Can Providers Address Dermatologic Conditions Adequately Via Telemedicine?

A recent retrospective study of nail telemedicine visits during the COVID-19 pandemic highlighted in a letter in Dermatologic Therapy found that certain patient populations benefitted more from virtual visits than others. The authors of the letter found guidelines for such visits lacking and submitted the results of their study of 107 visits (96 patients) over a 20-day period from March to May of 2020. The most frequent new concern was longitudinal melanonychia, followed by likely onychomycosis. Onychomycosis and psoriasis comprised the most common follow-up concerns. The cohort had an average age of 46.1 years and 68 percent were female.

Longitudinal melanonychia as a primary concern resulted in a recommendation for in-person follow up in seven out of eight patients. Onychomycosis, when a new concern, resulted in a request for in-person mycological confirmation in six out of seven patients. Overall, 57 percent of new nail-related visits resulted in recommendations to follow up in-person, which was 14 times more likely than those presenting for subsequent virtual visits. In-office visit requests from providers occurred most frequently when there was a need for clinical examination/dermoscopy (39 percent), nail clippings (32 percent), biopsy (18 percent) and other procedures (11 percent). Over the virtual visits as a whole, it was five times more likely that a provider would re-order or continue a medication than begin a medication.

The authors of the letter recommend pre-screening photographs to assist in triage to in-person versus virtual visits and propose that development of artificial intelligence systems for this purpose may be helpful. Acknowledging the limitations of their analysis, including sample size and other design features, they support more study of the subject and creation of rigorous, evidence-based guidelines. The authors conclude that telemedicine is best for patients with previously diagnosed nail issues and for diagnosis of some limited, new nail conditions. They felt longitudinal melanonychia and onychomycosis were best seen exclusively in in-person.

Tracey C. Vlahovic, DPM, FFPM RCPS (Glasg) also saw follow-ups for onychomycosis and nail psoriasis virtually during the COVID-19 pandemic, but noted difficulty in getting a clear picture of the nail during the call.

“I asked the patients before the visit to take clear, in-focus pictures to the best of their ability and e-mail them to me,” she explains. “Evaluating pigmented lesions was impossible, and if a patient needed confirmatory testing for their nail disease or debridement due to pain, that obviously couldn’t be done virtually.”

Patients with previously diagnosed nail disease could have a successful follow-up via telemedicine, agrees Dr. Vlahovic, a Clinical Professor in the Department of Podiatric Medicine at Temple University School of Podiatric Medicine in Philadelphia. However, she adds that anyone with new findings or a lesion that really requires close visual inspection needs to present in-person.

As we hopefully continue to emerge away from COVID-19, Dr. Vlahovic feels that podiatrists can still incorporate telemedicine for nail disorders in their practice, but under select circumstances.

“If a patient is on an antifungal medication, whether oral or topical, it can be a useful (virtual) visit, but for all of the other hands-on things that we as a profession do, it really isn’t practical,” she says. “We had to try this out of necessity, but the reality is, some things just aren’t meant for telemedicine.”

Is There Long-Term Financial Benefit To Podiatric Fellowship Training?

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent study in the Journal of Foot and Ankle Surgery aimed to evaluate the potential financial implications that a graduating resident may experience when electing to pursue a podiatric foot and ankle fellowship. Researchers obtained data on weighted mean income (general, research and associated research) for podiatric foot and ankle surgeons with and without fellowship training using manual searches of Open Source payments. An anonymous online survey provided demongraphic and clinical income data for graduate fellows of four programs, which the authors compared to socioeconomic data from the 2018 American College of Foot and Ankle Surgeons (ACFAS) compensation study.

They found that the net present value (NPV) of podiatric foot and ankle surgeons with and without fellowship training was $4.2 million and $3.03 million, respectively, with a respective comparative NPV and cumulative net income difference over 30 years of $1.2 million and $2.5 million. The authors also calculated annual mean comparative income differences across the various types of income studied. They conclude that one may consider pursuing an ACFAS-recognized podiatric foot and ankle fellowship in advanced reconstruction an “acceptable financial investment” with potential positive impact on earnings.

Calvin J. Rushing, DPM, AACFAS, lead author on this study, says that many variables factor into one’s decision to pursue fellowship-level training.

“Intuitively, financial factors are an important consideration, after four years of podiatric medical school and three years of residency, the potential lost income over the fellowship year, compounded with the capitalization of student debt interest, might dissuade some residents from pursuing advanced level training,” he explains. “Personally, I became motivated to conduct this study in an effort to begin to address the financial speculation I heard from proponents for and against the decision to pursue fellowship that all residents hear ultimately at some point or another during their training.”

He acknowledges that one limitation is that only surgical fellowships focusing on advanced reconstruction were included for the assessment. However, Dr. Rushing, a fellowship-trained podiatric surgeon in practice at Dallas Orthopedic and Shoulder Institute in Sunnyvale, Texas, also points out that it is important readers be cognizant of the inherent variability in calculated NPV.

“The NPV differed not only between the fellowship programs themselves, but also amongst graduate fellows from the same program,” he shares. “This study is the first of its kind, and additional research is warranted.”

Study Aims To Assess Potential Role Of Vitamin D In Ulcer Healing

By Jennifer Spector, DPM, FACFAS, Managing Editor

Though the detriment of low vitamin D levels in bone healing is well-documented, a recent study in the Journal of Wound Care contends that it may impact ulcer healing, as well. Authors analyzed 10 studies (2,359 participants) and found a strong correlation between low 25-hydroxy vitamin D levels and the presence of pressure, diabetic or venous ulcers. They add that it is not clear if this correlation simply that, or if the relationship is actually causal, encouraging more research on the topic to better differentiate understanding of the topic.

Chia Ding (JD) Shih, DPM, MPH, MA says in his practice, they do not currently track vitamin D levels for chronic wounds. However, he notes that they do check other factors such as albumin, total lymphocyte count, HbA1c, kidney function and arterial profile.

He continues to say that he feels this published review may rely on studies that have potential confounding factors and biases. Although a systematic review, typically the highest quality form of evidence, Dr. Shih points out that a high-quality systematic review would consult more than two databases, include a risk of bias assessment and have a clear research question.

“All of the collected studies, as the authors suggested, are observational studies,” he says. “As a result, the limitations are not only that the causal pathway is hard to establish, but that the risk of bias is often quite high. Given these considerations, the provided evidence is quite weak in this review and much more work is necessary on vitamin D’s effect on wound healing.”

He adds that he feels it is more important too focus on the underlying cause or etiology of a wound in addition to the overall nutritional status. Readers can take away from this study, though, that like many micronutrients, vitamin D is essential for the body, says Dr. Shih, an Assistant Professor at the California School of Podiatric Medicine at Samuel Merritt University.

“The direct link between wound healing and vitamin D level is not clearly established,” he says. “The evidence of supplementing vitamin D should be used with caution for wound healing purposes and patients with low vitamin D levels should consult endocrinologists.”