The findings of the study demonstrated that TD is a reliable tool for rheumatologists to consult with dermatologists about their patients who have skin and nail disorders. Furthermore, when approaching the skin/nail lesions they regularly face in their practice, rheumatologists' personal diagnoses are less compatible with the final diagnosis than teledermatologists'.
In daily practice rheumatologists frequently encounter with skin/nail lesions [12, 11]. This study's findings showed that there is a wide range of skin/nail lesions, including those inflammatory skin lesions, vasculitis, panniculitis, connective tissue disorders, infections, drug related skin disorders, etc. Rheumatologists often need a dermatologist’s opinion to identify this variety of skin/nail lesions. Furthermore, research of cooperation between two disciplines result in more comprehensive exams for improved illness control [13, 14]. This study discovered that dermatologists using TD had slightly higher predictive values than rheumatologists, including for lesions that rheumatologists were familiar with, such as PsO.
In this study, TD detected as a reliable tool for rheumatologists to consult with dermatologists for skin and nail disorders with a substantial inter-rater and perfect intra-rater agreements. Also diagnoses of teledermatologists were both in perfect agreement with final diagnosis. Recently articles on diagnostic accuracy assessments of TD for inflammatory dermatoses [4, 15, 16], primarily bringing data on PsO [17] were released. They showed that diagnoses of patients with PsO via TD were detected well comparable with FTF examination. A number of guidelines developed by dermatologists also provide some recommendations regarding the use of TD for PsO [18, 19]. As a result, while TD has been reported to be a useful technique for the diagnosis of PsO, FTF examinations are still required in patients who may require skin biopsy. These proposals are also consistent with our findings. In our study, it was observed that the majority of the patients with skin/nail disorders had PsO (23.9%), and TD evaluations were in perfect agreement with the final diagnosis.
This study demonstrates that dermatologists can diagnose skin/nail lesions in a particular group of patients without the need for further testing or biopsy (28.3% of all the patients). The majority of these lesions diagnosed clinically alone were PsO (16.8% of all the patients), especially for cases of PsO found in predilection areas, plaque-type PsO, and accompanied by psoriatic nail involvement. On the other hand, skin biopsy was used to make a diagnosis in 40% of rheumatologic patients. The most common biopsied conditions were vasculitis, EN, PsO, SLE, and morphea. Dermatologists were shown to favor to make a biopsy 100% of vasculitis, 71% of EN, 14.8% of PsO, 100% of morphea, and 75% of SLE lesions. These findings imply that in rheumatology practice, lesions as PsO will benefit from TD the most, and that dermatologists prefer FTF evaluations and biopsies for lesions like vasculitis. However, using TD is an effective approach that reduces the number of consultations and hence the cost [20]; especially for the cases with a probability that a FTF consultation could be prevented [21].
It has been reported in earlier research that photo quality significantly influences TD outcomes as well [22, 23]. The effect of photo quality on TD outcomes was variable in our study. This could be due to the small number of patients who had low photo quality.
TD is a rapidly expanding field in TM needing further optimization for special populations [24]. This study demonstrated the reliability of TD in the rheumatological patients as a specific population. Since the study consists of consecutive patients who applied during a specific time frame, our patient population may represent the rheumatologic patient community as a whole. Utilizing one of the teledermatologists from an entire remote institution mitigated bias sources. To reduce selection bias, all TD cases were included in the analysis regardless of the quality of the photographs.
The limitations of the study include histopathological diagnosis is not available for all patients. Biopsies were performed only to the extent deemed necessary by the dermatologist to make a diagnosis. In order to overcome this limitation, patients whose diagnosis was confirmed by histopathology were examined with sub-analysis; it was observed that TD rater agreements were similar. Our study was designed only as store and forward (SAF) approach. There was no opportunity to compare it to approaches that include direct patient involvement, such as real-time videoconferencing. Finally, this study included single center data, highlighted the necessity for larger-scale research on the use of TM in rheumatology.
TD is a reliable tool for consulting patients with rheumatological diseases who have skin and nail lesions. Skin/nail lesions allowing visual diagnosis like PsO will benefit best with TD in rheumatology practice. For the lesions that rheumatologists experienced with dermatologists using TD had slightly better positive predictive values than rheumatologists. Thus, rheumatologists' consultations with teledermatologists can strengthen their diagnosis for skin/nail disorders.
Consultations via TD could be an option for rheumatologists when the diagnostic process needs to be accelerated and when it is difficult for patients to get to dermatologists.