Strategic use of virtual and face-to-face visits for optimal care of dermatologic disease

Dear editor, We greatly appreciate Potestio et al.'s interest in our article “Not just pimple popping: The utility of hybrid telemedicine models beyond acne management amidst the ongoing COVID-19 pandemic”.1 In our letter, we discuss the emerging role of telemedicine for managing patients with chronic skin diseases. Recent evidence has shown that telemedicine results in excellent clinical outcomes. Since it also reduces costs and travel time, telemedicine will likely be an important part of dermatologic clinical practice far beyond the COVID-19 pandemic. In addition to acne, psoriasis, and onychomycosis, Potestio et al. stated that telemedicine is also useful in managing atopic dermatitis and hidradenitis suppurativa (HS) patients. However, virtual HS management poses unique challenges, since HS typically involves intimate body areas, including the submammary region and groin, has high rates of unstable disease, and requires skin palpation for diagnosis.2 In a retrospective analysis of HS consultations during the COVID-19 pandemic (April–October 2020),2 approximately half (50.7%) of patients had unstable disease, with 81.1% of those patients requiring medication adjustments or changes. All consults were conducted by telephone only, with patient-submitted photographs evaluated in only 8.1% of unstable disease consults due to patient privacy, comfort, and data security concerns. Therefore, HS patients may be reluctant to expose intertriginous and genital areas via videoconferencing, hindering virtual management. Alternatively, HS patients may use a secure email or patient portal to send photographs prior to the televisit, with these photographs uploaded directly into the electronic medical record there afterward.3 Nonetheless, even with optimized telemedicine, HS may still require in-person visits for surgical or other procedures (i.e., incision and drainage, intralesional steroid injections), differentiating it from other chronic inflammatory skin disorders that can be more easily managed via telemedicine. Potestio et al. suggested that new severity indexes be developed to assess disease severity during telemedicine visits. We disagree with this statement, as the creation of new indexes would make comparisons of disease progress or relapse difficult during reassessments at face-to-face visits. Instead, we suggest that patients are given clear and detailed instructions for taking high quality photographs. Specifically, photographs should be taken with neutral backgrounds, with the camera held close to the skin or nails and parallel to the area being photographed. At least two photographs should be taken with different angles, as well as a border photograph that captures both normal and affected skin or nails for comparisons.4 Dermatologists can refer to these photographs to streamline the visit, diminish technological imperfections (i.e., low video quality), and assess disease severity and scoring using already established indexes. As we have progressed past the strict restrictions and social distancing guidelines of the original COVID-19 pandemic, in-person dermatology visits are no longer limited. Therefore, we agree with Potestio et al. that face-to-face visits should not be exclusively for new patients, those with severe or unstable disease, or those needing diagnostic testing and procedures. However, given the important time and cost-saving benefits of telemedicine, dermatologists can streamline their practices, utilizing in-person and telemedicine visits based on the patient and disease type. Therefore, hybrid models that combine both face-to-face and periodic virtual visits will be of utmost importance moving forward, allowing dermatologists to monitor patients and make treatment decisions while still sustaining the core of the patient-physician relationship. All authors contributed substantially to the production of this manuscript. None. Ms. Falotico and Ms. Gu have no conflicts of interest. Dr. Lipner has served as a consultant for Ortho Dermatologics, Hoth Therapeutics, and BelleTorus Corporation. Data sharing is not applicable to this article as no datasets were generated or analyzed.