A study on clinicodemographical profile of patients availing the teledermatology service at a tertiary care center in Northeast India

INTRODUCTION

Telemedicine can be defined as a contemporary technology that provides remote health-care service. Dermatology, a field heavily reliant on visual assessment, is particularly well suited for this type of health-care approach. Teledermatology has served multiple functions: Health-care professionals can utilize this technology to offer clinical assistance to patients, monitor patient well-being, engage in consultations with fellow health-care providers, and grant patients access to educational materials.

Various models and modes of delivery of such services have been categorized based on the nature of the involved actors.^[1] The categories of teledermatology are described in Table 1 while Table 2 depicts the different delivery methods of teledermatology.^[2]

Thus, using the store-and-forward pattern,^[1,3] this study aimed to discern how teledermatology is being utilized, focusing on the patterns related to patient clinical and demographic characteristics.

MATERIALS AND METHODS

This study was conducted after ethical clearance from the institute. Data of patients was analyzed for one year (January 2022–March 2023). Demographic details of the patients, clinical signs and symptoms, diagnosis, differential diagnosis, and whether diagnosis could be made by image were collected and analyzed.

RESULTS

A total of 74 patients were included in this study.

Demographic details

While assessing the patients according to age groups in this research, our patients ranged from youngest being 6 months to oldest 88 years of age, and the highest frequency of users for this service was those aged between 20 and 30 years (35%). The median age was 24 years. Conversely, the number of older (>60 years) patients was notably lower, as indicated in the provided chart. Our findings indicate that only 4% of the patients were from the pediatric population and 2.7% were from the elderly population. The age-wise distribution of the patients is represented in Figure 1.

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Figure 1:

Age-wise distribution.

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Females outnumbered males with a M: F ratio of 1:2.5.

The majority of the individuals (about 88%) were from urban areas, whereas a mere 12% hailed from rural areas.

Clinical characteristics

A clinical diagnosis could be established for 61 individuals (making up 82% of the total). However, the condition of the remaining 13 patients (18%) could not be diagnosed.

Among the 61 patients in whom a diagnosis was attainable, acne (32.8%) followed by eczema (18%), melasma (14.8%), and superficial fungal infections (13.3%) were the most common diagnoses made. The various diagnoses made in our study are represented in Figure 2.

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Figure 2:

Graph depicting clinical case-wise distribution.

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Of the three pediatric cases encountered, the diagnosis could not be made in one, whereas the other two were identified as scabies and vitiligo, respectively.

The diagnosis was inconclusive for one of the two patients from the elderly population (>60 years), whereas the other was diagnosed with melasma.

Patients where a diagnosis was not possible were asked to follow up for a visit in the outpatient department (OPD); however, none of them turned up.

In terms of old versus new cases, the proportion was 1:73.

When considering the duration of the illness, we found that 74% of the cases presented to us were chronic (duration >6 weeks) and 26% were acute. Different illnesses by duration are represented in Table 3.

Table 3: Clinical conditions based on duration.

Acute	Chronic
Acne-7	Acne-13
Eczema-3	Eczema-9
Superficial fungal infections-4	Superficial fungal infections-4
Perniosis-1	Melasma-9
Scabies-1	Scabies-1
	Vitiligo-3
	Urticaria-2
	Psoriasis-1
	Alopecia-3
	Milia-1

Regarding the choice of follow-up of the patients where a diagnosis was possible, either by teleconsultation or face-to-face visit, merely 4% of them opted for a follow-up through teleconsultation while none of the patients preferred in-person consultation.

DISCUSSION

Many published teledermatology articles have typically centered around a single disease, such as melanoma,^[4-6] acne,^[7,8] or a specific class of diseases, such as malignant tumors.^[9-11] One study from north India by Tuknayat et al.^[12] had a more comprehensive approach, addressing a range of dermatological conditions. Our study marks the pioneering effort of its kind in northeast India.

A noteworthy observation was the age-related utilization pattern, where 44.5% of individuals seeking teledermatology services fell within the young adult age group, with a peak occurring between 20 and 30 years of age. This trend can potentially be attributed to the higher familiarity with using technology, having easier access to the Internet, and willingness to use the facility and share digital images in younger adults, compared to both older individuals and those who are even younger, leading to a variance in utilization patterns.

In a study from São Paulo, Giavina-Bianchi et al.^[13] reported that they found the peak age of utilization to be 60–69 years. This suggests that the elderly population in Western regions may be more adept at using technology than their counterparts in our demographic. There can be many barriers that limit the use of modern telecommunication techniques in the elderly; however, certain measures can be adopted to maximize engagement in them. These include a brief demonstration video or screenshots entailing step-by-step procedure on how to avail the service. For those without Internet/smartphone access, telephone-only encounters can still be effective for initial communication.

Similarly, the variation in patient statistics concerning urban and rural distribution can also be attributed to factors such as limited awareness and accessibility of teleconsultation services among the rural population, especially considering the terrain of the Northeast region where Internet facilities are limited.

However, this observation also underscores the potential for the growth of teledermatology in rural areas. The greater accessibility of teledermatology can benefit more patients, especially considering the limited number or unavailability of dermatologists in such regions.^[14]

Out of the 74 patients who were assessed, a diagnosis was achievable for 61 of them. However, factors such as poor quality of the images, insufficient clinical information from patients, and lack of adequate history taking by the health-care provider in the store-and-forward approach contributed to the inability to make a clinical diagnosis in about 13 patients (18%).

The effectiveness of each telemedicine platform is contingent upon factors such as the specific medical condition, image quality, and the proficiency of the health-care provider.^[14] Furthermore, accessing telemedicine is influenced by both network connectivity and socioeconomic status.^[15] Oakley and Rennie^[16] conducted a study involving 384 cases, a diagnosis was possible for 96% of the cases whereas 4% remained without a definitive diagnosis.

The patients where a diagnosis could not be made were asked to review either in the OPD or for a face-to-face visit but none of these patients came back for follow-up. In addition, out of all the patients on whom the diagnosis was possible, only 3 patients (4.9%) followed up for a re-consultation through teledermatology and none for a face-to-face visit.

This could be explained by different reasons; achievement of clinical improvement, the skin condition was not affecting the patient to the extent wherein they felt the need for an in-person visit or patients were reluctant to follow up. However, in a study conducted by Oakley and Rennie,^[16] the attendance rate for new patients was 86.6% and for follow-ups, it was 78.9% which was much higher than our study. Adherence to follow up can be increased by ensuring that there is a provision for a reminder text message, email, or call regarding the follow-up. In addition, a separate counter for registration of in-person visits for such patients will reduce the time of consultation, especially for those who are hesitant to come due to long waiting hours.

Regarding the distribution of cases based on diagnosis, the most common was acne (31.8%) followed by eczematous disorders (18%), melasma (14.8%), and superficial fungal infections (13.3%). In a study from North India by Tuknayat et al.,^[12] infections/infestations (29.5%), eczematous disorders (22.9%), and acne (12.6%) comprised the three most common conditions encountered. We can observe a discernible trend concerning the types and frequencies of various clinical conditions commonly encountered through teleconsultation. This data can potentially serve as valuable insight for future endeavors in triaging conditions through teleconsultation, aiming to minimize in-person visits for diseases that can effectively be managed online through teledermatology.

Another observation was that most of the conditions that were presented to us were chronic in nature, even in the eczematous group. Acne, eczemas, and superficial fungal infections were the three most common categories in both the acute and chronic groups, but the number of patients in the above-mentioned categories was higher in the chronic group as represented in Table 3. This discordance between acute and chronic groups could be explained by the fact that the patients with acute dermatological conditions preferred in-person visits because of their symptomatic nature contrary to the patients with chronic disorders, who opted for teleconsultation.

CONCLUSION

Through this study, our main purpose was to highlight the various conditions that we encounter in our teledermatology setup at a referral center using the store and forward method and to also see the demography of the patients particularly in the peripheral areas where such services are either not accessible or not utilized to its maximum potential as supported by our study where the majority of the utilizers were from an urban background. Similarly, we also observed that the elderly population in our part of the country is underutilizing this service despite its convenience and easy accessibility. In terms of dermatological conditions, acne, eczematous disorders, melasma, and superficial fungal infections were the most common dermatoses encountered, which can often be managed by primary health-care providers while patients with dermatological conditions that require specialist attention such as autoimmune blistering, connective tissue disorders, hair, nail related dermatoses, and skin cancers were not utilizing this facility at all.