Skin Conditions during COVID-19 Era: Comparison
Please note this is a comparison between Version 2 by Camila Xu and Version 1 by Claudio Marasca.

The most frequent inflammatory skin diseases are psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne. Their management is challenging for dermatologists since their relapsing chronic clinical course is associated with a great impact on quality of life.

  • telemedicine
  • telecare
  • tele health
  • telehealth

1. Introduction

The most frequent inflammatory skin diseases are psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne [1,2,3,4][1][2][3][4]. Their management is challenging for dermatologists since their relapsing chronic clinical course is associated with a great impact on quality of life. Nevertheless, the recent introduction of novel therapies, such as biological drugs and small molecules, has changed the history of these diseases. The COVID-19 outbreak has completely overturned ourthe daily routine, and lockdowns established by governments made it more difficult to access health care [5]. The physicians’ answer to health issues during the pandemic was telemedicine. Although telemedicine was introduced several years ago, the worldwide spread of the SARS-CoV-2 infection at the end of 2019 allowed for the worldwide spread of teledermatology, as well. Indeed, it has gained a key role, especially in the management of patients affected by chronic inflammatory skin diseases.

2. Each Skin Condition

2.1. Psoriasis

Psoriasis is a chronic relapsing disease that requires long-term treatments and frequent follow-ups [6]. Besides in-person consultations, teledermatology has become an opportunity in daily clinical settings for those who, for any reason, cannot attend the visit and at the same time require medical advice [7,8,9,10,11,12,13,14,15][7][8][9][10][11][12][13][14][15]. In fact, Anderesen et al., through a retrospective review of the teledermatology database in the Faroe Islands, a group of 18 islands in the North Atlantic, concluded that teledermatology is indispensable in specific contexts, such as rural areas, while in non-rural ones, should be destined to evaluate which disease can benefit from either in-person or online visits to give selectivity on resources destined for telemedicine [12]. Moreover, since the worldwide spread of the SARS-CoV-2 infection at the end of 2019, telemedicine has gained an increasingly important role in daily clinical practice, especially regarding patients affected by chronic diseases, such as psoriasis [16,17][16][17]. Villani and colleagues implemented an already existing teleconsultation service that was originally reserved for emergencies, and that turned routine during the COVID-19 pandemic, given the need to avoid social contacts [13]. Such measures appeared to be very important, particularly for those patients under immunosuppressive drugs that were at high risk of contracting the infection [13]. In general, Beer, Chambers, Pearlman, and Frühauf accordingly reported in their studies that online interactions were well accepted by patients and highly preferred to in-person visits [16,17,18,19][16][17][18][19]. Moreso, Yi et al. noticed a slight decrease in access to telehealth services for elderly and non-English speaker patients, suggesting potential unequal access to care for these vulnerable patients [20]. Favoring points for teledermatology were reported to be the easy accessibility, safety, and effectiveness of teleconsultations that were perceived as patient-centered, and the possibility of saving money and time [14,20,21,22][14][20][21][22]. As a result, patients’ compliance with treatment was shown to be high, and thus, a likely unnecessary worsening of psoriasis severity, given the unattended visits for control and renewal of treatments, was prevented, as reported by Brunasso et al. [15]. Likewise, telemedicine for psoriasis was appreciated by doctors, as it reduced the burden of visits that could be managed remotely, as well as saving time and money [17,18,19,20,21,22,23][17][18][19][20][21][22][23]. Moreover, there has been a great push towards digitalization that involved both patients and health care systems, giving teledermatology prospects for being part of clinical practice in the future [17]. The importance of telemedicine in assessing and monitoring psoriasis and its treatment was already shown previously by Julia Frühauf et al., who ran a pilot study comparing the data of psoriasis severity and therapeutic outcomes of 10 patients under etanercept derived from face-to-face and online visits [24]. They found no statistically significant differences between the assigned scores and, accordingly, therapeutic decisions in the two settings supported the feasibility of a remote follow-up of psoriasis patients [24]. Such findings were also confirmed by Balato et al., which demonstrated the usefulness of telemedicine in improving clinical outcomes and achieving better disease control by developing an educational and motivational support service through the reliance of text messages in guiding and reminding psoriasis patients about their treatment [25]. Moreso, online consultations raised the issue of accurately determining psoriasis severity on which disease progression evaluation and therapeutic decisions are based. In fact, either the quality of cameras, pictures, video calls, or internet connection as well as patients’ ability, may have impaired the assessment of the daily conventionally adopted psoriasis severity scores, such as the Psoriasis Area and Severity Index (PASI) or body surface area (BSA). For this reason, many authors tried to address such topics in different ways. In detail, Armstrong and colleagues developed an effective, innovative, and collaborative health model where patients were directly involved in their disease monitoring through self-calculating the PASI and BSA scores after appropriate training [23]. Moreso, Singh and colleagues ran the tele-PASI accuracy study with the aim to assess the reliability of PASI scores determined on the basis of standardized digital images—the tele-PASI score [26]. Twelve patients with confirmed psoriasis were recruited, as well as two dermatologists for a baseline face-to-face visit, and a third independent dermatologist who determined the remote PASI scores at weeks 6 and 14 [27]. Both intra- and inter-observer assessments were performed, showing a good agreement in PASI score determination between the three dermatologists as well as per each one at different times, confirming analogous findings reported by Julia Furhauf et al. [24]. Furthermore, some authors wondered about the accuracy of a remote determination of conventional psoriasis severity scores, given the specific virtual evaluation. For this reason, Wu et al. developed and validated a new model to estimate a total PASI score in the context of teledermatology (the tele-PASI score) where some characteristics of psoriasis, such as thickness, cannot be assessed, in contrast to erythema, scaling and affected areas of the body [27]. Hence, the tele-PASI score was the result of the original PASI, excluding thickness [27]. An amount of 3866 patients with moderate-to-severe plaque psoriasis were included in the study and randomized into three treatments groups: placebo, ixekizumab, and etanercept [27]. A strong correlation between original and modeled total PASI scores, either at screening, baseline, or during treatment up to week 12, was found, irrespective of treatments, showing that such a proposed modified score may be safely integrated into telematic clinical practice [27]. Nonetheless, further studies are needed in support of such findings. Concerning psoriasis treatment monitoring, teledermatology has been proven to be useful in prescribing and monitoring not only systemic therapies, i.e., biologicals, but also topicals and phototherapy, thus improving patients’ adherence to treatment and clinical outcomes [28,29,30,31,32][28][29][30][31][32]. Moreso, telemedicine assisted psoriasis patients not only with the cutaneous aspect of the disease but also on a psychological level [33]. Indeed, Young and colleagues ran a 12-month randomized controlled equivalency trial to assess the impact of teledermatology on psoriasis patients’ mental health and depression, finding no statistically significant differences compared to in-person care [33]. Moreover, even if the adult population is the main recipient of telemedicine, studies have also shown that children were directly involved in developing awareness of their disease and evolution during the COVID-19 pandemic [34]. In general, based on doctors’ perspectives, teledermatology has been proven effective and reliable as it allows to perform visits, maintain continuative medical assistance and improve clinical outcomes; from a patients’ perspective, it helps keep contact with physicians, enhancing straightforward communications, increasing compliance to treatment and moreover, is highly preferred, as it is time and money-saving, giving the feeling of a more free, flexible and empowered lifestyle [16,18,19,21][16][18][19][21]. Hence, wresearchers believe that telemedicine will keep an important role in daily health settings, especially with a complementary role in the follow-ups of chronic diseases, such as psoriasis. Such an idea is in line with Gisondi et al., that supports the use of online consultations for patients with stable psoriasis on maintenance treatment with biological agents, as routine visits usually end up with a confirmation of ongoing treatment—different from naïve or unstable patients who would rather benefit from in-person visits [14]. Likewise, Dahy et al. would encourage face-to-face visits for establishing a diagnosis, and online consultations for the follow-ups [6]. More applications will be found with the incorporation and implementation of digital platforms in health care systems. An emerging role of teledermatology for psoriasis is the possibility for health personnel to discuss the most difficult cases through dedicated social media, improving knowledge and ultimately patients’ clinical outcomes [35].

2.2. Acne and Hidradenitis Suppurativa

Acne and hidradenitis suppurativa (HS) are chronic, inflammatory, and often debilitant skin conditions, strongly affecting the quality of life of patients, and requiring targeted therapies and continuous follow-up [36,37,38][36][37][38].
In particular, during the COVID-19 pandemic period, new therapeutic and clinical approaches have been required in order to continue the diagnostic and treatment pathways for these pathologies, minimizing the risk of infection for both the patients and the clinicians and ensuring continuous monitoring of the disease [39].
Several modalities of teledermatology services, such as video calls, phone calls, WhatsApp and Facebook support groups, image evaluation, and emails have been developed during the COVID-19 pandemic period in order to minimize the impact of COVID-19 restrictions on the quality of life and quality of treatment in patients with HS and acne.
However, even if several studies reported the use of telemedicine in patients with acne, [40,41,42,43,44,45,46,47,48,49,50,51,52][40][41][42][43][44][45][46][47][48][49][50][51][52] the role of remote assessment for HS patients was not extensively investigated during the COVID-19 pandemic period [49,50,51,52][49][50][51][52].
Although Brunasso et al. showed the effectiveness of email and calls in preventing HS worsening or treatment discontinuation on 11 patients with HS, the efficacy of telemedicine in patients with HS has conflicting results and many concerns [15]. In fact, Patel reported the results of a retrospective analysis conducted from April to October 2020 on 41 patients attending 73 remote consultations, compared to 40 patients attending 70 face-to-face examinations [48]. Although the efficacy of telemedicine was confirmed despite the absence of a real examination, their results suggested the importance of clinical face-to-face assessment, since HS is usually an unstable disease and photographic or video evaluation should be handled sensitively due to the high prevalence of anxiety and depression in the affected subject, and the frequent involvement of intimate body areas [49].
Moreover, a survey conducted on Facebook groups supporting HS involving 335 respondents showed that patients with a higher Hurley stage disease disagreed that telemedicine provided equally effective care for their disease, compared to in-person clinic visits (182/335, 54.32%) [50].
In conclusion, different strategies in remote care are needed in patients with HS while considering the impact on quality of life and the frequent involvement of intimate body areas [51,52][51][52].
In regards to acne disease, the role of telemedicine in acne management was also investigated before the COVID-19 pandemic period [40]. In fact, Frühauf et al. reported the results of a randomized controlled trial with the purpose of assessing the superiority of mobile teledermatology in the care of patients with severe acne compared to outpatient services. Sixty-nine patients receiving oral isotretinoin were enrolled and randomized into either the teleconsultation or the outpatient consultation arm of the study for 24 weeks. This trial showed that teledermatology was a useful, effective, safe, and well accepted tool [39]. This approach has been strongly investigated during the COVID-19 pandemic period since acne is the main condition reported to be managed through teledermatology [40]. The use of teledermatology impacted the therapies and clinical assessment of patients with acne as well as patients’ features, which affected the efficacy of this approach.
In regards to therapies, Kazi et al. reported that biologics and immunomodulators were more commonly prescribed through synchronous than asynchronous teledermatology, defined as patient-to-physician store-and-forward visits in which a patient completed a questionnaire and supplied three images of their skin lesions [41]. Kazi et al. suggested that asynchronous telemedicine should be used for acne management, while synchronous teledermatology was preferable for severe forms of this disease [41]. A recommendation in the therapeutic approach has been reported by Gu et al. as well [42]. Indeed, even if the effectiveness of acne management through telemedicine was confirmed in their study, reporting their experience on 480 video visits, the reseauthorchers advised clinicians to be careful in the use of isotretinoin in female patients if visits are conducted in telemedicine since there are no studies assessing the efficacy and safety of teledermatology in this population [42]. Moreso, treatment adherence could be improved through telemedicine. In fact, Marasca et al. showed the importance of the WhatsApp supporting group in acne patients, reporting that the 80 subjects who received messages reminding them of acne medications had increased therapeutic adherence and better outcomes compared to the group of 80 patients not receiving medical advice in the 12-week study [43].
Regarding patient satisfaction and outcome with telemedicine, Ruggiero et al. showed the satisfaction of patients after a teledermatological visit in an observational prospective study, reporting patient experience and feeling with this technique, [44] as well as Villani et al., which reported the effectiveness of video consultants to assess acne severity, reducing treatment delay and in-person visits [45].
However, the need for a targeted teledermatological approach has been reported by Lee et al., who demonstrated that non-English speaking and elderly patients were more likely to use audio-only than video visits compared with the English speaking and younger patients, examining 1233 virtual visits conducted from March to May 2020. Their results suggested the importance of non-video telemedicine alternatives for these populations [46].
Finally, a comparison between patients seen via teledermatology and patients seen via face-to-face evaluation showed that the median time to follow-up was 45.5 days in the teledermatology group compared to 64 days in the face-to-face group (p < 0.001) and that oral antibiotics (43.0% versus 28.5%) were more used in teledermatology patients compared to face-to-face patients (p < 0.001), showing the need to improve teledermatology follow-up education and follow-up care [47].
All these reported studies confirmed the effective adherence to treatment and health-related quality of life of telemedicine in current clinical practice, also considering and overcoming the difficulties that this approach may have. Moreover, other studies are ongoing to refine this technique, and new scores are under investigation to evaluate acne severity through the use of images and telemedicine [52].

2.3. Atopic Dermatitis

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory skin condition characterized by intense itch, disruption of the skin barrier, and upregulation of type 2-mediated immune responses in the skin [53]. AD is considered one of the most common chronic conditions, affecting 15% to 30% of children and 2% to 10% of adults, with a global prevalence of nearly 230 million [54]. Over the past 30 years, there has been a significant burden of AD cases worldwide, with a rapid increase, especially in developing countries [55]. Furthermore, the early onset in childhood, the chronic course, the need for specialist visits, and the frequent atopic comorbidities make AD an important global public health issue [4]. In this context, telemedicine has set out to provide diagnostic and management solutions for AD, thereby optimizing the supply of in-person appointments with dermatologists for a lot of severe cases [56]. The European Academy of Allergy and Clinical Immunology concerning AD proposed that telemedicine could be useful for the monitoring of the severity of disease (using validated instruments for scoring the severity of AD in a mobile app), therapeutic education, patient communication, medication reminders, and research [57]. In the last years, the importance of telemedicine as a valid educational approach in supporting AD patients has been evaluated in some clinical studies [58,59,60,61][58][59][60][61].
Bergmo et al. have conducted a randomized controlled trial to analyze how web-based consultations for parents of children with AD affected self-management behavior, health outcome, health resource use, and family costs [58]. Patients were randomly assigned to intervention and control groups. The intervention group received remote dermatology consultations through a secure web-based communication system [58]. The control group was encouraged to seek treatment through traditional means, such as general practitioner visits and hospital care [58]. Both groups received a 30-min individual face-to-face educational session prior to the intervention [58]. After one year, no change in self-management behavior, health outcome, or costs has been found [58]. The intervention group tended to have fewer visits to practitioners offering complementary therapies than the control group, with a positive correlation between emergency visits at baseline and messages sent. Both groups, however, reduced the mean number of skincare treatments performed per week and had fewer total health care visits after the intervention [58].
The effects of online courses in continuing medical education were evaluated by Schopf et al., showing that this strategy could be a valid tool for the training of doctors and nurses, with the advantage of reducing costs related to travel expenses [59]. Recently, Giavina-Bianchi et al. have reported results of a retrospective study in a population of 30,976 individuals assisted by telemedicine [60]. Their aim was to evaluate the proportion of AD subjects who could be managed with the support of telemedicine and its accuracy [60]. AD was diagnosed in 5.3% of patients with an accuracy of 84.4%. Primary care physicians were able to manage 72% of the atopic patients, whereas 28% of them were referred to dermatologists [60]. Additionally, telemedicine is effective as usual face-to-face care about the quality of life and severity of disease, but with the advantage of a substantial cost-saving [61,62,63,64][61][62][63][64].
Furthermore, a universally recognized power of telemedicine is the ability to reduce distances and reach places where health resources are scarce [65,66][65][66]. Indeed, the position statement on AD in sub-Saharan Africa argues that the potential applications of telemedicine include its use for atopic schools, e-learning, webinars with AD experts with local knowledge of local drugs and practices, pigment-adapted apps, skin tutorial videos, and therapeutic education for patients and families [65]. Certainly, the COVID-19 pandemic has given a great implementation to the spread and use of telemedicine, allowing efficient diagnostic-therapeutic management in patients suffering from AD [15,67,68,69][15][67][68][69]. Telehealth consultations were useful for triage of the severity of the disease, ensuring in-person visits only for the severe cases, and remote monitoring of mild and moderate cases [68]. Indeed, during the COVID-19 pandemic, several approaches have been adopted, such as phone calls, e-mails, e-drug prescriptions, and e-lab prescriptions [15]. Napolitano et al., for example, used telephone consultations with adult AD patients treated with dupilumab to prevent patients from leaving their homes and crowding the hospital and to continue monitoring their condition [69].
An important aspect of telemedicine is the protection of privacy and, for this purpose, standardized digital platforms should be provided to patients and health care professionals [70]. When these methods are not accessible, more common tools could be used, providing adequately informed consent acquired from the patient for the treatment via telemedicine [70].


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