Psoriasis in teledermatology: analysis of the 2016‒2020 period in Santa Catarina

Demo, Maria Laura Orlandi; Nunes, Daniel Holthausen; Marcon, Chaiana Esmeraldino Mendes

doi:10.1016/j.abd.2022.01.010

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Original Article • An. Bras. Dermatol. 98 (1) • Jan-Feb 2023 • https://doi.org/10.1016/j.abd.2022.01.010 copy

Psoriasis in teledermatology: analysis of the 2016‒2020 period in Santa Catarina^☆ ☆ Study conducted at the Universidade do Sul de Santa Catarina, using data from the Teledermatology exam records of the Telemedicine and Telehealth System (TTS) in the state of Santa Catarina, Florianópolis, SC, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Psoriasis is a skin disease that affects 1.3% of Brazilians. The use of teledermatology (TD) in the public health sector has democratized access to dermatological care.

Objective

To analyze TD exams with suspected and/or diagnosed psoriasis performed between 2016‒2020 in the state of Santa Catarina (SC).

Methods

Analytical cross-sectional observational study that used secondary data collected from the records of TD exams from the Telemedicine and Telehealth System (TTS) of SC. The associations were evaluated by the chi-square test and Student'st test. The significance level was set at 5% (p < 0.05).

Results

During the period, 6,146 TD exams were related to psoriasis, 58% due to the diagnosis provided by the reporting dermatologist and 42% exclusively due to the suspected disease on the request of the examination. The male sex predominated among the diagnoses of dermatosis (51%; p < 0.001). Regarding risk classification, psoriasis diagnoses were predominantly yellow (58.7%; p < 0.001) or blue (39.7%; p < 0.001) risk, respectively indicating moderate to severe psoriasis (referral to tertiary care) and mild psoriasis (treatment in the primary health care [PHC] level). True positive tests, suspected by PHC and diagnosed with psoriasis through TD, were 34.1% (p < 0.001).

Study limitations

The TD service is available only for the public health network and analysis for a limited period (five years).

Conclusions

Psoriasis diagnoses performed by TD, when compared to other dermatoses, tend to receive treatment at the primary (p < 0.001) or tertiary (p < 0.001) health care level, reducing the number of referrals to the secondary care level.

Keywords
Dermatology; Psoriasis; Public health; Teledermatology; Telemedicine

	Diagnosis of psoriasis	Suspected without confirmed of psoriasis	Total	p-value
	(n = 3566)	(n = 2580)	(n = 6146)
Sex				< 0.001 ^a a Pearson’s Chi-square.
Female	49% (n = 1746)	54.8% (n = 1415)	51.4% (n = 3161)
Male	51% (n = 1820)	45.2% (n = 1165)	48.6% (n = 2985)
Age (years)				< 0.001 ^b b Student’s t.
Mean ± SD	48.1 ± 16.6	45.3 ± 19.4	46.9 ± 17.9
Age range				< 0.001 ^a a Pearson’s Chi-square.
≤19 years	4.8% (n = 171)	12.8% (n = 331)	8.2% (n = 502)	< 0.001^a a Pearson’s Chi-square.
20‒30 years	12.8% (n = 457)	12.7% (n = 328)	12.8% (n = 785)	0.906^a a Pearson’s Chi-square.
31‒49 years	31.4% (n = 1118)	27.8% (n = 717)	29.9% (n = 1835)	0.003^a a Pearson’s Chi-square.
50‒60 years	26% (n = 927)	21.8% (n = 562)	24.2% (n = 1489)	< 0.001^a a Pearson’s Chi-square.
≥61 years	25% (n = 893)	24.9% (n = 642)	25% (n = 1535)	0.887^a a Pearson’s Chi-square.
Phototype				0.030 ^a a Pearson’s Chi-square.
I	5.2% (n = 184)	5.9% (n = 152)	5.5% (n = 336)
II	20.3% (n = 724)	21% (n = 543)	20.6% (n = 1267)
III	44.1% (n = 1572)	39.8% (n = 1027)	42.3% (n = 2599)
IV	21.1% (n = 751)	22.7% (n = 585)	21.7% (n = 1336)
V	7.8% (n = 277)	8.8% (n = 228)	8.2% (n = 505)
VI	1.6% (n = 58)	1.7% (n = 45)	1.7% (n = 103)
Macroregion
Itajai River Mouth	2.1% (n = 75)	5.6% (n = 144)	3.6% (n = 219)	< 0.001^a a Pearson’s Chi-square.
Great Florianópolis	35.3% (n = 1258)	23.3% (n = 601)	30.2% (n = 1859)	< 0.001^a a Pearson’s Chi-square.
Great Western	9.8% (n = 348)	9.3% (n = 239)	9.6% (n = 587)	0.514^a a Pearson’s Chi-square.
Midwestern and Santa Catarina Mountain Range	12.7% (n = 454)	12.5% (n = 323)	12.6% (n = 777)	0.805^a a Pearson’s Chi-square.
Northern/Northeastern plateau	11.5% (n = 411)	13.3% (n = 343)	12.3% (n = 754)	0.037^a a Pearson’s Chi-square.
Southern	12.7% (n = 452)	16% (n = 414)	14.1% (n = 866)	< 0.001^a a Pearson’s Chi-square.
Itajaí valley	15.9% (n = 568)	20% (n = 516)	17.6% (n = 1084)	< 0.001^a a Pearson’s Chi-square.

BMI classification	Diagnosis of psoriasis	Suspected without a final diagnosis of psoriasis	Total	p-value^a a Pearson’s chi-square.
	(n = 3,394)	(n = 2,251)	(n = 5,645)
Low weight	1.6% (n = 56)	1.6% (n = 37)	1.6% (n = 93)	0.986
Healthy weight	27.1% (n = 920)	29.9% (n = 673)	28.2% (n = 1593)	0.023
Overweight	35.6% (n = 1208)	36% (n = 811)	35.8% (n = 2019)	0.738
Obesity grade 1	21.9% (n = 743)	20.2% (n = 455)	21.2% (n = 1198)	0.131
Obesity grade 2	9.3% (n = 315)	8.2% (n = 185)	8.9% (n = 500)	0.169
Obesity grade 3	4.4% (n = 151)	4% (n = 90)	4.3% (n = 241)	0.412

	Diagnosis of psoriasis	Suspected without a diagnosis of psoriasis	Total	p-value^a a Pearson’s chi-square.
	(n = 3,566)	(n = 2,580)	(n = 6,146)
Smoking
Never smoked	53.8% (n = 1920)	62.7% (n = 1617)	57.5% (n = 3537)	< 0.001
Ex-smoker	24% (n = 855)	19.6% (n = 505)	22.1% (n = 1360)	< 0.001
Smoker	22.2% (n = 791)	17.8% (n = 458)	20.3% (n = 1249)	< 0.001
Alcohol consumption
Never	57.1% (n = 2035)	64.5% (n = 1665)	60.2% (n = 3700)	< 0.001
Monthly	18.9% (n = 674)	14.8% (n = 382)	17.2% (n = 1056)	< 0.001
2-4 times/month	14.9% (n = 532)	14.5% (n = 373)	14.7% (n = 905)	0.614
2-3 times/week	5.4% (n = 192)	4.3% (n = 110)	4.9% (n = 302)	0.045
≥4 times/week	3.7% (n = 132)	1.9% (n = 50)	3% (n = 182)	< 0.001
Comorbidity	31.3% (n = 1115)	29.5% (n = 762)	30.5% (n = 1877)	0.146
Dyslipidemia	10.5% (n = 373)	11.2% (n = 288)	10.8% (n = 661)	0.380
DM	10.3% (n = 367)	8.7% (n = 224)	9.6% (n = 591)	0.035
SAH	25.3% (n = 903)	24.1% (n = 623)	24.8% (n = 1526)	0.293
CHF	1.6% (n = 58)	1.4% (n = 37)	1.5% (n = 95)	0.546
Other comorbidities	8.5% (n = 303)	8% (n = 207)	8.3% (n = 510)	0.506
Infection	1.7% (n = 62)	2% (n = 51)	1.8% (n = 113)	0.493
Hepatitis B	0.7% (n = 25)	0.5% (n = 12)	0.6% (n = 37)	0.238
Hepatitis C	0.7% (n = 25)	0.8% (n = 20)	0.7% (n = 45)	0.737
HIV	0.4% (n = 16)	0.7% (n = 19)	0.6% (n = 35)	0.139
Other infections	0.5% (n = 19)	0.4% (n = 11)	0.5% (n = 30)	0.555

	Diagnosis of psoriasis	Suspected without confirmed diagnosis of psoriasis	Total	p-value^a a Pearson’s chi-square.
	(n = 3,566)	(n = 2,580)	(n = 6,146)
Year				< 0.001
2016	17.3% (n = 618)	21.9% (n = 564)	19.2% (n = 1182)
2017	21.1% (n = 753)	20% (n = 516)	20.6% (n = 1269)
2018	23.7% (n = 845)	28% (n = 723)	25.5% (n = 1568)
2019	25.5% (n = 910)	30% (n = 773)	27.4% (n = 1683)
2020	12.3% (n = 440)	0.2% (n = 4)	7.2% (n = 444)
Number of sites with analyzed lesion				< 0.001
One (1)	32.1% (n = 1143)	46.3% (n = 1194)	38% (n = 2337)
Two (2)	40.4% (n = 1439)	37.8% (n = 975)	39.3% (n = 2414)
Three (3)	27.6% (n = 984)	15.9% (n = 411)	22.7% (n = 1395)
Body location
Scalp	11.6% (n = 413)	9.9% (n = 255)	10.9% (n = 668)	0.035
Face	5.8% (n = 207)	8.4% (n = 217)	6.9% (n = 424)	< 0.001
Ear	3.8% (n = 137)	3.1% (n = 79)	3.5% (n = 216)	0.101
Anterior cervical region	0.5% (n = 18)	1.4% (n = 35)	0.9% (n = 53)	< 0.001
Posterior cervical region	5% (n = 178)	5.1% (n = 131)	5% (n = 309)	0.879
Anterior thorax	6.5% (n = 232)	5.9% (n = 153)	6.3% (n = 385)	0.358
Posterior thorax	6.6% (n = 237)	4.8% (n = 124)	5.9% (n = 361)	0.002
Abdomen	11.7% (n = 417)	7.1% (n = 182)	9.7% (n = 599)	< 0.001
Anterior arm	4.5% (n = 161)	6.1% (n = 157)	5.2% (n = 318)	0.006
Posterior arm	14.6% (n = 521)	9% (n = 231)	12.2% (n = 752)	< 0.001
Anterior forearm	7% (n = 249)	8.3% (n = 213)	7.5% (n = 462)	0.062
Posterior forearm	23.2% (n = 828)	15.5% (n = 400)	20% (n = 1228)	< 0.001
Dorsum of hand	5.7% (n = 203)	10% (n = 258)	7.5% (n = 461)	< 0.001
Hand (palm)	7.9% (n = 281)	10.6% (n = 274)	9% (n = 555)	< 0.001
Lumbar area	10.6% (n = 379)	4.6% (n = 118)	8.1% (n = 497)	< 0.001
Gluteal region	2.8% (n = 101)	2.6% (n = 66)	2.7% (n = 167)	0.514
Genital/Inguinal region	0.8% (n = 29)	0.8% (n = 21)	0.8% (n = 50)	0.998
Anterior thigh	13.9% (n = 495)	9.9% (n = 255)	12.2% (n = 750)	< 0.001
Posterior thigh	4.7% (n = 166)	2.9% (n = 75)	3.9% (n = 241)	< 0.001
Anterior leg	28.8% (n = 1027)	20.3% (n = 525)	25.3% (n = 1552)	< 0.001
Posterior leg	5.4% (n = 192)	5.2% (n = 133)	5.3% (n = 325)	0.692
Dorsum of foot	6.7% (n = 240)	12.1% (n = 313)	9% (n = 553)	< 0.001
Foot (plantar region)	4.6% (n = 163)	6.3% (n = 162)	5.3% (n = 325)	0.003
Distribution of lesions
Single	5.4% (n = 191)	11.1% (n = 286)	7.8% (n = 477)	< 0.001
Localized	74.5% (n = 2657)	80.2% (n = 2068)	76.9% (n = 4725)	< 0.001
Disseminated	23.4% (n = 833)	11.5% (n = 296)	18.4% (n = 1129)	< 0.001
Generalized	3.6% (n = 129)	1.6% (n = 41)	2.8% (n = 170)	< 0.001

	Diagnosis of psoriasis	Suspected without a final diagnosis of psoriasis	Total	p-value^a a Pearson’s chi-square.
	(n = 3,566)	(n = 2,580)	(n = 6,146)
Main risk classification
White	0% (n = 0)	3.5% (n = 91)	1.5% (n = 91)	< 0.001
Blue	39.7% (n = 1416)	19.1% (n = 493)	31.1% (n = 1909)	< 0.001
Green	1.5% (n = 55)	72.6% (n = 1873)	31.4% (n = 1928)	< 0.001
Yellow	58.7% (n = 2095)	4.7% (n = 120)	36% (n = 2215)	< 0.001
Red	0% (n = 0)	0.1% (n = 3)	0.05% (n = 3)	0.042
Number of diagnoses				0.160
One (1)	94.6% (n = 3374)	95.7% (n = 2468)	95.1% (n = 5842)
Two (2)	5.1% (n = 183)	4.2% (n = 108)	4.7% (n = 291)
Three (3)	0.3% (n = 9)	0.2% (n = 4)	0.2% (n = 13)
Diagnosis of psoriasis	100% (n = 3566)	0% (n = 0)	58% (n = 3566)	< 0.001
Mild	41.3% (n = 1472)	0% (n = 0)	24% (n = 1472)	< 0.001
Moderate to severe	11.2% (n = 400)	0% (n = 0)	6.5% (n = 400)	< 0.001
Undefined severity	48% (n = 1711)	0% (n = 0)	27.8% (n = 1711)	< 0.001
Diagnosis of psoriasis associated with another dermatosis/diagnosis	4.9% (n = 173)	0% (n = 0)	2.8% (n = 173)	< 0.001

	True positive exams	p-value^a a Pearson’s chi-square.
Year
2016	26.8% (n = 435)	0.030
2017	41.4% (n = 526)	< 0.001
2018	39.3% (n = 616)	< 0.001
2019	30.5% (n = 513)	< 0.001
2020	1.6% (n = 7)	< 0.001
Total in the period	34.1% (n = 2097)	< 0.001
Macroregion
Itajai River Mouth	19.6% (n = 43)	< 0.001
Great Florianópolis	42.4% (n = 788)	< 0.001
Great Western	30.8% (n = 181)	0.078
Midwestern and Santa Catarina Mountain Range	35.1% (n = 273)	0.523
Northern/Northeastern plateau	27.2% (n = 205)	< 0.001
Southern	32% (n = 277)	0.153
Itajaí valley	30.4% (n = 330)	0.005
Risk classification
White	0% (n = 0)	< 0.001
Blue	40% (n = 764)	< 0.001
Green	1.3% (n = 26)	< 0.001
Yellow	59% (n = 1307)	< 0.001
Red	0% (n = 0)	0.212

	Itajai River Mouth (n = 219)	Great Florianópolis (n = 1859)	Great Western (n = 587)	Midwestern and Santa Catarina Mountain Range (n = 777)	Northern/Northeastern plateau (n = 754)	Southern (n = 866)	Itajaí valley (n = 1084)
Sex
Female	49.3% (n = 108)	53% (n = 986)	48.6% (n = 285)	53% (n = 412)	47.5% (n = 358)	51.7% (n = 448)	52% (n = 564)
Male	50.7% (n = 111)	47% (n = 873)	51.4% (n = 302)	47% (n = 365)	52.5% (n = 396)	48.3% (n = 418)	48% (n = 520)
p-value^a a Pearson’s chi-square.	0.523	0.097	0.142	0.342	0.020	0.849	0.664
Age
Mean ± SD	46.5 ± 17.3	48.7 ± 16.9	44.9 ± 19.1	45 ± 18.7	48.1 ± 16.8	47.2 ± 18.4	45.4 ± 18.1
p-value^b b Student’s t.	0.706	< 0.001	0.004	0.002	0.050	0.564	0.002
Risk classification
White	0.5% (n = 1; p = 0.201^a a Pearson’s chi-square. )	1% (n = 19; p = 0.050^a a Pearson’s chi-square. )	1.5% (n = 9; p = 0.912^a a Pearson’s chi-square. )	0.8% (n = 6; p = 0.080^a a Pearson’s chi-square. )	0.7% (n = 5; p = 0.047^a a Pearson’s chi-square. )	1% (n = 9; p = 0.246^a a Pearson’s chi-square. )	3.9% (n = 42; p < 0.001^a a Pearson’s chi-square. )
Blue	18.7% (n = 41; p < 0.001^a a Pearson’s chi-square. )	23.4% (n = 435; p < 0.001^a a Pearson’s chi-square. )	42.8% (n = 251; p < 0.001^a a Pearson’s chi-square. )	29.1% (n = 226; p = 0.203^a a Pearson’s chi-square. )	31.6% (n = 238; p = 0.749^a a Pearson’s chi-square. )	33.3% (n = 288; p = 0.132^a a Pearson’s chi-square. )	39.7% (n = 430; p < 0.001^a a Pearson’s chi-square. )
Green	55.7% (n = 122; p < 0.001^a a Pearson’s chi-square. )	24.3% (n = 451; p < 0.001^a a Pearson’s chi-square. )	30% (n = 176; p = 0.446^a a Pearson’s chi-square. )	31.7% (n = 246; p = 0.852^a a Pearson’s chi-square. )	35.7% (n = 269; p = 0.007^a a Pearson’s chi-square. )	35.1% (n = 304; p = 0.011^a a Pearson’s chi-square. )	33.2% (n = 360; p = 0.150^a a Pearson’s chi-square. )
Yellow	25.1% (n = 55; p = 0.001^a a Pearson’s chi-square. )	51.3% (n = 954; p < 0.001^a a Pearson’s chi-square. )	25.6% (n = 150; p < 0.001^a a Pearson’s chi-square. )	38.4% (n = 298; p = 0.151^a a Pearson’s chi-square. )	32% (n = 241; p = 0.013^a a Pearson’s chi-square. )	30.6% (n = 265; p < 0.001^a a Pearson’s chi-square. )	23.2% (n = 252; p < 0.001^a a Pearson’s chi-square. )
Red	0% (n = 0; p = 0.739^a a Pearson’s chi-square. )	0% (n = 0; p = 0.254^a a Pearson’s chi-square. )	0.2% (n = 1; p = 0.161^a a Pearson’s chi-square. )	0.1% (n = 1; p = 0.281^a a Pearson’s chi-square. )	0.1% (n = 1; p = 0.266^a a Pearson’s chi-square. )	0% (n = 0; p = 0.483^a a Pearson’s chi-square. )	0% (n = 0; p = 0.423^a a Pearson’s chi-square. )
Diagnosis of psoriasis	34.2% (n = 75; p < 0.001^a a Pearson’s chi-square. )	67.7% (n = 1258; p < 0.001^a a Pearson’s chi-square. )	59.3% (n = 348; p = 0.514^a a Pearson’s chi-square. )	58.4% (n = 454; p = 0.805^a a Pearson’s chi-square. )	54.5% (n = 411; p = 0.037^a a Pearson’s chi-square. )	52.2% (n = 452; p < 0.001^a a Pearson’s chi-square. )	52.4% (n = 568; p < 0.001^a a Pearson’s chi-square. )
Mild	10% (n = 22; p < 0.001^a a Pearson’s chi-square. )	18.3% (n = 341; p < 0.001^a a Pearson’s chi-square. )	35.8% (n = 210; p < 0.001^a a Pearson’s chi-square. )	22.3% (n = 173; p = 0.239^a a Pearson’s chi-square. )	24.9% (n = 188; p = 0.499^a a Pearson’s chi-square. )	24.8% (n = 215; p = 0.514^a a Pearson’s chi-square. )	29.8% (n = 323; p < 0.001^a a Pearson’s chi-square. )
Moderate to severe	3.7% (n = 8; p = 0.081^a a Pearson’s chi-square. )	7% (n = 130; p = 0.310*)	6.3% (n = 37; p = 0.832^a a Pearson’s chi-square. )	6.9% (n = 54; p = 0.593^a a Pearson’s chi-square. )	7.2% (n = 54; p = 0.437^a a Pearson’s chi-square. )	6.8% (n = 59; p = 0.695^a a Pearson’s chi-square. )	5.4% (n = 58; p = 0.089^a a Pearson’s chi-square. )
Undefined severity	20.5% (n = 45; p = 0.014^a a Pearson’s chi-square. )	42.5% (n = 791; p < 0.001^a a Pearson’s chi-square. )	17.7% (n = 104; p < 0.001^a a Pearson’s chi-square. )	29.3% (n = 228; p = 0.317^a a Pearson’s chi-square. )	22.8% (n = 172; p = 0.001^a a Pearson’s chi-square. )	20.8% (n = 180; p < 0.001^a a Pearson’s chi-square. )	17.6% (n = 191; p < 0.001^a a Pearson’s chi-square. )
Diagnosis of psoriasis associated with another diagnosis	3.7% (n = 8; p = 0.445^a a Pearson’s chi-square. )	2.5% (n = 47; p = 0.371^a a Pearson’s chi-square. )	4.3% (n = 25; p = 0.026^a a Pearson’s chi-square. )	2.1% (n = 16; p = 0.173^a a Pearson’s chi-square. )	4.4% (n = 33; p = 0.006^a a Pearson’s chi-square. )	1.2% (n = 10; p = 0.001^a a Pearson’s chi-square. )	3.1% (n = 34; p = 0.480^a a Pearson’s chi-square. )

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[1] ⁎ Corresponding author. E-mail: lauradermatol@gmail.com (M.L. Demo).