoses such as acne or eczema were reported to be more amenable to TD assessment and management. TD also appeared to be useful for the diagnosis of cutaneous involvement of COVID-19 infection and follow-up of stable onco-dermatology cases. Limitations Pooled analysis of all relevant outcomes was not always possible due to the heterogeneity in methodologies of included studies. Conclusions TD is a useful and convenient tool for the management of common ambulatory dermatoses in the COVID-19 pandemic.

delivering care remotely to patients during the COVID-19 pandemic 1 . TD has been validated 105 as an effective mode of care before the pandemic 2-4 ; but the scale and ubiquity, in which TD 106 is practised during the pandemic, has been unprecedented. TD can be defined as the practice 107 of dermatology at a distance 5 . Asynchronous TD involves the transfer of medical information 108 and clinical photographs to a dermatologist for a review at a different time and location, 109 whereas synchronous TD is usually conducted via video-conferencing or telephone calls that 110 allows real-time interaction between the patient and physician 6 . Hybrid TD involves a 111 combination of both asynchronous and synchronous methods. We plan to analyse and report 112 on the worldwide utilisation of TD for patient care during the COVID-19 pandemic. 113

A study protocol was registered with the PROSPERO register of systematic reviews 116 (CRD42021233065). We searched PubMed, SCOPUS, EMBASE, Web of Science and 117

Google Scholar for original articles written in English and published from December 1 st 2019 118 to October 15 th 2020. We excluded articles that lacked direct relevance to the use of tele-119 dermatology for patient-care in the COVID-19 pandemic (Figure 1 ). Articles that reported 120 objective evidence or concrete experiences on the practice of TD were included for analysis. 121

We extracted the following data from the included studies: country in which the study was 122 conducted, method of TD, population involved, dermatological conditions managed, main 123 findings and limitations. Selection of articles for inclusion and data extraction was performed 124 independently by LCH and OCC. Any disagreements were resolved with a third independent 125 author (TYC). A risk-of-bias assessment of all included studies was performed (Appendix A). 126

This systematic review was performed in accordance with the PRISMA guidelines. 127 128 RESULTS 129 We summarised the findings of 27 articles on the use of TD for patient care, involving a total 130 of 16,981 patients worldwide. 131 132 10 studies reported on the use of asynchronous TD (Table 1) , 6 studies utilised synchronous 133 TD (Table 2) , 8 studies utilised hybrid TD and 3 studies did not specify the method of TD 134 utilised (Table 3) . There had been a significant increase in uptake of TD in dermatology 135 practice worldwide during the pandemic 7-11 .The prevalence of TD utilisation across various 136 institutions and countries was not consistently reported in most of the included articles. In a 137 al found that approximately 60% of lesions of concern that were seen via TD had to be 181 converted to FTF review or biopsy, or both, suggesting that assessment of lesions of concern 182 for malignancy and whole body skin checks were best accomplished via FTF consultations 20 . were less likely to have access to synchronous TD 20 . Similar to asynchronous TD, the image 192 quality of synchronous TD may also be sub-optimal, leading to a higher likelihood of missing 193 incidental pathologies such as skin cancers 22 . 194 195 Hybrid TD 196 Dermatoses that are reported to be amenable to hybrid TD are: acne 9, 24 , rosacea 24 , psoriasis 24 , 197 eczema 24 , cutaneous neoplasms 9 , urticaria 25 , vitiligo 25 , herpes zoster 25 , hidradenitis 198 suppurativa 26 . A diagnosis of acne was reported to be more common with asynchronous TD 199 as compared to synchronous TD 9 . remained clinically stable when followed-up with TD 30 . However, inadequate or inaccurate 219 assessment in occurred in 11.6% of TD consultations for suspected cancerous skin lesions, 220 which required conversion to FTF appointments, resulting in a mean delay of care of 9.8 221 days 31 . Perkins et al reported that whole body skin checks and lesions of concern requiring 222 biopsy were less amenable to management with TD 24 . 223

There are 4 studies in which the method of TD was not specified. Cristaudo requiring biopsy were less suitable for TD 43 . This is likely because patients may not be able 269 to take pictures or videos of hard-to-reach areas to facilitate visual diagnosisthese areas TD suitable for acne and non-specific dermatitis. 60% of TD consults for lesions of concern converted to FTF consultation or biopsy or both. Older and non-English speaking patients were less likely to access TD.

Limited proficiency with technology. Difficult to organise interpreter service. Patients hesitant to use TD 

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 TD can be utilised to manage common ambulatory dermatoses and assess cutaneous manifestations of COVID-19 infection, reserving face-to-face appointment for urgent clinical cases. There remain further challenges to utilisation of TD around the world.J o u r n a l P r e -p r o o f