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Indian Journal of Dermatology
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Table of Contents 
IJD® SYMPOSIUM
Year : 2021  |  Volume : 66  |  Issue : 3  |  Page : 246-255
Clinical dermatology and COVID-19 pandemic: Narrative review


1 From the Departments of Dermatology, Mater Dei Hospital, Msida, Malta
2 Command Hospital (Eastern Command), India
3 College of Medicine and Sagore Dutta Hospital, India
4 Portsmouth Hospitals University NHS Trust, UK
5 KPC Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication13-Jul-2021

Correspondence Address:
Anupam Das
Department of Dermatology, KPC Medical College and Hospital, 1F, Raja Subodh Chandra Mallick Rd, Jadavpur, Kolkata - 700 032, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_463_21

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   Abstract 


The coronavirus disease of 2019 (COVID-19) pandemic has radical repercussions on every aspect of medical science, including dermatology. The magnitude of the impact on clinical dermatology cannot be overemphasized. Dermatologists have been forced to modify and reconsider the way they consult patients. Teledermatology has come up in a big way, with most of the clinicians resorting to technology and software-based consultations. Management of different dermatological conditions like papulosquamous disorders, vesiculobullous disorders, malignancies, etc., needs to be modified as per the different recommendations proposed by expert panels. This review is an attempt to highlight the impact of this destructive pandemic on various aspects of clinical dermatology.


Keywords: Clinical dermatology, COVID-19, teledermatology


How to cite this article:
Mintoff D, Chatterjee M, Podder I, Shipman A, Das A. Clinical dermatology and COVID-19 pandemic: Narrative review. Indian J Dermatol 2021;66:246-55

How to cite this URL:
Mintoff D, Chatterjee M, Podder I, Shipman A, Das A. Clinical dermatology and COVID-19 pandemic: Narrative review. Indian J Dermatol [serial online] 2021 [cited 2021 Aug 2];66:246-55. Available from: https://www.e-ijd.org/text.asp?2021/66/3/246/321319





   Introduction Top


The COVID-19 pandemic has greatly affected the healthcare sector across the board, including dermatology.[1],[2] Patients, as well as their caring physicians, had to rapidly adapt to a changing delivery of service. This article focuses on the impact that the COVID-19 pandemic exerted on various aspects of clinical dermatology by reviewing the extant literature.


   Methods Top


We conducted a thorough literature search across multiple databases such as 'PubMed', 'Embase', 'Medline' and 'Google scholar', using the keywords and Medical subject headings (MeSH) terms “COVID-19” OR “Coronavirus disease” OR “COVID pandemic” AND “clinical dermatology” OR “dermatology practice” OR “teledermatology” OR “dermatology” OR “Atopic Dermatitis” OR “Eczema”; OR “Psoriasis” OR “Hidradenitis” OR “Melanoma” OR “Basal Cell Carcinoma” OR “Squamous Cell Carcinoma” OR “Lupus” OR “Alopecia” OR “Biologics” OR “Vaccines.” All the obtained articles were scanned for relevance and their references were further studied to obtain new articles. The information retrieved from all relevant articles was reviewed and analyzed to prepare the current narrative review.


   Discussion Top


The risk of transmission of the coronavirus during clinical practice, especially due to lax personal protective measures, is a concern. Dermatology work, however, continued, with the usual referrals, e.g., emergencies and skin cancer plus additional skin eruptions due to hand washing and protective measures such as protected wearing of masks, goggles, and other personal protective equipment (PPE). Dermatologists, therefore, had to adapt to deliver their services safely and information on these changes follows below along with data about the impact the pandemic has had on service provision.

Impact on clinical practice during the pandemic

Measures to mitigate the risk of transmission during practice.

The main mode of viral transmission is through droplet spread, which is released by infected individuals during coughing, sneezing, or talking. Several professional dermatological bodies have made a recommendation for safe practice including[3],[4]:

Measures in the waiting area

  1. Encouraging a strict 'no-touch' policy wherever possible.
  2. Avoiding patient grouping by issuing timed appointments.
  3. Restricting relatives or friends accompanying the patients (except for minors).
  4. Providing spacious (1.5–2 m between seats) and well-ventilated (natural ventilation) waiting areas.
  5. Alcohol-based hand sanitizers are to be kept in the waiting room and their use to be encouraged.
  6. Surfaces, e.g., tabletops, door, and window knobs regularly sanitized throughout the day. Ultraviolet germicidal irradiation and air purifiers may be installed, if feasible.
  7. Staff and patients should wear masks at work. N95 masks are preferred, however, triple-layer surgical masks are an acceptable alternative. The use of gloves and face shields is to be encouraged.[5] The use of double masks is encouraged for enhanced protection.
  8. Prior to admittance, patients should be screened for symptoms of COVID-19 (e.g., fever, cough, respiratory distress) using preformed questionnaires and non-contact infrared thermometers. Patients with symptoms suspicious for COVID-19 infection should be referred for urgent swabbing, and quarantine until their result is issued. A follow-up appointment should be arranged accordingly.
  9. Online or card payment should be favored over payment with physical currency.


Additional measures in the consultation room

  1. Dermatologists should wear an N95 mask, face shield, goggles, and disposable gloves at all times. Preferably, patients are to be consulted from a distance (of at least 1.5 m). If needed, physical examination is to be carried out while maintaining all safety precautions or behind screens.[6],[7]
  2. A plastic or glass sheet may be installed between the patient and dermatologist as a physical barrier to prevent droplet spread.
  3. Staff should disinfect tabletops, sitting areas, and dermoscopes after every consultation. Some disinfectants which have been approved for use against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include 70% ethyl alcohol, isopropyl alcohol, sodium hypochlorite solution 0.5–1% (5,000 ppm to disinfect surfaces), hydrogen peroxide, quaternary ammonium, citric acid, chlorine dioxide, peroxyacetic acid, quaternary ammonium compounds, and glutaraldehyde.[8]


Additional measures in the procedure room

  1. Elective procedures should be deferred unless absolutely necessary.
  2. The dermatologist and ancillary staff should wear PPE to reduce the risk of transmission. Unless contraindicated, masks should be used to cover the nose and mouth of patients, along with disposable caps and shoes. If the mask has to be removed, the patient should have a COVID polymerase chain reaction (PCR) swab before the procedure and be told to self-isolate until the procedure. However, in the UK, the authors did not use PPEs on a regular basis while performing dermatologic surgeries (these procedures were considered non-aerosol-generating in the UK).
  3. Dermatologists should wash their hands rigorously with soap and water for at least 20 s before and after every procedure.
  4. The staff inside the procedure room should be limited to a dermatologist, the patient, and a technician.
  5. Additional precautions may need to be implemented, as necessary. Such measures include the installation of smoke evacuators, optimized ventilation, and the installation of air purifiers equipped with HEPA (high-efficiency particulate air) filters.


Measures concerning phototherapy units

Phototherapy may be considered in patients who have absolute indications for the same. Previously, fomite transmission was considered to be significant in cases of COVID-19 infection. However, based on available epidemiological data and studies of environmental transmission factors, it has been noted that surface transmission is not the main route by which SARS-CoV-2 spreads, and the risk is considered to be low.[9] Therefore, there is no significantly increased risk of acquiring infection from phototherapy units, if proper sanitization and disinfection protocols are followed.

Changing trends of dermatology practice

As with other medical specialties, the COVID-19 pandemic has also changed the recent trends of dermatology practice.[10] Some of the important changes are mentioned below:

  1. Indoor hospital admissions for chronic dermatoses like psoriasis and immunobullous disorders have decreased significantly compared to the pre-COVID times. However, referrals have been received due to skin eruptions in the COVID-19 suspected/positive patients.
  2. According to a recent study the incidence of contact dermatitis (hands—excess use of sanitizers,[11] retroauricular area—mask loops),[12] acne associated with dermatitis in the mask-covered area, alopecia, lichen planus, and herpes zoster have increased (non-COVID-related skin lesions). Several other authors have also reported mask-induced flaring of acne, suggesting a new nomenclature —'mask acne.'[13] Indoor restriction and less photo-exposure due to lockdowns and a replenished ozone layer due to reduced pollution during this pandemic have been proposed to be a possible factor for reduced incidence of malignant melanoma, however, there are concerns that, in fact, the incidence rate has not dropped, and instead, we have missed cases and skin cancer clinics need to continue as normal.[14]
  3. Dermatophytosis, a condition which had already acquired an epidemic-like scenario prior to the COVID-19 pandemic, is being increasingly encountered, with a distinct presentation on the facial area covered by masks. Authors have proposed the term “mask tinea” for the same.[15]
  4. The rates of elective dermatological procedures including skin biopsy have reduced considerably in view of the possible safety concerns. The use of disposables and absorbable sutures, wherever possible, maybe preferred but cutaneous inflammatory reactions are seen more frequently as a consequence.[16]
  5. Increased frequency of virtual consultations, i.e., teledermatology practice and non-invasive investigative modalities, e.g., dermoscopy.
  6. Conferences, courses, and teaching have been canceled, impairing dermatology training.[17]


Changing trends in investigational dermatology

Most of the hospitals have suspended patch testing (PE); however virtual reading of patch tests is being encouraged. Spanish Research Group on Contact Dermatitis and Skin Allergy (GEIDAC) of the Academia Espanola De Dermatologia Y Venereologia (AEDV), has proposed certain recommendations regarding PE during the COVID-19 pandemic[18]:

  • PE must be scheduled in a well-planned manner in order to avoid crowding in the waiting room (1 patient/h: 5–6 patients/week)
  • PE must be prioritized in conditions like occupational eczema, severe eczema, eczema of facial, hand, or generalized location unresponsive to conventional therapy, acute recurrent eczema of unknown etiology, patients with significant deterioration of quality of life, and those planned to undergo any intervention where the results of PE hold paramount importance like administration of a new drug, medical devices, glucose sensors/insulin pumps, dental, trauma, etc.
  • PE must be postponed in high-risk cases like geriatric patients, those with comorbid pathologies at risk for COVID: cardiovascular disease, diabetes, hypertension, obesity, chronic respiratory disease, liver disease, neoplasms, or immunosuppression.
  • The first reading may be carried out immediately after the removal of the patches and physical visits should be minimized as much as possible.


Dermoscopy is necessary for diagnosis in dermatology. However, the dermoscope itself can act as a possible source of nosocomial spread of infections and may also act as a potential source of SARS-CoV-2. Some of the recommendations proposed by the Special Interest Group (SIG) Dermoscopy- IADVL Academy are[19]:

  • The Dermoscope should be wiped with 70% isopropyl alcohol wipes for at least 1 min prior to using the instrument at every instance after use.
  • The patient should wear a facemask and wash their hands.
  • Use of possible disposable dermoscopic lens covers, plastic bottle cap, polyvinyl chloride food wrap between the lens and the lesion, transparent adhesive tape, polyethylene tube for mucoscopy or car phone holder for oculoscopy.
  • Noncontact dermoscopy and video dermoscopy are preferred.
  • Digital dermoscopy reports should be encouraged.


Teledermatology practice during COVID-19 pandemic

Dermatology is suitable for telemedicine as many of its disorders can be diagnosed by a good-quality image along with appropriate history. Telemedicine (teledermatology) involves two major technologies (i) 'Store-and-forward' (SAF) technology—clinical images and associated information are forwarded to a specialist at a suitable time (asynchronous) and (ii) real-time video conferencing (synchronous) with the dermatologist.[20] The common platforms being used for this purpose include WhatsApp, Facebook Messenger, Skype, email, and proprietary teledermatology consultation software.[21]

Remote working, i.e., teledermatology practices prevent the viral spread and suit lockdown messages, quarantines, and suspension of transportation networks.[22]

A recent German survey has reported that almost 40% of the dermatologists are now offering teledermatology service during this pandemic. This rate is more than double (>85%) in countries like the USA and India and 100% in the UK (with already running national systems and one health service for the entire Union). Almost 30% of the dermatologists are using it for the first time and this facility is mostly restricted to big cities.

Most of the studies have recorded a high degree of successful treatment by teledermatology, ranging from 70 to 94%. Overall, most patients were satisfied with their outcome and relieved as it reduced physical visits to the dermatologist.[23]

However, unrestricted use of teledermatology (medicine) may result in faulty diagnoses and unnecessary therapy in many patients, especially in unregulated medical scenarios like India. So, the Bombay High Court had passed legislation in 2018, to consider all prescriptions without diagnosis and consultation, and treatment on online platforms without physical examination of patients as illegal.[24] However, in view of the recent pandemic situation, the MCI (Medical Council of India) has laid down certain regulations[25] in March, 2020—A registered medical practitioner (RMP) can prescribe treatment via online platforms as a first consultation or as a follow-up; consent is implied when the patient initiates a consultation. The patients may be asked for a physical visit at any point in time and they may be charged at a reasonable rate. All medical ethics apply during online consultation, and prescription of category X drugs should be restricted. Another limitation of teledermatology is its restriction to bigger cities including metros, and lack of a uniform platform. So, more investments are needed in this field to make teledermatology more popular and accessible to all to reap its benefits in the long run. An important aspect of teledermatology, which should be kept in mind, is its limitation of two-dimensional visualization of a lesion that is three-dimensional in its morphology. Hence, even in the most ideal of situations, the possibility of errors are much higher in a teleconsultation as compared to a physical consultation.

Management considerations

The ever-changing landscape of dermatological therapy, which has recently gravitated toward a patient-centric, targeted approach has been extensively and rapidly adapted to the circumstances brought about by the global COVID-19 pandemic. All branches of dermatological disease, including inflammatory, immunobullous, and malignant diseases have been affected by global circumstances. Guidelines have been issued through various task forces and expert statements as well as anecdotal evidence by reporting observations in single cases as well as case series.

Atopic dermatitis

The rate of COVID-19 positivity and hospitalization in patients suffering from atopic dermatitis (AD) appears to be comparable, or even lower, than that of patients without AD.[26],[27] This is also true in patients receiving systemic immunosuppressants like prednisolone, methotrexate, and/or dupilumab.[26],[28],[29] The European Task Force on Atopic Dermatitis and the European Academy of Allergy and Clinical Immunology recommend that AD patients should have all of their immunosuppressive therapy continued during the pandemic.[30],[31] Clinicians should only consider pausing or delaying such treatment in SARS-CoV-2-infected individuals after interdisciplinary risk assessment[31]. The practice in Asia follows European recommendations in that topical and/or oral immunosuppressors/immunomodulators should not be omitted or their initiation postponed.[32] Education and allaying of fears through teledermatology can curb patient-driven discontinuation of immunomodulatory agents for the treatment of AD.[33] In the UK, all dermatology patients who were only on one immunosuppressant medication were not told to self-isolate and just continue with the same public health advice as the rest of the population. To be precise, dupilumab (good but esoteric), retinoids, low dose steroids (20 mg of prednisolone for less than 2 weeks and 10 mg for maintenance) may be given, and there is no need to change the ongoing therapy in the background of COVID-19.

Psoriasis

When compared to the general population, psoriasis patients (regardless of a treatment regimen) do not demonstrate an increased risk of infectivity[34],[35] or succumbing[35] to COVID 19. This includes patients receiving biological therapy.[36],[38],[39] Case reports have documented de novo generalized pustular psoriasis[40] as well as localized forms of pustular psoriasis progressing into generalized forms in the setting of COVID-19 infection.[41] Infections have also been associated with flares of psoriatic arthritis and enthesis.[42] Such findings have also been extrapolated in pediatric patients suffering from psoriasis who experienced disease flares during a mandatory lockdown and had their medication stopped for COVID-related reasons.[43] Despite these associations, as well as the excellent safety profile of biological agents in psoriasis patients infected with COVID-19,[44],[45],[46],[47],[48],[49],[50],[51] the rate of biological initiation for psoriasis has decreased during the pandemic.[52] This, as well as flares in disease, may be explained by diminished access to tertiary dermatology centers responsible for the initiation of biological agents[53] as well as patients fearing the initiation or continuation of immunosuppressive agents.[54] Evidence suggests that treatment of psoriasis with biological drugs should not be interrupted[55] even in areas where the pandemic is rife.[56] In fact, results from a global-registry-based study suggest that patients on biologic agents do comparatively better than patients on other systemic therapies, having a lower risk of being hospitalized from COVID-19-related complications.[57] The American National Psoriasis Foundation COVID-19 Task Force advises reinitiating any psoriatic treatment stopped during the treatment of COVID-19.[58] In the UK, in case of positivity, it has been suggested to keep a cautionary behavior and to postpone the initiation of biological therapy after the acute phase has disappeared and testing for SARS‐CoV‐2 has been repeatedly negative.[59]

The management of moderately severe psoriasis was also impacted by the suspension of service of various phototherapy units.[60] The photobiology group of the Spanish Academy of Dermatology and Venereology developed specific guidance for the safe administration of ultraviolet.[60] These guidelines are encapsulated by a “4;3Ts” approach outlined by an Italian focus group, namely Telemedicine, Triage and Treatment.[61]

With regards to COVID-19-related therapies, anecdotal evidence suggests that hydroxychloroquine (which was proposed as a therapeutic agent for COVID-19, but later shown to be associated with increased mortality in COVID-19 patients)[62] may also exacerbate psoriasis.[63]

According to the recommendations proposed by SIG Psoriasis (IADVL Academy), psoriasis patients diagnosed with COVID-19 disease should not be treated with methotrexate, azathioprine, and cyclosporine. However, retinoids and apremilast can be continued along with topical therapy. Cyclosporine should be carefully initiated in psoriasis patients from areas with high COVID-19 prevalence and the drug must be withheld in the event of exposure to a confirmed COVID-19 patient. Biologics should be discontinued, however, in severe cases of psoriasis, the final call needs to be taken on a patient-to-patient basis.[64] Moreover, drugs like cyclophosphamide, leflunomide, and mycophenolate mofetil belong to high-risk category and should be avoided. Besides, multiple immunomodulators at the same time should be avoided in the elderly, in those with comorbidities, and those with recurrent respiratory tract infections.

It should be remembered that, although median COVID-19 infection duration is in the order of 2 weeks, it would be sensible to discontinue systemic immunomodulators for at least 4 weeks, and until the patient has completely recovered.[65]

Cutaneous Lupus Erythematosus

Literature suggests that patients with cutaneous lupus living in high-risk, COVID-19 areas are more susceptible than the general public to become infected. The use of systemic agents for the treatment of cutaneous lupus, especially hydroxychloroquine—which had been given emergency approval for COVID-19[66] but later found to be associated with increased mortality—appears to unalter COVID-19 outcomes in infected patients.[67] Interestingly, patients pre-exposed to hydroxychloroquine were not found to have a survival outcome advantage when compared to patients without exposure[68]—casting further doubt on the use of the drug as a prophylactic or therapeutic agent for COVID-19 infection. Nevertheless, patients suffering from lupus have, however, experienced problems with accessing treatment especially during the first wave of the pandemic[69] because of hoarding and diversion of resources.[70] This translated not only to flares in the disease,[71] but also to significant patient anxiety—which was carried to the second wave of the pandemic when drug hoarding had greatly subsided.[72] Healthcare professionals should advocate for patients with cutaneous lupus to have their prescriptions for hydroxychloroquine filled.[73] This issue has highlighted the ethical implications of prescribing and dispensing in the setting of a global pandemic.[74]

Hidradenitis suppurativa

Despite the fact that hidradenitis suppurativa (HS) is a disease associated with poor COVID-19 prognosticators such as obesity[75] and other metabolic comorbidities, patients are, at face value, not at an increased risk of infectivity or mortality from COVID-19.[76] Neither are the outcomes or risk of COVID-19 infection increased in HS patients treated with Tumor necrosis factor-a inhibitors.[77],[78],[80] Such observations were made despite the fact that the PIONEER I and II studies highlighted a slightly increased risk for upper respiratory tract infections and nasopharyngitis in HS patients treated with adalimumab versus the placebo group.[81] While HS patients are weary of immunomodulation in the setting of a global pandemic, it appears that they are comfortable with continuing the medication to maintain disease control.[82] A global HS COVID-19 registry to “inform data driving management practices” has been set up to help guide the changing treatment landscape using real-world data.[83] Based on these findings, it is recommended that immunomodulatory medications are not abruptly stopped in patients suffering from this burdensome disease.[84],[85]

Autoimmune blistering diseases

Despite having comparable rates of COVID-19 infectivity and hospitalization, patients with bullous pemphigoid and pemphigus experience higher rates of COVID-19-associated mortality, but the risk of infectivity and COVID-19-associated hospitalization are comparable to controls. Notwithstanding, patients treated with systemic agents such as corticosteroids and adjuvant immunosuppressants during the COVID-19 pandemic are not associated with a worse outcome. Patients suffering from autoimmune blistering diseases, including those living in areas of high infectivity, feel safe continuing systemic medication.[86] An expert panel consensus statement recommends the continued use of oral immunosuppressant therapy but advises against the use of maintenance doses of rituximab to sustain disease remission.[87] In patients with newly diagnosed bullous pemphigoid, the use of topical super potent corticosteroids together with tetracycline antibiotics, upgraded to a low dose of immunosuppressive agents and intravenous immunoglobulins (IVIgs) may mitigate the risks in the pandemic.[88] Anecdotal evidence supports the use of IVIgs as part of the treatment repertoire for patients with comorbid mucous membrane pemphigoid and COVID-19 infection.[89] A case report also documents the uncomplicated recovery of a COVID-19-infected patient with pemphigus vulgaris who had received a top-up dose of rituximab to control disease flare shortly before infection.[90] Because of associated prothrombotic risk, patients suffering from comorbid autoimmune blistering disorders and COVID-19 may benefit from low-dose aspirin to reduce morbidity and mortality rates.[91] Patients on recurrent rituximab dosing may benefit from immunoglobulin level testing. If hypogammaglobulinemia exists, a physician should consider altering or delaying the dose or initiating IVIG therapy, or both.

Melanoma skin cancer

Patients suffering from melanoma have experienced particularly turbulent times which has negatively impacted their quality of life.[92] Significant changes in melanoma practices during the COVID-19 pandemic have led to a diagnostic delay translating to thicker tumors at presentation.[93],[94] Oncologists, including those in areas which are heavily burdened by COVID-19, have successfully managed to maintain the high-level standard of skin cancer care with immunotherapeutic agents.[95] Evidence shows that programmed cell death protein 1 (anti-PD 1) or cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4) immunotherapy may even protect cancer patients from COVID-19 infection.[96],[97] The rate of immune checkpoint inhibitor-associated adverse has not been shown to be increased in COVID-19-infected patients. On the other hand, the mortality rate as a repercussion of COVID-19 infection in this cohort of cancer patients appears to be increased.[98] Recent guidance from the European Academy of Dermatology and Venereology (EADV) task force on melanoma recommends complete excision biopsy of lesions suspicious for melanoma, with therapeutic lymph node dissection offered only to patients who have clinically identifiable regional lymph node metastasis.[99] This guidance is shared by the British consensus guidelines, which also make recommendations on radiotherapy and routine imaging.[100] It is recommended that, when indicated, excision of the primary tumor should be followed by the prompt (12-week window) initiation of adjuvant melanoma therapy. Immunotherapy should be continued in a patient suffering from locally advanced or metastatic melanoma.

One should also call attention to the importance of continued melanoma screening.[101] Screening campaigns can be adapted to the current global circumstances by focusing on the use of patient information leaflets, news outlets, and social media.[102]

Basal cell carcinoma

Some centers have reported a paradoxical increase in the number in the excision of basal cell carcinoma (BCC) and squamous cell carcinomas (SCC) during the first year of the COVID-19 pandemic.[103] The slow-evolving nature of BCC is very favorable in the context of delayed patient presentation. This substantiated the recommendation that low-grade BCC could have treatment postponed for 4 weeks.[104] Notwithstanding, some patients with advanced or multiple BCCs require treatment with hedgehog pathways inhibitors such as vismodegib and sonidegib. These agents should not be prophylactically discontinued for patients with advanced BCC in the COVID-19 setting.[105] Patients with high-risk BCCs should undergo imminent, complete surgical excision of their tumor.

Squamous cell carcinoma

SCCs are the second commonest cutaneous tumors. Timely diagnosis and excision of SCC are paramount to prevent metastatic spread. Lockdown practices in Spain have however not translated into a considerable increase in advanced SCC.[106] This conflicts with the more recent data which suggest that dermatology practice faces an accumulated cohort of undiagnosed patients. With regards to management, patients presenting with SCC in situ can have their treatment postponed for up to 4 weeks, while those with high-risk tumors should undergo prompt surgical excision of their tumor.[107] The treatment of patients with locally advanced or metastatic disease is more challenging. Recent breakthroughs in the treatment of metastatic SCC, specifically the use of PD-1 inhibitor pembrolizumab, have significantly improved survival outcomes.[108] For this reason, in patients with locally advanced or metastatic squamous cell cancer, treatment with immunotherapeutic agents should not be deferred.

Alopecia

Evidence suggests that the use of immunosuppressant agents (including traditional immunosuppressants and novel agents such as janus kinase (JAK) inhibitors) are safe to use for the treatment of alopecia in the setting of the global pandemic.[109] There is an increased risk of venous thromboembolism that may compound with COVID-19 infection, and therefore, the use of JAK Janus kinases (JAK), signal transducer and activator of transcription proteins (STAT) [JAK STAT] inhibitors should be done carefully. However, baricitinib and ruxolitinib do have antiviral activity via inhibition of receptor-mediated endocytosis of SARS-CoV-2 viral particles.

The prolonged use of hydroxychloroquine in patients with frontal fibrosing alopecia and lichen planopilaris has not been associated with improved COVID-19 outcomes.[109]

COVID vaccines in the background of immunotherapies[110],[111],[112]

A majority of the non-live vaccines are safe in dermatology patients receiving non-biologic systemic immunosuppressive drugs. However, patients on systemic immunosuppressives like azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or JAK inhibitors may have a reduction in the production of antibodies. Presently, when the symposium is being planned, COVISHIELD and COVAXIN are being administered to masses (both of which are non-live vaccines). The recommendations mentioned below have been derived after reviewing the existing guidelines of other non-live vaccines.

There is no need to alter the vaccination schedule in patients using systemic corticosteroids in a dose of prednisone equivalent <20 mg/day and anti-IgE biologics like omalizumab. Biologics like infliximab, adalimumab, etanercept, and secukinumab may be withheld 1 week prior to and 1 week after the first COVID-19 vaccine dose, and no interruption is required around the second dose of vaccination. However, patients on rituximab need to be dealt with carefully because rituximab may impair the formation of protective antibodies following vaccination. It is better to initiate the series of vaccination 4–6 weeks prior to the next scheduled rituximab cycle; after vaccination, rituximab may be delayed for 2–4 weeks after the final vaccine dose.

For patients on methotrexate and cyclosporine, the drugs should be withheld for 1 week after each of the two vaccine doses; and 2 weeks after a single-dose COVID vaccination provided the disease is well-controlled. Alternatively, the lowest dose possible may be used, for example, 7.5 mg/week (methotrexate) and 2.5 mg/kg/day (cyclosporine). Mycophenolate mofetil should be withheld for 1 week following each dose of vaccination. Similarly, for tofacitinib, a treatment-free period of more than 2 weeks, before and after vaccination.


   Conclusion Top


The COVID-19 pandemic has changed the way we practice clinical dermatology. Clinical examination, diagnosis, and treatment strategies have gradually evolved over the past few years and adapted to the new normal. Since the after-effects of this pandemic are going to be prolonged, this article will serve as a handy reference for dermatologists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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