Teledermatology-Supported Care for Skin Neglected Tropical Diseases and Common Skin Diseases in Cote dIvoire: a Mixed Methods Evaluation

This mixed-methods study in Cote d'Ivoire demonstrates that the eSkinHealth teledermatology app significantly improved the detection and diagnosis of skin neglected tropical diseases and confirmed diagnoses for common skin conditions in primary health centers, despite facing challenges related to technical issues, privacy concerns, and the high prevalence of non-NTD skin diseases.

The Gist

Imagine a world where the only doctors who specialize in skin problems are living in big, fancy cities, while millions of people in remote villages have to walk for days just to get a second opinion on a rash. That was the reality in Côte d'Ivoire, a country with 27.5 million people but only 80 dermatologists, most of whom were stuck in urban centers.

To fix this, the researchers built a digital bridge called the eSkinHealth app. Think of this app as a "magic tablet" for local nurses and community health workers. It works like a portable medical record and a video call station combined. When a patient comes in with a skin issue, the local worker takes a photo with the tablet, writes down the details, and sends it to a specialist dermatologist far away. The specialist looks at the photo, gives a diagnosis, and sends advice back. The best part? The tablet works even when the internet is broken, saving the data to send later when the connection returns.

The Experiment: A "Before and After" Look

The team tested this tool in two rural districts (Sinfra and Bouaflé) over seven months. They compared what happened before they had the tablets (using old paper notebooks) to what happened after they started using the app.

What they found:

• The "Hidden" Diseases Were Found: Before the app, many serious skin diseases (like Buruli ulcer, leprosy, and yaws) were going unnoticed or unrecorded. It's like trying to count fish in a dark pond; you only see the ones near the surface. With the app's "flashlight" (the ability to consult experts remotely), the number of detected skin diseases tripled. They found 91 cases of these neglected diseases during the study, compared to just 30 the year before.
• The "Common" Rashes Got Better Care: For everyday skin problems (like eczema or acne), the total number of people walking into the clinic actually went down slightly. However, this wasn't a bad thing. Before, almost no one got a confirmed diagnosis for these common issues (0%). With the app, 94% of them got a proper diagnosis. It was like upgrading from guessing the weather to having a precise forecast.
• Confidence Boost: The local health workers felt like they had a "superpower." They told the researchers they felt much more confident in their diagnoses and that patients started trusting them more, even bringing out conditions they used to hide due to shame.

The Hiccups: Why the Bridge Isn't Perfect Yet

Even though the tool worked well, the journey wasn't smooth. The researchers identified a few "potholes" on the road:

1. The Internet Ghost: Sometimes the internet was too weak to send the photos. It's like trying to mail a heavy package through a post office that's closed; the data gets stuck. About 14% of the time, the specialist couldn't see the image because the connection failed.
2. The "Free Medicine" Expectation: Many patients thought the project meant free medicine for everything. When they found out they had to pay for some treatments, they got disappointed or refused to come back.
3. The Privacy Worry: Some people, especially women with sensitive skin issues, were afraid their photos would be seen by everyone. They worried about their privacy, even though the app was designed so only the doctor could see the image.
4. The Long Walk: The app helped doctors see the patient, but it couldn't fix the roads. If a patient was too sick to walk to the clinic, or if the roads were washed out by rain, the digital help couldn't physically get them to the health center.

The Verdict

The study concludes that this digital tool is a game-changer for finding and diagnosing skin diseases in remote areas. It turned local health workers into confident experts by giving them a direct line to specialists.

However, the paper warns that a tablet alone isn't a magic wand. To make this work for everyone in the long run, you still need to fix the internet, provide reliable transportation for patients, and teach the community that their privacy is safe. The researchers say that while the tool is excellent, it needs to be part of a bigger plan that includes better roads, better internet, and more community trust to truly heal the skin of the nation.

Technical Summary

Technical Summary: Teledermatology-Supported Care for Skin Neglected Tropical Diseases and Common Skin Diseases in Côte d'Ivoire

Problem Statement
Skin-related neglected tropical diseases (skin NTDs) and other dermatological conditions disproportionately affect remote communities in endemic countries where access to specialized dermatological care is severely limited. In Côte d'Ivoire, a nation of 27.5 million people, there are only 80 dermatologists, most of whom are concentrated in urban centers. This scarcity creates a significant gap in the detection, diagnosis, and management of skin NTDs (including Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws) and common skin diseases. Previous surveillance indicated that regions with high skin NTD burdens also suffer from high incidences of other dermatological conditions, yet diagnostic capacity remains low.

Methodology
This study employed a mixed-methods, before-and-after implementation design across 16 primary health centers (PHCs) in the Sinfra and Bouaflé districts of central Côte d'Ivoire. The intervention utilized the eSkinHealth app, a digital health tool functioning as a portable electronic medical record and teledermatology platform. The app allows frontline healthcare workers (nurses and community health workers) to photograph skin lesions, record patient data offline, and synchronize information to a remote server when internet connectivity is available for review by dermatologists.

The study consisted of two parts:

1. Quantitative Analysis: A prospective pre-post study comparing data from a baseline period (August 2021–February 2022, collected via paper registries) against an intervention period (August 2022–February 2023, collected via the app). The analysis included 1,766 patients and focused on changes in disease detection rates, diagnostic confirmation, and registration volumes.
2. Qualitative Assessment: Semi-structured interviews and System Usability Scale (SUS) surveys were conducted with 44 healthcare providers (nurses and CHWs) to evaluate the tool's usability, acceptability, and feasibility.

Key Contributions and Results

• Enhanced Detection of Skin NTDs: The integration of the eSkinHealth app led to a statistically significant increase in skin NTD registrations, rising from 30 cases in the baseline period to 91 cases during the intervention (p < 0.01). Specific increases were observed in Buruli ulcer (6 to 14 cases, p = 0.05) and scabies (24 to 70 cases, p = 0.13). Notably, cases of leprosy, lymphatic filariasis, and yaws, which were previously unrecorded in the study sites, were newly detected and documented.
• Improved Diagnostic Confirmation for Non-NTDs: While the total number of registered non-NTD skin disease cases decreased (from 662 to 472, p < 0.01), the proportion of these cases receiving diagnostic confirmation increased dramatically from 0% at baseline to 94% during the intervention (p < 0.01). This suggests the tool improved the quality of diagnosis even if the volume of routine registrations shifted.
• Usability and Acceptability: The System Usability Scale (SUS) scores indicated a shift from "marginal" to "excellent" usability. In the Bouaflé district, scores improved markedly from a baseline of 55.4 to 89.3 at the study endpoint (p < 0.01). Qualitative data revealed that the app increased healthcare workers' confidence in diagnosis, improved patient engagement, and streamlined record-keeping.
• Operational Challenges: The study identified persistent barriers, including:
  • Technical Issues: Synchronization failures due to poor internet connectivity and large image file sizes resulted in 14.2% of cases lacking images for remote diagnosis.
  • Patient Barriers: Stigma and privacy concerns, particularly regarding photos of lesions in private areas, led to some patients refusing registration.
  • Logistical Constraints: Transportation difficulties prevented many patients from attending follow-up visits, and a lack of free medication for non-NTD conditions created unmet expectations among the population.
  • Workload: The median time to complete a registration (including photography) was 7 minutes and 16 seconds, which, while acceptable, contributed to a perceived increase in administrative burden.

Significance and Claims
The authors claim that the eSkinHealth app is an effective tool for enhancing diagnostic capacity for skin NTDs in resource-limited settings. The study demonstrates that digital health tools can bridge the gap between frontline workers and remote specialists, leading to a three-fold increase in the detection and documentation of skin NTDs compared to the previous year.

However, the paper maintains a modest tone regarding scalability. It acknowledges that while the tool improved diagnostic rates and provider confidence, capturing the full burden of high-prevalence non-NTD skin diseases proved difficult due to the increased administrative time required for digital entry. The authors conclude that for such tools to be sustainable and scalable, future implementations must address not only technical refinements (such as offline data synchronization) but also broader structural and social barriers, including transportation, privacy concerns, stigma, and the need for consistent community awareness and resource allocation. The study positions the eSkinHealth app as a complementary component to existing healthcare infrastructure rather than a standalone solution.