The COVID-19 pandemic required a rapid expansion of teledermatology services

Background: The COVID-19 pandemic required a rapid expansion of tele dermatology services. Objective(s): Analyse demographic shifts in a pediatric dermatology practice session with children of colour. Method(s): A retrospective chart review of pediatric dermatology patients seen in the four practice weeks preceding the New York COVID-19 lockdown and comparable tele dermatology visits during the COVID-19 pandemic lockdown. Demographic differences (e.g., race, age, gender and household income) were analysed. Result(s): A greater proportion of patients seen were White during lockdown (59.7%), compared to pre-lockdown (43.6%), with a reduction in Asian patients seen in lockdown (6.0%) compared to prelockdown (24.5%). A lower proportion of no-show patients (4.3%, 3/70 scheduled) were noted in lockdown compared to pre-lockdown (16%, 18/112). Preferred provider organizations and higher-income zip codes were more common for children seen during lockdown. Limitation(s): The sample addresses a limited New York pediatric dermatology practice during a short time-period. Conclusion(s): White patients and patients with preferred provider organizations were more likely to access telehealth, supporting disparity in tele dermatology services. These results demonstrate reduced healthcare access for lower-income and Asian children during the COVID-19 pandemic lockdown.

Consensus Guidelines for Teledermatology: Scoping Review

Background: Consensus guidelines and recommendations play an important role in fostering quality, safety, and best practices, as they represent an expert interpretation of the biomedical literature and its application to practice. However, it is unclear whether the recent collective experience of implementing telemedicine and the concurrent growth in the evidence base for teledermatology have resulted in more robust guidance. Objective: The objective of this review was to describe the extent and nature of currently available guidance, defined as consensus guidelines and recommendations available for telemedicine in dermatology, with guidance defined as consensus or evidence-based guidelines, protocols, or recommendations. Methods: We conducted a single-reviewer scoping review of the literature to assess the extent and nature of available guidance, consensus guidelines, or recommendations related to teledermatology. We limited the review to published material in English since 2013, reflecting approximately the past 10 years. We conducted the review in November and December of the year 2022. Results: We identified 839 potentially eligible publications, with 9 additional records identified through organizational websites. A total of 15 publications met the inclusion and exclusion criteria. The guidelines focused on varied topics and populations about dermatology and skin diseases. However, the most frequent focus was general dermatology (8/15, 53%). Approximately half of the telemedicine guidance described in the publications was specific to dermatology practice in the context of the COVID-19 pandemic. The publications were largely published in or after the year 2020 (13/15, 87%). Geographical origin spanned several different nations, including Australia, the United States, European countries, and India. Conclusions: We found an increase in COVID-19-specific teledermatology guidance during 2020, in addition to general teledermatology guidance during the period of the study. Primary sources of general teledermatology guidance reported in the biomedical literature are the University of Queensland's Centre for Online Health and Australasian College of Dermatologists E-Health Committee, and the American Telemedicine Association. There is strong evidence of international engagement and interest. Despite the recent increase in research reports related to telemedicine, there is a relative lack of new guidance based on COVID-19 lessons and innovations. There is a need to review recent evidence and update existing recommendations. Additionally, there is a need for guidance that addresses emerging technologies. © Mollie R Cummins, Triton Ong, Julia Ivanova, Janelle F Barrera, Hattie Wilczewski, Hiral Soni, Brandon M Welch, Brian E Bunnell.

The Impact of Telemedicine on Patients with Hidradenitis Suppurativa in the COVID-19 Era.

(1) Background: Hidradenitis suppurativa is a chronic, inflammatory skin disease. It is characterized by the transformation of normal skin into skin with abscesses, nodules, tunnels, and scars. The most commonly affected areas are the armpits, groins, buttocks, and subscapular area. Patients with HS require constant care under the supervision of the outpatient clinic. Due to the COVID-19 pandemic, consultations have been introduced in the form of telemedicine. The aim of this study was to evaluate the availability of HS treatment during the COVID-19 pandemic and to assess patient satisfaction, problems with access to medical care, and the impact of the pandemic on the course of the disease. (2) Methods: An internet survey with an anonymous questionnaire was used to assess the effectiveness of telemedicine consultations. The survey consisted of 25 closed questions, and responses were kept fully anonymous. (3) Results: Most respondents reported minor problems with accessing specialized HS medical care during the COVID-19 pandemic (n = 25, 35.71%). However, 35.71% (n = 25) of them reported major problems with appointments for specialized ambulatory treatment during the last few months of the pandemic, mainly due to delayed appointments. Almost half of the respondents had been diagnosed with COVID-19 (n = 34, 48.57%), and 58.57% (n = 41) of respondents did not see a correlation between COVID-19 infection and HS progression. (4) Conclusions: Our study showed that the pandemic significantly limited access to medical advice, and patients with hidradenitis suppurativa prefer standard consultations.

The Artificial Intelligence in Teledermatology: A Narrative Review on Opportunities, Perspectives, and Bottlenecks.

Artificial intelligence (AI) is recently seeing significant advances in teledermatology (TD), also thanks to the developments that have taken place during the COVID-19 pandemic. In the last two years, there was an important development of studies that focused on opportunities, perspectives, and problems in this field. The topic is very important because the telemedicine and AI applied to dermatology have the opportunity to improve both the quality of healthcare for citizens and the workflow of healthcare professionals. This study conducted an overview on the opportunities, the perspectives, and the problems related to the integration of TD with AI. The methodology of this review, following a standardized checklist, was based on: (I) a search of PubMed and Scopus and (II) an eligibility assessment, using parameters with five levels of score. The outcome highlighted that applications of this integration have been identified in various skin pathologies and in quality control, both in eHealth and mHealth. Many of these applications are based on Apps used by citizens in mHealth for self-care with new opportunities but also open questions. A generalized enthusiasm has been registered regarding the opportunities and general perspectives on improving the quality of care, optimizing the healthcare processes, minimizing costs, reducing the stress in the healthcare facilities, and in making citizens, now at the center, more satisfied. However, critical issues have emerged related to: (a) the need to improve the process of diffusion of the Apps in the hands of citizens, with better design, validation, standardization, and cybersecurity; (b) the need for better attention paid to medico-legal and ethical issues; and (c) the need for the stabilization of international and national regulations. Targeted agreement initiatives, such as position statements, guidelines, and/or consensus initiatives, are needed to ensure a better result for all, along with the design of both specific plans and shared workflows.

Teledermoscopy-Aided Self-Skin Examinations for Remote Triage of Skin Lesions

Purpose of Study: Teledermatology, defined as the use of technology to provide dermatology services to individuals in a remote setting, has grown considerably in popularity since the onset of the COVID-19 era. Teledermoscopy utilizes a dermatoscope attachment paired with a smartphone camera to visualize colors and microstructures within the epidermis and superficial dermis that cannot be seen with the naked eye alone. When combined with store-and-forward technology, teledermoscopy of lesions concerning for skin cancer can improve virtual referral and triage workflow. Methods Used: Our retrospective case-control study evaluated the efficacy of a smartphone dermatoscope borrow program in the remote triage of individuals with self-selected skin lesions of concern and its effect on subsequent in-person follow-up visits. A retrospective medical record review was conducted of all Oregon Health and Science University (OHSU) Department of Dermatology spot check image submissions utilizing the smartphone dermatoscopes between August 2020-2022. Dermoscopic images of skin lesions that included corresponding non-dermoscopic clinical images in their submission were included in our review (n=70). A blinded expert dermoscopist then reviewed the clinical and dermoscopic images separately and utilized standard clinical algorithms for skin cancer (ABCD criteria: asymmetry, irregular borders, multiple colors, diameter>= 6mm for clinical images;3-point checklist: dermoscopic asymmetry, atypical network, blue-white structures for dermoscopy images) to determine whether the imaged lesion should translate to an in-person visit for further evaluation. Summary of Results: Of the 70 skin lesions submitted, 59 warranted in-person evaluation from clinical (non-dermoscopic) image review compared to 29 warranting in-person evaluation from dermoscopic images of the same lesion. Thus, this is a 51% reduction of conversion to in-person consultation with the addition of smartphone dermatoscope images in virtual lesion triage (P<0.001, McNemar's Test). Conclusion(s): Implementing patient-led teledermoscopy may reduce frequency of in-person visits for benign lesions, and thus, may decrease wait times for other patients with concerning and possibly malignant lesions. Decreasing the frequency of unnecessary visits may not only improve patient quality of life, but also promote cost-effective expenditures for health systems at large.

Perceptions of teledermatology in the COVID-19 era: are patients ready for it?

Introduction: The COVID-19 pandemic has changed care provision models, with a rapid increase in the adoption of telemedicine to reduce in-person visits. Although there are many benefits to teledermatology, there are also factors that hinder its widespread adoption. We aimed to examine patients' perceptions of teledermatology to identify the barriers to its adoption. Methods: A prospective study was conducted from 15 June to 14 August 2020. Patients were invited to complete a questionnaire in an outpatient dermatology clinic via direct approach by clinical staff or posters posted at the door of consultation rooms. Results: Out of 2,276 clinic attendances, 997 survey responses (43.8%) were collected over a 3-month period. When asked if they would change their subsequent visit to teledermatology, 294 (29.5%) patients were keen, 166 (16.6%) were unsure and 537 (53.9%) declined. Significant factors for declining teledermatology were lack of prior exposure to videoconferencing (P < 0.01) and lower educational level (P = 0.019). Patients also raised concerns regarding the ability of teledermatology to address medical concerns (32.1%) and indicated a preference for face-to-face consultation (29.7%). Conclusion: Factors that influence patients' decision to adopt teledermatology, such as concerns about its ability to address medical issues, lack of IT literacy or experience in teleconferencing, are modifiable. Targeted strategies such as careful patient selection, a dedicated teleconsultation workflow, and the use of a novel 'teledermatology patient journey' (including a clinic walkthrough at the first visit) and an intuitive audio-enabled user interface, may improve patient perceptions and adoption of teleconsultation service.

Disparities in the Use of Teledermatology During the COVID-19 Pandemic Lockdown in a Pediatric Dermatology Practice.

Background: The COVID-19 pandemic required a rapid expansion of teledermatology services. Objective: Analyze demographic shifts in a pediatric dermatology practice session with children of color. Methods: A retrospective chart review of pediatric dermatology patients seen in the 4 practice weeks preceding the New York COVID-19 lockdown and comparable teledermatology visits during the COVID-19 pandemic lockdown. Demographic differences (e.g., race, age, gender, and household income) were analyzed. Results: A greater proportion of patients seen were White during lockdown (59.7%), compared with pre-lockdown (43.6%), with a reduction in Asian patients seen in lockdown (6.0%) compared with pre-lockdown (24.5%). A lower proportion of no-show patients (4.3%, 3/70 scheduled) were noted in lockdown compared with pre-lockdown (16%, 18/112). Preferred provider organizations (PPO) and higher-income zip codes were more common for children seen during lockdown. Limitations: The sample addresses a limited New York pediatric dermatology practice during a short time period. Conclusions: White patients and patients with PPO were more likely to access telehealth, supporting disparity in teledermatology services. These results demonstrate reduced health care access for lower-income and Asian children during the COVID-19 pandemic lockdown.

Evaluation of virtual dermatology clinic experience during coronavirus disease 2019 pandemic, advantages, and disadvantages

Introduction During the current lockdown due to the coronavirus disease 2019 (COVID-19) pandemic, the healthcare system should be modified to reach out to a large number of patients with effective service. Virtual clinics are one possible solution to the challenges healthcare systems face worldwide during the COVID-19 pandemic. Aim To evaluate the experience of the virtual clinic in Dermatology Department at King Khaled University Hospital and to evaluate its advantages and disadvantages, and whether or not this service is practical to apply in the future. Patients and methods To assess the patients' attitude toward virtual clinics, 1220 patients were offered a phone consultation during May 2020. A questionnaire was drafted with 23 questions sent to all the patients via cellular text. Seven of these questions were related to patient demographics. The remaining questions assessed patient satisfaction, occupational efficiency, and quality of care. Statistical analysis was performed using R v 3.6.3. Sociodemographic characteristics were included as independent variables. Ordinal logistic regression was used to assess patient satisfaction. Multivariate logistic regression was used to assess factors associated with satisfaction. Results Only 115 patients responded to the survey. About 34.8% of them found virtual clinics more comfortable compared with face-to-face visits, and 65.2% were satisfied with the care received through these clinics. However, 34.8% of the patients could not know the appropriate treatment, and 37.4% thought they did not receive all the needed information about their health condition. Overall, 71.3% of the patients were satisfied with the provided diagnosis. The most common reason for nonsatisfaction with virtual clinics was the lack of clinical examination (62.39%) and difficulty communicating with the physician (42.94%). Conclusion Virtual dermatology clinics can provide satisfactory dermatology care services to the patients during COVID-19 and can reduce the risk of exposure and transmission of the virus. These services have optimal occupational efficiency, patient-satisfaction rate, and quality of care.

Efficacy, perception, and utilization of pediatric teledermatology: A systematic review.

Background: The use of teledermatology abruptly expanded with the arrival of COVID-19. Here, we review recent studies regarding the efficacy, perception, and utilization of telemedicine in the pediatric population. Objective: To evaluate the current state of pediatric teledermatology. Methods: A literature search was performed using the terms "pediatric," "teledermatology," "dermatology," "telemedicine" and "telehealth" in PubMed, Scopus, Embase, and Google Scholar. 44 articles published between 2008 and 2022 were included. Results: Diagnostic concordance between pediatric teledermatologist and in-person dermatologist ranged from 70.1% to 89%. Conditions treated with pediatric teledermatology were similar to those treated in-person. The rate of in-person follow-up after an initial telemedicine appointment pre and postpandemic was 12% to 51.9% and 13.5% to 28.1%, respectively. Patient satisfaction with teledermatology was between 70% to 98% and provider satisfaction was approximately 95%. The integration of teledermatology can reduce missed appointments and wait times among pediatric patients. However, considerable technological challenges exist, particularly in underserved communities. Globally, teledermatology may expand access to care though limited literature exists regarding its use in pediatric populations. Conclusion: Telemedicine is effective for the diagnosis and treatment of many dermatological conditions in children, with high patient and provider satisfaction. Implementation of teledermatology can potentially increase access to care both locally and globally, but obstacles to engagement remain.

Dermatologists' perceptions of using teledermatology to manage hidradenitis suppurativa

The COVID-19 pandemic has led to rapid adoption of teledermatology. Hidradenitis Suppurativa (HS) is a chronic inflammatory condition that requires recurrent clinical evaluation and may be subjected to privacy concerns amongst patients when managed over teledermatology. We assessed dermatologists' perceptions of teledermatology in managing HS. Participants were invited to completed a survey electronically via a secure online platform. The survey was disseminated to members of the Asia Pacific Hidradenitis Suppurativa Foundation and through word of mouth, over February to June 2022. Demographics and survey responses were collated. Associations between demographics and attitudes towards teledermatology for HS were evaluated by multivariable ordered logistic regression. 100 responses were obtained comprising of 76 (81.7%) dermatologists and 17 dermatology trainees (18.3%). Older physicians tended to express sentiments that it was difficult to accurately assess disease severity for HS.There was increased tendency for physicians to perceive difficulty in managing HS compared to AD (assessed as a control cohort) - in terms of photography of sensitive areas (adjusted OR 4.71 (95% confidence interval: 2.44-9.07);p value < 0.001), accurate assessment (adjusted OR 2.66 (95% confidence interval: 1.48-4.79);p value 0.001), privacy issues from examination of private body areas (adjusted OR 2.75 (95% confidence interval 1.36-5.56);p value 0.005). This study, is the first, to our knowledge that assess physician attitudes towards the use of teledermatology in managing HS patients, and compares differential perspectives of its use on HS and AD patients. Physicians' efforts should be focused on streamlining patient selection and optimizing consult environments for patients with HS.Copyright © 2023

Teledermatology for Common Inflammatory Skin Conditions: The Medicine of the Future?

BACKGROUND: The COVID-19 pandemic period revolutionized daily clinical practice. Several strategies were adopted by clinicians to avoid reducing treatment for diseases without the risk of spreading the infection. Among the adopted strategies, telemedicine played a key role. In this scenario, several tools were used, including e-mails, phone calls, video calls, support groups, and messages. Fortunately, the COVID-19 pandemic period seems to be at an end. However, the use of teledermatology appears to be an excellent strategy for the future as well. Indeed, several patients may benefit from teledermatology. OBJECTIVE: In this manuscript, we aim to investigate the use of telemedicine in the dermatological field to point out how this tool may become the mainstay of future medicine. Only the use of teledermatology with common inflammatory skin conditions have been reported herein. MATERIALS AND METHODS: Investigated manuscripts included metanalyses, reviews, letters to the editor, real-life studies, case series, and reports. Manuscripts were identified, screened, and extracted for relevant data following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. RESULTS: A total of 121 records were identified from the analyzed databases. However, only 110 articles were assessed for eligibility. Finally, 92 articles were selected at the end of the literature research for our review. CONCLUSIONS: Teledermatology should be considered as a viable option for the dermatologist for the future. We believe that the pandemic has strengthened this service, and this will allow for ever better development in the future. Guidelines regarding the use of teledermatology are required as well as additional improvements for the future.

Evolving teledermatology policy and reimbursement landscape in the United States.

Background: Policymakers and payers are reevaluating the temporary telehealth flexibilities granted during the COVID-19 public health emergency, which will shape future teledermatology utilization. Objective: To summarize the recently expanded telehealth flexibilities in the United States, projected changes, and corresponding implications for dermatologists. Methods: Narrative review of the literature, United States policies and regulations, and white paper reports. Results: Key telehealth flexibilities included expansion of payment parity, relaxation of originating site requirements, loosening of state licensure requirements, and HIPAA (Health Insurance Portability and Accountability Act of 1996) enforcement discretion. These changes enabled widespread accessibility and adoption of teledermatology, which enhanced high-quality and cost-effective dermatologic care. Most waivers will end 151 days following the end of the public health emergency declaration. Notably, asynchronous telehealth was not included in the reimbursement expansion. Limitations: Only policies and regulations through December 2022 are included. Conclusion: It will be important for the field of dermatology to stay abreast of the upcoming changes in telemedicine policies and reimbursement, to demonstrate teledermatology's value through evidence-based studies and to advocate for enduring policies that will promote the accessibility of teledermatology for patients.

Utilization of teledermatology services for dermatological diagnoses during the COVID-19 pandemic.

Little is known about trends in teledermatology adoption and use for managing dermatologic patients, especially changes in use influenced by the COVID-19 pandemic. In this retrospective cohort study, we analyzed encounter data from the Healthjump dataset (containing electronic health record data from throughout the USA) for visits from November 2019 to July 2021 with a primary dermatology-related diagnosis. There was a striking rise in teledermatology use with the onset of the pandemic in February 2020, peaking in April 2020 with 2178 teledermatology encounters (32.8% of all encounters). Subsequently, teledermatology use waned. Most teledermatology care was delivered via synchronous means with little use of asynchronous or telephone communication. When compared to those with neoplastic skin diseases, patients with inflammatory skin diseases were more likely to be seen via teledermatology (OR 3.30, 95% CI 3.12-3.49). Certain demographic groups were less likely to receive care via teledermatology, such as men (compared with females, OR 0.76, 95% CI 0.74-0.78) and patients 65 and older (compared with those below 65, OR 0.59, 95% CI 0.57-0.62). Our work shows increased adoption of teledermatology at the onset of the COVID-19 pandemic with decreasing use over time. Future efforts are needed to ensure continued and expanded use of a valuable care modality to reach vulnerable populations.

Inpatient teledermatology service: baseline review - it works!

Setting up an inpatient teledermatology service over 1 year at our National Health Service-based district general hospital made absolute sense on two grounds: The COVID pandemic and the ever-increasing role of teledermatology enabling dermatology departments, often with limited resources, to 'work smart'. Over a 43-week period, 124 referrals were dealt with on our teledermatology platform (around 12 referrals per month). Average response time to referral was 0.65 days: 56% same-day response, 32% next-day response;and 92% a response within 3 days. Following this, 32% of patients were seen face to face on the wards and 40% were dealt with via remote advice and guidance. Around 10% of referrals were deemed not to be appropriate for dermatology review/advice. Around 12% of referrals were given dermatology face-to-face outpatient appointments rather than review on the wards, and 7% were declined an appointment (pending further information being received) as insufficient information was given for triage/advice and guidance. Initially, just 10% of referrals were sent (first time) with clinical images, but this increased to 54% after 4 months, and although there has been some monthly variation, up to 64% has been achieved (noting that clinical images are not always required for the question being asked). Around 50 different diagnoses were made, illustrating the diversity and complexity of dermatological practice, and the scale of the diagnostic problems facing ward-based teams. Previously published data revealed that around one-third of inpatient dermatology referrals were for 'red legs', which was replicated in the current results, with diagnoses of venous or atopic eczema (14%), drug reactions (12%), skin neoplasia (6%), cellulitis/erysipelas (5%), intertrigo (4%), erythroderma (4%), Gianotti-Crosti syndrome (2.5%), bullous pemphigoid (2.5%), pyoderma gangrenosum (2.5%) and vasculitis (2%). Having an inpatient teledermatology service benefits dermatology departments, enabling efficient working, appropriate triage, training opportunities and ease of second opinions from colleagues. Benefits for referrers are acute ward-based teams including rapid responses to referrals, enabling skin concerns to be dealt with quickly and avoiding delays in investigation, treatment and discharge. Some hospitals where dermatology does not have a permanent base may be able to access dermatology advice and guidance via teledermatology. Overall, patients benefit from teledermatology and it is COVID secure.

Occupational dermatitis virtual clinic for healthcare workers: clinics to increase training opportunities to dermatology registrars who are working from home

During the COVID-19 pandemic, there has been a demand from frontline healthcare workers (HCWs) wanting dermatological advice for occupational dermatitis due to increased infection-prevention measures. Various dedicated occupational skin disease clinics in the UK have been set up to help these HCWs, from virtual clinics to drop in clinics (O'Neill H, Narang I, Buckley D et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. Br J Dermatol 2021;184: 575-7). These clinics provide an opportunity for dermatology registrars to enhance their training in contact dermatitis and teledermatology. In a nationwide survey conducted in January 2020, it was felt that dermatology trainees lacked confidence in handling teledermatology referrals (Lowe A, Pararajasingam A, Goodwin RG. A paradigm shift in trainee confidence in teledermatology and virtual working during the COVID-19 pandemic: results of a follow-up UK-wide survey. Clin Exp Dermatol 2021;46: 544-7). At our institution, a virtual telephone clinic has been set up with occupational health input. A standardized pro forma is given and each person sends photos with an occupational health referral to an encrypted email service. By having this additional information beforehand, a history can be taken in the telephone clinic and appropriate management advice given. There is a dermatology consultant who is on hand to help with any queries that the trainee may have. Medications are sent out to the patient and a letter is copied to the patient, as well as the general practitioner, which details the consultation. The patients are usually discharged from the service;however, if the patients need to be seen a face-to-face appointment is given. In these clinics, various occupational dermatoses have been seen and managed. The most common diagnosis was irritant contact dermatitis of the hands due to increased handwashing and alcohol gel use, and most of these patients have a previous diagnosis of atopy (O'Neill et al.). Other occupational dermatoses seen include allergic contact dermatitis, acne and flare-up of atopic eczema. Owing to the COVID-19 pandemic, some dermatology registrars may be working from home. By doing these clinics, training opportunities in dermatology can continue with registrars still seeing patients virtually and managing the conditions. Teledermatology is being introduced in the new dermatology curriculum from August 2021. This service is also appreciated by the HCWs with these patients being seen promptly and getting their conditions managed, maintaining wellbeing in staff.

Is a hybrid skin cancer surveillance service for organ transplant recipients feasible? Lessons from the pandemic

Organ transplant recipients (OTRs) are highly vulnerable to SARS-CoV-2 infection and routine transplant consultations were converted primarily to virtual (VC) rather than face to face (F2F) from the outset of the pandemic. A similar strategy was adopted in our tertiary OTR dermatology clinic, but the implications of this on safe and effective skin cancer surveillance are uncertain. We audited clinical and patient experiences of our hybrid service with the aim of identifying the benefits and limitations of this approach, and improvements required to optimize a future hybrid VC-F2F model for skin cancer surveillance. All OTRs consultations held between 1 April 2020 to 31 March 2021 were identified through electronic patient records. Data collected included proportions and reasons for VC and F2F consultations, teledermatology requests, VC to F2F conversion rate, rates of skin cancer diagnoses and adherence to established follow-up protocols. All patients were invited to complete an online service evaluation. In total, 554 encounters (80.3% VC, 19.7% F2F) were recorded in 247 OTRs (42% with previous skin cancer). Of routine F2F consultations, this was patient preference in 17 of 109 (16%) and clinician-based risk assessment for the remainder. In 108 (25%) VCs, photographs were requested and received for 63%, of which 82% were adequate for diagnosis. Overall, 12% of VCs were converted to F2F and in 19 of 45 (42%) OTRs this was due to suspected skin cancer, which was confirmed in nine of 19 (47%). All other skin cancers were diagnosed in routine F2F consultations. Surveillance in 167 of 192 (87%) assessable OTRs adhered to established follow-up protocols. Of patients who responded to the online survey, 74% felt that there were benefits to VCs, but 41% expressed concern about the lack of skin examination and 57% reported little/no confidence in self-monitoring. Despite this, 59% expressed a preference to continue hybrid VC-F2F surveillance, with VC as routine and F2F consultation when required. Our audit provides preliminary evidence supporting the effectiveness, safety and patient acceptability of a VC-F2F hybrid model for the delivery of OTR skin cancer surveillance. We did not identify major delays in skin cancer diagnosis, although not all patients have yet been seen F2F. Certain aspects of service delivery will require optimization. In particular, despite routine skin cancer education, many patients expressed concerns about self-monitoring. Programmes specifically tailored to address this need will be required, as will information technology support for some OTRs. With this information we are redesigning our service to incorporate a VC-F2F model for routine skin cancer surveillance and are evaluating the incorporation of a patient-initiated follow-up pathway.

Teledermatology and the Montgomery rule of consent

The Montgomery vs. Lanarkshire case of March 2015 is one of the most important UK judgments on informed consent. The ruling dictated that any intervention should be based on a shared decision, whereby patients are aware of all options and supported in making an informed decision. There is debate over whether patients requiring a procedure after a store-andforward teledermatology consultation need a preoperative face-to-face (F2F) appointment to comply with this consent. We evaluated patient experiences of our skin cancer teledermatology pathway, whereby patients had a telephone consultation before a surgical appointment and their first visit to the hospital was for the procedure. On average, we receive 9000 2-week-wait referrals a year. In March 2020, following the UK's nationwide lockdown, our dermatology department had 700 new referrals pending without any opportunity of F2F appointments. To meet this demand and the subsequent restrictions of the COVID-19 pandemic, we established a teledermatology service. Patients attended a community hub where a detailed history was taken and lesions photographed by a medical photographer, including dermoscopic images. Clinical images were subsequently reviewed by a consultant dermatologist. For those requiring surgical procedures, preoperative telephone consultations were conducted. Patients requiring complex procedures and those with likely highgrade malignant melanoma were offered F2F appointments. During the telephone consultation, the planned procedure was explained, with risks, benefits and alternative treatments discussed. The first 50 patients were sent a survey comprising eight questions pertaining to their experience of the new pathway. Over a 4-week period, 34 responded. Mean age was 67 years (range 29-93). Ninety-seven patients felt photographs were taken in a timely manner. All patients reported that appropriate safety and social distancing precautions were taken. All patients described an overall positive experience, felt that sufficient information was provided throughout the pathway and were happy to engage with this service should they require a similar procedure in the future. In this cohort of patients, their first visit to hospital was for a procedure. There are many benefits in reducing F2F hospital attendances. As well as reducing footfall during the pandemic, there is less lost work time and cost of travel for patients or their relatives, more efficient use of hospital facilities and reduced carbon footprint. Our survey suggests that preoperative telephone consultations are liked by patients and appropriate in meeting the requirements of Montgomery consent for a teledermatology service.