Treating hidradenitis suppurativa during the COVID-19 pandemic: teledermatology exams of sensitive body areas

Telemedicine allows physicians to safely monitor their patients while reducing the risk of potentially spreading SARS-CoV-2 in hospitals and outpatient clinics. Recent articles discussed strategies for teledermatology during COVID-19 (1,2). With this technical infrastructure, dermatologists can now provide effective high-quality care while limiting both patient and physician exposure to SARS-CoV-2. Although teledermatology has promising applications, a major challenge of this technology is performing skin examinations of sensitive body areas. Skin examinations of private areas is important in dermatology, especially for hidradenitis suppurativa (HS), a chronic inflammatory skin condition characterized by painful nodules and boils that often result in hypertrophic scarring and draining sinus tracts (3). HS typically affects intimate regions such as the groin, axilla, perineal and perianal regions, inframammary folds, and buttocks (3). These recurrent lesions can become painful and odorous, often causing patients to feel self-conscious, anxious, and depressed (3,4). Considering the lack of establishing an emotional bond that is feasible during face-to-face visits, patient rapport is compromised and their feelings may be censored. This might affect their comfort in displaying their lesions or intimate regions and deter them from seeking virtual visits. Telemedicine examinations of delicate skin areas present several challenges (Figure 1). Instead of undressing and sharing their concerns in secure examination rooms, patients are expected to have those discussions through less secure video platforms. This potentially introduces problems, such as unapproved image use and outsider presence, which can negatively influence patients’ perception of trust. Patients may feel vulnerable and reluctant undergoing video skin exams since their privacy may be of concern. Unlike more accessible regions, providing the physician an acceptable view of genital and other personal body areas may be challenging via telemedicine. This, in combination with the inflexible time constraints through teledermatology, may restrict the dermatologist’s ability to assess delicate areas and counsel patients. Additionally, palpation allows the dermatologist to evaluate tenderness, induration, amount of draining, consistency, depth, and fixation (5). Therefore, the inability to palpate lesions may lead to suboptimal diagnosis or an inaccurate assessment of treatment response. To ensure patient comfort and privacy, dermatologists may consider virtual consent forms describing their privacy measures for patients. Additionally, physicians may need to rely more on patient reported symptoms especially for those who feel uncomfortable exposing confidential areas via teledermatology. Alternatively, some patients may feel more comfortable sending photographs of personal skin areas rather than showing them live via video, so dermatologists should consider a secure platform for photograph submission. Clear instructions for photographs to help accurately visualize these sensitive regions should also be considered. To help dermatologists monitor disease status and treatment responses as well as provide counseling, more frequent and extended teledermatology visits should be encouraged. The American Academy of Dermatology has a guide for teledermatology during COVID-19 titled the Teledermatology Toolkit and we encourage dermatologists to consult this as well as the Centers for Disease Control and Prevention guidelines. We hope additional consideration will be given to dermatologic examinations of intimate skin areas for diseases such as HS.