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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 1-4

COVID-19 and the dermatologist: finding calm in the chaos


1 Department of Dermatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Dermatology, Maulana Azad Medical College, New Delhi, India

Date of Submission02-Apr-2020
Date of Decision05-Apr-2020
Date of Acceptance05-Apr-2020
Date of Web Publication16-Apr-2020

Correspondence Address:
Dr. Rashmi Sarkar
Department of Dermatology, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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How to cite this article:
Jagadeesan S, Sarkar R. COVID-19 and the dermatologist: finding calm in the chaos. Pigment Int 2020;7:1-4

How to cite this URL:
Jagadeesan S, Sarkar R. COVID-19 and the dermatologist: finding calm in the chaos. Pigment Int [serial online] 2020 [cited 2020 Sep 29];7:1-4. Available from: http://www.pigmentinternational.com/text.asp?2020/7/1/1/282601



It is an uncertain time for the whole world, firmly under the grip of a tiny virus, thought to have originated in the meat markets of Wuhan, the capital city of Hubei province in China. A novel enveloped RNA beta corona virus, it was named- Severe acute respiratory syndrome coronavirus −2 (SARS-COV-2) on February 11, 2020[1] due to its structural similarity to the virus causing severe acute respiratory syndrome (SARS) in 2002 and 2003. The disease caused by the SARS-CoV-2 virus was termed Coronavirus disease/COVID-19.[2] Since the virus has a “basic reproduction number,” or R0 (average number of people who catch the virus from a single infected person) ranging from 2-3,[3] it spreads very easily and quickly, too. The studies looking into the evolving epidemiology of transmission of COVID-19 have reported a similar incubation period (mean incubation period- 5.2 days)and serial interval, pointing at an early peak of infectiousness, and possible transmission before the onset of symptoms.[4] Asymptomatic transmission is widely reported.[5],[6]

Reported first in early December 2019[7] it has spread far and wide across the globe to cause unforeseen health hazards and critical challenges impacting the entire spectrum of life, prompting the World health organization to label it as a pandemic on March 11, 2020. With India enforcing a lock-down for 3 weeks to tackle the COVID-19 pandemic beginning last week of March 2020, unprecedented in history, the scope of the crisis we face is evident.

The dermatologists of the country are impacted in multiple ways in the COVID-19 pandemic and have a significant role to play in the coming days.


  COVID-19 presenting to the dermatologist Top


Though skin manifestations in COVID-19 are not widely known, Recalcati et al.[8] analysed cutaneous involvement in COVID-19 patients who were hospitalized in Lombardy, Italy. They noted skin manifestations in approximately 20% of these patients. Erythematous rash, wide-spread urticaria and vesicular lesions resembling varicella-zoster were noted in these patients. Trunk was affected the most. Pruritus was minimal. No correlation was noted with disease severity. The authors surmised that the skin manifestations noted were similar to those seen in common viral infections.Also, COVID-19 presenting with a petechial rash resembling that seen in dengue has been reported from Thailand.[9] There are a few unpublished reports of emerging skin manifestations including transient livedoid eruptions, pseudo-frost bite and painful erythema, to name a few.

Some authors have hypothesized that diseases with epidermal barrier interruption could enhance the virus acquisition through indirect contact, putting dermatology patients at increased risk for acquiring COVID-19,[10] but these theories have not been validated.


  Skin lesions following personal hygiene measures and use of personal protection equipment Top


Skin lesions have been reported following frequent hand washing and the use of hand sanitizers. Contact dermatitis and hand dermatitis in atopic patients can be a rising concern. Repeated use of thick emollients and barrier creams has been recommended to mitigate the damage caused by the same. Moreover, skin problems related to personal protective equipment (PPE) have been reported in health care workers; thought to be caused by the hyper-hydration effect of PPE, friction, epidermal barrier breakdown, and contact reactions. Aggravation of previous dermatitis has been noted in the wearers and also skin lesions ranging from contact and pressure urticaria or contact dermatitis, after prolonged contact with masks and goggles.[11],[12] The heat and humidity can of course add to the skin problems associated with PPE use in our country and could possibly induce miliaria.


  Continuity of care Top


As most practices and private clinics have closed doors temporarily following the lock-down in the country, providing continuity of care to the patients under their follow-up pose a big challenge for most dermatologists. Patients with chronic diseases like psoriasis, vesiculobullous diseases, extensive atopic dermatitis, erythroderma may need to be referred to larger institutions if they need close monitoring and follow-up. The ones with milder disease could be managed over the phone or by video/tele-consultations (as and when they are legalized or permitted by medical council) and the non-emergent visits and elective procedures postponed, even in the big departments which continue to function.


  Patients on immuno-modulation Top


Patients on immunomodulation present a challenge in this scenario. The risk/benefit may be carefully weighed by the physician on a case-to-case basis regarding continuation and the dosage of treatment. Alternate options may be explored in high risk cases, if feasible. The patients should be given adequate counseling regarding the risks and the need for shielding. Those who require long term-immunomodulation may be maintained on the minimum possible dose and those who need to be newly started on immunomodulation, taken into confidence regarding the precautions and the hazards. Possibly withholding them in the Covid-19 scenario for as long as possible should be looked into after weighing the pros and cons.

‘Safe Prescribing and Monitoring Protocol for Systemic immunomodulatory therapies for immune-mediated inflammatory skin disease in the context of Coronavirus (COVID-19)’ is a framework developed by Guy’s and St Thomas’ NHS Foundation Trust to support clinicians reconfigure services in the context of COVID-19 (approval awaited) and is a good reference tool.[13] British Association of Dermatologists has also developed a ‘risk-stratification grid’ for patients on immunosuppressive medication.[14]

Regarding the use of biologics, guidance has been issued by the Academy of Dermatology, specifically regarding their use in the context of COVID-19.[15]


  Covid-19 and pigmentary disorders Top


It is difficult to say whether vitiligo patients, who suffer from an immunological disorder, would be more at risk to developing Covid 19 infections. Patients on mini pulse steroids, given twice a week, for active vitiligo, are not usually prone to increased infections. Those on immunosuppressants and JAK inhibitors may need to be observed. The patient may need to be maintained on the smallest possible dose after weighing the pros and cons. Narrow band UVB and PUVA therapy which require hospital visits will be compromised but in India, the practice of PUVASol could be continued. Hyperpigmentary disorders like melasma require the continuation of broad spectrum sunscreens and skin lightening agents. Staying indoors for close to 3-4 weeks maybe beneficial for melasma. However,sunscreens must be continued as people do sit out on terraces and balconies.


  Economic pressures Top


A significant chunk of the specialist dermatologists run private clinics or work with them. Practices will experience huge loss of revenue with no patients, at the same time having to bear the cost of the rent, the salaries of the support personnel, repayment of loan for expensive devices and other ancillary expenses. Those dermatologists who work on a salary in private institutions also may have to take cuts in their remuneration, depending on the institution they work for.

The concerned associations and organizations could request governmental support to sustain practices during this unprecedented emergency through zero-interest loans, tax relief, direct payments, rent-cuts, etc. Legalizing tele-dermatology and allowing payment for virtual visits including phone calls would also allow some relief. At this time, an online telemedicine educational program is being developed by the Medical Council of India, which will need to be completed within the next 3 years, by those desirous of practicing it for their patients.[16] The regional medical councils have also issued directives allowing practice of telemedicine temporarily, but subject to certain stipulations and conditions.However the legalities of tele-medicine are complex and until a comprehensive framework emerges looking into all the nuances; addressing liabilities and continued responsibilities even after the current situation is handled, one may have to tread very carefully.


  Redeployment during crisis Top


Dermatologists are not specialists who routinely handle medical emergencies. However in the event of a crisis, all physicians including dermatologists may be called upon to put their medical knowledge to the best use. Already, in government hospitals and large private institutions designated as COVID treatment centres, dermatologists take turns in managing the fever clinics. Certain institutes have also made guidelines regarding the deployment of preclinical, paraclinical and non-emergency dealing branches. Therefore, it may be worthwhile to spend some time on clinical considerations to deliver safe patient care, life support and personal protective equipment (PPE) training in the days ahead, considering the eventuality of being asked to step in. There are numerous online resources including training programs covering all aspects of COVID-19, for those who want to volunteer or contribute in tackling the crisis.


  Personal safety and protection of patients’ safety Top


Various measures need to be put in place including a careful history takingand triage (including travel, contact history and symptoms) at the entrance. This is especially important in view of the asymptomatic patients who may present with skin problems or for cosmetic indications without fever or respiratory symptoms. Only urgent out-patient visits or emergent in-patient consultations should be encouraged to avoid putting stress on the existing health care system and conserve resources.Medical tourism may be strictly discouraged for the time being. Training to use proper personal protective equipment is a must for patient encounters,along with social distancing. Practitioners that fit high risk criteria of being age 60 or older, immunocompromised, or pregnant maybe excused from evaluating patients. Resident/other trainees/consultants should be posted only on a rotational basis and their exposure staggered to protect the health care workforce, especially as they may need to be re-deployed if the situation escalates. Tao et al.[10] have published their observations and recommendations for handling COVID-19 from the perspective of a dermatology department.

In the daily changing scenario with respect to COVID-19, it may not be always easy to maintain the calm; however keeping oneself updated and prepared should help the dermatologist community in facing the challenges head-on…to give our best to our patients and the humanity at large.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gorbalenya AE, Baker SC, Baric RS et al. The species severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020;5:536-544.  Back to cited text no. 1
    
2.
WHO Coronavirus disease. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (Accessed February 18, 2020).  Back to cited text no. 2
    
3.
Imperial College London, MRC Centre for Global Infectious Disease Analysis. News/COVID-19—report 3: transmissibility of 2019-nCoV. 2020. Available at: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/news–wuhan-coronavirus/ (Accessed March 5, 2020).  Back to cited text no. 3
    
4.
Zhang J, Wang W, Wang Y et al. Evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside Hubei province, China: a descriptive and modelling study. Lancet Infect Dis 2020;3099:30230. Published Online April 2, 2020 https://doi.org/10.1016/ S1473-3099(20)30230-9.  Back to cited text no. 4
    
5.
Bai Y, Yao L, Wei T et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020 (published online Feb 21.) DOI:10.1001/jama.2020.2565.  Back to cited text no. 5
    
6.
Yu P, Zhu J, Zhang Z, Han Y, Huang L. A familial cluster of infection associated with the2019 novel coronavirus indicating potential person-to-person transmission during the incubation period. J Infect Dis 2020 (published online Feb 18.) DOI:10.1093/infdis/jiaa077.  Back to cited text no. 6
    
7.
nCoV-2019 Data Working Group. Epidemiological data from the nCoV-2019 outbreak: early descriptions from publicly available data. http://virological.org/t/epidemiological-data-from-the-ncov-2019-outbreak-early-descriptions-from-publicly-available-data/337 Date: 2020 (accessed March 30, 2020).  Back to cited text no. 7
    
8.
Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol 2020 Mar 26.  Back to cited text no. 8
    
9.
Joob B, Wiwanitkit V, COVID-19 can present with a rash and be mistaken for Dengue. Journal of the American Academy of Dermatology 2020, doi: https://doi.org/10.1016/j.jaad.2020.03.036.  Back to cited text no. 9
    
10.
Tao J, Song Z, Yang L et al. Emergency management for preventing and controlling nosocomial infection of 2019 novel coronavirus: implications for the dermatology department. Br J Dermatol 2020.  Back to cited text no. 10
    
11.
Yan Y, Chen H, Chen L, Cheng B, Diao P, Dong L et al. Consensus of Chinese experts on protection of skin and mucous membrane barrier for healthcare workers fighting against coronavirus disease 2019. Dermatol Ther 2020:e13310.  Back to cited text no. 11
    
12.
Elston DM. Letter from the Editor: occupational skin disease among healthcare workers during the Coronavirus (COVID-19) epidemic. J Am Acad Dermatol 2020 Mar 11. pii: S0190-9622(20)30390-X. doi: 10.1016/j.jaad.2020.03.012. [Epub ahead of print]  Back to cited text no. 12
    
13.
Safe Prescribing and Monitoring Protocol for Systemic immunomodulatory therapies for immune-mediated inflammatory skin disease in the context of Coronavirus (COVID-19) Key Considerations. http://www.bad.org.uk/healthcare-professionals/covid-19/covid-19-immunosuppressed-patients/ Date: March 24, 2020 (Date accessed Apri l1, 2020)  Back to cited text no. 13
    
14.
http://www.bad.org.uk/healthcare-professionals/covid-19/covid-19-immunosuppressed-patients/ Date: March 24, 2020 (D ate accessed Apri l1, 2020)  Back to cited text no. 14
    
15.
Guidance on the use of biologic agents during COVID-19 outbreak. https://assets.ctfassets.net/1ny4yoiyrqia/PicgNuD0IpYd9MSOwab47/07b614658aff5fc6ccc4c0bd910509a3/Biologics_and_COVID_19_FINAL_V2.pdf. Date; March 18, 2020 Date accessed: April 1, 2020.  Back to cited text no. 15
    
16.
Telemedicine Practice Guidelines Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. https://www.mohfw.gov.in/pdf/Telemedicine.pdf Date: 25 March 2020 (Date accessed 1, April 2020).  Back to cited text no. 16
    




 

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