Editor’s note: This article was previously published as an online exclusive and has now been published in the April 2020 issue of The Dermatologist. Given the fluidity of the pandemic, some information may be inaccurate based on new data after the time of publication.
As of March 27, 2020, the United States has become the epicenter of the coronavirus pandemic. Misha Rosenbach, MD, answered several questions regarding the current pandemic on March 23 and 27, 2020.
Dr Rosenbach is an associate professor of dermatology at the Perelman School of Medicine at the Hospital of the University of Pennsylvania in Philadelphia, where his roles include Dermatology Residency Program Director, director of the Cutaneous Sarcoidosis and Granulomatous Disease Clinic, and vice chair of Education.
1. What precaution should dermatology practices take to reduce the spread of COVID-19 and potential exposure?
Dr Rosenbach: As you know, the landscape is rapidly changing during this era and everything I am going to say could change overnight or next week. This is a critical question.
Everyone should follow the Centers for Disease Control and Prevention1 (or World Health Organization [WHO]) recommendations, though the American Academy of Dermatology (AAD) has been doing a good job of trying to keep accurate, updated information for members.2
Notably, on March 18th, Centers for Medicare & Medicaid Services (CMS) announced that all elective surgeries and nonessential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak. It would be reasonable for dermatologists to consider this in their plans. Specific hospitals and health systems have additional local, city, and state guidelines that readers could and should refer to—some states are imposing significant changes to guidelines, and readers should be familiar with their own local rules and regulations too.
Dr Warren Heymann’s Dermatology World Insights and Inquiries articles have covered this nicely as well.3-5
In general, everyone should keep in mind that the goal is to keep people away from people due to:
- Individuals can be asymptomatic and shed or transmit the illness;
- The US is not screening or testing enough people, so people with COVID-19 do not know they have it; and
- There is exponential, community growth – right now, right here (wherever you are).
The US is matching the trajectory of Italy, where the medical system was overwhelmed, and we are lagging their numbers by about 7 to 10 days. In New York City, as I write this, our medical systems are experiencing this in real time. This is true in Louisiana, Illinois, and Georgia as well, and rapidly developing across the country.
Dermatologists should try to reduce the spread of this deadly virus as much as they can, while still providing care for patients with urgent and emergent skin diseases. One widely circulated article recently includes recently released recommendations by the Partners system (Harvard’s healthcare system) following some of the guidance suggested by Atul Gawande, MD, in his recent New Yorker article.6,7
The Dermatologist: What is the role of the dermatology during this pandemic?
Dr Rosenbach: Dermatologists should continue caring for their patients, while keeping in mind the challenges that the rest of the health system is facing. It’s critically important that the emergency department (ED) be offloaded as much as possible. For instance, in some places a patient who calls at 6 pm on a Friday with a possible abscess in the past may have been told to go to the ED, but it may be more appropriate to manage this using telemedicine during this period, if safe to do so and medically possible. Patients with COVID-19 may have a nonspecific rash (a new paper came out today in the Journal of the European Academy of Dermatology and Venereology,8 though initial reports from Wuhan, China, suggested the rate of exanthem was quite low9), though this seems to occur late (it would be a different story if there were specific, diagnostic skin findings early in the disease, during the asymptomatic spreading period). (Editor’s note: additional studies have noted cutaneous manifestations of disease since this interview was conducted.10,11) Patients with COVID-19 who are hospitalized or in the intensive care unit (ICU) may develop secondary skin issues as well, and dermatologists may be required to help comanage those issues.
Also, dermatologists should familiarize themselves with the current information about COVID-19 and how it can impact their practices, and what they can do to limit the spread (including telehealth, caring for patients remotely, limiting family members or visitors, de-crowding waiting rooms and ensuring adequate physical distancing, et cetera). It is important that dermatologists are aware of a national shortage of personal protective equipment (PPE) and use gear appropriately, following guidelines, and ensure that frontline providers in sites such as the ED and ICU aren’t forced to use suboptimal gear if at all possible.
It is important that we keep caring for patients with skin diseases and do what we can to keep them out of the soon-to-be-overwhelmed EDs and primary care practices. As many dermatologists transition to telederm and telehealth, it may create opportunities to reach out to local primary care doctors to try to assist in remotely caring for their patients with dermatologic diseases, for instance.
The Dermatologist: Many patients on are immunosuppressants or have immune-comprising conditions. Are you making any specific recommendations for these patients and their caregivers, such as continuing biologic therapy?
Dr Rosenbach: The AAD has tried to develop some general guidelines for patients,12 as have specific patient organizations (such as the National Psoriasis Foundation13). In general, this is a very individual decision, based on the patients’ disease, comorbidities, job, exposure risk, and time on therapy. The Medical Dermatology Society and Society of Dermatology Hospitalists have also begun developing some guidelines for the types of patients that their members care for, generally patients with multiorgan disease, skin signs of systemic disease, or patients who routinely require immunosuppressant medications.14,15
COVID-19 is a new risk factor and should enter into these discussions, but it is very challenging to develop one broad statement that both provides accurate guidance to clinicians, protects patient health, and doesn’t lead to areas of potential uncertainty or even medical-legal exposure. The uncertainty in the US is even higher at the moment due to inadequate testing (diagnostic tests of suspected cases) and screening (testing of the population as a whole for asymptomatic cases, who can still be infected and transmitting disease). It is also important to remember that what we don’t want though is patients who are stable, en masse stopping effective therapies, flaring, and requiring urgent in-person evaluations during this period.
The Dermatologist: Hydroxychloroquine was investigated in one small study but has been suggested as a potential therapy for COVID-19 by the president and some consumer media outlets. Could you comment on this?
Dr Rosenbach: Dermatologists, like all doctors, are trained to practice evidence-based medicine. COVID-19 is an exponentially spreading pathogen and reports are sprouting up, at nearly the same rate, regarding potential treatments. I would urge dermatologists to listen to the words of Anthony Fauci, MD, and other medical experts, regarding the need for evidence-based medicine to help guide decisions.
While there was an early report that got some press and was amplified by some notable social media accounts, further studies have been less dramatic, and the initial small study has some notable flaws. Additionally, hydroxychloroquine is a necessary therapy for some of our patients and during this period it would be a shame if patients with lupus, sarcoidosis, or dermatomyostitis who were stable on antimalarials could not get that drug, flared, and required in-person evaluation, ED visits, or stronger, more immunosuppressive agents to control their disease.
The Dermatologist: Are there any other important considerations dermatologists should keep in mind?
Dr Rosenbach: COVID-19 is the single greatest health threat we have ever faced. Everyone should be pushing for maximal support for the health care system—hospitals, small groups, private practices, primary care providers, ancillary support staff, et cetera. There are health challenges with this virus, the most pressing being lack of sufficient PPE and impending lack of beds/ICUs and staff to care for these patients. These are coupled with financial challenges that many readers will be grappling with, but the focus now needs to be on flattening the curve of cases, and increasing healthcare capacity to manage patients who need support.
There needs to be a unified push from the country’s leaders to ensure physicians, nurses, respiratory therapists, and emergency medical technicians have the gear they need, support they need, and places they need to care for patients with COVID-19. Dermatologists who are currently unsure of how to directly help could consider advocating on behalf of these folks, and the field of medicine as a whole–including dermatology–to have the support we all need, now, to care for the coming surge of patients.
Reach out to your friends, family, and even patients, and advise them of the urgent need for strict physical distancing/social distancing to reduce the rates of transmission and slow the spread of this pathogen.
1. Centers for Disease Control and Prevention. Coronavirus (COVID-19). April 9, 2020. Accessed April 9, 2020. https://www.cdc.gov/coronavirus/2019-ncov/index.html
2. American Academy of Dermatology. Coronavirus resource center. Accessed April 9, 2020. https://www.aad.org/member/practice/coronavirus
3. Heymann WR. The profound dermatological manifestations of COVID-19. Dermatology World Insights and Inquiries. March 18, 2020. Accessed April 9, 2020. https://www.aad.org/dw/dw-insights-and-inquiries/2020-archive/march/dermatological-manifestations-covid-19
4. Heymann WR. The profound dermatological manifestations of COVID-19: part II. Dermatology World Insights and Inquiries. March 25, 2020. Accessed April 9, 2020. https://www.aad.org/dw/dw-insights-and-inquiries/2020-archive/march/dermatological-manifestations-covid-19-part-2
5. Heymann WR. The profound dermatological manifestations of COVID-19: part III. Dermatology World Insights and Inquiries. April 8, 2020. Accessed April 9, 2020. https://www.aad.org/dw/dw-insights-and-inquiries/2020-archive/april/dermatological-manifestations-covid-19-part-3
6. Coronavirus Resource Center. Harvard Medical School. Updated April 9, 2020. Accessed April 9, 2020. https://www.health.harvard.edu/diseases-and-conditions/coronavirus-resource-center
7. Gawande A. Keeping the coronavirus from infecting health-care workers. The New Yorker. March 21, 2020. Accessed April 9, 2020. https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers
8. Recalcati R. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. Published online March 26, 2020. doi:10.1111/jdv.16387
9. Hoel S, Rabenau H, Berger, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China. N Engl J Med. Published online February 18, 2020. doi:10.1056/NEJMc2001899
10. Lu S, Lin J, Zhang Z, et al. Alert for non-respiratory symptoms of coronavirus disease 2019 (COVID-19) patients in epidemic period: a case report of familial cluster with three asymptomatic COVID-19 patients. J Med Virol. Published online March 19, 2020. doi:10.1002/jmv.25776
11. Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for Dengue. J Am Acad Dermatol. Published online March 22, 2020. doi:10.1016/j.jaad.2020.03.036
12. American Academy of Dermatology. Guidance on the use of biologic agents during COVID-19 outbreak. March 18, 2020. Accessed April 9, 2020. https://assets.ctfassets.net/1ny4yoiyrqia/PicgNuD0IpYd9MSOwab47/07b614658aff5fc6ccc4c0bd910509a3/Biologics_and_COVID_19_FINAL_V2.pdf
13. National Psoriasis Foundation. Coronavirus concerns?: NPF Medical Board COVID-19 recommendations for patients with psoriatic disease. March 20, 2020. Accessed April 9, 2020. https://www.psoriasis.org/advance/coronavirus
14. COVID-19 medical and inpatient dermatology responses for patients. Medical Dermatology Society. Accessed April 9, 2020. https://www.meddermsociety.org/covid-19-medical-inpatient-dermatology-responses-patients/
15. Homepage for the Society of Dermatology Hospitalists. Society of Dermatology Hospitalists. Accessed April 9, 2020. https://societydermatologyhospitalists.com/