Impact of store-and-forward consumer to physician teledermatology as compared to in-person visits for patients with periorificial dermatitis: A retrospective study
Authors: Vrusha K. Shah, Alexandria Tso, Deesha D. Desai, Joseph C. English
Journal: Journal of the American Academy of Dermatology (2024)

To the Editor: Periorificial dermatitis is a common, often chronic inflammatory skin condition appearing in the ocular, nasal, and oral facial regions predominately in women.1Lipozencic J. Ljubojevic S. Perioral dermatitis.Clin Dermatol. 2011; 29: 157-161https://doi.org/10.1016/j.clindermatol.2010.09.007Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Previously, we showed that store-and-forward physician to physician outpatient teledermatology (TD) improves and provides proper diagnoses and treatment/management recommendations aligned with established standard of care.2Shah V.K. English 3rd, J.C. Store-and-forward outpatient teledermatology improves care for patients with periorificial dermatitis after an initial primary care consultation: a retrospective study.J Am Acad Dermatol. 2023; 88: 904-906https://doi.org/10.1016/j.jaad.2022.10.036Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar This retrospective analysis extends upon our previous study by evaluating the impact of another unique TD modality, store-and-forward consumer to physician TD, on diagnosis and management through a direct comparison with patients seen in-person. Data investigated in the University of Pittsburgh Medical Center (UPMC) Health System Epic electronic medical record revealed 394 TD and 250 in-person cases of periorificial dermatitis from 2016 to 2023. Patients residing in Pennsylvania using TD uploaded images of the facial skin eruption and completed a survey through our secure, transparent,3Resneck Jr., J.S. Abrouk M. Steuer M. et al.Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease.JAMA Dermatol. 2016; 152: 768-775https://doi.org/10.1001/jamadermatol.2016.1774Crossref PubMed Scopus (79) Google Scholar and Health Insurance Portabilabity and Accountability Act-compliant UPMC Teledermatology website (edermatology.upmc.com) following established recommendations.3Resneck Jr., J.S. Abrouk M. Steuer M. et al.Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease.JAMA Dermatol. 2016; 152: 768-775https://doi.org/10.1001/jamadermatol.2016.1774Crossref PubMed Scopus (79) Google Scholar The dermatology team, consisting of board-certified dermatologists and advanced practice providers under direct supervision, was notified about the TD consults and sent back their diagnosis, treatment, and follow-up recommendations, allowing for rapid patient-provider communication through the My UPMC patient portal. Patient descriptive factors are displayed in Table I. Chi-square tests using a 0.05 level of significance were used to generate P values. Patients seen via TD and in-person were both majority female (88.6% vs 88.8%; P = .931), Caucasian (92.4% vs 95.6%; P = .104), and insured (P = 87.8% vs 87.2%; P = .817). TD vs in-person patients were younger (29.95 vs 45.47 years; P < .0001), presented with new-onset periorificial dermatitis (79.2% vs 60.8%; P < .001), and more commonly used oral birth control pills (14.7% vs 7.3%; P < .001).Table IPatient descriptive factors among TD and in-person cohortsTD∗TD is an abbreviation for teledermatology.(n = 394)In-person dermatology visit (n = 250)P value†Significant P values (P < .05) are bolded.Sex Female (%)349, 88.6%222, 88.8% Male (%)45, 11.4%28, 11.2%.931Age at diagnosis Mean (standard error [SE])29.95 ± 0.6545.47 ± 0.96<.001Race Caucasian364, 92.4%239, 95.6%.104 African American7, 1.8%3, 1.2%.748‡Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an double dagger. Asian2, 0.5%4, 1.6%.214‡Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an double dagger. Multiracial1, 0.3%0, 0%1.000‡Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an double dagger. Other2, 0.5%0, 0%.524‡Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an double dagger. Unknown or N/A18, 4.6%4, 1.6%.043New condition vs follow-up New condition312, 79.2%152, 60.8% Follow-up82, 20.8%98, 39.2%<.001Onset Median6 mo4.4 mo—Patient time to assessment Mean (d)3 d21 d—Insurance status Insured346, 87.8%218, 87.2%.817 Uninsured46, 11.7%31, 12.4%.782 Other or not applicable2, 0.5%1, 0.4%1.000Other Mood disorder or comorbidity125, 15.1%101, 15.3%.877 Other dermatologic condition94, 11.3%94, 14.3%.088 Any atopic dermatitis53, 6.4%31, 4.7%.165 Uses alcohol218, 26.3%164, 24.9%.556 Uses birth control pill122, 14.7%48, 7.3%<.001 Sexually active105, 12.7%101, 15.3%.134 Overweight/obese/metabolic disorder113, 13.6%119, 18.1%.018∗ TD is an abbreviation for teledermatology.† Significant P values (P < .05) are bolded.‡ Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an double dagger. Open table in a new tab The dermatology team (advanced practice providers and supervising dermatologists) managing patients via TD and in-person significantly changed/modified treatment a majority of the time (99.0% vs 95.2%; P = .003) as seen in Table II. 44.9% and 61.6% of TD and in-person patients were recommended topical-only treatments including sulfacetamide sodium-sulfur, metronidazole, clindamycin, and moisturizer/emollients. 51.0% and 35.6% of TD and in-person patients (P < .0001) were recommended oral (doxycycline) and topical combination treatment. A majority of both TD (57.4%) and in-person (53.6%) patients (P = .349) were advised to discontinue topical steroids.Table IITreatment, follow-up, and diagnostic concordance factors for TD vs in-person cohortsTD∗TD is an abbreviation for teledermatology.(n = 394)In-person dermatology visit (n = 250)P value†Significant P values (P < .05) are bolded.Systemic/topical therapy management change390, 99.0%238, 95.2%.003 Discontinuing steroids as first line of treatment226, 57.4%134, 53.6%.349 Topical treatment only177, 44.9%154, 61.6%<.001 Oral treatment only16, 4.1%5, 2.0%.151 Both topical/oral treatment201, 51.0%89, 35.6%<.001 None0, 0%2, 0.8%.150Did patient follow-up? Yes, in the timeline requested51, 12.9%75, 30.0%<.001 Yes, but not in the timeline requested57, 14.5%40, 16.0%.596 No286, 72.6%135, 54.0%<.001Median days to follow-up among those returning in timeline requested Mean (standard error [SE])40.63 ± 3.277.25 ± 8.5<.001Mode of follow-up for those following up in the timeline requested by the dermatology team In-person20, 39.2%71, 94.7%<.001 TD22, 43.1%2, 2.7%<.001 Telemedicine‡Telemedicine refers to patients seen via a synchronous video visit with a board-certified dermatologist or advanced practice provider under direct supervision.9, 17.6%2, 2.7%.007§Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an section sign.Mode of follow-up for those not following up in the timeline requested by the dermatology team In-person12, 21.1%34, 85.0%<.001 TD42, 73.7%3, 7.5%<.001 Telemedicine3, 5.3%3, 7.5%.688Follow-up concordance analysisTD (n = 19)‖The total number of patients following up in-person among the TD cohort was 19 instead of 20 as specified under the heading "Mode of follow-up for those following up in the timeline requested by the dermatology team" because one visit was an in-person visit with an internal medicine physician, not dermatology, and therefore was excluded from the diagnostic concordance analysis.In-person dermatology visit (n = 71)P valueDiagnostic concordance between initial visit and in-person dermatology follow-up Yes16, 84.2%66, 93.0%.358 No3, 15.8%3, 4.2%.106§Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an section sign. Diagnosis not addressed0, 0%2, 2.8%1.000§Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an section sign.Kappa statistic (κ)¶Our kappa statistic suggested no agreement due to inadequate sample size for adequate power.0.000——∗ TD is an abbreviation for teledermatology.† Significant P values (P < .05) are bolded.‡ Telemedicine refers to patients seen via a synchronous video visit with a board-certified dermatologist or advanced practice provider under direct supervision.§ Fisher's exact test P values were used for cases that had at least one cell count with an expected value less than 5; marked with an section sign.‖ The total number of patients following up in-person among the TD cohort was 19 instead of 20 as specified under the heading "Mode of follow-up for those following up in the timeline requested by the dermatology team" because one visit was an in-person visit with an internal medicine physician, not dermatology, and therefore was excluded from the diagnostic concordance analysis.¶ Our kappa statistic suggested no agreement due to inadequate sample size for adequate power. Open table in a new tab All patients were requested to follow-up in 4-12 weeks if no improvement. Patients seen via TD versus in-person were less likely to follow-up in the timeline requested (12.9% vs 30.0%; P < .001) and more often preferred to follow-up using TD (43.1% vs 2.7%; P < .001) as displayed in Table II. Importantly, among patients following up with an in-person dermatology team member, diagnostic concordance between the initial TD or in-person diagnosis and in-person follow-up diagnosis was similar (84.2% vs 93.0%; P = .358). Our study shows that store-and-forward consumer to physician TD provides comparable diagnostic accuracy to in-person consultations, suggesting the utility of TD among periorificial dermatitis patients. Study limitations include a retrospective analysis, a majority Caucasian patient sample, and decreased follow-up adherence among TD patients. As previous studies found similar decreased rates of follow-up among TD patients,4Khosravi H. Zhang S. Siripong N. Moorhead A. English Iii J.C. Comparing acne follow-up: teledermatology versus outpatient dermatology visits.Dermatol Online J. 2020; 26 (13030/qt1424r02m)Crossref Google Scholar future prospective studies should focus on improving follow-up education among patients using TD to encourage continued care. None disclosed.