Skin diseases are a major public health concern, affecting nearly one-third of the world population, and ranking among the leading causes of nonfatal burden globally (1, 2). Moreover, the incidence of skin diseases is rising, with a total demand projected to rise by 12.45% from 2021 to 2036 (3). However, the growing demand for dermatological care remains largely unmet worldwide, with some countries having less than one dermatologist per one million people (4). Although this issue weighs the heaviest on low-income countries, middle- and high-income countries also experience a maldistribution of dermatologists (5). Recognizing this gap, the World Health Organization (WHO) urged to integrate telemedicine platforms into clinical practice, especially in remote areas (6).

Teledermatology provides dermatological care between two distant locations through telecommunication technologies (7). It may offer a solution by reducing waiting times and making patient care more accessible in rural and low-resource areas (8). Although it has been shown to be effective during the COVID-19 pandemic in reducing the need for in-person visits, there is a lack of evidence for its applicability in daily practice (9).

Teledermatology can be categorized by communication platform and type. According to communication platform, there are three main forms: store-and-forward, real-time, and hybrid methods (10). In the case of the store-and-forward method, the connection between the patient and healthcare provider is separated in both time and space. Clinical images may also be complemented by historical and/or clinical information (10). The real-time method uses video conferencing technology for live interactions, while the hybrid method combines the features of both approaches (10). The two types of communication are direct and indirect forms. In the direct form, the patient contacts the dermatologist directly, while in indirect teledermatology, the interaction is mediated by the referring healthcare provider, usually a general practitioner (11). The indirect form can be enhanced by the use of dermoscopy (12).

In light of these factors, teledermatology stands out as a promising tool for facilitating timely and affordable dermatological care worldwide. However, its wider implementation has been constrained by technological and human resource limitations. In addition, its diagnostic reliability across communication platforms and types, as well as its efficacy for evaluating different skin conditions remains uncertain (13). We aimed to comprehensively evaluate the diagnostic accuracy of teledermatology compared to in-person dermatological examinations.

The findings of our systematic review and meta-analysis provide the most comprehensive overview to date, with 155 studies comparing the diagnostic concordance of teledermatology and in-person dermatological examination in the diagnosis of skin diseases.

Our findings support that teledermatology provides diagnostic accuracy comparable to in-person care, with high concordance across all disease categories. This aligns with previous analyses by Kanthraj et al. (176) and Bourkas et al. (177), which also reported strong agreement between teledermatology and face-to-face diagnoses. In contrast, Bastola et al. (178) found teledermatology to be less reliable than in-person assessment, likely due to the small number of included studies and strict inclusion criteria. Our study applied a broader inclusion criteria; however, the analysis was restricted to studies in which diagnoses were established by dermatologists, thereby providing a clinically more relevant assessment (177). Moreover, our study uniquely highlights that the direct store-and-forward method, beside requiring fewer resources, achieves diagnostic performance on par with more complex modalities, indicating scalability across varying resource levels.

Our analyses found no significant differences in diagnostic concordance based on the communication platforms and types, regardless of disease category. This suggests that direct store-and-forward, the most convenient approach, is as effective as more complex and resource-heavy methods. Store-and-forward was the most commonly used platform in the included studies, likely due to its cost-effectiveness and minimal resource requirements (10). Previous studies have already urged its implementation in daily practice in resource-poor areas (176). The indirect method was used by most of the included studies, suggesting the low number and inaccessibility of direct teledermatology platforms. Our results suggest that the direct, patient-initiated method is reliable, and feasible for broad implementation.

Additional dermoscopic images did not significantly enhance diagnostic concordance in the group “pigmented lesions,” which involved only nevus and melanoma, suggesting its added importance in diagnosing non-melanoma skin cancers. A prior meta-analysis by Bourkas et al., which combined different types of skin lesions into a single analysis, suggested the limited additional value of dermoscopic images (177). In contrast, the meta-analysis of Chen et al. reported a substantially larger improvement in diagnostic accuracy for melanocytic lesions when dermoscopy was utilized in addition to clinical examination. This discrepancy, however, is likely attributable to methodological and contextual differences, as their study evaluated in-person, as well as remote clinical and dermoscopic examinations, whereas our present study focused solely on remote diagnostic agreement. They found that the diagnostic benefit of dermoscopy was more pronounced in purely in-person examinations and reduced when remote image assessment was included. These results suggest that the diagnostic gain of dermoscopy is attenuated in remote settings, consistent with our observations (179).

Although our results showed no significant benefit in the groups “all skin conditions” and “pigmented lesions,” we found that dermoscopy improves diagnostic accuracy for skin cancers. Our results, further supported by high sensitivity and specificity values, demonstrate that teledermatology has great potential as a screening tool for malignant skin diseases, including melanoma. As melanoma has the highest mortality among skin cancers, particularly when diagnosis is delayed, early detection is crucial to promote public health, reduce economic costs of health care, and improve patient outcomes (180, 181). However, analyses stratified by individual non-melanoma skin cancer subtypes were precluded by the lack of consistently reported, subtype-specific diagnostic outcomes in the included studies.

Further strengthening the easy applicability of teledermatology, we found no statistically significant difference based on the photography device and the training received for image acquisition. Contrary to previous findings, our results showed that images taken by patients with smartphones, without previous training for image acquisition, are not associated with lower diagnostic concordance, possibly due to the larger number of studies included in our analysis (177, 178, 182). This reinforces the feasibility of implementing the direct method more easily in daily practice.

Time efficiency is crucial to the widespread use of teledermatology. In our analysis, the mean diagnostic time was 1.05 min per case, which can be explained by the fact that all studies included in the analysis used the store-and-forward method, which is recognized in the literature as the fastest method (11). Although a direct comparison with face-to-face visits was not possible, prior studies suggest that traditional face-to-face visits can last up to 15–25 min (183), implying that significantly more patients can be managed through teledermatology in the same time frame. Patient satisfaction was also high, with 82% of patients expressing satisfaction with their teledermatology experience, suggesting that real-time interaction is not essential, since most included studies used the store-and-forward method.

The high concordance rates observed across all disease categories support the broad applicability of teledermatology for a wide range of skin conditions. Notably, our results indicate that teledermatological care remains reliable even without the use of dermoscopy, both for general skin conditions and for melanoma screening. This may be especially relevant in low-resource settings, where access to dermoscopic equipment and training may be limited (184). Given its efficiency, diagnostic accuracy, and high user satisfaction, teledermatology, particularly the direct store-and-forward approach, offers a scalable solution that can be effectively integrated into routine clinical workflows, however further tailoring for low-income settings should be implemented. These findings, in line with the WHO’s call to improve primary care for skin conditions, underscore the potential of teledermatology to alleviate the burden on dermatology services by enabling timely access to specialist care without compromising diagnostic reliability (6).

In conclusion, our study suggests that teledermatology is an effective tool for the remote diagnosis of a wide range of skin conditions. The high efficiency of the direct store-and-forward method, as the most easily applicable approach, indicates potential suitability in resource-limited settings, however, further research is needed to ensure its adaptability in low-resource environments.