National Psoriasis Foundation Telemedicine Task Force guidance for management of psoriatic disease via telemedicine

Telemedicine emerged as an alternative care delivery system used to offer effective long-term management to patients with chronic, inflammatory conditions such as psoriatic disease. Teledermatology can provide reliable clinical information through thorough history-taking and virtual evaluations that include patient-provided images and disease activity assessment tools that may help accurately diagnose and manage patients with psoriasis. The integration of validated screening tools for psoriatic arthritis and effective teledermatology practices may improve access to specialists, thus avoiding preventable delays in the diagnosis and treatment of patients with psoriatic arthritis. Although the provision of telehealthcare should not completely replace high quality, in-person dermatologic or rheumatologic visits, the convenience and collaborative nature of teledermatology may lead to expanded access and expedited care in the appropriate setting, whether it be in a virtual or in-person visit.


INTRODUCTION
The use of technology to provide access to health care is not a new idea, with reports dating back to the 1870s with the use of telephone. Physicians have since continued to leverage emerging technologies to deliver quality care from remote locations. 1 This was especially apparent when the COVID-19 pandemic caused sudden and drastic changes in health care delivery and access. Telemedicine utilization among dermatologists increased from under 15% to [95% after the pandemic, reflecting its marked popularity among patients and uptake for physicians. 2,3 Importantly, this has highlighted that teledermatology can be used beyond the context of a global health crisis to provide continuity of care and improve access to health care more broadly.

TELEMEDICINE AND PSORIASIS
Teledermatology emerged as an alternative care delivery system used to offer effective long-term management to patients with chronic, inflammatory skin conditions such as psoriasis. Unlike conventional in-person care, accurate diagnosis and management by virtual visits rely partly on the quality of live video images and photographs provided by patients.
When properly collected, these images can be of appropriate quality for physicians to make accurate assessments of disease severity using Psoriasis Area and Severity Index (PASI) scores in patients of different skin phototypes. 4,5 Alternatively, standardized online training videos may be used to teach patients how to assess PASI, affected body surface area (BSA), and patient global assessment to provide reliable assessments of disease severity when quality images are difficult to produce during virtual evaluations. 6,7 Physicians may also guide patients to perform thorough self-evaluations of other areas of their body that might be difficult to appreciate on live video or photographs, such as the scalp and genitals. 8 Physicians may tailor teledermatology evaluation strategies based on what tools are readily available and accessible to each individual patient.
As compared with in-person care, collaborative and efficient teledermatology models equivalently improve PASI scores, BSA, and dermatology life quality index. 7,9,10 The combination of thorough history-taking and virtual evaluations based on live video or photographs and patient assessments allows dermatologists to manage treatments for psoriasis to achieve significant improvements in disease severity.
Teledermatology expands the ability to deliver patient care. Distance, incapacity, and transportation costs are barriers to in-person care for many patients with psoriasis. 4 Teledermatology reduces travel costs and time to initiation of care and similarly improves functional status and mental health in patients with psoriasis compared with in-person care. 11,12 Teledermatology bypasses physical barriers to care and encourages patients to take active roles in the management of their condition, leading to improved treatment adherence, patient quality of life, and overall health. 9,13 Similarly, teledermatology allows physicians to reach patients with psoriasis in institutions with restricted access. Patients with psoriasis who are institutionalized for psychiatric reasons face uncommon difficulties in setting up external appointments and have a high patient turn-around time, in other words, the total time needed for patient transport and completion of an in-patient encounter. 14 Teledermatology allows comparable management strategies as in-person visits and reduces patient turnaround time by 90% for these patients. 14 This approach to dermatologic care optimizes patient comfort while providing effective treatment for psoriasis and decreasing the need for chaperoning staff members for in-person evaluations. 14 Imprisoned patients may also benefit from teledermatology when in-person consults are difficult to coordinate. This may also be used as a tool to address disparities in care provision. 15 Teledermatology can provide equitable, quality health care to specific subpopulations of patients with psoriasis.
Despite achieving comparable improvements in disease severity, the estimation of areas of involvement and induration of psoriatic lesions are different between teledermatology and in-person evaluations. 16 Low quality of photos and live video images, lagging internet connection, and lack of an in-person physical examination may contribute to the limited appreciation of certain lesional characteristics in virtual evaluations. Physicians can advise patients to take photos or conduct video visits in well-lit areas with a steady camera set-up to help assure clear, well-focused images for the virtual evaluation. The use of hybrid teledermatology that combines patientprovided photos and a real-time interaction via a telephone call can address issues encountered with a poor internet connection. 17 BSA determination can be automated, with 96% agreement of the automated photo-based measurement and dermatologists' BSA measurements. 18 Teledermatology can allow physicians to efficiently evaluate and manage patients with psoriasis of different skin phototypes and varying disease severity in remote locations. with psoriasis develop psoriatic arthritis (PsA); undertreatment and diagnostic delay of PsA lead to irreversible joint damage and significant functional impairment. 19,20 Dermatologists may play a key role in mitigating the disease burden by screening patients with psoriasis for joint disease, as 85% of patients develop psoriasis before PsA. 21 There are 3 validated PsA screening tools available: the Psoriasis and Arthritis Screening Questionnaire, the Psoriasis Epidemiology Screening Tool (PEST), and the Toronto Psoriatic Arthritis Screen. Of these, PEST has strong sensitivity, specificity, and positive and negative predictive values. 22 PEST is readily accessible for patients on the National Psoriasis Foundation's website (https://www.psoriasis.org/ psoriatic-arthritis-screening-test/), wherein patients can answer 5 simple questions and quickly receive their results for presentation at a virtual evaluation. 23 Following the identification of suspected PsA, an in-depth discussion and evaluation of joint involvement are warranted. Teledermatology applications using physician-guided palpation, photos of involved joints, and thorough history-taking allow physicians to accurately diagnose active arthritis, dactylitis, or enthesitis; evaluate pain through a visual analog scale; and manage therapeutics for PsA. [24][25][26] Further physician-guided evaluation techniques involve patients comparing suspected involved digits or joints with the uninvolved contralateral body area, with careful inspection for signs and symptoms of redness, swelling, and pain upon palpation. 8 In the setting of back pain and stiffness, a thorough evaluation of axial involvement may be conducted through a physician-guided physical examination using specific detailed tests and spinal range of motion tests. 27 Despite the development of virtual evaluation techniques, the accurate determinations of disease activity may be limited, in some cases of complex joint disease, without an in-person physical examination. 25,28 Employing a flexible approach to teledermatology for PsA, in which simpler and established cases are managed through virtual visits and complex cases are followed in an in-person fashion, has been proposed as a solution to provide quality care in the appropriate setting, based on each individual patient's needs. 29 Nevertheless, the collaborative approach of virtual evaluations may provide sufficient information to reliably assess for PsA, deliver comparable patient satisfaction to inperson visits based on patient-reported outcomes, and offer prompt management and referrals to a rheumatologist, especially when used to expand access to care when rheumatologists are in short supply. 25,29 CONCLUSIONS Teledermatology is a valuable tool that can be used to supplement other care modalities for patients with psoriatic disease. Although it is not a direct replacement for in-person care, when utilized appropriately, it can be used as a tool to achieve numerous goals of care, such as identifying patients who need a rheumatology referral and increasing access to care. Teledermatology can provide reliable clinical information through thorough history-taking and virtual evaluations that include patient-provided images and disease activity assessment tools that may help accurately diagnose and manage patients with psoriasis. The use of objective measures, including PASI and dermatology life quality index scores, is helpful to quantitively measure patient disease activity but is not necessary for routine clinical care, treatment selection, or assessing treatment response in nonresearch settings. The integration of validated screening tools for PsA and effective teledermatology practices may improve access to specialists, thus avoiding preventable delays in the diagnosis and treatment of patients with PsA. Although the provision of telehealthcare should not completely replace high quality, in-person dermatologic or rheumatologic visits, the convenience and collaborative nature of teledermatology may lead to expanded access and expedited care in the appropriate setting, whether it be in a virtual or in-person visit.

Position Statements
1. Teledermatology is a reasonable alternative for providing long-term management of patients with psoriasis. Teledermatology may be an option for initial visits, especially when incapacity, distance, and circumstances (eg, access issues among the institutionalized and imprisoned population) prevent the realization of an in-person evaluation. 2. It is important to guarantee the accessibility of in-person care for patients with psoriasis and ensure that telemedicine does not supplant such availability. 3. A discussion about the available virtual evaluation tools (ie, live video visits, patient-provided reliable, high quality image capture and appropriate workflows that emulate a dermatology in-person practicedis important in helping to expand the applicability and utility of teledermatology. Standardized, accessible, and objective modalities to assess BSA/PASI may be helpful in having objective measures to monitor for treatment response. The PEST should be provided to patients every 6 months to screen for PsA to help mitigate the undertreatment and delay in the diagnosis of this common comorbidity in patients with psoriasis. 5. A flexible approach to teledermatology for PsA proposes the efficient utilization of in-person and virtual care based on the severity and complexity of the appreciated joint disease. Thorough history-taking and collaborative evaluation techniques are useful in assessing for joint involvement in patients with suspect PsA. Simpler and established cases may be suitable for virtual evaluations, whereas complex or severe cases may warrant an in-person evaluation and referral to a rheumatologist. 6. Telemedicine has the potential to allow for collaborative connected-health models to expand the reach of experienced dermatologists to help comanage patients with primary care physicians and community dermatologists who are not comfortable with newer systemic treatments for psoriasis.