Teledermatology Versus In-Person Visits for the Follow-Up of Atopic Dermatitis Patients

Abstract

Background:

In recent years, teledermatology has rapidly emerged as a healthcare delivery method with potential implications for managing chronic inflammatory dermatoses like atopic dermatitis (AD).

Objectives:

This study assesses the utility of telemedicine in the management of AD by comparing virtual care with traditional in-office visits with the aim of identifying differences in clinical outcomes between these 2 healthcare delivery modalities.

Methods:

Patients of all ages with AD were recruited from 2 dermatology practices. Consecutive patients presenting to the clinics who met the inclusion criteria were invited to enrol in the study. Those who consented to participate were randomly assigned to the virtual or in-person arm of the study, with the opportunity to decline care in either study arm. The inclusion criteria required participants to have a confirmed diagnosis of AD. Exclusion criteria included significant comorbidity that might affect the course of treatment, inaccessibility to teleconsults such as not having a camera for video conferences, and self-declared limitations in operating Zoom. Patients were assessed at baseline (week 0), 4 to 6 weeks, and 8 to 12 weeks using 6 efficacy parameters.

Results:

In the virtual group, all 6 dermatological measures suggested improved outcomes. Average Body Surface Area scores decreased (β = −.07, 95% CI = −0.1, −0.3) over the course of follow-up. Virtual care patients had 80% lower odds of moderate-to-severe uncontrolled disease (OR = 0.2; 95% CI = 0.06, 0.5) and pruritus (OR = 0.2, 95% CI = 0.05, 0.7) over time.

Conclusions:

This study supports teledermatology as a feasible and effective option for providing follow-up care for atopic dermatitis patients of various demographic standings.

Introduction

Teledermatology has rapidly evolved as a method of healthcare delivery, gaining momentum over the past few years, particularly due to the restrictions imposed during the COVID-19 pandemic. ¹ Teledermatology enables healthcare professionals to offer clinical care and consultation services through remote communication channels such as video conferencing, smartphone apps, and live streaming. A global survey of over 700 dermatologists reported a 3-fold increase in telemedicine usage during the pandemic compared to before the pandemic. ¹ Care can be provided through asynchronous digital images, synchronous real-time video, or a hybrid of both methods.^2,3 This approach offers numerous advantages, including increased access to care in underserved regions, enhanced workflow efficiency, reduced wait times, and improved cost-effectiveness of healthcare delivery.^{4 -7} Amid the pandemic, a new framework of teledermatology was implemented in our clinics to maintain healthcare delivery while keeping COVID-related preventive measures in place. Through a secure organizational video chat platform, we currently employ a blended framework utilizing video live-streaming conferences with asynchronous digital images sent by the patient and telephone-based interviews as needed, as an alternative to in-person visits. Evaluating the impact of these new practices is essential to provide safe, efficient, and effective care for our patient population.

Atopic dermatitis (AD) is a chronic inflammatory condition affecting people of all ages and significantly affecting their quality of life. AD affects 20% of children and 10% of adults in high-income countries and is ranked as the skin disease with the highest global burden, as measured by disability-adjusted life years. ⁸ Patients require long-term care to monitor the disease course, adjust treatment plans, prevent complications, and optimize quality of life. The ongoing management of AD can be burdensome for patients, healthcare systems, and the health workforce. ⁹

This study assesses the utility of telemedicine in the management of AD by comparing virtual care with traditional in-office visits. The objective is to identify differences in clinical outcomes between these 2 healthcare delivery modalities. In addition, this study evaluates qualitative feedback from participants to discern patient-perceived advantages or challenges of virtual care in the treatment of AD.

Methods

Adult and pediatric patients of all ages with AD were recruited from 2 dermatology practices in Alberta, Canada. Consecutive patients presenting to the clinics who met the inclusion criteria were invited to enrol in the study. Those who provided consent were randomly allocated to either the virtual or in-person study arm, with the option to decline participation in either arm. The inclusion criteria required participants to have a confirmed diagnosis of AD, as defined by the criteria established by Williams et al. ¹⁰ Exclusion criteria included significant comorbidity that might affect the course of treatment, inaccessibility to teleconsults such as not having a camera for video conferences, and self-declared limitations in operating Zoom. Patient assessments occurred at baseline (week 0), 4 to 6 weeks, and 8 to 12 weeks. Patients were provided with a date and time for their next visit at the end of each visit. Prior to follow-up visits, the reception staff made reminder phone calls to patients, including direct conversations with patients and leaving recorded voice messages in instances of no answer.

Dermatological Outcome Measures

Dermatological health and disease progression were evaluated using 6 parameters. Several validated tools, including the Eczema Area and Severity Index (EASI), the Dermatology Life Quality Index/Children’s Dermatology Life Quality Index (referred to henceforth as Life Quality Index or LQI), the Investigator’s Global Assessment (IGA) scale, Body Surface Area (BSA), patient self-assessment score, and pruritus assessment score were used to evaluate outcomes for the virtual and in-person study arms. The frequency of complications and side effects during the treatment course were also evaluated.

The EASI, an international scale for assessing the severity of AD, is 1 of the 3 best-validated outcome measures for AD. ¹¹ The LQI presents a measure of the impact of skin disease on quality of life.^12,13 For children younger than 8 years, the LQI was completed by the primary caregiver. The IGA is a static evaluation of the overall severity of AD at a given time. ¹⁴ The patient’s self-assessment score is a semiquantitative score intended to reflect the patient’s own evaluation or, in infants and young children, the caregiver’s evaluation of disease control over the previous 7 days. It consists of a 4-point scale, ranging from complete disease control (0) to uncontrolled disease (3). The pruritus assessment score evaluates severity of pruritus in the previous 24 hours with use of a 4-point scale, ranging from no pruritus (0) to severe pruritus (3). Complications and side effects were reported for both patient groups, including the number/percentages of disease complications and/or management side effects. Satisfaction ratings using a Likert scale (very satisfied, fairly satisfied, somewhat satisfied, not satisfied, and not satisfied at all) were complemented by qualitative feedback from participants regarding their experience within each study arm.

Prior to analysis, EASI, BSA, and LQI scores for each patient were standardized using the percent of the maximum possible scaling method, which converts each measure to a scale ranging from 0 to 100. This standardization approach allows for changes in outcome scores to be interpreted in terms of percentage changes (eg, a 1-unit increase in outcome score corresponds to a 1% increase in severity) ensuring for comparability between different outcome scales. ¹⁵ IGA scores were dichotomized using a cutoff score of 3 to indicate moderate-to-severe AD. Patients’ disease severity and pruritus scores were dichotomized using cutoff scores of 2 to indicate uncontrolled disease and moderate-to-severe pruritus, respectively.

Teledermatology Intervention

To operationalize the treatment type, a dummy variable (0—in-person visit, 1—virtual visit) was generated. Teledermatology visits were conducted primarily via real-time video chat using Alberta Health Services (AHS) Zoom with the use of asynchronous digital images sent by the patient and telephone-based interviews in cases of technical difficulties. AHS has an agreement for an enterprise version of Zoom videoconferencing, allowing providers flexibility to connect with patients virtually via the secure and encrypted platform. When needed, patient-submitted pictures were transmitted to the clinic’s secure health services email account and directly uploaded to their Electronic Medical Record (EMR) chart on ConnectCare. In addition to written informed consent obtained at study entry, prior to all virtual visits, verbal informed consent was obtained, and the patient’s identity was confirmed.

Covariates

Sociodemographic factors captured in this study include age (derived using the date of birth), gender, and ethnicity. Age was retained as a continuous variable, and all other covariates were dichotomized. For all categorical variables, missing values were included as a distinct “missing” category to avoid listwise deletions of missing observations. Time was operationalized as the days from the baseline assessment to each subsequent follow-up point.

Statistical Analyses

Descriptive statistics were run for the full sample, as well as for the in-person and virtual groups separately, to evaluate the sociodemographic profiles of each patient group. Crude impacts of treatment (virtual vs in-person visits) on dermatological outcomes were determined using nonparametric Mann-Whitney U tests (EASI, BSA, and LQI) and Fisher’s exact tests (IGA, disease severity, pruritus score) to compare outcome scores between treatment groups at baseline and both follow-up visits. Longitudinal analyses were conducted using generalized estimating equation (GEE) modelling. GEE models accommodate the nesting of repeated measures within individuals and provide robust estimates for unbalanced data and small sample sizes. ¹⁶ Before constructing the GEE models, a polychoric correlation matrix was generated to evaluate potential collinearity among variables. All analyses were 2-sided (P ≤ .05) and performed using STATA (v16.1), StataCorp LLC.

Analysis of Patient Comments

Free-text comments from 20 participants were analyzed using an inductive approach that involved coding and theme development. Participants from both study arms were asked the following questions: (1) What are the perceived challenges and benefits of in-office consultation versus teledermatology? (2) What improvements do you believe could enhance in-office or virtual healthcare delivery services in the short and long term? Participants were also permitted to offer additional insights concerning both in-office and virtual healthcare delivery methods. Patient satisfaction within each study arm was assessed using a Likert scale, ranging from very satisfied to not satisfied at all.

Two researchers examined the data from each comment, identifying recurring words or phrases to establish a general coding framework. Comments were initially categorized at a high level (benefits to virtual care, barriers to virtual care, benefits to in-person care, barriers to in-person care, miscellaneous/neutral). Inductive codes were derived and applied to all relevant comments. Codes sharing similar meanings were consolidated into overarching themes.

The analysis resulted in the following 6 themes: Equivalency of Care Access and Quality, Preferences for In-Person Care, Technology Challenges in Virtual Care, Privacy Concerns, Convenience and Flexibility of Virtual Care, and Preference for Hybrid Care.

Results

In total, 38 patients accessing dermatology care through 1 of 2 dermatology clinics in Alberta were included in the study sample. Among these, 27 patients successfully completed baseline and 1 follow-up visit and 20 patients completed all 3 visits (baseline and 2 follow-up visits). A total of 18 (47.4%) patients were lost to follow-up during the study with 12 (50.0%) and 6 (42.8%) patients in the in-person and virtual cohorts, respectively. In the overall sample, most participants were female and non-white, constituting 57.9% and 52.6%, respectively. Within the in-person arm, these proportions were 58.3% and 45.8%, while in the virtual arm, they were 57.1% and 64.3% (Supplemental Table S1). The mean age of patients was 18.7 years (SD = 19.0), ranging from 0.38 years (4.6 months) to 67.7 years. On average, patients accessing care through in-person visits were younger compared to those accessing care through virtual visits.

A trend of decreasing outcome scores over time was observed across all 6 measures, indicating an improvement in dermatological outcomes for patients, on average, throughout the study duration (Figure 1). When stratified by visit type, virtual patients demonstrated consistently lower average outcome scores and proportion of moderate-to-severe scores compared to in-person patients at baseline and follow-up points, with the exception of LQI scores at baseline.

Figure 1.

Trajectories of 6 measured dermatology indicator scores stratified by all patient visits and individual visit types (in-person visits and virtual visits). A trend of decreasing outcome scores over time was observed across all measures. (A) Eczema Area and Severity Index (EASI) is an internationally recognized scale for assessing the severity of atopic dermatitis. (B) Body Surface Area (BSA) reflects the percentage of body surface area of active disease. (C) Life Quality Index is a measure of the impact of skin disease on quality of life. (D) Investigator’s Global Assessment scale (IGA) offers a static evaluation of the overall severity of atopic dermatitis. (E) Disease severity score is a semiquantitative score of the patient’s or caregiver’s, evaluation of disease control over the previous 7 days. (F) Pruritus score evaluates severity of pruritus in the previous 24 hours.

At baseline, the proportion of patients with moderate-to-severe pruritus was significantly higher in the in-person group (72.7%) compared to the virtual group (28.6%) (Fisher’s exact P = .016) (Supplemental Table S2). While this trend persisted throughout subsequent follow-up visits, the differences observed were not statistically significant. Similarly, for all other dermatological measures, average scores and proportions of more severe outcomes were consistently higher for in-person patients compared to virtual patients, though not statistically significant.

Satisfaction ratings using a Likert scale (very satisfied, fairly satisfied, somewhat satisfied, not satisfied, and not satisfied at all) were collected at each patient’s final visit. Patient satisfaction scores were comparable between the virtual and in-person study arms. Of the patients who completed the final survey, 92% in the in-person study arm and 88% in the virtual study arm were very satisfied with the care they received. The remaining patients were fairly satisfied with their care (8% in the in-person and 12% in the virtual arms). None of the patients reported being somewhat satisfied, not satisfied, or not satisfied at all.

On average, patients accessing dermatology care through virtual visits had 80% lower odds of moderate-to-severe uncontrolled disease (OR = 0.2; 95% CI = 0.06, 0.5) and 80% lower odds of moderate-to-severe pruritus (OR = 0.2; 95% CI = 0.05, 0.7) over time, compared to those receiving in-person care (Supplemental Table S3). Although the average odds of moderate-to-severe AD (as measured by IGA) were lower in the virtual group than in the in-person group, this association was not statistically significant (OR = 0.3; 95% CI = 0.08, 1.1). Likewise, while average EASI, BSA, and LQI scores were lower for patients in the virtual group compared to the in-person group, these differences were not statistically significant and displayed relatively wide confidence intervals. Average BSA scores decreased significantly over the course of follow-up (β = −.07; 95% CI = −0.1, −0.3). The impact of demographic covariates over time was predominantly nonsignificant, except for the odds of experiencing moderate-to-severe pruritus, which was 5.5 times higher (95% CI = 1.3, 24.0) for non-white participants compared to white participants throughout the study.

In analyzing the content of participants’ qualitative feedback, several key themes emerged.

• Equivalency of Care Access and Quality: Patients perceived equivalency in access to and quality of care across both the virtual and in-person study arms.

• Preferences for In-Person Care: Despite the overall satisfaction with both modalities, some participants expressed a preference for in-person care. This preference was linked to a greater likelihood of establishing a trusting therapeutic relationship with the physician through in-person visits.

• Technology Challenges in Virtual Care: Participants underscored technological issues associated with virtual care. These included concerns about the quality of images and video calls, the reliability of virtual physical examinations, and the difficulties in examining sensitive regions.

• Privacy Concerns: Privacy also emerged as a theme, particularly in relation to virtual care. Patients expressed concerns about both physical privacy at home and online privacy, suggesting apprehensions about the confidentiality and security of virtual consultations. One patient remarked, “in-person visits are more personal and are better for physical exams, and privacy at home and online privacy can be an issue with virtual care.”

• Convenience and Flexibility of Virtual Care: Convenience and cost-effectiveness were attributed by many patients to virtual care. Participants appreciated the reduced need for commuting and the decreased time spent in waiting rooms. “There is less wasted time commuting and sitting in the waiting room.” This aspect was particularly valued by parents and workers who noted the scheduling flexibility offered by virtual visits.

• Preference for Hybrid Care: A recurring suggestion was the desire for a hybrid model of care that incorporates both in-person and virtual visits. This preference was articulated as a desire for annual in-person visits combined with the option for virtual consultations for less urgent or severe cases. The flexibility and ease of virtual care for routine or maintenance follow-ups were noted, while recognizing the importance of periodic in-person care. One participant stated, “Home visits are convenient for simple maintenance follow-ups if the disease is not too active. I would still prefer at least one annual in-person visit and to have an option for virtual visits otherwise.” Another participant added, “Virtual care is easier and more flexible for less urgent or severe cases.”

Discussion

This study evaluates several outcome measures for mild-to-severe AD patients undergoing virtual versus in-person care. At baseline, the proportion of patients with moderate-to-severe pruritus was significantly higher in the in-person group in contrast to the virtual group. This trend persisted over subsequent follow-up visits, although not statistically significant. Similarly, the average scores and proportions of all other dermatological measures were higher for in-person patients, although not statistically significant. Stratification by visit type revealed consistently lower average outcome scores and proportion of moderate-to-severe scores in the virtual cohort across all visits, except for baseline LQI scores. Overall, symptom severity was lower among patients accessing virtual care, suggesting a potential preference for and increased comfort with virtual care in patients with minimal or well-controlled symptoms. However, further studies are required to delineate the underlying reason for this trend.

Qualitative feedback from participants regarding their experience within each study arm and their views on telemedicine was collected at the final visit. Although many patients perceived no significant difference in access to and quality of dermatologic care, others noted a preference for in-person care. These patients emphasized that in-person visits may provide a more personable experience and allow for a more trusting therapeutic relationship between the patient and physician. Patients also raised concerns about the technological challenges that can occur with virtual care, including the quality of pictures and video calls, reliability of virtual physical examinations, and challenges with examining sensitive regions. Other patients strongly preferred virtual care for its convenience, cost-effectiveness, and flexibility. Several patients declared they would prefer access to both in-person and virtual patient care. This suggests that offering both virtual and in-person care options might be the optimal approach, potentially enhancing overall patient healthcare outcomes and accommodating diverse patient needs and expectations.

Due to the small sample size, our results are limited by wide confidence intervals and a potential lack of generalizability to broader populations. However, GEE modelling is robust with sample sizes as small as 12 individuals, ¹⁶ and our results support the effectiveness and feasibility of telemedicine-based care/interventions. The study also faced high dropout rates, 50.0% in the in-person cohort and 42.8% in the virtual cohort, with a 7.2% differential rate between both groups. We hypothesize high dropout rates to be related to the episodic nature of AD. Given the chronic relapsing and remitting course of AD, participants without active symptoms at the time of their scheduled visit might perceive continued participation as unnecessary. The demands of the study, such as time commitment, travel, frequent visits, and completing questionnaires (eg, Dermatology Life Quality Index), could be especially burdensome for those without active symptoms. Prior studies suggest dermatology appointment nonattendance rates of 17% to 31%. ¹⁷ Commonly reported reasons for missed appointments include forgetfulness, travel difficulties, family responsibilities, and long wait times. ¹⁸ Our analysis may be further subject to residual confounding due to the exclusion of variables such as income and education level. Another limitation of the study is the random patient allocation process. Consecutive patients presenting to the clinics were randomized into either study arm. However, patients retained the option to decline participation in the assigned group. Although this mimics real-world practice patterns, this patient allocation method precludes the generalizability of conclusions for patients who are not comfortable with teleconsultations.

In general, there was a trend of decreasing outcome scores over time for all 6 measures in both study arms, suggesting that patients, on average, experienced improved dermatological outcomes over the course of follow-up.

Conclusion

The study observed a consistent decrease in outcome scores across all 6 measures in both study arms over time. This suggests that virtual care and in-person care provide comparable treatment outcomes for patients accepting care by either method of healthcare delivery. Our findings support teledermatology as a viable and effective care pathway in managing and providing follow-up care for chronic inflammatory conditions such as AD for patients of various demographic standings.