This prospective study evaluated the concordance between teledermatology (TD) and in-person dermatological diagnoses among 89 cases. TD diagnoses were made by three dermatologists using a mobile app 2 months after in-person visits. The high agreement rates, ranging from 77.5 to 89.9%, underscore the potential of TD in clinical settings, particularly when in-person consultations are not feasible. It is worth mentioning that after 2 months, the clinical dermatologist who participated in the teledermatology group, which assessed the same patients, did not remember any patients except two of them. Skilled doctors in Iran have extremely high workload to do because there is lack of specialists. On average, they visit 30 patients daily, so it is difficult to recall. They usually remember patients who have very rare and specific diseases, but the patients in this study had common diagnoses. The dermatologist who did the in-person exam in this study was also skilled and visit at least 30 patients daily on average, so it is doubtful that he could remember the same patient after 2 months. This time interval for physicians with low workload may be short and can impact recalling the patients.Compared to previous studies, our findings align with the reported kappa values, indicating excellent diagnostic agreement. However, variations in methodologies, such as the use of teledermoscopy and different imaging devices, make direct comparisons challenging. Despite these differences, the literature consistently suggests that TD is a reliable method for dermatological diagnosis. Two previous studies which implemented a mobile app reported the inter-observer kappa values of excellent (0.958)12, and good (0.6)13.Similar to the current study, most research on teledermatology’s concordance has compared diagnoses made by dermatologists using the gold standard of in-person evaluations14,15. Previous surveys have yielded mixed results regarding the accuracy of teledermatology for pigmented lesions. Some studies have demonstrated good diagnostic concordance with in-person dermatology, with kappa values ranging from 0.4 to 0.92,13,15,16,17,18,19. In a study by Nami et al., the concordance between in-person and store-and-forward diagnoses was 91.05%, supporting the validity of the SAF model15. Another study reported a high concordance rate of 93% between teledermatology and in-person diagnoses20. A study from the USA found moderate concordance for non-infective disorders (66%) and low concordance for infective disorders (39%)21. A recent systematic review reported a pooled diagnostic agreement rate of 68.9% between teledermatologists and in-person dermatologists, with a kappa value of 0.6722. However, another systematic review of 78 studies found that approximately two-thirds reported better diagnostic accuracy with in-person dermatology23. These variations make the comparisons between the findings of this study and those of the former studies and literature difficult, although the existing literature suggests that TD is accurate. It should be noted that there were significant methodological variations in previous studies19,20,24,25.In the current study, it seems that the mobile app over-diagnosed the eczema (9 in in-person vs 14 on app) and underdiagnosed the psoriasis (17 vs. 14). It seems that mobile app may have tendency toward confusing eczema with psoriasis. There are several factors that may explain this discrepancy, such as: the difficulty of distinguishing eczema from other skin conditions, especially psoriasis, based on images alone; the variability of eczema presentation and its severity among different patients; and the lack of a gold standard or a definitive test for eczema diagnosis.However, it may also reflect the inverse relationship between eczema and psoriasis, which are both inflammatory skin diseases but have different immune mechanisms. Some studies have suggested that patients with eczema may have a lower risk of developing psoriasis, and vice versa. Therefore, it is possible that the app and the dermatologists may have misdiagnosed some cases of psoriasis as eczema, or vice versa.Some studies use teledermoscopy for capturing the images, while we did not utilize it in the current study due to the fact that it is not used in real-world applications of TD and is not available in many primary health care settings. Indeed, we captured macroscopic images in the clinic using the high quality camera of a smartphone, similar to previous studies20,21,24,26 as compared to other studies which utilized a digital camera2,16,17,19,27. Although these two devices may produce poor-quality images, eliminating them can cause selection bias. Similar to a previous study2, in the current study, one of the three TD dermatologists was the clinical dermatologist who made in-person encounters and decisions. However, the TD interpretations were performed 2 months later to reduce the recall bias by the dermatologist.In general, trained photographer is an important factor in producing high quality photographs that can enhance the diagnostic accuracy and clinical outcomes. In current study, the implementation of TD is dependent on the preparation of images by a trained person. In other words, the findings of the study may be dependent on this factor. Given that the aim of this study, which is a part of telemedicine, is to develop an app for the empowerment of the medical staff. Therefore, patient empowerment is not our objective. Patient empowerment belongs to the domain of personal health records. In the other word, in current study, the patient wouldn’t use mobile in his/her possession at least for image acquisition.The common infectious diseases can be handled. However, more challenging skin disorders such as dermatological emergencies, those requiring immunosuppressive treatment, and targeted therapies may not be diagnosed by this app. Further research is needed to evaluate the effectiveness of the SAF mobile app method for these conditions. Cuurent app was developed to provide convenient way for patients with mild to moderate skin conditions to consult with dermatologists remotely, without the need to physical visits. However, this app with current specifications is not intended to replace the standard care for patients with severe to complex skin disorders that require urgent or specialized treatment.Store-and-forward TD helped clinicians avoid unnecessary physical contact with patients in the out-patient and in-patient settings during the COVID-19 pandemic. Asynchronous teledermatology will likely play a greater role in the future as the store-and-forward images become integrated into synchronous teledermatology workflows23,28.Some important aspects which need further attention during the setting up of a mobile app for TD programs, especially in the developing countries, are include privacy and ethical issues as well as medical responsibility of diagnosis and medication.Our study’s strengths include the use of board-certified dermatologists and the reduction of bias through independent reviews. The use of high-quality smartphone cameras for image capture also supports the generalizability of our results.Nevertheless, the study’s limited sample size and the narrow range of skin lesion types examined are notable limitations. These factors may impact the utility of TD for specific lesion groups. Additionally, while our protocol was ideal and standardized, real-world applications of TD may vary, potentially affecting the applicability of our findings.Future research should focus on expanding the sample size and lesion types to enhance the robustness of TD as a diagnostic tool. Attention must also be given to privacy, ethical considerations, and medical responsibility when implementing TD programs, especially in developing countries.
