key: cord-0787378-idgsivim authors: EL‐Komy, Mohamed H.M.; Abdelnaby, Asmaa; El‐Kalioby, Mona title: How does COVID‐19 impact psoriasis practice, prescription patterns, and healthcare delivery for psoriasis patients? A cross‐sectional survey study date: 2021-04-03 journal: J Cosmet Dermatol DOI: 10.1111/jocd.14104 sha: 8d99bdf11b0e8c9df44d3172e92b7e932ee17266 doc_id: 787378 cord_uid: idgsivim BACKGROUND: Psoriasis is a chronic skin disease that needs continuous medical care. During COVID‐19, delivering medical service was negatively affected. AIMS: To describe the impact of COVID‐19 on psoriasis healthcare delivery, management, and practice. METHODS: This observational cross‐sectional study was conducted on 197 dermatologists using a validated online questionnaire. The survey evaluated the effect of COVID‐19 on the decisions, prescription patterns, appointments rescheduling, and healthcare delivery for psoriasis patients by dermatologists. The questionnaire was developed and validated with a reliability score >0.7. RESULTS: During the pandemic, most dermatologists delayed initiating biological/immunosuppressive therapy for psoriasis unless urgently needed by the patient. For patients already receiving biologics or immunosuppressive treatment, most dermatologists favored continuation of therapy. Almost half (44.2%) of participants do not perform SARS‐CoV‐2 PCR screening before initiating biologics/immunosuppressive therapy. Dermatologists also reported an increased prescription of topical medications (79.2%), natural sunlight (28.4%), acitretin (26.9%), and home UVB (21.3%). Opinions regarding the use of hydroxychloroquine for COVID‐19 treatment/prophylaxis for psoriasis patients were controversial. Intervals between face‐to‐face follow‐up visits were prolonged by 71.6% of dermatologists. More than half of participants reported that their patients discontinued treatment without medical consultation. More than three fourth of responders either agreed or strongly agreed that COVID‐19 negatively affected psoriasis patients. CONCLUSIONS: The COVID‐19 pandemic has a negative impact on psoriasis management and healthcare delivery. Dermatologists are cautious about using biologics and immunosuppressive drugs during the pandemic, making case‐by‐case decisions. Psoriasis patients need compliance monitoring, and psychological support during the pandemic, which can be facilitated by teledermatology. Coronavirus disease emerged in Wuhan city in China by the end of December 2019. 1 Eventually, the virus spread far and wide to many countries all over the world. 2 On March 11, 2020, the World Health Organization declared COVID-19 as a pandemic. Authorities around the world issued restriction measures to limit virus transmission, for example, imposing lockdown, banning public gatherings, suspending schools and universities, and restricting travel. 1 Work-from-home was encouraged, whenever possible, with calls for a "stay home" policy. Hospitals' workforce was directed largely to the management of COVID-19 and urgent medical conditions, with a decrease in the outpatient clinics' capacity and elective procedures. Subsequently, healthcare delivery and medical services for patients with non-urgent conditions were constrained globally. [3] [4] [5] Psoriasis is a chronic immune-mediated inflammatory skin disease. Psoriasis patients need continuous monitoring and medical care. Stress, smoking, and physical inactivity are major exacerbating factors for the disease. 6 Psoriasis comorbidities, for example, obesity, hypertension, and diabetes mellitus were recognized as risk factors for severe COVID-19 infections. 7 With the COVID-19 outbreak, physicians and patients are concerned regarding the use of biologics and immunosuppressive therapies for the treatment of psoriasis. 8 Furthermore, hydroxychloroquine, a drug prescribed for COVID-19, can flare up psoriasis. 9 In this work, we aimed to describe how the COVID-19 pandemic affected the psoriasis practice and altered the decisions, prescription patterns, management, and healthcare delivery for psoriasis patients by dermatologists. This work was designed as an observational cross-sectional study. The data were collected using a validated online questionnaire conducted on Google forms. The questionnaire was designed and validated as follows: First, construct validity was performed by two dermatologists specialized in psoriasis and an epidemiology expert. Afterward, content validity was measured using Cronbach alpha reliability score and modified accordingly to reach >0.7 level. Finally, the questionnaire was pilot tested on 30 dermatologists. Dermatologists consented to participation in the research before filling the questionnaire. The questionnaire included 29 questions (21 multiple-choice questions, five checkbox questions, and three free-response questions). Questions covered demographic data, therapy decisions, appointments rescheduling, teledermatology use, and perception of the pandemic effect on healthcare delivery for psoriasis (Appendix I). The sample size for the study was calculated using EPI Info sample size calculator with a confidence interval of 95% and an expected frequency of 50%. The population size of dermatologists in the database was 400. Accordingly, the total sample size calculated was 196 dermatologists. Statistical analysis was done using SPSS (Statistical Package for the Social Sciences) version 21. Qualitative data were presented in terms of frequency and percentage, while quantitative data were presented in terms of mean and standard deviation (SD). Statistical tests for quantitative data were done using Chi-squared test and Fisher's exact test. The significant level was set to be equal to or less than 0.05. By the end of the survey period, 197 Egyptian dermatologists responded to the questionnaire (179 females, 90.9%, and 18 males, 9.1%). Their place of work was university hospital for 50 dermatologists (25.4%), public hospital for 32 dermatologists (16.2%), and private clinic for 23 dermatologists (11.7%). While ninety-two participants (46.7%) worked at more than one of these sectors. Their years of practicing dermatology ranged from 0.5 to 44 years with a mean ± SD of 8.86 ± 6.67 (Appendix II). Forty-seven percent (47%) of dermatologists recruited were not using biologics for psoriasis treatment. Interleukin (IL)-17 inhibitors were the most frequently prescribed, while IL12/IL23 inhibitors were the least used. During the pandemic, dermatologists significantly delayed systemic therapy initiation (p < 0.001) with phototherapy being the least delayed (53.8%). For biologics and immunosuppressive drugs, most dermatologists delayed initiation for most patients unless therapy is urgently needed, and this was statistically significant (p < 0.001) ( Table 1) . Among biologics prescribers, the initiation preferences were also for those in urgent need for therapy (Appendix III). There was a statistically significant difference in stopping certain therapies for psoriasis patients during the pandemic. Phototherapy and methotrexate were the least to be discontinued (no discontinuation in 53.8% and 42.6%, respectively), followed by cyclosporine (37.1%) and biologic therapy (17.3%) (p < 0.001) ( Table 2) . Interval between face-to-face follow-up visits was prolonged by 71.6% of dermatologists. This delay affected patients psychologically (34.4%), interfered with drug compliance (40.4%), and worsened psoriasis manifestations (23.8%) as observed by participating dermatologists. Overall, 60% of participating dermatologists used some form of teledermatology during the pandemic. Using teledermatology was reported by 41.6% and 60.9% of participating dermatologists for the first consultation and follow-up consultations, respectively. The most common method of teledermatology used was phone calls and photographs ( Figure 3 ). There was a significant relation between delaying face-to-face follow-up visits and teledermatology use (p = 0.004). Two-third of participants who used any form of teledermatology delayed their face-to-face follow-up visits. More than half of the dermatologists (57.1%) not using teledermatology did not delay their face-to-face follow-up visits. Three quarters (150, 76.1%) of dermatologists reported that none of their psoriasis patients developed COVID-19 infection. Type of psoriasis therapy among patients who developed COVID-19 is shown in Most dermatologists agreed that the COVID-19 negatively affected psoriasis patients and that appointments and phototherapy sessions were more frequently canceled by patients during the pandemic ( Table 3 ). The attitude toward the use of hydroxychloroquine as COVID-19 treatment or prophylaxis for psoriasis patients was mixed as listed in Table 3 . More than half of dermatologists (122, if the patient is infected or suspected of COVID-19 [13] [14] [15] During the pandemic, the dermatologists' preference to initiate/ continue phototherapy that we report here highlights the importance of rescheduling, adequate sterilization, and safety precautions to avoid crowding and long waiting times, thus maintaining safe phototherapy sessions for psoriasis patients. 14, 15 There is no consensus on routine SARS-CoV-2 PCR screening be- trusting the safety of these options; however, this may not be suitable for all cases and such increased tendency can be inadequate and should not be generalized. Old age and comorbidities were associated with higher prevalence and worse outcome of COVID-19 in psoriasis patients. [15] [16] [17] Three-quarters of dermatologists reported that none of their psoriasis patients developed COVID-19. However, this response is limited by COVID-19 stigma where patients may deny having COVID-19. Interestingly, among psoriasis patients who developed COVID-19 infection, 76% were on active treatment, and 24% were on off treatment in comparison with the PsoProtect registry where only 12.1% were on off treatment at the time of writing this manuscript. 18 The use of hydroxychloroquine for treatment or prophylaxis of COVID-19 infection is contradictory. 19 Exacerbation of psoriasis was reported following treatment of COVID-19 with hydroxychloroquine. 20 In the current survey, a controversy was evident among dermatologists regarding the use of hydroxychloroquine for treatment/prophylaxis of COVID-19 in patients suffering from psoriasis. Notably, the national psoriasis foundation recommends avoiding in psoriasis patients. 14, 15 Among the general population, the pandemic was associated with increased stress, anxiety, and smoking, and decreased physical activity, 21 all are known exacerbating factors for psoriasis. 6 During this pandemic, teledermatology was a safe alternative to face-to-face visits. 3, 23 In this survey, 60% of dermatologists used some sort of teledermatology in place of face-to-face visits to follow-up their patients with photographs (store and forward) and phone calls significantly more frequently than video consultations. On first assessment, however, more than half of dermatologists (58.4%) did not use teledermatology and preferred face-to-face con- The authors would like to thank all the dermatologists who responded to this questionnaire. The authors have no conflict of interest to declare. The data that support the findings of this study are included in the Mona El-Kalioby https://orcid.org/0000-0002-9208-2458 Timeline: WHO's COVID-19 response COVID-19 Coronavirus pandemic Update Dermatological consultations in the COVID-19 era: is teledermatology the key to social distancing? an Egyptian experience The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing Clinical and economic strategies in outpatient medical care during the COVID-19 pandemic Critical role of environmental factors in the pathogenesis of psoriasis The association between obesity, type 2 diabetes, and hypertension with severe COVID-19 on admission among Mexicans COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? 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