S2k‐Guideline for Teledermatology

Abstract

The guideline working group has marked several especially relevant paragraphs as requiring consensus, and has agreed upon these paragraphs in the consensus conferences. They are marked as grey, framed sections. The following terms and symbols were used for standardized characterization of our recommendations. Telemedicine is defined as remote transfer and use of digital data [1]. Teledermatology is the section of telemedicine dealing with dermatological diseases. Telemedicine is a part of digital medicine, which apart from remote transfer also utilizes data on site (Figure 1). “eHealth” or “digital health” is used synonymously for both digital medicine and non-medical digital processes in the healthcare field. Teledermatology has become increasingly important both in German-speaking countries and internationally [2-6]. The aim of this guideline is to evaluate the use of teledermatology for common dermatological diseases, based on evidence research and expert experience. The following recommendations cover various categories of teledermatology for defined diseases. It is assumed that the procedures are used correctly in terms of technology, organization, and personnel. In principle, these recommendations apply to both outpatient and inpatient care, as well as to cross-sectoral care. Note that most international studies on teledermatology have been performed in an outpatient setting. Further background information on basic principles, scope, indications and contraindications, quality standards, and legal frameworks for teledermatology are covered in “Leitfaden der Teledermatologie” (Augustin 2018 [1]), new edition. The international literature on teledermatology now comprises several hundred original publications, most of them from the last two decades [7]. Please consult the abovementioned “Leitfaden” [1] and current systematic overviews for further references beyond those cited in this guideline [8]. A total of six controlled studies on teledermatological care for psoriasis patients have been published [9-14]. In summary, these studies have shown that accompanying teledermatological care for psoriasis patients is effective and useful, especially monitoring the course of the disease from photographs and videos. Questions on patient counseling and assessing adherence and compliance have also been answered in the affirmative. In all, the abovementioned studies thus confirm the benefit of supportive teledermatological care for psoriasis patients. The emphasis will remain on monitoring of systemic treatment as well as patient counseling and support. *Two experts abstained from voting due to COI. **B2B, business-to-business connection between two medical experts. There are four controlled studies on teledermatology for atopic dermatitis (atopic eczema, neurodermitis) published in the international literature [15-18]. As is the case for psoriasis, the controlled studies in atopic dermatitis show that assessment and monitoring via teledermatology are feasible and valid. One publication is focused on newer methods for digital documentation of clinical findings, which, however, require further evaluation [16]. The potential benefits and economic efficiency of patient counseling via online video consultation remain a central issue. There are, however, currently no studies on this topic. *Two experts abstained from voting due to COI. Of all dermatological indications, melanocytic lesions and skin cancer show by far the largest publication volume in digital medicine, with 52 published reports [2]. The database on validity and practicability of the transmission and analysis of relevant, qualitatively satisfactory findings is sufficient, and this also applies for mobile and even web-based use [19, 20]. However, in a comprehensive meta-analysis, in-person diagnostics were superior to digital evaluation in a portion of the included studies [21]. The indication for digital assessment must thus be differentiated and adapted to the individual situation. *Two experts abstained from voting due to COI. Numerous studies support the use of teledermatological treatment of wounds in terms of evidence on the validity of the findings. Apart from skin tumors, the database in the international literature is best for chronic wounds [1]. Consistency between morphological findings gained via teledermatology and findings gained in person is sufficiently high that supplementary assessment via telemedicine may be useful and safe, at least in the care of established patients. The main focus here is on monitoring the course of the disease, and early detection of complications. Several controlled studies show that digital documentation and evaluation of wounds is non-inferior to in person documentation and analysis [22-24]. In these studies, the diagnostic quality of digital findings was equated to those of face-to-face assessment. While an early study concluded that the practical benefit of telemedical wound treatment in a home-care setting was only moderate [25], a more recent randomized treatment study in patients with leg ulcers in Denmark found a significantly higher healing rate when routine outpatient care was supplemented via teledermatology from the treatment center [26]. These findings suggest that, given the infrastructure, a) teledermatology should be integrated into patient care for established patients, and b) teledermatology-guided preparations, such as the planning of diagnostics procedures, should be made in advance of the in-person consultations in a specialized center. *Three experts abstained from voting due to COI. In view of the extremely large number of different skin diseases, it is not surprising that systematic studies on the efficacy and benefits of telemedicine are generally lacking for rare diseases. On the other hand, given the often small number of dermatological specialists and the frequent overtaxing of primary physicians, diagnostic concepts are especially important. The study by Heidenheim conducted in Denmark/Färöer Islands constitutes a positive example of such support for family and general physicians in cases of rare diseases [27]. This study substantiates the additional benefit of diagnostic support from dermatologists in a primary care setting. Subject to possible legal limits, early, appropriate and systematic diagnostics with the aid of teledermatological technologies can be beneficial for the provision of care. *Three experts abstained from voting due to COI. This guideline was prepared according to the current AWMF standards for an S2k guideline. Patient participation and the involvement of computer science experts were emphasized. We did, however, omit involvement of other medical specialties since teledermatological care remains at times poorly established in other medical fields. We envisage expansion to other disciplines in future revisions of this guideline. To date, no specific studies on the benefits and risks of teledermatological treatment have been conducted for a larger proportion of treatment-relevant dermatological diseases world-wide. These areas of care have therefore not been included in this guideline. Even for common indications such as psoriasis, data on the diagnostic equivalence of in-person care versus teledermatological care is sometimes lacking. An overview on conflicts of interest can be found in the long version of this guideline at https://www.awmf.org/leitlinien/detail/ll/013-097.html.

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