The coronavirus-19 pandemic is impacting every aspect of medicine, including dermatology. From practice-staggering patients to implementing telemedicine platforms at a faster rate than normal, dermatologists are having to adapt to a changing landscape along with their patients.
Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Feinberg School of Medicine, spoke with The Dermatologist about concerns related to patients with atopic dermatitis (AD), the transition to telemedicine in his practice, and what providers need to know as the COVID-19 pandemic evolves.
Q1: What are some tips for keeping hands clean and sanitized without triggering or exacerbating eczema?
Dr Lio: Hand washing is important to prevent infection, but it does take a toll on the skin. My advice to patients is to wash with a gentle cleanser and always moisturize right after to protect the skin and help prevent irritation. Also, anti-bacterial soaps will not add anything of value and just contain more chemicals that can possibly cause contact dermatitis.
Hand sanitizers can be particularly harsh, as they are alcohol based for the most part, so patients with open and irritated skin should minimize use of these.
Q2: Am I at risk?
Dr Lio: This is an important question, and I have to preface it by saying that we do not have enough evidence at this point to be able to say for sure whether patients with AD are at increased risk for COVID-19 compared with the general population. Because the coronavirus appears to be transmitted through contact transmission with the mouth, eyes, and airway mucosa, either directly or indirectly, it seems unlikely to me that damaged skin alone increases the risk.
Of course, bacterial infections are much more likely in compromised skin, as well as certain viral infections such as Herpes Simplex Virus (HSV). However, with this type of respiratory infection, I think there is not a significantly increased risk for patients with damaged skin from AD.
Additionally, even in severe AD, the immune system is disordered, but not compromised. In fact, we think of it as being an over-exuberant immune response rather than a compromised state. So just having eczema—even severe eczema—alone is probably not a significant risk factor for getting sick with or having a more severe case of COVID-19.
Q1: Should patients be taken off of biologic or immunosuppressant therapies during the COVID-19 pandemic?
Dr Lio: The general thinking seems to be that those with immunocompromised status, which includes older individuals in general whose immune system might not be as robust as it is in younger patients, have a greater risk for COVID-19.
We also think that being on traditional immunosuppressants such as prednisone, cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil could put patients at a higher risk of both contracting the disease and having a more severe case. For patients on these medications, I think it is advisable to try to reduce the dose to the lowest possible that still adequately controls the disease symptoms. In the event of an infection, these medications should probably be held until the infection is resolved.
While we do not know for sure, I believe the more targeted anti-inflammatory medications like dupilumab (Dupixent), which is thought to work by bringing abnormally high levels of IL-4 and IL-13 back closer to a normal level, apremilast (Otezla), and some of the newer, targeted biologic agents, such as those used for psoriasis, are not considered true immunosuppressant agents. These likely do not substantially increase the risk of contracting the virus.
More importantly, it is thought that in the event of an infection, it is not likely that these agents will significantly decrease the ability to fight the infection. I am not advising my patients to lower their dose or stop these targeted therapies at this time. However, in the event of a COVID-19 infection, it is probably advisable to stop them until the patient is fully recovered.
That said, if some patients prefer to stop their medications during this time, that is not unreasonable and other approaches to management can be considered.
Q2: What are your recommendations for preventing the spread of COVID-19 in the home and at dermatology practices?
Dr Lio: I think this is a bit touch-and-go right now, as the CDC guidelines appear to be changing. Ideally, a lot of testing and full personal protective equipment (PPE) would be best, but many places (and maybe most) do not yet have access to enough PPE to use them this way. Social distancing, avoiding unnecessary visits, and self-quarantining for anyone with symptoms will have to suffice for now.
For guidelines on keeping your practice open, visit: https://www.aad.org/member/practice/managing/coronavirus
For more information from the CDC, visit: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
For information regarding shortages of masks and gowns, visit: https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-_________________________________________________________________________________
My colleagues and I have closed our office except for urgent and emergent cases so that we can avoid having these patients go to the emergency department or urgent care: painful lesions, abscesses, worrisome new rashes, any skin infections or suspected infections, specific lesions worrisome for skin cancer, etc. We have shifted to video teledermatology, which has been an adventure, but I can honestly say it is much better than I feared initially and works well for a lot of clinical visits.
Q3: A lot of providers across various disciplines are moving to telehealth platforms. In addition, coverage of telehealth has expanded both at the federal level and by some states (Massachusetts). And, there was a relaxation of HIPAA for Skype calls. Are there any other changes that providers need to know as they begin implementing telehealth, especially ones who are not set up already?
Dr Lio: We are all following this closely, but I think that the spirit of the time is that we all have to pitch in to help. Payment is a secondary concern right now, and even the HIPAA guidelines have been bent a bit to allow more freedom and access here. I truly believe and hope that good-faith efforts will be rewarded and that, as long as the intention is to help, telemedicine is a great approach for many problems we face right now. That said, we are trying to be as “by the book” as possible. We are using a HIPAA-compliant service that has been excellent, and we are documenting in our regular EMR so that we can keep the quality of care as high as possible.
Q4: What are your recommendations for providers who may not be familiar with these platforms in terms of scheduling appointments, documentation, etc? And, what pitfalls do providers need to keep in mind to make sure they are still providing the best care for patients who cannot come into the office?
Dr Lio: I think we are all learning as we go. Even though I do have a fair amount of experience with store-and-forward teledermatology, the current situation has made teledermatology pretty different and, as a result, it is now opened up to almost all of our patients. I think choosing a system designed for this (such as doxy.me, the one we are using—I have no conflict of interest) makes things a lot easier than trying to use FaceTime or Google Chat since they were truly not designed for this. Documenting in your regular record (or on paper to be placed in the permanent record) is important too—most of these video visits will not be stored in any way, so if they are not documented like a regular visit, they will be lost. The hardest part is that some people have technical issues, and these visits take a lot more time. I cannot do more than 1 every 30 minutes because I have spent more than 10 minutes helping people turn on their Wi-Fi or allow their camera to be used, etc.
Q5: Thus far, how has the switch in the face of a pandemic been handled by your practice? How have patients with atopic dermatitis responded?
Dr Lio: In general, patients have been incredibly understanding. This is a pretty scary time, and no one has really experienced anything quite like it. I think everyone realizes we have to give each other a lot of slack. I am happy that, with AD, so much can be done remotely, and my practice life is still very busy. This is in contradistinction to one of my partners who really has a much older population and is more focused on skin cancer. He is not as busy right now and is mostly trying to calm those who are worried about missing melanomas during this time.
Q6: Any other important points to remember during this time?
Dr Lio: Fred “Mister” Rogers has a wonderful quote that my wife frequently cites: “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’” I would say that, as trained medical professionals in a time of need, we have to go beyond just looking—we have to be the helpers as much as we can.