The Hees and Haws of Tele-Dermatology.

It's been standard for a number of years now to wake up to “Good Morning” messages. Some perky with pictures of large faced, big eyed cartoons, some somber with profound quotes of Rumi, some with wonderful pictures of “nature” staring at us through wildly enlarged blooms. My mornings however often tend to take a a slightly different trajectory, when I wake up and reach for my phone and glasses, having reached that age where I am blind as a bat.

More often than not, I am met with at least one confounding image of a part of a person’s anatomy. While blearily wiping the last dregs of sleep from my eyes and squinting through my myopic eyes, I peer hard to try and figure out: Is this the neck? No, I can see what looks like the inside of an elbow, but wait where did that pore like appearance come from? Oh, I get it, it is the side of the nostril where an unbelievable large (read as less than 0.3 cm on a gigantic close up) red pimple is erupting. Hmmm, my day has begun!

I must confess we have been lucky. Dermatologists, that is. Even the pandemic did not derail peoples’ need to get skin advice too much. Almost since the second month, most of us

switched to online consultations. WhatsApp, Zoom, and other video calling platforms became our new clinics. The passage to this virtual existence has been fraught with its own difficulties, but nonetheless it has kept us engaged and growing. It has also created a memorable set of experiences for me, some of them exasperating, some of them endearing and some of them just laugh out loud funny!

So here goes: I read the government instructions and guidelines; set up a consulting process and would tell anyone who asked me that I was consulting online. It started slowly and then gathered some momentum. But then I realised that while my consulting hours were supposed to be 3 hours, I was spending a lot of time on my phone, almost twice that time. This is how a lot of typical appointments would go:

A patient texts asking for an appointment, gets directed to the web makes the appointment and payment, I get automatic notifications and so does the patient asking for history and photographs and a video call at the appointed time completes the process with a detailed PDF prescription. So Simple!

In reality, not so much! The process while simple, seems peppered with a lot more text message interactions and the process does not end even with a detailed prescription. Multiple exchanges fly back and forth with a lot of forgotten symptoms, confusion about the process of application and timing of medicines etc. Nonstop. And the payment process seems to throw people even if it is just a bank transfer. Do you have Paytm, G pay, Phone pe…. erm I’m sorry I’m only bank pe so please follow the instructions on the portal?

And some of the exchanges are pure frustration tinged with pure entertainment. After a particularly long consultation for hyperpigmentation ending with a detailed prescription, Nina a lovely lady from Chandigarh texts asking me if it ok to scrub a hot towel twice daily on her face as she likes the pink appearance her skin gets. This, after detailed explanations to avoid scrubbing! And then I realise hot towel treatment does not translate to scrubbing for a patient and I need to be more specific in my instructions, especially since hot towel can cause more inflammation! Now, it is part of my melasma treatment protocol to advocate avoidance of hot towel scrubs!

Anisha, a college student from Mumbai with occasional acne that has been addressed adequately texts to ask if chocolate cake is good for making the skin glow. I write a detailed explanation on avoidance of sugar and milk in diet due to acne, which is on the prescription too. “No, No, “she writes back.” I meant application of chocolate cake on the face. Whenever anyone has a birthday, we smear cake on them and then their skin glows, so I wondered if I should do it regularly?” I do a double take, then abandon texting and call her back to tell her that the glow is probably just redness from scrubbing it off and on no account to use it as a beauty treatment.

I am yet again reminded that the way I view a disease is so different from the way a patient does. I see a fungal infection; the patient sees a dirty skin condition and assumes erroneously his hygiene practices are imperfect. Hot water, intense cleaning with corrosive soaps etc. ensue, in spite of being warned not to do so. Hence I now try to think like a patient and preempt such behaviour. I see a tiny pimple, patient sees a blight on her face that must be obliterated at all costs and hacks away at it, worsening it sometimes beyond repair. I now make a list of such possible behaviours and try address it head on.

Positive feedback from patients is also immediate and gratifying. Suresh has a bad contact dermatitis to a new hair oil, texts back in 24 hours to let me know that his head now feels “cool cool!” Ronnie from Chennai feels just washing her face followed by a prescribed oil free sunscreen makes her face feel like a Jasmine. Radha from Poona says her mother’s hand psoriasis is cured after 20 years so she would like to send me hand make chakli by courier! I feel humbled and overwhelmed.

As we begin a new year full of hope and anticipation for better things in 2021, I am convinced tele dermatology with all its Hees and Haws is here to stay. And as I pack up my laptop for the day and get ready for bed, up pings a message: Vanita from Mumbai is confused as she doesn't know how to apply antibiotic cream on a boil on her bum, worried that it may rub off on her sheets! Should she sleep on her stomach with a pillow below so that she can keep the part elevated? I too am a little befuddled and respond with a “sure, whatever makes you feel comfortable” as I end yet another interesting day of tele-consultations.

(All patient names changed to protect confidentiality)