DTC teledermatology: Access to the specialists’ specialist – meeting an unmet need

Dear editor

We read with interest the article by Fogel and Sarin in which 22 of the most well-known direct-to-consumer (DTC) teledermatology services were analysed. As outlined in the article, the astounding growth of DTC teledermatology in the past one to two years has provided many more options for patients outside of the prototypical ‘in-network’ programmes predominantly available only at large academic medical centres. ¹ In light of the work done by Fogel and Sarin, we acknowledge that a DTC teledermatology programme, modelled after elements typically only found at a university medical centre, could be highly beneficial in meeting a need for innovation and access to specific professional expertise.

According to Fogel and Sarin, 73% of the DTC teledermatology programmes were willing to see patients for any cutaneous complaint, demonstrating the rapidly widening availability of general dermatology in cyberspace, rising to meet consumer demand for access across 36 states and Washington DC. The study also identified companies that offered services with limited scope of practice in a subspecialty within dermatology, noting specifically an emergence of acne and aging clinics.

Access to contact dermatitis specialists is one of the greatest needs within dermatology. Contact dermatitis accounts for more than 72 million cases and $1.6 billion in direct medical costs each year. ² Contact dermatitis is diagnosed and treated in majority by dermatologists. However, the dermatology-based providers trained in comprehensive contact dermatitis diagnostic patch test techniques who routinely evaluate >10 patients per month compromise only ∼1% of the dermatology workforce. Patient waiting times to schedule a visit with a contact dermatitis specialist are upwards of six months. Thus, in the interim, many patients are left treated with immunosuppressive medications to mitigate the immune responses. Such treatments are not only costly but may also have detrimental effects, as the source of patients' allergic reactions remain unknown, their exposures continue, symptoms propagate and, at times, even worsen, becoming systemic rather than localised.

Furthermore, there are some patients that are able to obtain a patch test by a provider who may not necessarily be specialized in contact dermatitis, who then are not adequately educated in the key allergen avoidance strategies needed to attain symptom relief. These patients are often secondarily referred to tertiary care centres for relevance determination of their test results and education about their condition (17% referral rate for test interpretations/education, personal observation practice parameter from one of our authors). Again, this suggests not only a need for education, but also an unmet need for service within the contact dermatitis field.

In a survey of general dermatologists undertaken by Scheman, 75% of the general dermatologists reported doing their own patch testing. However, upon further analysis, 83% reported that they perform five or fewer patch tests per year. ³ These findings underscore that the majority of contact dermatitis patients are being treated without confirmatory diagnostic testing (the patch test). Moreover, these results suggest that decreased experience in routine counselling of these patients might be contributing to the post-patch procedure referral rates. A recent study by Shahzad et al. studied the types of patients routinely being referred to tertiary care centres within Saudi Arabia in an attempt to reveal education lapses of their general dermatologist population. Of the 1147 patients referred to tertiary centres, 748 (65.2%) of those patients were referred for an allergic skin disorder, again underscoring the need for these specific dermatologic services. On the other hand, only 22 (1.9%) of the patients were referred for acne treatment. ⁴

Academic medical institutions are the United States’ equivalent to tertiary centres. It may take several months before a patient is able to get a face-to-face visit with a particular subspecialist residing at one of these centres. An innovative meld, combining DTC teledermatology and the fundamental components of an academic medical institution (funnelled access to subspecialists, evidence-based practice parameters and a systems-based approach based on data aggregation) could be a starting point to rectifying the need for improved access to the expert assessments that lie outside of the routine knowledge base of a general dermatologist.

Like acne, contact dermatitis is a condition for which a streamlined therapeutic regimen exists, namely avoiding the known trigger, while temporising the reaction with oral antihistamines, partnered with barrier repair and topical anti-inflammatory creams. Approximately 60% of US adults could have their chemical allergen identified with the Food and Drug Administration approved, commercially available patch test kit. ⁵ Given this information, the logical next step is to offer strategically based avoidance planning services for patients with confirmed allergic contact dermatitis. Notably, none of the companies listed by Fogel and Sarin had options for expert services exclusively in the sphere of contact dermatitis. To our knowledge, only one is currently available (www.dermatitisacademy.com has an AZOVA™-affiliated online contact dermatitis clinic).

There are multiple possible iterations when considering how patients should be triaged to teledermatology-based contact dermatitis specialists. In the AZOVA model, patients are divided into those with known contact sensitisation requiring the ‘5th visit’, for extended education counselling (the first visit representing the consult, then three patch procedure visits), and new non-patch-tested patients needing a comprehensive consultation. The ‘5th-visit’ patients can self-refer for additional avoidance counselling, as they are able to provide their known allergens into the consult report. Inquiry into our practice metrics for the face-to-face contact dermatitis clinic demonstrated that 17% of the referrals were for patients who had already been patch tested, knew their allergens and didn't know how to avoid them and thus were seeking counselling services (SEJ, unpublished observation).

The second set of non-patch-tested patients represent those who are seeking diagnostic evaluation. These patients can complete a comprehensive consult, including an extended questionnaire of medical and exposure history (including products) and upload photos through the secure portal. Again, evaluation of the face-to-face contact dermatitis clinic demonstrated a significant number of the consults being referred to rule out contact dermatitis that had other conditions that could have been diagnosed or teletriaged (e.g. psoriasis, dermatomyositis fixed drug and stasis dermatitis). Furthermore, given that approximately 30% of patients with allergic contact dermatitis can get better by avoiding the top 10 sensitising allergens, it would be prudent in cases highly suggestive of contact dermatitis to initiate pre-emptive avoidance while they await referral for face-to-face patch testing. ⁶

We propose a triage system in which allergists, general dermatologist or dermatology-trained mid-level providers directly consult contact dermatitis specialist for patients suspected to have contact dermatitis who have not been patch tested through an encrypted portal. In addition, patch-tested patients requiring subsequent education could self-refer. This triage measure could substantially decrease waiting times for contact dermatitis consultations and expedite patients’ access to avoidance strategy counselling.

We compared how DTC telehealth services aligned with the academic model. An academic medical environment combines the clinical expertise of multiple specialists within one centre, opportunities for charitable work and the platform for research. The results of our own comparison indicate that although some DTC telehealth services had one or more of the aforementioned elements, none of the programmes evaluated had all three aspects. Thus, none of the current DTC programmes are a complete cloud-based mirror of the university model. Specifically, all DTC programmes lacked the vitally important research component. A DTC model would be an ideal outlet for research, as patient data will inherently be in an electronic format, additional surveys and specific research-related questions could be easily inserted into the online ‘check-in’ process and data could systematically be extracted from DTC records. Due to the wide-access reach, data could be pooled on rare entities and compared regionally. The DTC model could serve as a major data resource for researchers worldwide.

We believe an efficient DTC teledermatology service which would offer dermatologic subspecialty care, global charity-outreach and research typical of the university medical organisation would help to fill a largely disregarded need within the telehealth movement and healthcare overall. The high prevalence, patient morbidity and lofty health-care costs of contact dermatitis in the setting of limited ‘in-person’ specialist providers represents a need for DTC access to specialist evaluation, and information not only on how to get tested and treated for contact dermatitis, but also on how to prevent future outbreaks through appropriate avoidance of allergenic chemicals. No matter what the condition, patients continue to travel long distances to seek expert-level care at academic institutions. It’s time to bring the professors – the master clinicians – directly to the patient.