Infrastructure improvements needed for teledermatology
Remote and Indigenous communities in Canada often lack the bandwidth for remote access to medical specialist expertise (1,500 words, 7 minutes).
There is a shortage of dermatologists practicing in remote northern and Indigenous communities in Canada, Eric McMullen told the 9th annual Skin Spectrum Summit on Oct. 21, 2023. While teledermatology could help residents of these regions with access to specialist care, most northern Indigenous communities lack adequate internet speed and reliability to support the service. Primary care physicians, who end up seeing many of the dermatology cases, also need more support and education to improve patient outcomes, he said.
McMullen is a final-year McMaster University medical student and a member of the Métis Nation of Ontario. His clinical interests include Indigenous dermatology, teledermatology, and rural care.
McMullen cited a paper titled “Patients Living in Rural Northern and Remote Areas of Ontario Have Inequitable Access to Dermatology Care Compared to Urban Areas” he co-authored, that found of 268 dermatologists in practice in Ontario, only five practices are in rural areas, and only 11 are in the province’s north.
The paper also evaluated internet speeds available in different regions, with a benchmark of 25 megabits per second as a minimum needed for effective teledermatology services. Some of the paper’s findings include:
Many Indigenous communities in northern Canada lack high enough speeds to permit reliable use of teledermatology.
In Ontario, higher internet speeds and dermatologists tend to be available in larger cities.
Smaller provinces such as New Brunswick or P.E.I. do have widespread access to high-speed internet, largely because less infrastructure is required to support broadband internet in a smaller area.
Increased awareness and increased funding are needed to find solutions to the barriers to widespread adoption of teledermatology, he said.
Bottom Line: There is a lack of dermatologists practicing in remote northern communities, leading to many Indigenous communities lacking access to skin care specialists. Teledermatology might be a solution, but internet speeds are not adequate in many remote Indigenous communities. More dermatologists practicing in remote areas are needed.
From the literature on teledermatology
Gender and ethnic disparities in teledermatology clinical trial participants: Cross-sectional analysis of ClinicalTrials.gov-registered trials
In this analysis, researchers evaluated available trial participant data from the ClinicalTrials.gov trial registry of the U.S. National Library of Medicine. They included all studies related to the use of teledermatology.
The database search yielded 35 clinical trials, of which 25 (71%) were completed and three (9%) had available results. At the time of the search, seven (20%) of the trials were recruiting, two (6%) had unknown status, and one (3%) was withdrawn. About 77% (27/35) were funded by non–National Institutes of Health, non–U.S. federal funding (i.e., industry). Eight (23%) studies were observational and 27 (77%) were interventional.
From the 1,153 participants in the three trials with results, women (19.7%) and Hispanic or Latino (9.9%) participants were a minority. While all three trials reported gender and ethnicity (Hispanic or Latino status), only one reported on the racial composition of the participants. The racial composition among the 296 participants analyzed was: 63.2% White, 23.6% belonged to more than one race, 6.4% were Asian, 2.7% were Black or African American, 1.7% were American Indian or Alaska Native, and 1.7% were Native Hawaiian or other Pacific Islander. In 0.7% of cases, race was unknown or not reported.
The authors conclude disparities exist in the gender and ethnic composition of trial participants for teledermatology and there is a lack of adequate reporting of trial participants by race.
An mHealth app (eSkinHealth) for detecting and managing skin diseases in resource-limited settings: Mixed methods pilot study
This study evaluated the usability and effectiveness of the eSkinHealth app, a field-adapted platform to serve as a portable electronic patient chart and for teledermatology, in rural Côte d'Ivoire, West Africa, for diagnosing and managing neglected tropical diseases (NTDs) of the skin and other skin diseases.
Researchers implemented a two-arm trial with local healthcare providers and patients with skin diseases over three months. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and eight community healthcare workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, the researchers evaluated their approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, the primary outcome was to evaluate the detection and management of five skin NTDs as targeted diseases using the eSkinHealth app. These NTDs included Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws.
The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (standard deviation (SD) 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including four dermatologists and program managers, were satisfied with the app. Community health care workers reported they felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (p=0.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (p<0.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a “dermatosis.” In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists.
Clinical features associated with the demand for in-person care by dermatologists: An observational cross-sectional study
Researchers compared the prevalence of required in-person dermatologist care in the presence or absence of certain clinical features.
They conducted an observational cross-sectional study of 11,661 teledermatology reports made from Feb. 2017 to March 2020, with the aid of automated text-mining tools.
Investigators found the need for dermoscopy was associated with a 348% increase in the possibility of referral for in-person dermatologist evaluations (prevalence ratio [PR]: 4.48, 95% confidence interval [CI]: 4.17-4.82). Infectious diseases were associated with a 64% lower possibility of referral (PR: 0.36, 95% CI: 0.30-0.43).
The authors write that some lesions and poorly documented cases are challenging to assess remotely. This study presents a different research approach to gathering more detailed data from teledermatology reports, using text mining, they note. The researchers conclude their findings show the likelihood that in-person dermatologic care will be requested, based on the features of the patient's case. They note the study is limited as variables related to lesion location, size, and extension were not analyzed.
Bridging the digital divide in teledermatology usage: A retrospective review of patient visits
In this paper, researchers analyzed the demographics of patients utilizing synchronous video visits (SVs), asynchronous visits (AVs), and in-office visits (IVs) following the implementation of SVs at a single medical centre.
The study was conducted through a retrospective electronic medical record review of deidentified data from the University of Pittsburgh Medical Center, a tertiary care center with an established asynchronous teledermatology program. Hybrid SVs were integrated into the University of Pittsburgh Medical Center patient care visit options in March 2020. Patients were instructed to upload photographs of their skin conditions before SV appointments. The study included 17,130 visits occurring between July and Dec. 2020. Visit types included SVs, AVs, and IVs.
Researchers compared diagnosis, age, sex, race, ethnicity, and insurance type across visit types.
They conclude the implementation of SVs may increase access to dermatologic care among medically marginalized patients. Patient engagement an, education, andvocacy for continued Medicaid payment parity regulations for SVs are needed to increase dermatologic care access.
VIDEO: PASSION project: AI-driven teledermatology for common skin conditions in Africa
Dr. Alexander Navarini, Chairman of the Department of Dermatology and Allergy, University Hospital of Basel, Switzerland, describes an ongoing project to develop and validate an AI-supported teledermatology app to support the diagnosis of the most common skin conditions in Africa.
At the intersection of skin and society
In Dec. 2023, the Toronto City Council agreed that landmark and public space Dundas Square should be renamed to Sankofa Square to separate the square from the legacy of Henry Dundas, 1st Viscount Melville.
The square’s new name, Sankofa, originates in Ghana and refers to the act of reflecting on and reclaiming teachings from the past, which enables people to move forward together, according to the release.
Three other city-owned sites—the Dundas and Dundas West subway stations and the Jane/Dundas Public Library—will also be renamed. Discussion continues on the potential renaming of Dundas Street itself.
The push to rename city property tied to Dundas arises from a recognition of the impact of the former parliamentarian’s legacy on Black and Indigenous citizens, according to a press release from the city. In particular, the release notes Dundas argued against an immediate abolishment of the trans-Atlantic Slave Trade in 1792, proposing instead that abolishment should be done gradually to not be economically disruptive. The release notes some scholars estimate the delay in abolishment to 1807 may have represented half a million more persons being enslaved and transported.
This week
Jan. 8 is National Winter Skin Relief Day in the U.S.
Jan. 11 is National Human Trafficking Awareness Day in the U.S.
Jan. 11 is International Thank-You Day
Something to think about in the week ahead. . .
—Walter Scott, Scottish novelist (1771 to 1832)
Next week
Miami-based dermatologist Dr. Anna Chacon discusses the impact of cold climate—such as is often encountered in remote northern communities—on skin health.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Lauren Lam (Calgary), Sam Hanna (Toronto), Benjamin Barankin (Toronto), and Renée A. Beach, (Toronto) discuss many of the new therapeutic options that arrived in 2023.
Dr. Andrew F. Alexis (New York City) details pigmentary disorders in patients with skin of colour.
An essay from Dr. Sheila Wang (Montreal) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Wang wrote about the development of new imaging technology to detect and assess ‘beneath-the-skin’ inflammation, perfusion, and tissue oxygenation in any skin phototype.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender.
Read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary* subscription or to receive a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode six, Dr. Vender discusses topical methotrexate, systemic medications in pediatric patients, and depression.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.