In this podcast, Ted Rosen, MD, reviews the diagnosis and management of sexually transmitted diseases for dermatologists, as well as how the pandemic has impacted patients with STDs.
Dr Rosen is a professor of dermatology at Baylor College of Medicine and Chief of Dermatology Service at Michael E. DeBakey Veterans Affairs Medical Center in Houston, TX.
Melissa: Hello, everyone. Welcome to another podcast with a dermatologist. Today, I’ll be speaking with Dr Ted Rosen about the diagnosis/management of sexually‑transmitted diseases during the COVID‑19 pandemic.
Dr Rosen is a professor of dermatology at Baylor College of Medicine in Houston Texas and Chief of Dermatology Service at Michael E. DeBakey Veterans Affairs Medical Center.
Thank you for joining us today, Dr Rosen.
Why is it important for a dermatologist to stay up to date on sexually‑transmitted diseases?
Dr Theodore Rosen: If you look at the history of dermatology, we have always been at the forefront, certainly involved if not at the forefront, of sexually‑transmitted diseases. Most of our early journals from the late 1800s all the way through 1955 all had the word either syphilology or venereology in them.
If you think about it for just a second, that makes perfect sense because most of the sexually‑transmitted diseases appear were on the skin. It happens to be genital skin, but it certainly, like secondary syphilis, can involve any portion of the cutaneous surface and the mucosal membranes which we often deal with, so for example, the lips and the tongue.
Other specialties are not I don’t think quite as attuned to sexually‑transmitted diseases. The urologists, the gynecologists are basically surgeons and are not terribly adept at recognizing the variations of STDs. It’s not really what they do. Infectious‑disease people are few and far between, and their main concern in this realm is HIV infection.
You think of the more common STDs like genital warts or genital herpes, and then the less common but as or more important things like syphilis, these are cutaneous diseases, so it’s very important for dermatologists to stay up to date in terms of diagnosis and therapy of sexually‑transmitted diseases.
Melissa: What important treatment considerations and counseling on prevention should dermatologists keep in mind?
Dr Rosen: I think a lot of the prevention counseling related to STDs often comes from other specialists unless we as dermatologists are directly asked. The most important thing of all is wherever there is a vaccination to encourage people to receive it.
There is a vaccination for HPV, genital warts. Coincidentally, it also protects against anogenital squamous cell carcinoma, cancer in that area. That’s a very important thing to recommend.
In general, dermatologists see everything from children through adolescence and certainly younger as well as older adults. The HPV vaccine, for example, is recommended between 9 and 45, which is the peak age that dermatologists see.
Other common‑sense prevention things can be reinforced, especially if someone has already been diagnosed with one STD. The basic common sense things would be, for example, watching the number of sexual partners one has and using appropriate barrier protection. That translates into condoms to help prevent STD acquisition or transmission.
As far as therapies go, those are very individualized depending upon the treatments, and diagnostic interventions or maneuvers are also a very individualized depending on the specific disease under consideration.
The best offense is a defense. Prevention, and there’s an old phrase that an ounce of prevention is worth a pound of cure. I think that’s from Benjamin Franklin, but it actually originated in the Middle Ages from Erasmus who talked about prevention is better than cure.
Melissa: What are some sexually‑transmitted diseases that dermatologists should keep in mind?
Dr Rosen: The most important one is syphilis. There’s an old phrase that William Osler, very celebrated physician, wrote that “He who knows syphilis knows medicine.”
It not only causes an ulcerative primary lesion but can cause all sorts of cutaneous lesions in its secondary phase including a rash that involves the palms, the soles, the trunk. It can include patchy, non‑scarring hair loss. It can include lesions on the face and the sometimes very specific‑looking lesions especially in the florid secondary syphilis.
Even late syphilis affects the skin causing destructive lesions. A wide spectrum of things that involve the cutaneous and mucosal surface can be involved in syphilis.
Of course, genital herpes is characterized by grouped, painful blisters on a red base, but again, there are variations of that. That’s particularly true in patients who are immunocompromised, or immunosuppressed, or co‑infected with untreated HIV. You can have persistent anogenital ulcerations that don’t look at all like typical herpes but are indeed a manifestation of genital herpes.
Genital warts look like warty lesions on the genitalia, but they need to be distinguished from condylomata lata which are lesions of secondary syphilis that may look very much like genital warts and occur in that area.
Who better than a dermatologist to distinguish between the two? That may even take a biopsy, and of course, dermatologists are very adept at doing a biopsy regardless of what portion of the anatomy the skin is being sampled from.
There are other uncommon sexually‑transmitted diseases, things like chancroid, lymphogranuloma venereum, and granuloma inguinale, also called donovanosis, which also all present on the cutaneous surface. This can be anything from a genital ulceration to a rapidly spreading, destructive, and genital ulceration.
Again, these are uncommon but can be diagnosed by appropriate cultures and biopsies which would be easily obtainable by a dermatologist.
Then there are very, very, very unusual sexually‑transmitted diseases that may cause somewhat atypical‑looking genital erosions or ulcerations, things like amebiasis, [inaudible 7:59] , which can actually be sexually transmitted not just from their usual route of transmission or acquisition. Again, this would be diagnosed properly best by biopsy, which dermatologists should be capable of doing.
Melissa: In the era of COVID‑19 pandemic, is there a concern for a possible increase or decline in STD prevalence or possibly undertreatment and screening because people can’t get the appropriate care?
Dr Rosen: In the COVID era, things have become very confused in the sexually‑transmitted disease world. There are good reasons, sound reasons, why sexually‑transmitted diseases should or could both increase and decrease.
Why might they decrease? Social isolation, wearing mask, closing of things where one might find a new, anonymous partner like bars certainly might be reasons for STDs to decrease. Also they might decrease because people have been out of work. When you’re out of work, you have lower self‑esteem. That might affect one’s ability or desire to have sexual relationships.
On the other hand, they might increase. Why might they increase? People have been at home a lot and what else is there to do after you’ve watched every single Lifetime movie there is? The more sexual activity, the more likely an STD is to be transmitted, especially if it’s one that typically is transmitted when the patient is asymptomatic, so they don’t know that they’re transmitting this disease.
Other reasons why STDs might go up, a lack of condoms. Several of the major manufacturers worldwide have had to close their plants because of COVID infection in the plant workers, and so there’s been a global shortage of condoms.
Lack of azithromycin, which is an antibiotic used to treat, along with ceftriaxone, certain STDs like gonorrhea. Azithromycin was at some point thought to be effective against COVID‑19, and so people started hoarding it, and then there was a shortage of supply.
There’s been a serious problem with obtaining STD screening, testing, and therapy, particularly at city, county STD clinics. A lot of these have closed or very slimly curtailed their hours of operation because they don’t have appropriate personal‑protective equipment, gowns, no, gloves, yes, masks, no.
Just the arrangement of the STD clinic, the physical layout, is usually maximized for the largest number of people in a small space, but we can’t do that because we’re supposed to be socially distancing.
Also the epidemiologists who worked in the public‑health arena, many of them, their work has been shunted towards case tracing of COVID‑19 cases and taken off of case tracing for STDs. There are good reasons why both STD incidence and rates might go up or might go down. We don’t really know for sure.
There are some statistics which are pretty interesting. If you look at 2014 through 2018, year‑over‑year, every STD was increasing rather dramatically. In 2019, the full statistics are not yet available. They usually are by now, but they’re not quite.
Again, the CDC has been more concerned with COVID. Preliminary statics indicate that during 2019 compared to 2018 all the STDs went up again, particularly gonorrhea, chlamydia, syphilis, and congenital syphilis.
For the first couple months of 2020, what data was available also shows that continuing trend of increasing numbers of STDs. Then suddenly in March, what data’s available from March until now in the fall actually showed rather dramatic decreases in STDs. In fact, syphilis decreased 33%, by a third.
The question is, is that a real decrease, or is that an artifact of the fact that data’s not being collected considering that about a quarter of the STD clinics in the US totally closed, about 60‑some percent of the STD clinics greatly curtailed their hours and their availability, and only about 8% of the STD clinics in the US continued to operate since March at full capacity and under normal circumstances.
Therefore, we don’t have the major data gathering places gathering data. That decrease, seeming decrease in STDs, might actually be totally bogus because patients aren’t coming in. They can’t come in to get themselves diagnosed and treated. It might just be a reflection of the fact that we’re not collecting appropriate data.
There’s an interesting paper from Italy where they looked at the major STD clinic in the hardest hit region of Italy, the hardest hit from COVID‑19. They actually stayed open. They said not only were STDs existent, they were the same or even higher depending on the disease compared to the pre‑COVID era.
In that paper, they have a quote which is very memorable. It said, “The option of not having sex is not an option.” Therefore, I think we’re going to find out that perhaps, “perhaps” STDs have actually silently increased during this COVID‑19 pandemic, but that is an educated guess. We really won’t know probably too well into 2021.
Melissa: You touched on this already, but how has this impacted the diagnosis/management of STDs?
Dr Rosen: The diagnosis and management of STDs was severely curtailed as STD clinics were closed or had their hours, manpower severely decreased or shunted into other activities related to COVID‑19, along with that, shortage of drugs, helped decrease of proper management of certain STDs. That’s a real problem.
From a public‑health perspective, also there have been campaigns in some states, New York being most notable, about don’t have sex because that means you’re in close proximity to another person. Obviously, the best way to catch COVID‑19, kissing and breathing on each other.
Those campaigns have been centered around things like pleasuring yourself, fostering things like masturbation, which might decrease STDs, but discouraging people from coming into STD clinics might be a problem with diagnosis and management.
COVID‑19 itself doesn’t seem to appear to change the response of this, of the various STDs to standard therapeutic interventions.
There was some concern that the COVID‑19 virus might act like HIV virus does and depress the person’s general immunity, therefore, allowing for really STDs to be worse than they would be or maybe less responsive to normal medication or other intervention. There doesn’t really seem to be much evidence in terms of that.
From a diagnosis and management standpoint, the virus itself, COVID‑19 virus itself, doesn’t seem to be a problem. It’s the way it’s disrupted, the way we normally diagnose and manage in all realms, even in the private sector.
For example in the dermatology world, if we were the ones that might be diagnosing and treating genital herpes or genital warts or recognizing, diagnosing, and either managing or sending to STD clinics syphilis, a lot of dermatology practices were closed. Then when they reopened, a very limited capacity because of the requirement to have the waiting room socially distanced and so forth.
If we made a diagnosis and it was something we had to refer to the public health clinic, that public health clinic might be closed. It’s the disruption of the normal pattern of diagnosis and management of STDs that COVID‑19 has been responsible for rather than the virus itself altering the diagnosis and management.
Melissa: What key takeaways would you like to leave with dermatologists?
Dr Rosen: For the dermatologist, the key takeaway should be that number one, we need to be involved in the STD arena. There’s an old phrase that was used during a kickoff of a he‑she, gender‑equality program, and it was if not us, who? If not now, when? That really applies to dermatology, dermatologists being knowledgeable about, able to diagnose, and able and willing to treat STDs. That’s number one.
Number two is STDs have not gone away. There might be some data to suggest that they’re less frequent, but I think that data is really false. It’s reflecting the lack of collection of proper data. You are still likely to see someone coming in to a dermatology practice with one of the common STDs and even the less common.
I have actually seen more cases of syphilis since March than I did in a comparable time period pre‑pandemic. Keep your eyes open and your cognitive faculties aware that STDs have not disappeared just because people are wearing masks and trying to stand six feet or more apart. Those are really the two key takeaways.
Melissa: Thank you for listening. If you have any questions or comments, please submit them in the feedback box below.