key: cord- -m asfqva authors: shah, monica; naik, haley b.; alhusayen, raed title: hidradenitis suppurativa: the importance of virtual outpatient care during covid- pandemic date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: m asfqva nan division of dermatology, department of medicine in addition to preventing the spread of infection, the role of the dermatologist is also to provide appropriate care to patients with skin disease to prevent complications, and to lower the burden on the consulted with ed physicians for hs symptoms (of which, % consulted with more than ed physicians), and % made or more trips to the ed in the pre-diagnosis stage. therefore, we strongly disagree with categorizing hs follow-up as "non-urgent/reschedule", as outlined by price et al. , as this approach would likely contribute to increased ed visits. studies have also demonstrated increased risk of antidepressant drug use (p < . ) and completed suicide (p = . ) in the hs population after adjusting for confounding factors. we caution against interruption in care for hs patients due to the potential for increased severity and/or frequency of suicidal behaviours, depression and anxiety, especially considering the additive stress and anxiety resulting from the current socially-isolating quarantine climate. in our complex medical dermatology practices, we have implemented a similar triage system to price et al. with categories: . in-person, . virtual/phone, . cancel/reschedule. we find that the follow- up of both hs and autoimmune bullous diseases through virtual visits is quite effective in a large proportion of patients, during which we utilize patient-reported outcomes such as pain scores, treatment satisfaction scores, and patient global assessments. virtual visits also allow us to counsel patients regarding maintenance regimens for the prevention of disease flares, hs action plans informing steps to take during hs exacerbations and when to contact a provider, and methods to improve overall mental health, including maintaining a healthy diet, utilizing warm compresses and engaging in support groups through the cspa. operations during covid- pandemic health care utilization patterns and costs for patients impact of sars on healthcare utilization by disease categories: implications for delivery of healthcare services. health policy increased suicide risk in patients with key: cord- -h kihj w authors: piccolo, vincenzo; bassi, andrea title: acral findings during the covid- outbreak: chilblain-like lesions should be preferred to acro-ischemic lesions date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: h kihj w nan we read with great interest the recent paper by fernandez-nieto et al published in jaad . the authors report a case series of patients with acute acro-ischemic lesions affecting nonhospitalized patients during the covid- outbreak. the same cutaneous findings have been described all over the world, including a preliminary study conducted by ourselves . in their paper, fernandez-nieto et al repeatedly use the appellative "acro-ischemic" for this cutaneous manifestation. moreover, they hypothesize a relationship between a covid- -related altered coagulation profile and these acral lesions. as the authors state, true ischemic lesions have been reported in severely-ill patients with proven coronavirus infection . although the comparison between acral lesions in asymptomatic patients and ischemic lesions in severe cases is important, we find the term "acute acro-ischemic lesions" not accurate. patients present with painful or itchy erythematous-edematous lesions of the extremities, sometimes evolving to blistering. this presentation is similar to what it is commonly seen in chilblains. the word "chilblains" itself etymologically refers to cold exposure (chill = cold, blain = sore). the term chilblain-like lesions, in our opinion, therefore would be preferable for the lesions that present in these patients rather than acro-ischemic lesions. in addition, histopathology of these lesions is quite similar to chilblains, with an absence of true necrosis; this is different to what it is typically found in hospitalized patients . although the exact pathogenesis of this cutaneous sign is not known yet, a worldwide common nomenclature would in our opinion be a good starting point in order to avoid confusion among clinicians. characterization of acute acroischemic lesions in non-hospitalized patients: a case series of patients during the covid- outbreak chilblain-like lesions during covid- epidemic: a preliminary study on patients covid- ) infectioninduced chilblains: a case report with histopathological findings key: cord- - aap cte authors: elston, dirk m. title: the coronavirus (covid- ) epidemic and patient safety date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: aap cte nan the coronavirus (covid- ) epidemic and patient safety dirk m. elston, md charleston, south carolina i n this issue of the jaad, chen et al discuss patient safety measures in a chinese dermatology clinic during the coronavirus outbreak ( -ncov acute respiratory disease), including patient screening, respiratory precautions, and telemedicine consultations. the steps they enacted serve as a reminder that we should have policies in place for infection control in every dermatology clinic. patients with varicella, measles, and other viral exanthems present to the dermatologist and may pose a risk to patients and office staff. employees should receive all appropriate vaccinations, and testing should be available for employees to determine their immune status. this is especially important for women of child-bearing age who may be exposed to diseases such as varicella and erythema infectiosum. if available, a negative pressure room should be designated as an isolation room for patients with respiratory pathogens, and exposed susceptible individuals should be furloughed during the incubation period. , large health care organizations often address these issues during in-processing of employees, but many dermatologists practice in private clinics and should review existing policies to prepare for the inevitability of contagious patients entering the clinic. this is not the first outbreak of a severe coronavirus. prior outbreaks of virulent coronavirus strains have also been associated with severe respiratory syndromes and patient deaths. individuals who are asymptomatic or who have only mild symptoms may spread the virus. however, superspreading eventsd instances where an index patient transmitted disease to $ subsequent patientsdwere typically associated with patients who were severely ill, initially not recognized as severe respiratory syndromecoronavirus cases, and subsequently died. delays in implementation of control measures contributed to secondary transmission, but contact tracing, testing, employee furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission. our responsibility for patient and employee safety is not limited to respiratory pathogens. virulent streptococcal infections associated with necrotizing fasciitis and death have been spread during liposuction in outpatient facilities. the procedures were performed by a single surgical team that traveled between locations, and team members were colonized by the organism. substandard infection control, including errors in equipment sterilization and standard precautions, contributed to the outbreak. prevention of transmission of blood-borne infections deserves special mention, and readers should review the jaad continuing medical education articles that focused on patient safety and blood-borne pathogens (https://www.jaad. org/article/s - ( ) - /fulltext and https://www.jaad.org/article/s - ( ) - /fulltext). [ ] [ ] [ ] standard precautions should be enforced, and policies should be in place for postexposure prophylaxis. as captains of our individual ships, it falls to us to put policies in place to prevent the spread of disease and prepare for the needle-stick injuries and transmissible diseases that are part of the practice of medicine. what are we doing in the dermatology outpatient department amidst the raging of the novel coronavirus? infection control in the outpatient setting nosocomial varicella. worth preventing, but how? scope and extent of healthcare-associated middle east respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in riyadh, saudi arabia invasive group a streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation patient safety: part ii. opportunities for improvement in patient safety patient safety: part i. patient safety and the dermatologist managing sharps injuries and other occupational exposures to hiv, hbv, and hcv in the dermatology office key: cord- -fynxciwg authors: peterson, danielle; damsky, william; king, brett title: calm before the storm: understanding the role of jak inhibitors in covid- date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: fynxciwg nan inhibit proteins potentially involved in sars-cov- entry into cells. not only is that work theoretical, that this potential inhibition might provide clinical benefit to patients infected with sars-cov- is even further unknown. also, based on in vitro assays, the concentration of baricitinib needed to inhibit aak and clathrin-mediated endocytosis would likely require doses far above the fda approved dose of baricitinib mg daily. lastly, the theoretical effect against viral endocytosis only applies to baricitinib; this is not a known property of other jak inhibitors, including upadacitinib. based on these considerations, we believe there is insufficient evidence to recommend continuing jak inhibitors in patients who are acutely infected with sars-cov- . napolitano et al suggest that baricitinib and upadacitinib might be useful in treating the cytokine release syndrome (crs) that can occur in sars-cov- infection. we strongly agree that there may be a role for jak inhibitors in treating sars-cov- -associated crs. however, it is important to note that this is typically a late manifestation of disease that occurs only in a subset of patients. furthermore, there is evidence in both rhesus macaques and mice infected with the original sars virus, sars-cov, that a suboptimal early anti-viral type i interferon response may predispose to this late manifestation. , jak cytokines including il- , interferon gamma, gm-csf, and g-csf. important to note is that the theoretical benefit of jak inhibitors in this setting is not limited to upadacitinib and baricitinib but also applies to other jak inhibitors including ruxolitinib and tofacitinib. we and others are undertaking clinical trials to evaluate jak inhibitors for sars-cov- -associated crs, and it will be interesting to see what they show. in summary, we believe there is insufficient evidence to recommend that jak inhibitors be continued in all patients taking these medications who are acutely infected with sars-cov- . while jak inhibitors may prove useful in the treatment of sars-cov- -associated crs, this is a separate consideration of a relatively uncommon manifestation of this viral infection that occurs late in disease course. baricitinib as potential treatment for -ncov acute respiratory disease covid- : combining antiviral and anti-inflammatory treatments dysregulated type i interferon and inflammatory responses cause lethal pneumonia in sars-cov-infected mice microbe exacerbated innate host response to sars-cov in aged non-human primates. baric rs key: cord- -ag l xa authors: akiyama, shintaro; yamada, akihiro; micic, dejan; sakuraba, atsushi title: the risk of respiratory tract infections and interstitial lung disease with il- / and il- antagonists in patients with autoimmune diseases: a systematic review and meta-analysis date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: ag l xa abstract background respiratory tract infections (rtis) and interstitial lung disease (ild) secondary to interleukin (il)- / or il- antagonists have been reported in autoimmune diseases. objective to assess the risk of rtis and non-infectious ild with these drugs. methods we conducted a systematic review and meta-analysis of randomized controlled trials (rcts). risk of rtis and non-infectious ild was compared to placebo by mantel-haenszel (mh) risk difference (rd). we divided rtis into upper rtis (urti), viral urtis, and lower rtis (lrtis) including infectious pneumonia. non-infectious ild included ild, eosinophilic pneumonia, and pneumonitis. results we identified rcts including , patients with six il- / or il- antagonists and , patients with placebo. these drugs significantly increased the risk of rtis (mh rd . , % confidence interval . - . , p = . ) which was attributed to urtis, but not viral urtis or lrtis. there was no significant difference in infectious pneumonia and non-infectious ild between two groups. limitations due to the rarity of infectious pneumonia and ild, sensitivity analysis was required. conclusion the use of il- / or il- antagonists for autoimmune diseases increased the risk of urtis, but not viral urtis, lrtis, and non-infectious ild. the clinical benefit of interleukin (il)- and il- inhibition has been demonstrated in psoriasis and crohn's disease (cd) by briakinumab , or ustekinumab. , furthermore, il- -specific antagonists, such as tildrakizumab, , risankizumab, , guselkumab, , and brazikumab, have completed phase or trials. currently, il- / or il- antagonists are the second most commonly prescribed category of biologics for psoriasis and cd, behind anti-tumor necrosis factor agents. however, randomized controlled trials (rcts) of these drugs reported respiratory tract infections (rtis) as the most common adverse events. furthermore, the surveillance conducted by food and drug administration (fda) reported the development of non-infectious interstitial lung disease (ild) following ustekinumab. hence, physicians need evidences to decide whether to continue or hold these drugs particularly during the current covid- pandemic. - this systematic review and meta-analysis aimed to determine the risk of rtis and non-infectious we evaluated the presence of heterogeneity across trials by using the i statistic. an i value of < % indicated low heterogeneity, - % as moderate heterogeneity and > % as considerable heterogeneity, respectively. heterogeneity was evaluated by using cochran's q-statistics with a significance level of p< . . begg's and egger's tests were performed to access publication bias and funnel plots were constructed to visualize possible asymmetry when three or more studies were available. , statistical analyses were performed using the comprehensive meta-analysis software (version . ; biostat, englewood, nj, usa). all statistical tests used a two-sided a value of . for significance. characteristics and outcomes of the included studies are summarized in table the percentage of studies which permitted to use concomitant drugs (e.g. corticosteroids, budesonide, thiopurines, methotrexate, calcineurin inhibitors, or aminosalicylates) during the trials was . % for risankizumab, . % for ustekinumab, . % for briakinumab, % for guselkumab, and % for tildrakizumab. as for brazikumab, one study for cd was included in this analysis and permitted concomitant drugs (table ) . meta-analysis with a random-effects model showed that the overall risk of rtis with anti-il- /il- or anti-il- agents was significantly higher than that of placebo (mh rd . , % confidence interval [ci] . - . , p = . ) ( figure ). the number needed to harm of rtis was . . subgroup analysis revealed a significantly increased risk of rtis with briakinumab (mh rd . , % ci . - . , p = . ) and risankizumab (mh rd . , % ci . - . , p = . ). heterogeneity was absent (i = %) in overall and subgroup analyses except for briakinumab (i = %). funnel plot demonstrated no asymmetry, therefore suggesting there was no small-study effects or publication bias, which was supported by begg's and egger's tests ( figure s ). we also assessed the differential risk of rtis by underlying disease and showed a significantly increased risk of rtis in psoriasis (mh rd . , % ci we divided rtis into urtis, viral urtis, and lrtis and investigated each risk with il- / or il- inhibitors. the overall risk of urtis was significantly higher in the treatment group compared to anti-il- /il- or anti-il- agents did not increase the overall risks of viral urtis (mh rd . , % ci - . - . , p = . ) and lrtis (mh rd , % ci - . - . , p = . ) ( figure s a , s a). heterogeneity was absent (i = %) in these analyses. publication bias was indicated in the analysis of viral urtis (begg: p < . , egger: p = . ) ( figure s b ) and lrtis (begg: p < . , egger: p = . ) ( figure s b ), but the funnel plots did not appear asymmetric on visual inspection. the total numbers of infectious pneumonia were and cases in the treatment group and placebo, respectively. mycobacterium tuberculosis and viral pneumonia were not reported. the overall risk of infectious pneumonia was not significantly increased in the treatment group compared to placebo (mh rd , % ci - . - . , p = . ) ( figure ). heterogeneity was absent (i = %). the funnel plot was not asymmetric, indicating no publication bias, which was supported by egger's test (p = . ) but not begg's test (p < . ) ( figure s ). in terms of non-infectious ild, and cases were identified in the treatment group and placebo, respectively. all cases were reported in the trials of ustekinumab and occurred within weeks after initiation of the trial. [ ] [ ] [ ] the overall risk of ild was not significantly increased in the treatment group (mh rd , % ci - . - . , p = . ) ( figure ). heterogeneity was absent (i = %). begg's (p < . ), but not egger's (p = . ), test was suggestive of publication bias, but the funnel plot was not asymmetric ( the sensitivity analysis revealed consistent results (table s - , s - , s , s ) except the analysis with . constant correction of zero-event studies showed a lower risk of infectious pneumonia (table s ) and based on the grade, an overall quality of evidence for this analysis was moderate as infectious pneumonia and ild were rare events (tables s and s ). our meta-analysis showed that il- / or il- inhibitors increased the risk of rtis, especially urtis, but not viral urtis and lrtis, and non-infectious ild in autoimmune diseases. we found that risankizumab and briakinumab particularly enhanced the risk of rtis and hypothesized that concomitant therapies during the trials might differentiate the risk of rtis. in terms of anti-il- agents, risankizumab showed a higher rate of rcts which permitted concomitant therapies ( . %) compared with guselkumab ( %) and tildrakizumab ( %). among rcts of risankizumab, the only study reporting an increased risk of rtis was performed in patients with ankylosing spondylitis who were permitted to use conventional disease-modifying antirheumatic drugs or low-dose systemic steroids. this suggests that combination therapy of anti-il- agents with immunosuppressants might work synergistically to surface the risk of rtis. as for anti-il- /il- agents, each of briakinumab and ustekinumab has a similar percentage of rcts which permitted concomitant drugs ( . % for briakinumab and . % for ustekinumab). other potential risk factors such as age and sex were not different among the drugs. given that briakinumab has been withdrawn from the application with fda due to severe adverse events, the difference in risk of rtis among two drugs would be explained by different properties of these drugs. our study might support that anti-il- / and anti-il- therapies can be safely used for autoimmune diseases even during the current covid- pandemic. however, given that influenza respiratory syndrome coronavirus showed that a patient with a poor outcome had an increased level of il- expression in the lung. these data suggest that il- / or il- inhibitors might theoretically be preventive for sars-cov- -induced pneumonia rather than detrimental in autoimmune diseases during the covid- pandemic. first, this study did not assess the long-term effect of il- / or il- antagonists on rtis and ild. however, . % ( / ) of included studies reported rtis during placebo-controlled phases. fda reported the onset of ild was acute or subacute, so our data would most likely include the incidence of these events. second, regarding infectious pneumonia and ild, many studies had both-armed zero-event ( % ( / ) and % ( / ), respectively). thus, we undertook comprehensive analyses that either included or excluded double-zero-event studies. the analysis with . constant correction showed a lower risk of these events in the treatment group. we also used treatment arm correction because this method performed better than . constant correction to examine rare events. third, our study may not reflect the risk in patients at high risk for rtis due to the possible exclusion of patients with recent rtis or chronic lung disease in clinical trials. fourth, we categorized rtis into urtis, viral urtis, and lrtis based on meddra which is widely used in clinical trials, but not so much in clinical research. furthermore, the included studies have been conducted before the pandemic. hence, it does not provide evidences whether there is an increase in rtis or ild during the pandemic in patients receiving il- / or il- antagonists, nor whether these agents can be autoimmune diseases is needed. nemoto et al blauvelt et al reich et al gordon et al sofen et al terui et al [wt> kg] at wk , s.c.at wk , tsai et al papp et al leonardi et al krueger et al ritchlin et al mclnne et al gottlieb et al feagan et al feagan et al sandborn et al sandborn et al khattri et al saeki (s) , mg/kg i.v. 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dose-ranging study key: cord- -j b p authors: gisondi, paolo; zaza, gianluigi; del giglio, micol; rossi, mattia; iacono, valentina; girolomoni, giampiero title: risk of hospitalization and death from covid- infection in patients with chronic plaque psoriasis receiving a biological treatment and renal transplanted recipients in maintenance immunosuppressive treatment date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: j b p nan manuscript words: we performed a retrospective observational study in order to determine whether hospital and compared to the verona population (n= , ) ( table ). the overall study population is resident in verona, so that its reference hospital is the same. data of verona residents were derived from national public database. data are expressed as means ± sd or percentages. statistical analyses for comparison between patients and general population included the unpaired-t test, and theχ -test. as of april , , the total number of covid -positive patients (including those that did not require hospitalization or die) in verona was , ( . % of population). -legend: * asymptomatic individuals were not tested so the true number of covid- positive patients is unknown; cni: calcineurin inhibitors; mtori mammalian target of rapamaycin; psa: psoriatic arthritis; pso: psoriasis data of psoriasis and transplant patients are derived from electronic medical record of the hospital. data of general population are derived from https://www.azero.veneto.it/-/emergenza-coronavirus and https://www.epicentro.iss.it and http://demo.istat.it accessed on th april . guidance on the use of biologic agents during covid- outbreak american academy of dermatology should patients stop their biologic treatment during the covid- pandemic should biologics for psoriasis be interrupted in the era of covid- ? key: cord- -vy c authors: mcgee, jean s.; reynolds, rachel v.; olbricht, suzanne m. title: fighting covid- : early teledermatology lessons learned date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: vy c nan covid- has exacerbated the unequal access to medical care experienced by historically marginalized patient populations. early data demonstrate that the infection and death rates of predominantly black neighborhoods are -fold and -fold higher, respectively, than in predominantly white neighborhoods. in response to the pandemic, both academic and private dermatology practices have quickly rolled out teledermatology service in an effort to continue access to care. our study aimed to evaluate early practice patterns to identify any variations in the quality of and access to teledermatology service. we randomly selected teledermatology visits conducted during the month of april in the department of dermatology at beth israel deaconess medical center. we reviewed each visit and extracted the following information including age, preferred language, diagnoses, disposition, visit type (telephone versus video), and visit duration. in addition, we randomly selected in-person visits conducted during the month of february for a pre-pandemic comparison. prior to the pandemic, % of patients seen in person were older than years and % of patients seen in person were non-english speaking, those defined as necessitating interpreter service (table ) . during the pandemic, % of patients seen in teledermatology were older than years and % of patient seen in teledermatology were non-english speaking ( table ). the two most common diagnoses seen in teledermatology, other than a lesion of concern, were acne and dermatitis at % and % of total visits, respectively ( table ). nearly all teledermatology visits with these diagnoses led to a recommendation for either discharge or follow-up via subsequent teledermatology visits. in contrast, % of teledermatology visits for evaluation of lesion(s) lead to a recommendation to follow up in person for re-evaluation and/or biopsy. lastly, % of teledermatology visits with durations of minutes or greater were conducted via telephone, rather than a video-based platform. limitations of this study include a small sample size, narrow scope, and a single institution. our study suggests that elderly patients and non-english speaking patients may be experiencing unequal access to teledermatology care during the pandemic. limited proficiency with technology, administrative burden to mobilize an interpreter service, and hesitancy on the part of patients to receive medical care via virtual platforms can all contribute to these findings. our study also suggests that teledermatology is best suited for acne and non-specific dermatitis. on the other hand, evaluations of lesion(s) may be best suited for in-person visits, as not to generate extra visits and unnecessary costs. lastly, our study found that longer visits were more likely to be conducted by telephone, rather than video. this finding raises a possibility that visual cues may be an important consideration in teledermatology visits. moving forward, we are tasked with creating a new practice model that is likely to be a hybrid of both in-person and teledermatology. our early data support allocating teledermatology resources for certain diagnoses including acne and rashes. however, we need further studies to understand the operational and financial implications of having extra teledermatology visits for the evaluation of lesion(s). racial, economic and health inequality and covid- infection in the united states covid- and african americans key: cord- - buoweg authors: avancini, joao; miyamoto, denise; arnone, marcelo; villas-boas gabbi, tatiana; ferreira, paula silva; neta, cyro festa; sanches, jose antonio title: absence of specific cutaneous manifestations of sars-cov- in a reference center in brazil date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: buoweg nan contents of the manuscript have not been previously published and are not currently submitted elsewhere. i accept responsibility for the scientific integrity of the work described in this manuscript. all listed authors have seen and approved of the manuscript and will sign off on any subsequent manuscript revisions. j o u r n a l p r e -p r o o f (clean version) to the editor: we read with interest the letters from the new york city report regarding the absence of covid toes lesions on their patients and the recommendation of caution when concluding that cutaneous findings are specifically due to the severe acute respiratory syndrome coronavirus (sars-cov- ). , since the global pandemic of sars-cov- , the university of sao paulo medical school hospital -a reference center and one of the largest university hospitals in latin america -re-organized its structure, offering about intensive care units and nursery beds fully dedicated to sars-cov- . five staff members of the dermatology department were exclusively assigned to assist the admitted patients that covid toes: phenomenon or epiphenomenon? caution in the time of rashes and covid- cutaneous manifestations in patients with covid- : a preliminary review of an emerging issue classification of the cutaneous manifestations of covid- : a rapid prospective nationwide consensus study in spain with cases key: cord- - bnifxm authors: lebwohl, mark; rivera-oyola, ryan; murrell, dedee f. title: reply to: “covid- , syphilis, and biologic therapies for psoriasis and psoriatic arthritis: a word of caution” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: bnifxm nan reply to: ''covid- , syphilis, and biologic therapies for psoriasis and psoriatic arthritis: a word of caution'' to the editor: we thank dr kansal from the all india institute of medical sciences for her pertinent comments in response to our publication on the use of biologic agents for psoriasis patients in the current covid- pandemic. certainly, there are other diseases for which screening could be considered in particular populations before starting a biologic, such as syphilis, as dr kansal makes a point about in her study. strongyloides and leprosy are others. these screening tests apply to all immunosuppressants, not just biologic immunomodulators. there will always be exceptions to the clinical trial data, but even with to years of real-world data reporting of many of these biologics, we have not seen alarming rates of influenza or other viral infections in the non-tumor necrosis factor inhibitor classes of biologics that would warrant advice to discontinue treatment. there are several reasons why biologic agents are different from traditional immunosuppressive drugs such as methotrexate or cyclosporine. they are very targeted and do not affect the entire immune system. most relevant to our current times, many do not impact host defenses against viral infection. for example, individuals born with deficiencies in molecules like interleukin or p are prone to chronic mucocutaneous candidiasis or to mycobacterial and salmonella infections. , they do not have increased rates of viral infections. moreover, the skin itself is a vector for spreading covid- , and the impact of active skin disease on transmission is unknown. in addition, there has been speculation that reducing overall inflammation in patients with covid- infection protects against the deadly pneumonia that has caused the demise of so many. finally, we know that dupilumab, in addition to treating atopic dermatitis, which in itself can be debilitating, also treats asthma, which could be a complicating factor in covid- infection. to be clear, we cannot know the long-term impact of biologic agents on patients with suspected or confirmed covid- until more time passes and we have more data. for now, the most medical organizations, including the american academy of dermatology, the national psoriasis foundation, and the international eczema council, among others, have advocated not discontinuing biologics in patients who are not infected. of course, these agents should be discontinued in patients with active infection. covid- , syphilis and biologic therapies for psoriasis andpsoriatic arthritis: a word of caution should biologics for psoriasis be interrupted in the era of covid- ? inborn errors of human il- immunity underlie chronic mucocutaneous candidiasis mendelian susceptibility to mycobacterial infection in man induction of pro-inflammatory cytokines (il- and il- ) and lung inflammation by coronavirus- (covi- or sars-cov- ): anti-inflammatory strategies key: cord- -yvbufnf authors: fernandez-nieto, d.; ortega-quijano, d.; suarez-valle, a.; burgos-blasco, p.; jimenez-cauhe, j.; fernandez-guarino, m. title: comment on: “to consider varicella-like exanthem associated with covid- , virus varicella zoster and virus herpes simplex must be ruled out. characterization of herpetic lesions in hospitalized covid- patients.” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: yvbufnf nan be performed in order to rule out other viral infections. marzano and genovese were not able to perform pcr tests in their previous study of varicella-like exanthem due to logistic reasons, but also due to clinical presentation not being suggestive of varicella. we previously conducted a prospective study of vesicular covid- rashes (all with positive nasopharyngeal swab for sars-cov- ) in our hospital from march st to april th, . out of a total of patients, were excluded because of an alternative herpes simplex/zoster clinical diagnosis (clinical data are summarized in table ). all patients presented typical clinical lesions and symptoms of herpes simplex/zoster. only one patient ( . %) had a previous history of immunosuppression. latency time between covid- symptoms and herpetic lesions was variable (median time days, range - ). in spite of performing pcr tests for sars-cov- from the content of the vesicles in only three patients, the results were all negative. regarding vesicular rashes or varicella-like covid- exanthems , we previously reported four cases in which we performed both pcr multiplex for herpesvirus and rt- pcr for sars-cov- , directly from the content of the vesicles. interestingly, both techniques were negative in all four cases . this reasonably rules out a role of herpes viruses , and a potential infective ability of sars-cov- through the vesicles. we agree with the authors that there is a potential role for herpetic viral infections and super-infections in covid- patients. in fact, some presumed covid- vesicular lesions have been later proven to be caused by herpetic infections , . in our prospective study, from a total of covid- dermatological consultations in the reported period, . % corresponded to herpes simplex/zoster diagnoses. however, we cannot categorically affirm that there is an incidence increase of these diagnoses in covid- patients, due to the lack of a control group. in our current experience, the diagnosis of herpesvirus infection in covid- patients does not usually involve diagnostic doubts, due to the clinical presentation and reported symptoms being typical of the disease, even when lesions are extensive (figure ) . in conclusion, complementary diagnostic tests for herpesvirus and even sars-cov- may prove useful for clinical research, and should be encouraged if the necessary resources are available. however, we believe that, regarding clinical practice, we should reserve these techniques for atypical clinical presentations or cases where therapeutic management would change significantly. figure : a) a -year-old male with covid- pneumonia and extensive orolabial hsv- reactivation. b) a -year-old female with covid- pneumonia and herpes zoster on the trunk key: cord- -egvdvvtx authors: damsky, william; peterson, danielle; king, brett title: when interferon tiptoes through covid- : pernio-like lesions and their prognostic implications during sars-cov- infection date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: egvdvvtx nan william damsky md, phd ,* , danielle peterson md brett king md, phd ,* has suggested that sars-cov- infection is sometimes characterized by a muted anti- viral type i and iii interferon (ifn) response, , which may explain progression to severe clinical manifestations in some patients; a robust type i ifn response was associated with rapid viral clearance and bland disease course. here, we describe pernio-like lesions as they have been reported in the literature and consider other settings where pernio is observed, including familial chilblains lupus, an interferonopathy syndrome. together, these data suggest that covid toes may be a marker of patients that are able to mount a robust anti-viral immune response to sars-cov- and prognosticate a milder course of covid- . sporadic pernio (also known as chilblains) is an idiopathic cold-sensitive inflammatory disorder that presents with red-to-violaceous macules or papules on acral sites; vesiculation and ulceration may occur. these lesions are typically located on the distal toes, but can also occur on fingers, heels, and even the nose and ears. histopathology reveals edema in the superficial dermis and marked superficial and deep perivascular and peri-eccrine lymphocytic inflammation (figure a) . interface change and/or vasculopathic changes (e.g. focal thrombosis) may be present. type i ifn response is associated with early viral control and a mild course, while an insufficient type i ifn response may be associated with progression to more severe disease ( figure b) . , therefore, we hypothesize that pernio-like lesions, which can occur with elevated type i ifn signaling, are the result of a robust anti-viral response in patients with covid- , and, therefore, are associated with a favorable disease course, as observed in these patients. characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of patients during the covid- outbreak chilblains in children in the setting of covid pandemic covid- ) infection- induced chilblains: a case report with histopathologic findings classification of the cutaneous manifestations of covid : a rapid prospective nationwide consensus study in spain with cases pernio-like skin lesions associated with covid- : a case series of patients from countries type i ifn immunoprofiling in covid- patients imbalanced host response to key: cord- -nnunjora authors: kolitz, elysha; smith, austin; taylor, oliver; mauskar, melissa m.; goff, heather title: “considerable unreimbursed medical care is delivered through electronic patient portals: a retrospective review” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: nnunjora nan we conducted a retrospective review to assess patient-initiated messages on the online portal used in the dermatology clinic at ut southwestern medical center called "mychart. and medical history questionnaires. the message type was verified, and medical advice requests were reviewed independently by each author. encounters where physicians managed the entire patient complaint through the mychart portal were considered as separate electronic e&m services of the patient's concern utilizing the cms guidelines and thus potentially eligible for provider reimbursement. there was a steady rise in patient-initiated mychart encounters each year (figure ). contact hours and patient clinic encounters also rose during this same time period, but the rise in messages outpaced the time spent in face-to-face care (figure ). in our sample, % of the messages were medical advice requests and . % of all messages met criteria for separate e&m services via the portal. other categories of messages included % for appointment changes, . % for history questionnaires, and . % for medication refill requests. the new england journal of medicine sampling techniques. nd ed medicare telemedicine health care provider fact sheet cpt® codes ( - ) -and payment for -online digital evaluation and management (e/m) services. codingintel covid- public health emergency key: cord- -vdbk pl authors: grant-kels, jane m. title: response to “risks of hydroxychloroquine use for covid- prophylaxis” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: vdbk pl nan prophylaxis" hcq has been demonstrated to be anti-viral but is also known for its successful antiinflammatory actions that has resulted in it being used extensively in autoimmune diseases; it can significantly decrease the production of cytokines and, in particular, proinflammatory factors. . although the rheumatologic literature has demonstrated that hcq is less toxic than chloroquine and a very safe medication, prolonged use and overdosing can still cause problems for our patients; major concerns surround the potential for ventricular arrhythmias, qt prolongation, and other cardiac toxicities. i applaud those at the front line trying desperately to help those suffering with this virus. a recent wall street journal article reported data compiled from the global rheumatology alliance (a coalition of rheumatologists) that more than five dozen "people taking hydroxychloroquine and other treatments for chronic rheumatologic diseases have become infected with covid- , according to an analysis of emerging data that is a sign the drugs may not protect people from the new coronavirus." . these findings cast doubt on the effectiveness of hcz prophylaxis. risks of hydroxychloroquine use for covid- prophylaxis does hydroxychloroquine combat covid- ? a timeline of evidence hydroxychloroquine in the management of critically ill patients with covid- : the need for an evidence base hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in covid- patients with at least a six-day follow up: an observational study efficacy of hydroxychloroquine in patients with covid- : results of a randomized clinical trial bell cl hydroxychloroquine in the treatment of rheumatoid arthritis hydroxychloroquine and other autoimmune drugs don't fully protect against coronavirus, early data suggest key: cord- -bqw zi authors: wambier, carlos gustavo; vaño-galván, sergio; mccoy, john; pai, suraj; dhurat, rachita; goren, andy title: androgenetic alopecia in covid- : compared to age-matched epidemiologic studies and hospital outcomes with or without the gabrin sign date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: bqw zi nan we would like to motivate other groups to evaluate aga in their populations, specifically comparing outcomes in covid- positive individuals. for example, our indian colleagues, in a pilot observational prospective study (raw data available at doi.org/ . /jdkx y fz. ), examined outcomes in admitted covid- patients by aga severity. in their cohort of men admitted for severe covid- , all patients had clinically significant androgenetic alopecia. however, the most severe outcomes (respiratory failure requiring ventilators or fatal outcomes) happened when hns was greater than . one patient was years-old, and had no previous co-morbidities; he required prolonged icu stay due to ventilator use, and had hns= v. study show an increase of relative proportions for hns= - of %, hns= - of %, and hns= - of %. this gap becomes particularly obvious when comparing the frequencies of hns= - in the age range of - years (fig. ) , which is the age group that contains the median age of the covid- hospitalized men. severe aga in young men also confers increased vulnerability. to further exemplify that, we present in this reply letter one of our unpublished patients from brazil: a previously healthy -year-old physician (hns= , depicted in fig ), with no previous co-morbidities; he required hospitalization for days, which included days in the icu (ventilator for days and hemodialysis for days). since vaccines are still not available, and the epidemic is affecting men disproportionately, particularly bald individuals, more emphasis could be given to investigations directed at anti- androgen therapies which are routinely prescribed both for hair loss and benign prostatic hyperplasia as standard of care (such as dutasteride and finasteride). finally, severe aga, (hns= - ) -the gabrin sign -is an objective phenotype, which reflects the individual androgen sensitivity throughout decades of life. aga is associated with individual vulnerability to severe sars-cov- infection through the androgen gateway. it is remarkable that severe outcomes such as requirement for ventilator and/or fatalities have occurred in men with this phenotype without other known co-morbidities at younger age groups, such as - years. androgenetic alopecia present in the majority of hospitalized covid- patients -the "gabrin sign androgenetic alopecia in covid- : compared to what? male pattern baldness: classification and incidence androgenetic alopecia in men aged - years : prevalence and risk factors androgen sensitivity gateway to covid- disease severity photograph of a year-old survivor hospitalized in brazil for severe covid- , without co-morbidities; required ventilator for days. the bars depict outcomes of a pilot study performed in india in may among men who had aga scored with hns. gabrin sign was associated with worse hospital outcomes (use of ventilator and deaths only men with gabrin sign had worse outcomes (red and black bars) age-matched comparison of aga, of very severe baldness between the australian data (general population) versus the spanish data (hospitalized men with severe covid- patients showed higher frequencies of very severe baldness at all age groups. the gap significantly increases after years. the majority of hospitalized patients due to severe covid- over years presented with very severe baldness. *very severe baldness accounted for "frontal and vertex" in data from severi et data from wambier et al. more details available at key: cord- -a qd xdr authors: xu, qiannan; chen, lihong; li, xia; zheng, jie title: if skin is a potential host of sars-cov- , il- antibody could reduce the risk of covid- date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: a qd xdr nan to the editor: in the era of the coronavirus disease pandemic, debates have emerged on whether biologics might increase the risk of contracting the disease . il- is a biologic that is widely used in dermatology. there were reports that viral reactivation, although extremely low, could be detected during the use of il- antibody . this led to concerns in using the il- antibody because it was believed that it could make patients more susceptible to severe acute respiratory syndrome coronavirus (sars-cov- ). when we read the article named skin is a potential host of sars-cov- : a clinical, single-cell transcriptome-profiling and histological study in a recently published issue , a question occurred to us: if skin is a target of sars-cov- , what might be the consequence of using the il- antibody? ace is the main entrance receptor for sars-cov- . the expression of ace is associated with the potential risk of making the target tissue susceptible to infection by sars-cov- . therefore, downregulating the expression of ace could lower the risk of covid- . to evaluate the influence of il- antibody on skin ace expression, we randomly selected five psoriasis patients who were treated with il- antibody (taltz, eli lilly and company). the skin lesions of these patients were biopsied on week and week and prepared for rna sequencing. the skin ace expression of patients who underwent the antibody therapy for weeks ( . ± . , n= ) was downregulated when compared with that at week ( . ± . , n= ), when the il- antibody treatment was just started (p < . , paired t-test). to confirm the result, we also selected three patients to compare the skin ace expression at weeks and with immunofluorescence. immunofluorescence staining revealed that the fluorescence intensity of ace was downregulated in the skin at week ( . ± . , n= ) when compared to that before the il- antibody treatment ( . ± . , n= , p＜ . ; unpaired t-test). hence, either the mrna or protein of ace obtained from psoriasis patients can reveal that il- antibody treatmentremarkably reduces ace expression. our work above proves that the il- antibody treatment during the covid- pandemic is not contraindicated. elevated ace expression and detection of sars-cov- in the skin of covid- patients implied skin was a potential host of sars-cov- . after il- antibody treatment, the skin ace expression was downregulated which meant il- antibody could lower the risk of covid- through lessening the cells which could interact with sars-cov- . additionally, il- antibody could reverse the deteriorated barrier and inflammatory status in the skin of psoriasis patient which meant less microbe infection.herein, the specific microbe could be sars-cov- . till now there is no evidence that covid- can be spread by contact with skin. however, sars-cov- could survive on skin for h , which indicated that sars-cov- might transmit through skin in the certain skin status like psoriasis. thus, whether il- antibody could reduce the covid- risk through reversing the inflammatory skin status with deteriorated barrier and preventing sars-cov- transmitting should be further discussed. should biologics for psoriasis be interrupted in the era of covid- ? risk for hepatitis b and c virus reactivation in patients with psoriasis on biologic therapies: a retrospective cohort study and systematic review of the literature skin is a potential host of sars-cov- : a clinical, single-cell transcriptome-profiling and histological study epub ahead of print sars-cov- endothelial infection causes covid- chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases survival of sars-cov- and influenza virus on the human skin: importance of hand hygiene in covid- the authors have declared that no conflict of interest exists. none of the authors has any financial interest in any products, devices or drugs used in the manuscript. there is also no conflict of interest related to any commercial associations or financial relationships. key: cord- -xsroivzj authors: manalo, iviensan f.; smith, molly k.; cheeley, justin; jacobs, randy title: a dermatologic manifestation of covid- : transient livedo reticularis date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: xsroivzj nan we read with great interest "covid- can present with a rash and be mistaken for dengue." to date, other described covid- -associated rashes include: nondescript erythematous rash, urticaria, and vesicles in italy, and dusky acrocyanosis and dry gangrene in critical intensive care unit (icu) patients in wuhan, china. no photos were available for the first two reports. we present two cases of transient unilateral livedo reticularis (lr) in covid- -positive non-icu subjects to bring awareness to a dermatologic manifestation. a -year-old caucasian male was hospitalized for covid- (nasopharyngeal swab pcrconfirmed) management. his symptoms began days prior with low-grade fever, nasal congestion, post-nasal drip, and cough without shortness of breath. seven days into his symptoms, he noted a transient non-pruritic blanching unilateral livedoid patch on the right anterior thigh resembling lr ( figure ). the eruption lasted for hours and resolved by the time dermatology evaluated the patient; thus no biopsy was taken. concurrent with the lacy patches on the leg, the patient also noted gross hematuria and generalized weakness. in concert with the netlike exanthem, the hematuria resolved within hours. he was eventually discharged home stable on supplemental oxygen. a -year-old caucasian female with history of celiac disease, hashimoto's thyroiditis, and portal vein thrombosis in with negative work-up for a hypercoagulable state (attributed to a long plane flight combined with prior oral contraceptive) tested covid- -positive. symptoms began with a mild headache, sinus pressure, anosmia, and fever, with highest recorded temperature of . °c. ten days after testing positive, and with complete clinical convalescence of covid- symptoms, she was sitting outside in long pants under direct sunlight for approximately - minutes. a unilateral asymptomatic rash on her right leg resembling lr was noticed incidentally immediately upon moving indoors (figure ) despite an equal amount of sun exposure on both legs. the rash lasted approximately minutes and did not recur upon re-challenge with sun exposure the following day. livedo reticularis is caused by conditions, including disseminated intravascular coagulation (dic), that reduce blood flow through the cutaneous microvasculature system leading to deoxygenated blood accumulation in the venous plexus. we hypothesize that the microthromboses that manifest in other organs (e.g. cardiopulmonary) for minutes; and did not recur upon rechallenge with re-exposure to the sunlight the next day. cutaneous manifestations in covid- : a first perspective livedo reticularis: an update acute pulmonary embolism and covid- pneumonia: a random association? abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia key: cord- - lpl eo authors: peterson, danielle; damsky, william; king, brett title: the use of janus kinase inhibitors in the time of sars-cov- date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: lpl eo nan during the time of the sars-cov- pandemic, questions arise regarding patients being treated with immunomodulatory therapies. in particular, is there an increased risk of acquiring the infection or experiencing a worse outcome from sars-cov- ? while this exact question is presently unanswerable, we can look at safety data from clinical trials to try to understand patient susceptibility to different infections. while others have addressed this in the context of biologic or classical small molecule therapy , the risk of janus kinase inhibitor (jaki) treatment has not been addressed. in light of the growing off-label use of jaki in dermatology in addition to pharmaceutical industry sponsored clinical trials of jaki for alopecia areata, atopic dermatitis, vitiligo, etc, dermatologists need data to better understand the risks of jaki treatment in order to best manage and counsel our patients during this unique time. we analyzed and collated adverse events data from jaki clinical trials. in particular, we focused on infections and pulmonary toxicities observed across the different fda-approved jaki for their fda- approved indications. when available, data from phase ii or iii clinical trials for dermatological indications was included. table shows the rates of various infections, including upper respiratory infections, nasopharyngitis and influenza, for jaki-treated groups versus placebo groups. overall, rates of infectious events are only mildly increased in jaki-treated patients. we also collated pulmonary toxicities of jaki to identify potential risks of worsening severe respiratory disease from sars-cov- , and such toxicities are all but absent. in order to understand the infection data, it is helpful to understand the mechanism and pharmacokinetics of jaki. cytokines can drive autoimmunity when their activity is exaggerated ( figure a). jaki, which are taken orally - times per day, largely impact pathogenically elevated cytokine activity, with relative sparing of normal cytokine activity because drug concentrations are sub- therapeutic for part of the day ( figure b in this time of the sars-cov- pandemic, we must be as informed as possible regarding the risks of the treatments we prescribe our patients. of course, shared decision-making reigns supreme, but without data we, as physicians, will be unable to provide our patients the guidance they rely on us for. should biologics for psoriasis be interrupted in the era of inflammatory diseases liver abscess ( ), pleural effusion ( ), pyelonephritis ( ) . mg dose-anal abscess ( ), cellulitis ( ), febrile infection ( ), otitis externa ( ), pneumonia ( ) . mg dose -furuncle ( ) . mg dose -peri-tonsillitis pna ( ), sinusitis ( ), sepsis ( ), lower respiratory infection ( ) . mg dose-viral infection ( ) key: cord- -urys ry authors: ortega-quijano, daniel; jimenez-cauhe, juan; burgos-blasco, patricia; jimenez-gomez, natalia; fernandez-nieto, diego title: reply to “varicella-like exanthem as a specific covid- -associated skin manifestation: multicenter case series of patients”: discussing specificity date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: urys ry nan title: reply to "varicella-like exanthem as a specific covid- -associated skin manifestation: multicenter case series of patients": discussing specificity daniel ortega-quijano, md , juan jimenez-cauhe, md , patricia burgos-blasco, md , natalia jimenez-gomez, md , diego fernandez-nieto, md . dear editor, we read with interest the article by marzano and colleagues addressing the specificity of varicella-like exanthem to diagnose coronavirus disease (covid- ) . although this type of covid- associated rash is rare, the authors claim that it is more specific than others without having performed a diagnostic accuracy study . this type of study would calculate the association of covid- status (yes/no) with the type of exanthem (varicella-like/non varicella-like) in a predetermined number of patients (to ensure sufficient statistical power) and in a defined population with a known prevalence of covid- disease. starting from the assumption that the data is not sufficient to draw such a robust conclusion, we would like to contribute our vision of such an important issue. firstly, for clinicians, specificity is of little value. the positive predictive value, that is, the probability that a person with a varicella-like rash has covid- , is much more relevant, as a high value would justify sars-cov- testing. the positive predictive value is affected by the prevalence of the disease. consequently, as we are going through the peak of the covid- pandemic, it is evident by applying bayes' theorem that the conditional probability of covid- given a varicella-like rash is enormous. however, this probability is as high given a dengue-like, erythematous or urticarial rash. therefore, the positive predictive value for covid- of skin rashes, regardless of which, is high. for us, the main contribution of the study by marzano and colleagues is that, with all exanthems currently having a high positive predictive value for covid- , that of varicella-like rash is probably the highest since vesicular rash is more specific for viral disease than others . in addition, at the current stage of the pandemic, covid- is more frequent in adults, where varicella is not. this gives varicella-like rash additional covid- positive predictive value compared to the rest of the rashes. the main factor that at this moment reduces the positive predictive value of rashes for covid- is adverse drug reactions. unfortunately, this topic is being less discussed in the literature. to conclude, since things will change fast as the pandemic progresses, it is expected that as the adult population become infected the age at diagnosis of covid- will decrease . at that time, this rash will be an important differential diagnosis of varicella itself. in this context, tzank test and varicella-zoster pcr should be subjected to new diagnostic accuracy studies. varicella-like exanthem as a specific covid- -associated skin manifestation: multicenter case series of patients cutaneous manifestations in covid- : a first perspective the challenge of diagnosing atypical exanthems: a clinico-laboratory study modeling infectious diseases in humans and animals key: cord- -pceenwb authors: falo, louis d. title: advances in skin science enable the development of a covid- vaccine date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: pceenwb nan expressing adenovectors and adjuvant in the same mnas resulting in a vaccine that induced both antibody responses and enhanced cytotoxic cellular immunity that is likely important for "universal" vaccines and cancer immunotherapies. taken together, these and studies by others demonstrate the potential for the development of cutaneous immune engineering strategies to control systemic immune responses including the potential for developing novel vaccine strategies and immunotherapies, and even negative immunization strategies to treat systemic allergy and autoimmune diseases. advances in skin biology are making important contributions to the fight against the covid- pandemic demonstrating once again that dermatology is more than skin deep. the immunological anatomy of the skin antigen-presenting cells in the skin microneedles for drug and vaccine delivery microneedle array delivered recombinant coronavirus vaccines: immunogenicity and rapid translational development improved cutaneous genetic immunization by microneedle array delivery of an adjuvanted adenovirus vaccine key: cord- -yiv rp y authors: guhan, samantha m.; nathan, neera r.; raef, haya; cavanaugh-hussey, margaret; tan, jennifer k. title: covid- and healthcare disparities: innovative ways to meet the dermatologic needs of patients experiencing homelessness date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: yiv rp y nan covid- and healthcare disparities: innovative ways to meet the dermatologic needs of patients experiencing homelessness samantha m. guhan, ba , neera r. nathan, md, mshs , haya raef, ba , margaret cavanaugh-hussey, md, mph , and jennifer k. tan, md , the medical community has taken multiple steps to increase access to care for this vulnerable population, such as creating facilities that offer isolation and treatment for peh suffering from covid- . we hypothesized that dermatologists can further aid this population by mobilizing critical supplies commonly found in our offices and using the generosity of local companies to create covid- care kits, which contain items necessary to protect peh from disease. goals of distribution included not only increased access to basic hygienic products, but also acknowledgement of our common humanity during a time of crisis. prior to supply collection, local shelters were contacted to identify the most useful items to patients. as dermatologists, we were especially well positioned to obtain products, such as soap and hand sanitizer, due to pre-existing relationships with skin care companies. local volunteers contributed facemasks and donors provided additional funds for entertainment items, covid- safety brochures, and packaging. the final kits contained soap, hand sanitizer, moisturizer, the annual homeless assessment report (ahar) to congress assessment of sars-cov- infection prevalence in homeless shelters -four covid- and racial disparities dental care products, puzzles, headphones, a covid- informational pamphlet, and other personal hygiene items ( figure ). in order to minimize the number of people in contact with patients, kits were delivered to a contact person at each shelter, who later distributed the kits. the success of this endeavor was measured by the number of kits distributed to local shelters. over kits were assembled between the months of march and june. this program is sustainable through the generosity of skin care companies, fund-raising efforts, and the incorporation of staff and trainees into the collection and assembly process. limitations include distribution to a single geographic area and variation in supply of donated items. building upon relationships we already have as dermatologists, we were able to create a covid- kit donation program that provided peh with necessary supplies to minimize the spread of disease. in the post-covid era, this effort will be expanded to involve the assembly of kits containing over-the-counter products to treat common skin conditions including acne, atopic dermatitis, and xerosis. we propose a call to action for the dermatology community to create similar programs in order to aid this critically marginalized population. to identify a clinic or shelter with which to partner, the following resources may be useful: national health care for the homeless council respite and grantee directories (nhchc.org), findahealthcenter.hrsa.gov, and www.homelessshelterdirectory.org. references: key: cord- -nclk bbo authors: do, mytrang h.; minkis, kira; petukhova, tatyana a.; lipner, shari r. title: strategies to prevent sars-cov- transmission during dermatologic head and neck surgery date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: nclk bbo nan . furthermore, the patient's mouth and nose are often exposed we hope that these suggestions provide the best possible protection for dermatologic efficiency particle air, rt-pcr, reverse transcription-polymerase chain reaction, sars-cov- , severe acute respiratory syndrome coronavirus head and neck surgery is a high-risk procedure for covid- transmission and there is a need for a preventive strategy to protect professionals detection of sars-cov- in different types of clinical . american college of surgeons. covid- : considerations for optimum surgeon /clinical-guidance/surgeon-protection american academy of dermatology. reopening the dermatologic surgery office in the key: cord- -aq vius authors: baniandrés-rodríguez, o.; vilar-alejo, j.; rivera, r.; carrascosa, j. m.; daudén, e.; herrera-acosta, e.; sahuquillo-torralba, a.; gómez-garcía, f. j.; nieto-benito, l. m.; de la cueva, p.; lópez-estebaranz, j. l.; belinchón, i.; ferrán, m.; alsina, m.; rodriguez, l.; carretero, g.; garcía-donoso, c.; ballescá, f.; llamas-velasco, m.; herrera-ceballos, e.; botella-estrada, r.; ruiz-genao, d. p.; riera-monroig, j.; descalzo, m. a.; garcía-doval, i. title: incidence of severe covid- outcomes in psoriatic patients treated with systemic therapies during the pandemic: a biobadaderm cohort analysis date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: aq vius nan the biobadaderm project is promoted by the fundación piel sana academia española de dermatología y venereología, which receives financial support from the spanish medicines and health products agency (agencia española de medicamentos y productos sanitarios) and from pharmaceutical companies (abbott/abbvie, almirall, janssen, leo pharma, lilly, novartis and ucb). the following companies have also collaborated in the past (msd and pfizer). collaborating pharmaceutical companies were not involved in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; decision to submit the manuscript for publication. • dr baniandrés-rodríguez acted as a consultant and/or speaker for janssen-cilag, abbvie, pfizer, novartis, lilly, celgene, leo pharma and almirall. • dr vilar-alejo participated as ab from janssen, novartis, abbvie, almirall and celgene. • dr rivera acted as consultant and/or speaker for and/or participated in clinical trials as ip for abbvie, almirall, celgene, janssen, leo pharma, lilly, novartis, msd and pfizer-wyeth. • dr carrascosa has participated as speaker and/or advisor for celgene, janssen, lilly, novartis, leo pharma, pfizer, msd, abbvie, biogen amgen. • dr dauden acted as consultant for abbott, amgen, astellas, centocor ortho biotech inc, galderma, glaxo, jansenn-cilag, leo pharma, novartis, pfizer, msd and celgene, received honoraria form abbott, amgen, janssen-cilag, leo pharma, novartis, pfizer, msd, celgene, participated in a speakers bureau for abbott, pfizer, msd and janssen and received grants from pfizer, abbott, janssen and msd. • dr herrera-acosta has served as consultant and/or speaker with leo pharma, novartis, janssen, lilly, celgene y abbvie. • dr sahuquillo has served as a consultant and/or paid speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis, including abbvie, celgene, janssen-cilag, leo pharma, lilly, novartis and pfizer. • dr de la cueva acted as a consultant and/or speaker for janssen-cilag, abbvie, msd, pfizer, novartis, lilly, almirall, ucb, biogen, celgene, amgen, sandoz, sanofi and leo-pharma. • dr lópez-estebaranz participated as ab and received educational grants from janssen, abbvie, msd, lilly, novartis, leopharma, pfizer. • dr belinchón acted as a consultant and/or speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis, j o u r n a l p r e -p r o o f the use of systemic treatments in psoriatic patients during the pandemic has been the subject of extensive debate. in march , we performed a specific study within the cohort of biobadaderm registry, a previously described national, multicenter, prospective cohort [ ] . our primary objective was to analyze the incidence of covid- infections and severe outcomes in a cohort of psoriatic patients treated with systemic therapies and to compare it to the general population. we reviewed all biobadaderm patient records and contacted the patients when needed. we collected information about current comorbidities related to outcomes in all active patients of the registry. we used the latest data updated on july . we estimated the age and sex standardized incidence ratio (sir) defined as the ratio of the observed cases to the expected number of cases according to the spanish population. the main analysis examined hospitalization, icu and death in pcr-confirmed patients included in biobadaderm as compared to pcr-confirmed cases published by the spanish ministry of health [ ] . also % ci were calculated for each sir to compare significance between the spanish figures and biobadaderm. in our study, we found that out of current active patients with systemic therapy, patients ( . %) had suffered from covid- , patients ( . %) required hospitalization, patient ( . %) needed icu and ( . %) patient died. patient characteristics are detailed in table . the profile of covid- cases was similar to that of the population of origin (biobadaderm) in age and sex [ ] , but with higher percentages of comorbidities like hypertension ( % vs %) or diabetes mellitus ( % vs %). in our main analysis ( [ ] that suggests that psoriatic patients receiving biologic treatments are not associated with worse outcomes. a strength of this study is that we analyzed a prospective cohort, that we know the base population and that we can calculate the incidences. this study therefore avoids problems of other ongoing international registries based on case notifications, which do not have a welldefined base population and likely suffer from selection bias [ ] . although the first data were reassuring at the start of the pandemic, some authors consider that it is necessary to confirm them using prospective studies of incidence with adequate denominators [ ] . the limitations of this study include the lack of serological or molecular confirmations for the diagnosis of covid- of all possible cases, which is because in cases of mild courses of the disease testing was often not done during the period of the study. in conclusion, this prospective cohort study suggests that classic systemic or biologic treatments increase neither the susceptibility nor the severity of covid- . ( ) ( ) ( ) ( ) ( ) ( ) ( ) psoriatic arthritis, yes ( ) ( ) ( ) ( ) ( ) ( ) ( ) treatment anti-tnf ( ) ( ) ( ) ( the biobadaderm project is promoted by the fundación piel sana academia española de dermatología y venereología, which receives financial support from the spanish medicines and health products agency (agencia española de medicamentos y productos sanitarios) and from pharmaceutical companies (abbott/abbvie, almirall, janssen, leo pharma, lilly, novartis and ucb). the following companies have also collaborated in the past (msd and pfizer). collaborating pharmaceutical companies were not involved in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; decision to submit the manuscript for publication. ( ) ( ) ( ) ( ) classic systemics treatments ( ) ( ) ( ) ( ) ( ) ( ) ( ) anti-il- /il- ( ) ( ) ( ) ( ) ( ) ( ) ( ) anti-il ( ) ( ) ( ) ( ) ( ) ( ) ( ) apremilast ( ) ( ) ( ) ( ) ( ) ( ) ( ) fumarates ( ) ( ) ( ) ( ) ( ) ( ) ( ) anti-il- p ( ) ( ) ( the use of systemic treatments in psoriatic patients during the pandemic has been the subject of extensive debate. in march , we performed a specific study within the cohort of biobadaderm registry, a previously described national, multicenter, prospective cohort [ ] . our primary objective was to analyze the incidence of covid- infections and severe outcomes in a cohort of psoriatic patients treated with systemic therapies and to compare it to the general population. we reviewed all biobadaderm patient records and contacted the patients when needed. we collected information about current comorbidities related to outcomes in all active patients of the registry. we used the latest data updated on july . we estimated the age and sex standardized incidence ratio (sir) defined as the ratio of the observed cases to the expected number of cases according to the spanish population. the main analysis examined hospitalization, icu and death in pcr-confirmed patients included in biobadaderm as compared to pcr-confirmed cases published by the spanish ministry of health [ ] . also % ci were calculated for each sir to compare significance between the spanish figures and biobadaderm. in our study, we found that out of current active patients with systemic therapy, patients ( . %) had suffered from covid- , patients ( . %) required hospitalization, patient ( . %) needed icu and ( . %) patient died. patient characteristics are detailed in table . the profile of covid- cases was similar to that of the population of origin (biobadaderm) in age and sex [ ] , but with higher percentages of comorbidities like hypertension ( % vs %) or diabetes mellitus ( % vs %). in our main analysis ( the results are consistent with the article published by gisondi et al. during the peak of the italian pandemic [ ] that suggests that psoriatic patients receiving biologic treatments are not associated with worse outcomes. a strength of this study is that we analyzed a prospective cohort, that we know the base population and that we can calculate the incidences. this study therefore avoids problems of other ongoing international registries based on case notifications, which do not have a welldefined base population and likely suffer from selection bias [ ] . although the first data were reassuring at the start of the pandemic, some authors consider that it is necessary to confirm them using prospective studies of incidence with adequate denominators [ ] . the limitations of this study include the lack of serological or molecular confirmations for the diagnosis of covid- of all possible cases, which is because in cases of mild courses of the disease testing was often not done during the period of the study. in conclusion, this prospective cohort study suggests that classic systemic or biologic treatments increase neither the susceptibility nor the severity of covid- . ( ) ( ) ( ) ( ) icu admission or similar ( ) ( ) ( ) ( ) ( ) ( ) ( ) death ( ) ( ) ( ) ( ) ( ) ( ) ( ) • dr herrera-ceballos has served as a consultant and/or speaker for and/or participated in clinical trials as ip and sponsored by companies that manufacture drugs used for the treatment of psoriasis, including abbvie, janssen-cilag, leo pharma, lilly, novartis and pfizer. • dr botella-estrada has served as a consultant and/or paid speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis verónica massó lópez marina sáez belló (hospital universitario dr. peset), Ángeles flórez menéndez miguel Ángel descalzo gallego infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the biobadaderm registry • dr carretero has been reimbursed by janssen, abbvie, novartis, pfizer, msd and celgene for advisory service and conference. • dr garcía-donoso participated as ab from abbvie, almirall and speaker for janssen, lilly and celgene. • dr llamas-velasco acted as a consultant and speaker and participated in clinical trials for janssen-cilag verónica massó lópez marina sáez belló (hospital universitario dr. peset), Ángeles flórez menéndez miguel Ángel descalzo gallego infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the biobadaderm registry institute of health carlos. covid- cases in spain nº the impact of the covid- pandemic on patients with chronic plaque psoriasis being treated with biological therapy: the northern italy experience international collaboration and rapid harmonization across dermatologic covid- registries more on covid- in immune-mediated inflammatory diseases this work was conducted within the biobadaderm study group. the following members participated in acquisition of data and review of the manuscript: esteban daudén, mar llamas-velasco, cristina santamaría (hospital universitario de la princesa); gregorio carretero, jaime vilar-alejo, blanca madrid Álvarez (hospital universitario de gran canaria dr. negrín); raquel rivera, carmen garcía-donoso, mª del mar onteniente gomis, diana batista cabrera (hospital key: cord- -pjdedw w authors: grant-kels, jane m. title: invited response to the comment on “dermatology residents and the care of covid- patients” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: pjdedw w nan i am greatly appreciative to dr. basil patel for his comments on the dermatoethic's piece entitled "dermatology residents and the care of covid- patients" . as someone who is intimately involved with dermatology residents at two universities, i am personally very aware of residency concern and fear over this pandemic. i will address each of the issues raised by dr. patel. although the fatality rate for those aged - is lower, i recognize that any risk, when it is personal, is terrifying. i did not mean to imply that fear was not appropriate. your assertion that theoretically upholding the hippocratic oath should make the fatality rate irrelevant has some merit. although physicians, as you state, do not need to be martyrs, they need to fulfill their professional responsibility the same as a fireman running into a burning building. there is now personal protective equipment (ppe) that reduces the infectivity rate substantially which if worn properly should be reassuring. i agree that having ppe available is crucial. peggy noonan penned an editorial in the wall street journal published april - , . she reflects upon the "…selflessness of doctors and nurses, for instance, and how they do their jobs because it's a calling. this tells us what bravery looks like, but also what a vocation is, and how a vocation is a spiritual event." . i am very sensitive to the fact that many residents are young with spouses and children. the risk of returning home after caring for infectious patients is something i did not mention but was acutely aware of. the need to be concise and conform to the word limit of a letter prevented me from raising this issue. finally, you raised the issue of power dynamics and that residents have little leverage. this implies that attendings are not fulfilling their obligation to care for these infectious patients. emergency room and hospital attendings (many of whom ,at many hospitals, include called-up dermatology attendings) are potentially jeopardizing their well-being just as you are. i hope that all are pitching in during this national emergency not out of fear that their contract will not be renewed but "to fulfill the key human desire to be part of something -'to be part of team humanity, to be useful." i am pleased that you are proud to be helping your community and i am confidant your community is grateful to you. those at the front line caring for these patients are heroes. this pandemic has tested all of us. i am hopeful that out of this trial we will grow as physicians and human beings. thank you for your service. comment on dermatology residents and the care of covid- dermatology residents and the care of covid- a holy week amid a national tribulation key: cord- -isgcm lj authors: lee, justin; yousaf, ahmed; fang, wei; kolodney, michael title: male balding is a major risk factor for severe covid- . date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: isgcm lj nan this manuscript is original, has not been published before, and is not being considered for publication elsewhere. we know of no conflicts of interest associated with this publication and there has been no financial incentive for this work that could have influenced results. as the corresponding author, i can confirm that the manuscript has been read and approved for submission by the other named authors. informed consent was obtained from all participants registered with the uk biobank. options included the following text: pattern "no hair loss," pattern "slight hair loss," pattern "moderate hair loss," pattern "severe hair loss." covid- testing was carried out on symptomatic patients per national health service guidelines . descriptive frequencies for covid- results, balding patterns, age, and bmi are reported in our study compared a large sample of hospitalized covid- positive patients to a control group of hospitalized covid- negative patients and thus builds upon and supports the observations of wambier and coauthors. a notable limitation of our work is that balding data was self-reported. while the exact mechanism remains unknown, severe androgenic alopecia seems to be associated with hospitalization for covid- . the large effect of baldness on the risk of covid- suggests that the presence of severe baldness may help clinicians and public health authorities identify and protect those at greatest risk. figure . descriptive frequencies for covid- testing results, balding patterns, age, and bmi. androgenetic alopecia present in the majority of hospitalized covid- patients -the "gabrin sign a preliminary observation: male pattern hair loss among hospitalized covid- patients in spain -a potential clue to the role of androgens in covid- severity male pattern baldness: classification and incidence resource screenshot from touchscreen questionnaire used to capture field . uk biobank coronavirus staff guidance inpatient testing protocol key: cord- -swex r authors: brumfiel, caitlin m.; jefferson, itisha s.; wu, albert g.; strunck, jennifer l.; veerabagu, surya; lin, krysta; brodell, robert t.; rosman, ilana s. title: a national webinar for dermatology applicants during the covid- pandemic date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: swex r nan diga is a national student-run organization composed of medical school chapters that serves as a forum for the exchange of information among students interested in dermatology. with support from the apd, a webinar titled 'the shifting landscape of the - dermatology application cycle in the era of the covid- pandemic' was developed. six u.s. residency program director panelists participated in the event. a total of viewers attended the webinar. an optional poll was administered; only medical students were asked to respond. of respondents, % were fourth year students ( % third year, % preclinical, and % identified as other). minorities underrepresented in medicine accounted for % of respondents; % of respondents reported attending an institution not affiliated with a dermatology residency program. during the webinar, panelists collectively addressed this year's residency application process via questions prompted by physician moderators (table ) . these questions had been collected from medical students via google questionnaires administered by diga in the weeks prior to the event. additional "real- time" questions from viewers were answered both verbally and in written form within zoom's question and answer and chat functions. program director panelists also presented highlights from the apd consensus statement, such as promoting application to fewer programs to allow for holistic review. panelists emphasized one recommendation letter may be written by any faculty member with whom a student has worked closely, regardless of specialty. this is important given one quarter of our attendees interested in dermatology do not have a home program. virtual away rotations were described as opportunities to learn more about specific programs but should not be perceived as necessary to match into dermatology. the webinar was recorded and is freely available for reference. the covid- pandemic has presented significant challenges for graduate medical education. fortunately, the broad adoption of video conference communication has translated into unique opportunities for medical students to stay informed on issues of significant value to them. the large number of webinar viewers suggests acute interest in this format and discussions for a future webinar on virtual interviews have begun. underrepresented minorities and students without home dermatology programs constituted a significant portion of the webinar audience, demonstrating the need and opportunity to fill gaps in recruitment and mentorship for these groups. beyond covid- and the resumption of the traditional residency application process, large-scale webinars may continue to be invaluable resources for dermatology applicants. j o u r n a l p r e -p r o o f approaching the dermatology residency application process during a pandemic e f /updated_dermatology_program_director_statement_on_ - the residency application process amid the covid- crisis. advice for the ophthalmology residency match season the shifting landscape of the - dermatology application cycle in the era of the • students submit no more than applications to dermatology programs (recommended - ) • students accept no more than interviews (recommended - ) • programs do not offer in-person away rotations, except for students without home dermatology residency programs • programs conduct virtual interviews for all applicants how should students express interest in specific programs given most dermatology away rotations are cancelled? who should i contact in the department/division? (program director? chief resident?) how do i find contact information? should a mentor advocate for me or make calls on my behalf? should i tailor my personal statement to specific programs? should i have a region-specific strategy? how should students without a home dermatology program approach away rotations? are test scores weighted differently this year and if so, how? how will different application components be weighted (e.g., letters of recommendation, personal statement, clerkship grades)? how can applicants strengthen their applications (especially those with weaker test scores and those who have had opportunities cancelled)? how should i address "red flags" on my application (e.g., lowstep score, personal leave of absence, repeating clinical rotations)? how should applicants prepare for virtual interviews? are programs going to be coordinating virtual interview dates? how should applicants get the best feel for programs now that in-person meet-and-greets, away rotations, and interviews are cancelled? is it beneficial to take a year off to do research in dermatology? how should i include research experiences and projects that have been delayed or cancelled on my application? how can international medical students strengthen their applications this year? will virtual rotations accept international medical students? table . questions directed to six dermatology residency program director panelists during the webinar. key: cord- - ndan authors: shaw, katharina s.; karagounis, theodora k.; yin, lu; gibbon, grace; betensky, rebecca a.; lo sicco, kristen i.; femia, alisa n. title: response to “patient preference for cellulitis treatment: at-home care is preferred to hospital-based treatment” date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: ndan nan preference of patients for at-home treatment of cellulitis rather than hospital-based care. notably, these results reflected patient preferences well before the onset of the covid- pandemic. in light of recent reports linking patient anxiety over covid- to delayed and decreased hospital presentations for acute medical problems such as myocardial infarction and stroke , we examined whether a similar trend was observed for patients presenting with skin and soft tissue infections (sstis) at an urban tertiary care center in the epicenter of the covid- after obtaining irb approval, we queried emergency department (ed) visits at nyu langone and , respectively) . our findings highlight a similar pattern observed by our cardiology and neurology colleagues - namely, that fewer patients sought hospital-based care for acute dermatologic problems like sstis during the height of the covid- pandemic. these results suggest that some patients with sstis may have avoided hospital-based evaluation and treatment due to fear of covid- . while we can neither comment on whether these patients sought evaluation elsewhere (such as in an outpatient or telemedicine setting) nor on the outcomes of patients who may have foregone hospital evaluation for sstis, the findings of gabel et al have proven prescient. thus, we argue for careful risk stratification of patients diagnosed with cellulitis in outpatient, urgent care and ed settings going forward. in the context of growing outbreaks in other states and concern for heightened incidence of covid- in the fall, we encourage outpatient treatment of cellulitis - including parenteral antimicrobial therapy when feasible -for those patients without relevant risk factors for poor outcomes. moreover, given that patients may be reluctant to seek hospital- based care, we highlight the need to remain accessible to patients in the outpatient setting or through virtual visits, particularly during periods of stress on local hospital systems. patient preference for cellulitis treatment: at-home care is preferred to hospital-based treatment st-segment elevation cardiac catheterization laboratory activations in the united states during covid- pandemic eerie emptiness of ers worries doctors: where are the heart attacks and key: cord- -y a qyi authors: price, kyla n.; frew, john w.; hsiao, jennifer l.; shi, vivian y. title: covid- and immunomodulator/immunosuppressant use in dermatology date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: y a qyi nan to the editor: we read with great interest the commentary by lebwohl et al recently published in the journal of the american academy of dermatology. the authors provided a pertinent overview of infection risk associated with commonly used biologics to treat psoriasis in light of the current coronavirus disease (covid- ) outbreak. we agree that this time has been particularly concerning for patients taking immunomodulators/immunosuppressants who are unsure of their risk for severe disease. in response to the previous commentary, the goal of this letter is to expand and provide the latest information about covid- along with considerations for addressing patient concerns surrounding dermatology-related immunomodulator/immunosuppressant use. theoretical data from previous coronavirus outbreaks has suggested a strong role for type i interferon, b-cellereleased antibodies, tumor necrosis factor-, and other cytokines in the viral immune response (fig ) . [ ] [ ] [ ] interleukin (il) cytokines are important for immune cell recruitment to infection sites to promote clearance, while also activating downstream cascades of cytokines and chemokines. il- promotes fever and the differentiation of t-helper cells to il- eproducing t cells. tumor necrosis factor-promotes dendritic cell differentiation, leukocyte recruitment, and mediates fever. antibodies produced by plasma cells help to neutralize the virus, limit infection, and prevent future infections. disruption of b-cell differentiation into plasma cells could limit antibody production. broad immunosuppression across multiple cytokine axes with immunosuppressants has the potential to increase susceptibility, persistence, and reactivation of viral infections. immunosuppressants decrease cytokines that recruit and differentiate immune cells needed to clear the infection. in addition, inflammatory mediators can become hyperactivated, resulting in a ''cytokine storm,'' which is the primary cause of death in severe disease. whether withdrawal of broadly immunosuppressive therapies may increase the risk of precipitating cytokine storm is unknown. therefore, classic immunosuppressants may present the most concerning risk for those affected by covid- (table i) . immunomodulators, such as biologics, that do not target vital domains within the viral immune response may dampen, but not significantly affect viral clearance. currently, there are no data describing the benefits or risks of stopping immunomodulators/ immunosuppressants during the covid- outbreak. however, each medication's mechanism of action, administration method/frequency, and pharmacokinetics/pharmacodynamics are important to consider. nonbiologic medications, including small molecule inhibitors and immunosuppressants, are typically easier to stop and restart within days to weeks due to shorter half-life. meanwhile, biologics generally have a longer half-life and include a risk of antidrug antibody formation with treatment cessation and subsequent continuation. however, biologics also tend to be more targeted and less involved in the previously mentioned components of the viral immune response. general medication considerations are included in table i . although patient dependent, clinicians may consider weaning patients with stable disease off of immunosuppressants. shared decision making is needed when deciding on a treatment plan that includes immunomodulators/immunosuppressants during the covid- outbreak. patients with existing comorbidities may require more conservative measures. physicians should continue to consult with the centers for disease control and prevention information for healthcare providers, which is updated daily (https://www.cdc.gov/coronavirus/ -ncov/hc p/index.html). once again, we thank the authors for raising awareness of patient concerns during this evolving outbreak. the resulting inflammatory cytokines and antibodies continue to stimulate the production of additional cytokines and antibodies, which may contribute to the ''cytokine storm'' noted in those with severe disease. ( ) the inflammatory cytokines and antibodies also promote the influx of neutrophils, monocytes, and macrophages along with additional inflammatory cytokines. (right) the drug targets for common dermatologic immunomodulators and immunosuppressants have also been included in this diagram. fgf, basic fibroblast growth factor; gcsf, granulocyte-colony stimulating factor; gmcsf, granulocyte-macrophage colonystimulating factor; il, interleukin; ip , interferon -induced protein ; irf, interferon regulatory factor; mcp , monocyte chemoattractant protein ; mip a, macrophage inflammatory protein -; nfat, nuclear factor of activated t cells; nf-b, nuclear factor-b; pde , phosphodiesterase ; pdgf, platelet-derived growth factor; pka, protein kinase a; t h , t-helper cell; tnf, tumor necrosis factor; vegfa, vascular endothelial growth factor a. created with biorender.com. bees, gpskin, altus labs, and skin actives scientific. there were no incentives or transactions, financial or otherwise, relevant to this manuscript. kyla n. price and drs frew and hsiao have no conflicts of interest to declare. irb approval status: not applicable. accepted for publication march , . reprints not available from the authors. should biologics for psoriasis be interrupted in the era of covid- ? the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak immune responses in covid- and potential vaccines: lessons learned from sars and mers epidemic coronavirus infections and immune responses centers for disease control and prevention. coronavirus (covid- ). available at key: cord- -vlwlgp authors: su, mack y.; das, shinjita title: expansion of asynchronous teledermatology during the covid- pandemic date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: vlwlgp nan person visits at our institution in april (n= ) represented less than % of the volume in april (n= ; table ). meanwhile, virtual visits were conducted in april compared to in april . asynchronous teledermatology visits also increased, driven primarily by evisits. in april , evisits were conducted compared to only in april , when the program was in a pre-pilot phase with only one dermatologist testing evisits. despite significant nationwide reductions in ambulatory visits , provider-to-provider dermatology econsults increased by more than % from april to april . importantly, the growth of evisits and econsults resulted in asynchronous teledermatology accounting for in of all dermatology visits conducted at our institution in april ( figure ). teledermatology was our lifeline for maintaining patient care while physical clinics were closed. even as clinics re-open, we encourage dermatologists to consider maintaining teledermatology as part of their practice in order to improve patient access and staff productivity and remain at the forefront of the changing healthcare delivery landscape. more specifically, our experience shows that asynchronous teledermatology has the potential to facilitate routine dermatology care and thus open in-office availability for more urgent issues. currently, limited reimbursement and efficacy data for asynchronous teledermatology have prohibited its widespread adoption. to address this, we advocate for more investigation of asynchronous teledermatology, including patient/provider satisfaction and patient outcomes. dermatology practices as vectors for covid- transmission: a call for immediate cessation of nonemergent dermatology visits teledermatology in the era of covid- : experience of an academic department of dermatology clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial implementation and evaluation of stanford health care direct-care teledermatology program the impact of the covid- pandemic on outpatient visits: a rebound emerges key: cord- - f frlr authors: yu, jiade; chen, jennifer k.; mowad, christen m.; reeder, margo; hylwa, sara; chisolm, sarah; dunnick, cory a.; goldminz, ari m.; jacob, sharon e.; wu, peggy a.; zippin, jonathan; atwater, amber reck title: occupational dermatitis to facial personal protective equipment in healthcare workers: a systematic review date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: f frlr background prolonged wear of facial protective equipment can lead to occupational dermatoses. objective to identify important causes of occupational dermatoses from facial protective equipment. methods a systematic review following prisma guidelines was performed using pubmed and embase databases. articles were included if they reported occupational dermatoses caused by surgical/procedure masks and/or n respirators. results articles were identified; were suitable for inclusion in this review. selected articles focused on facial occupational dermatoses in healthcare workers. allergic contact dermatitis was reported to the elastic straps, glue, and formaldehyde released from the mask fabric. irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (greater than hours). acneiform eruption was reported due to prolonged wear and occlusion. contact urticaria was rare. limitations only publications listed in pubmed or embase were included. most publications were case reports and retrospective studies. conclusions this systematic review from members of the american contact dermatitis society highlights cases of occupational dermatitis to facial protective equipment including potential offending allergens. this work may help in the diagnosis and treatment of healthcare workers with facial occupational dermatitis. personal protective equipment (ppe), including medical face masks, is essential to the safety of healthcare workers (hcws). there are two primary types of face masks: surgical/procedure masks and n respirators. surgical/procedure masks (also referred to as medical face masks) are designed to block large-particle droplets and provide varying levels of protection based on the masks' materials. n respirators block at least % of . -micron test particles. identified. after removal of duplicates and those that did not meet inclusion criteria (table ) , j o u r n a l p r e -p r o o f areas of involvement in these studies included cheeks, nasal bridge and forehead; these could be potential areas of focus for preventative workplace strategies. hcws at greater risk for adverse reaction during covid- wore ppe > hours/day. , length of wear could be a potential workplace modification to assist hcws experiencing mask-related adverse cutaneous reactions. two studies on hcws not in epidemics or pandemics described facial contact dermatitis and facial skin concerns, some of which may have been related to masks. while facial contact dermatitis typically refers to acd or icd, it is difficult to conceptualize a diagnosis with the term "skin concern". it would be advantageous if future studies on cutaneous face mask reactions included specific descriptive symptoms and signs. adhesive chemicals are used in the construction of medical face masks and n respirators. a case report described acd to mdbgn in the adhesive material beneath the mask polyester foam strip. mdbgn is a preservative that is used in some adhesives. formaldehyde has been described as an allergen in n respirators. , formaldehyde is a preservative and is used in the production of resins, plastics, plywood, and paper products. in one case report, chemical evaluation of an n respirator identified formaldehyde, possibly a byproduct of polypropylene degradation during production of the mask. , - other potential sources of undisclosed formaldehyde include its presence in raw materials or as a contaminant released from product packaging. , aside from the possible risk of formaldehyde release from polypropylene degradation, polypropylene itself poses a low risk of acd. identified. after removal of duplicates and those that did not meet inclusion criteria (table ) formaldehyde has been described as an allergen in n respirators. , formaldehyde is a preservative and is used in the production of resins, plastics, plywood, and paper products. in one case report, chemical evaluation of an n respirator identified formaldehyde, possibly a byproduct of polypropylene degradation during production of the mask. , - other potential j o u r n a l p r e -p r o o f following use of n facial masks allergic contact dermatitis from formaldehyde textile resins in surgical uniforms and nonwoven textile masks autoxidation of polyoxyethylenic non-ionic surfactants and of polyethylene glycols peroxides in polyethylene glycols and polyethylene glycol derivatives contact allergenic activity of tween before and after air exposure adverse skin reactions to personal protective equipment against severe acute respiratory syndrome--a descriptive study occupational contact dermatitis preferred reporting items for systematic reviews and meta-analyses: the prisma statement adverse skin reactions among healthcare workers during the coronavirus disease outbreak: a survey in wuhan and its surrounding skin damage among health care workers managing coronavirus disease- self-report occupational-related contact dermatitis: prevalence and risk factors among healthcare workers in gondar town -a cross-sectional study safety equipment: when protection becomes a problem occupational allergic contact dermatitis in an obstetrics and gynecology resident allergic contact dermatitis in dental professionals: effective diagnosis and treatment a review of non-glove personal protective equipment-related occupational dermatoses reported to epiderm between and surgical mask contact dermatitis and epidemiology of contact dermatitis following use of n facial masks allergic contact dermatitis from formaldehyde textile resins in surgical uniforms and nonwoven textile masks autoxidation of polyoxyethylenic non-ionic surfactants and of polyethylene glycols peroxides in polyethylene glycols and polyethylene glycol derivatives contact allergenic activity of tween before and after air exposure key: cord- - twnqr k authors: patrì, angela; gallo, lucia; guarino, maria; fabbrocini, gabriella title: sexual transmission of severe acute respiratory syndrome coronavirus (sars-cov- ): a new possible route of infection? date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: twnqr k nan to the editor: the severe acute respiratory syndrome coronavirus (sars-cov- ) is the virus responsible for the coronavirus disease (covid- ), first identified in wuhan, china, in december , and that has now actually spread worldwide. the human-tohuman transmission routes hitherto recognized include direct transmission, through cough, sneeze, droplet inhalation, and contact transmission, comprising contact with oral, nasal, and eye mucous membranes. to date, covid- has not been reported to be sexually transmitted. however, a series of data raises the possibility that sexual intercourse could be an additional direct way of infection. this hypothesis mainly derives from the recent evidence of a likely fecal-oral transmission. the exact mechanisms by which sars-cov- interacts with the gastrointestinal tract is unknown. however, angiotensin-converting enzyme ii (ace ) seems to be used by the virus as a receptor to enter cells. ace messenger rna is highly expressed in the gastrointestinal system, and immunofluorescent data show that the ace protein is abundantly present in the glandular cells of rectal epithelia. , in addition, sars-cov- rna identification and intracellular staining of viral nucleocapsid protein in rectal epithelia demonstrated that the virus infects such epithelial cells. [ ] [ ] [ ] the recognition of viral rna from feces indicates that virions are secreted from the virus-infected cells. [ ] [ ] [ ] moreover, sars-cov- can also be transmitted through the saliva, and ace has been detected on the mucosa of oral cavity, which is rich in epithelial cells. therefore, if saliva and feces are both capable of carrying the virus and ace is expressed both in the glandular cells of rectal epithelia and oral mucosa, how can we be sure that sexual intercourse does not represent another way of contagion? we thus hypothesize that practice of certain sexual behaviors could constitute an additional way for the contagion, both directly (eg through oral-anal contacts), or indirectly (eg with exposure of the rectal mucosa to the saliva for lubrication during anal sex). this issue could be particularly noteworthy if considering that a patient with covid- is actually considered cured after at least upper respiratory tract samples negative for sars-cov- are collected at $ -hour intervals. nevertheless, it has been demonstrated that patients can persistently test positive on rectal swabs even after negative results for nasopharyngeal testing. this means that the gastrointestinal tract may continue shedding the virus and that fecal-oral, or eventually sexual, transmission may be possible despite the apparent recovery. indeed, some authors recommend that real-time reverse transcription polymerase chain reaction be routinely performed to test for sars-cov- from feces. patients' sexual habits are often not investigated. these observations highlight the need for physicians, and dermatologists in particular, to strongly discourage sexual practices if infected during the pandemic covid- . indeed, beyond the hypothesized possibility of a direct sexual transmission, sexual intercourse involves close contact that inevitably expose individuals to the risk of contagion. refining the questions in epidemiologic surveys and conducting extensive studies of the mucosal sites ( genitals included) of sars-cov- shedding may perhaps confirm our hypothesis, allowing for a greater understanding about sars-cov- transmission routes and effective strategies to control infection spread. funding sources: none. transmission routes of -ncov and controls in dental practice covid- : faecal-oral transmission? nat rev gastroenterol hepatol evidence for gastrointestinal infection of sars-cov- high expression of ace receptor of -ncov on the epithelial cells of oral mucosa characteristics of pediatric sars-cov- infection and potential evidence for persistent fecal viral shedding key: cord- -x qqdr authors: geskin, larisa j.; trager, megan h.; aasi, sumaira z.; bickers, david r.; carvajal, richard d.; nghiem, paul; taback, bret; zeitouni, nathalie c.; samie, faramarz h. title: perspectives on the recommendations for skin cancer management during the covid- pandemic date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: x qqdr nan therapy-related travel for the high-risk category (high-risk cscc, invasive, thick and ulcerated melanoma, mcc, tumors with aggressive histology or in sensitive areas) must be weighed against each patient's risks. for rapidly growing cscc, particularly of the head and neck (eyes, ears, lips, mouth) and symptomatic lesions, more immediate treatment may be considered. mms may be utilized for high-risk scc and rare cancers (including undifferentiated pleiomorphic sarcoma and adnexal tumors with concern for rapidly developing metastasis). to telemedicine visits should be prioritized, limiting in-person visits for biopsies of highly suspicious lesions and for in-office therapies for the highest-risk cancers. this pandemic presents evolving challenges, and we must continue to provide optimal treatment for our patients while preventing global spread of the disease and preserving resources. managing cancer care during the covid- pandemic: agility and collaboration toward a common goal a new evidence-based risk stratification system for cutaneous squamous cell carcinoma into low, intermediate, and high risk groups with implications for management key: cord- -fp phk p authors: kearns, donovan g.; chat, vipawee s.; uppal, shelley; wu, jashin j. title: assessing the risk of adalimumab use for hidradenitis suppurativa during the covid- pandemic date: - - journal: j am acad dermatol doi: . /j.jaad. . . sha: doc_id: cord_uid: fp phk p nan despite prolonged quarantines and social restrictions, the covid- pandemic continues to persist in the united states and globally. questions still remain regarding the safety of various immunosuppressive medications for those with chronic conditions. with limited real-life data from covid- infection in patients with hidradenitis suppurativa (hs) receiving adalimumab, we can use previous drug trials to extrapolate the potential risk to patients, based upon the change in infection rate when compared to placebo. adalimumab, a tumor necrosis factor alpha (tnf-α) antagonist, is the only fda approved biologic treatment for patients > years with for moderate to severe hs. tnf-α is a pleiotropic cytokine with pro-inflammatory functions that serves to protect against bacterial, fungal and viral infection. primary infection or reactivation of hiv, varicella zoster virus, epstein-barr virus, hepatitis, cytomegalovirus, jc and human papillomavirus have all been reported in patients receiving tnf-α therapy. tnf-α has been shown to be significantly elevated in patients with the sars-cov- infection, and serum levels are positively correlated with disease severity. it is currently uncertain whether elevated tnfα is necessary for resolution of sars-cov- infection or if it plays a pathological role in the development of "cytokine storm". in two placebo-controlled phase iii clinical trials (pioneer i/ii), adults with moderate-tosevere hs were randomized to receive adalimumab ( mg), or placebo. the trials were divided into two periods. in period , patients' receiver either mg of adalimumab weekly (qw) or placebo for weeks. in period , patients received adalimumab ( mg) weekly, every-otherweek (q w) or placebo for weeks. at the end of period , infection developed in . % and . % of those receiving adalimumab qw, compared to . % and . % of patients receiving placebo, in pioneer and , respectively. at the end of period , infection occurred in . % and . % of patients receiving adalimumab qw, . and . of patients receiving the medication q w and . and . % of patients in the placebo control group, in pioneer and , respectively. there was no increase in serious infection or nasopharyngitis observed in active treatment groups. in both trials, it was concluded that the rate of infection was not increased in adalimumab-treated patients compared to placebo ( table ) . this study's analysis was limited by the original research from the adalimumab trials, as the authors of the trials did not specify the whether the cause of infection was bacterial or viral. however, the findings support the notion that healthy hs patients, without risk factors, who use adalimumab during the covid- pandemic are not predisposed to infection or nasopharyngitis ( table ) . this is consistent with a recent case series documenting mild, uncomplicated disease in a small cohort of hs patients receiving adalimumab. clinicians considering discontinuing adalimumab in high-risk patients should be aware that discontinuation of biologics has been shown to result in decreased response to treatment and the development of antidrug antibodies. *this data is a combined average of two-phase iii trials. the adalimumab group is a combined average of two treatment schedules (once per week or once per two weeks) tumor necrosis factor blockade and the risk of viral infection clinical features of patients infected with novel coronavirus in wuhan two phase trials of adalimumab for hidradenitis suppurativa experience in patients with hidradenitis suppurativa and covid- symptoms