Pediatric Teledermatology

Most physicians will woefully recall the anguishes (and triumphs) of March 2020, when virtual care became the predominant way to practice for months. Although the COVID-19 pandemic catapulted virtual care into our everyday lives, most dermatologists were accustomed to answering questions from patients and colleagues via text and email, and many dermatologists adopted formal telemedicine well before the pandemic. Telemedicine is likely here to stay and now is a great time to step back and see how it went, what we learned, and how things might look going forward. Specifically, this article focuses on the unique aspects of telemedicine in pediatric dermatology.

How Do We Define Teledermatology?

Teledermatology includes any communication utilizing a virtual space. The 2 main visit formats are store-and-forward (asynchronous) and live-interactive (synchronous). Store-and-forward teledermatology allows patients or other providers to share text and photographs on their own schedule with the dermatologist, who then formulates a diagnosis and treatment plan based on available data. In contrast, live-interactive teledermatology consists of the dermatologist and the patient, family, and/or other care providers communicating in real time with both audio and video. This modality can also incorporate photos uploaded before or during the visit.

Is Teledermatology Effective?

Dermatology is a visually oriented specialty that lends itself well to virtual care. Adult teledermatology has solid evidence-based support; however, pediatric teledermatology is less validated. Nonetheless, multiple studies demonstrate diagnostic concordance, high patient satisfaction, and reduced wait times, among other benchmarks.^5-8

Teledermatology has been identified as a way to improve children’s access to dermatologic care.^3,9 In March 2020, there were 317 board-certified pediatric dermatologists throughout the United States.¹⁰ Average wait times to see a pediatric dermatologist vary by region, but data show that the routine wait time between a referral and an appointment is 92 days.^11,12 Because many pediatric dermatologists are concentrated in larger cities, it is not uncommon for patients to travel long distances for care.¹³ Telemedicine bridges that distance. Even when in-person visits are required, teledermatology can allow at least some visits or acute issues to be managed virtually, requiring less travel.

Undoubtedly, it can be more convenient for families to meet virtually, even if only for some visits.¹⁴ Beyond travel time, there are fewer scheduling problems for families when the child and parent are not required to meet in the same physical space; for example, an appointed caregiver can sit with the child during the visit and the parents can join virtually from work. This results in less lost income from missing work and decreases travel expenses.¹⁵ Additionally, parents with multiple children overwhelmingly report satisfaction when they can wait in the comfort of their own space instead of a busy waiting room.¹⁴ Virtual visits reduce illness exposure, especially for babies too young to be vaccinated or those who are immunocompromised, and make it easier for children or parents who have difficulty leaving the house to access care. Telemedicine also bypasses transportation difficulties.

What Makes Pediatric Teledermatology Unique?

The pediatric patient population innately creates both unique joys and struggles compared with adult patients, especially during live-interactive visits. Some of these issues may also apply to the in-person setting.

First, the pediatric patient is rarely the only person interacting with the physician. Ideally, at least 2 individuals (the child and their caregiver) should be in the camera frame. Managing the needs of both the pediatric patient and caregiver simultaneously in any setting is a special dynamic, which may provide additional viewpoints and details but can also increase the time required for visits. Having the caregiver act as a “tour guide” who “drives” the camera can assist considerably with the examination.

Second, younger patients tend to move around, such as wiggling or running, and offer many surprises. It is not uncommon to visit a child while they are sleeping, eating, playing, or tantruming. To improve efficiency and examination quality in the face of unpredictability, photos sent before the visit are critical and allow the live video portion of the examination to confirm the distribution of the skin problem. A photo request sent before the visit with tips for taking high-quality photos can facilitate this. Additionally, for kids who require behavioral management, asking parents to pause and situate the child often progresses the visit faster than when they become flustered by communicating with the child and the physician simultaneously.

Despite the challenges, there are major benefits to live-interactive visits because there is simply no substitute for seeing a child in their own environment. It can be enlightening to witness firsthand the patient’s demeanor, the household living conditions, parental stressors, extended family involvement/other support in the home, sleep hygiene, and much more. One example might include watching a caregiver awaken their toddler for the first time that day at 11 am for the visit and then listening to them say they cannot get the child to function. This provides a view into the family’s world of poor sleep and lends itself to discussions on sleep hygiene and family dynamics. Similarly, home life information can drastically change the physician’s understanding of what a family is practically capable of; for example, a parent trying to work from home with several young children under their care concurrently may struggle to find the time required to apply multiple topical medications. In such instances, observations of the home situation may show that a systemic medication would be more practical and allow the family to function better.

Another indirect benefit of live-interactive visits is the immediate access to a child's medications. The guessing game that inevitably happens is instantaneously answered when caregivers quickly grab what is requested.

What Are the Drawbacks of Telemedicine?

To feel engaged with their care, patients rely on physician-patient relationships and effective communication. Conversing through a screen may feel awkward or distant. Gesturing and body language may be lost, and eye contact limited. These variables together may make it harder to establish rapport.

Technologic difficulties are another aspect to consider, especially during live-interactive visits. Internet connectivity may affect both audio and video quality. For patients who feel uncomfortable with technology, the visit may be perceived as less satisfactory if they have trouble navigating the software platform. Patients who upload photographs may also raise concerns regarding data privacy and security. Fortunately, for those treating the pediatric population, younger age and frequent computer use are independently associated with greater willingness to use telemedicine.¹⁶

Given the limited camera view and inherent impediments of telemedicine, examinations are less complete. Also, providers are unable to palpate the skin, making it more difficult to appreciate lesion quality, such as induration, atrophy, depression, and elevation. Although many conditions can be diagnosed during a virtual visit with high diagnostic concordance in new patients, some conditions may be better suited for an initial in-person visit.

When Is In-Person Follow Up Needed?

Understanding when to request an in-person follow-up evaluation is paramount for the skilled physician. The most obvious situation is when a procedure is required. Although procedures cannot be performed virtually, they can be explained and scheduled. In pediatric dermatology, biopsies or laser procedures are difficult to incorporate into an initial evaluation visit anyway due to time constraints because these procedures tend to take significantly longer in children or require pre-anesthesia. In addition to planning for a procedure during the virtual visit, this time can be used to prescribe topical numbing creams for parents to apply before the procedure, reducing the time spent in the office and the patient’s anxiety.

There are other situations where in-person follow up is warranted, including when a more complete exam is required, when genitalia or other sensitive body areas need evaluation, or if there is a disconnect between what a patient or caregiver describes and what the physician sees. Other situations include when a physician feels that it may help to demonstrate how to apply topicals, if the patient is not improving as expected and the diagnosis needs confirmation, or if the patient has pigmented lesions. In the case of pigmented lesions, telemedicine can be used to triage for urgency.

Is Telemedicine Here to Stay?

It is unclear how telemedicine will evolve long term. Straightforward complaints found their way into teledermatology long before the pandemic, and businesses scaled for such conditions with high patient satisfaction. With the pandemic, increasingly complex patients arrived in the virtual space. This forced technology to improve, and there are new opportunities still. Financial interests may be another clear predictor of the future; for example, one study showed a $140 savings per newly referred patient after implementing a teledermatology triage system within a capitated health care system compared with a conventional care model.¹⁸

Although there are potential drawbacks and we do not know where insurance reimbursements will head, patients are generally satisfied with telemedicine and there are clear societal benefits to decreasing resource utilization, especially for those who work. Ultimately, physicians who are willing to navigate the pitfalls of telemedicine may find there is surprisingly more to be gained than lost. By no means can telemedicine ever replace the human connection and thoroughness experienced during an in-person encounter. On the other hand, there are unexpected benefits when invited into someone’s home, which may include both happier children and patients.