This is Part 1 of an ongoing series on the coronavirus in dermatology. Stay tuned for more coverage on managing patients with psoriasis, atopic dermatitis, and more.
On March 11, 2020, the World Health Organization (WHO) classified the coronavirus disease 2019 (COVID-19) as a pandemic.1 Since December 2019, when the first case of unknown pneumonia was reported in China, the virus has spread from Wuhan, Hubei Province, China to 167 countries as of March 23, 2020, with 353,692 cases confirmed worldwide.2 The US has 35,241 confirmed cases, with 473 deaths, and these numbers will continue to rise well into the foreseeable future.2
The exact nature of the virus, such as how it spreads, how long it lives on surfaces, its incubation period, and how long people are considered contagious following exposure, are still being determined. According to the Centers for Disease Control and Prevention (CDC), the virus is thought to spread from person to person through respiratory droplets and contact with contaminated surfaces.3 However, the virus has been detected in blood, stool, and other extrapulmonary specimens. Whether contact with contaminated extrapulmonary fluids can spread the virus is still unknown.4
While COVID-19 is mild in most cases, older individuals and patients with comorbid conditions, such as lung disease, cardiovascular disease, or compromised immune systems, appear to have a higher risk for severe forms of the disease.5 In dermatology specifically, many patients have immune-mediated diseases that are associated with several high-risk comorbidities, for which these patients are taking immunomodulatory medications.
The Dermatologist spoke with Andrew Blauvelt, MD, MBA, president of Oregon Medical Research Center, and Adam Friedman, MD, interim chair of the department of dermatology at George Washington Medical School, about the coronavirus and what dermatology practices should be doing to both protect patients and ease their concerns.
Q1: Should Patients Continue Taking immunomodulatory Therapies?
Quick Answer: Yes, patients should remain on their prescribed immunomodulatory therapy.
Dr Blauvelt strongly recommends that patients should remain on immunomodulatory medications, both traditional and newer biologic therapies. However, if your patients become sick, they should stop their immunomodulatory therapies and focus on recovering from their illness.
Table 1, which was designed by Dr Blauvelt based on his clinical experience and the current literature, includes 4 categories of immunomodulatory medications and the associated risk for infection. Group A includes therapies that are more skin-targeted, whereas groups C and D include therapies that are more broad-acting. “This grouping, analogous to the old safety grouping of drugs for pregnancy (ABCX), has been helpful for patients who have been contacting me,” said Dr. Blauvelt.
According to Dr Blauvelt, a common misconception is that all biologics have the same increased risk for infection and cancer. “New biologic therapies have no clinically relevant risk of systemic infection or cancer, when compared to older TNF blockers,” added Dr Blauvelt.
Q2: What Precautions Should Dermatology Practices Take to Prevent the Spread of COVID-19?
Quick Answer: Wash hands with soap and water for at least 20 seconds, wiping down surfaces, avoid touching your face, and stay home if you are sick.
Dr Friedman: Caution is important, especially for our patients on immunomodulatory medications such as methotrexate, cyclosporin, azathioprine, and mycophenolate. Providers and patients alike should follow these simple rules to prevent the spread:
- Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use a hand sanitizer containing at least 60% alcohol.
- Avoid touching your eyes, nose, and mouth with unwashed hands.
- Avoid handshakes and hugs.
- Avoid close contact with people who are sick.
- Stay home if you are sick.
- Cover your cough or sneeze with a tissue or the inside of your elbow. Immediately throw the tissue in the trash and wash your hands.
- Clean and disinfect frequently touched objects and surfaces.
- Get an influenza vaccine if you have not already.
Dr Blauvelt: Wash your hands, wipe down surfaces, stay home if you are sick, and isolate patients who are sick if they come to the office.
Table 2 has a comprehensive list of the current procedures being implemented by Dr Blauvelt’s practice to prevent the spread of COVID-19, which is based on guidance from the CDC.5
Q3: What Are the Symptoms of COVID-19?
Quick Answer: Fever, cough, shortness of breath.
The CDC lists the following as the most common symptoms of COVID-19, which are based on epidemiological reports from China:
- Shortness of breath
Other reported symptoms include myalgia or fatigue, headache, sore throat, cough with sputum and/or blood, as well as diarrhea and nausea prior to respiratory symptoms and fever, although these are not as common.8
Q3: What Is Social Distancing, and Why Should Dermatologists Practice It?
Quick Answer: Social distancing involves avoiding large crowds, such as medical conferences, concerts, etc, and maintaining distance from others, about 6 feet, as much as possible.
The CDC and WHO recommend social distancing to prevent the spread of COVID-19. Social distancing is defined as “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.”10 Of note, individuals at risk for severe symptoms of this disease and hospitalization should take a more conservative approach to social distancing and stay home as much as possible if there is an outbreak in their community.5 Individuals who are young and healthy can still go out but should continue following best practices by washing their hands and avoiding physical contact.
Dr Blauvelt: Social distancing means avoiding groups of people, especially groups of more than 10. In all interactions, try to maintain 6 feet of distance between you and the other person.
Basically, it is taking yourself out of situations where you would interact with large groups of people.
Q4: What Should I Be Telling Caregivers?
Quick Answer: Follow Dr Friedman’s guidance to prevent the spread of COVID-19 to your loved ones. Wear a mask if you are sick or if a family member is sick but unable to wear a mask.
Surgical masks and other masks available to consumers do not protect the wearer from COVID-19 but do help reduce exposure to large particle-droplets and splashes, sprays, or splatter. These masks do not protect against small particles.
Health care providers have access to n-95 masks, which are able to protect against respiratory diseases, including COVID-19. The FDA has more information regarding n-95 masks, including strategies for optimizing the supply of these masks and answers to questions on shortages, which can be found at this link.
The CDC also recommends stocking up on the patient’s medical supplies and nonperishable foods to reduce the number of trips that need to be made to the grocery store. Table 3 includes recommendations for caregivers in a non-health care setting.11
Q5: What is the Role of the Dermatologist During This Pandemic?
Quick Answer: Be vigilant and follow CDC’s recommendations for prevention.
Dr Blauvelt: Everybody should be diligent with their own health, their family’s health, and their office’s health.
We need to have a measured approach and not underestimate or overhype the current public health crisis. This includes following the CDC’s recommendations and not doing anything that is not based on scientific fact, such as taking patients off of their immunomodulatory medications.
The CDC and WHO are important resources for patients and providers during this pandemic. In addition, the Center for System Science and Engineering at Johns Hopkins University has created an interactive map that is tracking all known global cases of the COVID-19 virus and can be found at this link.
1. WHO Director-General’s opening remarks at the Mission briefing on COVID-19. World Health Organization. Published March 12, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Accessed March 13, 2020.
2. Coronavirus COVID-19 Global Cases. John Hopkins University Center for Systems Science and Engineering. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Updated March 23, 2020. Accessed March 23, 2020.
3. How COVID-19 spreads. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Updated March 4, 2020. Accessed. March 13, 2020.
4. Healthcare professionals: Frequently asked questions and answers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html. Updated February 21, 2020. Accessed March 13, 2020.
5. People at risk for serious illness from COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html. Updated March 12, 2020. Accessed March 13, 2020.
6. Steps to prevent illness. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/about/prevention.html. Updated March 10, 2020. Accessed March 13, 2020.
7. US Department of Labor Occupational Safety and Health Administation. Guidance on preparing workplaces for COVID-19. https://www.osha.gov/Publications/OSHA3990.pdf. Accessed March 13, 2020.
8. Symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html. Updated February 29, 2020. Accessed March 13, 2020.
9. Hoel S, Rabenau H, Berger, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China [published online February 18, 2020]. N Engl J Med. doi:10.1056/NEJMc2001899
10. Centers for Disease Control and Prevention. Interim US guidance for risk assessment and public health management of persons with potential coronavirus disease 2019 (COVID-19) exposures: Geographic risk and contacts of laboratory-confirmed cases. https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html. Updated March 7, 2020. Accessed March 13, 2020.
11. Centers for Disease Control and Prevention. Preventing the spread of coronavirus disease 2019 in homes and residential communities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html#precautions. Updated February 14, 2020. Accessed March 13, 2020.