July 16, 2014, MedPage Today
Last year, a dermatologist in New Mexico realized that he could do something for patients with acne, many his own, who had to wait weeks and drive for hours to be evaluated and treated.
That something is a web application, PocketDerm, founded by David Lortscher, MD, along with Nancy Satur, MD. Using the app, patients send in pictures of their acne and receive a diagnosis from a licensed dermatologist. Prescriptions come through the mail.
"We're trying to be conservative and only doing things that we can do online," Lortscher told MedPage Today. "And what I've found is that the patients are having a better experience because they can just message us if they have questions."
For a monthly subscription, patients have direct access to one of two dermatologists. Together the dermatologists are licensed in a total of 36 states.
Patients pay a monthly subscription fee of $19.95, for which they may receive unlimited consultations. Prescriptions for topical medications -- which can cost hundreds of dollars if bought at pharmacies -- are included in the price.
The topical prescriptions include commonly used agents such as tretinoin, clindamycin, and azelaic acid. Some oral medications can also be prescribed through the app. Isotretinoin -- the generic name for what was sold as Accutane, until its adverse effects drove the branded drug off the market -- is not available through the app.
Richard Usatine, MD, a dermatologist and assistant director of the Center for Medical Humanities & Ethics at the University of Texas Health Science Center in San Antonio, said he was skeptical when he first heard of the idea of PocketDerm.
"But I see that what they've managed to do not only looks like a good quality of care, but tremendously affordable," he said.
Cameron Rokhsar, MD, a laser surgeon at the New York Cosmetic, Skin, & Laser Surgery Center, told MedPage Today that he was not a fan of directing treatment through an app.
"You can't really fully monitor people," said Rokhsar, who is also assistant professor of dermatology at Mount Sinai Hospital. "I just think it's a very simplistic way to treat a medical condition, and they can't offer the broad scope of things. What if the patient needs laser treatment for it? What if there's a hormonal issue that's causing the problem?"
Patients are asked to fill out a questionnaire when signing up. Treatment history, current medication, and skin type are all covered in the questionnaire. Usatine, at the Center for Medical Humanities & Ethics, said that he e-mailed Lortscher about the questions and found that the company was asking the right ones.
"Between the survey questions, the use of photographs, use of proven medicines at an affordable price, I actually say more power to them," he said.
He also said that good telemedicine could fill an important gap in the country.
"Getting in to see a dermatologist is not easy in this country. We have a shortage of dermatologists, and we have a distribution problem with dermatologists," Usatine said.
To combat the problems with access to dermatologists in certain areas, Usatine trains primary care doctors to deal with acne. But he said that acne treatment from a primary care doctor is "either hit or miss."
"I can say honestly that they're not all well-trained, so they may not be giving optimal care," he said.
Rosalyn George, MD, a fellow of the American Academy of Dermatology practicing in Wilmington, N.C., predicted that services like PocketDerm would grow.
"Tele-dermatology in a lot of ways will become more and more prominent just because of the lack of access," she said.
Many skin conditions, like melanoma, couldn't be properly treated using this model, she said. But acne treatments are relatively straightforward, and she said she treats many of her own patients over the phone or online with pictures.
"Could it be a slippery slope? Yes. But specifically for PocketDerm with acne, it seems like a really very helpful tool for patients," she said.
Rosamond Rhodes, MD, the director of bioethics education at Mount Sinai's Icahn School of Medicine, agreed that PocketDerm could be valuable to people who lack access to a good dermatologist.
"I don't see any specific reasons for holding on to a traditional view of how medicine has been practiced, so I think experiments should be tried to see if they work," she said.
Rhodes identified one potential concern: what the doctors do with incidental findings of melanoma or other serious skin conditions. Lortscher said that, since PocketDerm began operating a couple of months ago, they have had a few patients with non-acne findings including rosacea, keloids, and vitiligo. In those cases, they've found a dermatologist in the patient's area for in-person treatment.
"If the incidental finding is something pivotal like a potential melanoma, we would speak directly with the local dermatologist to give them our concerns and to get diagnostic confirmation after the visit," Lortscher said.