key: cord-1010364-e3bs87u1
authors: Cavanagh, Gregory; Wambier, Carlos
title: Reply to: Personal Protective Equipment Recommendations Based on COVID-19 Route of Transmission
date: 2020-04-25
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.04.102
sha: 823ae09026236f039e6a21a7a4d9e28bc21cae0a
doc_id: 1010364
cord_uid: e3bs87u1

nan

Dear Editor, we thank Gupta and Lipner 1 for the comments and for the opportunity to further clarify the risks of hand irritation from excessive handwashing among healthcare workers, and we agree that alcohol sanitizers are practical, safe, and possibly more effective in neutralizing the virus from hand skin. As an insight for an effective coronavirus hand-washing, hexachlorophene, a very potent bisphenol antiseptic agent, was the active ingredient of two discontinued hospital hand-wash soaps: Septisol and pHisohex. In a screen for small molecules, hexachlorophene and nitazoxanide demonstrated inhibition to Middle East respiratory syndrome coronavirus. 2 Nitazoxanide is currently being tested in clinical trials for SARS-CoV-2 (NCT04541493), and exhibited similar inhibitory potential of remdesivir in vitro. 3 . If not discontinued for important environmental and newborn toxic risks, hexachlorophene could have represented an ideal candidate for hand-washing product in high risk COVID-19 hospital areas, due to residue on the skin after rinsing.

About viral entry mechanism through the skin, serine proteases including TMPRSS2 are expressed in capillary morphogenesis and angiogenesis. 4 mRNA transcripts were found in human blood vessels specimens. As such, the presence of TMPRSS2 in skin capillaries may be a possibility, allowing the transmission of SARS-CoV-2. Since TMPRSS2 expression is androgen receptor-dependent, hormonal expression might be the key gateway for vulnerability to SARS-CoV-2. 5 Currently, the need for external hormones could be reevaluated in healthcare workerssuch as the use of progestins with androgenic activity (for example levonorgestrel or medroxyprogesterone) and the use of androgen replacement therapy -because of the likelihood of increased TMPRSS2 expression in all tissues where it is expressed, including airways and blood vessels. coronaviruses through labile blood products still theoretically possible. 6 Fissures are known to be a transmission route for many pathogens, including other positive-sense, enveloped, RNA viruses such as HIV and Hepatitis C. 7 Fissures and erosions represent discontinuity of the epithelium coverage, making damaged mucosa and skin functionally equivalent for the purposes of the transmission we hypothesize as possible.

While SARS-CoV-2 seems to be transmitted primarily through respiratory droplets, not enough is known about the virus to assume that it does not infect through open wounds. As such, a cautious approach to skin health and hygiene is needed at this time.

Personal Protective Equipment Recommendations Based on COVID-19 Route of Transmission

A screen of the NIH Clinical Collection small molecule library identifies potential anti-coronavirus drugs

Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro

Endothelial cell serine proteases expressed during vascular morphogenesis and angiogenesis

SARS-COV-2 infection is likely to be androgen mediated