key: cord-1023419-bf3m5ah0
authors: Torres, Angeli Eloise; Ozog, David M.; Hruza, George J.
title: COVID-19 and Dermatology Practice Changes
date: 2021-05-31
journal: Dermatol Clin
DOI: 10.1016/j.det.2021.05.004
sha: a2ab637dd3e4de5a036444d812409906068e38fa
doc_id: 1023419
cord_uid: bf3m5ah0

The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the “new normal” in various domains of dermatology practice – namely, dermatology consultation, procedural dermatology, and phototherapy – will also be provided. Lastly, we emphasize that COVID-19 is a rapidly evolving situation with expert recommendations changing at an almost daily basis. Therefore, dermatologists must update themselves periodically and make necessary adjustments in accordance with local, state, and federal guidelines and mandates.

The COVID-19 pandemic has substantially impacted medical practice worldwide. At its peak, lockdown measures were implemented in an effort to curb viral spread and reallocate resources and manpower towards the pandemic response. This entailed the closure of ambulatory sites that are deemed non-essential, which included dermatology outpatient clinics. As clinics began to re-open, dermatologists were faced with the challenge of navigating clinical practice while adhering to enhanced safety protocols (i.e. physical distancing, mask wearing, frequent hand washing), and teledermatology -often referred to as the "new normal." In this chapter, we describe how the COVID-19 pandemic has restructured the practice of dermatology, and provide a summary of expert guidelines on the safe conduct of dermatology consultations, procedures, and phototherapy in the midst of this global health crisis.

During the height of the COVID-19 pandemic, many workers switched to working remotely in order minimize in-person encounters and limit viral transmission. The medical field was no exception, as face-to-face patient encounters have been minimized to reduce the need for personal protective equipment (PPE) in short supply, while telemedicine was maximized.

Telemedicine is defined as "the use of electronic information and communications technologies to provide and support health care when distance separates the participants." 1 This encompasses radio dispatching of emergency personnel, robotic surgery, and telephone and/or video consults. 1 Being a highly visual field, dermatology is a field well-suited to maximize telemedicine. The term "teledermatology" has been used to describe the utilization of telemedicine to evaluate skin lesions, review laboratory findings, and diagnose and treat patients remotely. 2 

First developed during the 1960s, the practice of teledermatology has increased exponentially in recent years. 2 It has proven vital during the peak of COVID-19 restrictions and, even as clinics have re-opened, teledermatology continued to account for a significant proportion of overall dermatology visits. 3 A recent analysis of trends in teledermatology utilization found that from May 2020 to June 2020, teledermatology consults for common dermatoses (i.e. acne, rosacea, psoriasis, atopic dermatitis, and eczema) increased, while consults for skin malignancies decreased. 3 This indicates that despite the availability of in-person consultation as an option, both patients and physicians felt comfortable addressing benign skin conditions via teledermatology. 3 It is therefore reasonable to expect the long-term integration of telemedicine into dermatology practice, which necessitates the development of guidelines for optimal delivery of this service ( Table 1) .

 Secure a verbal or written informed consent from the patient prior to the start of the telemedicine encounter.

 Both patient and health care provider should stay in a room/environment that ensures visual and auditory privacy.

 Before commencing with the consult, both parties should identify all persons present in the room and verify that all can be clearly seen and heard.

 Seating and lighting should be conducive for a professional interaction between the J o u r n a l P r e -p r o o f patient and provider. There should be minimal background light from windows or other sources.

 Cameras should be placed at eye level on a stable platform to minimize unnecessary movement and allow clear visualization for both parties.

 The provider should obtain all data necessary in order to arrive at a diagnosis, differential diagnosis, appropriate work-up, and treatment plan.

 While a full body skin examination is feasible through video consult or photographs, it may not show all skin lesions and surfaces with sufficient detail. It may help to obtain multiple images from several angles and enhance lighting.

 For examination of hair-bearing skin, the patient may be required to physically displace or even remove hair. Special lighting may be helpful.

 Examination and diagnosis of pigmented lesions may be challenging and require a high index of suspicion.

 For examination of mucosal lesions and orifices (including genitalia), special attention should be given to adequate lighting and exposure.

 Note that certain lighting and background conditions may alter the color of skin lesions when captured in photo or video.

 Coordinate care with the patient's usual physician (if applicable).

 Make referrals as indicated.

 Communicate encounter notes to the referring physician and/or the patient.  At a minimum, documentation should include a summary of findings, diagnosis and/or differential diagnosis, and management/treatment plan. Teledermatology aims to improve access and accessibility to care, increase efficiency, and reduce cost; 2,5 however, it also has limitations. These include technical difficulties (i.e. poor internet connection), privacy concerns, patient challenges with technology, access to technology, and lack of insurance coverage. 6, 7 In addition, there is potential for misdiagnosis due to incomplete history taking, poor photo/video quality, and inability to perform physical examination (e.g. lesion palpation) and diagnostic procedures. 7 One review reports that over half of teledermatology consultations require a subsequent in-person visit. 2 Hence, clinicians must assess the appropriateness of teledermatology on a case-to-case basis. 4

Trends in average weekly patient visits during the initial phase of the pandemic (mid-February to mid-April) showed an 81% decline (from 149.7 to 28.2), with an uptick observed in mid-May (96.5 patients seen per week), commensurate with the gradual easing of lockdown J o u r n a l P r e -p r o o f restrictions in the United States. 8 This means that from February to May 2020, a potential 10.2 million patient visits were missed, which equates to an estimated decrease in revenue of $2.3 billion. 8 In addition, a global web-based survey of 733 dermatologists revealed that in-person consultation decreased by 54% following the onset of the pandemic, while teledermatology utilization increased three-fold. 9 More than two-thirds of survey respondents expect continued use of teledermatology in the future, further emphasizing its role in dermatology practice beyond the pandemic. 9

Nonetheless, despite its increasing acceptability among both patients and practitioners alike, it is unlikely for teledermatology to entirely replace traditional face-to-face consultation.

One study found that when presented with the same patient, there was a high degree of concordance (72%) between the diagnosis made by a dermatologist through teleconsultation versus another dermatologist through face-to-face visit. 10 However, it was also noted that 20% of the patients were deemed unfit for teleconsultation. This included conditions that cannot be sufficiently diagnosed without closer inspection and palpation, dermoscopy, fungal or viral microscopy, and biopsy. 10 Hence, dermatology practice during the "new normal" involves determining whether a patient is suitable for teledermatology or in-person consultation.

Dermatology practices generally fall under the low-risk category for COVID-19 exposure. 11 However, according to a study by Gerami et al., a dermatologist is likely to encounter one (1) active COVID-19 case per week in the outpatient clinic, given an average of 165 new COVID-19 cases a day in a population of 100,000. 12 Hence, during the pandemic, it is still prudent to have administrative and engineering measures in place to ensure the safety of both patients and staff. The American Academy of Dermatology recommended steps for running J o u r n a l P r e -p r o o f dermatology practice during the COVID-19 pandemic, first shared on their website in December 2020 ( Table 2) . 11 Table 2 . Steps for running dermatology practice during the COVID-19 pandemic

Step 1: Be aware of the COVID-19 prevalence in the community.

 Areas with higher prevalence will likely require more stringent infection control measures.

 Use 70% ethyl alcohol, 0.5% sodium hypochlorite, or any disinfectant product that meets standard criteria for use against SARS-CoV-2.

 In the examination room, clean commonly touched surfaces (e.g. tabletop, examination bed/table, door handle/knob, light switch) in-between patients.

 Clean all other common areas (e.g. bathroom, reception, waiting area) at the end of each day.

 Provide signs and/or floor markings to direct patient traffic and maintain appropriate physical distancing.

 Ensure adequate PPE for all staff members.

 Mask and eye protection should be worn during patient encounters, and patients should be wearing masks.

 Consider measures to conserve PPE as needed (i.e. decontamination and reusing of J o u r n a l P r e -p r o o f masks).

 Prioritize urgent cases.

 Consider transitioning non-urgent cases and follow-ups to telemedicine.

Step 6: Organize your staff.

 Limit the number of staff members per room to facilitate physical distancing.

 Screen staff daily.

 Staff members who are experiencing COVID-19 symptoms should refrain from reporting to work and be referred to employee health services.

Step 7: Screen patients.

 Unless a companion or caregiver is needed (e.g. minors or elderly in need of assistance), patients should come to the appointment alone.  Treat all patients as potentially infectious even if they pass screening.  Health care workers with skin diseases that interfere with their delivery of service.

 Patients with severe skin diseases that are potentially life-threatening, functionally debilitating, or causes significant impairment to quality of life.

 Diagnostic procedures for confirmatory purposes, especially when the differential diagnosis includes high-risk conditions (e.g. melanoma, severe infection, mycosis fungoides, autoimmune blistering diseases).

 Patients with skin disease resulting in significant functional and/or emotional impairment who have no access to or cannot effectively use telemedicine.

 Patients with similar prognoses should be selected randomly as to who gets a particular appointment.

In addition, COVID-19 screening (temperature and symptom check) and wearing of masks became a routine, and in most cases even a pre-requisite for a patient or staff member to J o u r n a l P r e -p r o o f be allowed entry into the clinic. It is recommended that staff members who are suspected to have COVID-19either through positive screening or exposure to an infected individualbe sent home and follow the Centers for Disease Control and Prevention (CDC) guidelines for returning to work following a COVID-19 exposure (Figure 1) . 14 Overall, these adjustments were made to facilitate physical distancing and curtail viral transmission.

Based Table 2) .

With regards to Mohs micrographic surgery (MMS), a United Kingdom-based nationwide survey revealed that almost half of Mohs surgeons completely ceased services during the height of the pandemic, while 36% and 15% had reduced and normal operations, respectively. 16 In order to minimize patient visits, those who continued to perform MMS showed J o u r n a l P r e -p r o o f an increased preference towards the use of absorbable sutures for wound closure, as well as telecommunications (telephone/video) for follow-up visits compared to before COVID-19. 16 On the other hand, post-Mohs reconstructions performed by other specialties were significantly decreased (74%) together with face-to-face consultations (91% decrease). 16 In early 2021, the American Society for Dermatologic Surgery (ASDS) together with the American Society for Laser Medicine and Surgery, Inc. (ASLMS) released guidelines for the safe practice of cosmetic dermatology during COVID-19 ( Table 3) . 17 The document detailed and graded ancillary evidence on various infection prevention and control measures (e.g.

mask/respirator use, eye protection, and handwashing), as well as the risk of viral transmission associated with certain dermatologic procedures. 17 

The COVID-19 pandemic significantly impacted the utilization of chronic dermatologic treatments, including phototherapy. Many phototherapy centers worldwide were closed during the height of the pandemic, while the few that remained open experienced a decline in patient census. In one of the biggest health systems in Israel, the number of patients coming in for phototherapy decreased by more than 50% since March 2020. 18 This decrease was found to be primarily driven by patients declining treatment continuation due to fear of contracting the virus;

the interruption in care posed the risk of a skin disease flare. 18 Photoimmunosuppression may also be of particular concern amidst the pandemic, since it is one of the mechanisms by which phototherapy controls skin disease. However, based on clinical experience with HIV-positive patients, phototherapy is a safe and reasonable option during this time. 19 The risk of SARS-CoV-2 transmission in phototherapy units is currently unknown. 20 While safety protocols observed in other hospital units are largely applicable, there are certain elements unique to phototherapy that require special attention. First, phototherapy involves J o u r n a l P r e -p r o o f having a patient come to the clinic multiple times a week, which potentially increases exposure to both the patient and staff. Second, localized treatments (i.e. excimer laser or light) entail close contact between the patient and the staff for a relatively prolonged period, and treatment of the face and periorificial areas where patients need to be unmasked puts the staff at even higher risk.

Third, full-body treatmentsthough generally preferred during the pandemicare typically administered in enclosed booths where patients stand in close proximity to phototherapy equipment surfaces made of plastic or steel. 21 This can potentially facilitate viral transmission as SARS-CoV-2 has been found to survive for up to 9 days on these surfaces, 21 Therefore, the decision to resume phototherapy should be made based on the weight of its perceived benefit versus the potential risks to both patient and staff. Most guidelines recommend prioritizing patients with severe skin disease, those who are more likely to respond to phototherapy, and in cases wherein other options besides phototherapy are limited or unavailable. 20 Home phototherapy is also a reasonable option and may even be preferable during this time; however, it may not be feasible for all patients.

If in-office phototherapy is deemed necessary, efforts must be taken to conduct operations as safely as possible. 

J o u r n a l P r e -p r o o f  All patients should be scheduled.

 Schedule appointments not more than every 30 minutes in order to limit the number of patients treated per day, and allow adequate time for disinfection in between patients.

 Have all patients screened for COVID-19 symptoms prior to entering the phototherapy unit. Patients with symptoms may be refused treatment and referred to the appropriate COVID-19 referral unit.

 Patients should ideally come alone for their phototherapy appointment. If a companion is necessary (i.e. patient is a minor, an elderly who requires assistance, or disabled), only one (1) is allowed.

 All patients should wear a face mask, except during total body phototherapy treatment.

 All staff and patient companions (if any) should wear a face mask.

 All patients, patient companions, and staff must practice strict hand hygiene at all times. These should includebut are not limited tothe following instances: before entering the phototherapy unit, before and after treatment (for patients), before and after the patient encounter (for staff), after touching high-touch surfaces, before exiting the phototherapy unit.

 Maintain physical distancing at all times. As of February 2021, a total of 72.8 million doses of COVID-19 vaccine have been administered in the United States, the majority of which were first given to healthcare workers (HCWs). 24 In Israel, which was the first country to vaccinate most of their population, fully- 

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Trends in teledermatology use during clinic reopening after COVID-19 closures

Teledermatology: key factors associated with reducing face-to-face dermatology visits

Teledermatology in the wake of COVID-19: Advantages and challenges to continued care in a time of disarray

The aftermath of COVID-19 in dermatology practice: What's next?

The continuing impact of COVID-19 on dermatology practice: Office workflow, economics, and future implications

Impact of covid-19 pandemic on dermatology practice: results of a web-based, global survey

A comparative study of teleconsultations versus face-to-face consultations

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Return to Work Criteria for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance)

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Impact of COVID-19 on Mohs micrographic surgery: UK-wide survey and recommendations for practice

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Ultraviolet and COVID-19 pandemic

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Philippine Dermatological Society Photodermatology Subspecialty Core Group Post-Quarantine Guidelines for Phototherapy Centers

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Frequently Asked Questions about COVID-19 Vaccination