Teledermatology May Benefit Marginalized Populations: National and Institutional Trends during the COVID-19 Pandemic

The study investigates how teledermatology (TD) was utilized across demographic groups during the COVID-19 pandemic. Prompted by rapid expansion of TD due to changes in licensure, billing, and infrastructure, the research addresses the gap in demographic-specific utilization data. The purpose is to understand TD utilization patterns nationally and institutionally to inform how virtual care can improve access—particularly for underserved populations—and guide resource optimization and future healthcare delivery models.

The paper situates TD within existing literature noting its potential to provide better, faster, and more cost-effective care and to improve access to dermatology for underserved populations. Prior work highlights barriers such as the digital divide, variable broadband access, and shortages of dermatologists, which can exacerbate disparities. References include reports of TD aiding underserved groups and past Medicaid TD usage demographics showing greater use among youth and females. The discussion references geospatial disparities in both healthcare and internet access and acknowledges that telephone-based telehealth, with a lower technological barrier, may help mitigate digital divide concerns.

Design: Retrospective cohort analysis using national and institutional datasets during the COVID-19 pandemic. Data sources and periods: (1) National: American Academy of Dermatology’s DataDerm registry, aggregated encounters from 1 April 2020 to 30 June 2021. (2) Institutional: Duke University Health System (DUHS), all dermatology encounters from 1 March 2020 to 30 April 2021. Variables: Encounter type (teledermatology [TD] vs in-person); patient sex, race, age (≤40 vs >40 in national data), and location (in- vs out-of-state; national only). Institutional data additionally stratified age by generation (Greatest Generation, Silent Generation, Baby Boomer, Generation X, Millennial, Generation Z, Generation Alpha) and included no-show rates. Definitions: TD utilization defined as the proportion of TD users within a demographic cohort (e.g., females, non-white) relative to total TD users, compared against the demographic distribution among in-person encounters in the same time window. No-show rate: percentage of scheduled encounters with no-shows. Statistical analysis: Associations between encounter type and demographic variables assessed by chi-square tests; significance at alpha = 0.05 with Bonferroni-adjusted p-values to control family-wise error. Analyses conducted using SAS 9.4. Ethics: Aggregate, non-identifiable data; IRB exemption granted; conducted per Helsinki Declaration.

• Sample sizes: National (DataDerm) n=13,964,816 encounters; Institutional (DUHS) n=54,402 encounters (TD n=2,851; 5.2%). - Significant associations: Nationally, sex, race, age, and location were significantly associated with TD utilization (adjusted p < 0.001). Institutionally, sex, race, and age were significantly associated (adjusted p < 0.001). - Sex: TD users were majority female (DataDerm 66.0% vs in-person 58.3%; DUHS 61.7% vs in-person 57.0%). - Race: Non-white patients comprised a higher share of TD users (DataDerm 15.0% vs in-person 11.7%; DUHS 37.4% vs in-person 22.3%). - Age: Younger patients used TD more often (DataDerm age ≤40: 63.6% of TD vs 26.3% of in-person; DUHS younger generations [Gen X, Millennial, Gen Z, Gen Alpha] 62.6% of TD vs 43.8% of in-person). - Location (national): Out-of-state utilization was higher for TD (14.6%) vs in-person (4.0%). - Temporal trends: National TD encounters decreased from 2020 Q2 to 2021 Q2, with percentage of total visits that were TD declining from 2.9% (n=78,698) to 0.3% (n=7,002). DUHS TD utilization fell from 8.2% (n=1,976; Mar–Sep 2020) to 2.9% (n=875; Oct 2020–Apr 2021). - No-show rates (institutional): TD vs in-person no-shows were lower among Black patients (11.8% vs 19.2%; adjusted p < 0.001) and younger generations (9.8% vs 12.8%; adjusted p < 0.001). Differences were not significant for females vs males overall, white patients (5.5% vs 6.1%; p=0.27), or other races (10.6% vs 13.6%; p=0.08).

Findings demonstrate that TD was disproportionately utilized by females, non-white patients, younger individuals, and out-of-state patients during the pandemic, addressing the research question on demographic-specific trends. These patterns, consistent across national and institutional data, suggest TD can improve access and engagement for populations historically facing barriers to dermatologic care. Lower TD no-show rates among Black patients and younger cohorts further indicate improved engagement via virtual modalities. Despite early adoption, TD utilization declined over time, potentially due to initial inflated early uptake, challenges with technology, diagnostic limitations (e.g., need for biopsies), and suboptimal image/video quality. Nevertheless, options like telephone visits with lower technological requirements may help sustain access gains. The results underscore the need to maintain accessible TD pathways as part of dermatologic care models, tailoring offerings to patient preferences and addressing digital divide issues.

This study provides national and institutional evidence that teledermatology use during COVID-19 was higher among females, non-white patients, younger patients, and those living farther away (out-of-state), and that TD may reduce no-shows in certain groups (e.g., Black patients, younger generations). These findings indicate TD’s potential to enhance access and engagement for marginalized populations and inform resource optimization and future care delivery models. Future research should include national or multicenter studies with individual-level longitudinal data, diagnosis-specific analyses, and assessment of geographic and technology access factors to better understand sustained utilization and outcomes.

• No-show analyses were from a single institution (DUHS) and may not generalize to national or non-academic settings. - National data were limited to practices participating in AAD’s DataDerm, potentially introducing selection bias. - Early-pandemic shutdowns of in-person services may have inflated initial TD utilization, complicating temporal comparisons. - Aggregate data precluded individual-level and detailed temporal analyses, including diagnosis stratification. - Potential geographic differences in TD utilization (e.g., internet access, technology availability) could not be assessed due to data limitations.