Patients with autoimmune blistering diseases are not only treated with immunosuppressant medications but may require more care from family members or health care providers to treat their wounds, which could have important implications during the COVID-19 pandemic. Jules Lipoff, MD, assistant professor of clinical dermatology at the Perelman School of Medicine, spoke with The Dermatologist about patients’ concerns, treatment considerations, and the role of telemedicine in managing patients with these conditions.
The Dermatologist: Data is limited, but so far patients with skin diseases like psoriasis or atopic dermatitis are not at an increased risk for the virus, excluding known comorbid risk factors, such as hypertension. In your opinion, are patients with blistering autoimmune skin diseases at an increased risk for the virus?
Dr Lipoff: I have not seen any data yet that makes me concerned that patients with blistering autoimmune skin diseases would have an increased risk for the virus. However, as a great number of these patients are older and treated with immunosuppressant medications, we certainly are concerned that these would be risk factors for complications from COVID-19.
The Dermatologist: What are common questions you have been hearing from patients, and how have you and your staff been addressing them?
Dr Lipoff: Patients are asking if they should continue their immunosuppressant medications, or if they should delay initiating a new medication. How we respond to these questions really depends on the individual patient, but certainly, as a general rule, we should be even more careful with whom and how we immunosuppress in a crisis such as this.
The Dermatologist: What are your recommendations for patients on steroids or other therapies with potential immunosuppression?
Dr Lipoff: I am supportive of the statement put out by the American Academy of Dermatology about biologics during this crisis, and I think the same risk management and careful selection applies to the use of all immunosuppressant medications at this time.1 Some immunosuppressants, such as prednisone, appear to be more concerning than others, such as IL-17 inhibitors and IL-23 inhibitors. I think it would be prudent to defer initiating these medications for patients who can wait, while proceeding cautiously for those patients who need these strong medications more urgently.
I am not recommending stopping any patients currently on these medications but, in my own practice, I am certainly more conscious of trying to limit the use as much as possible.
The Dermatologist: Are there any additional steps providers and caregivers should be taking for wound care for patients with open wounds and/or blisters?
Dr Lipoff: As far as we know, this virus is not transmitted through the skin or wounds, so no special considerations are necessary at this time except for avoiding unnecessary use of personal protective equipment to ensure those taking care of COVID-19 patients will have sufficient supplies. The same precautions should continue to be used in treating wounds on any patient, including those with autoimmune blistering diseases.
The Dermatologist: What are the challenges of treating patients with autoimmune skin diseases during the pandemic?
Dr Lipoff: The challenges include examining patients using telemedicine, which will not be sufficient in many cases, and avoiding health care avenues as much as possible, even during flares, while trying to deliver the best care. We must strive to balance the demands of treating the population while respecting the needs of individual patients. If we can reduce the number of non-urgent, non-essential patient visits, then the risk to the patients who do need these visits will be lower, and the resources will be available to those who need them.
The Dermatologist: Has telemedicine been an effective tool for reassuring patients during this time and also talking to them about their disease?
Dr Lipoff: Telemedicine was an important method of care before this crisis, but it has become essential because it allows us to allocate in-person care to those who need it most while promoting social distancing to flatten the curve of the pandemic. It is not a replacement for in-person care, but it is an excellent alternative. For instance, I care for an older patient with extensive pyoderma gangrenosum on her leg, and I have been able to manage her care without subjecting her to unnecessary travel or additional potential exposure to the virus.
The Dermatologist: How has the current hydroxychloroquine (HCQ) shortage impacted dermatology?
Dr Lipoff: HCQ is a medication in the armamentarium for many dermatologic diseases. While it is not usually used for autoimmune blistering disease, it remains a pressing issue for all physicians to consider during this time.
We must consider the entire population we are treating and know that no action is without other effects. At this time, given limited data and evidence, I think we should strongly consider only giving HCQ to patients with confirmed COVID-19 in the context of randomized clinical trials, while trying to conserve it for the treatment of diseases for which the drug is FDA-approved or at least highly evidence based, such as for lupus and rheumatoid arthritis.
Resource for patients and providers
International Pemphigus and Pemphigoid Foundation. Information for Pemphigus and Pemphigoid Patients Related to Coronavirus Disease (COVID-19). http://www.pemphigus.org/information-for-pemphigus-and-pemphigoid-patients-related-to-coronavirus-disease-covid-19/
1. American Academy of Dermatology. 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. Updated March 19, 2020. Accessed April 2, 2020.