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taken by the patient . They may need the help of family members for this . The images should be forwarded , generally via a text system , which will insert them in the patient notes . Give them guidelines for taking clear and useful images – see box , below .

with a clear introduction , setting out expectations of a virtual consultation The consultation starts with you sending the video link or making the phone call . Begin by establishing that the patient can hear you , and for a video call , see you . Confirm who you are speaking to and ask if anyone else is in the room or listening in . Introduce yourself to everyone even if they are off camera . For a phone call , a speakerphone may be used . Start by asking for verbal consent for the consultation . Reassure the patient that the consultation will be similar to a face-to-face one and that the call or video is confidential and secure . ⁴

a comprehensive history and use dermatology assessment tools Patient history and assessment must be comprehensive on a virtual call . Include discussion of past and current topical skin treatments ( see tip 5 ). Assess for any triggers and ask , ‘ what do you think makes your skin condition worse ?’ Also ask whether the patient has any diagnosed allergies . In children , check normal growth and development – height , weight and milestones .

the patient about past skin treatments Assess skin management and ask about current and previous treatment . Gather this information by taking the patient through their day and find out when they apply emollients and topical treatments . Also ask about any oral treatment , such as use of antihistamines and antibiotics . Ask :

How often do they use emollient and topical treatments ( daily skin routine )? Where do they use them ? How much do they apply ? What size are the packs ?

Instructions for patient images ( adapted from the Primary Care Dermatology Society ) ⁷

References 1 Schofield J , Grindlay D , Williams H . Skin conditions in the UK : a health needs assessment . Centre of Evidence Based Dermatology , University of Nottingham 2009 2 Charman C , Venn A , Williams H . The patientoriented eczema measure : development and initial validation of a new tool for measuring atopic eczema severity from the patients ’ perspective . Archives of Dermatology 2004 ; 140 : 1513-19 3 Finlay A , Khan G . Dermatology Life Quality Index ( DLQI ) – a simple practical measure for routine clinical use . Clinical Experimental Dermatology 1994 ; 19:210-16 4 Greenhalgh T . Video consultations : information for GPs . Interdisciplinary Research In Health Sciences Research Group . University of Oxford 2020 5 National Eczema Society . Topical steroid factsheet . eczema . org / information-andadvice / eczema-bookletsfactsheets / factsheets / 6 Cork M , Danby S . Skin barrier breakdown : a renaissance in emollient therapy . British Journal of Nursing 2009 ; 181:872-7 7 Primary Care Dermatology Society . Photography for the patient . pcds . org . uk / clinical-guidance / photography-for-the-patienthow-to-take-a-goodphotograph-of-a-skin-conditi 8 British Association of Dermatologists . Covid-19 : Clinical guidelines for the management of dermatology patients remotely – Patient consent . bad . org . uk / healthcare-professionals / covid-19 / remotedermatology-guidance

They must be in focus Ask someone to take the pictures in a bright light – ‘ selfies ’ are not usually suitable

Take an orientation picture ( eg , the whole arm ) then a close-up of the affected area

Take several images and select the best ones to send Make sure image files are under 1MB Advise that the images will be stored in the electronic referral system ( ERS ). Explain about onward data transfer and storage of images and ask for the patient ’ s consent . See the British Association of Dermatologists ’ Covid-19 : clinical guidelines for the management of dermatology patients

remotely ⁸

Which treatments are effective or have helped ? Which treatments have not helped ? Are there any specific concerns with treatments

( for instance , topical steroids )?

Be aware of red flags and be ready to arrange a face-to-face appointment if there is any concern An awareness of red flags or deteriorating symptoms is very important . Assess for clinical evidence of secondary infection – is the skin sore , wet and weepy with yellow crusting ? Is the condition flaring ? Are there different symptoms ? Pain and vesicular blistering may indicate eczema herpeticum – a dermatological emergency , requiring same-day antiviral treatment . Is anyone else in the family experiencing the same symptoms ? For example , intense itching may indicate a scabies outbreak .

Work with the patient on a treatment plan so they can self-manage An individual treatment plan is essential to help patients self-manage , especially for chronic and long-term skin conditions . You may need to involve the patient ’ s family ( with permission ) in helping with the treatment plan . Focus on general skincare and prevention of flares , for example , complete emollient therapy ( washing and moisturising ). It is important that the patient is given realistic expectations of what to expect from topical treatment , what to apply , where to apply it , how long to use the treatment for and when to stop . One example is a two-week treatment burst for an eczema flare , with the topical steroid matched to the severity and body area to be used once a day for the first week and every other day for the second . ⁵

Use ‘ talking in pictures ’ for patient education , especially for phone consultations A helpful technique is to ‘ talk in pictures ’. The brick-wall analogy for explaining the differences between normal and dry skin is well-known . ⁶ Others include a fire analogy for treating eczema . When the flames ( inflamed skin ) are present , an extinguisher ( topical steroid ) is needed to stop the fire ( acute treatment ), which leaves the embers , which need to be dampened down , so treatment needs to be reduced ( sub-acute treatment ), until dust ( dry skin ) needs to be mopped up ( daily complete emollient therapy ).

Set a review date Plan review appointments according to severity and treatment expectations – two weeks for an eczema flare , four weeks for eczema or psoriasis management , two months for acne . The review could be done by phone but ask patients to complete assessment tools and send images for a thorough review .

Always provide a summary of the treatment plan and review plan when you finish Summarise the consultation . Reinforce the treatment plan and ensure the patient understands it . If they are uncertain , ask them to repeat it back . Remind them to collect any new prescriptions from their nominated pharmacy . Recommend the NHS pre-payment certificate ( PPC ) for working adults . Inform the patient you are closing the consultation .