This editorial begins our 35th anniversary journal celebrations. Our special features include a series of Practice Reflections with insights into the past, present, and future from experts in our specialty that will continue throughout this year.
One of the journal's initial goals was to keep our readers abreast of the latest developments and research in our specialty field.1 The COVID-19 pandemic has resulted in the greatest generational threat to "in-person" wound care and patient visits. We have been challenged with the need for social distancing, quarantines, lockdowns, and limited visitation to healthcare facilities. Healthcare professionals, patients, and providers have been forced to find viable alternative methods of care delivery.
Out of necessity, virtual format models have been implemented and studied. Our continuing education article features a scoping review of wound care telemedicine practice models published over 22 years. These models had at least one or more of the following elements: image assessment, video/telephone consultation, and text-based communication. In the 2 years since the start of the pandemic, as many telemedicine wound care studies have been published as in any other 5-year period of the scoping review. Of 57 models, most were blended formats combining live patient care with virtual formats (87.7%). There were only seven purely virtual models, and six of these came post COVID-19!
Previous scoping reviews have concluded that telemedicine wound care was not inferior to live patient care. However, there are several challenges to implementation. Onsite photographs are much easier to obtain than patient images; poor video image quality can hinder patient care. Although improved images can be produced with semiprofessional photographic equipment and digital cameras, patients may not have access to or familiarity with these devices or room for the equipment. Smartphones are often the best alternative, but transmission, especially with poor internet connectivity, can be problematic.
Healthcare providers must also have secure email connections and electronic medical records to send, receive, and store sensitive images and information. More recently, text-based provider-to-patient communication has been used successfully. These advances should be adapted postpandemic for efficient, cost-effective care. Blended models may prevail, with in-person care necessary for active surgical debridements, biopsies, and other procedures. However, remote communities especially can benefit from virtual models; ultimately, we can all stand to learn how to increase accessibility to care with these tools.
The case reports in this issue illustrate patients who could benefit from these new models. First, the case study by Cosansu et al describes a patient with a giant cutaneous horn. Cutaneous horns are common among older adults, and it is common for patients to send providers virtual photographs, promoting the use of virtual formats to assess these lesions. A cutaneous horn is a hard cornified skin growth, often yellow to brown in color. A giant cutaneous horn has a larger width-to-height ratio. This huge external appendage had a benign tissue biopsy at the base; the reported incidence of benign lesions at the base varies from 30% to 60%, whereas malignancy rates vary from 20% to 58%.2 (A case series of 163 patients had 37 [22.70%] squamous cells in situ and 56 [34.36%] invasive squamous cell carcinomas.2) A giant horn with lots of differentiation is less likely to be malignant. Malignant lesions often have erythema at the base and are more likely to be associated with localized pain or discomfort. These patients can often be assessed with quality photographs and high-risk patients given a timely appointment for lesion removal.
In a second case study in this issue, Giuggioli describes a patient with Raynaud phenomenon (decreased blood flow to the fingers and/or toes) because of vascular spasms in response to cold exposure alone that evolved to a diagnosis of systemic sclerosis. The progression is probably attributable to the proinflammatory stimulus of COVID-19, which could also be documented virtually.
COVID-19 has advanced virtual care, and some of its lessons will be important long after the pandemic has ended. In the meantime, we must continue to advocate for vaccination and booster shots for all and share vaccines with the developing world to help eradicate COVID-19.
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
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