key: cord-289855-11pkt4uu authors: bhargava, shashank; rokde, richa; rathod, dipali; kroumpouzos, george title: employing dermatologists on the frontline against covid‐19: all hands on deck date: 2020-05-13 journal: dermatol ther doi: 10.1111/dth.13420 sha: doc_id: 289855 cord_uid: 11pkt4uu nan healthcare system is well equipped to manage the upcoming onslaught of cases. low-resource countries with weakened healthcare systems are likely to become overwhelmed with a sudden surge of cases due to exponential growth and community transmission. therefore, it becomes all the more imperative to consider measures such as social distancing and complete lockdowns with a great deal of seriousness, in order to "flatten the curve" and prevent hospitals from being overburdened. healthcare providers should be recruited in critical care management depending upon their skill set and confidence level. 4 redeployed dermatologists should not be expected to make critical decisions in patient management or carry out complex procedures such as ventilator management. they should receive training in simple procedures such as vascular access, straightforward intubations, proning maneuvers, and fluid management in uncomplicated patients in order to take off some of the pressure from icu staff. as the focus shifts from containment efforts to disease mitigation, the healthcare community must step up as a whole to lend its expertise as never before. in a survey among indian dermatologists, 57% of the respondents would consider redeployment in covid-19 "hot zones" if a need to augment the medical workforce arises. this confirms the altruistic mentality of physicians as they are not averse to stepping outside of their comfort zones for the greater good of society. 5 these are exceptional times that call for exceptional measures. our patients need us to move out of our comfort zones and heed the clarion call for "all hands on deck" in order to defeat covid-19. dermatology staff participate in fight against covid-19 in china cutaneous manifestations in covid-19: a first perspective coronavirus disease (covid-19): a primer for emergency physicians strategic planning and recommendations for healthcare workers during the covid-19 pandemic our thanks to all healthcare workers on the frontlines caring for our most vulnerable key: cord-274331-0i2opmcn authors: wang, catherine j.; truong, allison k. title: covid‐19 infection on il‐23 inhibition date: 2020-07-14 journal: dermatol ther doi: 10.1111/dth.13893 sha: doc_id: 274331 cord_uid: 0i2opmcn nan test was negative, and his chest x-ray was normal. given mild symptoms, the patient was discharged. the next day, the patient returned to the ed with new onset hemoptysis. computed tomography (ct) chest demonstrated bilateral ground glass opacities and his sars-cov-2 polymerase chain reaction (pcr) test was positive. the patient's hospital course was mild, and he was treated symptomatically with nebulizers, benzonatate, and guaifenesin. the patient was discharged 1 week later on home quarantine. two weeks later, he recovered completely. per the recommended risankizumab dosing schedule (every 12 weeks after initial loading doses at week zero and four), the patient received his next dose in april with no complications. the patient in this manuscript has given informed consent to publication of his case details. risankizumab is a monoclonal antibody that inhibits the p19 subunit of il-23 1 another question is when biologics with long half-lives should be restarted. in our case, the patient recovered from covid-19 before his next scheduled risankizumab dose. however, more data needs to be obtained about biologics in covid-19 patients, in particular whether or not biologic dosage timeline should be adjusted based on resolution of infection. a database to collect information on covid-19 patients on biologic therapy and their outcomes would be instrumental to guide clinicians on best practices for now and in future pandemics. in conclusion, this case illustrates that il-23 inhibition via biologic therapy in covid-19 may not correlate with severe respiratory disease. however, the decision to continue biologic treatment should be a shared process between physician and patient on a case-by-case basis. efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (ultimma-1 and ultimma-2): results from two double-blind, randomised, placebocontrolled and ustekinumab-controlled phase 3 trials clinical features of patients infected with 2019 novel coronavirus in wuhan advances in the research of cytokine storm mechanism induced by corona virus disease 2019 and the corresponding immunotherapies th17 responses in cytokine storm of covid-19: an emerging target of jak2 inhibitor fedratinib pathological findings of covid-19 associated with acute respiratory distress syndrome sars-cov-2 infection in a psoriatic patient treated with il-23 inhibitor key: cord-255583-kgph7lr8 authors: kutlu, ömer; metin, ahmet title: a case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a patient with covid‐19: will cases of psoriasis increase after covid‐19 pandemic? date: 2020-04-24 journal: dermatol ther doi: 10.1111/dth.13383 sha: doc_id: 255583 cord_uid: kgph7lr8 nan psoriasis exacerbated with hydroxychloroquine and oseltamivir treatment in a patient with covid-19 will be presented. a 71-year-old woman with no skin lesions was admitted to the pandemic clinic with the diagnosis of covid-19. the patient had a history of psoriasis that has been activated occasionally since childhood. the patient was started orally oseltamivir 2 × 75 mg and hydroxychloroquine on 2 × 400 mg on the first day then 2 × 200 mg. on the fourth day of treatment, the patient had an exacerbation of silver-scaled psoriatic plaques spread quickly all over the body separated from the surrounding tissue with sharp borders. this is the first case of exacerbation of psoriasis during covid-19 infection in a patient receiving oseltamivir versus hydroxychloroquine. the exacerbation of psoriasis in this patient can be explained by several conditions. first, it is well known that hydroxychloroquine is an inhibitor of the epidermal trans-glutaminase, cause to the collection of the epidermal cells. 5 in addition, hydroxychloroquine promotes il-17 production through p38-dependent il-23 release resulting in keratinocyte growth and differentiation. 6 therefore, hydroxychloroquine treatment, which was started as a high dose on the first day, maybe the main factor that exacerbates psoriasis in this patient. to date, we did not find any 10, granulocyte-colony stimulating factor, interferon-inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1 alpha, and tumor necrosis factor α. 7 the increasing some cytokines in the covid-19 that are also accused in the etiopathogenesis of psoriasis may suggest that covid-19 may be a new entity that exacerbates psoriasis vulgaris. as a result, it can be speculated that hydroxychloroquine, a commonly used drug for covid-19 infection, can lead to a worldwide increase number of psoriasis that is prevalence between 1% and 3%. this condition may lead clinicians to new treatments that do not have immunosuppressive properties. 8 characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention understanding sars-cov-2-mediated inflammatory responses: from mechanisms to potential therapeutic tools treating covid-19 off-label drug use, compassionate use, and randomized clinical trials during pandemics the covid-19 epidemic the in vitro effect of hydroxychloroquine on skin morphology in psoriasis chloroquine promotes il-17 production by cd4+ t cells via p38-dependent il-23 release by monocytederived langerhans-like cells clinical features of patients infected with 2019 novel coronavirus in wuhan covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action key: cord-281216-7t647fww authors: goldust, mohamad; zalaudek, iris; gupta, atula; lallas, aimilios; rudnicka, lidia; navarini, alexander a. title: performing dermoscopy in the covid‐19 pandemic date: 2020-05-05 journal: dermatol ther doi: 10.1111/dth.13506 sha: doc_id: 281216 cord_uid: 7t647fww nan a novel coronavirus (sars-cov-2) that has recently emerged from china in late 2019 has become a global pandemic. research has revealed that human coronaviruses can remain infectious on inanimate surfaces at room temperature for up to 9 days. recent data has suggested that sars -cov2 can remain viable in aerosols for multiple hours. on stainless steel and plastic, the virus has shown a median half-life of 5.6 h and 6.8 h respectively. 1 dermoscopy is a very useful diagnostic tool in the daily practice of a dermatologist. however, cross-infection is a significant concern with contact dermoscopy especially during a viral pandemic. previous studies conducted by quadros et al. established that staphylococcus epidermidis, micrococcus species and corynebacterium species were frequently identified on dermatoscope lenses and smartphone adaptors. 2 presence of hpv dna has also been reported in a study on dermoscopic lenses. the aerosol particle sizes of covid-19 range from 3-100 nm and using an ffp3 respirator offers a filtration rate of 99% for all particles measuring up to 0.6 μm. 3 this article is protected by copyright. all rights reserved. to disinfect hands with 60-70% isopropyl alcohol, provide verbal consents, and wear surgical masks before entering procedure rooms. b) dermatologists: dermatologists must wash hands with soap and water or alcohol-based hand rubs before and after procedure. in addition, all health care workers should avoid touching of their own eyes, mouth, and nose. it is preferred to use a polarized non-contact dermatoscope or even a digital dermatoscopic device with image evaluation on screen instead of hand-held dermatoscopes. alternative approaches like the use of a disposable polyethylene lens cover, polyvinyl chloride (pvc) film with mineral oil and glass slide in front of the dermoscopic lens, might also be applied to prevent cross contamination. alcohol containing solutions may be used as an interface medium. it is advisable to wear adequate eye protection (goggles or visor) considering that exposed mucous membranes and unprotected eyes can increase the risk of sars-cov2 transmission. 4 mucous membrane dermoscopy should only be performed when the examination has fundamental significance for therapeutic decisions. preprocedural mouth rinse with 0.2% povidone-iodine or 0.5-1% hydrogen peroxide have been studied to reduce coronavirus in saliva. 5 this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. aerosol and surface stability of sarscov-2 as compared with sars-cov-1 identifying gram-positive cocci on dermatoscopes and smartphone adapters using maldi-tof ms: a cross-sectional study evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators 2019-ncov transmission through the ocular surface must not be ignored transmission routes of 2019-ncov and controls in dental practice key: cord-274090-eab7i4f6 authors: gaspari, valeria; lanzoni, anna; patrizi, annalisa; orioni, gionathan; viviani, filippo; bardazzi, federico title: can covid‐19 be a sexually transmitted disease? posterity will judge date: 2020-05-24 journal: dermatol ther doi: 10.1111/dth.13676 sha: doc_id: 274090 cord_uid: eab7i4f6 nan up to now the precise mode of transmission of sars-cov-2 (severe acute respiratory syndrome-coronavirus-2) has still not been completely described, however the main route is through humanto-human transmission via droplets 1 . multiple studies have concluded that asymptomatic carriers can spread the virus unknowingly 2 , thus leading governments to implement very restrictive rules of social distancing, also recommending the avoidance of multiple sexual intercourses. the knowledge of all possible modes of transmission of sars-cov-2 infection is the key to improving both the identification of the asymptomatic population and the necessary isolation measures in order to further flatten the curve. we operate in a free service for the prevention and treatment of sexually transmitted diseases (stds), and owing to the lack of publications concerning this specific population, we are speculating that a certain percentage of the asymptomatic population could be spreading sars-cov-2 through sexual contact (vaginal, anogenital and orogenital). the presence of sars-cov-2 rna in the feces of covid-19 patients (66.67%) has already been demonstrated in recent studies in wuhan, without being statistically related to gastrointestinal symptoms and/or disease severity. furthermore, 64.29% of these patients showed a persistent positivity for rna search by polymerase chain reaction (pcr) in the stool following viral clearance (negative nasopharyngeal and oropharyngeal swabs) 3 . from a molecular point of view, the ace2 (angiotensin-converting enzyme 2) receptor, largely expressed along the gastrointestinal mucous membranes, has been demonstrated as the cell entry for sars-cov2 4,5 . the human testis has also been indicated as a potential target of sars-cov-2, due to the expression of ace2 receptor in the leydig cells and cells of the seminiferous tubules, leading to potential defects in spermatogenesis 6 . in addition, some authors suggest that the human testis could provide another potential route of infection. moreover, the positivity for sars-cov-2 on vaginal swab raises the possibility of both sexual and mother-to-child transmission 7 , although further studies are needed on these issues since no definitive proofs have been found. over the past weeks we have observed 7 cases of confirmed sars-cov-2 infection in our msm population. this additional data seems to support our speculation, however rectal swabs for the execution of sars-cov-2 pcr are not still available in our stds clinic. in conclusion, it would be useful to confirm the possibility of other alternative ways of viral transmission. if these speculations are confirmed, we should consider implementing an anal swab in all covid-19 patients, also in those with negative pharyngeal swab. a further step would be adding sars-cov-2 serology, pharyngeal, anal and vaginal swabs to our usual std screening also in the asymptomatic population, in order to identify positive cases and to confirm the sars-cov-2 orogenital route of transmission. covid-19 outbreak: an overview evidence for gastrointestinal infection of sars-cov-2 scrna-seq profiling of human testes reveals the presence of the ace2 receptor, a target for sars-cov-2 infection in spermatogonia sars-cov-2 possible contamination of genital area: implications for sexual and vertical transmission routes hepatitis a outbreak disproportionately affecting men who have sex with men (msm) in the european union and european economic area key: cord-297532-ktiwfcop authors: de fata salvatores, gaia; villani, alessia; fabbrocini, gabriella; di guida, adriana title: patients with bullous disorders during covid‐19 period: management and adherence to treatment date: 2020-05-26 journal: dermatol ther doi: 10.1111/dth.13697 sha: doc_id: 297532 cord_uid: ktiwfcop nan dear editor, pemphigoid is included in the group of rare autoimmune bullous disorders affecting the skin and the mucous membrane. it mainly occurs in elderly patients that usually present other comorbidities such as cardiovascular and respiratory problems. this bullous disorder is characterized by an alteration of t-cell immune response, leading to the production of pathogenetic autoantibodies directed against different proteins of the desmosome, and by the release of pro-inflammatory cytokines. this immune alteration clinically manifests with vescicles and erosions on the epithelium of the mucous membrane and of the skin, exposing patients to a higher risk of comorbidities and secondary infections 1 . sars-cov2 infection has now spread all over the world and higher mortality rates have been reported among elderly and comorbid (diabetes, cardiovascular disease, immunosuppression) patients. in this scenario, patients with bullous pemphigoid are part of the high-risk population and preventive measures in order to minimize the risk of infection must be implemented. we want to share our experience about the management of patients with bullous disorders, in particular pemphigoid disease in our outpatient clinic during covid-19 pandemic. since the beginning of march 2020, in our dermatological clinic, outpatient visits have been suspended with the postposition of all non-urgent visits, except for oncological dermatology and emergencies. 10 patients (6 women and 4 men) with a median age of 68.5 years, affected by bullous pemphigoid, all histologically confirmed, were already followed in our day-hospital service before the covid-19 pandemic spread. 7/10 (70%) patients had a mild-moderate grade of the disease, this article is protected by copyright. all rights reserved. it has been widely recognized that the use of immunosuppressive agents, such as oral ccs is associated with an increased mortality in patients with coronavirus pneumonia 2 , but, on the other hand, there are no evidences suggesting the preventive discontinuation of ccs in patients on longterm treatment with these drugs, especially for the risk of acute adrenal insufficiency 3 . weekly telephonic consultations were performed in order to control patients adherence to treatment and to avoid the risk of covid-19 infection. patients received information about the importance of home isolation and the early identification of covid-19-related symptoms. video-call visits were performed and ccs dosages were tapered in case of adverse events and according to the reported skin condition, showing good results and without discontinuing their treatment. in literature, several articles suggesting the use of teledermatology services, such as video-call visits, e-mail and mobile applications as useful tool to take care of patients during this pandemic period have already been bullous pemphigoid the effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis corticosteroid treatment of patients with coronavirus disease covid-19) teledermatology: a useful tool to fight covid-19 teledermatology in the wake of covid-19: advantages and challenges to continued care in a time of disarray this article is protected by copyright. all rights reserved.reported 4, 5 . this tele-service resulted to be effective also in the follow-up of our patients with rare autoimmune disorders; nevertheless reports on larger sample size are needed. key: cord-276549-r5l4pse8 authors: dastoli, stefano; bennardo, luigi; patruno, cataldo; nisticò, steven paul title: are erythema multiforme and urticaria related to a better outcome of covid‐19? date: 2020-06-09 journal: dermatol ther doi: 10.1111/dth.13681 sha: doc_id: 276549 cord_uid: r5l4pse8 nan gering factor, 2 while a little is known about such eruptions not clearly associated to drugs. eosinophilic cells blood count seems to have a major role in covid-19 diagnosis and prognosis. eosinopenia has been associated in up to 81% of cases 3 and was proposed as possible diagnostic marker for the disease. 4 persistent eosinopenia was associated to higher mortality. 3 on the other hand, an increase of eosinophils in blood was related to an improvement of the overall condition of the patient. 5 furthermore, patients with pre-existing atopic disease (asthma, rhinitis, and atopic dermatitis) seem to be less affected by covid-19. 4 therefore, eosinophilia was associated with a protective effect toward the development of covid-19. 6 histopathology of some skin rashes arising during covid-19 shows a perivascular and dermal infiltrate rich in eosinophilic cells. 7 various theories have been proposed in order to explain these findings. eosinopenia may be secondary to cell depletion due to the viral infection or to stress-induced glucocorticoid secretion. 8 eosinophilia might be beneficial thanks to its antiviral effect, as demonstrated for influenza and parainfluenza virus. 5 we can speculate that the non-drug related em and u might be associated to systemic eosinophilia secondary to a strong response to covid-19, and therefore possibly to a better outcome of the disease. indeed, nondrug-induced em has been mostly reported in young healthy nonhospitalized covid-19 patients. 9 u not related to drug reaction was reported in up to 4% of covid-19 patients, 10 in conclusion, we might suppose that em and u, when associated to eosinophilia, could be related to a better outcome of covid-19. however, more clinical data would be needed to prove this association. eosinophilic skin diseases: a comprehensive review dermatology staff participate in fight against covid-19 in china clinical features of 85 fatal cases of covid-19 from wuhan: a retrospective observational study clinical characteristics of 140 patients infected with sars-cov-2 in wuhan covid-19, chronic inflammatory respiratory diseases and eosinophils-observations from reported clinical case series eosinophil responses during covid-19 infections and coronavirus vaccination clinical and histopathological study of skin dermatoses in patients affected by covid-19 infection in the northern part of italy patients of covid-19 may benefit from sustained lopinavir-combined regimen and the increase of eosinophil may predict the outcome of covid-19 progression characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak cutaneous manifestations in covid-19: a first perspective key: cord-296022-yl3j2x5p authors: gupta, mrinal; abdelmaksoud, ayman; jafferany, mohammad; lotti, torello; sadoughifar, roxanna; goldust, mohamad title: covid‐19 and economy date: 2020-04-08 journal: dermatol ther doi: 10.1111/dth.13329 sha: doc_id: 296022 cord_uid: yl3j2x5p nan concern, covid-19 is having major consequences on the world economy, and experts have predicted that covid-19 will lower global gross domestic product growth by one-half a percentage point for 2020 (from 2.9% to 2.4%). the whole world is now a single global community, where any major happening in one part is bound to have repercussions in rest of the world. 2 chinese government, in order to control the spread of the disease, had to close the major production centers and as china being a manufacturing hub, led to disruption in the global supply chain which affected almost all sectors ranging from pharmaceuticals to automobile. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) going viral-covid-19 impact assessment: a perspective beyond clinical practice how is the world responding to the 2019 coronavirus disease compared with the 2014 west african ebola epidemic? the importance of china as a player in the global economy the global macroeconomic impacts of covid-19: seven scenarios the australian national university key: cord-277971-7upcsmg4 authors: al‐niaimi, firas; ali, faisal r. title: covid‐19 and dermatologic surgery: hazards of surgical plume date: 2020-05-15 journal: dermatol ther doi: 10.1111/dth.13593 sha: doc_id: 277971 cord_uid: 7upcsmg4 nan we read with interest the article by yang et al. 1 on the safety measures implemented for post covid-19 resumption of dermatologic surgery services. whilst we commend the authors for their work and comprehensive actions put in place, there was an omission of a critical factor highly pertinent to dermatologic surgery and potential covid-19 transmission, namely surgical plume. whilst ablative lasers are not ubiquitous in dermatologic surgery departments, the use of cautery forms an integral part of the discipline. numerous studies have shown the hazards of surgical smoke containing toxic gases and metabolites harmful to both the operating dermatosurgeon as well as the patient, in addition to acting as a vector for infectious particles 2,3 . covid-19 has exposed new occupational hazards given the highly contagious nature of the virus through aerosolised procedures. the use of surgical masks may offer partial protection to respiratory droplets; however fine aerosolised particles from surgical plume may continue to pose an infectious risk to patient and staff. the use of specialised masks able to filter particles smaller than 5 microns (the threshold size for surgical masks) such as laser-specific masks or n95 masks offer better protection to aerosolised particles 4, 5 . it is recognised that particular diathermic instruments and parameters used can alter the composition of emitted plumes, with lower temperature this article is protected by copyright. all rights reserved. plumes (such as those produced by ablative lasers) being more likely to harbour infectious material. 3 dermatosurgeons may wish to consider using bipolar cautery, which causes lower concentrations of small aerosolised particles, 6 than monopolar cautery when operating with lower power settings. additionally, measures to safely extract generated plume are required such as the use of appropriate plume extractor. air filtration in the surgical theatre should ideally constitute of air-conditioned medical high-efficiency particulate air or ultra-low particulate filter in addition to the above named measures 7, 8 . given that many dermatologic surgical procedures involve the head and neck area, careful attention to hazards posed by surgical plume and ablative lasers and attempts to mitigate these are essential interventions in the covid-19 era. to resume outpatient dermatologic surgery safely during stabilized period of coronavirus disease-2019: experiences from wuhan surgical smoke in dermatology: its hazards and management surgical smoke exposure in operating room personnel. a review surgical smoke: risk assessment and mitigation strategies respiratory protection provided by n95 filtering facepiece respirators and disposable medicine masks against airborne bacteria in different working environments]. (article in chinese) zhonghua lao dong wei sheng zhi ye bing za zhi analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility respiratory protection for laser users. korean society for laser medicine and surgery laser-generated airborne contaminants key: cord-289819-1kji8bbn authors: chang, michelle j.; lipner, shari r. title: caring for deaf and hard of hearing patients in dermatology during the covid‐19 pandemic date: 2020-08-14 journal: dermatol ther doi: 10.1111/dth.14185 sha: doc_id: 289819 cord_uid: 1kji8bbn nan the novel coronavirus disease 2019 (covid-19) has caused drastic interruptions in traditional dermatologic patient care globally. safety procedures have been implemented to protect patients and providers, some of which may interfere with effective communication for deaf and hard of hearing (dhh) patients, who already face significant challenges. hearing loss has been associated with increased health care expenditure and resource utilization, 1 making it more difficult for dhh patients to receive appropriate care. in this letter, we make recommendations for mitigating communication barriers for dhh dermatological patients during the covid-19 pandemic. in-person dermatological care has changed, mandating the use of personal protective equipment this article is protected by copyright. all rights reserved. professional interpreter is not available, a smartphone speech-to-text app can be utilized to create automated captions. 4 to limit risk of covid-19 transmission, dermatology practices have dramatically reduced inperson visits and increased utilization of telemedicine and telephone calls, 5 posing significant and unique challenges to dhh patients. televisits with dhh patients should employ 3-way video conferencing with a sign language interpreter. dermatologists may also provide a visual prop with photographs of various skin morphologies and questions about symptoms, such that patients may respond to questions even with limited hearing. if an interpreter is not available for video conferencing, dermatologists should facilitate the encounter via telephone, so that dhh patients may use their preferred telecommunication relay service. this system utilizes an operator who voices the typed conversation to the physician and then types the responses back to the dhh patient, such that communication can occur using a standard telephone. 3 written instructions on taking photographs of the area of concern should be given prior to telephone calls. images must be in-focus, with multiple viewpoints, and a coin or ruler can be placed in the frame for scale. the covid-19 pandemic requires that dermatologists be creative in providing dhh patients with timely and effective care. strategies used for each dhh patient will vary depending on severity of hearing loss, and language and communication preferences. we hope that this letter will make our dermatology community more sensitive to the needs of dhh patients and that these recommendations will be useful in diagnosing and treating these patients both during and following this pandemic. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. trends in health care costs and utilization associated with untreated hearing loss over 10 years overcoming additional barriers to care for deaf and hard of hearing patients during covid-19 dermatology practices as vectors for covid-19 transmission: a call for immediate cessation of nonemergent dermatology visits how do i communicate with doctors, nurses, and staff at the hospital during covid-19? key: cord-309195-0scmephx authors: blicharz, leszek; czuwara, joanna; samochocki, zbigniew; goldust, mohamad; chrostowska, sylwia; olszewska, małgorzata; rudnicka, lidia title: hand eczema ‐ a growing dermatological concern during the covid‐19 pandemic and possible treatments date: 2020-05-08 journal: dermatol ther doi: 10.1111/dth.13545 sha: doc_id: 309195 cord_uid: 0scmephx nan hand eczema (he) is a relapsing and chronic condition of a heterogenous etiology. irritant contact dermatitis is the most frequent cause, followed by atopic dermatitis, allergic contact dermatitis and other forms of eczematous disorders. in many patients several of these entities overlap, which creates diagnostic and therapeutic challenges. 3 regardless of he etiology, exposure to detergents and soaps, frequent hand washing (>20 times/day) and the use of occlusive gloves are all well-known risk factors of disease onset this article is protected by copyright. all rights reserved. and/or exacerbation. 3, 4 the necessity to use these measures during the covid-19 pandemic may increase the frequency of he. he may be an occupational disease. in developed societies, it is most frequently diagnosed in the workers of the healthcare, cleaning services, farming, and industry sectors. 5 it can be speculated that the relative prevalence of occupational he will rise in healthcare professionals, while it is likely to remain similar in farming and slightly decrease in the workers of other sectors due to workplace restrictions. in view of the above, we believe that primary prevention of he should be intensively promoted during the covid-19 pandemic. evidence-based interventions include using moisturizers in combination with barrier creams and constant education on skin protection. 4 in case of active he, a detailed history must always be taken, and additional examination such as patch skin testing or atopy score should be considered to identify underlying contact allergy or atopic dermatitis. 6 the treatment of he varies based on the severity of symptoms and disease phase (acute, chronic), with emollients and moisturizers being the baseline. topical steroids such as clobetasol propionate and mometasone furoate are usually the first-choice anti-inflammatory agents, though they may interfere with the skin barrier regeneration and thus their long-term this article is protected by copyright. all rights reserved. use must be closely monitored. topical calcineurin inhibitors, i.e. tacrolimus and pimecrolimus, are deprived of these side-effects and are recommended in patients who are likely to require prolonged treatment. in the case of he refractory to topical corticosteroids, puva-therapy may be introduced. 6 lastly, systemic agents should be considered in severe cases refractory to topical treatment. therapeutic options include short courses of systemic steroids during disease exacerbations, oral retinoids, e.g. alitretinoin, acitretin, and immunosuppressants such as methotrexate, azathioprine, and cyclosporine a. 6 despite the lack of evidence on the increased risk of severe covid-19 in immunocompromised patients, 7, 8 we believe that the first-line systemic treatment should involve oral retinoids followed by immunosuppressants in recalcitrant cases. however, because of the insignificant possibility of deteriorating the outcome of covid-19 and good effect in most cases, topical therapy should be preferred in he. this article is protected by copyright. all rights reserved. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak hand eczema hand eczema: epidemiology, prognosis and prevention prevalence of, and work-related risk factors for, hand eczema in a norwegian general population (the hunt study) hand eczema: treatment coronaviruses and immunosuppressed patients. the facts during the third epidemic clinical course of covid-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies key: cord-293711-qgefn164 authors: abdelmaksoud, ayman; goldust, mohamad; vestita, michelangelo title: comment on “covid‐19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action” date: 2020-04-16 journal: dermatol ther doi: 10.1111/dth.13360 sha: doc_id: 293711 cord_uid: qgefn164 nan apy their recommendations for treatment of patients with psoriasis at time of new covid-19 pandemic. the authors pointed to the importance of therapeutic reassessment of all psoriatic patients, particularly those with moderate-to-severe disease, who are candidate to systemic, mostly immunosuppressive, therapies in the era of covid-19. the authors recommended topical and/or drugs with a lower impact on the immune system to avoid spread of the infection. 1 though of interest, we have few points to comment on these recommendations based on the current literature review. psoriasis is a worldwide systemic inflammatory disease that has been associated with a number of comorbidities and increased mortality. older patients with moderate-to-severe disease are more prone to cardiovascular and neurological comorbidities, such as hypertension and dementia, respectively. independent of treatment, there is a twofold increased risk of serious infections among older adults with psoriasis compared to those without psoriasis. covid-19-infected patients with hypertension are associated with higher rate of morbidity and mortality. covid-19 virus has neurotropic potential that partially explains the higher rate of acute respiratory distress in elderly patients. 2 the tumor necrosis factor-α inhibitors, adalimumab is currently under evaluation for use in treating severe covid-19 pneumonia. unwise patients stopping biologics temporarily with or without their physician recommendation may lead to development of antidrug antibodies, and possible loss of response when these drugs reintroduced. 10, 11 according to a very recent study testing direct acting antiviral drugs against covid-19 model, the author noted that sofosbuvir, ribavirin, and remedisvir can tightly bind to covid-19 rnadependent rna polymerase and contradict its function leading to viral eradication. 12 that would be plausible for patients living in hcv-high prevalent countries, such as italy. ultraviolet a1 (uva1) phototherapy has a comparable efficacy in moderate-to-severe plaque-type psoriasis and could improve the clinical manifestations and quality of life more quickly than narrow band ultraviolet b therapy with no significant side effects, including lack of increased risk of cutaneous malignancies. 13, 14 with the recent covid-19 outbreak, dermatologists should prioritize and individualize treatment protocols to psoriatic patients based on diseases severity, patients medical conditions, and viral invasiveness. for biologics in the precoronavirus era, respiratory infection rates were comparable to placebo. biologics may be tried in elderly patients with psoriasis. for the absolute highest risk patients, those with cardiovascular and pulmonary comorbidities, the risk-benefit may favor discontinuation on a case-by-case basis. uva1 may be also considered. hcv-positive patients coinfected with covid-19 may benefit from direct acting antiviral. in other word, patients ranking for aggressive or conventional treatment modalities are to be considered. covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds prevalence, incidence, and risk of cancer in patients with psoriasis and psoriatic arthritis: a systematic review and meta-analysis challenges and countermeasures of integrative cancer therapy in the epidemic of covid-19 older adults on systemic treatment for psoriasis and risk of infection:a propensity score matched population-based study risk of serious infection in patients receiving systemic medications for the treatment of psoriasis dermatology staff participate in fight against covid-19 in china should patients stop their biologic treatment during the covid-19 pandemic should biologics for psoriasis be interrupted in the era of covid-19? anti-hcv, nucleotide inhibitors, repurposing against covid-19 no association between whole-body uva1 phototherapy and skin cancers in humans: a cancer registry linkage study the efficacy of uva1 phototherapy in psoriasis: clinical and histological aspects key: cord-307000-mc5tpnbj authors: montero‐vilchez, t; martinez‐lopez, a; salvador‐rodriguez, l; molina‐leyva, a; arias‐santiago, s title: management of patients with hidradenitis suppurativa during the covid‐19 pandemic date: 2020-06-19 journal: dermatol ther doi: 10.1111/dth.13875 sha: doc_id: 307000 cord_uid: mc5tpnbj nan the recent coronavirus disease 2019 (covid-19) pandemic, caused by the sars-cov-2 virus, has spread all over the world. as of april 21, 2020, there were 2,478,948 cases of infection, of which 652,046 have resolved, and 170,399 people have died in 185 different countries 1 . the elderly and people with underlying conditions such as cardiovascular disease, obesity, diabetes or cancer are at the highest risk of infection and prone to serious outcomes 2 . hidradenitis suppurativa (hs) is a chronic, recurrent, debilitating autoinflammatory skin disease characterized by disfiguring nodules, abscesses and suppurating lesions. adults and children with hs are at higher risk of cutaneous, extracutaneous and systemic infections, at even higher rates than in patients with psoriasis and atopic dermatitis, which leads to increased mortality 3 . a recent publication also noted that compared to a placebo, hs patients treated with adalimumab may be at a moderately higher risk of general infections and nasopharyngitis 4 . moreover, hs and covid-19 share many negative prognostic factors such as cardiovascular disease, obesity and diabetes 2,5 . however, it is controversial whether or not hs patients are particularly susceptible to covid-19. hs patients are frequently treated with immunosuppressive drugs 5 , based on the inhibition of specific molecular or cellular targets such as tumor necrosis factor-α, il-1β, il-10, and the il-23/t-helper (th) 17 and il12/th1 axes 6 . in the most severe covid-19 cases, the infection is probably associated with a cytokine storm, which is characterized by increased this article is protected by copyright. all rights reserved. although there are no reports on hs treatment during the covid-19 pandemic or a previous coronavirus epidemic, the guidelines do not recommend stopping treatment due to potential infection risks in the community. furthermore, patients being treated with anti-tnf-alfa drugs have a similar risk of infection as the general population during seasonal influenza and h1n1 influenza 9 . therefore, while there is no evidence that biologics increase the risk or morbidity of a covid-19 infection, we should not recommend preventively discontinuing these medications. we propose close monitoring of hs patients and assessment of their comorbidities, age, conditions and specific situation to decide on a case-by-case basis. besides, the most important recommendations to prevent infection are frequent hand washing, avoiding touching the face with unwashed hands and avoiding close contact with people 9 . our decisions should be made based on evidence. obviously, in a life-threatening situation, hs would become a secondary concern. nevertheless, we should not forget that hs is a severe disease with a great impact on patients' life. stopping effective treatment might have unnecessary risks of aggravating the disease. all comorbidities should be considered when this article is protected by copyright. all rights reserved. assessing our hs patients while waiting for specific data concerning the risk of covid-19 infection in hs patients. this article is protected by copyright. all rights reserved. coronavirus covid-19 global cases by the center for systems science and engineering (csse) at johns hopkins university (jhu) characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention associations of cutaneous and extracutaneous infections with hidradenitis suppurativa in u.s. children and adults adalimumab for treatment of hidradenitis suppurativa during the covid-19 pandemic: safety considerations hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization -systematic review and recommendations from the hs alliance working group novel therapeutic approaches and targets for treatment of suppurativa hidradenitis induction of pro-inflammatory cytokines (il-1 and il-6) and lung inflammation by coronavirus-19 (covi-19 or sars-cov-2): anti-inflammatory strategies covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action should patients stop their biologic treatment during the covid-19 pandemic key: cord-270140-omr30shm authors: albuquerque brandão, maria girlane sousa; barros, lívia moreira; mendonça, jamilly de aquino; ramalho, aline de oliveira; de araújo, thiago moura; veras, vivian saraiva title: clinical and histopathological findings of cutaneous manifestations of covid19 patients date: 2020-07-07 journal: dermatol ther doi: 10.1111/dth.13926 sha: doc_id: 270140 cord_uid: omr30shm covid19 became pandemic since this is a disease with a high infection rate. the study's object is to identify clinical and histopathological findings of cutaneous manifestations of covid19 patients. the evidence was analyzed in pubmed, cinahl, cochrane, web of science and scopus, with the search strategy (covid 19 or covid‐19 or corona or coronavirus or sars‐cov‐2) and (cutaneous or cutaneous manifestations or), and 17 studies were included, involving 351 cases with covid19 and skin manifestations. the lesions were classified mainly as maculopapular, erythematous, vesicular and urticarial. histopathological analyzes suggest a predominance of spongiosis, perivascular infiltrate of lymphocytes and thrombogenic vasculopathy. this article is protected by copyright. all rights reserved. covid19 became pandemic since this is a disease with a high infection rate. studies indicate cutaneous manifestations as symptoms from covid19 1-3 . however, they are still superficially reported and the consequences of identifying cutaneous lesions early on and its progression were not extensively studied. therefore, the disease's cutaneous and histopathological manifestations must be an object of study among specialists to favour the resolution of the clinical picture 4 . to comprehend how covid19 causes dermatological alterations, affected areas, types of cutaneous manifestations, the period of appearance, cure and histological findings can provide subsidies for the disease's early recognition, to support a more effective clinical management of cutaneous lesions and give assistance in the screening and risk stratification 5 . the study's object is to identify clinical and histopathological findings of cutaneous manifestations of covid19 patients. the bibliographic research was made in june 2020, using the research strategy (covid 19 or covid19 or corona or coronavírus or sars-cov-2) and (cutaneous or cutaneous manifestations) in the following databases: pubmed, cinahl, cochrane, web of science and scopus. the publication period was limited to 2020. a total of 142 articles were identified in the search, two reviewers independently analysed abstract and complete texts. seventeen studies that involved 351 cases with covid19 and skin manifestations were included, most were adults, female and their age varied between 12 to 89 years old (chart 1). the lesions were classified, mainly as maculopapular, erythematous, vesicular and urticarial 3, 6, 9, 14 . however, such lesions must be cautiously analysed, because they are common and may have divergent origins. cutaneous polymorphism can be related to different reasons such as differences in the virus and the host 21 . the predominant places were the torso and body's extremities and the latency period of the cutaneous symptoms varied from one to 30 days, in contrast, the lesions' progressive disappearance varied from four days to three weeks. histological analysis and biopsies of the skin suggest the prevalence of spongiosis, perivascular infiltration of lymphocytes and thrombogenic vasculopathy 8,11,20 . spongiosis can ben related to the immune response to the infection, which leads to the activation of langerhans' cells and vasodilation 22 . the thrombotic vasculopathy occurs due to the deposition of c5b-9 and c4d, in addition to their co-location with glycoprotein arising from covid19 2 . covid19 can manifest several skin changes and mostly are maculopapular, erythematous, vesicular and urticarial. these lesions differ from their intensity, appearance period and duration. histopathological findings suggest spongiosis, thrombogenic vasculopathy and perivascular infiltration of lymphocytes. urticarial erup-tion in covid19 infection complement associated microvascu-lar injury and thrombosis in the pathogenesis of severe covid19 infec-tion: a report of five cases acral cutaneous lesions inthe time of covid19 cutaneous manifestations of the coronavirus disease 2019 (covid19): a brief review a late onset widespread skin rash in a previous covid19 infected patient: viral or multidrug effect cutaneous small vessel vasculitis secondary to covid19 infection: a case report sars-cov-2 infection presenting as a febrile rash classificationof the cutaneous manifestations of covid19: a rapid prospective nationwide consensus study in spain with 375 cases covid19 and the skin-heuristicreview. dermo sprint. 2020 this article is protected by copyright. all rights reserved.case report 19 key: cord-254628-706vpjsv authors: stewart, claire r.; lipner, shari r. title: safeguarding dermatologist attendings and residents amid the covid‐19 pandemic: focus on special populations date: 2020-06-03 journal: dermatol ther doi: 10.1111/dth.13749 sha: doc_id: 254628 cord_uid: 706vpjsv nan as of may 13, 2020, the center for disease control (cdc) reported over 1.3 million covid-19 cases in the united states. 1 older adults and those with comorbidities have an increased complication risks and higher mortality compared to the general population. 1 despite appropriate precautions to reduce transmission risk, many dermatology faculty, residents, staff, and their families are at increased risk for covid-19 infection while caring for patients. telemedicine is being well utilized to treat certain routine and less urgent conditions, and dermatologist attendings and residents continue to treat urgent/emergency cases in-person. as stay at home orders expire, delayed surgeries and in-person semi-urgent appointments will be scheduled, with increased patient volume and heightened covid-19 infection risk. our specialty must establish guidelines to protect those most susceptible to complications and mortality due to covid-19. per the cdc, adults 65-84 years comprise an estimated 31-59% of hospitalized patients and 8 of 10 deaths due to covid-19. 1 in 2018, the association of american medical colleges reported that 44.2% of dermatologists were older than 55. 2 those with comorbidities, including hypertension, diabetes, and obesity, are at even higher risk for hospitalization substantiated by a case series of 5700 individuals hospitalized with confirmed covid-19 infection. 3 special care must be taken to implement precautions for this vulnerable group. in 2016, the national graduate medical education census reported that 64.1% of dermatology residents are women, many of whom are of childbearing age. 4 in a 2017 survey of this article is protected by copyright. all rights reserved. 183 members of the women's dermatologic society, 51% reported having their first child as residents and 36% as an attending physician. 5 while limited data is available on pregnant women with covid-19, early reports and lessons from other severe respiratory infections, including severe acute respiratory syndrome and middle east respiratory syndrome, suggest that pregnant women may be at increased risk for complications. 6 in a case series of 9 women with third trimester covid-19 diagnoses, intrauterine fetal distress was noted in 6 pregnancies and 6 infants were born preterm. 6 an unconfirmed report of a 30-hour infant with covid-19 infection suggested the possibility of in utero transmission; transmission of covid-19 through breastmilk is unknown. 6 while further research is needed to quantify pregnancy and breastfeeding risk, female dermatologists and partners of women considering pregnancy deserve special consideration. to reduce risk of covid-19 infection acquired in the workplace, we must maintain an adequate supply of personal protective equipment (ppe) and enforce social distancing. trainees and faculty should receive fit testing for n95 respirators and education in the proper use of ppe and donning/doffing procedures. efforts are needed to create workspaces that minimize exposures, including protocols to limit the number of individuals in patient examination rooms to only necessary personnel. scribes should work remotely; student shadowing should be limited or virtual. patients should be instructed to attend their appointment alone; for pediatric or disabled patients requiring a caregiver, only one individual should be permitted in the room. additionally, dermatology departments and private practices must foster an atmosphere where all this article is protected by copyright. all rights reserved. employees feel comfortable raising concerns about personal safety without negative consequences to their training or employment status. association of american medical colleges and the northwell covid-19 research consortium. presenting characteristics, comorbidities and outcomes among 5700 patients hospitalized with covid-19 in the new york city area changes in sex and ethnic diversity in dermatology residents over multiple decades parenting and female dermatologists' perceptions of work-life balance coronavirus disease 2019 (covid-19) and pregnancy: what obstetricians need to know this article is protected by copyright. all rights reserved key: cord-265921-0sb59rmm authors: do, mytrang h.; minkis, kira; petukhova, tatyana a.; lipner, shari r. title: recommendations for personal protective equipment and smoke evacuation for dermatologic surgeries amid the covid‐19 crisis date: 2020-05-15 journal: dermatol ther doi: 10.1111/dth.13592 sha: doc_id: 265921 cord_uid: 0sb59rmm nan to the editor: the coronavirus disease 2019 (covid-19), caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has significantly affected clinical practices. currently, elective dermatologic procedures (ablative laser procedure, laser hair removal) are deferred, with only emergency dermatological surgeries being performed to lessen viral spread and preserve personal protective equipment (ppe). as covid-19 prevalence decreases, postponed procedures will be scheduled. for mohs micrographic surgery (mms) and excisions, hemostasis is often achieved by electrosurgery, generating surgical smoke plume. although data on transmission of sars-cov-2 via surgical smoke is unavailable, human immunodeficiency virus, hepatitis b virus, and human papillomavirus have been detected in surgical smoke 1 . since sars-cov-2 may be transmitted through aerosols 2 , it is critical to reexamine recommended protective measures for dermatologic surgery. the use of fitted respirator or surgical masks and smoke evacuators was recommended to minimize the infectious, inhalation, chemical and mutagenic risks of surgical smoke prior to covid-19 1 . for smoke evacuators, minimal flow rate, determined by internal diameter and suction strength, nozzle positioning, filtration efficiency, and regular maintenance impact efficacy 1 . since covid-19 is transmitted through droplets and aerosols 2 , it is premature to resume elective laser procedures, including ablative co2 and hair removal. however, deferred nonelective excisions and mms for skin cancer will need to be performed in the near future. the centers for disease control and prevention (cdc) recommends n95 respirator use for healthcare workers participating in aerosol-generating procedures (agp) 3 . therefore, n95 respirators are essential for dermatologic surgeons and staff operating on mucosal regions and/or generating aerosols with electrocautery (table i) . the cdc recommends against extended use this article is protected by copyright. all rights reserved. or reuse of respirators following agp 3 . however, given n95 shortages, particularly in outpatient dermatology practices, following this recommendation may be unrealistic, with extended use unavoidable. a surgical mask covering the n95 respirator may be considered to extend longevity. decontamination of n95s for reuse 3 or 3d-printed masks have also been proposed; testing would be required to ensure effective filtration 4 . in an intubation simulation 5 , secretions were recovered from exposed skin (i.e. neck and ears) and hair of healthcare providers following two coughing episodes despite use of n95 respirators, eye protection, gowns, and gloves, suggesting that use of standard ppe is likely insufficient. this study raises concern for a similar inoculation pattern from surgical smoke potentially laden with sars-cov-2 in the dermatologic surgeon's exposed skin and hair, suggesting that a hood covering hair, ears and neck should be utilized. in addition, this infectious material may be transferred to the eyes, nose, or mouth via self-inoculation, a process that can be prevented with proper hand hygiene. finally, to minimize smoke production, electrosurgery units should be set to the lowest effective settings for achieving hemostasis. recommendations for ppe, smoke evacuation, and hand hygiene are shown in table 1 . many hospitals are adequately supporting redeployed resident and attending dermatologists caring for covid-19 inpatients. as we are discharged from redeployments and perform increasing numbers of essential outpatient dermatological surgeries, it is incumbent upon hospitals, as well as, state and federal governments to ensure adequate access to ppe for all dermatologists and staff. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. surgical smoke: risk assessment and mitigation strategies aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 centers for disease control and prevention. information for healthcare professionals about coronavirus faqs on 3d printing of medical devices, accessories, components, and parts during the covid-19 pandemic accessed 5/2/2020 exposure to a surrogate measure of contamination from simulated patients by emergency department personnel wearing personal protective equipment key: cord-302571-vb9ks4mq authors: damiani, giovanni; pacifico, alessia; bragazzi, nicola l.; malagoli, piergiorgio title: biologics increase the risk of sars‐cov‐2 infection and hospitalization, but not icu admission and death: real‐life data from a large cohort during red‐zone declaration date: 2020-05-19 journal: dermatol ther doi: 10.1111/dth.13475 sha: doc_id: 302571 cord_uid: vb9ks4mq during covid‐19 outbreak there are discordant opinions toward the impact on biologics in psoriatic (pso) patients. thus we performed a single‐center case‐control study in lombardia, the italian region with the higher number of covid‐19 confirmed cases. we enrolled 1193 pso patients treated with biologics and small molecules and we used the entire lombardia population as controls. notably, 17 pso patients covid‐19 confirmed were quarantined at home and five hospitalized, no pso patients were admitted to intensive care unit (icu) or died. with respect to the general population of lombardy, patients on biologics were at higher risk to test positive for covid‐19 (odds ratio [or] 3.43 [95% confidence interval (ci) 2.25‐5.73], p < .0001), to be self‐quarantined at home (or 9.05 [95% ci 5.61‐14.61], p < .0001) and hospitalized (or 3.59 [95% ci 1.49‐8.63], p = .0044), however, not increased risk of icu admission or death were found. pso patients on biologics should be carefully monitored with telemedicine during covid‐19 outbreak and early treated at home to limit hospital overwhelm. since march 8, 2020, lombardia region experienced covid-19 lockdown and only after 2 days the entire italy became red-zone. nowadays, lombardia is the italian region with more confirmed, hospitalized, and dead covid-19 patients. despite the higher risk for covid-19 displayed by obese, active smokers, and copd patients, 1 almost no data are present toward psoriatic (pso) patients and biologics. moderate to severe psoriasis benefit from systemic treatment as biologics and small molecules; at the same time these drugs, capable to clear psoriasis, are related also to an increased risk of airway infections. 2 pso patients also display a baseline airway inflammation that triggers the constellation of chronic respiratory comorbidities, such as asthma and chronic obstructive pulmonary disease (copd). 3 furthermore, pso patients are frequently smokers and cigarettes increased flares as well as psoriasis severity, predisposing to copd and exacerbating asthma crisis. 4 thus, we performed this study aiming to understand the effect of biologics in pso patients during covid-19 outbreak focusing on symptomatic patients quarantined at home, hospitalized, and their prognosis. pso patients on biologics displayed higher risk to be infected and to be hospitalized/self-quarantined at home, but icu hospitalization and death did not differ from the general population. notably, pso patients display baseline airway inflammation that clears with anti-pso therapies, preliminary data suggest that airways inflammation is downregulated by treating skin inflammation. 8 the lung-skin inflammatory reciprocal interactions was modelized by nadeem et al claiming that skin inflammation via il-23/stat3 signaling modulates airway inflammation and vice versa. 9 these findings offer also a rationale to continue biologics in pso patients to prevent the lung-skin inflammatory axis and to inhibit the progression to the hyperinflammatory phase. despite this study is the first to assess the impact of biologics among pso patients during covid-19, it did not assess the family members, so future studies should also evaluate this aspect. biologics may not increase the risk of icu hospitalization and death; however, they increase the risk of mild to moderate disease. thus, pso patients on biologics should be carefully monitored with teledermatology and early treated at covid-19 symptoms early onset. clinical features and short-term outcomes of 221 patients with covid-19 in wuhan safety of systemic agents for the treatment of pediatric psoriasis psoriasis and respiratory comorbidities: the added value of fraction of exhaled nitric oxide as a new method to detect, evaluate, and monitor psoriatic systemic involvement and therapeutic efficacy lifestyle changes for treating psoriasis covid-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal a subset analysis of efficacy and safety outcomes from phase 3 clinical studies of ixekizumab for the treatment of patients with severe plaque psoriasis why tocilizumab could be an effective treatment for severe covid-19? increased airway inflammation in patients with psoriasis psoriatic inflammation enhances allergic airway inflammation through il-23/stat3 signaling in a murine model biologics increase the risk of sars-cov-2 infection and hospitalization, but not icu admission and death: real-life data from a large cohort during red-zone declaration the authors declare no potential conflict of interest. https://orcid.org/0000-0002-2390-6505alessia pacifico https://orcid.org/0000-0003-0348-0620 key: cord-297295-lsewt5t2 authors: matusiak, łukasz; szepietowska, marta; krajewski, piotr; białynicki‐birula, rafał; szepietowski, jacek c title: inconveniences due to the use of face masks during the covid‐19 pandemic: a survey study of 876 young people date: 2020-05-14 journal: dermatol ther doi: 10.1111/dth.13567 sha: doc_id: 297295 cord_uid: lsewt5t2 nan the use of face masks by general population became ubiquitous during the covid-19 pandemic (1) . personal protective equipment (ppe) can cause harm to the skin (2) (3) (4) (5) , however, little is known on inconveniences of face masks wearing (4) (5) (6) (7) . this study was undertaken to analyze the most bothersome issues reported by young people using face protection during current viral pandemic. the survey was created with google® forms and posted on facebook® groups for students in poland. the recall period was the last 7 days. the data were collected in 48 hours (12 th -14 th , april 2020). at that time wearing face masks in poland was not mandatory. 2315 answers were received, 8 questionnaires were removed (incompleteness of data). out of 2307 responders 1393 (60.4%) declared face masks wearing. as 517 (37.1%) participants used several types of face masks they were excluded and finally, 876 questionnaires were considered. the age of the group was 18-27 years. the responses were downloaded for statistical analysis (statistica 13; statsoft, tulsa, ok, usa). out of 876 participants only 27 people (3.1%) did not complain of any problems related to face mask wearing. out of all reported inconveniences, difficulty in breathing appeared to the most common one (35.9%), followed by warming/sweating (21.3%), misting up of the glasses (21.3%) and slurred speech (12.3%). interestingly, other skin bothersome reactions related to wearing of face masks were reported less often (itch -7.7%, skin irritation -0.9%). difficulties in wearing the glasses and limited visibility were rarely reported (0.3% each). in the model of logistic regression analysis we found that wearing surgical masks among the other types of masks showed significantly lower risk for the development of most common bothersome issues, as difficulty in breathing, warming/sweating, glasses misting up, slurred this article is protected by copyright. all rights reserved. speech and itch (or=0.42, or=0.60, or=0.10, or=0.17 and or=0.04, respectively). in contrast, cloth masks use was related to higher risk of difficulty in breathing (or=1.56), warming/sweating (or=1.31), glasses misting up (or=1.92), slurred speech (or=1.86) and itch (or=2.99). respirators were found to be at increased risk only for glasses misting up (or=1.65) ( table 1) . adverse reactions to ppe were mostly reported in health care workers (hcw) (2-5). to the best of our knowledge we presented for the first time a real life data on the most bothersome aspects of face mask use within general public. we documented that wearing surgical masks was linked to significantly lower risk of adverse reactions. this is supported by roberge et al. (7) who postulated that surgical mask use at low-moderate work rate was not associated with clinically significant physiological impact. however, some participants complained on skin irritation (11%), moisture build up (11%), sticking to the skin (11%), significant face warmth (26%) and pinching (7%). during the viral pandemics due to shortage of medically graded masks, cloth masks became more popular (8) . although there is no enough strong evidence the cloth masks may be only slightly less effective than surgical masks in blocking emission of particles. they are thought to be fivefold more effective than not wearing face protection (9) . this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. rational use of face masks in the covid-19 pandemic skin damage among healthcare workers managing coronavirus disease-2019 adverse skin reactions among healthcare workers during the coronavirus disease 2019 autbreak: a survey in wuhan and its surrounding regions skin reactions to n95 masks and medical masks among health care personel: a self-reported questionnaire survey in china adverse skin reactions to personal protective equipment against severe acute respiratory syndrome--a descriptive study in singapore this article is protected by copyright. all rights reserved wear n95 mask with plastic handle reduce pressure injury absence of consequential changes physiological, thermal and subjected responses from wearing a surgical mask covid-19: should the public wear face masks? testing the efficacy of homemade masks: would they protect in an influenza pandemic this article is protected by copyright. all rights reserved key: cord-273680-tqlg5bac authors: bachevski, dimitri; damevska, katerina; simeonovski, viktor; dimova, maja title: back to the basics: propolis and covid‐19 date: 2020-06-07 journal: dermatol ther doi: 10.1111/dth.13780 sha: doc_id: 273680 cord_uid: tqlg5bac nan propolis (bee glue) is a complex resinous mixture produced by honeybees (apis mellifera) used by humans since ancient times for its medicinal properties. substances collected from various plants are mixed with the β-glycosidase enzyme of the honey bee saliva, digested, and added to beeswax to form the final product. propolis has an important role in hive construction as a waterproof resin; however it also acts as a barrier to yeasts and molds, bacteria, and viruses. propolis is a highly complex mixture, containing over 300 chemical moieties, a number of which have documented beneficial health outcomes. the main constituents of propolis include resins, waxes, essential oils, and pollen, as well as various organic compounds, among which are phenolic compounds, flavonoids, terpenes, esters, aromatic aldehydes and alcohols, and several specific antioxidant compounds including beta-carotene, caffeic acid and kaempferol. a new compound isolated from brazilian green propolis, 3,5-diprenyl-4-hydroxycinnamic acid (artepillin c), may be a key immunomodulatory compound. 7 the biochemical composition of propolis is highly variable, and this variety is significantly affected by the geographical origin, climate, water availability and other environmental factors. it is widely recognized, for example, that propolis from temperate climatic zones are rich in flavonoids, phenolic acids and their esters, while propolis from tropical regions are rich in prenylated benzophenones, diterpenes and flavonoids. 7,8 that being said, all types of propolis possess antimicrobial, anti-neoplastic, anti-inflammatory, antioxidant, hepatoprotective, cariostatic, and immunostimulatory activity. 8 the natural variety of propolis has traditionally been an obstacle in research and a standardizing medical use. 7 it also cannot be used as raw material (figure 1) , and it must be purified by extraction with solvents. be it alcoholic or aqueous, propolis extracts from temperate climate have been shown to possess a potent and broad-spectrum antiviral activity against a diverse panel of viruses such as hsv-1, a promising pharmacological approach for treatment of covid-19 is targeting the downstream effectors, such as p21-activated kinases (paks). caffeic acid phenethyl ester (cape), one of the most important constituents of propolis, has shown the property to down-regulate rac (a signaling protein found in human cells), therefore acting as a rac/cdc42-activated kinase 1 (pak1) blocker. these data support the idea that cape can be useful as an agent to stop or inhibit coronavirus-induced fibrosis in the lungs. 16 although propolis belongs to the safest natural remedies, on rare occasions, adverse effects of propolis or its constituents are to be expected, especially allergic reactions. therefore, when used in prevention or treatment of covid-19, hypersensitivity reactions should be taken into account. 8 viruses causing respiratory diseases invade their host via the nasopharyngeal, oropharyngeal or tracheal mucosa. at present, there are no specific antiviral drugs or vaccines against sars-cov2 infection for potential therapy of humans. identifying methods able to reduce or prevent colonization, viral adhesion and promote virus shedding on mucous membranes or have the ability to inactivate pathogens and thus reduce virus dose and/or increase immune response would be essential in the management of covid-19 outbreak. therefore, we suggest that propolis (or its constituents) may represent a low-cost treatment option that may act as potential inhibitors of sars-cov-2 in the oropharyngeal niche. propolis should be explored as a prophylaxis in high-risk groups, such as individuals in close contact with infected patients. further studies should be conducted for the validation of these compounds using in vitro and in vivo models. these studies must thoroughly characterize the biological activities and underlying mechanisms of action and isolating the most beneficial compounds, mainly those related to antiviral properties. composition and functional properties of propolis (bee glue): a review inhibiting activity of própolis on the influenza virus effects of propolis flavonoids on virus infectivity and replication severe acute respiratory syndrome epidemiology and control coronavirus disease 2019 (covid-19): first indication of efficacy of gene-eden-vir/novirin in sars-cov-2 infection pak1-blockers: potential therapeutics against covid-19 raw propolis cannot be used, and it must be purified by extraction with solvents, to remove the inert material and preserve the polyphenolic fraction key: cord-258039-046s47v6 authors: jindal, anuradha; noronha, malcom; mysore, venkataram title: dermatological procedures amidst covid‐19: when and how to resume date: 2020-05-12 journal: dermatol ther doi: 10.1111/dth.13561 sha: doc_id: 258039 cord_uid: 046s47v6 the pandemic of covid‐19 has captivated more than 3 million people across the globe affecting the dermatology practice as well. due to the novel nature of the virus and concomitant lack of research, standard guidelines have not been set in place regarding the procedures. currently, due to fear and spread of coronavirus aesthetic practice has taken a seat back. dermatologic surgeon/aesthetician have to be prepared for the forthcoming alterations in the practice and adjust to the necessary precautionary methods. this articles aims to prepare dermatologist for the upcoming difficulties and precautions to be taken for conducting procedures in amidst of coronavirus. this article is protected by copyright. all rights reserved. hence mental well-being of the patient. as a dermatologists we will have to cater to the needs of the patients. chose the patient wisely and cautiously considering the following factors; rapid spread of virus, incubation period of 14 days when the patient is asymptomatic but still transmitting the virus, more than 78% cases being asymptomatic, 3 low sensitivity of the rapid test being 35-80%, 4 uncertainty about the vaccine and drug for treatment of covid-19 and upon that the worldwide scarcity of personal protective equipment and masks. the ideal time to start practice would depend on the rules laid down by local or central governing bodies but the most important factor is that the treating physician should be prepared both mentally and administratively and be well informed about the current scenario. the prime thing would be to have a disinfection strategy in place and adequate supply of ppes for protection for self and staff in the clinic. transmission -current information suggests that the two main routes of transmission of the covid-19 virus are respiratory droplets and contact. vertical transmission has also been reported. 6 respiratory droplets are generated when an infected person coughs or sneezes. any person who is in close contact (within 1 m) with someone who has respiratory symptoms (coughing, sneezing) is at risk of being exposed to potentially infective respiratory droplets. droplets may also land the virucidal efficacy of chemical germicides against coronavirus has been investigated. a study of disinfectants against human coronavirus 229e found several disinfectants were effective after a 1-minute contact time; these included sodium hypochlorite (at a free chlorine concentration of 1,000 ppm and 5,000 ppm), 70% ethyl alcohol, and povidone-iodine (1% iodine). a study also showed complete inactivation of the sars coronavirus by 70% ethanol and povidoneiodine with an exposure time of 1 minute and 2.5% glutaraldehyde with an exposure time of 5 minute. 11 although glutaraldehyde (ga) is an effective disinfectant but it potential to cause severe allergic dermatitis and should be used cautiously. studies have shown that sars corona virus can survive on plastered walls, stainless steel surfaces, plastics and even glass slides from 24-72 hours. it is stable in feces and urine for at least 1-2 days. 9, 12 hence, all the surfaces should be disinfected as they can act as potential source of infection before commencing and after finishing the procedures.  waiting time before procedures can be limited by providing pre-procedure instructions through telecommunication e.g. to trim/shave the area for laser hair reduction, apply topical anesthesia 45 min before procedure which can be done easily at home if given proper instructions. this article is protected by copyright. all rights reserved. hepa filters and upla filters should be employed in the set up where lasers or other plumes generating procedures are being held. 19 the suction power of a smoke-evacuating system is defined by its ability to generate a threshold minimum amount of airflow. a minimum airflow of 0.012-0.017 m 3 /s was recommended by hunter for electro cautery whereas even higher minimum airflow is required for procedures generating higher amount of plumes like laser hair reduction. a combination of charcoal filter with upla filter provides the best filtration. 14 nozzle -to obtain maximum capture of smoke, nozzle should be placed within 2 inches of the site to be treated. 19 ventilation of room -perform procedures in an adequately ventilated room; i.e. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. viruses: a systematic review and meta-analysis rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance geneva: world health organization during pregnancy and possible vertical transmission sars-cov-2 viral load in upper respiratory specimens of infected patients molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents the need for evidence-based aesthetic dermatology practice recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings comparison of nitrile and latex examination gloves decontamination and reuse of filtering facepiece respirators laser-generated airborne contaminants covid-19 infection: origin, transmission, and characteristics of human coronaviruses who publication/guidelines. natural ventilation for infection control in health-care settings key: cord-284158-5qvq27hu authors: abdelmaksoud, ayman; vestita, michelangelo; el‐amawy, heba saed; ayhan, erhan; an, i̇sa; öztürk, murat; goldust, mohamad title: systemic isotretinoin therapy in the era of covid‐19 date: 2020-05-20 journal: dermatol ther doi: 10.1111/dth.13482 sha: doc_id: 284158 cord_uid: 5qvq27hu nan the recommended daily dose of isotretinoin ranges from 0.3 to 0.5 mg/kg for a duration of at least 6 months in the european guidelines. in case of insufficient response, the course of treatment period can be extended. two or three courses of isotretinoin may be required for relapsed cases, that is, acne retrial. relapse rate may be correlated directly with decreased total systemic exposure to isotretinoin. 5 lidose-isotretinoin was hence suggested by experts to improve drug bioavailability. 6 most of the side effects of isotretinoin are skin related and associated with xerosis. 5 drylip/cheilitis was the most known side effect reported by 241 patients on isotretinoin studied by tugrul et al. 7 in another study, dry nasal membrane has also been reported in twothirds of patients during isotretinoin treatment, 2 which can lead to epistaxis. nasal complications are generally not serious, especially with low-dose isotretinoin. 8 nasal mucosa is a vulnerable area for virus or bacteria to colonize owing to its abundant blood vessels, mucinous glands, and serous glands which create a humid environment. angiotensin-converting enzyme-2 (ace2) receptor expression was found in the basal layer of the nonkeratinizing squamous epithelium in nasal mucosa. breakdown of nasal mucosal, exposing the basal layer, would increase of likelihood nasal mucosa invasion by coronaviruse. 9 isotretinoin treatment disturbs nasal mucociliary clearance significantly, which reduces normal and regenerated mucosal thickness, causing severe inflammation, increasing the reactive changes in the respiratory epithelium, and higher recruitment of neutrophils in the nasal surface mucosa. 10, 11 a theoretical increased risk of covid-19 viral load is hence thought by the british association of dermatologists (https:// www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6661). chinese experts recommended to clean nasal vestibule with normal saline, tap water or suds, or to wipe the nasal vestibule using gentle cotton swab dipped with water/mucosa disinfectants for three to five rounds to ensure entire cleansing, which could be applied for both health care worker dealing with covid-19 patients and those on isotretinoin. 12 nasal moisturizers (d-panthenol, vaseline, glycerin, hypertonic solutions, and hyaluronic acid) are also recommended for these patients before starting isotretinoin, during the treatment, and for few months after the end of the treatment, as recommended by otorhinolaryngologist. 13 coronavirus may be also detected in the nasal discharge of patients with olfactory dysfunction. nasal cavity olfactory epithelium is the likely site of enhanced binding of sars-cov-2. olfactory epithelium non-neural cell types express two host receptors, ace2 and type 2 transmembrane serine protease (tmprss2), that facilitate sars-cov-2 replication and accumulation, and subsequently central nervous system invasion which may lead to respiratory failure of covid-19 patients. 14 lechien et al noted that 85.6% of their patients had olfactory dysfunction (79.6% were anosmic and 20.4% were hyposmic) related to covid-19 infection, with no significant associated rhinorrhea or nasal obstruction. olfactory dysfunction signs may appear before, during, or after the general symptoms of covid-19. 15 olfactory dysfunction can be a possible phenotypic marker of folate deficiency in treatment-resistant depression. 16 isotretinoin has an enhancing effect on olfactory function in acne patients. 17 as transcription of tmprss2 gene requires androgen receptor hyperactivity. patients with hyperandrogenic phenotype, such as polycystic ovaries (pco), might have a risk of covid-19 increased viral load, increased viral dissemination and severity of lung involvement. 18 feily et al noted that low-dose isotretinoin (0.5 mg/kg/day for 15-20 weeks) in pco patients with moderate-to-severe nodulocystic acne resulted in significant decreases in levels of serum total testosterone, prolactin, and dihydrotestosterone but increased dehydroepiandrosterone levels. 19 in nutshell, till further studies on the multifaceted pathogenesis of covid-19 infection, we suggest low, lid-dose of isotretinoin with folic acid supplement, together with proper nasal mucosal care for isotretinoin patients. isotretinoin treatment should be questioned in all covid-19 suspected patients presented with nasal/olfactory dysfunction symptoms. low dose of isotretinoin: a comprehensive review adult acne versus adolescent acne: a retrospective study of 1,167 patients characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention rapid asymptomatic transmission of covid-19 during the incubation period demonstrating strong infectivity in a cluster of youngsters aged 16-23years outside wuhan and characteristics of young patients with covid-19: a prospective contact-tracing study comparison of guidelines and consensus articles on the management of patients with acne with oral isotretinoin an open-label, phase iv study evaluating lidose-isotretinoin administered without food in patients with severe recalcitrant nodular acne: low relapse rates observed over the 104-week post-treatment period perceptions about oral isotretinoin treatment influence of isotretinoin on nasal mucociliary clearance and lung function in patients with acne vulgaris tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis effects of oral ısotretinoin on normal and wounded nasal mucosa: an experimental study effect of systemic isotretinoin therapy on mucociliary clearance and nasal surface mucosa in acne patients consensus of chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019 evaluation of nasal mucociliary clearance, nasal obstruction symptom evaluation, and epistaxis severity score in isotretinoin treatment cov-2: olfaction, brain infection, and the urgent need for clinical samples allowing earlier virus detection olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study olfactory and gustatory dysfunction in depression: could it be a marker of folate deficiency? effects of isotretinoin on the olfactory function in patients with acne sars-cov-2 infection is likely to be androgen mediated the effect of low-dose isotretinoin therapy on serum androgen levels in women with acne vulgaris key: cord-293515-n4v86dii authors: luo, pan; liu, dong; li, juan title: topical rh‐afgf: an effective therapeutic agent for facemask wearing‐induced pressure sores date: 2020-06-01 journal: dermatol ther doi: 10.1111/dth.13745 sha: doc_id: 293515 cord_uid: n4v86dii protecting healthcare workers is crucial during coronavirus disease 2019 (covid‐19) pandemic and facemask wearing is considered an effective measure to prevent severe acute respiratory syndrome coronavirus 2 (sars‐cov‐2) infection. however, long‐time use of a facemask can cause pressure sores on the ears and nose bridge and increase the risk of infection. the topical recombinant human acidic fibroblast growth factor (rh‐afgf) was used to cure pressure sores for healthcare workers at zhongfaxincheng campus of tongji hospital. the results from a small sample size survey conducted in zhongfaxincheng campuses of tongji hospital showed that treatment with topical rh‐afgf could significantly inhibit the progression of pressure sores and accelerate the wound healing with no apparent ill‐effects. therefore, we propose that topical rh‐afgf is an effective therapeutic agent for facemask wearing‐induced pressure sores and worth of popularizing and applying. this article is protected by copyright. all rights reserved. coronavirus disease 2019 (covid-19), caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), is now overwhelming spreading in the world, and been declared a pandemic by the world health organization. among the infection prevention measures for healthcare workers, facemask (the n95 health care particulate respirator and surgical mask) wearing is considered as an effective measure to prevent sars-cov-2 transmission. 1 however, long-time use of a facemask with earloop-style can result in pressure sores on the ears' skin. 2 moreover, pressure sores on nose bridge is also liable to occur while working for long time since the metal strip always needs to be extruded to cling the to nose bridge to reach a good respiratory protection. 3 these pressure sores could cause intense discomfort, sick leave, even permanent scarring and high risk of infection for users, which would bring adverse impact on the medical service system. to solve this thorny problem, topical recombinant human acidic fibroblast growth factor (rh-afgf) was provided to healthcare workers to help curing pressure sores at zhongfaxincheng campus of tongji hospital in wuhan, china. zhongfaxincheng campus of tongji hospital is a designated hospital for severe covid-19 and nearly 2000 covid-19 patients were admitted. there are more than 3000 healthcare workers have participated in the fight against covid-19, and sizeable numbers of them had suffered pressure sores at varying degrees caused by facemask wearing. once the pressure sores occur, continuing to wear facemasks daily or every other day without any intervention will make the condition from bad to worse. however, our results from a small sample size survey conducted in the healthcare workers in zhongfaxincheng campus of tongji hospital who have used the topical rh-afgf with a concentration of 2500 u/ml to cure the stage i/ii facemask wearing-induced pressure sores which were less than 1 cm 2 in size show that treatment with topical rh-afgf could significantly inhibit the progression of pressure sore and accelerate the wound healing. the pressure sores healed within 5 days in all these respondents after treated with rh-afgf consecutively, although masks were still wearing every day or other day along with the treatment. topical rh-afgf is indicated to promote wound healing, including burn wounds and chronic wounds. in the early wound, macrophages and endothelial cells at damaged parts released acidic fibroblast growth factor (afgf) to stimulate proliferation of fibroblasts and keratinocytes, and then enhance local generation of tissue collagen, protease, and various cytokine which appear to be involved in the mechanisms underlying wound healing. 4, 5 actually, numbers of studies have showed that afgf could improve wound healing in various animal models and clinical trials. 6, 7 therefore, based on the established role of afgf, it is not unexpected that rh-afgf has a good effect on pressure sores induced by facemask wearing. considering that rh-afgf can increase the expression of collagen and muscle fibers, resulting in enhanced tissue remodeling, 6 a worry that whether excessive tissue repair after long-term repeated rh-afgf application would result in scar formation was raised. however, there was a research demonstrated that the high-dose, repeated rh-afgf application did not cause excessive repair of the tissue or scarring. 8 moreover, the research also demonstrated that no obvious toxicity to the target organs and tissues was observed during the repeated treatment of rh-afgf. 8 these results were consistent with our survey feedback that no healthcare workers have claimed any discomfort or scarring happened during the use of rh-afgf. therefore, we propose that topical rh-afgf is an effective therapeutic agent for facemask wearing-induced pressure sores and worth of popularizing and applying. wounds should be cleaned with chlorhexidine acetate immediately before rh-afgf sprayed. the dosage and frequency of rh-afgf is recommended as 100 u/cm 2 twice daily based on the labeling document and our experience. and if necessary, especially for these nasal pressure sores, cover the wounds with a benzalkonium chloride patch or sterile dressings after the treatment. moreover, besides afgf, the fibroblast growth factor family also comprises basic fibroblast growth factor (bfgf). it was reported bfgf has a role in accelerating skin wound healing and reducing scar formation. 9 thus, topical bfgf may be also a promising choice for pressure sores caused by facemask wearing. however, there are also some points that should be noted. alcohol, iodine, and hydrogen peroxide which are commonly used during the covid-19 epidemic to kill sars-cov-2 can affect the activity of rh-afgf. therefore, contact with these substances should be avoided when using rh-afgf. in addition, proper storage temperature for rh-afgf is 2~8 ℃, don't exposure the product to a high temperature or froze it. it should be mentioned, though, that the rh-afgf use is only an expedient measure, improving protective equipment would be meaningful and benefit global health. and measures including wearing facemask with a plastic handle and pasting benzalkonium chloride patch to the nose bridge before wearing mask were proposed as may have a role in preventing facemask wearing-induced pressure sores. 2,3 policies on the use of respiratory protection for hospital health workers to protect from this article is protected by copyright. all rights reserved. coronavirus disease (covid-19) wearing the n95 mask with a plastic handle reduces pressure injury covid-19: countermeasure for n95 mask-induced pressure sore cellular and molecular basis of wound healing in diabetes acceleration of diabetic-wound healing with pegylated rhafgf in healing-impaired streptozocin diabetic rats tat-mediated acidic fibroblast growth factor delivery to the dermis improves wound healing of deep skin tissue in rat randomized, multicenter, double-blind, and placebo-controlled trial using topical recombinant human acidic fibroblast growth factor for deep partial-thickness burns and skin graft donor site long-term toxicity study of topical administration of a highly-stable rh-afgf carbomer 940 hydrogel in a rabbit skin wound model proapoptotic effect of control-released basic fibroblast growth factor on skin wound healing in a diabetic mouse model the authors of the present article declare that they have no conflicts of interest. juan li and dong liu were responsible for the design of the study and revised the final manuscript. pan luo conducted the survey and wrote the draft. key: cord-287013-9lgg5gya authors: matusiak, łukasz; szepietowska, marta; krajewski, piotr k.; białynicki‐birula, rafał; szepietowski, jacek c. title: the use of face masks during the covid‐19 pandemic in poland: a survey study of 2315 young adults date: 2020-07-13 journal: dermatol ther doi: 10.1111/dth.13909 sha: doc_id: 287013 cord_uid: 9lgg5gya face masks wearing during the coronavirus disease 2019 (covid‐19) pandemic became ubiquitous. the aim of our study was to assess the use of face masks among young adults during the current viral pandemic. the survey was based on specially created google forms and posted on numerous facebook groups for young people in poland. seven days were considered as a recall period. a total of 2315 answers were obtained, 2307 were finally analysis, as eight questionnaires were removed because of data incompleteness. 60.4% of responders declared using the face masks. those who reported an atopic predisposition wore face masks significantly (p = .007) more commonly (65.5% and 57.7%, respectively). cloth masks (46.2%) appeared to be most popular ones, followed by surgical masks (39.2%), respirators (n95 and ffp) (13.3%), half‐face elastomeric respirators (0.8%) and full‐face respirators (0.4%). females significantly more frequently (p = .0001) used cloth masks; respirators, half‐face elastomeric respirators and full‐face respirators were used more commonly by males (p < .0001, p = .001 and p = .001, respectively). 23.9% of responders who used single‐use mask wore it again. moreover, 73.6% participants declared mask decontamination; however, the procedures were not always appropriate. we suggest that our results may be of help in construction of general public education campaigns on the proper use of face masks. studies, who gave their comments on the proper wording and understanding of each question. a 7-day period was taken as a recall period. the final survey was created with google forms and posted on numerous facebook groups for young people in poland. this population was our target as young adults are the most mobile and active part of population, and therefore particularly exposed to increased risk of viral infection. on 9 april 2020, polish ministry of health announced that starting from 16 april 2020 covering the nose and mouth when being in public space is obligatory. thus, we intentionally collected data in 48 hours (between 12 april 2020, 10:00 pm and 14 april 2020, 10:00 pm) when face masks use was not obligatory, but clearly recommended. a total of 2315 answers were obtained. due to the incompleteness of the data, eight questionnaires were removed. therefore, 2307 surveys (99.7%) were considered for final analysis. such sample size reached 95% confidence level with only 2% margin of error (385 people were calculated as a representative sample size). the mean age of the group was 20.2 ± 1.7 years (range: 18-27 years). the selected responses were downloaded for statistical analysis (statistica 13; statsoft, tulsa, oklahoma). the chi-square test was applied to determine statistical differences between the studied groups. the resulting p values were considered significant if p < .05. in total, 1393 responders (60.4%) declared the use of face masks. there was no difference (p = .12) in the frequency of face protection use between females and males (table 1) . interestingly, significantly more responders (p = .007) who reported an atopic predisposition wore face masks (65.5% and 57.7%, respectively). having selfreported sensitive skin did not influence the frequency of face masks wearing (p = .06). 34.0% participants (significantly more males, p = .0012) used several types of face masks ( table 1) . out of all usages, cloth masks (46.2%) appeared to be the most popular ones, followed by surgical masks (39.2%), respirators (n95 and ffp (filtering facepiece)) (13.3%), half-face elastomeric respirators (0.8%) and full-face respirators (0.4%). females significantly more frequently (p = .0001) used cloth masks; respirators, half-face elastomeric respirators and full-face respirators were used more commonly by males (p < .0001, p = .001 and p = .001, respectively) ( table 1) . among those using several types of masks, 52.7% declared cloth mask as the most frequently used, 36.8% responders declared surgical mask as a dominant type and the remaining 10.5% preferred respirators. most frequently, face masks were worn, independent of the sex of responders, for less than 1 hour per day; however, almost 4% of users wore them for more than 5 hours per day (table 1, figure 1 ). concerning all the masks used, single-use masks constituted 52.5%. it appeared that 23.9% of responders who used single-use staff wore it again. there was no difference in this attitude between males and females (table 1) . 73.6% of participants declared mask decontamination (table 1 ). this procedure was significantly more common among females (p = .004). washing combined with ironing was the most common modality applied (63%), followed by the use of disinfectants (19.4%), ironing alone (4.8%) and putting into the oven (3.5%). other procedures, such as washing alone, microwaving, boiling and scalding with boiling water, were practiced by a single responder. in this survey, we documented that people with self-reported atopic predisposition wore face masks more frequently. it seems to be obvious as atopic disorders are clearly linked to the involvement of respiratory tract and increased risk of infections. 6, 7 such relationship could be bidirectional with atopy predisposing to viral infections and viral infection may trigger the atopic asthma. 8 in the previous viral pandemics, there was a clear crisis in the availability of professional face protection. 3 therefore, cloth masks were used commonly. this is in agreement with our findings showing the popularity of cloth mask protection used by the general public. one can consider that despite of protection provided by face masks they may be the cause of some side effects, including breathing difficulties, slurred speech, warming/ sweating and itching. [9] [10] [11] this may influence the use of face masks when they are only recommended and not obligatory. limited availability of professional face masks most probably was the reason that almost one-quarter of our responders used single-use masks several times. moreover, three-quarters of the evaluated individuals wearing face masks declared mask decontamination. nonetheless, our results showed that some practices among young people could be regarded as inappropriate. this can lead to decreased efficacy of face protection and eventual spread of viral infection. therefore, we believe that our results might be of value in construction of general public education campaigns on the proper use of face masks, especially if the role of face mask wearing in controlling the spread of infection is clearly documented. rational use of face masks in the covid-19 pandemic australian government releases face masks to protect against coronavirus mask crisis during the covid-19 outbreak covid-19: should the public wear face masks? nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-personal protective and environmental measures association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in us adults risks for infection in patients with asthma (or other atopic conditions): is asthma more than a chronic airway disease? role of viruses in asthma inconveniences due to the use of face masks during the covid-19 pandemic: a survey study of 876 young people face mask-induced itch: a self-questionnaire study of 2,315 responders during the covid-19 pandemic skin reactions of n95 masks and medial masks among health-care personnel: a self-report questionnaire survey in china key: cord-277693-6lrawta5 authors: wang, yuanzhuo; fang, rouyu; zhang, hanlin; tang, keyun; sun, qiuning title: contributions of dermatologists to covid‐19 research: a brief systematic review date: 2020-05-30 journal: dermatol ther doi: 10.1111/dth.13713 sha: doc_id: 277693 cord_uid: 6lrawta5 coronavirus disease 2019 (covid‐19) has been declared a pandemic. we conducted a systematic review to reveal the contribution of dermatologists in covid‐19 research. 298 articles were included and classified into cutaneous manifestations of covid‐19, operating experience against covid‐19, mechanisms and treatment of covid‐19, disinfection and personal protective equipment(ppe)‐related skin diseases and other topics. the value of these articles and their impact on clinical impact were discussed and we hope that dermatologists can have a better understanding of these areas from this study. this article is protected by copyright. all rights reserved. coronavirus disease 2019 (covid-19), first emerged in wuhan, china, rapidly spread all over the world. up to now, the number of confirmed cases has reached over 4 million. dermatologists have contributed a lot to covid-19, such as cutaneous manifestations of covid-19, teledermatology, and management on patients with inflammatory skin diseases. 1, 2 here, we systematically reviewed what dermatologists contributed to covid-19 research. the literature search was conducted on pubmed database on may 14, 2020. the searching strategy was (covid* or coronavirus*) and (dermatol* or skin* or cutaneous*), and language was restricted to english. the inclusion criteria were (1) articles published in dermatologic journals based on incites journal citation reports accepted article or (2) articles published in journals of other categories with the first author from the department of dermatology. 529 articles were identified in pubmed. after independent selection by two authors, 298 articles were included in the systematic review. 70 articles focused on cutaneous manifestations of covid-19 (n=70), followed by the management on patients with common skin diseases (n=68), operating experience against covid-19 (n=49), mechanisms and treatment of covid-19 (n=34), disinfection and personal protective equipment(ppe)-related skin diseases (n=27) and other topics(n=50). the detailed classification was shown in table 1 . 212 articles were comments, 73 were case reports or case-series, 12 were reviews and only 1 was case-control study 3 . the included studies were published in 36 different journals. 12 journals had more than three articles, all of which were dermatologic journals. 78 articles were published in journal of the american academy of dermatology, followed by spain, and 63 from other countries. the current pandemic of covid-19 aroused great public concern. the number of publications had rapid growth over time, as the plague of covid-19 spread rapidly all over the world, and dermatologists contributed some precious experience to the community, especially those from the frontline in the "red-zone" area. cutaneous manifestations of covid-19 has gained much attention. it has been pointed out that a common pattern of cutaneous symptoms may facilitate early diagnosis of covid-19 4 . although the cutaneous signs were highly variable and heterogeneous, a recent study reviewed the literature to summarize common features 5 , including vascular complications, maculopapular eruptions, urticarial rash, vesicular eruption, petechiae/ purpuric eruptions, erythema multiforme-like rash, palmar erythema, perifollicular eruption, pruritus, mucosal lesions, and androgenetic alopecia. a systematic investigation is warranted as most studies were derived from case reports and case series under the heavy burden of the pandemic. of note, these articles supported the important role of dermatologists working side by side with their staff from other departments. severe cutaneous manifestations suggested poor prognosis for patients and were beneficial for risk stratification at the early stage of the disease 5 . the management of patients with common skin diseases also attracted much attention, such as psoriasis, skin cancer, pemphigus and atopic dermatitis. long-term this article is protected by copyright. all rights reserved. use of immunosuppressants or biologics was common in these patients. given that these drugs were critical in the treatment and may stimulate the progress of covid-19 as well, it is a dilemma to make a decision. studies in march, early april were comments based on expert opinions 6 , and studies of case-series in may provided additional evidence to guide the usage of these drugs 7 . the dermatologists are recommended to read these publications to weigh and judge the risks and benefits, for discontinued usage of biologics may decrease the infection risk of covid-19 and lead to the aggravation of primary diseases at the same time 8,9 . dermatologists also focused on measures on quarantine, triage, and resumption, and tricks of wearing masks, and performing dermoscopy. many studies also focused on the personal protective equipment (ppe) and the need for disinfection of public places. a long time of wearing masks or other ppes had reached consensus in causing related skin diseases like dermatitis, and the medical workers should be educated to use them properly to avoid damage. 10 these articles also included the operating experience of dermatology clinics or hospitals, such as the area of telemedicine and emergency management. procedural dermatology was significantly influenced in the pandemic, including surgical and cosmetic techniques, laser, and the photodynamic therapy 11 . the experience facilitates the resume of outpatient dermatologic surgery with efficiency and safety 12 . there still exist some topics having little to do with dermatology were also discussed in dermatologic journals, such as mechanisms and treatment of covid-19 13 , covid-19 and racial disparities 14 , covid-19 and economy 15 . most articles were comments, personal perspectives with low level of evidence. due to the epidemiologic feature of covid-19, cohort study, case-control study, and randomized controlled trial were difficult to conduct to further reveal cutaneous manifestations of covid-19 and disinfection and personal protective equipment-related skin diseases. studies with larger population are warranted to further evaluate the current findings. national or international studies are also needed for further research. a growing trend was observed in the number of articles, which means covid-19 has been increasingly attracting the attention of dermatologists. most articles were from epidemic countries, and as the pandemic was declared, dermatologists should have more understanding of covid-19, and its relation with dermatology. we would like to suggest our advice as a healthcare worker in the "red-zone" area. services of the dermatology outpatient department and surgery were postponed except for emergency treatment. at the same time, we prioritize the use of telemedicine consultation, particularly for patients receiving biologics treatment. to minimize the risk of exposure, we also conveyed medical knowledge about usage of ppe, skincare, household cleaning, and the coronavirus to protect the dermatological patients. this study systematically reviewed contributions of dermatologists to covid-19 research. research topics, journals, publication time, and country of origin were accepted article identified, and the value of these articles and their influence on the clinical practice were discussed in detail. we hope this study may help dermatologists to have a better understanding of the mechanisms, management, and the cutaneous manifestations of covid-19, the operating experience of dermatology clinics in the " red-zone" area, and to use disinfectant and personal protective equipment properly. how dermatologists can learn and contribute at the leading edge of the covid-19 global pandemic challenges of covid-19 pandemic for dermatology. dermatologic therapy biologics increase the risk of sars-cov-2 infection and hospitalization, but not icu admission and death: real-life data from a large cohort during red-zone declaration cutaneous manifestations of the coronavirus disease 2019 (covid-19): a brief review. dermatologic therapy cutaneous signs in covid-19 patients: a review. dermatologic therapy covid-19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: an australian/new zealand consensus statement. the australasian journal of dermatology novel coronavirus disease (covid-19) and biologic therapy in psoriasis: infection risk and patient counseling in uncertain times biologic therapy for psoriasis during the covid-19 outbreak: the choice is to weigh risks and benefits. dermatologic therapy a challenging case of psoriasis flare-up after covid-19 infection personal protective equipment recommendations based on covid-19 route of transmission phototherapeutic approach to dermatological patients during the 2019 coronavirus pandemic: real-life data from the italian red zone. the british journal of dermatology to resume outpatient dermatologic surgery safely during stabilized period of coronavirus disease-2019: experiences from wuhan, china. dermatologic therapy what does androgenetic alopecia have to do with covid-19? an insight into a potential new therapy. dermatologic therapy covid-19 and racial disparities atomic dermatitis 3others 24mechanisms and treatment of covid-19hydroxychloroquine 7anti-cytosine therapy 5biologics 3 infection possibly mediated by androgen 3 operating experience against covid-19telemedicine 10 dermatologists' perspective in the pandemic 9measures conducted for outpatient clinic visits 9impact of covid-19 outbreak on dermatologic clinics 6procedural dermatology 6others 9others -50accepted article key: cord-296128-kjoi54ea authors: balestri, riccardo; magnano, michela; rizzoli, laura; rech, giulia title: do we have serological evidences that chilblain‐like lesions are related to sars‐cov‐2? a review of the literature date: 2020-08-26 journal: dermatol ther doi: 10.1111/dth.14229 sha: doc_id: 296128 cord_uid: kjoi54ea the outbreak of chilblain‐like lesions (cll) coincidentally to the covid‐19 pandemic is a topic of great concern. sars‐cov‐2 was initially hypothesized as the etiologic agent of cll, but, since nasopharyngeal swabs seldom resulted positive, dermatologists’ attention focused on the search for specific sars‐cov‐2 antibodies. many papers were published contemporarily on this topic, reporting limited case series. we reviewed the english literature up to the 1(st) july 2020 and, excluding single case reports, we considered 13 studies that serologically investigated 220 patients. the presence of specific antibodies was detected in 18 subjects (8,2%): isolated iga were found in 6 patients, iga and igg in 1, isolated igg in 5, and igm in 2. in 4 patients, isotypes were not specified. our review demonstrated a high prevalence of negative serological results in cll: antibodies were observed only in a few patients, that are even less excluding those with positive iga, not clearly involved in the pathogenesis of the disease. in conclusion, although it is still uncertain whether cll are related to sars‐cov‐2 infection, patients affected by cll seem not to be prone to shedding the virus, hence, if they are asymptomatic, we can reassure them, thus avoiding hospital referral this article is protected by copyright. all rights reserved. the outbreak of chilblain-like lesions (cll) coincidentally to the covid-19 pandemic is a topic of great concern 1 sars-cov-2 was hypothesized as the etiologic agent of cll, initially on the basis of the temporal correlation between the "burst" of skin manifestations and the viral pandemic. however, it has been shown that cll are not related to an acute infection, since real-time reverse transcription polymerase chain reaction (rt-pcr) tests from nasopharyngeal swabs seldom resulted positive 1-9therefore, dermatologists' attention shifted to the search for specific sars-cov-2 antibodies. many papers were published contemporarily on this topic, reporting limited case series. the aim of our review is to collect more data concerning seroprevalence and to better understand the role of sars-cov-2 in the development of cll. this article is protected by copyright. all rights reserved. we reviewed the english literature up to the 1 st july 2020 in the pubmed medline database using combinations of the key search terms "acral", "acro-ischemic", "acro-syndrome", "chilblain", "chilblain-like", "covid-19", "pernio", "pernio-like", "perniosis", "pseudochilblain", "sars-cov-2". search terms were used in combinations. the search was limited to articles published in english we included only case series, clearly declaring that a search for sars-cov-2 specific antibodies had been performed. single case reports were excluded. data were independently extracted by two authors (mm and rb), then the results of data extraction were compared. the initial research on pubmed returned 72 papers focusing on cll and sars-cov-2. we retrieved 13 articles reporting serological studies performed on case series that included at least 8 patients (table 1) . twelve studies took place in europeand the last one is an observational survey conducted in 8 us states. a total of 220 patients were serologically investigated. testing methods were various: chemiluminescent immunoassays were used in 3 studies, chromatographic immunoassay was used by 2 groups, enzyme linked immunosorbent assays (elisa) in other 2, one study used both a chemiluminescent immunoassay and an elisa and one both chromatographic and elisa. in 4 papers test types were not specified. performances declared in the manufacturers' package insert of each test are reported in table 2 . the presence of specific antibodies was detected in 18/220 (8.2%) cases. the detected isotypes were: isolated iga 6 (2.7%); iga and igg 1 (0.4%), isolated igg 5 (2.3%); igm 2 (0.9%). in 4 cases, the isotype was not specified. 1, 7, 11, 12 . one study declared only the total median (25 days) 6 . one hundred and ninety-two patients also underwent rt-pcr, resulted negative in all cases. this article is protected by copyright. all rights reserved. at the beginning of the cll epidemic, a role of sars-cov-2 was hypothesized only on the basis of the temporal correlation with the covid-19 pandemic, searching for evidence from nasopharyngeal swabs. it is now clear that cll do not represent an acute cutaneous manifestation of sars-cov-2, hence swabs are completely useless to confirm the infection. the attention of the scientific community therefore shifted to serology, assuming that specific antibodies may validate thishypothesis. the present review shows a high prevalence of negative serological results in cll, indicating that this is a wrong strategy to demonstrate the role of coronavirus in cll. in fact, antibodies were observed only in a limited percentage of patients, which becomes very low (5,45%) if we exclude patients with iga, whose role remains doubtful in the pathogenesis of the disease. some considerations and hypotheses can be raised to explain this finding: three groups support this theory, considering these skin lesions caused by lifestyle changes due to containment and lockdown measures 7, 11, 12 . however, although this may be true for some of these cases, given the large number of new reports of cll coincidentally with the covid-19 pandemic, it is not sufficient to explain all the cases. moreover, mean european temperatures during the first months of 2020 were similar or higher compared to those of the last 29 years, and solely the sedentary habits and barefoot walking at home seem inadequate to justify an epidemic of cll. this was particularly true with the initially-available tests, since they had been rapidly developed and placed on the market with limited validationhowever, we can exclude this hypothesis because this article is protected by copyright. all rights reserved. serological tests showed excellent clinical performance in real life 1 and the authors used 8 different types of test, achieving similar findings. higher levels of igm and igg have been found in the second and third week of illness, then igm begins to decline and almost disappears by week 7, while igg persists 14 . the duration of their persistence still remains unknown: data suggest a serological profile similar to sars-cov 14 , although asymptomatic/paucisymptomatic patients seem to present lower levels of specific antibodies compared to severe disease 22 . lower levels do not mean an absence of antibodies, hence we can also exclude this hypothesis. another issue could be the timing in which tests had been performed, since a sufficient time lapse is necessary to develop antibodies. this information is reported only in 4 studies, and the timing proved adequate to detect antibodies in most cases. locally recruited cytotoxic cd8 t cells could be the effector of skin lesions. during mild forms of the disease, such as those developing cll, t cell exhaustion and viral-associated immunosuppression may reduce the production of sars-cov-2 specific antibodies, therefore an incomplete viral clearing may induce delayed cutaneous lesions without detectable antibodies 9 . in genetically predisposed individuals the contact with sars-cov-2 triggers a robust interferon response, of which chilblains are the cutaneous expression. this hypothesis is supported by the fact that chilblains are a prototypical sign of a few inherited disorders of innate immunity, characterized by a strong interferon signature and a severe microangiopathy (i.e. interferonopathies). this strong this article is protected by copyright. all rights reserved. ifn-i response would mute early viral replication, clearing the virus without intervention of the adaptive immune system, thus avoiding the development of detectable igm/igg 1 . finally, we could consider the involvement of another viral agent in the epidemic of cll, and the seldom test-positivity to sars-cov-2 may therefore be only a casual finding. however, a viral outbreak during another viral pandemic seems highly improbable. in conclusion, while recent findings seem to suggest that sars-cov-2 could have a pathogenetic role in the development of cll, also serological screening failed to prove that acral skin lesions are a specific marker of sars-cov-2 infection. further studies are needed to obtain a definitive confirmation. in the meanwhile, it seems that patients affected by cll are not prone to shedding the virus; consequently, in the case of otherwise asymptomatic patients, we canreassure them, without referring them to hospital to perform any sort of covid-19 test, or quarantining them. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. chilblain-like lesions during covid-19 pandemic: a serological study on a case series no evidence of sars-cov-2 infection by pcr or serology in children with pseudochilblain chilblains in children in the time of covid-19: new evidence with serology assay a clinical, histopathological and laboratory study of 19 consecutive italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with covid-19 infection online ahead of print pernio-like skin lesions associated with covid-19: a case series of 318 patients from 8 countries chilblain-like lesions in pediatrics dermatological outpatients during the covid-19 outbreak evaluation of chilblains as a manifestation of the covid-19 pandemic covid toes"): histologic, immunofluorescence and immunohistochemical study of 17 cases no antibody response in acral cutaneous manifestations associated with covid-19 ? acute acral cutaneous manifestations during the covid-19 pandemic: a single-centre experience major cluster of pediatric " true " primary chilblains during the covid-19 pandemic: a consequence of lifestyle changes due to lockdown assessment of acute acral lesions in a case series of children and adolescents during the covid-19 pandemic recent outbreak of chilblain-like lesions is not directly related with sars-cov-2 infection igm/igg duo assay 99 igm/igg rapid test igm: 94.4% igg covid-19 elisa kit, vircell, igm/igg+iga igm+iga: 98% igg: 98% igm+iga: 98% igg: 98% key: cord-301107-0njnjqeb authors: dursun, recep; temiz, selami aykut title: the clinics of hhv‐6 infection in covid‐19 pandemic: pityriasis rosea and kawasaki disease date: 2020-05-31 journal: dermatol ther doi: 10.1111/dth.13730 sha: doc_id: 301107 cord_uid: 0njnjqeb a new type of coronavirus family (sars‐cov‐2), which can be found in humans and animals, with many varieties and clinical symptoms, was first seen in wuhan, china in late 2019, under the name novel coronavirus disease 2019 (covid‐19). in the literature, cutaneous symptoms related to the disease are generally emphasized. however, it is not yet known whether this new sars‐cov‐2 virus, which has entered our lives, plays a role in the etiopathogenesis of dermatological diseases. the patients who were admitted to the dermatology outpatient clinic between 1 april and may 15, 2019, and on 1 april and may 15, 2020 were retrospectively analyzed by searching the hospital automation system and patient files. the reason for the same months to be included in the study was to exclude seasonal effects on the diseases. after pandemic, the number of patients with pityriasis rosea and kawasaki disease increased significantly in patients who applied to the dermatology outpatient clinic. our study is the first study showing pityriasis rosea increase during the pandemic period. we think that this increase is related to hhv‐6 reactivation. herein, we wanted to draw attention to two diseases in which human herpes 6 (hhv‐6) was accused in etiopathogenesis: kawasaki disease and pityriasis rosea. this article is protected by copyright. all rights reserved. a new type of coronavirus family (sars-cov-2), which can be found in humans and animals, with many varieties and clinical symptoms, was first seen in wuhan, china in late 2019, under the name novel coronavirus disease 2019 . it spread to the world very quickly, and was accepted as a pandemic on march 11, 2020 (1) . clinical, therapeutic, vaccination, anti-virus, and anti-spreading studies have been initiated all over the world related to this virus, where human immunity was first introduced. because viral disease was spreading very fast and had a very lethal feature (2) . it is also reported that there are many patients with covid-19 disease asymptomatic. there are many publications about the cutaneous findings of the disease. in the literature, disease-related skin lesions have been reported in approximately 2-20% of covid-19 patients (3) . in the literature, cutaneous symptoms related to the disease are generally emphasized. however, it is not yet known whether this new sars-cov-2 virus, which has entered our lives, plays a role in the etiopathogenesis of dermatological diseases (4) . herein, we wanted to aim to evaluate whether two diseases (pityriasis rosea and kawasaki disease), in which human herpesvirus 6 (hhv-6) was held responsible for etiopathogenesis, after the covid-19 pandemic. this study was conducted at the necmettin erbakan university hospital, a major tertiary hospital, and sees over 1,200,000 patients per year. the patients who were admitted to the dermatology outpatient clinic between 1 april and 15 may 2019, and on 1 april and 15 may 2020 were retrospectively analyzed by searching the hospital automation system and patient files. the reason for the same months to be included in the study was to exclude seasonal effects on the diseases. in the evaluation made based on before and after the covid-19 pandemic, the total number of patients admitted to the outpatient clinic during these periods was determined. the numbers and rates of patients with pityriasis rosea and kawasaki disease among the total patients who applied to the outpatient clinic were calculated. local ethics committee approval was also obtained for the study. data analysis was performed using the spss 22.0 program. mean ± standard deviation and percentage were used for descriptive statistics. chi-square test was performed and the p value of less than 0.05 was accepted as statistically significant. the total number of patients admitted to the dermatology outpatient clinic between 1 april and 15 may 2019 was 6467. female patients had a slight predominance (55.9%). the mean age of patients was 35.7 ± 29.1. the total number of patients admitted to the dermatology outpatient clinic between 1 april and 15 may 2020 was 1292. female patients had a slight predominance (54.8%). the mean age of patients was 36.6 ± 30.2. in terms of age and gender, there was no significant difference in outpatient applications before and after the covid-19 pandemic. table 1 shows the distribution of the patients who applied to the dermatology outpatient clinic before and after the pandemic. among the patients who applied to the dermatology outpatient clinic between april 1 and may 15, 2019, 52 patients (0.8%) were diagnosed with pityriasis rosae. among the patients who applied to the dermatology outpatient clinic between april 1 and may 15, 2020, 50 patients (3.9%) were diagnosed with pityriasis rosae. after pandemic, the number of patients with pityriasis rosea increased significantly in patients who applied to the dermatology outpatient clinic (p:0,000). among the patients who applied to the dermatology outpatient clinic between april 1 and may 15, 2019, 2 patients (0.03%) were diagnosed with kawasaki disease. among the patients who applied to the dermatology outpatient clinic between april 1 and may 15, 2020, 4 patients (0.3%) were diagnosed with kawasaki disease. after pandemic, the number of patients with kawasaki disease increased significantly in patients who applied to the dermatology outpatient clinic (p:0,009). table 2 shows the distribution of patients with pityriasis rosea and kawasaki disease before and after the pandemic. covid-19 has already had many effects on the routine dermatology practice (5) . however, it is clear that there will be many more developments and new information in the relationship between covid-19 and dermatology in the following days. sars-cov-2, which is the cause of covid-19 disease, is not actually a dermatotrophic virus. however, various cutaneous manifestations associated with the disease have been reported to develop during covid-19 disease (3, 6) . cutaneous symptoms can be classified under five main categories (urticarial lesions, livedo and necrosis, maculopapular eruption, vesicular rash, pseudo-chilblain) (3). however, dermatological diseases triggered by sars-cov-2 remain a mystery for now. in our study, it was found that the rate of pityriasis rosae patients who applied to the dermatology outpatient clinic this year during the pandemic period increased approximately 5 times compared to the same time last year. the fact that there was no significant increase in the total number of pityriasis rosae patients was attributed to the low number of total admissions to the hospital during the pandemic period. in our opinion, the increase in the rate of pityriasis rosae patients among polyclinic patients was more important data. previously, a case of pityriasis rosea associated with covid-19 disease has been reported (7) . our findings are the first study in the literature showing the increase of pityriasis rosea patients and their relationship with covid-19. pityriasis rosea has been mostly associated with reactivation of human herpesvirus 6 and 7, but other viral etiology, vaccination, psychological stress, and drugs have also been implicated as the cause of this reaction (8) . hhv-6, a member of the herpes virus family, is usually transmitted in the first two years of life (roseola infantum) and settles in the salivary glands, causing a latent infection (9) . there are two types of hhv-6, a and b (10) . the reactivation of hhv-6 is blamed for many diseases, including pitriasis rosae (11) . it has been argued that one of the factors causing activation of herpes viruses is coronaviruses (12) . along with the covid-19 pandemic, it was thought that reactivation of hhv-6 could explain this obvious increase in pityriasis rosea cases. another possible trigger could be psychological stress caused by the pandemic period. kawasaki disease is a systemic vasculitis of childhood that can affect the coronary arteries. the diagnosis of kawasaki disease is based on clinical features. cutaneous symptoms with diagnostic criteria are: erythema of the mouth or pharynx, strawberry tongue, or stomatitis; polymorphous rash; erythema or edema of the hands or feet (13) . the etiology of kawasaki disease is still unknown. hhv-6 is one of the accused reasons for the etiology (14) . in a study conducted during the covid-19 pandemic, kawasaki disease was found to increase 30-fold compared to previous years (15). in our study, there was a 10-fold increase in the rate of patients with kawasaki disease who applied to the dermatology outpatient clinic compared to the previous year. we think that this increase in kawasaki disease during the covid-19 pandemic may be due to coronavirus triggering of hhv-6, which is responsible for the etiology. the covid-19 disease caused by sars-cov-2 still contains great mysteries for dermatology. in order to solve the mysteries about the disease, a lot of data are published about the clinical symptoms caused by the disease, the effects and side effects of drug treatments, and the associated diseases. kawasaki disease has been reported to increase compared to previous years. however, there is no data to show the increase of pityriasis rosae patients in which hhv-6 plays a role in etiopathogenesis, as in kawasaki disease. our study is the first study showing pityriasis rosea increase during pandemic period. we think that this increase is related to hhv-6 reactivation. herein, we wanted to draw attention to two diseases in which human herpes 6 (hhv-6) was accused in etiopathogenesis: kawasaki disease and pityriasis rosea. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding clinical characteristics of 2019 novel coronavirus infection in china classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases viral exanthem in covid-19, a clinical enigma with biological significance evaluation of dermatology consultations in the era of covid19 cutaneous manifestations in covid-19: a new contribution pityriasis rosea as a cutaneous manifestation of covid-19 infection pityriasis rosea recurrence is much higher than previously known: a prospective study molecular epidemiological studies of human herpesvirus 6 in families a populationbased study of primary human herpesvirus 6 infection additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and-7 shedding light on the effect of natural anti-herpesvirus alkaloids on sars-cov-2: a treatment option for covid-19 kawasaki disease: part i. diagnosis, clinical features, and pathogenesis reactivation of human herpesviruses 6 and 7 in kawasaki disease key: cord-264264-7j3xirfg authors: türsen, ümit; türsen, belma; lotti, torello title: coronavirus‐days in dermatology date: 2020-04-15 journal: dermatol ther doi: 10.1111/dth.13421 sha: doc_id: 264264 cord_uid: 7j3xirfg severe acute respiratory syndrome‐corona virus‐2 (sars‐cov‐2), which causes coronavirus disease 2019 (covid‐19), is highly contagious and a particularly popular problem in all around the world and also in all departments of every hospital. in order to protect the well‐being of healthcare providers while providing a sufficient workforce to respond to the coronavirus disease (covid‐19) are vital for pandemic planning. in this article, we will discuss this problem from a dermatological aspect. this article is protected by copyright. all rights reserved. maintain at least 1 metre distance from anyone who is coughing or sneezing, to avoid touching eyes, nose, hair, ear and mouth, and to stay home if one feels unwell. the best way to protect everybody against covid-19 is done by frequently cleaning the hands. by doing this ; we eliminate the viruses that may be on our hands and avoid infection that could occur by then touching our eyes, mouth, and nose. some antiseptics such as alcohol or chlorine can try to kill the viruses that have already entered our body. but these substances can be harmful to clothes or mucosal surfaces including eyes and mouth. soap works better than alcohol and disinfectants at destroying the structure of viruses. soap dissolves the fat membrane, and the virus falls apart like a house of cards and "dies," or rather, it becomes inactive as viruses aren't really alive. viruses can be active outside the body for hours, even days. disinfectants, or liquids, wipes, gels and creams containing alcohol have a similar effect but are not as good as regular soap. apart from alcohol and soap, antibacterial agents in those products don't affect the virus structure much. consequently, many antibacterial products are just an expensive version of soap for virus killing. soap is the best, but alcohol wipes are good when soap is not practical or handy, for example in office reception areas. soap contains fat-like substances known as amphiphiles, structurally similar to the lipids in the virus membrane. the soap molecules "compete" with the lipids in the virus membrane. that is more or less how soap also removes the normal dirt of the skin. the soap molecules also compete with a lot of other non-covalent bonds that help the proteins, rna and the lipids to stick together. the soap is effectively "dissolving" the glue that holds the virus together. when you add to that all the water it is even better. the soap also outcompetes the interactions between the virus and the skin surface. soon the virus gets detached and falls apart like a house of cards due to the combined action of the soap and the water (ying-hui jin et al 2020). alcohol-based products include all "disinfectants" and "antibacterial" products that contain a high share of alcohol solution, typically 60%-80% ethanol, sometimes with a bit of isopropanol, water and a bit of soap. ethanol and other types of alcohol do not only readily form hydrogen bonds with the virus material but, as a solvent, are more lipophilic than water. hence, alcohol does dissolve the lipid membrane and disrupt other supramolecular interactions of the virus. however, you need a fairly high concentration (may be 60%-plus) of the alcohol to get a rapid dissolution of the virus. to sum up, viruses are almost like greasenanoparticles. they can stay active for many hours on surfaces and then get picked up by touch. then they get to our face and infect us because most of us touch our face frequently. water is not effective alone in washing the virus off our hands. alcohol-based products work better. but nothing beats soapthe virus detaches from the skin and falls apart readily in soapy water. supramolecular chemistry and nanoscience tell us not only a lot about how the virus self-assembles into a functional, active menace, but also how we can beat viruses with something as simple as soap (chloé , varbanov, raphaël , 2012). alcohol-based antiseptics are better tolerated and lesser irritant than soaps (williams 2011). however, it was observed that washing hands with soap is better than using alcohol-based disinfectants in removing the noroviruses, rhinovirus and h1n1 influenza virus from hands (tuladhar 2015, kopra 2012, grayson 2009 ). acidic syndets are lesser irritant than standart soap and we can propose syndet uses during covid-19 war (korting 1995). according to the literature knowledge, we can see erythematous rash, petechia, urticaria and vesicles during covid-19 infection as 20 %. . this finding can indicate that covid-19 may not be a lung disease but rather a red blood cell-targeting disease. this finding can also clarify these vascular changes of skin during covid-19 infection. in our opinion, we will also see erythroderma, erythema nodosum, erythema multiforme, pruritus and different rashes associated with covid-19 in the future. also we have a risk of covid-19 vaccine-related skin eruptions in the future years like other viral vaccine-related eruptions such as urticaria, scleroderma, maculapapular rashes (recalcati, 2020) . if our patients have atypical skin rash accociated with fever, cough and shortness of breath; we must think covid-19 associated skin rash as the diferential diagnosis. during this covid-19 pandemia, we can see skin problems associated with the personal protective equipments in health-care workers. medical masks can induce acne vulgaris, rocasea, irritation, ecchymosis, even erosions. we can recommend topical benzoiyl peroxide, retinoic acid, antibiotics for acne vulgaris; topical metronidasole and azeleic acid for rosacea, barrier creams to prevent facial irritation and also frequent changing of the mask. medical gloves can cause maceration and contact dermatitis reponding well to topical steroids and moisturizer creams. we can recommend regularly changing of the gloves especially of latex-free type. frequent washing of the hands with soap and also using antiseptics may induce allergic and irritant contact dermatitis. we can advise moisturizer and barrier creams after cleaning and also bar soaps with moisturizers. ( after covid pandemia, we postponed all non-urgent dermatological procedures such as biopsy, electrocauterisation, cryotherapy, patch and prick tests, dermoscopy, all aesthetic dermatology interventions in mersin university like in all other dermatology departments. we discharged all hospital inpatients who are medically fit to leave and in these days we have only 4 inpatients in our department. we also minimised all non-essential outpatient appointments and we accept only serious and emergent cases now. we are trying to use telemedicine, whatsup, e mail or phone for simple skin issues in our city. there is a very limited evidence base to formulate a specific advice for dermatology patients on immunomodulators with regards to covid-19. the following is based on expert opinion, taking into account the known risks of other rna viruses. there are complex interactions between coronaviruse's replication and host immune response in covid-19. since there are limited studies, we need more information on the the risk of immunosupression in patients exposed to this virus (beth et al, 2020). we can propose that mono-immunosupressive therapy, target therapies, immunomodulatory agents such as intravenous immunoglobulin, acitretin etc. in the presence of significant comorbidies including diabetes mellitus, hypertension, obesity . we should do a patient-by-patient evaluation about ongoing treatments in patients with psoriasis, lupus erythematosus, lichen planus etc. in our university, standart medicine student education was cancelled due to covid-19 outbreak. all universities created e-learning programme such as webinar, online lectures with powerpoint slides and also online conversations. after march 2020, all national and international congress, symposiums and training events have been cancelled or postponed due to covid-19 pandemia. we barely accomplished our international indercos congress in 11-14 march 2020 and more than 20 international and national lecturers couldn' t come because of covid-19 including our hononary congress president prof lotti. we use hydroxychloroquine for the treatment of discoid lupus erythematosus and understand its relative safety. hydroxychloroquine and chloroquine have antiviral activity against covid-19 in vitro and in small uncontrolled clinical studies with limited and inconclusive results. in covid-19, a small non-randomized study from france indicated some benefits with serious methodological flaws, and a follow-up study still lacked a control group. however, another very small, randomized study from china in patients with mild to moderate covid-19 found no difference in recovery rates. sadly, reports of adverse events have increased, with several countries reporting side-effects including ventricular arrhythmias, qt prolongation, other cardiac toxicities, ocular toxicity and even death. we should know that these drugs may pose particular risk to critically ill persons. due to the remarkable pharmacokinetics and efficacy, azithromycin with immunomodulatory and anti-inflammatory properties, is well established as a potent treatment for some skin diseases such as rosacea, psoriasis and synovitis, acne, pustulosis, hyperostosis, osteitis (sapho) syndrome. combining hydroxychloroquine with the antibiotic azithromycin has also been associated with positive patient outcomes according to low-powered france study (gautret et al, 2020) . whether this results in better clinical outcomes --ie. if patients recover more quickly --is still being debated. colchicine has been used to treat various dermatologic diseases, some of which are quite seldom, which include behçet's disease, epidermolysis bullosa acquisita, recurrent oral aphthosis, cutaneous vasculitis, chronic urticaria and sweet syndrome fot its anti-neutrophilic immunomodulatory effect. in the last clinical trial called colcorona (colchicine covid-19 trial), colchicine is being used to reduce the inflammatory reaction caused by covid-19 that can lead to pulmonary involvement, organ failure and death. it will be used for its anti inflammatory and anti-cytokine storm effects when treating covid-19 (cynthia et al, 2020). a variety of repurposed drugs and investigational drugs have been identified for covid19 treatment. however, evaluation of investigational agents requires adequately powered, randomized, controlled trials with realistic eligibility criteria and appropriate stratification of the patients. these are globally uncertain and testing times. we can prefer webinar and online education models, online examinations, and online patient examination until the covid-19 pandemic is over. but the most important thing is that we have to work together as a professional community to support one another, therefore upcoming challenges will undoubtedly create learning experiences for us all. literature knowledge suggests that humans have been afflicted by viruses throughout their evolutionary history, although the number and the types have changed. endogenous retroviral insertions since the divergence between humans and chimpanzees were capable of directly affecting hominid evolution through changes in gene expression and development. it is estimated that there are about 10 31 viruses on earth and most of the viruses are bacteriophages, and most of them are in the oceans. the human genome project has revealed the presence of numerous viral dna sequences scattered throughout the human genome. these sequences make up around eight per cent of human dna, and appear to be the remains of ancient retrovirus infections of human ancestors. these pieces of dna have firmly established themselves in human dna. most of this dna is no longer functional, but some of these friendly viruses have brought with them novel genes that are important in human development ( pattern of early human-to-human transmission of wuhan a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version duval . human coronaviruses: insights into environmental resistance and its influence on the development of new antiseptic strategies.viruses cutaneous manifestations in covid-19: a first perspective emollients and moisturisers for eczema cochrane database syst rev covid-19 and the otolaryngologist-preliminary evidencebased review adverse cutaneous reactions to influenza vaccinations and chemotherapy associations between immune-suppressive and stimulating drugs and novel covid-19-a systematic review of current evidence. e cancer medical science hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial the first endogenous herpesvirus, identified in the tarsier genome, and novel sequences from primate rhadinoviruses and lymphocryptoviruses genomewide function conservation and phylogeny in the herpesviridae il-12 family of cytokines in infection, inflammation and autoimmune disorders patients with moderate-to-severe psoriasis recapture clinical response during retreatment with etanercept continuous dosing versus interrupted therapy with ixekizumab: an integrated analysis of two phase 3 trials in psoriasis should biologics for psoriasis be interrupted in the era of covid-19 reducing viral contamination from finger pads: handwashing is more effective than alcohol-based hand disinfectants efficacy of soap and water and alcohol-based hand-rub preparations against live h1n1 influenza virus on the hands of human volunteers single treatment with ethanol hand rub is ineffective against human rhinovirus--hand washing with soap and water removes the virus efficiently the influence of the regular use of a soap or an acidic syndet bar on pre-acne the use of a measure of acute irritation to predict the outcome of repeated usage of hand soap products covid-19 can present with a rash and be mistaken for attacks the 1-beta chain of hemoglobin and captures the porphyrin to inhibit human heme metabolism key: cord-270951-6nq3jwgr authors: amerio, paolo; prignano, francesca; giuliani, federica; gualdi, giulio title: covid‐19 and psoriasis: should we fear for patients treated with biologics? date: 2020-05-05 journal: dermatol ther doi: 10.1111/dth.13434 sha: doc_id: 270951 cord_uid: 6nq3jwgr the new coronavirus pandemic poses question and challenges for dermatologists. one of question is if psoriasis patients treated with immunomodulating and immunosuppressive drugs have to discontinue their treatment in the midst of fears for the infection and its consequences. one of the challenges is how can we support our patients in this critical time. previous coronaviruses outbreaks reports, current published evidences on pathogenesis and on clinical reports of covid infection in immunosuppressed patients are used to make a scientifically based decision. a new coronavirus infection started in china in december 2019 and it quickly spread to other countries in and outside asia. in january 2020 the world health organization termed this new virus sars-cov-2 as it is very similar to the one that caused the sars outbreak (sars-covs). 1 the ongoing sars-cov-2 or covid 19 pandemic is a great concern for public health and italy is one of the countries that has the largest outbreak outside mainland china with increasing number of infected people and deaths. 2 psoriasis is an immune mediated disease that affects almost 3% of population. it is treated targeting effector cytokines identified as crucial in the pathogenesis of this disease: tnf alpha, il-12-23, il-17 and il-23. the usual approach to this disease is to suggest continuous treatment for patients since alteration of therapeutic schedule could enhance the risk of immunogenicity and thus treatment failure. 3 recently some concern over the possibility that cytokine directed immunosuppressive treatment may be a risk factor for sars-cov-2 infection in psoriasis patients has been expressed. 4 the pandemic scenario changes very rapidly with new data on the clinical and serological characteristics of affected cases being reported every day. we think that is time to review more thoroughly the available data in the literature, in order to give a clearer advice to dermatologist. we screened concerning the pathogenesis of sars and mers it seems that a th1 activation associated with the production of high levels of proinflammatory cytokines may play a pivotal role in the disease. cytokines such as il-1, il-6 and il-12, and chemokines such as il-8, ccl2 and cxcl10 were elevated in sars patients 6 and diminished in patients that recovered, accompanied by a robust anti-virus antibody response. 7 in mers a worst outcome was associated with high levels of il-10 and cxcl10 and with high levels of il-17 and il-23 8 . moreover proinflammatory cytokines genes such as il-1, il-6, tnf, and chemokines such as cxcl1 and ccl20, were found to be overexpressed in sars cov infection by microarray datasets analysis. 9 the importance of the role of massive release of proinflammatory cytokines (cytokine storm) is underlined by the fact that there is a significant difference in the concentration of serum of ifn-γ, il-1, il-6, il-12, and tgfβ and of chemokines such as ccl2, cxcl10, cxcl9, and il-8 between severe disease sars patients compared to uncomplicated sars patients. 8 lethality in sars was directly correlated with the serum concentration of ifn α and γ and with up regulation of ifn-stimulated genes such as cxcl10 and ccl2. furthermore, patients with severe disease had low levels of anti-inflammatory cytokine il-10. 10 both in sars and mers it seems that the severity of the disease depends from viral load in the airways, age and comorbid condition. no comment has been ever made, in literature, on concomitant immunosuppression in these patients. 11, 12 being older with comorbid conditions such as hypertension, diabetes, obesity, heart and renal failure were associated with more severe cases. 11, 12 several treatments have been proposed for sars and mers else than clinical support: antiviral, anti-malaria drugs, interferons, immunoglobulins, and vaccines. given the potential role of proinflammatory cytokines in the pathogenesis of sars and mers severe disease, also ant inflammatory drugs have been suggested as novel treatments in these diseases. drug repurposing studies have identified immunosuppressive drug, cyclosporine, as potentially useful. 13 moreover given the role of tnfα in these diseases, this cytokine has been suggested as a putative target in respiratory viral disease in which a partial tnf-α inhibition may benefit patients. 10 recent reports have shown that infection with sars-cov2 induces the production of il-1 β, ifn-γ, ip10, and mcp-1. the concentration of these cytokines (ip10, mcp-1) is directly related to the severity of the disease and with the probability of being admitted to the icu. 14 . since there are also reports that sars-cov-2 may induce also production of th2 type cytokines further studies are needed to clarify the role of the cytokine storm into this disease. high levels of il-2, il-7, gm-csf, mip1-α, and tnf-α have also been correlated with disease severity in sars-cov-2 infected patients. 15 among predictors of fatality in retrospective studies from china cases, high il-6 plasma levels was suggested, implying that mortality might be due to virally driven hyperinflammation. 16 thus, it could be suggested that a cytokine storm is responsible for massive tissue destruction and correlates with disease severity also in sars-cov2 disease. 15 this aspect has been also suggested for pediatric patients. 17 even in this age group, critically ill patients showed high levels of il-6, il-10, and ifn α. anedoctical case series and trials with promising results have been reported with drugs with immunomodulating activities: hydroxychloroquine and azithromycin 18 as well as cytokine targeting drugs such as tocilizumab 19 and jak-kinase inhibitors 20 . however currently, effective infection control intervention is the only way to prevent the spread of sars-cov-2. 20 what about patients with inflammatory conditions? how should we treat them during covid-19 pandemic? there is controversy on this argument: question is to carefully balance the higher risk of infection in patients on immunomodulating therapy with the potential beneficial effect of reducing immunity. 14,21 as already reported for sars and mers, also patients with sars-cov-2 infection may present with some characteristics that can predict severity of disease. literature is very consistent in reporting that elderly male patients, with comorbidities were more prone to develop more severe disease. the most frequent comorbidities present in 30% to 80% of critically ill patients are: diabetes, cardiovascular disease, pulmonary disease (copd), hypertension and malignancy. 14,22,23 a very large study of 72 314 patients from china confirmed that the majority of cases and the higher mortality (14,8%) were among elderly people. the same study showed that the fatality rate among those without comorbidities was 0,9% while in those with cardiovascular disease it was 10,5%, and 7,3% in those with diabetes, 6,3% in those with chronic respiratory diseases, 6% for those with hypertension, and 5,6% for those with cancer. 24 some author wisely acknowledge that patient characteristics may change in different population affected, however an early analysis of the difference between italian and chinese cases concluded that the most at risk patients for severe disease were very similar. 25 more recent italian data confirm that 84% of deceased patients were 70 years of older and that more than 50% had three or more comorbidities the most frequent of which were: hypertension, ischemic heart disease and diabetes. 26 the only relevant publication reporting immunosuppression and potentially lethal sars cov-2 illness was the one regarding the very limited washington state outbreak in which other comorbidities associated with the 21 patients admitted to icu were: history of organ transplant (9,5%), immunosuppression (14,3%), and rheumatologic disease (4,8%). 27 case reports and large patients series, however, mitigate the fear about the potential high risk for immunosuppressed patients. at the best of our knowledge two papers address the issue. 28, 29 the first is a large case series coming from a city in the epicenter of the outbreak in italy. it describes the cases recorded in a very big pediatric liver transplant population. only three patients tested positive and no patient among over 200 liver transplanted, 100 with autoimmune liver disease and 300 under chemotherapy for liver cancer developed serious illness due to covid-19. 28 the second is a case report from wuhan, reportedly one of the cities with the largest number of kidney transplant in china, it describes the case of an adult kidney transplant patient with covid-19 pneumonia. this patient recovered after immunosuppressive treatment reduction and introduction of intravenous immunoglobulins and low dose steroids. noteworthy is the evidence that also this patient had high plasma levels of il-2, il-6, and tnf-α and that his disease course was similar to nonimmunosuppressed patients. 29 3 | conclusion 3.1 | should we fear for our psoriasis patients treated with biologicals? during this pandemic we have to base the decision on whether continue or withhold psoriasis treatment on scientific evidences. we must be very careful and act with caution since, as we presented, we only have indirect evidences. in times in which the covid-19 fear could lead to over psychological distress, people with disease such as psoriasis, may worsen, since they are already striving with a chronic psychologically distressing disease. 30 stopping immunosuppressive or immunomodulating treatment in psoriasis could lead to reduced response at retreatment due to several reasons, the most important of which is immunogenicity. 3 we can speculate on three strong evidences that were discussed above: 1 the evidence that no reports have being published so far on immunosuppression being a risk or worsening condition for covid-19 disease. 2 the evidence that the severity of the disease, as happened for other coronaviruses outbreaks, is linked to a "cytokine storm "that has to be controlled in order to reach recovery. moreover cytokines targeted by psoriasis treatment (such as tnf-α, il-17, il23) are not among the most relevant in covid related inflammation. 3 the evidence that the most important risk factors leading to more severe illness for covid-19 sars are comorbidities that we can find also in our psoriatic patients, 31 the more obvious consequence of this evidence is that that we have to stress virus containment measure to these fragile patients. in conclusion we think that with all due caution, the treatment of psoriatic patients with biologicals should not be discontinued during the time of this pandemic. caution has to be focused on elderly patients with coexisting morbidities such as hypertension, diabetes and obesity that enhance their chance of developing, if ever infected, a more severe disease. in this specific group of patients the decision to suspend the treatment should be made when patients develop flu like or covid-19 specific (anosmia, asthenia) symptoms and if are exposed to high risk contact with infected people. pa and gg conceived and the manuscript, participated in the analysis and interpretation of data or acquisition of data, and drafted the manuscript. fg and fp participated in the acquisition and interpretation of data and revised the manuscript. all authors have given final approval of the version to be published. https://orcid.org/0000-0003-1589-9672 francesca prignano https://orcid.org/0000-0002-5997-2045 evaluation and treatment coronavirus (covid-19) covid-19 coronavirus pandemic immunogenicity of anti-tnfα therapy in psoriasis: a clinical issue? covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action middle east respiratory syndrome: pathogenesis and therapeutic developments plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome coronaviruses post-sars: update on replication and pathogenesis mers-cov infection in humans is associated with a pro-inflammatory th1 and th17 cytokine profile identification of common biological pathways and drug targets across multiple respiratory viruses based on human host gene expression analysis pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology epidemiological, demographic, and clinical characteristics of 47 cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study clinical and laboratory findings of sars in singapore drug repurposing for viral infectious diseases: how far are we? clinical features of patients infected with 2019 novel corona virus in wuhan covid-19: consider cytokine storm syndromes and immunosuppression clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients amerio et al. from wuhan, china clinical features of severe pediatric patients with coronavirus disease 2019 in wuhan: a single center's observational study new insights on the antiviral effects of chloroquine against coronavirus: what to expect for covid-19? the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the perspectives of clinical immunologists from china the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak -an update on the status comment on "covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action clinical features and treatment of covid-19 patients in northeast chongqing the novel coronavirus pneumonia emergency response epidemiology team. vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19)-china covid-19 and rationally layered social distancing similarity in case fatality rates (cfr) of covid-19/sars-cov-2 in italy and china istituto superiore di sanità -l'epidemiologia per la sanità pubblica, analisi sui decessi characteristics and outcomes of 21 critically ill patients with covid-19 in washington state coronaviruses and immunosuppressed patients. the facts during the third epidemic successful recovery of covid-19 pneumonia in a renal transplant recipient with long-term immunosuppression expressive suppression and negative affect, pathways of emotional dysregulation in psoriasis patients psocube, a multidimensional assessment of psoriasis patients as a both clinically/practically sustainable and evidence-based algorithm covid-19 and psoriasis: should we fear for patients treated with biologics? dermatologic therapy key: cord-263882-s5oxr6es authors: najar nobar, niloufar; goodarzi, azadeh title: patients with specific skin disorders who are affected by covid‐19: what do experiences say about management strategies? : a systematic review date: 2020-06-18 journal: dermatol ther doi: 10.1111/dth.13867 sha: doc_id: 263882 cord_uid: s5oxr6es background and aim: in patients with dermatologic disorders who are affected by new corona virus, we know little about course (underlying disease and new onset‐infection) and the most proper management strategies include both issues that are what this systematic review targets. method: databases of pubmed, scopus, google scholar, medscape and cebd coronavirus dermatology resource of nottingham university searched completely and initial 237 articles selected to further review and finally nine articles (including 12 patients) entered to this study. result: from 12 patients with chronic underlying dermatologic disease treated with systemic therapies, only one patient required icu admission, the others have been treated for mild‐ moderate symptoms with conventional therapies. the biologic or immunosuppressive/ immunomodulator agents has been ceased during the course of disease. the course of covid‐19 its management was as similar as normal populations. their underlying dermatologic disease was exacerbating from mild to moderate. their treatment has been continued as before, after the symptoms improved. conclusion: exacerbation of patients underlying dermatologic disease is mild‐ moderate. discontinuing the treatment in the acute period of covid and the restart after recovery may prevent severe recurrence in these patients. this article is protected by copyright. all rights reserved. manifestations. there are growing reports of dermatologic manifestation among children like morbiliform or urticarial rash and conjunctivitis (33, 34) or non-specific exanthematous, urticarial rashes and facial ulceration in affected infants may born from infected mothers (33, 35) . hydroxychloroquine-induced rashes solely or in combination with other therapies, are responsible for the main cutaneous drug reactions especially generalized pustular eruptions (36) (37) (38) . there are some secondary covid-19 related dermatoses like incidence of an acute new dermatologic entity for a limited time period that could be stress-related (e.g. herpes simplex, herpes zoster, alopecia areata ad etc…) or physical-environmental-related (e.g. contact dermatitis, acute urticaria…) or presence of a new dermatoses which have tendency to become chronic, like telogen-effluvium, various types of dermatitis, neurocutaneous or psychocutaneous disorders. in the pandemic, some preexisting chronic dermatoses may become poorly-controlled or aggravated by the stress, irregular visits, treatment interruptions, delayed therapies, physical and environmental situations like wearing masks and latex gloves, frequent washing and disinfectants, excessive sweating and etc (11) . dermatologic visits and cosmetic or elective surgical procedure have been affected largely by a decreasing manner during pandemic (39) . adherence to personal and social hygiene strategies, social isolation and distance are the rules of pandemic for better controlling any situations and the role of teledermatology is really important in this area regarding educational and therapeutic issues (40) . in dermatology, one of the most important concerns in the pandemic setting is the manner of disease management especially in the case of patients under treatment with immunosuppressive immunomodulators. non-infected non-at risk patients do not need to any change in their therapeutic protocols but at-risk patients or who suspected to being infected (like having suggestive symptoms) need altering drug regimen as dose reduction, increase dose interval or transient stop of drug usage for at least 2 weeks. it is not any doubt that, every patient with an active corona virus infection should discontinue systemic biologic or non-biologic immunosuppressive for at least 1 month or completely being symptom-free. a more severe covid-19 course is usually predictable in the setting of dermatologic diseases which are treating by systemic immunomodulators. presence of any comorbidities related to underlying dermatologic disorder (like older age, metabolic syndrome and vital organ dysfunctions especially respiratory and cardiovascular involvements that may be seen in psoriatic or atopic patients or who with hidradenitis suppurativa, immunobullous or collagen vascular disorders), is associated with poorer outcomes in the case of being infected by covid-19. some studies suggested that more sever skin conditions are at risk for higher rate of pneumonia and symptomatic respiratory involvement. in future vaccination of these groups of patients is one of priority issues. it seems that in patients with any severe and serious dermatologic disorders, under treatment with systemic agents, if there is not any suspicion about concurrent infection or any high risk exposures, not only it is not recommend to cessation therapy but only emphasize that these drugs could prevent disease flare-up and control cytokine storm that both in a negative direction, affect the covid-19 course (41) (42) (43) (44) (45) (46) (47) (48) . one of the most important perspectives in the field of dermatology is to approach patients with any documented skin or mucosal disorders especially who are using immunomodulators and now are affected by covid-19. for consensus and more exact expert recommendations in this group of patients, we need data gathering about people who were in this situation and know more about what experience say about dermatologic disease course, covid-19 course and manner of managing both conditions in the best possible way? so in this systematic review we focused on specific patient groups with a dermatologic disorder (usually under therapy) that concomitantly have been infected by the new corona virus and summed up their data in all aspects of underlying and infectious disease course and management. this study is implemented according to the prisma (preferred reporting items for systematic reviews and meta-analyses) statement. inclusion criteria comprised all studies about patients with any documented skin or mucosal disorders especially who were using immunomoduators and now were affected by covid-19. the exclusion criteria consisted of all publications not meeting the above contents and non-english literature. we searched databases of pubmed, scopus, google scholar, medscape and cebd coronavirus dermatology resource of nottingham university (https://www.nottingham.ac.uk/). our key words were ( "covid-19" ) or ( "severe acute respiratory syndrome coronavirus 2" ) and ( "skin" ) or ( "skin diseases" ) or ( "skin manifestations" ) or ( "dermatology" ) or ("skin and connective tissue diseases" ) or ( "eczematous" ) or ( "eczema" ) or ( "eczematous dermatitis" ) or ( "eczematous eruption" ) or ( "eczematous skin" ) or ( "dermatitis, atopic" ) or ( "papulosquamous" ) or ( "psoriasis" ) or ( "hidradenitis, suppurativa" ) or ("alopecia" ) or ( "pemphigus" ) or ( "pemphigoid" ) or ( "immunobullous" ) or ( "skin cancer" ) or ( "dermatologic agents") or (" immunomodulator") or ( " systemic drugs" ) or ( "biologics" ) or (" immunomodulator") or ( "immunospress" ) or ( "immunospressive" ). in the search of cebd coronavirus dermatology resource of nottingham university we focused on the link of skin manifestations of coronavirus and coronavirus and specific patient groups. we finally complete our search up to may/15/2020. in the first screening 237 articles assigned to the inclusion and exclusion groups and then the titles and abstracts of articles were review by two expert dermatologists and acceptable articles (23) searched to find their full text and finally 9 articles (including 12 patients) selected to data entry for this systematic review (37, (49) (50) (51) (52) (53) (54) (55) (56) . after researching, we have found nine related articles and the information of these articles are prepared as a table. of the 12 patients reviewed in these articles, ten had psoriasis/ psoriatic arthritis and two had immunobullous disease included pemphigus and mucous membrane pemphigoid. their underlying disease was treated with the following drugs:  from patients with psoriasis/psoriatic arthritis, eight patients were treated with biologic agents (guselkumab: three patients, secukinumab: two patients, apremilast: one patient, adalimumab: one patient, ustekinumab: one patient); two patients were on other immunosuppressive/immunomodulators agents include cyclosporine and methotrexate.  one patient with mucous membrane pemphigoid was treated with prednisolone, rituximab, mycophenolate mofetil and high dose ivig  one patient with pemphigus was treated with mycophenolate mofetil this article is protected by copyright. all rights reserved. at the time of the pandemic, many patients were diagnosed with various dermatoses treated with biological agents or immunosuppressive/ immunomodulators (57) . although, there is still no strong evidence of a higher risk of infection with covid-19 in these patients, and clinicians emphasizes that the symptoms and management of disease in these patients are similar to those in the general population (26) . in addition, for many dermatoses, any mental or physical stress, such as infection or anxiety, may exacerbate the disease (61-62) . this study has evaluated nine case reports of patients with chronic dermatologic diseases treated with systemic agents. of the 12 patients reported, the two patients did not show any symptoms despite close contact with people with confirmed cases of covid-19; at the time of quarantine, these patients showed no signs of the disease and their treatment continued as before. of the remaining ten patients, only one required hospitalization in the intensive care unit. five patients were treated with conventional therapies such as hydroxychloroquine, oseltamivir, lopinavir/ritonavir, antibiotics. other patients were treated with supportive/symptomatic therapies. at the time of the covid-19, the biologic agents were discontinued except for one case (which was treated with guselkumab) but the patients did not report any severe exacerbation of their underlying dermatologic disease despite treatment discontinuation. there was only one case of severe relapse of psoriasis after covid-19, in which the patient was previously treated with cyclosporine and methotrexate. investigation of these articles showed that the severity of covid-19 in patients with underlying dermatologic disease treated with biological agents was not more than in the general population. the management of these patients was in the form of discontinuation of the biological agents or immunosuppressive/ immunomodulators and the use of routine and conventional treatments. after the symptoms have improved, treatment of the underlying dermatologic disease can be recommenced as before. our knowledge about managing patients with dermatologic disorders (especially chronic disorders under treatment with systemic immunomodulators) who are affected by covid-19 in the pandemic is really scarce so for better controlling and managing both underlying dermatoses and concurrent corona virus infections, we need to sum up current relevant data that we did in this systematic review so far. we found that the severity of the disease or the need for hospitalization in these patients was not greater than in normal population. the treatment of the disease in confirmed cases with covid-19 were similar to that of normal population, with the difference that it is better to stop the patient's previous medications until the symptoms improve. in patients who have already been treated with biological drugs, recurrence of underlying dermatologic disease was mild. after the symptoms of the disease have improved, the patient's treatment could be continued as before. covid-19: 'co' stands for corona, 'vi' for virus, 'd' for disease, and '19' for 2019. cebd: centre of evidence based dermatology classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases cutaneous manifestations in covid-19: a new contribution cutaneous lesions in a patient with covid-19: are they related? cutaneous manifestations in covid-19: a first perspective cutaneous manifestations in covid-19: a first perspective " by recalcati s clinical and histopathological study of skin dermatoses in patients affected by covid-19 infection in the northern part of italy cutaneous manifestations of covid-19: report of three cases and a review of literature dermatologic findings in two patients with covid-19 cutaneous manifestation of covid-19 in images: a case report alert for non-respiratory symptoms of coronavirus disease 2019 (covid-19) patients in epidemic period: a case report of familial cluster with three asymptomatic covid-19 patients occupational skin disease among health care workers during the coronavirus (covid-19) epidemic a distinctive skin rash associated with coronavirus disease a case of covid-19 pneumonia in a young male with full body rash as a presenting symptom morbilliform exanthem associated with covid-19 rash as a clinical manifestation of covid 19 photographs of a patient sars-cov-2 infection presenting as a febrile rash urticarial eruption in covid-19 infection urticarial exanthem as early diagnostic clue for covid-19 infection a case of covid-19 presenting in clinical picture resembling chilblains disease. first report from the middle east chilblain-like lesions on feet and hands during the covid-19 characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak chilblain-like lesions during covid-19 epidemic: a preliminary study on 63 patients complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases acral cutaneous lesions in the time of covid-19 acute acro-ischemia in the child at the time of covid-19 coagulopathy and antiphospholipid antibodies in patients with covid-19 covid-19 can present with a rash and be mistaken for dengue": petechial rash in a patient with covid-19 infection petechial skin rash associated with severe acute respiratory syndrome coronavirus 2 infection covid-19 can present with a rash and be mistaken for dengue varicella-like exanthem as a specific covid-19-associated skin manifestation: multicenter case series of 22 patients varicella-like exanthem associated with covid-19 in an 8-year-old girl: a diagnostic clue? a dermatologic manifestation of covid-19: transient livedo reticularis cutaneous manifestations in the current pandemic of coronavirus infection disease (covid 2019) a child confirmed covid-19 with only symptoms of conjunctivitis and eyelid dermatitis characterizing the adverse dermatologic effects of hydroxychloroquine: a systematic review a case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a patient with covid-19: will cases of psoriasis increase after covid-19 pandemic? generalized pustular figurate erythema: a newly delineated severe cutaneous drug reaction linked with hydroxychloroquine an assessment of united states dermatology practices during the covid-19 teledermatology: a useful tool to fight covid-19 should patients stop their biologic treatment during the covid-19 pandemic advice regarding covid-19 and use of immunomodulators, in patients with severe dermatological diseases covid-19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: an australia/new zealand consensus statement managing cutaneous immune-mediated diseases during the covid-19 pandemic dermatology patients' knowledge and concerns regarding their immunomodulatory medication during the covid-19 pandemic the prompt use of rituximab could decrease adverse effects in patient with pemphigus vulgaris: a preliminary evaluation biologic therapy for psoriasis during the covid-19 outbreak: the choice is to weigh risks and benefits no evidence of increased risk for covid-19 infection in patients treated with dupilumab for atopic dermatitis in a high-epidemic area systemic isotretinoin therapy in the era of covid19 evolution of covid-19 infection in 4 psoriatic patients treated with biological drugs occurrence of sars-cov-2 during mycophenolate mofetil treatment for pemphigus mucous membrane pemphigoid and covid-19 treated with highdose intravenous immunoglobulins: a case-report covid-19 pulmonary infection in erythrodermic psoriatic patient with oligodendroglioma: safety and compatibility of apremilast with critical intensive care management a challenging case of psoriasis flare-up after covid-19 infection covid-19 in an elderly patient treated with secukinumab improvement of sars-cov2 symptoms following guselkumab injection in a psoriatic patient sars-cov-2 infection in a psoriatic patient treated with il-23 inhibitor systemic immunobiological, immunosuppressant and oncologic agents for the treatment of dermatologic diseases during the sars-cov-2 (covid19) pandemic emergency: a quick review for a quick consultation evaluating the role of stress in skin disease. stress and skin disorders association between stress and skin disease the authors would like to thank rasoul akram hospital clinical research development center (rcrdc) for its technical and editorial assists. the authors contribute equally to all stages of this study. the team has reviewed the manuscript and the data, and all contributors were in full agreement. the authors declare there is no conflict of interest in this study. this study had no funding. key: cord-254580-nhpjvgt4 authors: ricardo, jose w.; lipner, shari r. title: considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the covid‐19 pandemic date: 2020-05-27 journal: dermatol ther doi: 10.1111/dth.13687 sha: doc_id: 254580 cord_uid: nhpjvgt4 coronavirus disease 2019 (covid‐19), is responsible for at least 2,546,527 cases and 175,812 deaths as of april 21, 2020. psoriasis and atopic dermatitis are common, chronic, inflammatory skin conditions, with immune dysregulation as a shared mechanism; therefore, mainstays of treatment include systemic immunomodulating therapies. it is unknown whether these therapies are associated with increased to covid‐19 susceptibility or worse outcomes in infected patients. in this review, we discuss overall infection risks of non‐biologic and biologic systemic medications for psoriasis and atopic dermatitis, and provide therapeutic recommendations. in summary, in patients with active infection, systemic conventional medications, the jak inhibitor tofacitinib, and biologics for psoriasis should be temporarily held until there is more data; in uninfected patients switching to safer alternatives should be considered. interleukin (il)‐17, il‐12/23 and il‐23 inhibitors are associated with low infection risk, with il‐17 and il‐23 favored over il‐12/23 inhibitors. pivotal trials and postmarketing data also suggest that il‐17 and il‐23 blockers are safer than tnf‐blockers. apremilast, acitretin and dupilumab, have favorable safety data, and may be safely initiated and continued in uninfected patients. without definitive covid‐19 data, these recommendations may be useful in guiding treatment of psoriasis and atopic dermatitis patients during the covid‐19 pandemic. this article is protected by copyright. all rights reserved. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a novel human coronavirus, with 2,546,527 confirmed cases of coronavirus disease 2019 (covid-19) and 175,812 deaths worldwide (april 21, 2020). 1 it was declared a pandemic by the world health organization. an overall case fatality rate of 3.61% has been reported, 2 however, inaccuracies may exist because those who are asymptomatic or suffer from mild disease may never receive confirmation. psoriasis and atopic dermatitis (ad) are common, chronic, inflammatory skin diseases, affecting 2-3% of the general population and 7% of adults in the united states (us), respectively. 3, 4 disease mechanisms are multifactorial, with immune dysregulation important for both conditions, and mainstays of treatment immune-modulation. 5 systemic therapy is preferred for psoriasis treatment in patients with body surface area>10%, involvement of sensitive areas or topical therapy failure. 6 systemic treatment is recommended for ad patients with severe disease or recalcitrant to topical therapy. 7 immunocompromised patients are highly vulnerable to infections, which is particularly concerning in the context of the covid-19 pandemic. in this review, we summarize the current literature regarding overall infection risks with systemic immunomodulating agents for psoriasis and ad, and provide evidence-based treatment recommendations during the covid-19 pandemic. systemic corticosteroids are immunosuppressive medications used to treat ad flares, but very rarely psoriasis. they have been shown to increase infection risk. in a systematic review of 101 studies on ad children (n=6,817) treated with systemic corticosteroids ≥15 days, infection rate was 8.7%, with 21 associated deaths. 8 in a meta-analysis of corticosteroid use in patients with influenza pneumonia (10 studies, n=6548), compared with placebo, corticosteroids were associated with higher mortality, longer intensive care unit length of stay and a higher rate of secondary infection. 9 therefore, oral corticosteroids should be avoided, weighing the risks of disease flare vs. sars-cov-2 infection, to prevent covid-19 susceptibility. before discontinuation, dose tapering may be considered to avoid a negative effect on respiratory symptoms. methotrexate and cyclosporine are amongst the most frequently used systemic medications for psoriasis and ad, with both associated with increased infection rates. there was a 58% higher overall infection risk with cyclosporine vs. methotrexate in the biobadaderm registry (spanish registry of adverse events for biological therapy in dermatological disease) including 2153 psoriasis patients. 10 in a head-to-head comparison of methotrexate (n=50) versus cyclosporine (n=47) in moderate to severe ad adults, infections rates were 32% and 24%, respectively. 11 while methotrexate and cyclosporine are associated with decreased infection rates and favored over treatment with systemic corticosteroids, 12 their impact on susceptibility to/severity of covid-19 is unknown and, if essential, precautions should be taken to avoid infection. of interest, cyclosporine has anti-coronavirus activity in vitro, but the effect in humans is unknown. 13 the systemic retinoid, acitretin, is anti-inflammatory and inhibits cell differentiation; it is food and drug administration (fda)-approved for psoriasis. 14 it does not suppress the immune system to the extent of the other conventional treatments for psoriasis. in an observational cohort study, there was no increased rate of overall serious infections among acitretin-treated psoriasis patients vs. methotrexate; acitretin increased risk of cellulitis compared to methotrexate (propensity score-adjusted hazard ratio [hr], 1.76; 95% ci, 1.11-2.80), possibly due to skin fragility and staphylococcus aureus colonization. 15 therefore, acitretin has not shown increased viral/respiratory infection risk and can be safely used during the pandemic. retinoids have been shown to inhibit human herpesvirus eight replication, their effect on sars-cov-2 remains to be established. 16 this article is protected by copyright. all rights reserved. azathioprine is used off-label in the us for ad treatment in patients recalcitrant or who have contraindications to cyclosporine and methotrexate. in 12 ad children treated with azathioprine, there were no associated infections. 17 in a double-blind, placebo-controlled, crossover study of 37 ad adults treated with azathioprine, there were five cases of upper respiratory infections (uris) (14%), two cases folliculitis (5%), and one report each impetigo (3%) and sore throat (3%). 18 in a retrospective analysis of 232,611 systemically-treated adults with ad (six months), there were increased risks of serious and opportunistic infections with azathioprine (rr=1.89) and prednisone (rr=1.78) compared with methotrexate, with a reduced risk with cyclosporine (rr=0.87). 12 therefore, azathioprine may increase susceptibility to infections, and if essential, exposure to covid-19 should be minimized. apremilast, an orally administered phosphodiesterase four inhibitor is fda-approved for moderate to severe plaque psoriasis and has been used off-label for ad. [19] [20] [21] although it does modulate immunologic cascades, this pathway does not seem to particularly increase susceptibility to infection. in a pooled safety analysis of two randomized, controlled trials (rcts) involving psoriasis patients treated with apremilast (n=1184), uris and nasopharyngitis occurred in 19.2% and 16.6% of patients, respectively; serious infections (urinary tract infection n=2; appendicitis n=3; pneumonia=2) occurred in 1.4%. 22 furthermore, in an observational cohort study including systemically treated psoriasis patients, overall serious infections were decreased with apremilast vs. methotrexate (hr, 0.50; 95% ci, 0.26-0.94). thus, apremilast seems to be a safe alternative for uninfected psoriasis patients during the pandemic, but specific covid-19 data is needed. data regarding infection risks of nonbiological therapies for psoriasis and ad is summarized in table 1. biologic medications are widely used for psoriasis and ad patients, with limited data regarding infection risk. since biologics inhibit immune-mediated pathways involving specific cytokines, there is at least theoretical risk of increased susceptibility to and severity of infection. a common reason for discontinuation of biologics is infection. 23 among the targeted cytokines for these biologics, tumor necrosis factor-alpha (tnf-α) plays a crucial role in the immune response against intracellular pathogens and formation of granulomas, 24 and interleukin (il) -12 and il-23 are involved in cell-mediated immunity by inducing interferon-γ. 25 il-23 also induces t-helper 17 cell differentiation and il-17secretion, fundamental in providing immunity against bacteria, viruses, fungi and parasites. 26, 27 il-4 and il-13 play key roles in the immune response against helminth infections. 28 five classes of biologic therapies are used for psoriasis or ad: tnf-α inhibitors (table 2) , il-17 inhibitors, an il-12/23 inhibitor, il-23 inhibitors, an il-4/13 inhibitor, and a janus kinase (jak) inhibitor (table 3) . this article is protected by copyright. all rights reserved. anti-tnf-α therapies inhibit a crucial immunological pathway, therefore an immunosuppressive effect and increased infection risk are expected. there is an fdarequired black box warning of infection susceptibility. 29 however, assessing infection risk is challenging because rcts are often not adequately powered to detect rare events and ineligibility criteria may exclude up to 30% of real-world patients. 30 certolizumab increased risks of all infections, uris and nasopharyngitis by 5%, 2% and 2%, respectively. 29 additionally, anti-tnf-α therapy is associated with latent tuberculosis reactivation, even with chemoprophylaxis; infliximab is associated with increased risk of herpes zoster. 34, 35 therefore, based on available data, anti-tnf-α biologics should be held similarly, an 11% increased risk in overall infections with secukinumab was reported based on pivotal trials, with most attributable to yeast infections; uris were increased slightly for secukinumab, but not for ixekizumab or brodalumab. 29 since il-17 plays an important role in immunological response against candida infections, there is a theoretical increased risk of yeast infections with anti-il17 therapies. 40 in a pooled analysis from 10 phase two and three clinical studies on 3,430 psoriasis patients treated with secukinumab 300 mg (n=1,1410), 150 mg (n=1,395) and etanercept (n=323), candida infections were reported in 2.9%, 1.5% and 1.2% of subjects, respectively. 41 all infections were mild, resolved spontaneously or responded to standard treatment, without causing treatment discontinuation. 41 overall, increased infection risk has been shown with il-17 inhibitors, but yeast infections may constitute a large proportion of that increase; uris are particularly uncommon. therefore, il-17 inhibitors may be safely prescribed and continued, unless the patient is symptomatic or positive for sars-cov-2. ustekinumab inhibits il-12 and il-23, with il-12 playing an important role in protection against viral infections. 29, 42, 43 however, no increased susceptibility to infection with ustekinumab has been reported. in a pooled analysis of four phase two/three studies of 3, 117 this article is protected by copyright. all rights reserved. contrary to il-12/23 inhibitors, anti-il-23 therapies do not target il-12, and il-12 plays a key role fighting viral infections. 29, 45 reduced risks of salmonella, candida and mycobacterium infections were seen in il-23p19-targeted vs. il-12/23p40-targeted animal models. 46-49 nonetheless, rcts on il-23 inhibitors have shown conflicting results regarding infection risks. in a phase iii, double-blinded, placebo-controlled study on 837 psoriasis patients randomized to treatment with guselkumab, adalimumab or placebo, overall, candida, and serious infections, occurred at comparable rates across treatment groups. 50 in 798 risankizumab-treated psoriasis patients, there was increased overall infection risk in two this article is protected by copyright. all rights reserved. phase three studies. 51 the most common infections were uris, urinary tract infections and influenza. 51 two cases of latent tuberculosis were reported in the risankizumab group; both patients tested negative at baseline. 51 data assessing infection risk with tildrakizumab is sparse. lebwohl et al reported an increase in nasopharyngitis (4%) with tildrakizumab compared with placebo. 29 risk, however, is low and comparable to placebo. therefore, based on available data, il-23 inhibitors may be continued/initiated, unless the patient is symptomatic or positive for sars-cov-2. tofacitinib is a small molecule inhibitor of tyrosine kinases of the janus family, preferentially jak1 and jak3, downregulating cytokines crucial for lymphocyte development; therefore, there is potential for increased risks of intracellular bacterial and viral infections. 52 it has been hypothesized, nonetheless, that fluctuations in plasma levels of jak inhibitors throughout the day may preserve immunogenicity against infectious pathogens. 53 tofacitinib carries an fda-required black box warning for serious infections. in one placebo-controlled phase three trial of 422 patients with psoriatic arthritis, randomized to treatment with 5-mg or 10-mg tofacitinib, adalimumab, or placebo, nasopharyngitis (in 7%, 12% and 10%, respectively) and uris (in 9%, 11%, and 8%, respectively) were the most common adverse events. 54 there were three cases of serious infections (influenza, appendicitis and pneumonia) and four cases of herpes zoster in the tofacitinib-treated group. 54 similarly, in two randomized, placebo-controlled studies of 745 and 741 psoriasis patients treated with tofacitinib 5-mg and 10-mg, respectively, nasopharyngitis and uris were the most common infections, and 5 serious infections (pneumonia, herpes zoster and erysipelas in the 5-mg group; and appendicitis, pneumonia and pyelonephritis in the 10-mg group) were reported in tofacitinib-treated patients. 55 furthermore, herpes zoster was reported in 12 tofacitinib-treated patients versus none in the placebo groups. 55 thus, tofacitinib has an association with increased infection risk in psoriasis/psoriatic arthritis patients. tofacitinibtreated patients may be more susceptible to covid-19, strict protective measures are recommended to minimize viral exposure. dupilumab targets il-4 and il-13, elements of the type two immune response. 56 as type one and type two immune responses cross-regulate each other, suppression of type one immunity can potentially facilitate uncontrolled or persistent viral and bacterial infections. 57 nonetheless, dupilumab has been associated with a reduced infection rate in ad patients. a pooled analysis of seven rcts on dupilumab-treated ad adults showed a decreased risk of serious infections, skin infections and herpes infections (eczema herpeticum or herpes zoster) in the dupilumab groups compared with placebo. furthermore, by also treating asthma, dupilumab may theoretically decrease risk for covid-19 infected patients for severe respiratory disease. 56 therefore, current evidence suggests continuing and initiating dupilumab treatment in ad patients during the covid-19 pandemic. it is difficult to make definitive conclusions about susceptibility to sars-cov-2 infection in psoriasis or ad patients on systemic treatments, solely based on general infection risk data. furthermore, the majority of studies included patients with mean age of approximately 40 years; therefore, these recommendations may not be applicable to older individuals, who on average have higher covid-19 associated mortality. there is also a potential role for some of these medications as treatments of covid-19 but this remains largely unknown. in we suggest the following algorithms for treatment of psoriasis and ad during the covid-19 pandemic (figures 1, 2) . this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. coronavirus covid-19 global cases by the cross-country comparison of case fatality rates of covid sleep disturbances in adults with eczema are associated with impaired overall health: a us population-based study national health and nutrition examination surveys atopic dermatitis and psoriasis: two different immune diseases or one spectrum? recategorization of psoriasis severity: delphi consensus from the international psoriasis council systemic treatment of adult atopic dermatitis: a review systematic review of the toxicity of long-course oral corticosteroids in children the effect of corticosteroids on mortality of patients with influenza pneumonia: a systematic review and meta-analysis infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the biobadaderm registry methotrexate versus cyclosporine in adults with moderate-to-severe atopic dermatitis: a phase iii randomized noninferiority trial comparative safety of systemic immuno-modulatory medications in adults with atopic dermatitis suppression of coronavirus replication by cyclophilin inhibitors a review of its pharmacology and therapeutic use risk of serious infection in patients receiving systemic medications for the treatment of psoriasis retinoic acid analogues inhibit human herpesvirus 8 replication adalimumab therapy for moderate to severe psoriasis: a randomized, controlled phase iii trial efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: results from the phase iii, double-blind, placebo-and active comparator-controlled voyage 2 trial etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial secukinumab in plaque psoriasis--results of two phase 3 trials infliximab monotherapy provides rapid and sustained benefit for plaque-type psoriasis infliximab induction and maintenance therapy for moderate-to-severe psoriasis: a phase iii, multicentre, double-blind trial a randomized comparison of continuous vs year in the treatment of moderate-to-severe plaque psoriasis certolizumab pegol for the treatment of patients with moderate-to-severe chronic plaque psoriasis: pooled analysis of week 16 data from three randomized controlled trials guselkumab versus secukinumab for the treatment of moderate-to-severe psoriasis (eclipse): results from a phase 3, randomised controlled trial longterm safety profile of ixekizumab in patients with moderate-to-severe plaque psoriasis: an integrated analysis from 11 clinical trials ixekizumab treatment for up to 5 years in adult patients with moderate-to-severe psoriasis: results from greater than 17,000 patient-years of exposure a prospective phase iii, randomized, double-blind, placebo-controlled study of brodalumab in patients with moderate-to-severe plaque psoriasis key: cord-305076-v56y5nyt authors: singh, parmvir; schwartz, robert a. title: disseminated intravascular coagulation: a devastating systemic disorder of special concern with covid‐19 date: 2020-07-23 journal: dermatol ther doi: 10.1111/dth.14053 sha: doc_id: 305076 cord_uid: v56y5nyt disseminated intravascular coagulation (dic) is linked with severe covid‐19, prompting considerable concern. dic can be a devastating systemic disorder. it is often markedly manifest on the skin as acrocyanosis or as petechiae and purpura with progression to hemorrhagic bullae. subcutaneous hematomas may occur, as may thrombotic findings including necrosis and gangrene. this article is protected by copyright. all rights reserved. disseminated intravascular coagulopathy (dic) is linked with severe covid-19, as are other covid-19-associated coagulopathies 1 (dic) is a clinically striking condition of inflammatory, systemic hemostasis first reported by dupuy in 1834. [1] [2] [3] this activation overcomes anti-coagulation mechanisms, leading to fibrin clot formation within small and medium sized vessels. 1, 2, 4 the pathogenesis involves endothelial injury, exposing sub-endothelial collagen, so that microthrombi are formed as the underlying pathology. 5, 6 hemostasis, along with inflammation, may lead to organ failure, particularly in those that are critically ill. 1, 7 depletion of coagulation factors leads to risk of serious hemorrhagic complications. 1, 2 dic may be caused by malignancy, infection, hypoxia, hypoxemia, trauma, burns, vascular disorders, immunologic disorders, toxins, hepatic disease or peri-partum complications. 1, 2, 5, [8] [9] [10] [11] [12] [13] dic may occur with metastatic cutaneous melanoma. 2 acute myeloid leukemia and prostate cancer are the most common causative malignancies. 8 the severity of skin findings in dic has not been classified. the development of dic in patients with covid-19 unfavorably alters its clinical course 3 . routine monitoring of hemostasis tests is important in selected covid-19 patients. clinical patterns with dic are varied, exemplified by those identified with covid-19, from petechial to acro-ischemia presentations including finger/toe cyanosis, skin bulla and dry gangrene, some resembling chilblains disease (figures 1,2) 7 . hypercoagulable states in dic are associated with a set of common cutaneous manifestations. 14 in a study of 36 patients with dic, cutaneous findings were the presenting sign in 47% of them. 8 they were caused by either initial thrombosis or hemorrhage secondary to consumption of coagulation factors. 8, 9 skin manifestations caused by hemorrhage occur with the following frequencies: petechiae (61%), purpura (83%), palpable purpura (32%), hemorrhagic bullae (19%), subcutaneous dissecting hematomas (31%), or bleeding from wound/iv sites (39%). 8, 15 skin manifestations caused by thrombosis include acral cyanosis (25%) and gangrene (17%). 9 purpura fulminans is a combination of hemorrhagic and thrombotic findings. in dic, petechiae are miniscule, pin-point sized, macules caused by hemorrhage from skin capillaries. 8, 9 they are sometimes papular, palpable petechiae (figures 1,2 ). purpura is evident as nonblanching, erythematous macules, patches, or plaques varying in size from 5 to 20 millimeters. they may be flat or raised, palpable purpura with clear or necrotic centers. 8 purpura and petechiae become palpable due to increased hemorrhage and edema. 9 purpura is similar to petechiae, but larger and in this setting often has sharply demarcated borders. petechiae and purpura are usually limited to the extremities. 8 they have a propensity to occur in wounds and at pressure points. 9 the purpura may become large and widespread enough to converge and develop into hemorrhagic bullae ( fig 3) . 8 when less than 24 hours duration, petechiae and purpura are characterized by thrombi in the superficial vascular plexus at the junction of the papillary and reticular dermis. older lesions contain epidermal necrosis, subepidermal bullae, and glandular necrosis. other hypercoagulable states that cause purpura include thrombotic thrombocytopenic purpura, warfarin skin necrosis, heparin induced thrombocytopenia, calciphylaxis, and catastrophic alpa syndrome. 14, 16 palpable purpura may be caused by septic emboli, allergic cutaneous vasculitis, drug reaction (penicillin, sulfonamides), or systemic necrotizing angitis. 8, [17] [18] [19] palpable purpura is the hallmark of leukocytoclastic vasculitis. hemorrhagic bullae are filled with blood. large hemorrhagic bullae may undergo necrosis and gangrenous change and require distinction from erythema multiforme or bullous pemphigoid. 8 bullae in dic must also be differentiated from steven-johnson syndrome, the flaccid bullae in toxic epidermal necrolysis (ten) and dissecting hematomas, which are extensive subcutaneous accumulations of blood that are rapidly progressive and painful. 8, 19, 20 dic may also be evident with cyanosis, which appears as a non-blanching, central grey area surrounded by irregular, erythematous or purplish borders. it is most commonly located on the digits, but may also be found on the ears and nose. acral cyanosis may evolve into gangrene. indwelling arterial and venous catheters are associated with a higher risk of acral cyanosis and gangrene. acral cyanosis must be distinguished from raynaud's phenomenon, chilblains, and acrocyanosis. 8 it is important to differentiate the thrombotic/coagulopathic vasculopathic acral ischemia as seen in dic from chilblain-like lesions (blue "covid toes"), also associated with the this article is protected by copyright. all rights reserved. severe disease reflects a hypercoagulable state and highly elevated d-dimer levels. unlike the other skin findings in covid_19, chilblain-like lesions are unassociated with severe disease but may represent a clue to covid-19 diagnosis 20 . they clinically and histologically strongly resemble idiopathic and auto-immune related chilblains 21 . there are no data to our knowledge to support that acral ischemia and chilblain-like findings are different degrees of involvement within the same spectrum 7, 8, 20 . gangrene of hands, feet, tip of the nose, ear, and posterior scalp may occur in dic. 15 symmetrical peripheral gangrene (spg) is gangrene of the acral parts of the body. the hypercoagulable state of dic results in microvascular occlusion beginning distally and advancing proximally. 22 symmetrical peripheral gangrene manifests as fever, followed by cyanosis, pallor, and pain. 22, 23 there is an association between a cold ambient temperature and the development of gangrene, postulated to be related to increased vasospasm. 21 spg is almost universally associated with dic. gangrene has been found to have a mortality of 35%. [23] [24] [25] gangrene may lead to osteomyelitis. 15 in one study of 12 patients, 3 died within one week and 8 of the remaining 9 required amputation. 24 there is also some risk of auto-amputation of digits. 8 purpura fulminans, the most fatal presentation of dic, is a dermatologic emergency. 14 it manifests as multiple purple/erythematous, nonblanching, confluent macules, hemorrhagic bullae, and skin necrosis. 5, 14 purpura fulminans is rapid in onset and extensive. 5, 8, 12 late findings in purpura fulminans include geographic plaques, hemorrhagic bulla, gangrene and firm eschar. 12, 26, 27 the distal extremities are most commonly involved, but any part of the body is susceptible. 5, 23 it is associated with high mortality due involvement of visceral organs. 5, 9, 28 multiple organ failure makes dic difficult to distinguish from ten. 19, 20 other causes of purpura fulminans include congenital protein c/s deficiency, sepsis, trauma, malignancy, obstetric complications, hepatic failure, toxins, or immunologic reactions. 14 dic may manifest at varying degrees of severity. one study found that 58% of patients presented with petechiae, 31% with purpura, 19% with palpable petechiae or purpura, 11% with acral cyanosis. 8 19% of purpura progressed to hemorrhagic bullae. two patients progressed to purpura fulminans. palpable purpura was usually found in association with n. meningitidis infection. the combination of septic shock, palpable purpura, and acral cyanosis is very suggestive of dic. etiology (table 1) sepsis, particularly bacterial sepsis, is the condition most commonly associated with dic. 4 more than half of covid-19 pneumonias admitted to intensive care at a large texas hospital developed clinically significant thromboses that were associated with hypercoagulable thromboelastographic parameters alone 1 . in fact, 30-50% of patients with gram-negative sepsis have dic, but it is just as common in those with gram-positive sepsis. 4, 29 systemic coagulation is activated by lipopolysaccharide, endotoxin, or this article is protected by copyright. all rights reserved. exotoxin. 4 trauma, particularly brain trauma, results in dic by the release of fats and phospholipids, hemolysis, and endothelial damage. 4 both solid and hematologic malignancies cause dic due to expression of tissue factor on tumor cells. 4 purpura fulminans is associated with a deficiency of protein c or protein s. it is commoner in children than adults, usually linked in the former with scarlet fever, varicella, or pneumococcal infection. a cutaneous biopsy specimen may be beneficial in establishing the diagnosis, but the diagnosis is mainly clinical ( table 2 ). dic is characterized by fibrin thrombi within capillary walls. 8, 9 these fibrin thrombi lack the associated inflammation that is seen in vasculitis. 9 many histochemical stains can aid in the identification of vascular occlusion. 32 fibrin is strongly pas positive. it also shows a deep blue color with phosphotungstic acid hematoxylin. fibrin colors bright red on carstairs' stain, which is a picric acid-acid fuchsin-based stain. platelets are gray-blue using this stain. immunofluorescent staining with antifibrin serum yields positive results. after vascular occlusion, endothelial cells become edematous, resulting in capillary congestion. this article is protected by copyright. all rights reserved. there is no definitive blood test to diagnose dic. 1 most patients show depletion of coagulation proteases and thrombocytopenia. 1, 8, 9 depression of coagulation factor levels is due to consumption, as well as decreased production. low platelet count, although characteristic of dic, is not a specific finding. 1 more than 80% of critically ill, postoperative patients have less than 100,000 platelets/ul. 1,33 10-15% of patients with dic will have platelet counts below 50,000. 1 compared to those with normal platelet levels, these individuals have an enhanced risk of developing hemorrhagic complications. 1, 34 the differential for thrombocytopenia due to dic includes sepsis, impaired production, blood loss, hypersplenism. 1 this article is protected by copyright. all rights reserved. the prothrombin time (pt) is prolonged in dic. 8, 9 due to its standardization, many centers are beginning to use inr instead of pt time. an abnormal pt or aptt is found in most patients with dic. the differential for an elevated pt includes hepatic failure, blood loss, and vitamin k deficiency. the differential diagnosis for an elevated ptt includes hepatic failure, blood loss, and heparin therapy. the levels of factor 8 are increased in dic because it, along with von willebrand factor, is released from injured vascular endothelial cells. 1, 6 measurement of fibrinogen level has no proven utility in the diagnosis of dic. 1, 35 fibrin degradation products are increased in dic. 1, 8, 9 they are elevated in 40% of critically ill patients, 80% of trauma patients, and nearly 100% of dic patients. 1, 36 as such, the specificity of fibrin split products is not high. the differential includes hematoma, post-op status, systemic inflammation, deep vein thrombosis, and pulmonary embolism. 1 inhibitors of coagulation, such as protein c, protein s, and antithrombin, are decreased in 90% of patients with dic. 1 the reason for their decrease is consumption, decreased production, and increased processing by neutrophil elastase. 1, 37 other causes include hepatic failure and capillary leakage. 1 the international society on thrombosis and hemostasis has created a composite scoring system to assess the likelihood of coagulopathy. 38 this scoring system is based on platelet count, pt, d-dimer, and fibrinogen levels. if the score is greater than or equal to 5 out of 8, then it is considered compatible with overt dic. other scoring systems that rely on inr instead of pt are pending widespread validation. the higher the composite score, the lower the survival rates. 1 the scoring should be repeated daily if it is greater than or equal to 5. 38 prolonged elevation of pt and platelets has been affiliated with poorer outcomes. 1,39 a gold standard does not exist for the ideal diagnostic criteria, but three are primarily used throughout the world. 38, 40, 41 patients with dic can show signs of organ failure. 8, 9 blood cultures may show growth of a causative organ, such as staphylococcus aureus, group a streptococci, neisseria meningitidis, vibrio species, varicella virus. 5, 8, 11, 13, 15, 28, 42 one study reported n. meningitidis as the most common causative organism. 8 if other laboratory tests are equivocal, a punch biopsy specimen of cutaneous lesions may reveal fibrin thrombi. 8, 9 treatment treatment of dic usually requires a multidisciplinary approach in an intensive care unit. ,24 therapy of dic is not directed at the skin, but rather at the management of the causative condition. 1,24,43-46 covid-19-associated dic therapy should follow accepted strategy employing thromboembolic prophylaxis for critically ill hospitalized patients and standard supportive care measures 47 . however, a lack of thrombocytopenia may mean that covid-19 dic is not always a typical consumptive coagulopathy with additional this article is protected by copyright. all rights reserved. strategies possibly necessary 45 . transfusion of platelets, plasma, cryoprecipitate or fibrinogen concentrate should be considered for hemorrhaging patients. 1, 5, 11, 43 patients with dic due to infection should have it treated, depending on the causative organism. 15 leukopenia is a poor prognostic factor. 21 resection of necrotic tissue, including escharotomies, may be required. 26 skin grafting should be performed, if possible. 5, 28 amputation of gangrenous areas may be compulsory. 5, 8, 15 while patients are being optimized for treatment, padding or vascular boots may be applied to the affected parts. 21 improvement of the dermatologic findings is a useful measure in determining response to therapy. 9 with covid-19 producing florid dic in some hospitalized patients and acral cyanosis in variety of settings, dic has risen to the forefront with no clear therapy yet of proven value for the covid-19 itself 1, 4, 5, 7, 48 preliminary data suggests that low dose dexamethasone may reduce deaths in hospitalized covid-19 patients on ventilation, although its effects on dic in this setting are yet to be determined 49 . one must also watch for co-infections, as the covid-19 pandemic may merge with the candida auris global epidemic in the intensive care unit with dic being produced by either and possibly both of them 50 . references: mortus this article is protected by copyright. all rights reserved. with coronavirus disease 2019 who are critically ill thromboelastometry in critically ill patients with disseminated intravascular coagulation prominent changes in blood coagulations of patients with sars-coc-2 infection zhonghua xue ye xue za zhi. [clinical and coagulation characteristics of 7 patients with critical covid-2019 pneumonia and acroischemia complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases vascular endothelium in the regulation of immune response covid-19 with dermatologic manifestations and implications: an unfolding conundrum chilblains in children in the setting of covid-19 pandemic disseminated intravascular coagulation: a dermatologic disease disseminated intravascular coagulation unmasked by mohs micrographic surgery purpura fulminans associated with <i>streptococcus pneumoniae</i> septicemia in an asplenic pediatric patient angioimmunoblastic t-cell lymphoma presenting as purpura fulminans purpura fulminans in a child as a complication of chickenpox infection the skin and hypercoagulable states symmetrical peripheral gangrene due to disseminated intravascular coagulation linear localized coumarin necrosis dress syndrome: part i. clinical perspectives dress syndrome: part ii. management and therapeutics toxic epidermal necrolysis: part i. introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases covid toes"): histologic, immunofluorescence and immunohistochemical study of 17 cases symmetrical peripheral gangrene: a rare but dreadful complication of sepsis peripheral symmetrical gangrene presentation and outcome of purpura fulminans associated with peripheral gangrene in 12 patients at mayo clinic protein c substition in sepsisassociated purpura fulminans spectrum of purpura fulminans: report of three classical prototypes and review of management strategies predicting mortality in patients with disseminated intravascular coagulation after cardiopulmonary bypass surgery by utilizing two scoring systems gram-positive organisms and sepsis. archives of internal medicine in situ detection of tissue factor in vascular endothelial cells: correlation with the malignant phenotype of human breast disease the obstetric patient and disseminated intravascular coagulation dermatopathology of skin necrosis associated with purpura fulminans thrombocytopenia in a surgical icu* thrombocytopenia prognosis in intensive care prospective validation of the internatinal society of thrombosis and haemostasis scoring system for disseminated intravascular coagulation d-dimer correlates with proinflammatory cytokine levels and outcomes in critically ill patients* the disturbance of hemostasis in septic shock: role of neutrophil elastase and thrombin, effects of antithrombin iii and plasma substitution* comparison of a new criteria for sepsis-induced coagulopathy and international society on thrombosis and haemostasis disseminated intravascular coagulation score in critically ill patients with sepsis 3.0: a retrospective study prognostic value of a simple evolving disseminated intravascular coagulation score in patients with severe sepsis guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines diagnostic criteria and laboratory tests for disseminated intravascular coagulation staphlococcal scalded skin syndrome: diagnosis and management in chidlren and adults guidelines for the diagnosis and management of disseminated intravascular coagulation disseminated intravascular coagulation coagulopathy of coronavirus disease anticoagulant therapy for septic coagulopathy and disseminated intravascular coagulation: where do kybersept and scarlet leave us? acute med surg covid-19 and its implications for thrombosis and anticoagulation pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid-19 covid-19: low dose steroid cuts death in ventilated patients by one third, trial finds covid-19 with dermatologic manifestations and implications: an unfolding conundrum covid-19 patient with purpuric eruption, thigh (reprinted from ref 7. almutairi n, schwartz ra. covid-19 with dermatologic manifestations and implications: an unfolding conundrum key: cord-303460-abutfxtf authors: searle, tamara; ali, faisal r.; al‐niaimi, firas title: screen rhytides: the cosmetic legacy of covid‐19 date: 2020-08-21 journal: dermatol ther doi: 10.1111/dth.14211 sha: doc_id: 303460 cord_uid: abutfxtf nan contraction may reduce the length of time that botulinum toxin exerts its effects, resulting in an increased demand for more sessions of botulinum toxin with shorter intervals between each treatment. the authors are observing a sharp increase and awareness of glabellar and lateral canthal lines with patients directly referring the effects to increased "screen activity". emerging reports of patients self-administering botulinum toxin with black-market at home kits demonstrates some patients' desperation, with devastating potential adverse effects. 3 covid-19 lockdown restrictions necessarily prohibited access to most aesthetic injectable treatments and as cosmetic clinics start to reopen, cosmetic dermatologists are likely to have a backlog of patients. 4 we suggest cosmetic practitioners should assess for and treat wrinkles and other facial changes resulting from prolonged screen activities. locked-down digital work key: cord-265052-hfuvm1oh authors: turan, çağrı; metin, nurcan; utlu, zeynep; öner, ümran; kotan, özgür sadık title: change of the diagnostic distribution in applicants to dermatology after covid ‐19 pandemic: what it whispers to us? date: 2020-06-12 journal: dermatol ther doi: 10.1111/dth.13804 sha: doc_id: 265052 cord_uid: hfuvm1oh we aim to evaluate the change in the diagnostic spectrum in dermatology outpatient applications compared to before covid‐19. all patients were enrolled from the department of dermatology between february 12 and may 8, 2020, the duration of 4 weeks before covid‐19 and eight weeks after were analyzed in 3 parts consisting of 4 weeks. data obtained from the database such as age, gender, diagnoses were anonymized. repeated applications with the same diagnosis in ten days after the first presentation were ignored. compared to the pre‐outbreak, there was a 3.5‐fold decrease in dermatology applications in the first month after covid‐19 and an 8.8‐fold in the second month. we found a significant increase in the frequency of diagnoses such as generalized pruritus, pityriasis rosea, alopecia areata, bacterial skin/mucosa diseases, and zona zoster after covid‐19. the frequency declined in diseases such as verruca vulgaris, hyperpigmentation, skin tag, melanocytic nevus, seborrheic keratosis/solar lentigo. it has been found that the frequencies of most diseases, including acne (⁓25% of patients), did not change. we think that many factors, such as affecting the quality of life, risk perception, increased stress burden may cause a change in the diagnostic distribution of the dermatology applications. this article is protected by copyright. all rights reserved. pneumonia cases caused by a newly identified coronavirus arose in wuhan, china, on december 31 2019. the world health organization (who) named the disease as the coronavirus disease 2019 (covid-19) on february 2020 1 . covid-19, which initiated in china, affected many countries in a short time and spread to the whole world. the first case in turkey was seen on march 11, 2020, the day who declared a pandemic 2, 3 . although the disease affects all age groups, it is more common in men 4 . some patients can be defined as a high-risk group for death because it is more severe in the elderly and those with underlying comorbidity. it was reported that of the patients who died, 42.2% were aged 80-89 years, 32.4% were aged 70-79 years, 8.4% were aged 60-69 years 5 . thus, we estimate that the risk perception in the population may differ according to age and gender. after the first confirmed-case, the government took step-by-step a series of radical measures, including curfews, to ensure social isolation due to arising new cases in all cities across the country within a short time. in this context, face-to-face education was stopped in schools and universities and distance education was started. flexible working hours were set at all public institutions, including hospitals. common areas such as shopping malls, hairdressers, barbershops, restaurants, places of worship, cafes, cinema, and theatre were closed indefinitely. domestic and international flights and intercity trips have been stopped. a curfew was imposed over the age of 65 and fewer than 20 as of the last week of march and the first week of april, respectively. in some cities, curfews were imposed on all age groups only on weekends and public holidays. the call "stay at home" to all citizens has been repeated continuously through all media channels. as a result of all these measures, there this article is protected by copyright. all rights reserved. were over 167410 identified cases and 4630 death of covid-19 by june 4, 2020, in turkey per worldometer, a reference website that provides real-time world statistics 6 . the case fatality rate (⁓2.77%) in our country is slightly lower than the overall case fatality rate envisaged as 3% in the article published in lancet on january 24 7 . during the pandemic, it has been recommended to limit the outpatient services and to develop mechanisms to filter elective applications until the outbreak is controlled 8 . we aim to evaluate the change in the frequency, profile and diagnostic spectrum of the patients who applied to dermatology department, which may occur due to all these regulations, restrictions and covid risk perception varying according to the patient. we ask to have a sense about the motivation reasons pushing to seek medical advice in such a period, to understand our patients better. all patients were enrolled from the department of dermatology and venereology in the regional training and research hospital between february 12 and may 8, 2020. we evaluated the months within these dates to divide them into four weeks of five consecutive working days, excluding weekends and public holidays. thus, a 3-month period consisting of 4 weeks before the covid-19 outbreak and eight weeks after the first confirmed case was achieved. data such as age, gender, application dates, the first three of the icd-10 (international classification of diseases-10 th revision) codes entered into the system were obtained from the electronic registration database. these data were anonymized on the condition that individual uniqueness was maintained in applications to outpatient clinics. patients with recurrent presentations for control or follow-up and their diseases were identified. however, this article is protected by copyright. all rights reserved. repeating applications with the same diagnosis in ten days after the first presentation were ignored. the reasons such as the wide diagnostic spectrum, lack of icd-10 code corresponding to each diagnosis, and the unique style of each doctor at the entrance of icd-10 codes in the dermatology practice necessitated the standardization of diagnostic data within the framework of certain principles in such a retrospective study. for this purpose, the first three icd-10 codes entered into the system for each patient were reassessed by each patient's own doctor, based on the classification of the diseases in dermatology textbook edited by bolognia et al. 9 . for the same patient, separate diagnoses related to each other were attempted to be expressed as a single origin diagnosis, free from sub-breakings of the disease classification (e.g. xerosis + dermatitis = xerotic eczema, pruritus ani + lichen simplex chronicus = lichen simplex chronicus, pruritus + atopic dermatitis = atopic dermatitis etc.). patients without an additional dermatological diagnosis other than pruritus were evaluated as the "idiopathic pruritus and dysesthesia". a small number of patients who applied for consultation only and had no significant complaints were included in the title of "undetermined reason for examination and observation". we considered only the first icd-10 codes for patients with multiple irrelevant diagnoses. thanks to these principles, 371 different icd-10 codes, including sub-breakings in the raw data, were reduced to 17 main titles and 90 subtitles. then, the application date and the diagnoses of patients with repeated presentations were compared with each other via the program. in this way, according to the previous presentations of the relevant patient, application types could be classified under the names of normal and control/follow-up. this article is protected by copyright. all rights reserved. this single-centre cross-sectional retrospective-study was approved by the ethics committee of regional training and research hospital, erzurum, turkey (decision no: 2020/11-122) and ministry of health scientific research platform (application form number: 2020-05-14t17_30_07). this study was conducted as per the latest version of the "helsinki declaration" and the "guidelines for good clinical practice". no patient consent was required, provided that the data such as name and citizenship numbers were anonymized by the it team and with the permission of the ethics committee. nevertheless, informed consent for the study was obtained from 30 patients who were only interviewed by phone. pearson's chi-squared test was used for categorical variables. in chi-square tests with a degree of freedom greater than 1, pairwise comparisons (post-hoc) were performed using the z-test. after checking the normality distribution of scale variables by kolmogorov-smirnov test, independent samples were compared with appropriate significance tests (kruskal-wallis h test or mann-whitney u test). results were presented as the median (interquartile range) or count of the patients (percentage). the change in application frequency and age distribution by workdays and weeks was displayed with the "scatter with straight lines" graphic. two-sided p-values of <0.05 were considered statistically significant. correction for alpha inflation (bonferonni style) was applied as post-hoc after the kruskal-wallis h and chi-square tests. it was determined that 9531 (9.2%) of 104142 applications to all clinical departments, except covid-19 outpatient clinic, were made to dermatology outpatient clinics within 12 weeks (12 february-8 may 2020). as with the dermatology outpatient clinic, there was a gradually significant decrease in hospital-wide applications (p <0.001). also, the proportion of those who visited the dermatology outpatient clinics, among applicants to the hospital was about 10.3% before covid-19 and then decreased statistically significantly to 7.3% and 6.9%, respectively (p <0.001). 8905 different patients were evaluated at 9531 visits. 6554 (73.6%) patients with 6820 (71.5%) applications presented in the last 4-weeks before covid-19. in the first and second months after covid-19, 1747 (19.6%) patients with 1940 (20.4%) applications and 652 (7.3%) patients with 771 (8.1%) applications attended to our outpatient clinics; respectively ( table 1 ). the changes in application frequencies, age, and gender distribution before and after covid-19 summarized in table 1 , figs. 1, and 2. it was observed that after the firstconfirmed covid-19 case, the number of patients examined in the daily outpatient clinics has decreased from 350 to 150 in the first week, to 50 and below in the second week. the patient's median age, following a stable curve before covid-19, followed a fluctuating course during the outbreak, and the frequency of female-dominant application turned out to be equal over time. before and after covid-19, the diagnostic distribution of patients applied to the dermatology outpatient clinics for three periods consisting of 4-weeks was as in table 2 . the repeated applications in the three months belonged to 518 patients, and their number of visits ranged from 2 to 5. respectively, 234 (45.2%) and 59 (11.4%) of them were diagnosed with acne and verruca vulgaris. others applied to the outpatient clinics more than once with the following diagnoses: various eczematous dermatitis (28, 5 .4%), urticaria/angioedema (n=20, 3.9%), anogenital warts (19, 3.7%), idiopathic pruritus (17, 3.3%), scabies (17, 3.3%), superficial skin/nail fungal infection (15, 2.9%), atopic dermatitis (14, 2.7%), psoriasis (11, 2.1%), bacterial skin/mucosa diseases (10, 1.9%) and callus (87, 1.4%); respectively. besides, a total of 67 (12.9%) patients with 30 different diagnoses consisting of 1-5 patients, applied to the outpatient clinic at least two times. the rate of repeated applications was statistically significantly higher during the outbreak compared to before (p<0.001). 10.3% of 2276 acne patients examined in these three months had repeated application. apart from this, the diagnoses of those who applied to the outpatient clinic more than once during this period were as follows in order of frequency: anogenital warts (n = 19/56, 33.9%), verruca vulgaris (59/365, 16.2%), scabies (17/180, 9.4%), psoriasis (11/140,7 .9%), idiopathic generalized pruritus (17/315, 5.4%), urticaria/angioedema (20/394, 5.1%), atopic dermatitis (14/308, 4.5%), bacterial skin/mucosa diseases (10/268, 3.7%), superficial fungal skin/nail infections (15/503, 3.0%). after the covid-19 pandemic, which rapidly affected the whole world, there were significant changes in the application to outpatient clinics due to reasons such as measures, call to "stay at home", and panic in the community. it was understood that the number of patients decreased for the first time in the period when there was news that the refugees from iran quarantined in our city. however, it increased again quite rapidly with the announcement of favorable developments (fig. 1) . it is noteworthy that a slight fluctuation occurred in the this article is protected by copyright. all rights reserved. median age of patients who applied to outpatient clinics during this period. we have found a logarithmic decline in the frequency of application to our outpatient clinics within about 2 weeks after the first confirmed case was announced. this shows how effective awarenessraising campaigns are in reducing application to hospitals without any legal restrictions yet. compared to the pre-pandemic, there was a 3.5-fold decrease in applications to dermatology outpatient clinics in the first month after covid-19 as a transition period, and an 8.8-fold decrease in the second month. in general hospital applications, there was a decrease of 2.5 times and then 5.9 times, respectively. so, compared to other departments, there was a more obvious loss in applications to dermatology outpatient clinics. while there was female dominance in dermatology before covid-19, the gradual equalization of the female to male ratio indicates that the risk perception does not differ in terms of gender. after the first confirmed case, the median age line slipped up, and the curve became more stable with the introduction of a curfew for less than 20 years of age. the slight movements of the curve before curfews and the fluctuating course until the curfew for less than 20 years of age indicate that the risk perception varies by age. however, the young age group exhibits inconsistent behavior in outpatient applications. although the risk of death from covid-19 is lower in young individuals, they can cause the disease to spread rapidly 10 . considering their inconsistent behavior, we understood that the curfew brought to this age group is crucial. there were significant changes in the distribution of diagnosis for some dermatologic diseases after the outbreak ( table 2 ). considering that the frequency of application to the outpatient clinic captured a stable curve after two weeks, we found it appropriate to consider the first month after covid-19 as a transition period. when evaluating the change in frequency distributions, we commented on the results between "last 4-weeks before covid-19" and "2 nd 4-weeks after covid-19" to reveal the difference more clearly. in our study, we found a significant increase in the frequency of diagnoses such as idiopathic generalized pruritus, pityriasis rosea, alopecia areata, bacterial skin/mucosa diseases, and zona zoster/post-zoster neuralgia after covid-19. in such an analysis to be made at an ordinary time, the frequency changes will suggest that it is due to the seasonal relationship of the disease and the change in its frequency in the community. in such an extraordinary period, it can be assumed that the causes such as the differentiation of personal risk perception due to age, comorbidity, occupation, etc., increased social stress, and changing personal hygiene habits may alter the diagnostic distribution. various studies have shown that psychological disorders such as anxiety and depression increase in the community during the covid-19 outbreak 11, 12 . it is known that diseases such as idiopathic generalized pruritus, alopecia areata and zona zoster/post-zoster neuralgia are associated with stress 13, 14 . besides, these diseases can significantly affect the quality of life (qol) [15] [16] [17] . therefore, the needs of patients to seek medical advice may be superior to the risk perception of covid-19. the increase in bacterial skin/mucosa diseases may be through the shifts from departments such as infectious diseases and internal medicine, which have a primary role in outbreak management. also, it may be secondary to xerosis and eczema, the frequency of which is reported an increase due to changes in personal hygiene behaviors 18, 19 . the absence of an increase in the frequency of xerotic eczema and contact dermatitis in our study should not be concluded that such complaints do not increase in the community. because, based on many studies and our experience, we think that the frequency of xerosis cutis and contact dermatitis increases in the this article is protected by copyright. all rights reserved. community 19, 20 . the absence of an increase can be explained by the reasons such as predicting the etiology by patients, not associating with covid-19, not being experienced for the first time and easily treating the disease with the use of a moisturizer. the increase in the frequency of pityriasis rosea can be explained by the opposite of the reasons listed for contact dermatitis. because pityriasis rose-like lesions have been reported among the cutaneous findings of covid-19, but it may also cause undue anxiety in patients who experience the disease for the first time 21 . another reason is that pityriasis rosea increases in the spring seasons, which coincides with the period after covid-19 22 . although a significant increase in the frequency of panniculitis is unusual, statistical analysis could not be performed due to the low number of cases. in 20% of covid-19 patients, many skin findings, except panniculitis, such as erythematous rash, petechia, urticaria, vesicular rash, livedo reticularis, and pernio have been reported 23, 24 . all pityriasis rosea (n=24) and panniculitis (n=6) patients diagnosed after covid-19 were contacted by phone, and any suspicious condition related to covid-19 was questioned. however, no patient had an anamnesis associated with covidit was found that the frequencies of most diseases did not change. acne, which is onequarter of the applications among all diseases, was in this group. various studies have shown that depression, anxiety disorders, and body dysmorphic disorder are higher in acne patients 25, 26 . also, it was reported that there was a significant effect on the qol, depending on the severity of acne 27 . some diseases (such as psoriasis, urticaria/angioedema and behçet's disease) requiring follow-up can seriously impair patients' qol when they are severe 28 . this article is protected by copyright. all rights reserved. one or more of the following reasons: the risk perception of patients in this group is similar, the treatment plan for chronic diseases is pre-drawn, and some diseases do not cause severe deterioration in their qol. the frequency decline in diseases such as verruca vulgaris, hyperpigmentation, skin tag, melanocytic nevus, seborrheic keratosis/solar lentigo suggested that these diseases do not affect the qol too much or that such diseases can be ignored during the outbreak. it was reported that melasma compared to vitiligo is less associated with depression, anxiety, and somatoform disorders, though it causes more severe impairment of life quality 29 . unlike hyperpigmentation, the constant frequency of hypopigmented skin diseases suggested that the motivation for outpatient applications is different for each disease. acne (45.2%), verruca vulgaris (11.4%), urticaria/angioedema (3.9%) and anogenital warts (3.7%) were the primary ones in the distribution of patients with repeated applications within three months. besides, anogenital warts (33.9%), verruca vulgaris (16.2%), acne (10.3%) and scabies (9.4%) were at the forefront in the frequency of disease-specific repeated applications. it was understood that the patients who desired treatment (drug or procedure) and experienced treatment failure needed to come to the polyclinic more than once during the pandemic. indeed, the frequency of repeated application was significantly higher in the post-covid-19 period than before. the study has certain limitations. since the study was retrospective, we had no data such as detailed clinical examinations, life quality, anxiety levels, their treatments, and individual risk perception for covid-19. patients often have multiple independent complaints, and sharing their complaints without prioritization may change the order of the this article is protected by copyright. all rights reserved. diagnoses in the database. besides, due to the extreme diversity of dermatological diseases, dermatologists work within a narrow framework for the use of icd-10 in clinical practice. this study was carried out to understand the reasons why patients with dermatological diseases with low urgency and mortality come to the hospital in such a worldwide fatal pandemic period. many factors such as affecting the qol, risk perception varying according to the individual, increased stress burden, dermatological rashes encountered for the first time caused the change in the diagnostic distribution of the dermatology applications during the pandemic period. however, the motivation for application to dermatology outpatient clinics was not similar for all diseases and related to the nature of the disease this article is protected by copyright. all rights reserved. † other than covid-19 outpatient clinics, ‡ repeated applications within ten days after the first application were excluded. a: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "1 st 4-weeks after covid-19". b: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "2 nd 4-weeks after covid-19". c: adjusted p value<0.05 for the difference between "1 st 4-weeks after covid-19"; and "2 nd 4-weeks after covid-19". after covid-19 bonferroni correction was applied as post-hoc (z-test) after chi-square tests. significant values were shown in bold. a: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "1 st 4-weeks after covid-19". b: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "2 nd 4-weeks after covid-19". c: adjusted p value<0.05 for the difference between "1 st 4-weeks after covid-19"; and "2 nd 4-weeks after covid-19". . pearson's chi-squared test was used. bonferroni correction was applied as post-hoc (z-test) after chi-square tests. significant values were shown in bold. a: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "1 st 4-weeks after covid-19". b: adjusted p value<0.05 for the difference between "last 4-weeks before covid-19" and "2 nd 4-weeks after covid-19". c: adjusted p value<0.05 for the difference between "1 st 4-weeks after covid-19"; and "2 nd 4-weeks after covid-19". hyperpigmentation (melasma, ephelides, post-inflammatory hyperpigmentation), verruca vulgaris, skin tags, melanocytic nevus, seborrheic keratosis/solar lentigo it was designed according to diseases with significant differences between "last 4-weeks before covid-19" and "2 nd 4weeks after covid-19". † see table 2 for the complete list. ‡ one or more remarks may be appropriate, provided that the nature of the disease is considered. figure 1 . change in daily patient frequency before and after covid-19 outbreak 1. february 24: there was news that many illegal refugees from iran, where has been fighting against the covid-19 outbreak, quarantined in our city. 2. february 28: it was announced that the refugees' covid-19 test results were negative 3. march 11: the first covid-19 case was confirmed in turkey, and the world health organization has declared a pandemic. 4. march 17: the first death due to covid-19 was reported in turkey. march 22: curfew was declared indefinitely for individuals over the age of 65. 6. april 4: curfew was declared indefinitely for individuals under the age of 20. 7. may 11: country-wide normalization process has been started. the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak -an update on the status a review of coronavirus disease-2019 (covid-19) general directorate of public health. covid-19 (sars-cov2 infection) guide (science board study): general information, epidemiology and diagnosis. republic of turkey ministry of health website novel coronavirus: where we are and what we know covid-19 and italy: what next? covid-19 coronavirus pandemic. worlometers website clinical evidence does not support corticosteroid treatment for 2019-ncov lung injury covid-19 pandemic: effects and evidencebased recommendations for otolaryngology and head and neck surgery practice this article is protected by copyright. all rights reserved covid-19 and italy: what next? mental health, risk factors, and social media use during the covid-19 epidemic and cordon sanitaire among the community and health professionals in wuhan, china: cross-sectional survey stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain the role of stress in the development of herpes zoster and postherpetic neuralgia the psychiatric aspects of skin disorders the impact of pain intensity on quality of life of postherpetic neuralgia patients impact of herpes zoster and post-herpetic neuralgia on health-related quality of life in japanese adults aged 60 years or older: results from a prospective, observational cohort study effect of the pruritus on the quality of life: a preliminary study staphylococcus aureus and hand eczema severity occupational skin disease among health care workers during the coronavirus (covid-19) epidemic consensus of chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease pityriasis rosea as a cutaneous manifestation of covid-19 infection the pityriasis rosea calendar: a 7 year review of seasonal variation, age and sex distribution coronavirus-days in dermatology cutaneous manifestations in covid-19: a first perspective type d personality, anxiety sensitivity, social anxiety, and disability in patients with acne: a cross-sectional controlled study the frequency of body dysmorphic disorder in dermatology and cosmetic dermatology clinics: a study from turkey this article is protected by copyright. all rights reserved quality of life, self-esteem and psychosocial factors in adolescents with acne vulgaris the impact of skin diseases on quality of life: a multicenter study psychological disturbances in patients with pigmentary disorders: a cross-sectional study key: cord-309813-qojacnli authors: lipner, shari r.; ricardo, jose w. title: recommendations for diagnosis and treatment of onychomycosis during the covid‐19 pandemic date: 2020-05-30 journal: dermatol ther doi: 10.1111/dth.13709 sha: doc_id: 309813 cord_uid: qojacnli nan to the editor: onychomycosis is the most common nail disorder seen in clinical practice with worldwide prevalence 10% and significant impact on quality of life. 1 prior to the covid-19 pandemic, clinical examination, dermoscopy, and mycological examination were recommended for all patients with suspected onychomycosis, followed by a discussion of appropriate treatment options. 2 however, with prevalence of covid-19, non-urgent inperson visits are deferred, and telemedicine may be utilized to address some aspects of onychomycosis diagnosis and treatment. in this communication, we review the literature and suggest guidelines for onychomycosis management during the covid-19 pandemic. telemedicine may be appropriately utilized to assess patients with suspected onychomycosis, but is better optimized for patients with prior mycological confirmation. all 20 nails and web spaces are examined, as well as, both surfaces of digits, hands and feet in an area with excellent lighting. the video examination is best supplemented with photographs sent prior to the visit. clinical findings suggestive of onychomycosis include onycholysis, subungual hyperkeratosis, and nail plate thickening/yellowing. scale in the web spaces and/or plantar feet may be indicative of tinea pedis. confirmatory testing is cost-effective 3 and fundamental to avoid treatment failures, misdiagnosis, and unnecessary side effects. 1 prior records of potassium hydroxide with direct microscopy, fungal culture, polymerase chain reaction, or clipping with histopathology are reviewed. 1 a recent report demonstrating the presence of hyphae and/or fungal speciation is sufficient for discussion and initiation of treatment. for this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. liver enzyme abnormalities may also occur. 6 nonetheless, interval laboratory monitoring of liver enzymes in otherwise healthy adult or pediatric patients treated with oral antifungals is not recommended because of low incidence of hepatotoxicity, laboratory testing costs and patient discomfort. [7] [8] [9] most importantly, limiting laboratory monitoring may decrease patients' exposure to covid-19, which is of utmost important during the pandemic. onychomycosis treatment guidelines prior to the covid-19 pandemic are no longer applicable. telemedicine can be used for initial consultation of patients with onychodystrophy and topicals prescribed for tinea pedis if indicated; patients with confirmed onychomycosis can be monitored for clear nail growth and side effects. mycological confirmation and baseline bloodwork are deferred until covid-19 is less prevalent. this article is protected by copyright. all rights reserved. onychomycosis: clinical overview and diagnosis onychomycosis -a small step for quality of care confirmatory testing prior to initiating onychomycosis therapy is cost-effective management of onychomycosis and co-existing tinea pedis telehealth: helping your patients and practice survive and thrive during the covid-19 crisis with rapid quality implementation retrospective analysis of adverse events with systemic onychomycosis medications reported to the united states food and drug administration laboratory monitoring during systemic terbinafine therapy for pediatric onychomycosis retrospective analysis of adverse events with topical onychomycosis medications reported to the united states food and drug administration retrospective analysis of laboratory abnormalities in patients prescribed terbinafine for onychomycosis key: cord-295995-uabnyomr authors: abdelmaksoud, ayman; vestita, michelangelo; goldust, mohamad title: sexually transmitted covid19 date: 2020-07-08 journal: dermatol ther doi: 10.1111/dth.13982 sha: doc_id: 295995 cord_uid: uabnyomr nan in their study on healthy women, yuksel and ozgor found a significant higher sexual desire and frequencies of sexual intercourse during covid19 pandemic compared with 6-12 months prior. 3 in another study by qiu et al. 4 on 10 severely infected women with covid-19, no sars-cov-2 virus was noted in their vaginal fluids. they concluded that likelihood of transmitting sars-cov-2 to sexual partners through vaginal fluids may be low. however, only postmenopausal women were studied, and the vaginal swabs were taken 17 days or more after disease onset, that was not ideal for viral detection by reverse transcription-polymerase chain reaction (rt-pcr). lower viral spreading to genital organs and genital secretions may be due to low rate of viremia for covid-19. 5 genital contamination with genital fluids, even with low rate, is not unexpected. due to risk of "genital" contamination with sarsthis article is protected by copyright. all rights reserved. patients with sexual minorities should have more attention in the current situation. they are at risk of not only stds, but also sars-cov2 through genital contamination. covid19 patients presented with pr, or known std, should be enquired about their sexual behavior/preference, and should undergo more than a nasopharyngeal swab before considering negativity of infection. this article is protected by copyright. all rights reserved. can covid-19 be a sexually transmitted disease? posterity will judge can covid 19 virus be transmitted through sex? effect of the covid-19 pandemic on female sexual behavior sars-cov-2 is not detectable in the vaginal fluid of women with severe covid-19 infection covid-19 and semen: an unanswered area of 328. 6: delfino m this article is protected by copyright. all rights reserved. key: cord-302676-aarcjyia authors: goldust, mohamad; shivakumar, swathi; kroumpouzos, george; murrell, dedee f.; mueller, simon m.; navarini, alexander a. title: where do we stand as dermatologists in combat with covid‐19 date: 2020-05-22 journal: dermatol ther doi: 10.1111/dth.13638 sha: doc_id: 302676 cord_uid: aarcjyia nan the novel corona virus disease (covid-19 due to sars-cov-2) which began in wuhan, china in late december 2019, quickly spread to involve the rest of the world within a span of few weeks. [1] [2] [3] hygiene measures are of paramount importance to combat transmission of covid-19 including social distancing, meticulous hand hygiene measures like frequent hand washing, avoiding touching the face and wearing masks. healthcare workers, who are at high risk of acquiring the infection are advised to wear personal protective equipment (ppe). 4,5 while these measures have been advocated to minimize risk of spread, they have lead to a whole new range of dermatological problems. a rise in hand eczema has been reported, due to contact dermatitis from frequent use of antiseptics and also due to glove latex allergy. 6 the protective goggles, n95 masks and face shield have lead to dryness and irritation of skin at the areas of tight contact. 7 in addition, few health care workers also experienced an aggravation of acne/ rosacea due to the increased heat from using the ppe, as well as due to stress. other pre-existing dermatosis which this article is protected by copyright. all rights reserved. aggravate during periods of stress, like psoriasis, eczema, atopy and neurodermatitis can also flare up either in health care workers or in patients. 8 a recent study reported a case of covid-19 which was initially misdiagnosed as dengue fever. the patient presented with petechiae rash and lab reports showed thrombocytopenia, the two common features of dengue. however, the patient later on developed respiratory symptoms and upon positive rt-pcr testing, covid-19 was diagnosed. 9 so far, there is no specific treatment for covid-19. the over the counter availability of drugs including antibiotics, coupled with anxiety has led people to an increased self-administration of both pharmaceutical drugs as well as natural remedies. in consequence, drug reactions must be considered in patients presenting with acute urticaria and other pruritic lesions. 8 interestingly, ace-2, the functional receptor of sars-cov2 to enter cells has been identified in skin tissue of sars patients in 2004. whether this also holds true for sars-cov2, is still under investigation and therefore the pathophysiological role of the latter on the skin is not yet conclusively clarified. with most countries announcing a lockdown period, dermatologists face a moral dilemma in outweighing risks and benefits of keeping their clinics functional. teledermatology and/or telephone consultations may be a valuable solutions to this dilemma that many dermatologist harness during this exceptional situation. such alternatives are primarily useful for triage purposes and to follow-up long-term patients, but they clearly cannot replace clinical this article is protected by copyright. all rights reserved. examination (supported by dermoscopy). 10 this is where systems such as the vectra 3d system can be useful for sensitive monitoring for changes or new lesions. in conclusion, dermatologists in collaboration with other specialties are fighting against this worldwide dilemma, however much more data needs to be collected to shape our strategy in combat with this pandemic. solidarity and transparency against the covid-19 pandemic clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet priorities for global health community in covid-19 pandemic the effect of quarantine and isolation for covid-19 in general population and dermatologic treatments letter from the editor: occupational skin disease among healthcare workers during the coronavirus (covid-19) epidemic personal protective equipment: an emerging issue in the covid-19 pandemic dermatology staff participate in fight against covid-19 in china covid-19 can present with a rash and be mistaken for dengue teledermatology in the wake of covid-19: advantages and challenges to continued care in a time of disarray key: cord-320929-8h44wf36 authors: sarkar, rashmi; bhargava, shashank; chander, ram; rathod, dipali; singh, ajay kumar title: webinars as a mode of e‐discussion by indian dermatologists during the covid‐19 era: a boon or a bane? date: 2020-08-21 journal: dermatol ther doi: 10.1111/dth.14220 sha: doc_id: 320929 cord_uid: 8h44wf36 nan the term 'webinar' is composed of two words 'web' (from the worldwide web) and 'seminar'. a live presentation, recorded video, or lecture broadcast online in real-time using the software defines 'webinar'. the interaction between the speaker and participants usually takes place via webcam and microphone. in different parts of the world, virtual education has been implemented even for school students and higher education during these trying this article is protected by copyright. all rights reserved. times. [3, 4] online webinars make it interesting for the speakers as well as for the participants in the following ways: • real-time audio-visual communication (5), alopecia (5), use of immunosuppressants (4), aesthetics (4) and the ways to restart procedures in private practice (3) once the lockdown restrictions are removed and various others. on the other hand, these webinars are very much dependent on technology, which isn't always so reliable. in the case of poor internet connection or of an inadequate bandwidth, attendees are unable to participate. and when technical problems are on the organizer's side, the webinar gets either cancelled or postponed. dermatologists in india now feel that they are overburdened by the number of webinars planned and hence they have become reluctant to attend them. hence webinar is like a 'double-edged sword' which can be beneficial for some while others (non-qualified healthcare workers and those practicing traditional medicine) can misuse it by implementing the information incorrectly on patients (they are mostly not aware about pharmacokinetics, pharmacodynamics, interactions and contraindications of allopathic medications), especially those without appropriate qualifications and knowledge. it also increases the chances of quackery in dermatology practice if not properly monitored, although knowledge is also available in books. webinars are definitely a game-changer, only if practiced and conducted ethically without doing much damage to the healthcare system. in the future, we hope to profit more from virtual teachings, [5] and the latest technologies that have to offer nothing but the best! instant paper from the field" on rehabilitation answers to the covid-19 emergency the fate of major dermatology conferences and meetings of 2020; are e-conferences and digital learning the future? transition to virtual learning during covid-19 crisis in iran: opportunity or challenge medical students' perceptions and an anatomy teacher's personal experience using an e-learning platform for tutorials during the covid-19 crisis will virtual teaching continue after the covid-19 pandemic? key: cord-336695-jx0waah0 authors: kroumpouzos, george; gupta, mrinal; jafferany, mohammad; lotti, torello; sadoughifar, roxanna; sitkowska, zuzanna; goldust, mohamad title: covid‐19: a relationship to climate and environmental conditions? date: 2020-04-24 journal: dermatol ther doi: 10.1111/dth.13399 sha: doc_id: 336695 cord_uid: jx0waah0 nan has spread rapidly throughout the world, and world health organization declared it a health emergency. 1-3 a significant number of infectious diseases, including human covs, display seasonal patterns in their incidence. environmental factors such as temperature and humidity play an important role in progression and spread of severe acute respiratory syndrome (sars)-cov infection with the virus retaining its viability for over 5 days at temperatures of 22 c to 25 c and relative humidity (rh) of 40% to 50%. higher temperatures and higher rh (38 c, and >95% rh) have been found to reduce virus viability. 4, 5 covid-19, caused by sars-cov-2, started in low temperature areas of china, with major outbreaks following in south korea, japan, iran, and northern italy. it is noteworthy that the new epicenters of virus showed similar temperature and latitude and were all along the 30 to 0 n 00 zone. the diseases then spread to higher temperature areas like india, thailand, and middle east, which can be attributed to the global traveling. weather patterns in covid-19 (5 c-11 c and 47%-70% rh) are similar to those of sars-cov mentioned above and known laboratory conditions that favor cov survival (4 c, 20%-80% rh). 5 nevertheless, the dynamics of viral transmission depend on many other factors like physical property of the virus, outdoor and indoor environments, population densities, hygiene, space, and genetic predispositions, which may be the reason for its spread in relatively warmer areas. 6, 7 the presence of central air-conditioning, which tends to maintain a lower ambient room temperature, may play a role in virus spread in closed spaces irrespective of the outside temperature. lack of hygiene, close contact as seen in high density population areas, poor living conditions with lack of ventilation may be predisposing factors for viral transmission in warmer areas. 6, 7 the seasonality and dynamics of covid-19 are not well under world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action learning from history: coronavirus outbreaks in the past the effects of temperature and relative humidity on the viability of the sars coronavirus effects of air temperature and relative humidity on coronavirus survival on surfaces clinical features of patients infected with 2019 novel coronavirus in wuhan early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia key: cord-297400-l8fhy1hu authors: adebanjo, ganiyat adenike ralitsa; francesca romana, parisella; cittadini, andrea; luzi, fabiola; tammaro, antonella title: a case of dermatitis artefacta during a pandemic date: 2020-08-26 journal: dermatol ther doi: 10.1111/dth.14235 sha: doc_id: 297400 cord_uid: l8fhy1hu nan dear editor, the beginning of the pandemic of covid-19 was associated to extreme measures taken by different countries to prevent and contain its spread: italy was among the first states that decided to set up travels bans and policies in order to limit the burden of the disease. the implications of this crisis have been associated to adverse psychological outcomes in the general population: as a matter of fact, individuals who were already at risk had to endure additional psychological trauma because of the loss of their loved ones, unemployment and the need to be isolated or quarantined 1 . a 68-year-old woman, who had been affected by mood and anxiety disorders for many years, presented during the covid-19 lockdown period with self-inflicted skin lesions on several part of the body. this article is protected by copyright. all rights reserved. on physical examination, she had numerous pruritic circular erythematous lesions on the extensor surfaces of her forearms ( figure 1, figure 2 ). a biopsy of the lesioned skin was performed and it showed an excoriated epidermis with pseudoepitheliomatous hyperplasia (pruritic eczema-like findings). furthermore, the superficial dermis was characterized by small proliferating capillary vessels indicating a chronic process. laboratory routine investigations were normal. all in all, given the clinical picture of the patient, a diagnosis of dermatitis artefacta was made and the patient was sent to the psychiatry department of our hospital for a consultation. the diagnosis was confirmed by the psychiatrist as well: in fact, he reported that the patient injured her skin in a compulsive way and could not avoid it although aware of the risks underlying this behavior. in previous distressing conditions of her life (a conflicting relationship with her adopted child, breast cancer and chemotherapy at 58 years old, and pituitary gland surgery), the patient had never injured her skin producing dermatitis. nevertheless, she experienced depression and anxiety. during the recent period, the fear of a possible covid-19 infection, reinforced by media information, the lockdown condition and staying at home all day for several weeks produced an increased anxiety state with severe emotional distress. the patient was prescribed oral tablet sertraline (100 mg/day) and oral tablet alprazolam (1 mg/day); plus, she was given additional appointments to follow up her psychological status. emollient creams were applied on the lesions, improving the pruritus and the appearance of the erythematous areas. this article is protected by copyright. all rights reserved. week follow-up ( figure 3 ). dermatitis artefacta, which is also referred to as factitious dermatitis, is a frequently unrecognized clinical entity associated with self-injury behavior, in which conscious or unconscious manipulation causes skin lesions 2,3 . the auto-inflicted damage is likely to be found in areas of the body that are easily reachable and it stems from an attempt to shift the focus from psychological and/or social conflicts to a tangible entity like the skin 4 . factitious dermatitis is a psychocutaneous disorder which is more prevalent among women and it is frequently associated to a variable degree of psychological distress and a history of psychiatric disorders 4 . there is a plethora of skin lesions which may be associated to dermatitis artefacta and they are often endowed with non-specific pathophysiological findings 5 as in the case of our patient. the diagnosis can be challenging because of the dearth of unequivocal diagnostic tools 3, 4 , hence it is made by exclusion of other skin diseases. the conditions that should be included in the differential diagnosis are vascular disorders, allergic contact dermatitis and prurigo nodularis 6, 7 . typically, the latter presents with dome shaped lesions on the extensor surfaces of the limbs on the background of a preexisting chronic pruritic condition 8 . on the other hand, dermatitis artefacta is usually associated to lesions which are heterogeneous in appearance and that are produced to fulfill a subconscious need to be seen as vulnerable 9 : in this case the pruritus is a consequence of the disease and not a preceding factor. this article is protected by copyright. all rights reserved. we decided to report this case because in this patient dermatitis artefacta seems to be related to and appeared in coincidence with the covid-19 emergency and lockdown. moreover, we believe that there will be an increase of dermatitis artefacta incidence in the near future resulting from the ubiquitous effects of the covid-19 emergency. covid-19, mental health and psychological first aid dermatitis artefacta: selfinflicted genital injury dermatitis artefacta: psychological and neurological distress? self-inflicted skin diseases. a retrospective analysis of 57 patients with dermatitis artefacta seen in a dermatology department dermatitis artefacta psychiatric disorders and pruritus primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations statpearls psychosomatic factors in pruritus key: cord-340283-5w444i1g authors: das, anupam; singh, vinay title: erythematous‐oedematous type of chilblain‐like lesions and covid‐19 : an indian perspective date: 2020-06-27 journal: dermatol ther doi: 10.1111/dth.13912 sha: doc_id: 340283 cord_uid: 5w444i1g nan the burning and tingling sensation could not be attributed to any other systemic or cutaneous etiology. although two patients (age 52 and 32 years) were diabetic, they did not have any such complaints prior to the diagnosis of covid-19. pure neuritic leprosy was excluded in our patients on the basis of time of onset of the lesions, non-specific findings on nerve conduction velocity and resolution of the symptoms following recovery from the disease. one of our patients presented with symptoms of "erythromelalgia", and this could be attributed to microvascular thrombotic injury. complement associated microvascular injury and thrombosis have been already implicated in the pathophysiology of severe covid-19 infection, and the development of "erythromelalgia" like symptoms could be attributed to a similar mechanism. therefore, the temporal association, complaints of the peculiar neurological sensation followed by development of erythema and swelling in our patients, supports the probable association of the cutaneous manifestations, with covid-19. the patients had been advised symptomatic treatment, and the signs and symptoms disappeared following recovery from the disease. in a recent study published by recalcati et al. from italy; commonest signs were erythematous rash (77.8%) followed by urticaria (16.7%) and vesiculation (5.6%). 2 other skin changes that have been reported include dusky acrocyanosis and dry gangrene from china; 3 chicken-pox like rash from italy, 2 transient unilateral livedo reticularis from united states, 4 dengue-like rash from thailand, 5 plaques in the heels from spain. 6 in one of the largest series published from spain, cutaneous manifestations were pseudochilblains (19%), vesicular eruptions (9%), urticaria (19%), maculopapular rashes (47%) and livedo (6%). 7 in the spanish series, 19% of the cases were classified as "pseudochilblains", characterized by presence of asymmetrical areas of erythema and oedema, over the hands and feet. 7 in another series published from italy, authors noticed an outbreak of chilblain-like lesions in italy contemporary to covid-19 epidemic, who reported two varieties of lesions, namely erythematous-oedematous type and blistering type. 8 cutaneous manifestations in covid-19: a first perspective a dermatologic manifestation of covid-19: transient livedo reticularis covid-19 can present with a rash and be mistaken for dengue cutaneous manifestations in covid-19: a new contribution classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases chilblain-like lesions during covid-19 epidemic: a preliminary study on 63 patients chilblain-like lesions on feet and hands during the covid-19 pandemic absence of skin of colour images in publications of covid-19 skin manifestations this article is protected by copyright. all rights reserved key: cord-305966-a61v2615 authors: pourani, mohammad reza; nekooghadam, sayyed mojtaba; youssefian, leila; vahidnezhad, hassan; abdollahimajd, fahimeh title: cd147 inhibitors as a treatment for melanoma: promising agents against sars‐cov‐2 infection date: 2020-10-24 journal: dermatol ther doi: 10.1111/dth.14449 sha: doc_id: 305966 cord_uid: a61v2615 nan fa, mrp and smn contributed to the conception of the work. mrp drafted the manuscript. fa, hv and ly critically revised the manuscript. all authors gave final approval and agreed to be accountable for all aspects of the work ensuring integrity and accuracy scientists have conducted many research projects to discover optimal treatment options. 1 the cd147 protein (known as basigin) is a transmembrane protein that has recently been suggested as a potential receptor for sars-cov-2. this protein interacts with several extracellular and intracellular proteins like cyclophilins a and b and matrix metallopeptidases (mmps). 2 recent studies have reported that the spike protein of sars-cov-2 attaches to host cells via angiotensin-converting enzyme-2 (ace-2) and cd147 receptors. cd147 is expressed in different tissues such as epithelia, as well as lymphoid and myeloid cells. notably, cd147 plays an essential role in the pathogenesis of several diseases including certain infectious/inflammatory conditions and cancers. 3 in fact, recent studies have suggested cd147 as a novel tumor marker in the early diagnosis of some cancers like head and neck squamous cell carcinoma and hepatocellular carcinoma. 4 in melanoma, cd147 overexpression fulfills important roles in the proliferation, metastasis, invasiveness, and angiogenesis of malignant melanoma cells. it has been shown that melanoma cell proliferation, migration, and metastasis this article is protected by copyright. all rights reserved. decrease secondary to cd147 silencing via the regulation of mmp-2, mmp-9, and vascular endothelial growth factor. 5 hatanaka et al. used a combination therapy of egfr and cd147 inhibitors to treat braf-mutated malignant melanoma. 6 shielding of the sars-cov-2 spike protein that binds to the cd147 and ace2 receptors. 8 in conclusion, considering the possible role of cd147 in the pathogenesis of covid-19, cd147 inhibitors may be considered as promising treatments for sars-cov-2 infection. however, the risks/benefits of anti-cd147 agents as a covid-19 treatment option should be appraised. high-quality studies concerning this therapeutic target are warranted. treatment options for covid-19: the reality and challenges statins: could an old friend help the fight against covid-19? cd147 as a target for covid-19 treatment: suggested effects of azithromycin and stem cell engagement targeting cd147 is a novel strategy for antitumor therapy cd147 is a novel chemotherapy or prevention target in cd147-targeted sirna in a375 malignant melanoma cells induces the phosphorylation of egfr and downregulates cdc25c and mek phosphorylation downregulation of cd147 induces malignant melanoma cell apoptosis via the regulation of igfbp2 expression fda approved drugs with pharmacotherapeutic potential for sars cov-2 (covid-19) therapy a proposed randomized, double blind controlled study evaluating doxycycline for the prevention of covid-19 infection and disease in healthcare workers with ongoing high risk exposure to covid-19. medrxiv the authors declare no conflict of interest data availability statement: data sharing is not applicable to this article as no new data were created or analyzed in this study this article is protected by copyright. all rights reserved. key: cord-290137-3jyhc63d authors: szepietowski, jacek c; krajewski, piotr; biłynicki‐birula, rafał; poznański, paweł; krajewska, magdalena; rymaszewska, joanna; matusiak, łukasz title: mental health status of health care workers during the covid‐19 outbreak in poland: one region, two different settings date: 2020-06-17 journal: dermatol ther doi: 10.1111/dth.13855 sha: doc_id: 290137 cord_uid: 3jyhc63d nan phone: +48-601534853 email: jacek.szepietowski@umed.wroc.pl during the covid-19 pandemic health care workers (hcw) have been demonstrated to have higher level of anxiety and depression (1) . lu et al. (2) suggested that hcw of the departments with high-risk contact with sars-cov-2 infected patients demonstrated higher mental health impact. here, we present our data on mental health status of hcw of two various departments, including university department of dermatology, in wroclaw, poland, having different settings. such analysis has not been reported so far.department of dermatology, venereology and allergology is located in a separate building which is exclusively dedicated for patients with cutaneous diseases. department of nephrology and transplantation medicine is a part of complex hospital with many departments; however, no infectious disease ward is located there. there were several hcw and patients infected with sars-cov-2 in this hospital (in the department of nephrology two hcw and six patients were infected). there were no sars-cov-2 infections among hcw and patients of the department of dermatology. up till now (data on the 7 th of june 2020) in the region of wroclaw 2708 infected people and 117 deaths due to covid-19 have been reported. we invited 123 hcw of both departments (58 hcw from the department of dermatology and 65 hcw from the department of nephrology) to participate in the study. they were asked to fill in the following questionnaires: general anxiety disorder -7 (gad-7), patient health questionnaire -9 (phq-9) and hospital anxiety and depression scale (hads). the following cut-off points to suspect anxiety and depression were employed: gad-7 -≥5 points, phq-9 -≥10 points, hads -≥8 points (for each subscale), respectively (3) (4) (5) . the obtained results were statistically analysed with chi 2 pearson test and mann-witney u test were applicable (statistica 13; statsoft, tulsa, ok, usa). p value less than 0.05 was regarded significant. response rate was assessed as 97.6% (96% at the department of dermatology and 98.5% at the department of nephrology). the detailed characteristics of the study group is given in table 1 . there was no difference in terms of sex, physician/nurse, chronic comorbidities distribution, as well as the mean age and duration of professional activity between hcw of both evaluated departments. analysing the whole studied group anxiety was suspected among 29.2% (hads-a) -45% (gad-7), while depression in 14.2% (hads-d) -20% (phq-9). the only significant difference (p=0.04) between sexes was found in the prevalence of anxiety assessed with gad-7 (m/f ratio: 0.54). there were no significant differences in the frequency of both anxiety and depression with regard to the type of hcw (physician/nurse), however, more nurses achieved the cut-offs for both anxiety and depression (table 2) . anxiety, assessed with hads-a, and depression, evaluated with phq-9, was significantly more prevalent (p<0.01 for both scales) among hcw reporting chronic comorbidities ( table 2) . despite of the higher frequency of depression, assessed with hads-d in hcw of the department of nephrology (p=0.03), we were unable to find any other significant differences in anxiety and depression occurrence in hcw between both departments of different settings (table 2) . our data are on the prevalence of depression and anxiety in hcw are in concordance to these recently reported in pooled analysis of depression and anxiety (1), 29.2-45.0% vs. 10.5-44.7% and 14.2-20.0% vs. 10.6%-50.4%, respectively. there were no marked distinctions in mental health of hcw between both analysed departments. the difference between our study and chinese colleagues might be due to higher number of infected patients in high-risk contact departments (2) . it seems that, at least in our country, neither setting nor its different specificity, but general covid-19 pandemic situation may have crucial influence on the mental health status of hcw. accepted article table 2 percentage (number) of health care workers fulfilling the criteria for suspected anxiety (gad-7, hads-a) and depression (phq-9 hads-d) prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study a brief measure for assessing generalized anxiety disorder: the gad-7 optimal cut-off score for diagnosing depression with the patient health questionnaire (phq-9): a meta-analysis is the hospital anxiety and depression scale (hads) a valid measure in a general population 65-80 years old? a psychometric evaluation study. health qual life outcomes key: cord-307925-0nhsf90c authors: ordóñez‐rubiano, maria fernanda; campo, isabela; casas, mirian title: dupilumab in atopic dermatitis, a protocol for sars‐cov 2 infected patients date: 2020-08-10 journal: dermatol ther doi: 10.1111/dth.14172 sha: doc_id: 307925 cord_uid: 0nhsf90c nan during sars-cov 2 pandemic scarce articles have been written regarding the possible effects of biologics and immunosuppressants in chronic inflammatory skin diseases, such as atopic dermatitis (ad) 1 . looking after optimal skin care, the most appropriate topical and systemic treatments and balanced mental status of ad patients is an important role of dermatologist not only for patients, but for health systems and emergency rooms occupancy. therefore, it is important as dermatologist to be involved in health care of infected or covid-19 patients having severe dermatological diseases and making appropriate decisions for their skin health. biologics have shown minimal increased risk of infection and its discontinuation can lead to loss of efficacy and drug-autoantibodies 2 . dupilumab is an inhibitor of il-4 and il-13 signaling pathway that, theoretically, could lower risk for sars-cov-2 2 . the virus has tropism for cells expresing the angiotensin converting this article is protected by copyright. all rights reserved. enzyme 2 receptor and then hyperactivates the immune response (cd8+ and cd4+, specially helper 1, t cells) releasing proinflammatory cytokines that results in lung impairment 3 . but il-4 and il-13 pathways have not been implicated in the host defense mechanism against viral infections, neither cytokine storm in covid-19 3 . this type of cellular response also appears to be common to other coronavirus-induced infection 2 . also, by treating asthma dupilumab may theoretically decrease risk for covid-19 and severe respiratory disease 7 . in latin america covid-19 is rapidly spreading, in colombia numbers are increasing, positioning us now as the second country with the most cases in latin america and it has encountered our ad clinic. we report a 22 year old male nurse, diagnosed with ad at 14 with no comorbidities, who is in treatment with dupilumab since september 2019. on this article is protected by copyright. all rights reserved. november 2019 he stopped dupilumab for 3 months due to insurance problem (the medication was not provided because of an administrative issue) and had to be admitted in the er because of a severe flare. he restarted dupilumab in january 2020 with control of the disease and no new flares. on may 18th, 2020 he was diagnosed with asymptomatic sars-cov 2 by pcr due to occupational exposure, to our knowledge the first patient in latin america infected while in treatment with dupilumab. given the documented flare with suspension and need for er attention we decided to continue the medication and stablished a protocol (shown in figure 1 ) for these patients at our clinic (currently 90 patients treated with dupilumab for severe ad). we would like to highlight the importance of reassessing decisions periodically in all immunodepressed or immunomodulated patients due to scarce information this article is protected by copyright. all rights reserved. 2, 4, 5, 6 . it is stated that dupilumab may be preferred over traditional immunosuppressive drugs when starting treatment in selected severe cases during the pandemic 4,5 . as described in the literature, in our country biologics are difficult to dispense due to administrative problems and costs that make them inaccessible many times to patients and that makes continuity and adherence to medications difficult for ad patients, even though it this article is protected by copyright. all rights reserved. is the only biological authorized for the treatment of severe adult ad 8 . we share our institutional protocol in order to optimize ad patients care, especially in centers where severe ad is treated with dupilumab. this article is protected by copyright. all rights reserved. evidencedbased best practice advice for patients treated with systemic immunosuppressants in relation to covid-19 dupilumab and covid-19: what should we expect? safety of dupilumab in atopic patients during covid-19 outbreak belloni fortina a. sars-cov-2 asymptomatic infection in a patient under treatment with dupilumab european task force on atopic dermatitis (etfad) statement on severe this article is protected by copyright. all rights reserved acute respiratory syndrome coronavirus 2 (sars-cov-2)-infection and atopic dermatitis management of adult patients with severe atopic dermatitis treated with dupilumab during covid-19 pandemic: a single center real-life experience considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the covid-19 pandemic severe adult atopic dermatitis: clinical challenges figure 1: protocol for atopic dermatitis in patients treated with dupilumab this article is protected by copyright. all rights reserved accepted article this article is protected by copyright. all rights reserved. key: cord-312331-k87js3aw authors: tatu, alin laurentiu; nadasdy, thomas; nwabudike, lawrence chukwudi title: new data about sexually transmitted covid‐19 date: 2020-11-01 journal: dermatol ther doi: 10.1111/dth.14426 sha: doc_id: 312331 cord_uid: k87js3aw nan tial for sexual transmission via alternative forms of sexual contact, such as anal-oral contact. this currently seems like a plausible mechanism as viral shedding may indeed continue in the gastrointestinal tract for a period of time beyond that which can be proven through nasopharyngeal swab testing. 4 we also propose that close contact between partners might be a risk for viral transmission as the lipid envelope that encapsulates the coronavirus could allow it to be stable in areas with high sebum production such as on the hair of the scalp, eyelashes, ears, or beard. it is also possible that arthropods found on as evidenced by the ability of small molecules to interrupt viral attachment to host cells. 5 as such, we recommend strict hygiene measures be adhered to, especially in people who share close quarters. 6, 7 the presence of a viral rash on patients is an especially interesting subject. recent reports have been made of a vesicular coronavirus rash, and it is still unclear whether such rashes contain viral particles within the vesicular fluid. to date, real-time polymerase chain reaction assays from the vesicular fluid of suspected sars-cov-2 vesicles have been unable to demonstrate viral rna, but current data are limited to only four patients and the study notes a lack of assay standardization and a low viral load as possible sources of error. 8 if such affirmations turn out to be true, this too could potentially be a source of viral contamination between sexual partners. 9 bearing this in mind, we recommend that patients who present with a possible viral exanthem related to the sars-cov-2 refrain from close contact with others, and in such circumstances the recommendation of sexual abstinence would be appropriate. the authors declare no potential conflict of interest. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. viral shedding of covid-19 in pregnant women coronavirus disease 2019 in pregnant women: a report based on 116 cases no evidence of sars-cov-2 in semen of males recovering from covid-19 chitosan as a lipid binder: a langmuir monolayer study of chitosan−lipid interactions. biomacromolecules natural small molecules as inhibitors of coronavirus lipid-dependent attachment to host cells: a possible strategy for reducing sars-cov-2 infectivity? observations about sexual and other routes of sars-cov-2 (covid-19) transmission and its prevention familial clustering of covid-19 skin manifestations clinical and histological characterization of vesicular covid-19 rashes: a prospective study in a tertiary care hospital varicella-like exanthem as a specific covid-19-associated skin manifestation: multicenter case series of 22 patients key: cord-322332-0pi3wcv5 authors: conforti, claudio; giuffrida, roberta; zalaudek, iris; di meo, nicola title: doxycycline, a widely used antibiotic in dermatology with a possible anti‐inflammatory action against il‐6 in covid‐19 outbreak date: 2020-05-15 journal: dermatol ther doi: 10.1111/dth.13437 sha: doc_id: 322332 cord_uid: 0pi3wcv5 nan ) is the protagonist of cytokines that are activated as a result of a dysregulated host immune response at alveolar level, which may contribute to the development of a pulmonary parenchymal inflammation with consequent lung interstitiopathy causing a reduction in respiratory function. 5 the efficacy and safety of a number of il-6 receptor antibodies are currently under investigation, with no definitive results available at the moment. an open-label nonrandomized clinical trial suggested that chloroquine and its less toxic metabolite, hydroxychloroquine, may be effective against covid-19. 6 gautret et al supported the synergistic effect of the combination of hydroxychloroquine (200 mg × 3/day for 10 days) and the macrolide antibiotic azithromycin (500 mg on the first day then 250 mg/day for 5 more days) that is known to have a broad spectrum of action against most causes of pneumonia, as well as a potential anti-inflammatory effect. 6 since then, many authors described the abovementioned combination as therapeutic or prophylactic in the sars-cov-2 pandemic. in view of this, doxycycline (a semisynthetic derivative of tetracycline) would seem to be a valid alternative to azithromycin. in fact, in addition to its well-defined antibiotic effects (bacteriostatic action by inhibition of bacterial protein synthesis), in vitro studies have shown doxycycline to exert anti-inflammatory effects at low (20-40 mg/day) and high (100 or 200 mg/day) doses with inhibitory action on metalloproteases and modulating effects of pro-inflammatory cytokines il-6, il-8, and tumor necrosis factor-alpha. 7 the anti-inflammatory properties of doxycycline and other components of tetracycline has been demonstrated for several inflammatory airway diseases, including, acute respiratory distress syndrome. 8 thereby, low doxycycline doses have been shown to be more effective than high doses to prevent induction of pro-inflammatory cytokines (such as il-6) in inflammatory diseases. 7 doxycycline is rapidly and almost completely absorbed after oral administration. it is a safe and inexpensive drug with a minimal toxicity. 7 the most common side effects are gastrointestinal (stomach pain, nausea, vomiting, diarrhea, and gastritis) and dermatological (rash, sensitivity to the sun). 7 doxycycline is contraindicated during pregnancy due to its potential adverse teratogenic effects and in children under coronavirus disease 2019 (covid-19): facts and controversies priorities for global health community in covid-19 pandemic covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action hlh across speciality collaboration, uk. covid-19: consider cytokine storm syndromes and immunosuppression interleukin-6 use in covid-19 pneumonia related macrophage activation syndrome. autoimmun rev hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial antiinflammatory properties of low and high doxycycline doses: an in vitro study tetracyclines and pulmonary inflammation abnormal weight gain and gut microbiota modifications are side effects of long-term doxycycline and hydroxychloroquine treatment key: cord-322718-zpf2ri9k authors: goldust, mohamad; sharma, aseem; murrell, dedee f.; kazemi, negin; rudnicka, lidia; kassir, martin; navarini, alexander; mueller, simon m. title: dermatology and specialty rotations: covid‐19 may reemphasize the importance of internal medicine date: 2020-07-11 journal: dermatol ther doi: 10.1111/dth.13996 sha: doc_id: 322718 cord_uid: zpf2ri9k nan since the first case was identified in wuhan, china in november 2019, the novel coronavirus (covid-19) has spread worldwide and affected almost all parts of the globe with unprecedented epidemiological, psychosocial, political, financial and educational repercussions. [1] [2] [3] in dire times like this, other specialists including dermatologists have stepped up and volunteered their services to help ease the burden and share the medical workload. dermatologists across the globe have been screening outpatients, manning isolation wards, tending to non-dermatology wards, assisting in stepdown intensive care units, and so on. 4,5 some dermatology departments have been converted to quarantine units, with the same manpower detailed for duties. 6 in short, all efforts are being made to "flatten the curve" of new covid-19 cases. the flipside lies in the fact that not all dermatologists feel competent enough to discharge duties of the said nature. in most countries including switzerland, dermatology residency entails five years of training including ward rounds, inpatient care, outpatient consultation, mandatory dissertations, research projects, case presentations, scientific writing and specialists exams -but all pertinent to the subject. 7 thereafter, we diverge into the various sub-specialties of dermatology. the ramification of this article is protected by copyright. all rights reserved. this is a relative dissociation from general, internal and emergency medicine per se. this may be particularly palpable in solitary private practitioners, dermatologists working exclusively in specialty clinics and private hospital employees.. some countries, such as australia and new zealand, have barely any dermatologists in their public hospitals. at least in teaching hospitals, there exists an interdisciplinary integration with frequent clinical meetings, interdepartmental seminars and house calls, wherein, there is significant exposure to internal medicine and its machinery. even in the armed forces teaching institutes, serving as a general practitioner is mandatory before dermatology residency to become trained in, internal medicine and infectious diseases. in brief, internal medicine rotations should be made mandatory for dermatologists as this foundation may of use not only for our professional routine but also for exceptional healthcare crisis such as covid-19. being capable of basic interdisciplinary multitasking ready to be deployed at sudden times of need could certainly help to correct misconceptions of dermatologists being rather cosmetologists than competent physicians. this assumption may reinforced with the skinserious campaign launched by the american academy of dermatology which reemphasizes the integral role of dermatologists in health care. 8 this article is protected by copyright. all rights reserved. priorities for global health community in covid-19 pandemic utility and risk of dermatologic medications during the covid-19 pandemic safety measures in dermatology help minimize spread of covid-19 covid-19: challenges and opportunities for dermatology response dermatology residents and the care of covid-19 patients dermatology staff participate in fight against covid-19 in china evaluating dermatology residency program websites key: cord-334933-br1cr8kj authors: arora, gulhima; kroumpouzos, george; kassir, martin; jafferany, mohammad; lotti, torello; sadoughifar, roxanna; sitkowska, zuzanna; grabbe, stephan; goldust, mohamad title: solidarity and transparency against the covid‐19 pandemic date: 2020-04-13 journal: dermatol ther doi: 10.1111/dth.13359 sha: doc_id: 334933 cord_uid: br1cr8kj nan social distancing, and accessing health care only if symptoms are severe, may be lacking in poorer countries due to inadequate information and illiteracy. dispersion of misinformation and false beliefs are also more common. 4 amidst this somber situation, the blame of "politics of epidemics" in which politics mostly attributes to the broad effect of local, national, and international establishments, on the health consequences of communities in disease outbreaks, in asian countries like india and iran is challenging. 5 this has been attributed to various factors and sentiments, for example, fear of low tourist inflow causing recession or fear of creating panic in the public. this is in sharp contrast to developed countries like italy, whose transparency helps developing appropriate strategies. as we have entered a pandemic, we need to act fast and right. furthermore, solidarity must define our onward battle. who develops plans based on the principle of solidarity among countries such as gathering the world's leading experts for discussions on top research and innovation. it also works with member states to promote knowledge and empower communities. by working together, countries promote efficiency. cooperation is a key weapon in the battle against covid-19. we each need to recognize our unique risks, the prevailing cultural and social practices in our region and work a way around. let us stand together in solidarity, beyond borders as "the human race," to fight and overcome the covid-19 threat. we confirm that the manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work. stephan grabbe 10 mohamad goldust 7,11,12 1 world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) covid-19: what is next for public health? characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention feasibility of controlling covid-19 outbreaks by isolation of cases and contacts the politics of disease epidemics: a comparative analysis of the sars, zika, and ebola outbreaks https://orcid.org/0000-0001-6358-9068torello lotti https://orcid.org/0000-0003-0840-1936mohamad goldust https://orcid.org/0000-0002-9615-1246 key: cord-299681-smhto9em authors: elsaie, mohamed l.; youssef, eman a.; nada, hesham a. title: herpes zoster might be an indicator for latent covid 19 infection date: 2020-05-23 journal: dermatol ther doi: 10.1111/dth.13666 sha: doc_id: 299681 cord_uid: smhto9em various cutaneous manifestations have been observed in patients with covid‐19 infection. herpes zoster is a viral skin disease caused by varicella zoster that remains dormant in the dorsal root ganglia of cutaneous nerves following a primary chicken pox infection. in this report we describe two cases covid infection who first presented with herpes zoster. we are here by suggesting that the clinical presentation of hz at the time of the current pandemic even in patients giving mild or no suggestive history of upper respiratory symptoms should be considered as an alarming sign for a recent subclinical sars cov2 infection. this article is protected by copyright. all rights reserved. most patients with covid-19 exhibit mild to moderate symptoms, but approximately 15% of the cases progress to severe pneumonia and about 5% eventually develop acute respiratory distress syndrome (ards), septic shock and/or multiple organ failure (3, 4) . finding tools for recognition of asymptomatic carriers would be very helpful in the management of this outbreak. a wide array of skin manifestations in covid 19 infection were reported including macuulopapular eruptions, morbilliform rashes, urticaria, chicken-pox like lesions, livedo reticularis, covid toe, erythema multiforme and pitryasis rosea and several other patterns (5). we present two cases of clinically diagnosed herpes zoster infection attending two different clinics, both patients' showed no or mild symptoms of covid 19 infection and denied any history of contact with known or suspected covid19 cases. case 1 a 68-year-old man presented with painful blisters on the right side of his right loin. the pain was severe, continuous and stabbing in nature. he gave a history of initial stabbing pain followed by onset of blisters. the blisters were initially small and few in number; they later increased in number covering the entire right half of the loin with a watery discharge that turned hemorrhagic. fig1 no relevant medical history was given except for rare bouts of untreated hypertension and hypercholesterolemia. the area surrounding the vesicular eruption was flared and tender to touch. the patient was discharged and prescribed valaciclovir 1g twice daily for 1 week, acyclovir cream and paracetamol for his fever. two days following the presentation, the patient developed a heavy cough, sore throat, dyspnea and fever that required hospitalization. several studies agreed that covid 19 infection is associated mostly with reduction in lymphocytes, monocytes and eosinophils (7-10) with drastically reduced numbers of cd4+ t cells, cd8+ t cells, b cells and natural killer (nk) cells (11) . in addition the follow-up of the dynamic changes of the lymphocyte counts along the course of the disease showed that the non-survivors developed more severe lymphopenia over time. white blood cell counts and neutrophil counts were higher in non-survivors than found in survivors and also the lymphocyte counts continued to decrease until death occurred in non-surviving patients (12). this article is protected by copyright. all rights reserved. early transmission dynamics in wuhan, china, of novel coronavirusinfected pneumonia a genomic perspective on the origin and emergence of sars-cov-2. cell clinical features of patients infected with 2019 novel coronavirus in wuhan pathological findings of covid-19 associated with acute respiratory distress syndrome cutaneous signs in covid-19 patients: a review herpes zoster-typical and atypical presentations hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (covid-19): a meta-analysis epub ahead of print clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china clinical features of covid-19 and factors associated with severe clinical course: a systematic review and meta-analysis epub ahead of print covid-19: immunopathology and its implications for therapy clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan functional exhaustion of antiviral lymphocytes in covid-19 patients elevated exhaustion levels and reduced functional diversity of t cells in peripheral blood may predict severe progression in covid-19 patients key: cord-346159-0bi2f3gb authors: babu, bibilash; shivakumar, swathi; dr. asokan, karthika title: “thinking outside the box in covid‐19 era”‐application of modified aerosol box in dermatology date: 2020-06-04 journal: dermatol ther doi: 10.1111/dth.13769 sha: doc_id: 346159 cord_uid: 0bi2f3gb nan this article is protected by copyright. all rights reserved. in march 2020, dr. lai hsien-yung, a taiwanese doctor, devised an aerosol box to minimize risk of infection to health care personnel during high aerosol generating procedures like intubation. it consists of a transparent plastic box, with an opening on one side to fit over the patient's chest and 2 holes on the opposite side through which physicians can fit their hands. 4 the efficacy of this aerosol box was later tested on mannequins with simulated cough reflex. 5 currently, many modifications of the original aerosol box have been proposed for application in other fields like dentistry and otorhinolaryngology. 6 dermatology is another speciality where the physicians have a high risk of exposure to the virus while examining and operating on lesions on the face. hence, the authors propose a modified design of this aerosol box to assist in performing dermatological procedures on the face like electrocautery, microneedling with a dermapen/dermaroller, chemical peels and lobuloplasty, amongst others. this modified aerosol box ( figure 1) consists of: • a narrower base on the head end, so as to be accommodated on a procedure chair, which gradually widens by 10cm towards the foot end, to accommodate the shoulders of patients. • in addition to the two circular working ports on the back surface at the doctor's end, this modified aerosol box also has two more working ports on each of the other two surfaces. this facilitates access of the patient's face from all directions during a procedure. • height of the box is 50cm, with extra 5cm length of the frame projecting downwards from the base u-plate. this provides stability to the box and prevents it from sliding down from an inclined chair. the box can be easily disinfected using 0.5% hypochlorite solution or 70% alcohol and reused for multiple patients on the same day. the authors acknowledge that this aerosol box, just like any other device, is not 100% protective or fail proof. it has been proposed to aid in providing protection to the dermatologist, in case the patient inadvertently sneezes/coughs suddenly during a procedure. currently, dermatologists are faced with a moral dilemma of whether to continue their practice or not. most clinics are offering consultations only for emergency cases, while the routine cases are advised to follow up through tele-consultations. 7 while this can be followed for a short time, until we tide over the acute crisis of covid-19, it is not practical in the long run. dermatological procedures cannot be postponed indefinitely. at the same time, we cannot restart our practice the same way as before the covid era. we need to restructure our work environment to adapt to the current scenario. 8, 9 at present there is no specific treatment or vaccine for covid-19 which can help to eradicate the infection in the near future. we need to prepare to resume our daily lives, despite the prevalence of the infection. who recommends using covid-19 rapid tests only in research setting and not in clinics, as they were found to lack both sensitivity as well as specificity. 10 hence, we propose the use of this aerosol box, as a precautionary measure, to minimize spread of infection to the maximum possible extent. this article is protected by copyright. all rights reserved. accepted article who announces covid-19 outbreak a pandemic the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak taiwanese doctor invents device to protect us barrier enclosure during endotracheal intubation aerosol box for dentistry dermatology practices as vectors for covid-19 transmission: a call for immediate cessation of non-emergent dermatology visits covid-19 pandemic: university of naples federico ii dermatology's model of dermatology reorganization face the covid-19 emergency: measures applied in an italian dermatologic clinic advice on the use of point-of-care immunodiagnostic tests for covid-19 acknowledgements: we would like to thank ann's group for making the prototype of the aerosol box. key: cord-324794-h08uzro4 authors: kutlu, ömer; aktaş, habibullah title: the explosion in scabies cases during covid‐19 pandemic date: 2020-05-23 journal: dermatol ther doi: 10.1111/dth.13662 sha: doc_id: 324794 cord_uid: h08uzro4 nan the covid-19 pandemic emerged in conjunction with changes in many areas of life that need to reassessed and adjusted. 1 these changes also reflected in dermatology outpatient and inpatient clinics. 2, 3 recently, we reported that not number but percentages of patients with scabies, psoriasis, urticaria, and scabiesrelated visits to dermatology outpatient clinic increased immediately ten days after covid-19 pandemic. 4 however, we observed a sudden rise in the number of scabies two months after the first case of covid-19 in turkey. this finding can be addressed in the context of the pandemic-related "stay at home" policy which is very crucial to control the outbreak. the severe clinical manifestation of scabies basically occurs after 4-6 weeks of the first infestation. this may be the reason why scabies is not seen in high number at the beginning of pandemic and then cause an explosion. it is reported that incubation period is 2-3 weeks on average in scabies. sarcoptes, which can live for three days outside the body at normal room temperature, can remain infectious for up to 10 days in hyperkeratotic crusts and become very infectious. 5, 6 in this regard, there are several explanations that can be a scabiesrelated increasing the number of the patient during the pandemic. firstly, the temporary workplace closure in the urban areas that the source of the covid-19 outbreak allowed patients to migrate from urban to rural areas where scabies can be seen as more commonly. in addition, the increasing close contact as a result of the this article is protected by copyright. all rights reserved. stay at home policy might facilitate the scabies contagiousness of individuals living in the same home. lastly, the high hospital bed turnover rate during the covid-19 pandemic may lead to the hospital to be one of the possible sources of scabies. in the literature, the increasing number of patients with scabies during covid-19 pandemic has not yet been reported in european countries. the possible reason for this condition may be explained in several factors. given turkey's cultural structure, the lifestyle such as living in the same household with a large number of people, which has become more common due to pandemic-related temporary migration is more frequent than european countries. furthermore, the percentage of turkey ruralurban households is higher than in european countries, which might have contributed to the more shifting traditional rural infectious diseases to urban settings in turkey during the covid-19 pandemic. we should also highlight one point that many european countries confronted more severe and common coronavirus cases than in turkey. thus, these countries focused on the covid19 cases that caused temporarily shuted the doors to outpatient clinics that are not directly related to the pandemic cases including dermatology outpatient departments. on the other hand, although the number of patients who requests for outpatient clinics that are not directly related to the pandemic cases decreased in turkey, most of the hospitals continued to provide healthcare services in all branches of medicine including dermatology. 4 all these factors may be a possible explanation of why turkey has more scabies cases than european countries. this article is protected by copyright. all rights reserved. in conclusion, understanding the increasing number and impacts of scabies during pandemics will allow for better preparation of countries to fight scabies infestation which is another type of outbreak. priorities for global health community in covid-19 pandemic a case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a patient with covid-19: will cases of psoriasis increase after covid-19 pandemic? dermatol ther dermatological diseases presented before covid-19: are patients with psoriasis and superficial fungal infections more vulnerable to the covid-19? dermatol ther the effect of the "stay-athome" policy on requests for dermatology outpatient clinic visits after the covid-19 outbreak uyuzlu hastaya yaklaşım key: cord-328718-j9p7ahl8 authors: goldust, mohamad; agarwal, komal; podder, indrashis; navarini, alexander a. title: skin cancer and covid‐19 date: 2020-07-23 journal: dermatol ther doi: 10.1111/dth.14050 sha: doc_id: 328718 cord_uid: j9p7ahl8 nan coronavirus disease (covid-19) emerged in wuhan, china in late 2019 and soon attained the status of a pandemic in early 2020. it primarily affects the respiratory system, often leading to multiple organ failure and death. 1 the high infectivity of this virus with no definite treatment or vaccine yet, has lead to national lockdown and quarantine in various countries to flatten the curve forcing people to stay indoors. this has also affected the health care system with restricted footfall at regular hospital outpatient departments (opds) and private clinics. this pandemic has altered every aspect of patient care, comprising both indoor and outdoor patients. some of the worst affected patients include those with chronic illnesses like skin cancers (basal cell carcinoma, squamous cell carcinoma and melanoma). due to minimal availability of public transport and doctors in regular clinics, several skin cancer patients are going undiagnosed, leading to delayed diagnosis resulting in worsening of its grade and prognosis. 2 the ones already on treatment are finding it difficult to procure the medicines or attend hospitals for regular follow up. this article is protected by copyright. all rights reserved. many patients with skin cancer are already immunosuppressed, thus increasing their susceptibility to various infections including covid-19. besides, the severity and prognosis of covid-19 is poor in patients with co-morbidities and immunosuppression. 3 interestingly, some authors have reported the role of psychologic stress in the pathogenesis of squamous cell carcinoma. 4 covid-19 is undoubtedly a stressful situation owing to limited knowledge regarding the nature of virus and lack of definite treatment. 5 thus, covid-19 induced stress may predispose patients to squamous cell carcinoma. newer anti-cancer molecules like immune checkpoint inhibitors (pembrolizumab, ipilimumab, nivolumab) are being used in melanoma 6 but there are reports of pembrolizumab induced neutropenia. 7 this weakens the immune system of patient leading to increased risk of covid-19. thus, the risk benefit ratio of a drug should be carefully evaluated, especially during such times. 8 the treatment regimens are also being modified to decrease the need of hospital visits by these patients to reduce the spread of covid-19 viz. pembrolizumab is being prescribed at 400 mg 6 weekly instead of 200 mg 3 weekly for cutaneous melanoma. 9 during such a health crisis with limited number of beds and shortage of anaesthetists, continuation of surgery seems extremely difficult. covid-19 related pneumonia in the postoperative period is a major risk and is most likely to prove fatal. thus, invasive procedures like biopsies and surgeries for all skin malignancies should be confined to only urgent cases. [9] in such times, dermoscopy may prove to be a valuable diagnostic tool, and invasive procedures may be postponed if feasible. this article is protected by copyright. all rights reserved. clinical characteristics of coronavirus disease 2019 in china cancer patients in sars-cov-2 infection: a nationwide analysis in china prevalence of underlying diseases in hospitalized patients with covid-19: a systematic review and meta-analusis chronic stress and susceptibility to skin cancer. journal of the national cancer institute anxiety, worry and perceived stress in the world due to the covid-19 pandemic immune checkpoint inhibitors in melanoma: a review of pharmacokinetics and exposure-response relationships a case of severe pembrolizumabinduced neutropenia the powerful immune system against powerful covid-19: a hypothesis. med hypotheses covid-19: impact on cancer workforce and delivery of care. the lancet oncology virtually perfect? telemedicine for covid-19 another approach that can be universally adopted is to switch out-patient consults to online mode (teleconsultation) instead of a face-to-face interaction. this relieves the undue surge of patients in the hospital, ensures and enforces self-quarantine and decreases risk of exposure to patients as well as health care workers. 10 face-to-face consultations, if needed, can be decided on case to case basis after the teleconsultation, for immunosuppressed cancer patients, a separate ward with a distinct set of doctors can be used who do not come in contact with covid-patients.this pandemic has forced us to make drastic changes in our system of patient care, especially in case of chronic illnesses like cancers, it would be wise to learn from these changes and implement it in the future as well so that we are better prepared for such circumstances. key: cord-319820-eb5y7gxj authors: kutlu, ömer title: analysis of dermatologic conditions in turkey and italy by using google trends analysis in the era of the covid‐19 pandemic date: 2020-07-02 journal: dermatol ther doi: 10.1111/dth.13949 sha: doc_id: 319820 cord_uid: eb5y7gxj many areas of life including patterns of dermatological diseases that patient attend to the hospital were tremendously affected by implementing stay‐at‐home orders during the covid‐19 pandemic. we aimed to identify the dermatologic interest of the public during the covid‐19 pandemic by using google trends. the terms “acne”, “hair loss”, “eczema”, “genital warts”, “molluscum contagiosum”, “botox”, “skin cancer”, “sunscreen” were analyzed on first april, first may, first june 2020, and the corresponding period of the previous year in turkey and italy by using google trends. the searching spectrum was between 3first march 2019‐first june 2020. the relative change of search term “acne” was +10, +29, +13/ ‐1, +17,+33, “hair loss” was +14, +40, +16/+3, +16, +15, and “eczema” was +2, +34, −4/ +3, +25, +18, on the other hand, the relative change of the “genital warts” was −15, −48, +10/ ‐44, −30, +18 and “molluscum contagiosum” was −12, −2, −4/ ‐4, −1, −12 while “botox” was, −10, −43, −8/ ‐41, −31, +4, “skin cancer” was −27, −38, −38/−22,+33, −7 and sunscreen was −6, −25, −71/−13,0,‐45 in turkey/italy on 1 st april, 1 st may, and 1 st june, 2020, respectively. a statistically significant positive correlation was found between the number of covid‐19 cases in turkey and search terms of the general dermatology group during the covid‐19 pandemic (p < 0.05). the search terms including “acne”, “eczema”, “hair loss” appears to be increasing while “molluscum contagiosum”, “genital warts” “botox”, “skin cancer”, and “sunscreen” decreasing in the era of the covid‐19 pandemic. understanding the trends and impacts of dermatologic diseases on public perceptions during the covid‐19 pandemic will allow for better preparation of dermatologists. this article is protected by copyright. all rights reserved. warts", "molluscum contagiosum"), cosmetology and surgery ("botox", "skin cancer", "sunscreen"). these terms were searched in turkish and italian languages by using google trends in two countries (https://trends.google.com/trends/?geo=tr and https://trends.google.com/trends/?geo=it). we compared the data of turkey with italy which was one of the most affected countries by the covid-19 pandemic in order to investigate whether these searching terms objective for other communities or not. although the first case of covid-19 in italy appeared earlier than turkey, similar measures such as the shutdown of all schools and universities, lockdown orders, closure of museums, cultural centers, cinemas, theatres, pubs and suspending of international flights were taken in both countries at approximately the same time. 12, 13 the search terms in three groups were analyzed on 1 st april, 1 st may, 1 st june 2020, and the corresponding period of the previous year in order to rule out seasonal effects. the searching spectrum was between march 31, 2019, and june 1, 2020. the correlation between diseases in general dermatology groups and the number of covid-19 cases in turkey were investigated. the statistical analysis for correlation was performed from 11 march to 1 june 2020 in order to the first case of covid-19 was appeared on march 11, 2020, in turkey. the study was approved by the institutional review board. this article is protected by copyright. all rights reserved. the data were evaluated in the spss 20.0 (spss inc., chicago, illinois) program and were considered statistically significant when p<0.05. shapiro-wilk test was used for the normal distribution of data. spearman's rho correlation was used for not normally distributed data in continuous measurement variables. in turkey/italy on 1 st april, 1 st may, and 1 st june, 2020, in the general dermatology group, the relative change of "acne" was +10, +29, +13/ -1, +17,+33 while "hair loss" was +14, +40, +16/+3, +16, +15, and "eczema" was +2, +34, -4/ +3, +25, +18, respectively. in the venereology group, the relative change of the "genital warts" was -15, -48, +10/ -44, -30, +18 while "molluscum contagiosum" was -12, -2, -4/ -4, -1, -12, respectively. in cosmetology and surgery group, the relative change of "botox" was -10, -43, -8/ -41, -31, +4, while "skin cancer" was -27, -38, -38/-22,+33, -7 and sunscreen was -6, -25, -71/-13, 0,-45, respectively ( figure 1-3) . the most common search term in the general dermatology group in turkey was "eczema" followed by "hair loss", and "acne", respectively, whereas it was "acne" followed by "eczema", and "hair loss" in italy (figure 4, 5) . in the venereology group, "genital warts" was more common in turkey, whereas molluscum contagiosum was more common in italy (figure 6, 7) .in both countries, cosmetology and surgery groups, botox was the most common search term followed by sunscreen, skin cancer, respectively (figure 8, 9 ). this article is protected by copyright. all rights reserved. a statistically significant positive correlation was found between the number of covid-19 cases in turkey and search terms of the general dermatology group during the covid-19 pandemic (table 1) . after the covid-19 pandemic, the number of patients who request dermatology outpatient clinic visits was decreased in many countries because of stay at home policies in order to deal with the global pandemic. 2, 14, 15 thus, certain diseases that may be increased in number after the covid-19 pandemic remained concealed. dermatology outpatient clinics represent only the tip of the iceberg during the covid-19 pandemic days. therefore, it can be expected that using the internet quite increased by the public in order to access their health information during the current pandemic. 16 the investigation of the public trends may give some clues on the frequency of certain diseases in the covid-19 pandemic. in this context, according to this study, interestingly, relative changes in search terms were similar between turkey and italy after the covid-19 pandemic. we found that "acne", "hair loss", and "eczema" search terms increased after the covid-19 outbreak both in turkey and italy. the relative change in these terms was more prominent in april and may 2020. as compared to each other, the most common search term among general dermatologic diseases was "eczema" followed by "hair loss" in turkey, whereas "acne" was the most common disease followed by "eczema" in italy. there are some points that should be addressed in this regard. the enhanced preventive precautions for hand hygiene by using antiseptics, cologne, liquid soap allows patients to deal the effect of the "stay-athome" policy on requests for dermatology outpatient clinic visits after the covid-19 outbreak evaluation of dermatology consultations ın the era of covid19 dermatological diseases presented before covid-19: are patients with psoriasis and superficial fungal infections more vulnerable to the covid-19? dermatol ther the explosion in scabies cases during covid-19 pandemic skin changes attributed to protective measures against covid-19: a compilation hand disinfenction in the combat against covid-19 gene polymorphism is associated with the effect of diet as a risk factor in acne vulgaris diet, smoking and family history as potential risk factors in acne vulgaris-a community-based study family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults telogen effluvium: a review alopecia areata: review of epidemiology, clinical features, pathogenesis, and new treatment options key: cord-336384-sollv92j authors: goren, andy; mccoy, john; wambier, carlos g.; vano‐galvan, sergio; shapiro, jerry; dhurat, rachita; washenik, kenneth; lotti, torello title: what does androgenetic alopecia have to do with covid‐19? an insight into a potential new therapy date: 2020-04-08 journal: dermatol ther doi: 10.1111/dth.13365 sha: doc_id: 336384 cord_uid: sollv92j nan in newborns, it has long been recognized that male infants are more susceptible to respiratory distress syndrome 2 and less likely to respond to prenatal glucocorticoid therapy to protect against respiratory distress. 3 respiratory distress is intimately tied to the production of pulmonary surfactant, for example, pulmonary surfactant proteins have been demonstrated to protect against influenza a. 4 in animal studies, it was demonstrated that a sexual dimorphism in fetal pulmonary surfactant production is influenced by the androgen receptor (ar). 5 for example, in rabbits, dihydrotestosterone was shown to inhibit fetal pulmonary surfactant production in both males and females while an anti-androgen, flutamide, was demonstrated to remove the sexual dimorphism in surfactant production. 3 while severe covid-19 symptoms are primarily manifested in older adults, the similar sexual dimorphism in the severity of respiratory disease is of interest. in addition, ar expression is low prior to pubertal maturation and may contribute to the low incidence of severe covid-19 infection in children. [6] [7] [8] as such, we propose that the lower rate of severe covid-19 infection in female patients may be attributed to lower ar expression. 9, 10 additional evidence to the possible implication of androgens in covid-19 infection severity is found in the molecular mechanism required for sars-cov-2 infectivity. sars-cov-2 is part of the coronavirus family of viruses including sars-cov-1 and mers-cov. coronavirus predominantly infects type ii pneumocytes in the human lung. 11 previously, it was demonstrated that sars-cov-2 cell entry depends on priming of a viral spike surface protein by transmembrane protease serine 2 (tmprss2) present in the host. 12, 13 in type ii pneumocytes, tmprss2 expression is associated with an increase in ar expression, 14 specifically connecting ar expression to sars-cov-2, due to ar-regulated tmprss2 gene promoter (figure 1 ). 15 moreover, angiotensin-converting enzyme 2 (ace2) has been recognized as the attachment molecule to the viral spike surface protein, thus termed the "receptor of sars-cov-2". 16 interestingly, ace2 has been shown to have reduced activity by the decrease of androgen hormones (experimental orchidectomy), possibly by decreased expression of ace2. 17 to test this hypothesis, it would be informative to study the epidemiology of covid-19 patients that are predisposed to either lower or higher ar expression, such as, males suffering from androgenetic alopecia, benign prostatic hyperplasia, or women suffering from polycystic ovary syndrome. in addition, analyzing ethnic variation in ar expression may predict covid-19 ethnic mortality differences. additionally, the activation of ar can be reduced by several classes of drugs including ar antagonists, androgen synthesis inhibitors, and antigonadotropins. for example, the fda-approved 5-alpha reductase inhibitor finasteride demonstrated reduction of activation of ar in multiple tissues. 10 other potential drugs that could be studied include: cyproterone acetate, megestrol acetate, chlormadinone acetate, spironolactone, medrogestone, oxendolone, osaterone, bifluranol acetate, flutamide, bicalutamide, nilutamide, topilutamide, enzalutamide, apalutamide, dienogest, drospirenone, medrogestone, nomegestrol acetate, promegestone, trimegestone, ketoconazole, abiraterone acetate, seviteronel, aminoglutethimide, dutasteride, epristeride, alfaestradiol, and isotretinoin. taken together, the evidence warrants further studies to elucidate the role (if any) of the ar on the severity of covid-19 infection. f i g u r e 1 tmprss2 gene transcription promoter site requires an activated androgen receptor, with androgens such as testosterone. dihydrotestosterone (dht) a potent androgen receptor activator and is intracellularly produced in particular cells of tissues such as prostate, hair, and liver that express 5-alpha-reductases, the targeted enzyme for drugs such as dutasteride and finasteride (5-alphareductase inhibitors) clinical characteristics of coronavirus disease 2019 in china sex differences in fetal lung maturation dihydrotestosterone inhibits fetal rabbit pulmonary surfactant production evidence for a protective role of pulmonary surfactant protein d (sp-d) against influenza a viruses androgen receptors influence the production of pulmonary surfactant in the testicular feminization mouse fetus regulation of brain androgen receptor immunoreactivity by androgen in prepubertal male ferrets changes in amount and intracellular distribution of androgen receptor in human foreskin as a function of age intrinsic versus extrinsic aging: a histopathological, morphometric and immunohistochemical study of estrogen receptor β and androgen receptor different levels of 5alpha-reductase type i and ii, aromatase, and androgen receptor in hair follicles of women and men with androgenetic alopecia androgen receptor expression is greater in macrophages from male than from female donors. a sex difference with implications for atherogenesis immunohistochemical, in situ hybridization, and ultrastructural localization of sars-associated coronavirus in lung of a fatal case of severe acute respiratory syndrome in taiwan sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor evidence that tmprss2 activates the severe acute respiratory syndrome coronavirus spike protein for membrane fusion and reduces viral control by the humoral immune response androgen receptor and androgen-dependent gene expression in lung prostate-localized and androgen-regulated expression of the membranebound serine protease tmprss2 predicting the angiotensin converting enzyme 2 (ace2) utilizing capability as the receptor of sars-cov-2 sex hormones promote opposite effects on ace and ace2 activity, hypertrophy and cardiac contractility in spontaneously hypertensive rats key: cord-318866-3arxrm8m authors: magnano, m.; balestri, r.; bardazzi, f.; mazzatenta, c.; girardelli, c.r.; rech, g. title: psoriasis, covid‐19 and acute respiratory distress syndrome: focusing on the risk of concomitant biological treatment date: 2020-05-30 journal: dermatol ther doi: 10.1111/dth.13706 sha: doc_id: 318866 cord_uid: 3arxrm8m nan the management of psoriatic patients under biologics during sars-cov-2 outbreak is of great concern, as well as the outcome of the coronavirus disease (covid-19) in this population. we report here 9 cases of 3 italian districts largely hit by covid-19 (bologna, lucca and trento). on a pool of 720 psoriatic patients followed by our 3 referral centers for severe psoriasis, we registered 9 swab-confirmed cases of sars-cov-2 infection (table 1) . mean age was 53.9±9.7 years. the most common comorbidity was obesity (mean bmi=30.9±5.5), followed by hypertension. this article is protected by copyright. all rights reserved. our case series roughly reflects the study of gisondi et al. 1 , who concluded that, despite the cardiovascular and metabolic comorbidities affecting psoriatic patients and also representing risk factors for severe covid-19, patients seldom required hospitalization. among our cases, one middle-aged man developed critical covid-19. this is the first report of ards in a psoriatic patient undergoing biological treatment, however this may be related to his other serious comorbidities. this percentage (1/9-11.4%) is consistent with the rate of ards in the general population, estimated at around 14.8% of affected individuals. 2 the appropriateness of withdrawing biologic therapies preventively in psoriatic patients is still debated and it is also unclear whether their use influences the course of covid-19 or not. 3 although it seems that most psoriatic patients experience mild covid-19, our case series raises some considerations. we know that the main risk factor for severe covid-19 is old age. 4 the psoriatic population treated with biologic therapies is on average young 5 , since elderly patients with multiple comorbidities are usually excluded from systemic treatments. our sample is in line with this data, therefore we can expect a lower fatality rate than in the general population. nevertheless, the course of covid-19 could be complicated by the concomitant administration of immunomodulators, which in pivotal trials have demonstrated to increase the susceptibility of respiratory infections. particularly, anti-tnf drugs seem to increase such condition by up to 7% compared with placebo. 6 however, high levels of tnf-α have been observed in severe covid-19 patients, while interleukin-17 may also be involved in the cytokine cascade, having been linked to severe cases. 7 therefore, the abrupt interruption of biologics may increase the systemic inflammation, which may worsen the associated comorbidities and the prognosis of covid-19. however, we decided to withdraw biologic therapies in 8 of the 9 patients after the diagnosis, this article is protected by copyright. all rights reserved. mainly to avoid other microbial infections, although the asymptomatic patient did not develop any complications throughout the course of the disease. it is also noteworthy that obesity was the most represented comorbidity. despite the fact that obese patients tend to have more severe forms of covid-19 also at younger ages 8 , 88.9% of our patients were mild or asymptomatic. biologics may play a role in these cases, modulating the inflammatory response, usually overexpressed in obese patients. although this case series is limited, we evidenced that ards can represent a complication also in patients under biologics. however, these subjects do not seem to develop critical covid-19 more often than the general population of same age range. the impact of covid-19 pandemic on patients with chronic plaque psoriasis being treated with biologic therapy: the northern italy experience online ahead of print the viral, epidemiologic, clinical characteristics and potential therapy options for covid-19: a review biologic therapy for psoriasis during the covid-19 outbreak is not a choice epidemiologic study in a real-world analysis of patients with treatment for psoriasis in the french national health insurance database should biologics for psoriasis be interrupted in the era of covid-19? covid-19 and immunomodulator/ immunosuppressant use in dermatology obesity could shift severe covid-19 disease to younger ages acknowledgment: "the patients in this manuscript have given written informed consent to publication of their case details." key: cord-335104-8b2tpbsh authors: carugno, andrea; gambini, daniele mario; raponi, francesca; vezzoli, pamela; robustelli test, elisa; arosio, marco enrico giovanni; callegaro, annapaola; sena, paolo title: coronavirus disease 2019 (covid‐19) rash in a psoriatic patient treated with secukinumab: is there a role for interleukin 17? date: 2020-07-27 journal: dermatol ther doi: 10.1111/dth.14011 sha: doc_id: 335104 cord_uid: 8b2tpbsh nan various cutaneous manifestations have been observed in covid-19 patients 1 and there has been worldwide concern among patients undergoing biologic therapies. [2] [3] [4] we report our experience with a covid-19 psoriatic patient treated with anti-interleukin-(il)-17 who developed a late onset rash. a 69-year-old obese, hypertense, diabetic man was previously followed for psoriasis and psoriatic arthritis; he was treated with secukinumab 300 mg every 4 weeks for 2 years. about 25 days after the last dose of secukinumab he had close contact with his father, who died of covid-19 a few days later. in the following days the patient developed mild fever, asthenia, and ageusia, bringing high suspicion of sars-cov-2 infection. after consultation, as precaution, we advised him not to administer the next injection of secukinumab. all symptoms, except ageusia, were resolved in 5 days. about 5 weeks later, he referred to us due to the rapid onset of a mild pruritic erythematooedematous morbilliform rash, rapidly spreading from arms to trunk and lower limbs; he also showed an initial flare-up of his psoriasis the patient developed a mild form of covid-19, even though his age and comorbidities are most typically associated with poorer prognosis. 6 the rash occurred about 40 days after the systemic symptoms and approximately 8 weeks after the last secukinumab dose. the rash appeared together with the recurrence of psoriasis. at the onset of the rash, the patient still had a positive swab, but the rt-pcr search for viruses in the skin was negative. these observations seem consistent with the hypothesis of cytokine storm and th17 involvement in the pathogenesis of covid-19 and covid-19-related cutaneous manifestations. 3, 4, 7 in our case, the covid-19 clinical course was mild and therefore we can assume secukinumab does not increase risks for the patient and could support the hypothesis of the possible therapeutic use of il-17 inhibitors in covid-19. [7] [8] [9] the mechanisms of covid-19 cutaneous manifestation are still not well known. 1 the appearance of the manifestations 8 weeks after the last dose of the drug and the negativity of skin research of the virus with rt-pcr seem more consistent with the hypothesis of inflammatory pathogenesis than with the presence of peripheral viral particles. further observations are needed to confirm these hypotheses. the patient in this manuscript has given written informed consent to publication of his case details. we wish to express our gratitude to dr. fabio maria carugno and dr. matteo alberto mariani for their precious help and advice. novel coronavirus disease (covid-19) and biologic therapy in psoriasis: infection risk and patient counseling in uncertain times covid-19 and acute respiratory distress syndrome: focusing on the risk of concomitant biological treatment unraveling the mystery of covid-19 cytokine storm: from skin to organ systems cutaneous manifestations of covid-19: report of three cases and a review of literature detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr covid-19: risk factors for severe disease and death covid-19: a case for inhibiting il-17? reducing mortality from 2019-ncov: host-directed therapies should be an option should patients stop their biologic treatment during the covid-19 pandemic the authors have no conflict of interest to declare. key: cord-280774-r2xm164s authors: gallizzi, romina; sutera, diana; spagnolo, alessandra; bagnato, anna maria; cannavò, serafinella patrizia; grasso, loredana; guarneri, claudio; nunnari, giuseppe; mazza, francesca; pajno, giovanni battista title: management of pernio‐like cutaneous manifestations in children during the outbreak of covid‐19. date: 2020-09-19 journal: dermatol ther doi: 10.1111/dth.14312 sha: doc_id: 280774 cord_uid: r2xm164s background: during the outbreak of covid‐19 many pernio‐like lesions have been increasingly reported. the aim of the study is to describe our management of these skin manifestations and to evaluate a possible correlation to sars‐cov‐2 infection. methods: all patients underwent clinical and laboratory tests to detect a possible underlying connective disease and also to specific sars‐cov‐2 investigations such as oropharyngeal swab and igg‐igm serology. results: nine patients aged between five and fifteen years old were evaluated. skin lesions observed were purplish, erythematous and oedematous, in some cases painful and itchy. six out of nine had respiratory and systemic symptoms (cough, nasal congestion, chills, fever, asthenia) that preceded cutaneous findings of approximately two weeks. concerning blood exams, three out of nine had d‐dimer weakly increased, four had ana positivity: two with a title 1:160, one with 1:320 and one with 1:5120 and a speckled pattern. the latter patient had also ena ss‐a positive and rf positivity, confirmed at a second check, so as to allow us to make a diagnosis of connective tissue disease. four out of nine had apl positivity (igm). reactants acute phase were all negative. oropharyngeal swabs and serology tests for sars‐cov‐2 was negative (borderline in one patient for igm). no treatment was needed. conclusions: even if we do not have enough data to prove it, we hypothesize a correlation between pernio‐like lesions and sars‐cov‐2 infection for an increased number of these lesions described during the pandemic and also because such manifestations appeared when temperatures were mild and patients were at home in isolation for the lockdown. many questions remain open about interaction host‐virus. this article is protected by copyright. all rights reserved. during the outbreak of covid-19 many skin manifestations have been reported, and among these, in very significant numbers, newly vascular eruptions and peculiar pernio-like skin lesions have been described in observational studies 1, 2, 3, 4 . pernio, also referred to as chilblains, is a rare inflammatory condition. chilblains derives from two old english words "chill" (cold) and "blegen" (sore). most commonly, pernio affects acral skin and develops among susceptible individuals who are exposed to cold, the lesions usually appear in fall or winter and disappear in spring or early summer. it is typically idiopathic and acute, nevertheless chronic forms also exist 5 . the diagnosis of pernio is largely clinical and based on a thorough history and physical exam. the differential diagnosis must exclude diseases that can often be confused with other forms of pernio or vasculitis processes like systemic lupus this article is protected by copyright. all rights reserved. erythematous (sle) or other conditions as raynaud phenomenon, acrocyanosis, cryoglobulinemia, cold panniculitis and interferonopathies. the prognosis of pernio is good with minimal chronic sequelae. single or multiple erythematous, purplish, edematous lesions appear, accompanied by intense pain, itching, or burning. usually, pernio affects the toes and dorsum of the proximal phalanges 6 . the mainstay of treatment is the avoidance of the cold and, in some cases, drugs as nifedipine and other calcium channel blockers are needed for the resolution of existing lesions 5 . since march 2020, children with acral red and painful skin lesions, referable to chilblain have come to our attention. the increased number of cases of pernio-like lesions compared to the cases per year we usually observe, the mild temperatures of those months in southern italy and the concomitant lockdown, led us to hypothesize a possible correlation with sars-cov-2 infection. we evaluated the personal history and photographs of skin lesions of 26 patients, sent to us by their pediatrician, through multidisciplinary telematic meetings with dermatologists, rheumatological pediatricians, infectious disease specialist. we only included patients with pernio-like skin lesions (nine patients). patients who could not perform the oropharyngeal swab for sars-cov-2 were not admitted to the hospital. we collected informed consent to obtain clinical information and photos of patients and to perform blood chemistry sampling. therefore, we evaluated 9 cases of children who in our group of patients no significant difference in gender was detected (5 females and 4 males). the median age was 11,4 years (from 5 to 15 years). two patients were siblings. all patients were from the south of italy coming from the town of messina and surrounding. their family histories and their personal histories were negative for autoimmune disorders, raynaud's phenomenon, acrocyanosis, chilblains or photosensitivity except for one child who had suffered from an episode of raynaud's phenomenon a few years earlier. no family member of these patients presented symptoms attributable to sars-cov-2 infection but, for work reasons, their parents were in contact with public. only two siblings had both parents with compatible symptoms and confirmed sars-cov-2 infection by positive nasal swab. the cutaneous manifestations observed were purplish, erythematous and edematous, four children reported subjective symptoms, painful and pruritus localized to the sole of the feet or to the toes and/or fingers or heels ( fig. 1,2,3 ). feet alone were mostly affected (6 out of 9), hands alone (3 out of 9) (fig.1) . six patients had respiratory and systemic symptoms (cough, nasal congestion, chills, fever, asthenia) that preceded the skin lesions by about two weeks (table1). this article is protected by copyright. all rights reserved. we evaluated 9 cases of children who presented pernio-like lesions, since march to april 2020 during the outbreak of covid-19. we performed first level tests, all negative except for d-dimer weakly increased in three of our patients. d-dimer is a marker of activation of coagulation and fibrinolysis and it provides a rapid evaluation of thrombotic activity. its level correlated to coagulopathy have been described as prognostic factors in the evolution of sars-cov-2 infection, especially in more severe patients. zhang's study developed a triage, testing d-dimer levels at the admission, on the first and third day to predict survival in a cohort of patients and to evaluate management and follow up. the result was that a regulatory level of d-dimer at the presentation is highly predictive for survival 7 . this is useful to highlight, as in our case, the d-dimer of our patients was weakly increased, a condition perfectly correlated with the mild symptoms of sars-cov-2 putative infection presented. we have also performed autoimmunity tests, three out of nine had ana positivity (speckled pattern): two with a title of 1:160, one 1:320 not confirmed at a subsequent check after two months, another asymptomatic cases generated specific antibody responses for sars-cov-2 9 . the case of our family is emblematic: two parents presented striking symptoms of sars-cov-2 infection, high fever and this article is protected by copyright. all rights reserved. difficulty in breathing, and three positive swabs; the father had positive serology with high igg, such as to allow donation of his plasma for therapeutic purposes and the mother was surprisingly negative. sons who came to our observation, both with chilblain, presented mild respiratory symptoms and they were negative for both swabs and igg serology, while in one of the two cases, the igm were borderline. despite the negativities of diagnostic test for sars-cov-2, we are still convinced that there is a correlation between this infection and the development of pernio-like lesions, as described nasopharyngeal swab for sars-cov-2 gave negative results 4 . in a report of 19 adolescent patients with a clinical diagnosis of pernio-like lesions nasopharyngeal swab and igg serology for sars-cov-2 nucleocapsid protein were negative. importantly, iga serology for s1 domain of sars-cov-2 spike protein was positive in 6 patients and borderline in 3 patients 10 . in a study performed in sicily (italy) via teledermatology a total of 22 patients complaining of perniosis-like lesions were screened, mainly in the pediatric age (≤18yrs). all of them were tested with rhino-pharyngeal swabs and sars-cov-2 was detected in 6 patients, 5 of whom were children 11 . the understanding of the immunopathogenetic mechanisms of interaction between the sars-cov-2 infection and children is very intriguing but current knowledge does not seem to be sufficient. why some children who come into contact with the sars-cov-2 do not develop striking respiratory symptoms but present pernio-like lesions with negativity on diagnostic tests? matricardi et al developed the first model of interaction between the human immune system and sars-cov-2, as an attempt to produce a synthesis of the actual knowledge 12 . what emerges is that innate immunity represents the first line of defense against the new sars-cov-2 and this first comparison establishes the natural history of the pathology: either the infection will effectively block in the upper airways or if the virus manages to reach the lungs. innate immunity is essential for controlling virus replication before an adaptive immune response is generated 13 . type i interferones (ifn-i) are major components of the innate immune system and it represents critical antiviral molecules 14 . it is hypothesized that the ifn-i response may induce microangiopathic changes, producing chilblains and lupus-like erythematous eruption. a mechanism has recently been considered to explain the appearance of autoimmune phenomena following the whole sars-cov-2 infection: molecular mimicry 16, 17, 18 . lucchesi and floel 19 have hypothesized a molecular mimicry mechanism between neuronal proteins present in the brain stem respiratory pacemaker neurons (dab1, aifm and surf1) and viral epitopes of sars-cov-2 treated antigenic. the same mechanism, according to angileri et al., could be responsible of anosmia, leukopenia and multi-organ failure caused by vascular damage, assuming they are associated with the molecular mimicry 20 . a type 3 hypersensitivity therefore occurs with the deposition of antibody antigen complexes precipitating inside the tissues, in particular the blood vessels, inducing a serious inflammatory state by the action of the complement anaphylatoxins (c3a and c5a), which in turn stimulate the release of histamine from mast cells and the recruitment of phagocytes, first in neutrophils, the main cause of tissue damage and following «leukocytoclastic vasculitis» (lcv), also reported in the english medical literature from the term «hypersensitivity vasculitis 21, 22 ». this pathogenic mechanism could explain the appearance of pernio-like lesions due to sars-cov-2 infection. in conclusion, we think there is a correlation between pernio-like lesions and sars-cov-2 infection, but further studies are needed to prove it. this, for the increased number of these lesions described during this short time, as in our experience, and because such manifestations appeared when temperatures were mild in southern italy and patients were at home for the lockdown. to our knowledge, this is one of the few studies that collects a series of pediatric patients with perniolike lesions, evaluating the possible association with covid 19 (oropharyngeal swab and serology test) but also for rheumatological diseases. this article is protected by copyright. all rights reserved. chilblain-like lesions during covid-19 epidemic: a preliminary study on 63 patients chilblain-like lesions on feet and hands during the covid-19 pandemic acral cutaneous lesions in the time of covid-19 pernio (chilblains) statpearls treasure island (fl): statpearls publishing d-dimer levels on admission to predict in-hospital mortality in patients with covid-19 autoantibodies in nonautoimmune individuals during infections yuxin chen & bing gu (2020) different longitudinal patterns of nucleic acid and serology testing results based on disease severity of covid-19 patients a clinical, histopathological and laboratory study of 19 consecutive italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with covid-19 infection diversity of clinical appearance of cutaneous manifestations in the course of covid-19 the first, holistic immunological model of covid-19: implications for prevention, diagnosis, and public health measures type i interferons (a/b) in immunity and autoimmunity covid-19) infection-induced chilblains: a case report with histopathologic findings covid-19 a proteiform disease inducing also molecular mimicry phenomena? guillain barre syndrome associated with covid-19 infection: a case report covid-19 and molecular mimicry: the columbus' egg? molecular mimicry between sars-cov-2 and respiratory pacemaker neurons molecular mimicry may explain multi-organ damage in covid-19 immunobiology: the immune system in health and disease leukocytoclastic vasculitis list of abbreviations acl: anti-cardiolipin antibodies aifm: apoptosis-inducing factor 1, mitochondrial ana: antinuclear antibodies anti-β2gp1: anti β-2-glycoprotein1 antibodies apl: antiphospholipid antibodies c3a: complement factor 3 anaphylotoxin c5a: complement factor 5 anaphylotoxin cbc: complete blood count clia: chemiluminescent microparticle immunoassay covid key: cord-306070-2dgs5oih authors: askin, ozge; altunkalem, rozerin neval; altinisik, dursun dorukhan; uzuncakmak, tugba kevser; tursen, umit; kutlubay, zekayi title: cutaneous manifestations in hospitalized patients diagnosed as covid‐19 date: 2020-06-24 journal: dermatol ther doi: 10.1111/dth.13896 sha: doc_id: 306070 cord_uid: 2dgs5oih background: cutaneous manifestations of covid‐19 disease have not yet been fully described. objectives: to describe cutaneous manifestations of covid‐19 disease in hospitalized patients. methods: we examined the cutaneous manifestations of 210 hospitalized patients. results: cutaneous findings were observed during covid‐19 infection in 52 of the patients. lesions may be classified as erythematous scaly rash (32.7%), maculopapular rash (23%), urticarial lesions (13.5%), petechial purpuric rash (7.7%), necrosis (7.7%), enanthema and apthous stomatitis (5.8%), vesicular rash (5.8%), pernio (1.9%) and pruritus (1.9%). cutaneous manifestations were observed statistically significantly more in certain age groups: patients of 55 to 64 and 65 to 74 years of age complained of more cutaneous manifestations than the other age groups. as for gender, there was no significant difference between male and female patients in terms of cutaneus findings. the relationship between comorbidity and dermatological finding status was statistically significant. the relationship increases linearly according to the comorbidities. according the statistical results the patients who were hospitalized in the intensive care unit had a higher risk of having cutaneous findings due to covid‐19 infection. conclusions: with this study we may highlight the importance of overlooked dermatological findings in patients that are hospitalized. this article is protected by copyright. all rights reserved. in december 2019, first cases of pneumonia with unknown cause were reported in wuhan, china. the pathogen, called severe acute respiratory syndrome coronavirus 2 (sars-cov-2), was isolated from lower respiratory tract of infected patients. the resulting disease was termed as covid-19 (coronavirus disease 2019). sars-cov-2 has rapidly spread throughout china and across the world, until reaching the level of a pandemic disease (1) (2) (3) (4) . the sars-cov-2 infection mainly presents flu-like symptoms such as fever, cough, asthenia and can affect different organ systems, probably including the skin. there are few descriptions of the cutaneous manifestations of covid-19 (5) . hydroxychloroquine (hcq), azitromycin (azm), oseltamivir are used in the standard treatment regime for covid-19 infection. favipravir and tocilizumab are added to the regimen when necessary. (6) (7) (8) (9) (10) after our hospital was declared a pandemic hospital, private policlinics were opened. between 10.03.2020 and 03.05.2020, 54.373 patients applied to outpatient clinics of istanbul university-cerrahpasa, cerrahpaşa medical faculty hospital and 12.452 of these patients were tested for suspicion of covid-19. 1470 patients' tests were positive and 862 of them were hospitalized. 122 of these hospitalized patients needed intensive care. we examined the cutaneous manifestations of 210 patients hospitalized in cerrahpasa medical faculty, istanbul, turkey. during this pandemic, several case reports, and some articles were published about cutaneous manifestations of covid-19 infection. cutaneous manifestations are important in the diagnosis of various viral infectious diseases. with this study we may highlight the importance of overlooked dermatological findings in patients that are hospitalized. this study is a prospective observational study that evaluated 210 patients who were diagnosed as covid-19 and hospitalized in istanbul university-cerrahpasa, cerrahpasa this article is protected by copyright. all rights reserved. medical faculty during april 2020. 47 of 210 patients were in the intensive care unit (icu). we visited directly, got information about their medical history and took clinical images. the diagnosis of the patients was made according to computed tomography (ct) or reverse trancription-polymerase chain reaction (rt-pcr) results. rt-pcr test of nasophrygeal or throat swabs is the gold standard for the diagnosis of covid-19 however it is time consuming and may yield false-negative results (11) . although the rt-pcr was negative, patients were hospitalized when the ct findings were positive. the typical imaging characteristics of patients with covid-19 are single or multiple ground-glass opacity with subpleural distribution, crazy paving and diffuse consolidation with ground-glass opacity (12) . rt-pcr and ct were performed to all patients and findings were recorded. clinicopathologic confirmation of the patients could not be made due to the pandemic conditions. all patients gave their informed consent to participate and an explicit consent to use their pictures in publications. numerical and percentage represention was obtained by taking the frequency tables of the data. comparison of cutaneus manifestations according to variables of hospitalization (ward vs intensive care unit), age, gender, rt-pcr result was performed using chi-square independence test. the difference in cutaneus findings by age groups was performed using chi-square conformity analysis. this article is protected by copyright. all rights reserved. 1.erythematous scaly rash %32.7 of cases (17) . most of the lesions were seen on hands (fig1). these erythmatous rashes were generally thought to be due to washing hands and using disinfectants. 2.maculopapular rash %23 of cases (12) . most of the lesions were seen on the trunk, one was seen on the extremities and one was seen only on the upper part of the trunk. one of the lesion on the trunk was similar to pityriasis rosea (fig2). 3.urticarial lesions %13.5 of cases (7) . mostly distributed in the whole body (fig3). 4 .petechial purpuric rash %7.7 of cases (4) . while most of them were on the distal extremities (fig4) and petechial, one patient had generalized and petechial purpuric eruption. platelet levels and coagulation tests of the patients were normal. 9.pruritus %1.9 of cases (1). the symptom was thought to be related to vancomycin, but clinicopathological confirmation could not be made. the relationship between age and cutaneous findings was examined by chi-square independence test and a statistical relationship was obtained between them (χ 2 2= 25,538; sd = 6; p <0.001). accordingly, cutaneous findings were obtained more often in some age groups and this was statistically significant (p<0,05) ( table 1) . insert table 1 here. when cutaneous findings were analyzed according to the gender, 26.8% (33) of men and 21.8% (19) of women had dermatological findings. the relationship between gender and cutaneous findings was examined by chi-square independence test and no statistical relationship was obtained between them (χ 2 2 = 0.681; sd = 1; p> 0.05) ( table 2) . insert table 2 here. the relationship between pcr positivity and cutaneous findings was examined by chi-square independence test and no statistical relationship was obtained between them ( χ 2 =1.990; sd=1; p>0.05) ( table 3) . insert table 3 here. in our study 41.9% (88) of the patients did not have comorbidity, 22.9% (48) had one and 35.2% (74) had two or more comorbidities. when dermatological findings are examined according to comorbidity; dermatological findings were found in 21.1% (11) of those without comorbidity, 32.9% (17) of those with one and 46.1% (24) of those with two comorbidities. the relationship between comorbidity and dermatological finding status was examined by chi-square independence test and a statistically significance was obtained between them (χ 2 2 = 21.562; sd = 2; p <0.001). the relationship increases linearly according to the comorbidities (table 4 ). insert table 4 here. when the dermatological findings of the patients hospitalized in the icu and in the ward are examined; cutaneous findings were found in 34 of 163 patients hospitalized in the service and 18 of 47 patients in the icu. the relationship between cutaneous findings and being in the icu or being in the ward was examined by chi-square independence test and a statistically significance was obtained between them (χ 2 2 = 5.955; sd = 1; p <0.05). it was determined that the patients who were hospitalized in the icu had a higher risk of having cutaneous findings due to covid-19 infection (table 5) . insert table 5 here. in our study, we evaluated the cutaneous manifestations of the hospitalized patients due to the covid-19 pandemie. in our study 24% of the patients who were hospitalized showed cutaneous findings during covid-19 infection. recalcati et al. reported that 20.4% of the 88 patients diagnosed with covid-19 had cutaneous findings such as erythematous rash, widespread urticaria and chickenpox-like vesicles (13) . also a spanish medical ward collected nationwide data from 375 patients and classified lesions as acral areas of erythema with vesicles or pustules (pseudo-chilblain), other vesicular eruptions, urticarial lesions, maculopapular eruptions and livedo or necrosis (14) . of the 47 patients who were hospitalized at the icu 38.2% (18) of them showed cutaneous findings in current study. the greater percentage of the patients at the icu may be due to the severe infection. five studies reported on the possible association between covid-19 and skin lesion severity in 23 patients. in 21 patients (91.3%), the severity of cutaneous lesions was unlikely to be or was not correlated with covid-19 severity. contrarily, in 2 separate reports by mahe and estébanez, covid-19 and skin lesion severity were linked in 2 patients (8.7%) (15) . the patients who had comorbidities showed a greater percentage of cutaneous manifestations than those without comorbidities. according to our study, there was no significant difference in the frequency of dermatological findings in men and women. in a literature review that analyzed 16 articles, showed that of the 50 patients with determined gender, 27 (54%) were males and 23 (46%) were females (16) . in another literature review that analyzed 18 articles, males accounted for 38.9% of reported cases, females accounted for 27.8% of cases (17) . the result of our study was also compatible with these articles. the most commonly observed skin eruption in covid-19 patients was erythematous scaly rash in our study. the increased frequency of hand-washing and the use of the disinfectants increase the risk of irritant contact dermatitis (18) . maculopapular skin rash and urticarial rash were the second and third most commonly seen cutaneous manifestations. maculopapular rash was most commonly seen on the trunk; urticarial lesions were generalized. maculopapular lesions and urticaria may occur due to covid-19 disease itself or the antiviral drugs used in the treatment (15) . the increased frequency of maculopapular rash and urticaria in our study group is in alignment with the previously reported literature (15, 16, 19) . petechial and purpuric lesions and necrosis were also observed in our study group. a case series from china reported vasculopathic skin lesions ranged from acral cyanosis to dry gangrenes in 7 patients (20) . unlike the previously reported publishings, neither "chickenpox-like vesicles' nor chillblain-like symptoms were not observed in our study. there was only one patient with the diagnosis of pernio. the limitation of our study was that we just evaluated the hospitalized patients, and we could not perform clinicopathological confirmation. our study is the first prospective study that evaluates the patients' cutaneous findings at the covid-19 wards or the covid-19 icu in turkey. in this regard our study may give an opinion to the dermatologists about moderate/severe covid-19 infections' cutaneous manifestations. table 1 . age group and cutaneous findings table 2 . gender and cutaneous findings table 3 . pcr result and cutaneous findings table 4 . comorbidities and cutaneous findings table 5 . differences in the appearance of cutaneous findings of patients in the wards and intensive care unit (icu) this article is protected by copyright. all rights reserved. all patients in the figures had confirmed covid-19. a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) sars-cov-2 infection among travelers returning from wuhan, china this article is protected by copyright. all rights reserved the novel coronavirus originating in wuhan, china: challenges for global health governance early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia the sars-cov-2 outbreak: what we know new insights into the antiviral effects of chloroquine hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial the cytokine release syndrome (crs) of severe covid-19 and interleukin-6 receptor (il-6r) antagonist tocilizumab may be the key to reduce the mortality trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 favipiravir versus arbidol for covid-19: a randomized clinical trial. biorxiv preprint detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr the many faces of covid-19: spectrum of imaging manifestations. radiol cardiothor imag cutaneous manifestations in covid-19: a first perspective classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases cutaneous manifestations of covid-19: report of three cases and a review of literature cutaneous manifestations of the coronavirus disease 2019 (covid-19): a brief review cutaneous manifestations in covid-19: lessons learned from current evidence frequent hand washing for covid-19 prevention can cause hand dermatitis: management tips cutaneous manifestations in covid-19: the experiences of barcelona and rome clinical and coagulation characteristics of 7 patients with critical covid-2019 pneumonia and acro-ischemia this article is protected by copyright. all rights reserved key: cord-348501-8cvtqj7w authors: beyzaee, amir mohammad; rahmatpour rokni, ghasem; patil, anant; goldust, mohamad title: rituximab as the treatment of pemphigus vulgaris in the covid‐19 pandemic era: a narrative review date: 2020-10-20 journal: dermatol ther doi: 10.1111/dth.14405 sha: doc_id: 348501 cord_uid: 8cvtqj7w pemphigus vulgaris (pv), an autoimmune blistering disease is treated with immunosuppressive medications. as the immunosuppressive effect of rituximab, the first‐line therapy of pv, lasts more than 6 months, many concerns have raised due to the ongoing novel coronavirus disease (covid‐19) pandemic. with this background, our objective was to review the currently available literature as well as important websites for the evidence related to rituximab, pv and covid‐19, adverse effects associated with drugs, and relevant guidelines. “pubmed” and “google scholar” database were systematically searched for retrieving all articles related to anti‐cd20 therapy in pemphigus vulgaris and covid‐19 published up to 14 july 2020. a total of seven clinical studies are performed with anti‐cd20 therapy in covid‐19, three of which are performed on pemphigus patients, and have shown concerns employing rituximab in patients with covid‐19. evidence for treating pv patients with rituximab in covid‐19 pandemic is limited. until sufficient evidence or guideline for pemphigus and covid‐19 treatment is available, we advocate caution commencing rituximab in patients with pemphigus, due to the reported adverse outcomes. pemphigus, an autoimmune disease with yearly incidence of one to seven cases every million in european and american population has subtypes, that is, pemphigus vulgaris (pv) and pemphigus foliaceus with contribution of 75% and 20% patients, respectively. 1 pv is potentially fatal disease with blisters involving mucocutaneous surfaces such as skin and oral cavity. intraepidermal vesicles with acantholysis and intact basal layer are the characteristics of pv lesions. 2 autoantibodies are targeted against desmosomal cadherins desmoglein-1 and desmoglein-3 antigens, which play role as adhesive factors between nearby keratinocytes. the result is loss of adhesion between cells and development of blisters. 1, 3, 4 studies have shown that blood serum level of anti-desmoglein igg is associated with disease activity in pv patients. 1, 4 mortality rate in patients with pemphigus has decreased from 75% to 30%, by treating with corticosteroids. about 30%-50% of patients experience complete remission by long-term systemic corticosteroids administered in the high-dose (prednisolone in the dose of 1.0 mg or more per kg every day). 5 current pv treatment includes corticosteroids given in high doses and immunosuppressive drugs. 6 consequences of such combination therapy can include long standing suppression of immunity, and outcomes associated with this condition are the most common cause of mortality in pv. 7 patients not responding to the mentioned combination therapy, or who present with severe side effects, are given intravenous immune globulin (ivig). this is a successful method, and its monotherapy can be associated with long-term remission. 8, 9 removing the autoantibodies from blood circulation can be considered as a therapeutic approach, due to their pathogenic role in pemphigus. a trial reported significant reduction in the anti-desmoglein antibodies in serum with single cycle of high-dose intravenous immunoglobulin (2 g/kg) and resulted in satisfying clinical outcome. 10 rituximab, a mouse/human monoclonal antibody (igg 1 -κ) targets the cd20 antigens presenting on b lymphocytes surface. it clears the blood circulation out of cd20 expressing b lymphocytes by binding to cd20 antigens. most patients taking rituximab experience lymphopenia, which lasts about 6 months. complete recovery of b lymphocytes in peripheral blood circulation is usually observed nine to 12 months after the treatment course, when no cd20 antigen is expressed on hematopoietic stem cells. 1, 11 for the first time in 2007, thousands of pv and pemphigus foliaceus patients were treated with rituximab worldwide. in 2015, the european academy of dermatology and venereology guideline suggested rituximab as a third-line treatment. 1, 12, 13 rituximab decreases blood serum level of anti-desmoglein autoantibodies rapidly, which results healing of pemphigus lesions after few weeks of infusion, and complete remission is achieved after 3-6 months. 1, 14 experimental studies have shown that anti-cd20 therapy is the most important advance method for treating patients with pemphigus, after the advent of corticosteroids. 1 old age and comorbidities (eg, hypertension, diabetes, obesity, smoking, and cardiovascular and lung disease) are considered as risk factors for the novel coronavirus disease (covid-19). 15 immunocompromised patients, for example, those with pv receiving immunosuppressive disease-modifying therapies can also have increased risk of severe infection with coronavirus. as a result, any physicians and patients are concerned about the ongoing situation, particularly patients taking immunosuppressive drugs, as well as pemphigus patients. in this article, we reviewed the literature focusing on the treatment, management, and subsequent consequences of rituximab as a treatment for pv in the present covid-19 pandemic era. we performed a computer-assisted search of "pubmed" and "google scholar" databases up to 14 july 2020 using the keywords "anti-cd20 therapy," "pemphigus vulgaris," and "covid-19." we also searched other related keywords such as coronavirus, rituximab, immunocompromised, immunosuppressive drugs, pathogenesis, clinical presentations, treatment, and outcome. experimental studies have proven that rituximab, monoclonal antibody has capability of binding to cd20 antigen and removing b lymphocytes expressing cd20 from blood. according to the literature, it is considered as the first-line treatment for patients with pv based on the efficacy and safety profile. 16 due to the immunosuppressive role of rituximab, which could last at least 6 months, some cautions needs to be exercised when employing rituximab for treating patients with pv, especially during ongoing covid-19 era. patients with autoimmune bullous diseases (aibds) must never drop out their immunomodulating therapy. unjustified withdrawal can result in uncontrolled disease activity and lead to increased risk of morbidity and mortality. risk of opportunistic infections (including viral infections) is much more in patients with aibds receiving immunosuppressive therapies, than the healthy population. infections can activate the bullous activity. it is important to note that pemphigus as well as pemphigoid are associated with amplified risk of mortality due to pneumonia. 17, 18 athough some studies may have reported that risk of infections is not different between aibd patients treated with rituximab or high dose corticosteroids, 16 coronavirus can target the central nervous system (cns), which is protected by humoral immunity. 21, 22 although a theory proposed the expression of ace 2 (receptor for corona virus on the surface of host cell) in the brain, the exact mechanism of cns involvement in covid-19 is still unknown. 22 according to the mentioned significant role of humoral immunity in corona virus infection, treating pv patients with rituximab is potentially risky. given the fact, patients with pv who are treated with rituximab should be monitored closely, concurrent corticosteroids regimen should be tapered, and risk of taking rituximab must be weighed precisely, to minimize the risk of infections. 16, 23 analysis of outcome of patients with known autoimmune and auto-inflammatory diseases and having covid-19 showed that outcomes may differ because of the immunomodulatory therapeutic regimen. it suggested that patients treated with hydroxychloroquine, tnfα antagonists, 24 anakinra, 25 or tocilizumab, 26 27 or secukinumab seems to have the worst outcomes, according to the rate of intensive care unit (icu) admissions. 28 high amount of il-6, a strong factor related to mortality in covid-19 patients, is seen in patients given rituximab and secukinumab, that can be due to the failure of rituximab and secukinumab to modulate il-6. 28, 29 according to a report of patients with granulomatosis and polyangiitis presenting with severe covid-19 infection, shortly after taking rituximab, suggested the drug may not be as safe as usually considered. 30 monti et al proposed that rituximab should be considered with caution during the covid-19 pandemic. 31 also, guilpain et al reported three systemic sclerosis (ssc) patients treating with rituximab, which resulted to late clinical worsening to severe pneumonia due to the covid-19 infection. 32 while searching data about anti-cd 20 treatments in covid-19 pandemic era, we found some studies regarding the efficacy and harmlessness of anti-cd20 drugs for treating multiple sclerosis (ms) patients during covid-19. although prevalence of infections in ms patients treated with ocrelizuma, were slightly more common than the comparator arms, 33, 34 but the data indicates that anti-cd20 therapies are may be safe to initiate and re-dose in ms patients during the covid-19 period. 15 rituximab is a monoclonal antibody which irreversibly affect cd20-expressing b lymphocytes and remove them from blood circulation. it is the only us-fda approved agent for moderate to severe pemphigus. although it is a the first-line treatment for pv patients, 16 some concerns have been made due to the immunosuppression in the ongoing covid-19 pandemic. infectious events (ie) after treatment by rituximab can be extremely severe, particularly in patients immunocompromised by several drugs. 35 on the other hand, therapeutic regimen of pemphigus patients almost contains corticosteroid dose with other immunosuppressives (such as anti-cd20 agents). 6 . besides, cns is almost only protected by humoral immunity. there are evidences showing that cns can be involved by coronavirus. 23 based on the available literature, we believe that reconsideration must be applied for therapeutic principles of treatment of patients with pemphigus receiving rituximab, during the present pandemic. we propose that it is better to taper corticosteroids, and temporarily discontinue rituximab from the therapeutic regimen of patients with pemphigus, or reduction in the doses can be considered. we can consider intravenous immunoglobulin as a replacement for rituximab, which is beneficial for both pemphigus 36 and covid-19. 37 also we can use hydroxychloroquine instead of rituximab, which is used to treat elderly or pregnant pemphigus patients. 38 although anecdotal evidence in pemphigus and covid-19, plasmapheresis could also be considered. efficacy convalescent plasma in pemphigus is unknown. 20 overall, care should be taken while starting immunomodulatory drugs associated with a definitive risk of severe infection especially rituximab or some other nonbiologics such as tnf-alpha inhibitors. 39 emerging selective agents for example, a new oral bruton tyrosine kinase inhibitor which works via reversible covalent binding may offer some advantages for pemphigus. immunomodulatory effect of this agent is self-limited. access to this agent can be very useful, particularly in the present extraordinary circumstances. 20 additionally, ofatumumab a human monoclonal cd20 antibody has short duration of action than rituximab. despite early promise in pemphigus treatment, a phase 3 clinical trial was prematurely stopped because of changing priorities of the sponsor. tocilizumab, an antiinterleukin 6 humanized monoclonal antibody, proposed for treatment in inflammatory phase of covid-19 has anecdotally reported to be of use in pemphigus. 20 another approach is extended-interval dosing of rituximab, in cases we can-not cut off rituximab. anti-cd20 therapies used to treat pemphigus patients, including rituximab, are typically given every 4 weeks. the b-cell depletion effect usually lasts much beyond 6 months (the scheduled dosing interval). 40, 41 in the ongoing covid-19 pandemic, dosing at longer interval should be considered, particularly in b cell depleted patients at the time of the next scheduled dose or those with reduced level of serum igg. the mentioned approaches reduce hospital visits of patients, which has a great effect on reducing the exposure of patients to coronavirus. although, all of the above is suggested as a novel beneficial therapeutic principle for pemphigus patients in the covid-19 pandemic, the final decision should be made by the relating physician, taking into account the severity of the disease, side effects of the drugs, risk of continuing the previous treatments and the consequences of changing the patient's treatment regimen. although evidence for treating pv patients with rituximab in covid-19 pandemic is limited, and outcomes of ms patients taking rituximab was controversial, until sufficient evidence as a guideline for pemphigus and covid-19 treatment is available, we advocate caution commencing rituximab for pemphigus patients and adherence to basic principles of infection control and decreasing drug induced immunosuppression as possible. the authors declare no conflicts of interest. rituximab as first-line treatment of pemphigus pemphigus: current concepts desmosomes and extradesmosomal adhesive signaling contacts in pemphigus pemphigus, bullous impetigo, and the staphylococcal scalded-skin syndrome the adjuvant therapy of pemphigus: an update treatment of pemphigus vulgaris corticosteroids: a review with emphasis on complications of prolonged systemic therapy treatment of autoimmune mucocutaneous blistering diseases with intravenous immunoglobulin therapy consensus statement on the use of intravenous immunoglobulin therapy in the treatment of autoimmune mucocutaneous blistering diseases a systematic review of randomized controlled trials for pemphigus vulgaris and pemphigus foliaceus rituximab in autoimmune bullous diseases: mixed responses and adverse effects treatment of pemphigus vulgaris with rituximab and intravenous immune globulin efficacy of rituximab for pemphigus: a systematic review and meta-analysis of different regimens anti-cd20 immunosuppressive disease-modifying therapies and covid-19 first-line rituximab combined with short-term prednisone versus prednisone alone for the treatment of pemphigus (ritux 3): a prospective, multicentre, parallel-group, open-label randomised trial pemphigoid diseases expert recommendations for the management of autoimmune bullous diseases during the covid-19 pandemic treatment considerations for patients with pemphigus during the covid-19 pandemic protective humoral immunity in the central nervous system requires peripheral cd19-dependent germinal center formation following coronavirus encephalomyelitis evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms management of pemphigus in covid-19 pandemic era; a review article recovery from covid-19 in a patient with spondyloarthritis treated with tnf-alpha inhibitor etanercept anti-inflammatory therapy may ameliorate the clinical picture of covid-19 covid-19 in a patient with systemic sclerosis treated with tocilizumab for ssc-ild rituximab for granulomatosis with polyangiitis in the pandemic of covid-19: lessons from a case with severe pneumonia covid-19 in rheumatic disease patients on immunosuppressive agents autoinflammatory and autoimmune conditions at the crossroad of covid-19 efficacy, immunogenicity and safety of vaccination in adult patients with autoimmune inflammatory rheumatic diseases: a systematic literature review for the 2019 update of eular recommendations clinical course of covid-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies severe covid-19-associated pneumonia in 3 patients with systemic sclerosis treated with rituximab ocrelizumab versus placebo in primary progressive multiple sclerosis ocrelizumab versus interferon beta-1a in relapsing multiple sclerosis clinical and microbiological characteristics of the infections in patients treated with rituximab for autoimmune and/or malignant hematological disorders a randomized double-blind trial of intravenous immunoglobulin for pemphigus high-dose intravenous immunoglobulin as a therapeutic option for deteriorating patients with coronavirus disease 2019 pemphigus in elderly adults: clinical presentation, treatment, and prognosis covid-19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: an australian/new zealand consensus statement treating multiple sclerosis and neuromyelitis optica spectrum disorder during the covid-19 pandemic rituximab: a monoclonal antibody to cd20 used in the treatment of pemphigus vulgaris rituximab as the treatment of pemphigus vulgaris in the covid-19 pandemic era: a narrative review a.m.b. conceived and designed the study, wrote the draft; g.r.r. collected the data and wrote the draft. a.p. wrote and revised the draft; m.g. supervised the findings of this work, wrote and revised the draft. data sharing not applicable to this article as no datasets were generated or analysed during the current study. https://orcid.org/0000-0002-9455-4025mohamad goldust https://orcid.org/0000-0002-9615-1246 key: cord-338135-zwo7e7gy authors: melis, daniele; mugheddu, cristina; sanna, silvia; atzori, laura; rongioletti, franco title: clinical efficacy, speed of improvement and safety of apremilast for the treatment of adult psoriasis during covid‐19 pandemic date: 2020-05-30 journal: dermatol ther doi: 10.1111/dth.13722 sha: doc_id: 338135 cord_uid: zwo7e7gy time to improvement is a crucial characteristic for effective treatments of chronic inflammatory conditions, such as psoriasis. apremilast is a recently approved drug, belonging to the small molecule phosphodiesterase 4 inhibitors, whose optimal safety and efficacy profile is somewhat affected by slow activity rate in clinical trials. real world case series are suggesting a more consistent improvement, and with this additional personal investigation on 48 patients, we signal that 58% of patients achieved pasi50, and 19% pasi75 improvement in the first 8 weeks of treatment. results at 16‐week are remarkable, with overall 55% of patients achieving pasi 75, 21% pasi 90 and 14% pasi 100. only 8 patients (18, 6%) had slightly improved, although satisfied with the regimen, and determined to continue. noteworthy, our population was rather problematic in terms of comorbidities (86%), and resistance to other treatments, with only 28% naïve to systemics, including biologics. moreover, the observation period includes the italian outbreak of covid‐19 epidemic, and further information on apremilast safety are provided, no one of the patients having stopped treatment. in such a critical period, the apremilast satisfactory speed of therapeutic response in a real‐world setting has further strengthens patient’s compliance to remain safely at home, which is the best strategy to limit contagion. this article is protected by copyright. all rights reserved. dear editor: apremilast is an innovative small-molecule phosphodiesterase 4 inhibitor that has been approved for the treatment of moderate-to-severe plaque psoriasis in adult patients; it has a remarkable efficac y and safety profile and does not require particular screening or follow-up blood tests. 1 the main criticism seems to be its slower activity, in terms of the time required for improvement, with a low rate of psoriasis area and severity index (pasi) 75 achievement at week 16 in clinical trials: 33.1% of patients in esteem1 and 28% of patients in esteem2. 2, 3 however, in daily practice, the results were much more satisfactory from the first follow-up, even in very difficult patients. thus, a study was conducted in a real-world setting at the dermatology clinic of the university of cagliari to investigate the short-term clinical rate of response: at 8 and 16 weeks of treatment. the secondary endpoints were efficacy and safety for difficult-to-treat areas and challenging comorbidities. data collection was initiated in december 2019, and two months later, the novel coronavirus disease (covid-19) outbreak emerged, spreading across italy and raising concerns about the risk of contagion and severity of covid-19 in immunosuppressed patients. 4 thus, enhanced surveilla nce has been arranged in this cohort of patients, advising them to continue the treatment and contact the psoriasis service on noticing the occurrence of any symptoms. forty-eight patients were recruited after they provided informed consent to participate in the study, comprising 25 men and 23 women, with a mean age of 59 years (range, 20-82). each patient was administered apremilast (30 mg, twice a day) as monotherapy, after initial titration to minimize side effects. a wide range of different subtypes of psoriasis was included, with 56% of patients affected by difficult-to-treat conditions, including palmoplantar psoriasis, scalp psoriasis, and 3 suberythrodermic forms (table 1) . comorbidities with contraindications to other treatments were present in 86% of patients: hypertension and dysmetabolic syndrome, a history of malignancies (mammar y tumor, bladder cancer, or colorectal cancer), severe viral infections (human immunodeficiency virus, hepatitis c virus, hepatitis b virus), latent tuberculosis, psychiatric disorders, and advanced-stage liver disease. only 14 (29%) patients were naïve to systemic therapies, while several courses of traditional systemic treatment were used in 19 (39%) patients, and 11 patients (23%) were required to discontinue biologics because of cancer occurrence or hepatic impairment. four patients were treated with narrow-band ultraviolet b-rays without consistent improvement ( table 2) . at the 8-week follow-up (table 2) , the primary efficacy endpoint of consistent improveme nt, quantified as at least a 50% reduction (fig. 1) in baseline signs and symptoms (pasi 50), was achieved in 58.3% of patients (28/48), 9 of whom (18.7%) achieved pasi 75 (fig. 2) . four patients discontinued treatment because of the development of gastrointestinal adverse events (aes). the remaining 17 patients showed a less consistent improvement, although considering the absolute pasi, there was a mean reduction from 9.2 to 6.4, and patients were satisfied with the treatment. at the 16-week follow-up, 43 patients were assumed to be taking apremilast, and another patient had discontinued taking apremilast because of treatment failure. the improvement was remarkable, with an additional 6 patients achieving pasi 50. overall, 55% of patients achieved pasi 75, 21% achieved pasi 90, and 14% achieved pasi 100, with a mean absolute pasi score of 3.29 (table 2 ). only 8 patients (18.6%) showed slight improvements in symptoms, although they were satisfied with the regimen and were determined to continue. few real-world studies have investigated the profile of apremilast; [5] [6] [7] [8] [9] there have been no reports of efficacy after 8 weeks of treatment, which we valued as a pasi 50 achievement in 58% of patients and pasi 75 in 19%. outcomes at 16 weeks were comparable with those of previous case series, even with respect to aes and the rate of discontinuation. 9 notably, our population was problematic in terms of comorbidities (86%), and only 28% of the patients were naïve to systemic treatments, including biologics. overall, only 1 patient was considered a non-responder, and 8 patients experienced a less remarkable but progressive improvement. the latter might represent a subset of slow responders. the achievements of pasi 90 and pasi 100 were unexpected after only 4 months of treatment. the main limitation to apremilast adherence was the intensity of aes during the first weeks (41.6%), leading to discontinuation in 4 patients (8.3%), and reports of mild, bearable, and healed with treatment prosecution in the remaining 16 patients. as expected, diarrhea was the most frequent ae (28%), followed by abdominal discomfort, nausea, vomiting, and headache. unlike other reports, no weight loss or worsened psychiatric disease was observed. 5, 6 none of the patients developed symptoms requiring assessment for covid-19. during the observation period, the italian outpatients' services were required to suspend all visits because of the covid-19 pandemic outbreak in italy and the recommendation to prevent patient access to hospitals (decree of the president of the council of ministers, 03/09/2020). thus, an extraordinary effort was made to implement monitoring of and support for this cohort of patients by distance. regular telephone recalls were performed to assess whether patients had discontinued taking the drug or had contracted covid-19. we followed current experts' opinion 9 that apremilast is one of the safer options for moderate-to-severe psoriasis management due to its very specific, nonimmunosuppressive mechanism of action. recent experience in a covid-19 disease affected patient, who maintained apremilast treatment during the bilateral pneumonia course and recovered completely, confirms safety and compatibility with critical patient's management. 10 exacerbation of psoriasis might have occurred as a consequence of stress burden, with the covid-19 pandemic conferring severely limited wellness and opportunities to relieve anxiety and mood disorders through social activities. of course, covid-19, as well as certain medications currently used to control the disease, might exacerbate psoriasis, as recently reported. 12 in this very critical period, the satisfactory speed of the therapeutic response to apremilast in a realworld setting has further strengthened patient compliance to remain safe at home and led to patients eventually enduring the initial side effects, although further studies are warranted to explore this topic. accepted article apremilast (otezla): a new oral treatment for adults with psoriasis and psoriatic arthritis apremilast, an oral phosphodiesterase 4 (pde4) inhibitor, in patients with moderate to severe plaque psoriasis: results of a phase iii, randomized, controlled trial (efficacy and safety trial evaluating the effects of apremilast in psoriasis [esteem] 1) efficacy and safety of apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate-to-severe plaque psoriasis over 52 weeks: a phase iii, randomized controlled trial (esteem 2) novel coronavirus disease (covid-19) and biologic therapy in psoriasis: infection risk and patient counseling in uncertain times short-term reasons for withdrawal and adverse events associated with apremilast therapy for psoriasis in real-world practice compared to clinical trials: a multicenter retrospective study real-world experience with apremilast in treating psoriasis apremilast in psoriasis -a prospective real-world study real-world, single-centre experience of apremilast for the treatment of moderate to severe psoriasis real-world data on the efficacy and safety of apremilast in patients with moderate-to-severe plaque psoriasis covid-19 pulmonary infection in erythrodermic psoriatic patient with oligodendroglioma: safety and compatibility of apremilast with critical intensive care management a case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a patient with covid-19: will cases of psoriasis increase after covid-19 pandemic? key: cord-317323-wp3vh4c1 authors: kandhari, rajat; kohli, malavika; trasi, shrilata; vedamurthy, maya; chhabra, chiranjiv; shetty, kamlakar; dhawan, sachin; rajan, renita title: the changing paradigm of an aesthetic practice during the covid‐19 pandemic: an expert consensus date: 2020-10-28 journal: dermatol ther doi: 10.1111/dth.14382 sha: doc_id: 317323 cord_uid: wp3vh4c1 until vaccination for the sars‐cov‐2 becomes a reality, it appears that the infection is here to stay. with many countries lifting lockdown restrictions, aesthetic clinics have started reopening with strict standard operating procedures in place. it is pertinent that the physician today understands the infection, disinfection measures, and personal protective equipment to reduce chances of viral transmission and provide safe clinical settings for oneself, the staff and the patients. an online meeting of eight experts in the field of aesthetic dermatology was convened, which particularly focussed on ppe in detail, risk categorization of aesthetic procedures, preprocedure recommendations, and generalized and specialized sop's for aesthetic procedures. these recommendations were aimed to bridge the gap between published guidelines and clinical practice and are by no means fully conclusive, but signify learnings over the past few months in an active clinical aesthetic practice. the sars-cov-2 pandemic has changed the homeostasis of the medical world, affecting millions worldwide. amidst the global crisis, other than the health implications, there are major consequences on the world economy. 1 in light of this massive economic slowdown, many nations have ended their lockdowns, albeit on shaky ground. with reopening of services in many countries, dermatology and aesthetic clinics, which were staring at a bleak future, have started opening up with strict standard operating procedures (sop's) in place. in any pandemic, the need to feel good is inherent to a healthy mental-well-being, and wishing away the need for an aesthetic practice as "nonessential" may appear weak to some. while certain guidelines and expert consensus have recently been published [2] [3] [4] providing an overview of "safe" working protocols, it appears that we are evolving every day in our practices with respect to "what works" and "what does not." our article aims to bridge the gap between guidelines and in-clinic experiences to provide a set of best practices to follow for aesthetic procedures after reopening our practices. an invitation to participate in the consensus group meeting along with a formulated questionnaire was sent by email by one of the moderators (rk) to seven experts in the field of dermatology and aesthetics, having experience in the working and administration of single or multiple clinics, from different parts of india, in order to avoid a regional bias. the questionnaire focused on scope of the guidelines, the preparation before resuming practice, triaging/categorization patients, ppe and general sop's and specialized sop's for aesthetic procedures. (table s1 ) while analyzing the questionnaire, the response to general sop's (cleaning, sanitization etc.) and triaging achieved over a 75% concordance in response the final meeting focussed on ppe and specialized sop's for aesthetic procedures. an online meeting of the group members was held on 31 may 2020, using zoom online app. the virtual meeting was led by the moderators, via a prepared slide deck. further, the meeting was recorded for final analysis and simultaneous notes were taken. to encourage equal participation the moderators used an open questioning style, however, few of the questions were closed ended (yes/no) to arrive at a consensus. analysis of the detailed discussion was divided into the following sections to provide recommendations for optimal and safe "in clinic" functioning for the physician. seven out of the eight experts had reopened their clinics after overcoming initial apprehensions. all the participants agreed that they were functioning at limited capacity in terms of number of staff visiting the clinic, number of days and/or hours at work. those with more than one center started reopening with a single/flagship center and slowly imposed similar guidelines after 2 weeks of work in other centers. all participants agreed that a "dry run" prior to reopening is crucial for staff training and creating awareness and educating oneself and the staff, as the margin for error learning on the job would be minimal. moreover, constant updating of oneself and the staff resulted in smoother functioning and execution of new sop's. the experts agreed upon the fact that the patients have been understanding and appreciative of clinic efforts and responsive in terms of cooperating with protocols. all experts agreed to doing and encouraging tele consultation. while certain modes of viral transmission have been suggested, 5 in a statement issued by the who precautions have been laid out for droplet transmission, contact, and airborne precautions for aerosol generating procedures. 6 an aerosol is defined as a suspension of fine solid particles or liquid droplets in air or another gas, which maybe produced by either natural or anthropogenic phenomena. 7 the coronavirus has the potential to become "aerosolized" by certain procedures leading to a possible airborne transmission. the exact definition of "aerosol generating procedures" (agp's) in the theme of aesthetic procedures seems unclear with no clear evidence regarding the same. although, it is clear that an aerosol generating procedure increases the risk of viral transmission in healthcare workers (hcw) and should only be undertaken when necessary, this is primarily suggested for respiratory and surgical procedures generating aerosols. the different types of aerosol comprise: 1. respiratory aerosol: respiratory or upper airway secretions, containing a higher viral content and a greater risk of viral transmission. 2. surgical or nonrespiratory aerosol: aerosolisation of blood and tissue fluids leading to relatively lower risk of viral transmission. the who defines "droplets" as >5 μm in diameter and "airborne particles" as <5 μm in diameter. 8 droplet transmission is the result of larger particles, which have the tendency to settle on the ground and on nearby surfaces. this type of transmission occurs due to proximity of the hcw with the patient. in contrast, the occurrence of airborne transmission is due to smaller particles, which maybe suspended in the air for long periods and can infect people distant from the source (eg, agp's)ppe consists of protective apparel and/or equipment designed for providing protection against infectious agents to hcw's and their patients. the appropriate use of ppe is crucial, and the decision regarding the ppe to be used is based on the setting between the hcw and the patient, the procedure being carried out, the secretions produced. the panel recommendations for ppe are discussed below. globally, recommendations for protection of hcw's against covid-19 for nonaerosol-generating procedures (nonagp's) are conflicting. [9] [10] [11] [12] with the barrage of masks available, choosing the right one becomes crucial. the expert panels recommendation and the differing types of masks have been elaborated ( table 1 ). the panel felt that while the role of the staff and the type of procedure would be key factors defining the type of mask used, the space in the clinic would also be a defining factor, as certain clinics would be smaller wherein maintaining an "ideal social distance" (6 ft apart/2 arm's length) maybe a challenge. 13 in such scenarios, an n95 respirator maybe used by the support staff as well ( figure 1 ). use of n95 facial facepiece respirator (ffr) 1. all the experts unanimously agreed upon the use of n95 respirators for themselves, particularly when involved in non-agp's close contact procedures or agp's. 3. beard hair:it is recommended for one to be clean shaven, however, beard styles such as soul patch, side whiskers, pencil, toothbrush, lampshade, zorro, zappa, walrus, painter's brush, chevron, and handlebar maybe considered. 17 the recommendations are to make sure that the n95 ffris well fitted on face. 4. use of n95 ffr in sikhs: the religious beliefs in the sikh population, leads to an inability to trim or cut the beard hair leading to difficulty in achieving a tight fit of the respirator. in such cases, either a powered air-purifying respirators (papr) maybe used, which provides facial coverage despite the facial hair or any facial irregularity. 18 paprs are more expensive than n95 ffr's. else, the individual in question can make use of a "cotton cloth" or "thatha" around the beard and tie a knot on the top of the turban. this allows for coverage and a smooth surface over the facial hair for the respirator to sit on and achieve a tight fit. • use of paper bags: while only considered single use masks, all panel members agreed to reuse of their masks. a 5-mask set maybe used by each individual, along with four brown paper, breathable bags, which are marked 1 to 5. after use of first mask, it should be placed in the paper bag and allowed to dry for 4 days. it should be reused on day 6. the masks maybe used sequentially in such a manner and once all masks have been used five times, they should be discarded. use of a disposable, surgical three ply mask/face shield on top of the respirator will further prevent it's contamination. 19 this was being followed by three of the panelists and has been suggested as an additional safe practice. the physiological burden (heart rate, oxygen saturation, tidal volume, respiratory rate, etc.) of using a surgical mask over an n95 respirator has been a matter of concern and while using it for short durations appears to have no significant physiological burden, studies with usage over longer periods are suggested in order to consider this as a routine practice or recommendation in daily practice. 20 • uvc (254 nm) at the appropriate dosing 21 or vaporous hydrogen peroxide 22 if available can be used for decontamination of the n95 mask. • negative seal check: on inspiration face piece should collapse. • fogging: while minimal fogging of glasses is inevitable, due to water vapor released via the edge of the mask, it may suggest that the ffr may not be air tight. it is recommended to squeeze the metal frame on the upper edge of the mask in such cases and re-assess the fit of the mask. following strict hand hygiene along with use of nonpowdered, latex gloves are adequate for examination of patients and/or consultation room. the recommendations for hand hygiene include use of an alcohol-based hand sanitizer (60% ethanol or 70% isopropanol) or hand wash for at least 20s with soap and water. 25 • nitrile gloves are preferable over, latex gloves in the procedure rooms, as they are resistant to damage by chemicals or disinfectants, and are hypoallergenic. • housekeeping staff may use nitrile or rubber gloves which cover above the wrists. • while donning of gloves one must make sure the gloves extend to cover above the wrist of the isolation gown. a. face shield and goggles: • the panel agreed upon the use of a face shield as a routine measure in current circumstances, during all consultations and procedures as it not only provides protection to the mucosal surfaces but also prevents inadvertent touch to the face, eyes, nose or mouth with a contaminated hand. • face shield and/or goggles are a must in agp's. • use of face shield/goggles may result in fogging at times due to expired air escaping from the mask, in such circumstances one may reassess the fit of the mask or seek the use of well fitted antifogging goggles ( figure 5 ). 26 b. coverall or gowns • disposable, below knee, spunbondmeltblownspunbond (sms) material, breathable gowns are adequate for consulting and examination. an autoclavable, below knee, surgical cloth gown for routine consultations was suggested by three of the experts, however, the panel did not arrive at a consensus for this. practice. if a coverall is used, one coverall should be used per patient and these maybe reserved for agp's. one may use a 60-70 gsm, coverall, as extrapolated from data during the ebola outbreak. • a plastic apron maybe used over the gown, in procedures involving body fluid splatter or splash. • the panel agreed upon the use of head caps during "close contact" procedures and these should be worn by the patient and the doctor/therapist. if wearing a coverall, that itself would provide head coverage, else a surgical head cap should be used. • experts felt that that if regular cleaning and sanitation of the premises is being carried out, the use of shoe covers is not mandatory. • if shoe covers are used they should be made ideally be impermeable, for example, plastic • one of the experts on the panel suggested the use of washable rubber slippers for patients and staff in place of shoe covers. • the common principles regarding use of ppe, including hand hygiene prior donning and during doffing of ppe, protocols of donning/doffing and correct disposal should be repeatedly discussed with the clinic staff. • a room with a mirror is ideal for donning and doffing of ppe.developing a "buddy system" may help, that is, a team member who may observe the donning and doffing process. 28 and/or use of zinc ointment before donning and after doffing the ppe. 31 4. make sure the ffr is "well fit" and not "overtight". the lips touching the front of the mask is suggestive of a tight fit and can become uncomfortable for the user. a mix of "natural" and "mechanical ventilation" is ideal for a clinical premises, which allows the air to flow from areas where there is a suspected source, towards the areas free of susceptible individuals. the use of laser and ebd's, requiring contact of the skin with the laser tip, particularly need to be handled with caution. the cases for laser procedures maybe divided into low, medium or high risk (table 4 ). further, certain points regarding the procedures maybe taken into consideration. certain laser systems, (ablative co2, erbium yag) lead to "plume" the panel categorized the risk involved with injectable procedures in the following manner: (table 5) a. low risk: the mask of the patient can remain on. b. medium risk: the mask of the patient is off. c. high risk: the mask of the patient is off and the procedure involves the oral or nasal mucosa. certain procedures for example, periorbital enhancement even though carried out on the upper face, are often done with cannulas and ideally require the mask be off, so that the injector can carry out the procedure comfortably and look out for vascular events. further, a tight fitting mask during and postprocedure may lead to external compression and/or make evaluation of a unexpected vascular event challenging. the risk categorization for chemical peels is below: • low risk: body peels, spot peels on face with mask, peels for nails and periorbital area. • low risk: prp therapy for scalp and body areas, mesotherapy for scalp and body (stretch marks) • moderate risk: prp and mesotherapy for face numerous other procedures carried out in an aesthetic clinic have been categorized below (table 6 ). the above recommendations do not necessarily signify a "cook book" approach but are learnings over the past few months in an active clinical aesthetic practice during the ongoing pandemic. while one must adapt fast to the "new norms", the real challenge would lie in the strength of the practitioner to balance one's own and our staffs mental health, to attain equilibrium of financial setbacks with concerns over self, staff, and patient safety, and to conduct practices in a just manner. the well-known adage to "lead as an example" is the best reinforcer of safe practices and general wellbeing. the authors declare no conflict of interest. covid-19 and economy covid-19 pandemic: consensus guidelines for preferred practices in an aesthetic clinic safety guidelines for non-surgical facial procedures during covid-19 outbreak lasers use in dermatology practice in the evolving covid-19 scenario: recommendations by sig lasers (iadvl academy) coronavirus disease (covid-19): an updated review based on current knowledge and existing literature for dermatologists world health organization. modes of transmission of virus causing covid-19: implications for ipc precaution recommendations: scientific brief nosocomial transmission of emerging viruses via aerosol-generating medical procedures infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings european centre for disease prevention and control. guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed covid-19 rational use of personal protective equipment for coronavirus disease 2019 (covid-19) coronavirus disease (covid-19): for health professionals aerosol filtration efficiency of common fabrics used in respiratory cloth masks hair care during covid-19: practical tips for health care workers to papr or not to papr? can effect of surgical masks worn concurrently over n95 filtering facepiece respirators: extended service life versus increased user burden surgical mask placement over n95 filtering facepiece respirators: physiological effects on healthcare workers decontaminating n95 masks with ultraviolet germicidal irradiation (uvgi) does not impair mask efficacy and safety: a systematic review extended use or reuse of n95 respirators during covid-19 pandemic: an overview of national regulatory authority recommendations respiratory performance offered by n95 respirators and surgical masks: human subject evaluation with nacl aerosol representing bacterial and viral particle size range hand hygiene recommendations. guidance for healthcare providers about hand hygiene and covid-19 personal protective equipment (ppe) and its use in covid-19: important facts aerodynamic characteristics and rna concentration of sars-cov-2 aerosol in wuhan hospitals during covid-19 outbreak skin damage among health care workers managing coronavirus disease-2019 reply to: skin damage among healthcare workers managing coronavirus disease-2019 wearing the n95 mask with a plastic handle reduces pressure injury natural ventilation for infection control in health-care settings. geneva: world health organization possible aerosol transmission of covid-19 and special precautions in dentistry health technical memorandum 03-01: specialised ventilation for healthcare premises. part a -design and installation. estates and facilities division. london: the stationery office covid-19: infection prevention and control guidance personal protective equipment during the coronavirus disease (covid) 2019 pandemic: a narrative review the use of povidone iodine nasal spray and mouthwash during the current covid-19 pandemic may reduce cross infection and protect healthcare workers microbiologic activity in laser resurfacing plume and debris human immunodeficiency virus-1 (hiv-1) in the vapors of surgical power instruments risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts safe management of surgical smoke in the age of covid-19 aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 coronavirus disease 2019: coronaviruses and blood safety covid-19: new insights on a rapidly changing epidemic the changing paradigm of an aesthetic practice during the covid-19 pandemic: an expert consensus key: cord-323082-p0km31by authors: jakhar, deepak; kaur, ishmeet title: callous attitude toward doctors during covid‐19 date: 2020-07-07 journal: dermatol ther doi: 10.1111/dth.13885 sha: doc_id: 323082 cord_uid: p0km31by nan the government condemns and issues several notices to stop such acts, but in the absence of a strict law these attacks do not seem to be stopping. more importantly, it is for the general population to understand that doctors do their best, even risk their lives, to deliver the health care services. hope the day arrives! the authors declare no potential conflict of interest. death from covid-19 of 23 health care workers in china more than 60 doctors in italy have died in covid-19 pandemic coronaphobia: covid-19 warriors live in torment doctor assaulted over death of covid-19 patient coronavirus: india doctors 'spat at and attacked indian doctors have an unexpected problem while battling coronavirus chennai: family of doctor who died due to covid-19 not allowed to bury him key: cord-348846-mfhxac5c authors: coletto, lavinia agra; favalli, ennio giulio; caporali, roberto title: psoriasis and psoriatic arthritis: how to manage immunosuppressants in covid‐19 days date: 2020-05-02 journal: dermatol ther doi: 10.1111/dth.13415 sha: doc_id: 348846 cord_uid: mfhxac5c nan disease flare implies systemic inflammation and immunological disruption, two recognized factors responsible for increasing susceptibility to infection in systemic polyarthritis. 3 furthermore, an active disease entails the need of a medical reassessment, which is best to be avoided at this time, given the higher risk of contagion due to moving around and being in the hospital. diabetes and metabolic syndrome are acknowledged as associated with psa and psoriasis 4 ; these comorbidities in the setting of a poorly controlled disease may worsen due to inflammation itself. in conclusion, before interrupting a chronic therapy, even if patients with psa have an increased risk of comorbidities and serious infections compared with patients with psoriasis, 7 we suggest evaluating not only the infectious profile of immunosuppressants but also the underlying inflammatory nature of psoriatic disease itself, especially if severe and/or associated with articular involvement. covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action risk of serious infection with biologic and systemic treatment of psoriasis: results from the psoriasis longitudinal assessment and registry (psolar) the risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment. rheumatology (oxford) diabetes incidence in psoriatic arthritis, psoriasis and rheumatoid arthritis: a uk populationbased cohort study. rheumatology (oxford) clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet chinese clinical trial registry. a multicenter, randomized controlled trial for the efficacy and safety of tocilizumab in the treatment of new coronavirus pneumonia (covid-19) the incidence and predictors of infection in psoriasis and psoriatic arthritis: results from longitudinal observational cohorts key: cord-315166-ga6e3lqp authors: isoletta, eugenio; vassallo, camilla; brazzelli, valeria; giorgini, chiara; tomasini, carlo francesco; sabena, anna; perlini, stefano; de silvestri, annalisa; barruscotti, stefania title: emergency accesses in dermatology department during the covid‐19 pandemic in a referral third level center in the north of italy date: 2020-07-18 journal: dermatol ther doi: 10.1111/dth.14027 sha: doc_id: 315166 cord_uid: ga6e3lqp during the lockdown period most planned visits have been postponed and the number of accesses to emergency department (ed) has dramatically reduced. the aim of our study is to analyze the impact of the lockdown on the number, type and severity of dermatological ed diagnosis. we performed a retrospective review of all dermatological consultations in the ed of ircss san matteo during the lockdown period in italy (february 22nd ‐ may third 2020) and compared them with those from the same period in 2019. we noticed a sharply reduction in the number of dermatological consultations requested in the ed: from 164 patients in 2019 to 33 in 2020. some diagnostic categories showed a significant difference with a higher incidence of vasculopathic lesions (0.6% vs 12.1%, p < 0.0001), urticarial rashes (8.5% vs 21.2%, p = 0.03) and scabies (3% vs 12.1%, p = 0.023). we observed an increase in the proportion of patients starting medications, before coming to the ed 26.2% in 2019 vs 66.7% in 2020 (p < 0.001). furthermore, we noticed a significant increase in the average complexity of cases presenting to the ed in 2020, as proven by the increased need for biopsies and systemic therapy. this article is protected by copyright. all rights reserved. the severe acute respiratory syndrome coronavirus (sars-cov-2) has put emergency services under heavy strain all over the world and in particular in the north of italy. since february 21 st , 2020, when the first case in italy was confirmed, an overwhelming number of sars-cov-2 infections were detected and hospital organizations have adapted to cope with the emergency, 1,2 . fondazione irccs policlinico san matteo, pavia, a tertiary center and teaching hospital in northern italy, became a national sars-cov-2 referral center. it was one of the first institutions to enact separate routes for suspected sars-cov-2 patients referring to the emergency department (ed) in order to isolate them from other patients, minimizing the risk of contamination of the general ed 3 . from february 22 nd to may 3 rd , accesses to the ed have dramatically reduced, also for dermatological consultations [4] [5] [6] . the aim of our paper was to analyze how the lockdown period has changed dermatological accesses to the ed and analyze the differences in dermatological consultations at ed between february 22 nd to may 3 rd , 2020 and the same period in 2019. this article is protected by copyright. all rights reserved. we performed a retrospective review of all dermatological consultations in the ed of ircss san matteo between february 22 nd (date of the first proven autochthonous covid-19 case) and may 3 rd (date of the end of the "phase 1" of the lockdown). we compared these data with those from the same period in 2019. we extracted data from medical records of all patients admitted to the ed for dermatological consultation and stored them in a database; the data was then entered in an excel spreadsheet (microsoft corporation, seattle, wa, usa). we collected demographic data and data regarding clinical diagnosis, prescription of topical or systemic therapy, need to execute a biopsy, scheduling of a follow-up visit, and administration of any kind of therapy before the consultation. diagnosis was considered definitive if clinically determined without a differential diagnosis or if confirmed by biopsy or other exams. to handle data more efficiently, all diagnoses were classified into 16 groups (table 1) . our aim was to evaluate the impact of the ongoing pandemic on the number of dermatological ed consultation, on the severity of cases presented to the ed with cutaneous symptoms, and on the diagnoses at discharge. the median number of urgent consultations per week was compared between 2019 and 2020 using mann-whitney test. all other data related to clinical presentation and management in the ed were compared between 2019 and 2020 with chi square test. we collected 197 patients who required a dermatological consultation: 164 patients from february 22 nd to may 3 rd 2019, 33 in the same period in 2020. median number per week was 13 in 2019 and 2.5 in 2020 (p=0.002). in 2019, 78 (47.6%) were females, and 86 (52.4%) were males. in 2020, 12 (36.4%) were females, and 21 (63.6%) were males (p=0.24). the average age was 44.7 ± 23.7 years in the 2019 cohort, and 44.5 ± 25.7 years in the 2020 cohort. the relative frequency of the diagnoses on the whole was significantly different in the two cohorts (p < 0.003). in the 2019 cohort, the most frequent consultation causes were eczema and dermatitis (n=27, 16.5%) and acute infections (n=25, 15.2%). in the 2020 cohort, urticarial rashes were the most common cause of presentation (n=7, 21.2%), followed by acute eczema and infectious diseases (n=5 for both, 15.2% each). the difference in relative frequencies of diagnoses between the two cohorts was statistically significant for urticarial manifestations (8.5% in 2019 and 21.2% in 2020) (p=0.03), for scabies (3% in 2019 and 12.1% in 2020) (p=0.023) and for vasculopathic lesions (0.6% in 2019, 12.1% in 2020) (p<0.0001) ( table 1) . this article is protected by copyright. all rights reserved. in 2020, 22 (66.7%) patients had already started a therapy before the access in ed, either selfadministrated or prescribed by the family doctor. in 2019 the majority of patients (121, 73.8%) came without a previous therapeutic approach (p<0.001). concerning the prescription of drugs as a result of the consultation, topical therapy was prescribed in 136/164 (82.9%) patients in 2019, and in 30/33 (90.9%) patients in 2020 (p=0.251). systemic therapy was prescribed in 111/164 (67.7%) patients in 2019, and in 28/33 (84.8%) patients in 2020 (p<0.05). after the consultation, a follow-up visit was scheduled in 68/164 cases (41.5%) in 2019, and 17/33 cases (51.5%) in 2020 (p=0.287). a biopsy was deemed necessary in 6/164 (3.7%) patients in 2019 and 5/33 (15.1%) patients in 2020 (p<0.01). the first finding emerging from our data was a dramatic reduction in the request for dermatological ed consultations during the covid pandemic comparing to the same period in 2019, from 164 patients to 33, with an absolute difference of -79.9 percentage points ( table 1 ). this result is consistent with the experience of other medical specialties in different centers [4] [5] [6] [7] [8] and it probably reflects the fear of both being infected in the hospital environment and of violating lockdown restrictions. the data showed an increase in the proportion of patients starting medications before coming to the ed. this result confirmed our hypothesis that patients were delaying non-critical care. we noticed a rise in the frequency of biopsy requests (p<0.01) and in the prescription of systemic therapy (p>0.05) as a result of the consultation. this suggested an increased average complexity in the cases presenting to the ed for a skin condition in 2020 compared to the control year. in 2019, the most common skin diseases were eczematous disorders (n=27, 16.5%), infectious diseases (n=25, 15.2%) and physical and chemical injuries to the skin (n=22, 13.4%), confirming the findings from similar studies in the past 9, 10 . in 2020, all these categories were less frequent. a few diagnostic categories showed significant difference in terms of incidence: scabies (3% vs 12.1%, p=0.023), urticarial rashes (8.5% vs 21.2%, p=0.03), and vasculopathic lesions (0.6% vs 12.1%, p<0.0001). for scabies it is reasonable to believe that spending prolonged periods of time in close proximity with relatives might have increased the risk of contracting the infection. regarding the other two diagnostic categories, both cutaneous reactions have been described to correlate with the ongoing pandemic in the most recent literature [11] [12] [13] . a limitation of this study is the small sample size for the current year; nevertheless, it reflects the reality of the recent period and it is an interesting finding by itself, despite the fact that it limits the statistical power of our analysis. another limitation lies in the unavailability of serological testing for covid-19 in patients presenting an atypical rash or acroischemia due to protocol restrictions on serological procedures. in conclusion, our analysis showed that the coronavirus epidemic sharply reduced the number of dermatological consultations requested in the ed. however, the complexity of cases was higher, as proven by the increased need for biopsies and systemic therapy. this may highlight how often, in normal times, the ed is used for deferable pathologies. we don't exclude that the reduction in consultations in the current period may lead to a possibly higher number of requests for dermatological visits after the lockdown, to a higher delay in diagnosis and a possible increase in morbidity and mortality 14 . finally, the types of cutaneous disorders diagnosed in the ed was different, with a higher relative frequency of scabies, urticarial rashes and vasculopathic lesions. hospital emergency management plan during the covid-19 epidemic containing covid-19 in the emergency room: the role of improved case detection and segregation of suspect cases covid-19 irccs san matteo pavia task force. rapid response to covid-19 outbreak in northern italy: how to convert a classic infectious disease ward into a covid-19 response centre decline of acute coronary syndrome admissions in austria since the outbreak of covid-19: the pandemic response causes cardiac collateral damage reduced rate of hospital admissions for acs during covid-19 outbreak in northern italy online ahead of print which are the "emergent" dermatologic practices during covid-19 pandemic? the fear of covid-19 infection is the main cause of the new diagnoses of hand eczema: report from the frontline in milan dermatological conditions presenting at the emergency department in siena university hospital from emergency consultations in dermatology in a secondary referral hospital in southern switzerland: a prospective cross-sectional analysis urticarial eruption in covid-19 infection vascular skin symptoms in covid-19: a french observational study cutaneous signs in covid-19 patients: a review. dermatol ther. 2020 m ay 10 online ahead of print collateral damage of covid-19 pandemic: delayed medical care key: cord-338754-xdid58vn authors: olisova, o. yu; anpilogova, e.m.; shnakhova, l.m. title: cutaneous manifestations in covid‐19: a skin rash in a child date: 2020-05-30 journal: dermatol ther doi: 10.1111/dth.13712 sha: doc_id: 338754 cord_uid: xdid58vn nan symptoms in children are fever, dry cough, fatigue, sometimes respiratory or gastrointestina l symptoms 3 . dr recalcati made the first report on cutaneous manifestations in covid-19 nearly a month ago 4 , and since then, several authors have also noticed covid-19-associated skin rash in adults [5] [6] [7] [8] [9] . according to them, skin symptoms may include erythematous rash, localized or widespread urticaria, chicken-pox-like lesions, vascular lesions and dengue-like rash. the trunk and the limbs are reported to be the most commonly involved sites. however, the data on covid-19-associated skin disorders in children are scarce. we observed that a 12-year-old girl who was confined to her home in moscow due to covid-19 self-isolation in mid-april had a fever of 38.2°c for 2 consecutive days. no clinical symptoms of any bacterial or viral infection were noted except for fatigue and headache. on the second day of fever the pcr covid-19 test was positive. the general blood test was normal except for elevated c-reactive protein level and erythrocyte sedimentation rate. chest ct scan revealed no pulmona r y changes. the patient was most likely infected by her covid-positive mother, who is a nurse looking after many covid-19 patients. the treatment was unspecific and consisted of paracetamol. on the third day of illness the fever dramatically ceased and the skin rash appeared. on examination we noted purpuric eruptions and erythematous macula rashes of 3 to 4 mm size mainly on the upper eyelids, above the eyebrows and in temporal region (figure 1 ). besides that, her tongue was slightly swollen and irritated with pronounced lingual papillae ( figure 2 ). the described eruptions were asymptomatic and completely disappeared within three days without treatment. our observation confirms the idea that the covid-19 infectious syndrome not infrequent l y includes different types of skin rashes and as seen in this first description with a rare involveme nt of the oral mucous membranes. along with fever and fatigue, these eruptions may be considered as the only clinical manifestation of these particular covid-19 infections in children. this could be due to cd8 hyperexpression, which participates in antiviral immunity 10 . we think it is important to monitor the skin not only in adults but also in children who can transmit this virus asymptomatically. in the case of any skin alterations we would strongly recommend that a nasopharyngeal and oropharyngeal swab is performed to confirm the possible covid-19 diagnosis and in this way break the chain of transmission immediately. this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. novel coronavirus: where we are and what we know updated diagnosis, treatment and prevention of covid-19 in children: experts' consensus statement (condensed version of the second edition) cutaneous manifestations in covid-19: a first perspective cutaneous manifestations in covid-19: lessons learned from current evidence cutaneous manifestations in covid-19: the experiences of barcelona and rome acute urticaria with pyrexia as the first manifestations of a covid-19 infection covid-19 can present with a rash and be mistaken for dengue cutaneous signs in covid-19 patients: a review the patients in this manuscript have given written informed consent to the publication of their case details. key: cord-320862-ua69gcxv authors: giacalone, serena; bortoluzzi, paolo; nazzaro, gianluca title: the fear of covid‐19 infection is the main cause of the new diagnoses of hand eczema: report from the frontline in milan date: 2020-05-20 journal: dermatol ther doi: 10.1111/dth.13630 sha: doc_id: 320862 cord_uid: ua69gcxv nan the center for disease control and prevention (cdc) asserted that hand washing and surface decontamination are primary measures to reduce covid-19 propagation [1] . in parallel, recent studies revealed an increased incidence of hand eczema (he) in health care workers [2] , as well as among general population [3] . during the period corresponding to italian lockdown, from march 9 to may 4 2020, 24 cases of new he were detected (the equivalence of 11.8% -24/203-of all urgent and deferred consultations provided by our dermatologic unit) [4] . women exceed male (17 vs 7) and the median age was 51 (range 16-63). the diagnosis was made on history and clinical observation: irritant contact dermatitis (icd) prevailed on allergic contact dermatitis (acd), that was suspected in 5 people. about 13 patients (54.1%) complained occasionally itching. none of the patients was a health care worker. detailed anamnesis revealed that all of them washed hands more than 10 times a day and used often alcohol gel sanitizing. we asked patients to describe their hygiene routine and emerged some repetitive and obsessive actions not required by proper procedures. for example, more than one reported to use gel sanitizing after hand washing with soap. others believed that hot water or harsh soap are strategies more effective for virus inactivation. more than two-thirds used cleaners without gloves. moreover, 15 patients (62.5%) asserted during the visit to be particularly anxious about possible contagious of relatives. in regard of suspicious cases of acd we reported some common aspects: fragrance and/or quaternary ammonium-presenting sanitizers, long term or additional layers latex gloves used. this group of patients is waiting to perform patch tests. fourteen patients received 1-week treatment with 0.1% betamethasone plus 2% fusidic acid bid. the remaining ten patients were suggested two or three daily applications of reparative hand cream this article is protected by copyright. all rights reserved. mainly composed by shea butter, stearic acid, ceramide 3 and cholesterol. after three weeks, most of them showed an improvement. above all, we focused our attention on giving information about rational of hand hygiene and preventing clinical relapses with daily application of moisturisers in association with barrier creams [5] . on may 4, a new government decree came into force replacing the strict lockdown rules and giving people back more liberties. our dermatological unit hypothesizes a rising incidence of cutaneous adverse effect related to hygiene measures. because it has been demonstrated that a damaged skin barrier could be a gateway for covid-19 [6] , to preserve a high compliance in cdc actions recommended for the prevention of person-to-person viral transmission, dermatologist have the role to educate people to maintain "healthy hands". this article is protected by copyright. all rights reserved. coronavirus disease 2019 how to protect yourself & others skin damage among healthcare workers managing coronavirus disease-2019 overzealous hand hygiene during covid 19 pandemic causing increased incidence of hand eczema among general population what is the role of a dermatologist in the battle against covid-19? the experience from a hospital on the frontline in milan interventions for preventing occupational irritant hand dermatitis tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis legend fig 1. hand eczema in 16 years old women before (a) and after (b) two weeks of hand cream application twice daily and interruption of excessive washing key: cord-348430-8xk4dt7t authors: bragazzi, nicola luigi; riccò, matteo; pacifico, alessia; malagoli, piergiorgio; kridin, khalaf; pigatto, paolo; damiani, giovanni title: covid‐19 knowledge prevents biologics discontinuation: data from an italian multicenter survey during red‐zone declaration date: 2020-05-28 journal: dermatol ther doi: 10.1111/dth.13508 sha: doc_id: 348430 cord_uid: 8xk4dt7t sars‐cov‐2 become pandemics and there is still a dearth of data about its the potentially among dermatological patients under biologics. we aimed to assess health literacy, disease knowledge, treatment dissatisfaction and biologics attitudes toward covid‐19. we performed a cross‐sectional, questionnaire‐based survey on 98/105 consecutive dermatological patients treated with biologics—51 suffering from plaque psoriasis, 22 from atopic dermatitis, and 25 from hidradenitis suppurativa. an ad hoc, validated questionnaire has 44 items investigating the following domains: knowledge of covid‐19 related to (a) epidemiology, (b) pathogenesis, (c) clinical symptoms, (d) preventive measures, and (e) attitudes. patients data and questionnaires were collected. despite only 8.1% thought that biologics may increase the risk of covid‐19, 18.4% and 21.4% of the patients were evaluating the possibility to discontinue or modify the dosage of the current biologic therapy, respectively. globally, male patients (p = .001) with higher scholarity level (p = .005) displayed higher knowledge of covid‐19. patients with lower dlqi (p = .006), longer disease duration (p = .051) and lower scholarity (p = .007) have thought to discontinue/modify autonomously their biologic therapy. at the multivariate logistic regression, only the knowledge of epidemiology and preventive measures resulted independent predictors of continuation vs discontinuation and modification vs no modification, respectively. dermatologists should promote covid‐19 knowledge to prevent biologics disruption. covid-19 pandemic has forced everyone to use personal protective equipment (ppe), such as goggles, n95 masks, double-layers gloves, and face-shields, and to follow methodically sanitization protocols. 2 hence, health care workers due to too scrupulous and continuous hand-washing and use of preventive measures and protective equipment could develop hand eczema and related skin disorders. 4 lan and colleagues recruited a sample of 542 health care and in 97% of them they found a dermatological disorder related to the personal protective equipment (ppe) and to the preventive measures, mainly affecting the nasal bridge, the hands, the cheeks and the forehead, with dryness and desquamation being the most commonly reported symptoms/signs. 5 however, mainly occupational aspects have been investigated so far. to the best of our knowledge, there is a dearth of data concerning the covid-19 perceptions of dermatological patients under biologics, a therapy traditionally associated to an increased risk of infections. [6] [7] [8] [9] this aspect is of particular interest since it may affect the patients' compliance leading to treatment discontinuation or autonomous modifications. 10 although biologics have revolutionized the management of chronic dermatological disorders, their interplay between disease, disease activity, and its pharmacological treatment is complex and multifaceted, and sometimes drug-related side effects may occur (ie, airway infections). side effects are also capable to detriment dermatologist-patients relationship leading to a decreased compliance. 11 furthermore, also inside the dermatological field the attitude towards biologics are discordant 12, 13 due to the dearth of available data. in these historical and scientific context of uncertainty, in which hospitals are overwhelmed by covid-19 emergency and at the same time are struggled also by the normal routine (acute patients and chronic ones), we decided to perform a study to assess how covid-19 impacts patients under biologics to optimize our daily approach. the protocol study of the present investigation was in-depth reviewed, respected the ethical principles of seventh helsinki declaration and received full ethical clearance by the involved institutions. all patients signed a written consent form. this cross-sectional, questionnaire-based survey was performed in sidemast.org/blog/coronavirus). patients scheduled for these days were consecutively enrolled if they met the eligible criteria. patients were enrolled in the present study if meeting the following inclusion criteria: (a) aged ≥18 years, (b) diagnosis of plaque psoriasis, atopic dermatitis or hidradenitis suppurativa performed by two independent board-certified dermatologists lasting more than 5 years ago, (c) with a severity. • in psoriatic patients: psoriasis area severity index (pasi) 14 ≥10 and or disease activity index for psoriatic arthritis" (dapsa) 15 remarkably, in these departments patients undergoing a biological therapy were affecting only by psoriasis (pso), or atopic dermatitis (ad) or hidradenitis suppurativa (hs). after verifying medical history and demographics already recorded in the database, two board-certified, independent dermatologists clinically assessed the enrolled patients collecting the appropriate severity scores in compliance with the italian guidelines. [19] [20] [21] [22] [23] ad patients were evaluated using dermatologic quality of life score (dlqi) 23, 24 and eczema area and severity index (easi). pso patients were evaluated using dlqi, pasi and dapsa (if psoriatic arthritis was co-diagnosed), whilst hs patients underwent dlqi, hurley score, ihs4 and autoinflammatory disease damage index (addi). 25 before commencing any statistical analyses, data were visually inspected for capturing potential outliers. descriptive statistics was performed, by expressing values as means ± sds. scores were also assessed in terms of kurtosis and skewness. regression analyses were carried out to shed light on the determinants of the knowledge score. scores for each domain and for the overall questionnaire are reported in table 2 . noteworthy, no differences among the disease groups remarkably, 28 (28.6%) patients perceived that their chronic dermatological disease expose them to a moderate-to-severe risk to contract sars-cov2, whereas 17.3% and 54.1% regard it as low or null. despite only 8.1% thought that biologics expose them to a moderate to severe risk to contract sars-cov2, 18.4% and 21.4% of the whole patients declared that they have assessed the possibility to discontinue or modify the dosage of the current biologic therapy, respectively. at the multivariate regression analysis, knowledge regarding the virus epidemiology was found to correlate with male gender (coefficient globally male patients (coefficient regression 6.97, p = .0003) with higher scholarity level (coefficient regression 2.57, p = .0049) displayed higher knowledge of covid-19. further details are reported in table 3 . table 4 . (table 5 ). during covid-19 pandemics 40% of dermatological patients under biologics have thought to autonomously modify or even discontinue their therapy. sars-cov2 displayed a special tropism for respiratory epithelium, thus it may cause respiratory symptoms of different severity spacing from mild cough to death in 7.2% of the cases in italy. 27, 28 since covid-19 pathogenesis involved mainly respiratory airways, patients with respiratory comorbidities might have higher risk, but at the moment no data are present to confirm it. 29 in literature, both psoriasis, atopic dermatitis and hidradenitis suppurativa displayed an higher risk of respiratory comorbidities; in accord with this evidence 30% of the interviewed patients thought that their dermatological disease could increase the sars-cov2 infection risk. psoriatic patients displayed a baseline airway inflammation, 30, 31 that may lead to the epidemiologically proven increased risk of asthma, and chronic obstructive pulmonary disease (copd). 32 ad theory of "atopic march" gives the pathogenetic rationale to the increased asthma risk found in atopic patients. 33 however, the present study is not without any limitation. the major shortcoming is represented by the relatively small sample size employed. furthermore, the knowledge was limited to pre-pandemic period. it would be interesting to evaluate knowledge of dermatological patients undergoing biologics also in postpandemic period. the knowledge of covid-19 has a paramount importance in dermatological patients undergoing biologics and dermatologists should promote it. therapy continuation during covid-19 emergency seems to strictly depend on the quality of information that patients acquire. discontinuing or modifying biologic therapy expose patients to the risk of losing response to a drug previously useful. t a b l e 5 multivariate logistic regression analyses shedding light on the determinants of continuation vs discontinuation and modification vs no modification of biologic therapies in the considered sample of dermatological patients the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak the sars-cov-2 outbreak: what we know phototherapeutic approach to dermatological patients during the 2019 coronavirus pandemic: real-life data from the italian red zone occupational skin disease among healthcare workers during the coronavirus (covid-19) epidemic skin damage and the risk of infection among healthcare workers managing coronavirus disease-2019 biologics increase the risk of sars-cov-2 infection and hospitalization, but not icu admission and death: real-life data from a large cohort during red-zone declaration comparative risk of serious infections among real-world users of biologics for psoriasis or psoriatic arthritis conversion to positive latent tuberculosis infection status is low in hidradenitis suppurativa patients taking biologic medications efficacy and safety of dupilumab monotherapy in adults with moderate-to-severe atopic dermatitis: a pooled analysis of two phase 3 randomized trials (liberty ad solo 1 and liberty ad solo 2) medication adherence: who cares? female patients are less satisfied with biological treatment for psoriasis and experience more side-effects than male patients: results from the prospective biocapture registry covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action should biologics for psoriasis be interrupted in the era of covid-19? severe psoriasis-oral therapy with a new retinoid evaluation of the appropriateness of composite disease activity measures for assessment of psoriatic arthritis the eczema area and severity index (easi): assessment of reliability in atopic dermatitis axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa and familial benign pemphigus. surgical approach development and validation of the international hidradenitis suppurativa severity score system (ihs4), a novel dynamic scoring system to assess hs severity italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis italian guidelines for therapy of atopic dermatitis-adapted from consensus-based european guidelines for treatment of atopic eczema (atopic dermatitis) hidradenitis suppurativa: guidelines of the italian society of dermatology and venereology (sidemast) for the use of anti-tnf-α agents italian guidelines in patch testingadapted from the european society of contact dermatitis (escd) validation of a visual-aided questionnaire for the self-assessment of hidradenitits suppurativa dermatology life quality index (dlqi): a simple practical measure for routine clinical use autoinflammatory disease damage index (addi): a possible newborn also in hidradenitis suppurativa daily practice point-of-care diagnostic of sars-cov-2: knowledge, attitudes, and beliefs (kap) of medical workforce in italy covid-19, cytokines and immunosuppression: what can we learn from severe acute respiratory syndrome? case-fatality rate and characteristics of patients dying in relation to covid-19 in italy clinical features of 69 cases with coronavirus disease increased airway inflammation in patients with psoriasis narrowband ultraviolet b phototherapy in psoriasis reduces proinflammatory cytokine levels and improves vitiligo and neutrophilic asthma psoriasis and respiratory comorbidities: the added value of fraction of exhaled nitric oxide as a new method to detect, evaluate, and monitor psoriatic systemic involvement and therapeutic efficacy collegium internationale allergologicum update 2020 psoriasis and smoking: links and risks hidradenitis suppurativa and smoking: a systematic review and meta-analysis active smoking is not associated with severity of coronavirus disease 2019 (covid-19) two phase 3 trials of adalimumab for hidradenitis suppurativa dupilumab safety and efficacy in uncontrolled asthma: a systematic review and meta-analysis of randomized clinical trials coronavirus disease 2019 and transplantation: a view from the inside coronaviruses and immunosuppressed patients. the facts during the third epidemic poor medication adherence in patients with psoriasis and a successful intervention web app based patient education in psoriasis -a randomized controlled trial biologic therapy adherence, discontinuation, switching, and restarting among patients with psoriasis in the us medicare population facing covid-19 in italy -ethics, logistics, and therapeutics on the epidemic's front line global coronavirus pandemic (2019-ncov): implication for an italian medium size dermatological clinic of a ii level hospital covid-19 in italy: momentous decisions and many uncertainties covid-19 knowledge prevents biologics discontinuation: data from an italian multicenter survey during red-zone declaration the authors declare no potential conflict of interest. key: cord-322963-r0fhnpdn authors: katerina, damevska; lence, neloska; viktor, simeonovski; andrej, petrov; irena, dimitrovska; natasa, teovska‐mitrevska; anita, najdova; nora, pollozhani title: impact of covid‐19 outbreak on dermatology services: dermatology in isolation date: 2020-05-22 journal: dermatol ther doi: 10.1111/dth.13552 sha: doc_id: 322963 cord_uid: r0fhnpdn nan dear editor, the current pandemic of covid-19 demanded fast reorganization, as well as the necessity to adapt existing and administered extraordinary working protocols of dermatological services worldwide. 1 we present a unique experience from republic of macedonia where an abrupt interruption of the dermatology service on a national level, and the covid-19 outbreak, occurred simultaneously, with a significant impact on the quality of care. the fourth diagnosed case of covid-19 in the republic of macedonia was a dermatologist employed at the university clinic for dermatology in skopje, the only tertiary care hospital in the country. prior to being diagnosed, the doctor made direct contact with nearly all medical and non-medical personnel of the clinic. the doctor also held a previously scheduled seminar, which was attended by an additional 95 dermatologists and dermatology residents from across the country. in the first hours following the diagnosis, rapid action was taken by government officials, and 128 dermatologists and dermatology residents were put in home quarantine for 14 days. only 9 dermatologists in secondary care could resume practice in the period from in an effort to discover which of the dermatological conditions demanded immediate attention, we conducted a survey where we asked colleagues about the number and reasons for teledermatological consults. overall, 77 dermatologists participated in the survey. ninety-one percent of respondents had received requests for consultations by patients. eighty-two percent felt that consultation via a communication application was useful for patient follow-up; however, these methods were appropriate in less than 30% of cases for initial consultations. the most common motives for consultations with patients were therapy follow-ups, acute exacerbations of chronic diseases, and deficiencies of certain medications due to difficulties in drug importations. most frequently, dermatology input was requested from general practitioners (gps) and pediatrics ( table 1 ). the dermatologists, who were not subject to the home isolation measure, held 163 outpatient examinations, in the majority of which pediatric dermatological pathology dominated ( dermatology is largely considered a nonacute, outpatientcentered specialty, with a continued reduction in dedicated dermatology beds. 5, 6 our survey contributes by presenting the dermatoses, which demanded dermatological consult and which were a diagnostic and therapeutic challenge to the gps and other specialties. these included pediatric dermatoses, dermatoses of pregnancy, patients with perennial retinoid therapy, bullous dermatoses, and cases of drug eruptions, including sjs and ten. this is deducted from a 14-day period and concerned a population of a little over 2 million. pediatric dermatoses constitute roughly 50% of both urgent visits and telecommunication consultations. the present results are broadly in line with those of previous studies, 7 confirming the role of the dermatologist in the pediatric care. the authors declare no conflict of interest. inpatient care for dermatological patients during sars-cov-2-a case report from portugal the first 15 macedonian doyens at the faculty of medicine in skopje ulcerative tuberculoides experimental studies of endogenous factors in cutaneous fungoid infection the need for dedicated dermatology beds care of patients with psoriasis: an audit of u.k. services in secondary care pediatric dermatology consultations: a retrospective analysis of inpatient consultations referred to the dermatology service key: cord-355354-1zwgjfc7 authors: mutalik, sharad d.; inamdar, arun c. title: mask‐induced psoriasis lesions as köebner phenomenon during covid‐19 pandemic date: 2020-09-29 journal: dermatol ther doi: 10.1111/dth.14323 sha: doc_id: 355354 cord_uid: 1zwgjfc7 nan it has been shown that the disruption of a functional and structural permeability barrier is critical for the appearance of psoriasis as köebner reaction. 4 accordingly, the importance of the rupturing of the epidermis in initiating the köebner response has been well documented. along f i g u r e 1 well-defined plaque with silvery white scales f i g u r e 2 face mask with ear loops european task force on contact dermatitis statement on coronavirus 19 disease (covid-19) outbreak and the risk of adverse cutaneous reactions a case of goggle-mask-related impetigo at the time of the covid-19 pandemic koebner phenomenon in psoriasis. a common response to skin trauma stratum corneum structure and function correlates with phenotype in psoriasis are newly discovered drivers of immune-mediated skin disorders expressed in normal skin regenerating from standardized surface injury? face mask-induced itch: a self-questionnaire study of 2,315 responders during the covid-19 pandemic wearing the n95 mask with a plastic handle reduces pressure 59 injury key: cord-343739-t3z6ghyp authors: conforti, claudio; giuffrida, roberta; di meo, nicola; zalaudek, iris title: management of advanced melanoma in the covid‐19 era date: 2020-05-14 journal: dermatol ther doi: 10.1111/dth.13444 sha: doc_id: 343739 cord_uid: t3z6ghyp nan visits and surgery that cannot be postponed are carried out regularly. for patients undergoing treatment with immunosuppressive or immunomodulating drugs for chronic dermatological diseases, such as psoriasis, several guidelines suggest to assess on a case-by-case basis the initiation of a new therapy with a biological drug as well as the possible suspension in case of positivity. 2 apart from psoriasis, which can sometimes also be treated in an alternative way, we must focus our attention on the most fragile patients in dermatology, that is, oncologic patients suffering from advanced melanoma. in fact, we should remember that cancer-related treatments may cause immunosuppression, and the first available data suggest that patients with cancer have a risk of excess mortality due to sars-cov-2. coronavirus disease 2019 (covid-19): facts and controversies covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action oncology practice during the covid-19 pandemic infezione da coronavirus: vademecum per i pazienti affetti da psoriasi cutanea e/o artropatia psoriasica aiom, rischio infettivo da coronavirus covid-19: indicazioni per l'oncologia cancer patient management during the covid-19 pandemic key: cord-351457-fzj3ciif authors: vezzoli, pamela; di mercurio, marco; carugno, andrea; gambini, daniele mario; robustelli test, elisa; imberti, gianlorenzo; castagna, angelo francesco; sena, paolo title: cutaneous lupus erythematosus patients in a high‐epidemic covid‐19 area, bergamo, italy date: 2020-06-07 journal: dermatol ther doi: 10.1111/dth.13776 sha: doc_id: 351457 cord_uid: fzj3ciif nan dear editor, the current pandemic of coronavirus disease 2019 (covid-19) has raised the interest in reporting the management's experience with systemic lupus erythematosus (sle) patients under long-term treatment with immunosuppressor drugs or hydroxychloroquine (hcq). sle patients could have a higher potential risk of a severe covid-19 course 1-2 due to underlying immune dysregulation, the potential presence of organ damage associated with the disease and comorbidities. 3, 4 indeed, infections remain a leading cause of mortality in lupus patients. 5 recently, some authors reported the importance to maintain disease remission in lupus patients, especially in high-epidemic areas, avoiding unnecessary emergency room visits and hospitalization. therefore, it has been suggested not to discontinue current therapy in such patients. 5, 6 however, no data about the management of risk infection in cutaneous lupus erythematosus (cle) during the current pandemic are present in the literature to date. our hospital is located in a high-epidemic area of lombardy: we decided to advice patients affected by sle with cutaneous manifestations and cle, to scrupulously comply with hygiene rules and protective devices use, to maintain social distancing, not to spontaneously suspend ongoing therapy and to inform the dermatologist in case of the onset of symptoms, as suggested this article is protected by copyright. all rights reserved. by the italian society of dermatologists (sidemast) 7 and several papers. 5 observation of these data shows that lupus patients with cutaneous manifestations could have susceptibility to covid-19 independently of contact with known or suspected covid-19 patient. in particular a higher risk factor to experience sars-cov-2 infection can be observed in sle patients as reported in the literature. [4] [5] [6] [7] fortunately, all the 4 covid-19 suspected this article is protected by copyright. all rights reserved. patients experienced mild symptoms without severe respiratory complications. furthermore, none of our patients showed a recurrence of the underlying disease. the role of hcq on covid-19 is still debated 12 and our data do not allow us to draw conclusions on the matter. therefore, we think it is important to create a communication channel with patients to reduce in-person follow-up visits, to give human support and help in managing therapies. we observed that it is essential to advise and empower le patients on activities to limit the risk of infection (hand hygiene, social distancing, use of protective devices), not only in the systemic form but also in the cutaneous form. managing cutaneous immune-mediated diseases during the covid-19 advice regarding covid-19 and use of immunomodulators, in patients with severe dermatological diseases covid-19) in a series of 17 patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine baseline use of hydroxychloroquine in systemic lupus erythematosus does not preclude sars-cov-2 infection and severe covid-19 coronavirus disease-2019: implication for the care and management of patients with systemic lupus erythematosus impact of covid-19 pandemic on sle: beyond the risk of infection sidemast) infezione da coronavirus, vademecum per i pazienti affetti da malattie bollose e malattie autoimmuni management strategies for patients with autoimmune diseases during the covid-19 pandemic: a perspective from china covid-19 infection in a northern-italian cohort of systemic lupus erythematosus assessed by telemedicine key: cord-340029-iv2x1vap authors: farabi, banu; bhargava, shashank; goldust, mohamad; atak, mehmet fatih title: comment on “psoriasis, covid‐19 and acute respiratory distress syndrome: focusing on the risk of concomitant biological treatment” date: 2020-06-14 journal: dermatol ther doi: 10.1111/dth.13840 sha: doc_id: 340029 cord_uid: iv2x1vap nan we have read with great interest the review article published by magnano et al. which was recently published in dermatologic therapy journal (1) . we found it interesting to expand the discussion in this regard that may be practically helpful for the dermatologists in the era of covid19 pandemic. the authors pointed out the abrupt interruption of the biologics may increase the systemic inflammation, which may worsen the associated comorbidities and the prognosis of covid-19. herein, we agree with the authors and add more points that would be of interest for further interpretation in this critical time. it is an area of debate whether it is advisable or not to stop biologic agents in the treatment of psoriasis during covid-19 pandemic. various scientific societies like american academy of dermatology (aad) and international league of dermatological societies (ilds) have issued guidelines to discontinue only in covid-19 positive patients but can be carefully considered on a case-by-case basis if the patient is covid-19 negative and with no symptoms by weighing risk vs. benefit ratio. on the other hand, many of the published case series, retrospective studies have shown that although psoriasis patients have metabolic and cardiovascular comorbidities, there is no early sign of an increased hospitalization rate amongst these patients (2, 3) . moreover, the retrospective study conducted by gisondi et al. showed that there is no death due to covid-19 and only one hospitalization, fully recovered amongst the patients with chronic plaque psoriasis receiving a biological treatment and renal transplant recipients who were under immunosuppressive therapies (4) . various studies have suggested to discontinue biologics only in covid-19 positive patients and consider biologics on case-by-case basis considering the severity of psoriasis and other co-morbidities (5, 6). nuclear factor kappa b (nf-κb) is a protein transcription factor that orchestrates inflammation and other complex biological processes and is a key regulatory element in a variety of immune and inflammatory pathways, in cellular proliferation and differentiation and in apoptosis. therefore nf-κb is a crucial mediator involved in the pathogenesis of psoriasis. several antipsoriatic therapies, including tumor necrosis factor-α blockers and glucocorticoids, reduce active nf-κb levels and related down-stream elements, and other biologics currently in development, including interleukin-17 blockers, may also target this pathway. sars-cov-2 is known to be engulfed into the human cell along with the ace2 receptor it had combined with. this reduces the number of ace2 receptors on cells, leading to an increase of a polypeptide, called angiotensin ii, in the blood. angiotensin ii triggers an inflammatory pathway involving nf-κb and il-6-stat3 particularly in nonimmune cells including endothelial cells and epithelial cells. this pathway forms a positive feedback cycle, named il-6 amplifier, resulting in its excessive activation and therefore the cytokine storm and ards (7). it can be hypothesized that immunosuppressive/immunomodulator therapies using in psoriasis may suppress and/or control the "cytokine storm in covid-19" and/or suppress viral activity in order to reach recovery. zumla et al. also hypothesized that blocking il-17 could have the potential to improve covid-19's aberrant immune response and acute respiratory distress syndromerelated mortality (8) . moreover, previous studies have shown that biologic agents seem to have an acceptable safety profile and high effectiveness in the presence of immunocompromising such as hiv-positivity. biologic agents had a positive effect on cd4 and viral counts when used in combined with highly active anti-retroviral therapies in these individuals (9, 10) . since, we do not have much data on biologics in psoriasis patients effecting covid-19 disease course, current data suggests that there is no increase morbidity/ mortality amongst these patients. to reveal the relationship with immunomodulator therapies and its effects on covid-19, further case-control studies are required. covid-19 and acute respiratory distress syndrome: focusing on the risk of concomitant biological treatment evolution of covid-19 infection in 4 psoriatic patients treated with biological drugs biologics for psoriasis patients in the covid-19 era: more evidence, less fears risk of hospitalization and death from covid-19 infection in patients with chronic plaque psoriasis receiving a biological treatment and renal transplanted recipients in maintenance immunosuppressive treatment covid-19 and psoriasis: is it time to limit treatment with immunosuppressants? a call for action antipsoriatic treatments during covid-19 outbreak novel coronavirus disease (covid-19) and biologic therapy in psoriasis: infection risk and patient counseling in uncertain times reducing mortality from 2019-ncov: hostdirected therapies should be an option safety and effectiveness of conventional systemic therapy and biological drugs in patients with moderate to severe psoriasis and hiv infection: a retrospective multicenter study psoriasis treatment in hiv-positive patients: a systematic review of systemic immunosuppressive therapies key: cord-340474-hbcu72cm authors: kaushik, akanksha; parsad, davinder; kumaran, muthu sendhil title: urticaria in the times of covid‐19 date: 2020-06-12 journal: dermatol ther doi: 10.1111/dth.13817 sha: doc_id: 340474 cord_uid: hbcu72cm nan morbidity and severe economic disruptions in recent times. of late, there has been a growing interest regarding the dermatological manifestations in covid-19. in an early retrospective study among 140 patients zhang et al 1 reported 11.4% patients to have drug hypersensitivity and 1.4% to have urticaria. in a report from italy, 18/88 (20.5%) patients had dermatological manifestations, with 3 patients reporting widespread urticaria. 2 as per one review, 88/256 (34.3%) patients across 16 studies demonstrated skin manifestations, mostly as erythematous maculopapular rash, urticaria or vesicular rash. 3 on closer look, we find urticaria to be a commonly reported finding among covid-19 patients. in one of the large prospective studies involving 375 covid 19 cases, urticaria was present in 19% cases, with mean duration of urticaria being 6.8 days. 4 while there was a report of one covid-19 patient presenting with urticaria and dry cough without any fever, 5 the timing of appearance of urticaria was variable, with lesions appearing before, with, as well as >48 hours after onset of fever. [6] [7] [8] [9] in most cases, diagnosis of urticaria was made clinically and oral 2 nd generation antihistamines were prescribed with satisfactory results. [6] [7] [8] [9] although skin manifestations did not correlate with disease severity in most case reports, 2,6 the prospective this article is protected by copyright. all rights reserved. study from spain suggested that presence of urticaria and maculopapular lesions were associated with more severe covid 19 illness and a higher (2%) mortality. . 4 pathophysiology of urticaria in covid-19 infection is hypothesised to be multifactorial. while drug-induced urticaria may be an obvious explanation, urticaria preceded drug therapy or showed spontaneous remission despite continuation of therapy for covid-19, 6 with an ever-rising number of patients, it is too early to determine a precise prevalence of urticaria in covid-19 and full understanding of pathophysiologic mechanisms may also take time. with an eye on the reported literature, we make a few suggestions regarding urticaria in this article is protected by copyright. all rights reserved. (table 1) . from management perspective, oral 2 nd generation antihistamines seem to be an initial prudent choice. omalizumab can be used in refractory patients, with the first two doses being given in a hospital setting as per a recent guidance summary. 11 we reiterate that data so far is relatively sparse and at times, incomparable. as more studies are performed, medical science would be in a better position to elucidate the conundrum of urticaria in covid-19. clinical characteristics of 140 patients infected with sars-cov-2 in wuhan cutaneous manifestations in covid-19: a first perspective cutaneous manifestations of the coronavirus disease 2019 (covid-19): a brief review classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases this article is protected by copyright. all rights reserved sars-coronavirus-2 and acute urticaria acute urticaria with pyrexia as the first manifestations of a covid-19 infection urticaria in a patient with covid-19: therapeutic and diagnostic difficulties comment on: cutaneous manifestations in covid-19: a first perspective. safety concerns of clinical images and skin biopsies complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases the role of cytokines including interleukin-6 in covid-19 induced pneumonia and macrophage activation syndrome-like disease this article is protected by copyright. all rights reserved. service. accessed june 7, 2020. https://www.sps.nhs.uk/articles/summary-of-covid-19medicines-guidance-skin-disorders/ this article is protected by copyright. all rights reserved.2. in patients with refractory urticaria and/or atypical morphology, the decision to perform skin biopsy and histopathological examination can be individualised.3. for symptomatic management of urticaria, standard doses of potent, second-generation, non-sedating h1 antihistamines (e.g. fexofenadine/ levocetrizine) in twice-daily dosing can be used. in non-responders, the dose can be increased upto four-fold the recommended dose (eaaci guidelines). key: cord-347725-w03ef08b authors: schwartz, robert a.; janniger, camila k. title: generalized pustular figurate erythema: a newly delineated severe cutaneous drug reaction linked with hydroxychloroquine date: 2020-04-16 journal: dermatol ther doi: 10.1111/dth.13380 sha: doc_id: 347725 cord_uid: w03ef08b a severe cutaneous drug reaction resembling acute generalized exanthematous pustulosis resulting from ingestion of hydroxychloroquine has been documented. it is distinguishable by its longer incubation period, more varied morphology with initially urticarial and later targetoid and arcuate plaques, recalcitrance to therapy and longer duration. given the anticipated surge in the use of hydroxychloroquine due to its reported benefits in those with coronavirus disease 2019, specific recognition of this entity is pivotal. we delineate it as generalized pustular figurate erythema. severe potentially life-threatening cutaneous drug reactions are a huge concern, most specifically acute generalized exanthematous pustulosis (agep), stevens-johnson syndrome (sjs), toxic epidermal necrolysis (ten), generalized bullous fixed drug eruption, and drug reaction with eosinophilia and systemic symptoms (dress) syndrome. 1-8 agep was originally misclassified as a form of pustular psoriasis; however, it is not associated with psoriasis. 9 agep is a severe cutaneous adverse reaction characterized by the rapid development of sterile nonfollicular pustules on an erythematous base. 2, 3 it is usually attributed to drugs, antibiotics being the most common, with an onset typically within 48 hours of ingestion, often with an acute onset of fever and leukocytosis. there is another rare acute severe generalized disorder, one usually characterized as agep, but with an onset of 2 to 3 weeks (range 4-27 days) rather 1 day after initial drug exposure, typically due to hydroxychloroquine, more severe, more difficult to treat, with a longer duration, and recognized as likely having a different pathogenic mechanism from the usual type of agep. 10 this perplexing disorder has been described as atypical agep, 11,12 recalcitrant agep, 13,14 pustular dress syndrome, 15 agep/sjs overlap, 16 agep/ten overlap, 17, 18 and sweet's syndrome following hydroxychloroquine. [19] [20] [21] we delineate and highlight it as generalized pustular figurate erythema (gpfe). some cutaneous sloughing and excoriations may also be observed with blisters or erosions occasionally noted. there may be little or no mucosal involvement. skin biopsy specimens may initially show mainly the changes of urticaria, but evolve into subcorneal and/or intraepidermal neutrophilic pustules sometimes with mild focal the fixed drug eruptions: an update emphasizing the potentially lethal generalized bullous fixed drug eruption acute generalized exanthematous pustulosis: a review and update childhood acute generalized exanthematous pustulosis induced by oral ketoconazole drug rash with eosinophilia and systemic symptoms (dress) syndrome: part i: clinical perspectives dress syndrome: part ii: management and therapeutics toxic epidermal necrolysis. part i. introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis toxic epidermal necrolysis. part ii. prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment erythema multiforme, stevens-johnson syndrome, and toxic epidermal necrolysis generalized pustular psoriasis: a review and update on treatment risk factors for acute generalized exanthematous pustulosis (agep)-results of a multinational case-control study (euroscar) acute generalized exanthematous pustulosis induced by hydroxychloroquine: a case with atypical clinical presentation prolonged pustular eruption from hydroxychloroquine: an unusual case of acute generalized exanthematous pustulosis successful treatment of hydroxychloroquine-induced recalcitrant acute generalized exanthematous pustulosis with cyclosporine: case report and literature review a case of recalcitrant acute generalized exanthematous pustulosis with sjogren's syndrome: successfully treated with low-dose cyclosporine pustular dress syndrome secondary to hydroxychloroquine with ebv reactivation agep overlap induced by hydroxychloroquine: a case report and literature review acute generalized exanthematous pustulosis simulating toxic epidermal necrolysis: case presentation and literature review acute generalized exanthematous pustulosis and toxic epidermal necrolysis induced by hydroxychloroquine sweet's syndrome following therapy with hydroxychloroquine in a patient affected with elderly-onset primary sjogren's syndrome drug-induced sweet's syndrome related to hydroxychloroquine: about 2 cases drug-induced neutrophilic dermatoses chloroquine for the 2019 novel coronavirus sars-cov-2 the trial of chloroquine in the treatment of corona virus disease 2019 (covid-19) and its research progress in forensic toxicology cyclosporine for corticosteroidrefractory acute generalized exanthematous pustulosis due to hydroxychloroquine-induced gpfe with numerous nonfollicular pustules atop atypical targetoid plaques. gpfe, generalized pustular figurate erythema hydroxychloroquine acute generalized exanthematous pustulosis induced by hydroxychloroquine successfully treated with etretinate a case of hydroxychloroquine induced acute generalized exanthematous pustulosis confirmed by accidental oral provocation generalized pustular figurate erythema: a newly delineated severe cutaneous drug reaction linked with hydroxychloroquine key: cord-333684-j1sg46w9 authors: filippi, federica; loi, camilla; evangelista, valeria; bardazzi, federico title: covid‐19 era: a chance to learn something new about monitoring psoriatic patients in biological therapy date: 2020-06-10 journal: dermatol ther doi: 10.1111/dth.13805 sha: doc_id: 333684 cord_uid: j1sg46w9 nan the novel coronavirus (severe acute respiratory syndrome coronavirus: sars-cov-2) and the related disease (coronavirus disease-19: covid-19) emerged in china in december 2019 and rapidly spread over the continents in a matter of months; it has dramatically changed not only our daily life, but also our daily dermatological practice 1,2 . however, these forced changes have provided us food for thought. about 750 psoriatic patients assuming biological therapy currently refer to our psoriasis outpatient service, in sant'orsola-malpighi university hospital, bologna (italy), with an average of 80 patients visited weekly. in the screening and monitoring of psoriatic patients, we follow the latest italian guidelines 3 : blood tests (full blood count, creatinine and electrolytes, liver function tests, serum lipids, fasting glucose) as well as psoriasis disease severity assessment and general physical examination should be performed at baseline and periodically afterwards, on average every 3-4 months, based on clinical judgement, in particular extension of the disease (body surface area, nail involvement, critical areas localization), diagnosis of arthropatic psoriasis, comorbidities and other associated symptoms. in consequence of the covid-19 pandemic and in accordance with the ministerial decree of march 9, 2020 (gu serie generale n.62 09-03-2020), all non-urgent dermatological consultations were suspended in our country, so face-to-face visits decreased markedly in favour of the now familiar this article is protected by copyright. all rights reserved. "teledermatology" 4,5 . on march 13, 2020, the italian medicines agency (aifa) allowed the automatic renewal of all expiring therapeutic plans for biologic drugs for 90 days, to prevent patients from coming to the hospital only to renew their prescription 6 . non-urgent blood tests were also suspended, including monitoring in psoriatic patients undergoing biological therapy 7 . this was the situation until may 4, 2020, when "step 2" was implemented: a slow reactivation of the activities and a soft but important relaunch for italy 8 . scheduled visits were re-established, and the retrieval of the missed follow-up visits has begun. however, blood tests are still performed only in selected cases, to avoid hospital overcrowding. considering the last 2 months, 250 of the approximately 400 patients to retrieve were visited, 180 of whom had been in biological therapy with the same drug for at least 1 year and were considered responders. out of these 180 patients, 6 had self-interrupted the treatment, fearing an increased risk of infection; 10/180 responders had a slight worsening of the disease (from 10% to 25% worsening of pasi compared to the previous examination, about 3 months earlier); in the remaining 170/180 patients, psoriasis remained well controlled (less than 10% worsening of pasi compared to the previous examination, about 3 months earlier). in addition, none of the patients had been able to undergo the monitoring blood tests. so far, the disease appears to have been well-controlled in most of our patients under biological therapy, despite the undeniable period of perceived stress, income loss and outdoor activity restriction, partly thanks to the many telephone consultations we provided during the lockdown. therefore, telemedicine has proven to be a successful method in monitoring patients in "welltested" biological therapy, and it could be considered a valid option for many months to come, as this article is protected by copyright. all rights reserved. social distancing will remain the most effective safeguard, probably until the introduction of a vaccine. for the same reason, blood tests will be performed less frequently than the usual 3-4 months; we will be able to tell in a few months if this forced procrastination will have had negative consequences on the outcome of our patients. if this is not so, it could be the starting point for a further lengthening of the monitoring time of psoriatic patients considered responders to biological therapy. active implications for dermatologists in "sars-cov-2 era": personal experience and review of literature the covid-19 outbreak in italy: preventive and protective measures adopted by the dermatology unit of bologna university hospital italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during covid-19 emergency in a tertiary center in italy store-and-forward teledermatology in the era of covid-19: a pilot study transitional measures concerning the extension of the aifa treatment plans for the containment and management of the epidemiological emergency from covid-19 ulteriori disposizioni attuative del decretolegge 23 febbraio 2020, n. 6, recante misure urgenti in materia di contenimento e gestione dell'emergenza epidemiologica da covid-19, applicabili sull ulteriori disposizioni attuative del decretolegge 23 febbraio 2020 key: cord-328090-bprnq9wx authors: abdollahimajd, fahimeh; youssefian, leila; pourani, mohammad reza; vahidnezhad, hassan; uitto, jouni title: novel coronavirus 2019 (covid‐19) and epidermolysis bullosa: report of three cases date: 2020-08-14 journal: dermatol ther doi: 10.1111/dth.14194 sha: doc_id: 328090 cord_uid: bprnq9wx nan dear editor, recent demonstration of ace2 and tmprsss expressions, both necessary for entry of the virus into the host cells, in human epidermis suggests that skin might be a cellular host and a potential transmission route for sars-cov-2 , especially in skin fragility conditions 1 . epidermolysis bullosa (eb) is a skin fragility disorder caused by mutations in genes expressed in the cutaneous basement membrane zone 2, 3 . while an international consensus panel recently provided recommendations for prevention and multidisciplinary care of eb patients during the covid-19 pandemic 4 , the phenotypic outcome in these patients in comparison to the general population has not been reported; however eb patients, particularly those with syndromic forms, may be at higher risk for infection with severe complications 4, 5 . here, we reported three eb patients infected by covid-19 during this pandemic. year-old male who experienced low-grade fever, pleuritic chest pain, myalgia, and dry cough (figure 1e-g) 7 . this mutation was disclosed by gene-targeted next-generation sequencing panel for eb 8 . he initially adhered to most recommendations of isolation; however, he worked as a construction worker and experienced mild signs of infection. a nasopharyngeal swab specimen for sars-cov-2 was positive. since his symptoms were mild, homequarantine was recommended. after one week, his symptoms were resolved without any specific treatment. patients with chronic diseases such as eb, may face health issues during the covid-19 pandemic 9 . it has been suggested that disrupted epidermal barrier may provide an entry route for sars-cov-2 10 this article is protected by copyright. all rights reserved. our patients did not experience a severe course of covid-19 despite some eb related complications, including severe anemia, esophageal strictures and growth retardation; in addition, one of the kidneys of the third patient was non-functional. two patients experienced transient symptoms while in home-quarantine, and the third one required hospitalization. thus, the severity of the covid-19 in these eb patients was in the spectrum experienced by the general population. however, further clinical studies are required to investigate the prevalence and course of covid-19 in eb patients. this article is protected by copyright. all rights reserved. high expression of ace2 on keratinocytes reveals skin as a potential target for sars-cov-2 molecular pathology of the basement membrane zone in heritable blistering diseases: the paradigm of epidermolysis bullosa phenotypic spectrum of epidermolysis bullosa: the paradigm of syndromic versus non-syndromic skin fragility disorders multidisciplinary care of epidermolysis bullosa during the covid-19 pandemic -consensus: recommendations by an international panel of experts epidermolysis bullosa and the covid-19 pandemic: challenges and recommendations dystrophic epidermolysis bullosa: col7a1 mutation landscape in a multi-ethnic cohort of 152 extended families with high degree of customary consanguineous marriages recessive mutation in tetraspanin cd151 causes kindler syndrome-like epidermolysis bullosa with multi-systemic manifestations including nephropathy multigene next generation sequencing panel identifies pathogenic variants in patients with unknown subtype of epidermolysis bullosa: subclassification with prognostic implications comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis the microbiome and atopic eczema: more than skin deep this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved. key: cord-337382-b3wd182c authors: bassi, andrea; azzarelli, andrea; vaccaro, angelina; mazzatenta, carlo title: at home dose escalation of propranolol for infantile hemangiomas during the covid‐19 pandemic date: 2020-07-07 journal: dermatol ther doi: 10.1111/dth.13977 sha: doc_id: 337382 cord_uid: b3wd182c nan the novel coronavirus disease 2019 (covid-19) has drastically changed our life and the healthcare delivery worldwide. a widespread reduction in ambulatory visits has been documented for all the different specialties in order to minimize the risk of exposure and transmission of covid-19. therefore, the use of telemedicine has been widely implemented in different dermatological fields giving the opportunity to rapidly identify new clinical entities related to the pandemic virus (1, 2) and to be able to follow up patients with chronic skin diseases (3, 4) . infantile hemangiomas (ih) often requires urgent evaluation and risk stratification to determine which infants need treatment and which one could be managed with continued observation (5) . since most of the ih growth is between 1 and 3 months, prompt initiation of therapy with propranolol is the gold standard for those children requiring treatment. as the need for early treatment could be hindered by parents' fear to access public hospitals during the pandemic period, since the last days of february we encouraged pediatricians and colleagues to send us pictures (via email or whatsapp) to perform a first screening of patients with higher risk ih needing beta-blocker treatment (5) . from march to may 2020 we identified 7 children with ih at high risk of scarring and/or disfigurement due to the localization (face, eye) or early ulceration and requiring propranolol treatment. we decided to perform at least one direct clinical evaluation since the received pictures were often of low quality, posing a risk of misleading (figure 1 ). after confirming indication for propranolol therapy, all the patients, in the same day, carried out a cardiologic and a pediatric evaluation. if no this article is protected by copyright. all rights reserved. contraindications were present, treatment was immediately started at the standard dose of 1 mg/kg daily in two divided doses. usually, as a standard of care, children come back a week later to increase the dosage to 2 mg/kg daily and the third week to achieve the maximum daily dosage of 3 mg/kg. during these clinical controls blood pressure, heart rate, glycemic stick and weight of the child are usually evaluated. in this emergency situation, to avoid unnecessary access to our hospital heavily engaged in the treatment of covid-19 patients, we decided, after informed consent, to slowly increase the dose of the drug at home and to monitor the treatment by telemedicine with parents and with the referring pediatrician. we considered ethically correct to implement this protocol, given to the high safety profile of propranolol, with an almost complete absence of adverse events when properly used (6). in our "emergency" protocol, we addressed families to increase the dose of the drug by 25% each week achieving the dosage of about 2 mg/kg daily (1.95 mg/kg) after 3 weeks and the maximum dosage of about 3 mg/kg daily (3.05 mg/kg) after 5 weeks (figure 2) . we decided to scale up the dose of propranolol to the maximum dose suggested, as it has been clearly demonstrated that there are no differences of adverse events incidence between 1, 2 or 3mg/kg (7). parents were thoroughly counseled about clinical signs of potential adverse events and advised to immediately discontinue the drug and promptly inform us and the community pediatrician in case of sign/symptom such as cough, wheezing, gastrointestinal symptoms or lethargy. in all cases no adverse effects were reported and, in line with literature data, a good response has been observed. to date our patients are still followed-up with the aid of telemedicine and a control visit has been planned at the 6th month of therapy. we found this protocol really helpful to manage our patients in this particular period however we believe that further studies are needed to confirm that at home scale-up of this article is protected by copyright. all rights reserved. propranolol could be also used in non-pandemic period, in order to reduce disease burden for families in term of travel, loss of working-days and costs. chilblain-like lesions during covid-19 epidemic: a preliminary study on 63 patients chilblain-like lesions during the covid-19 pandemic: should we really worry? teledermatology in the wake of covid-19: advantages and challenges to continued care in a time of disarray did whatsapp® reveal a new cutaneous covid-19 manifestation? management of infantile hemangiomas during the covid pandemic propranolol in the treatment of infantile key: cord-331687-o5031cxp authors: singh, yogendra; gupta, gaurav; satija, saurabh; negi, poonam; chellappan, dinesh kumar; dua, kamal title: raas blockers in hypertension posing a higher risk towards the covid‐19 date: 2020-05-02 journal: dermatol ther doi: 10.1111/dth.13501 sha: doc_id: 331687 cord_uid: o5031cxp nan covid-19 (coronavirus disease 2019) is a fatal disease that could lead to a serious respiratory illness. the world health organisation (who) declared the disease, a global pandemic on 11 march 2020, even as covid-19 rapidly spread across the world. according to the 2019 who data, an estimated 1.13 billion people suffer from hypertension. most of the hypertensive patients are assisted by angiotensin converting enzyme inhibitors (acei) or angiotensin receptor blockers (arbs) or both. some patients with cardiac mortality are additionally managed with other classes of combinational therapy. these drugs improve the cardiac profile through an increase in ace-2 expression. moreover, the level of ace-2 predominantly available in lung epithelial tissue is an indication of the protective role in respiratory distress syndrome and acute lung injury 1,2 . there is plenty of evidence to suggest that ace2 converts ang i to ang-(1-9) in the body and ang ii which is converted to ang-(1-7). ace2 is further thought to be an essential peptide that binds to the mas receptors in the ras cascade 3 (figure 1 ). a recently published study suggested that covid-19 also uses ace2 as a cellular entry receptor, as this was detected in the isolates of the bronchoalveolar lavage fluid of one of the critically ill patients 4 . moreover, this was further confirmed by another recent study from china, which reported their findings on virus infectivity studies using hela cells that were both, expressing and not expressing ace2 proteins in humans, chinese horseshoe bats, civets, pigs, and mice. we believe that covid-19 is capable of using all, but mouse, ace2, as a receptor to enter within the cells that express ace2, but not in cells that lack ace2, suggesting ace2 as the most likely cell receptor for covid-19 5, 6 . the sars-cov, which is genetically homologous to covid-19, have spikes that are composed of trimers of s glycoprotein that are further cleaved into s1 and s2 subunits by cathepsin l proteases. a fragment located within the s1 subunit, which spans the amino acids 318-510, is believed to be the minimal receptor-binding domain (rbd) complexed with its receptor ace-2 7, 8 . this is the primary component responsible for the binding, with the peptidase domain of ace2, eventually resulting in enhanced human ace2-binding affinity of the covid-19. there is enough evidence to believe that the zoonotic covid-19 is completely dependent on human ace2 as a receptor for entry, thus having high replication potential in human cells. thus, patients who adhere to raas blockers (assisted with acei or arbs) are believed to have a higher risk towards the deadly viral attack of covid-19, and progressively they must be switched on to other class of anti-hypertensive drugs. a crucial role of angiotensin converting enzyme 2 (ace2) in sars coronavirus-induced lung injury angiotensin-converting enzyme 2 in acute respiratory distress syndrome. cellular and molecular life sciences : cmls olmesartan is an angiotensin ii receptor blocker with an inhibitory effect on angiotensin-converting enzyme a novel coronavirus from patients with pneumonia in china discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin clinical features of patients infected with 2019 novel coronavirus in wuhan structure of sars coronavirus spike receptor-binding domain complexed with receptor structure of severe acute respiratory syndrome coronavirus receptor-binding domain complexed with neutralizing antibody key: cord-353659-wtacr6qj authors: almutairi, nawaf; schwartz, robert a. title: coronavirus disease‐2019 with dermatologic manifestations and implications: an unfolding conundrum date: 2020-05-09 journal: dermatol ther doi: 10.1111/dth.13544 sha: doc_id: 353659 cord_uid: wtacr6qj the novel coronavirus sars‐cov‐2 has caused coronavirus disease‐2019, widely known as covid‐19, now a pandemic with extraordinary infectivity, mortality, and fomite adhesiveness. as a nosocomial infection for hospital and nursing home patients and health care workers, it represents an extraordinary challenge. the cutaneous markers of this pandemic are being elucidated with preliminary experiences being shared and rapidly communicated. we will review covid‐19 from both a dermatologic and public health perspective. this article is protected by copyright. all rights reserved. cov-2 capable of causing severe disease. the four others produce only mild symptoms. sars-cov-2 is a novel coronavirus, an rna virus closely related to the original sars-cov (9). it has been proclaimed as unlikely to have been derived through laboratory manipulation of a related sars-cov-like coronavirus (10). measures including frequent hand washing, social distancing by maintaining physical distance from others, covering coughs and sneezes with a tissue or inner elbow and keeping unwashed hands away from the face. the use of masks by everyone when outside is also believed to limit its spread and has been recommended by many countries. current management basically involves symptomatic treatment, supportive care, isolation and certain experimental therapeutic measures. lungs are the most severely affected organ by covid-19 because the virus enters the host cells via the integral membrane protein angiotensin-converting enzyme 2 (ace2), which is attached to cellular membranes in the lungs, arteries, heart, kidney, and intestines. it is most abundantly found in the type ii alveolar cells of the lungs. the virus uses a special surface glycoprotein called a "spike" (peplomer) to connect to ace2 and gain entry into the host cell (10). the virus also affects gastrointestinal organs as ace2 is abundantly expressed in the glandular cells of gastric, duodenal and rectal epithelium as well as endothelial cells and enterocytes of the small intestines (11). it also effects the cardiovascular system (12,13), where it causes acute injury to myocardium, more commonly documented in critically ill patients. they also have a high incidence of thromboses and venous thromboembolisms, the presence of which is associated with a poor prognosis (14, 15) . pathology: limited data is currently available about the microscopic changes occurring in various organs with covid-19 (16) . autopsy specimens have highlighted pulmonary involvement with a severe pneumonia showing diffuse alveolar damage with diffuse alveolar exudates, findings linked with acute respiratory distress syndrome and severe hypoxemia. other findings include disseminated intravascular coagulation and a leukoerythroblastic reaction. dermatological implications fall into four main categories: cutaneous manifestations of covid-19, skin changes from covid-19 lifestyle alterations, cutaneous adverse effects of covid-19 medications, effects of covid-19 and its therapy on primary skin diseases and their therapy. covid-19 has not at least so far been associated with any particular or characteristic skin manifestations. however, certain dermatoses have been described in these patients, similar to those also observed previously with other respiratory viruses like sars and mers (17) . changes in lifestyle, including prolonged contact to personal protective equipment, and excessive personal hygiene, may produce cutaneous findings, including pressure injury, contact dermatitis, and contact urticaria, as we too have noted too (fig 12-15 ) (33-39). the exacerbation of pre-existing skin diseases like seborrheic dermatitis, atopic dermatitis, and acne, can be anticipated (33). most frontline health care workers will develop cutaneous lesions affecting the nasal bridge, hands, cheek, and forehead. as expected, frequent hand hygiene was associated with a higher incidence of hand dermatitis. there is also an enhanced another important concern is management of patients with autoimmune and chronic inflammatory disorders being treated with biologic drugs or immunosuppressants, psoriasis, atopic dermatitis, connective tissue diseases, and hidradenitis suppurativa (41). european task force dermatology specific guidelines were published (42), suggesting continuing all immune-modulating treatments, including immuno-suppressive therapy, since exacerbations of underlying diseases can have a large negative impact on patient immunity. it lamented that many conventional systemic immune-modulating agents, such as cyclosporine, may interact with the human body's defense mechanisms against viral disease, but warned that it is not currently known how sars-cov-2 affects atopic dermatitis patients and specifically those on immune-modulating therapies. public health policy is pivotal and varied (5,43-51). at-home testing and monitoring for possible covid-19 represent a solid approach to keeping these covid-19 patients out of understaffed limited-equipment hospitals (52). as another measure to prevent people from being hospitalized, it might be wise to actively discourage health care workers at high-risk, no matter how well-meaning, from being present at health care facilities, given both direct and fomite covid-19 spread. since risk is stratified by age, with deaths concentrated at older ages, and underlying co-morbidities, recommendations by us have been made (table 1) . calling for older health care workers to volunteer is questionable. a study of 663 covid-19 patients from wuhan, china stressed that patients more than 60 years old and those with chronic diseases were at enhanced risk of severe covid-19, and more likely to die (43). a larger chinese study using multivariate cox regression analysis showed that age≥75, age between 65-74 years, coronary heart disease, cerebrovascular disease, and dyspnea were independent risk factors associated with fatal outcome (44). neuropsychiatric sequelae of covid-19 should be a concern (55-61). we the continuing 2019-ncov epidemic threat of novel coronaviruses to global health -the latest 2019 novel coronavirus outbreak in wuhan, china caution warranted: using the institute for health metrics and evaluation model for predicting the course of the covid-19 pandemic zhong ns; china medical treatment expert group for covid-19. clinical characteristics of coronavirus disease 2019 in china toning down the 2019-ncov media hype-and restoring hope incidence of thrombotic complications in critically ill icu patients with covid-19 prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia a pathological report of three covid-19 cases by minimally invasive autopsies epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study cutaneous manifestations in covid-19: a first perspective key: cord-279056-mmcoqtb5 authors: seirafianpour, farnoosh; sodagar, sogand; mohammad, arash pour; panahi, parsa; mozafarpoor, samaneh; almasi, simin; goodarzi, azadeh title: cutaneous manifestations and considerations in covid‐19 pandemic: a systematic review date: 2020-07-08 journal: dermatol ther doi: 10.1111/dth.13986 sha: doc_id: 279056 cord_uid: mmcoqtb5 background: covid‐19 had a great impact on medical approaches among dermatologist objective: this systematic review focuses on all skin problems related to covid‐19, including primary and secondary covid‐related cutaneous presentations and the experts recommendations about dermatological managements especially immunomodulators usage issues method: search was performed on pubmed, scopus, embase and sciencedirect. other additional resources were searched included cochrane, who, medscape and coronavirus dermatology resource of nottingham university. the search completed on may/03/2020. 377 articles assigned to the inclusion and exclusion groups result: eighty‐nine articles entered the review. primary mucocutaneous and appendageal presentations could be the initial or evolving signs of covid‐19. it could be manifest most commonly as a maculopapular exanthamatous or morbiliform eruption, generalized urticaria or pseudo chilblains recognized as “covid toes” (pernio‐like acral lesions or vasculopathic rashes). conclusion: during pandemic, non‐infected non‐at risk patients with immune‐medicated dermatologic disorders under treatment with immunosuppressive immunomodulators are not needed to alter their regimen or discontinue the therapies. at‐risk and infection‐suspected patients needed to dose reduction, interval increase or temporary drug discontinuation (at least 2 weeks). patients with an active covid‐19 infection should hold the biologic or non‐biologic immunosuppressives until the complete recovery occur (at least 4 weeks). this article is protected by copyright. all rights reserved. totally there were 453 articles with 76 duplicate data that were deleted. 377 articles were screening by the authors. from 377 articles, 240 article were met exclusion criteria in the first step. and, 39 article met exclusion criteria in the second step. 89 articles were met inclusion criteria. 27 articles were about cutaneous manifestation of covid-19; from them, 19 articles were case-reports and 8 articles were case-series. you can see the details in figure 1 (in the supplement file). in table 1 and 2, we summarized case reports and case series of primary cutaneous covid-19-related reactions, respectively. in table 3 , you can see cutaneous drug reactions related to covid-19 treatment, till to our systematic search. since there are wide categories of proposed drugs for treatment of covid-19, in table 8 (in the supplement file) the most prevalent and important cutaneous adverse reactions of these drugs is visible according to tursen, u et al. review had done on all covid-19 drugs skin reaction (8) . totally 5 article were about skin drug reactions of covid-19 treatments; two of them were original studies as case reports that were summarized in table 7 (in the supplement file). also, in sharma, ajay n et al. and jakhar, d et al. studies, adverse effect of hydroxychloroquine were reviewed (2, 9) . 11 articles were about skin injuries among medical staff fightingcovid-19 & general population and usable recommendation about skin care in this global crisis that summarized in table 3 . and in table 4 , prevalence of areas affected by secondary skin complications were recorded. also, 46 articles were about concerns in management of immune-based dermatologic disorders and autoimmune rheumatologic disorder and collagen vascular disease, and immunomodulator treatments in this pandemic. 26 of them don't have certain usable recommendation and 20 of them had specific advice that reported in table 5 .table 6 (in the supplement file) shows our exact search strategy. eczema not reported *frequent use of emollients/ *use soap-free cleanser; synthetic detergents have a neutral or slightly acidic ph and have relatively high free fatty acid content/ *use alcohol-based cleansers or other antibacterial hand rub/ *use lukewarm water (45°c-50°c)/ *use paper towels drying of hands after washing instead electric air dryers/ *apply an ointment-based emollient during work time after hand washing and after work, at home/ *avoid a water-based moisturizer/ *avoid coming into direct contact with chemicals that are used for surface disinfection/ *use anti-inflammatory topical medication under the supervision of a specialist (59) dermatologic patients postpone initiation of biologic treatments in icular period this part the lack of sufficient data concerning the interaction of sars-cov-2 and biologics is also an important factor that should be taken into consideration when examining the option of initiating therapy with the latter. another logistic parameter that should not be underestimated is the need of frequent careful monitoring under such treatments that includes both regular laboratory examinations as well as routine dermatologic follow-up visits, which could constitute a problem under the emerging societal circulatory restrictions that are posed in order to control the pandemic unnecessary biologic discontinuation would lead to a worsening of psoriasis and psoriatic arthritis in a high percentage of the cases. as a consequence, there may be higher disease n, destructive impact on quality of life, burde as well as increased health care costs due to the augmented number of consultations and recovery. furthermore, the unavoidable subsequent return to biologic therapy could be cost associated with switching toward higher known lower efficacy of -drugs, due to the well biologics in the same patient after their interruption coronavirus widespread quickly across the world and in the march 2020,who announced the pandemic condition (11) . there is necessity to paying more attention to skin and its appendix (hair, nail) and the mucosal manifestation of covid 19 also being more aware of them and updates our knowledge according to the latest reports. these manifestations could be the presenting signs of covid19 which may help for early disease diagnosis. in addition, we had many concerns about patient who are suffering from chronic dermatologic disorders which needed to have repeated follow ups or who are on immunomodulator agents specifically immunosuppressives that are needed to be controlled without any more risk to getting infected with covid19 or getting involved with its consequences. this article is protected by copyright. all rights reserved. according to the study which has done among 88 positive patients with covid19, in italy, 20.4 % of patient had skin manifestation that the most common manifestation was erythematous rash or patchy exanthematous red rash. also, there was urticarial eruption that could be localized or widespread, and 1 case of chickenpox-like blisters. the most involved area was trunk and all of the lesions were pruritic. there was not no any relation between disease severity and skin manifestations (29) . in a study carried out in france between 103 patients, skin manifestations were seen in 5(4.9 %), which were red rashes or urticarial rashes, mostly in the face and upper trunk. and there was a case of hsv-1 in an intubated patient (33) . there were reports of covid19 patients with mottling or livedo-reticularis (lr) that could be because of disseminated intravascular coagulation (dic) (18) . transient lr have been also seen in 2 covid19 patients who weren't in bad general condition (18) . petechial skin rash (dengue-like) could be considered as a presenting sign of covid19, like acute hemorrhagic edema of infancy (10) . symmetrical pruritic papules on both heels which were confluent yellowish-erythematous in color appeared 13 days after symptoms onset of covid19 in a 28-year-old previously healthy woman,that gradually became erythematous hardened pruritic plaques (10) . acroischemic lesions (pseudo-chilblain or pernio-like lesion) or "covid toe" which are micro thrombotic presentations of covid occur in both children and adolescents when they are in good health condition, and the main affected parts were the feet and hands. the color of lesions were red and purple or blue and they could become blistering or having a black crust (68) . in a study of 63 patients who complained about chilblain like lesions in italy, the range of patient's age was 12-16 years old, and the most affected area was the feet (85.7 %), then the both hands plus feet in the second place (7%), and next the only hands (6%). most this article is protected by copyright. all rights reserved. lesions were erythematous edematous, and in blistering form. most of the cases were in good general conditions, some of the patients were sympotomatic as, gastrointestinal (11.1%) , respiratory (7.9%) or febrile (4.8%) before showing skin manifestations. it was not possible to perform confirmatory tests for sars-cov-2 in all patients, but in those who did (18 cases), 4 of them turned positive. a study stated the hypothesis of chilblain-like lesions could be occur because of delayed immune reaction to covid-19 in genetically prone ones (32) . a similar study with these finding performed in spain (14) . in a case series of 14patients, 11 children with average age of 14.4 years and 3 adult patients with average age of 29 years were reported, they did not have any systemic symptoms except cough and fever in 3 cases from 3 weeks before skin eruption onset. the morphology of rash was a red-purple maculopapular eruption on the feet, hand of both sides and in 2 children papular targetoid lesions appeared on the hands and the elbow after few days. the rash diminished without any treatment during 2-4 weeks. the tests of 4 of them showed a negative result for covid19 (35) . acral ischemic lesions, 2 healthy young females who complained of bilateral papules on the dorsum of their fingers in a red-purple color reported, a 35-year-old patient had another complaint about diffuse redness under the nail of her right thumb. they both confirmed for having sars-cov-2 (13) . digit ischemia may happen due to transient increase in antiphospholipid antibodies in severe illnesses or in viral disorders (69) . another assumption was that this digit ischemia could be related to immunological mechanism or prothrombotic activation states (14) . pruritic lesions in severe covid-19related respiratory failures revealed an inflammatory thrombogenic vasculopathy with trace amount of c5b_9 and c4d depositions (22) . maculopapular lesions which were fixed erythematous blanching on the trunk and limbs presented 2 days after onset of covid infection symptoms in a 57 years old woman with not any significant past medical history (12) . this article is protected by copyright. all rights reserved. in another case who was a 48 years old man with htn, 3 days after onset of fever, the macules, papules and petechial lesions appeared in a symmetric pattern in buttocks, popliteal fossae, proximal anterior thighs, and the lower abdomen. the petechial lesions were similar to parvovirus b19 infection (70) . in a 6 years old boy after 14-16 days' work-up for fever and elevated liver enzymes, erythematous, nonpruritic maculopapular rashes appeared first in the trunk and neck and then gradually spread to the other areas. the lesions diminished with no specific therapies after 5 days (28) . a 32 years old healthy female, 6 days after symptomatic current corona virus infection presented with generalized progressive maculopapular and petechial lesions in a reddish base that by the time became scaly, more itchy and less erythematous (71) . in the most cases of maculopapular lesions palmoplantar region and the mucosa were spare. a 60-year old man with a history of flulike symptoms and positive covid19 infection experienced sudden disseminated red macular lesions which turned into papules on bilateral flank, groin ,back and proximal lower extremities (17) . in a 71-year old caucasian woman scattered maculopapular eruption (morbilliform) with cervical lymphadenopathy ,fever and cough was seen in addition to hemorrhagic macular exanthem on the legs (16) . pruritic papulovesicular lesions was seen in a 72 years old woman who had a history of flu-like symptoms 4 days before skin rash appearance and the rash was on sub-mammary folds, hips and trunk (16) . petechial lesions have been seen in above case and another one in thailand who misdiagnosed as dengue fever (70, 72) . digitate papulosquamous lesions occurred in a hospitalized old man who infected with covid 19. the initiate periumbilical scaly patches widespread rapidly toward flank and thigh and the other areas, some of them were only papular. the lesions resembled pityriasis rosea and diminished suddenly in 7 days (73) . a 34 months old child with conjunctivitis and eyelid dermatitis confirmed sars-cov-2 in china (15) . acute urticaria and low-grade fever was noticed in 2 months girl lasted 4 days, and spread in few hours from face and upper extremities toward lowers limbs and trunk (28) . a 27 years old previously healthy women who complained of diffuse arthralgia, odynophagia and pruritic reddish plaque in the acral area and the face proceed by fever ,chills and chest pain (11) . urticaria have been seen in a female patient who just had dry cough in the past days and her ct scan confirmed the covid19 infection (20) . also in a 61 years old spanish md male patient, progressive pruritic urticarial lesions manifested which lasted about 10 days without no other symptoms (27). a 60-year old woman with a history of flu-like and gastrointestinal symptoms 9 days ago, presented to dermatology department with complaint of diffuse urticarial plaques on the trunk, head and limbs (17) . about febrile rash it could be say that in a 39 years old male patient with 39 °c fever and rashes which appeared at the same time of the fever onset presented, the lesions morphology were red, annular, stable plaques in neck, chest, abdomen, upper limbs and palms without involvement of face and the mucosa. the rash were edematous and erythematous and non-pruritic. he had no medication use in recent days and weeks before initiation of rash (74) . varicella-like exanthema was foun in a 8 years old girl who had only mild cough 6 days before papulovesicular skin rash starts which had a symmetrical and bilateral pattern on the trunk. the test of she and her family confirmed for sarscov-2.the lesions diminished after a week (75) . morbilliform exanthema presented in a 58 years old man who complained about cough and pain in limbs, the physician prescribed azithromycin and benzonatate for him and after a few days, pruritic progressive erythematous macule appeared in upper and lower limbs, neck and shoulders and trunk which had morbilliform pattern and through the time, lesions expanded and confluent as patches more than 10 cm on the trunk (24). this article is protected by copyright. all rights reserved. a 20 years old healthy male who complained of 6-day lasting fever and rash presented to emergency department and admitted in icu. he had spreading nonpruritic maculopapular morbilliform rash on her trunk and limbs, respecting face, mucosa and the eyes. his covid19 confirmed in day 2 (21). skin rash in infants of positive covid-19 mother, none of infant had positive test result among those who have been tested (3 of 4), 2 of the infant had two different patterned rashes, one of them diffuse red maculopapules and the other had ulceration on the forehead. their rash diminished without any treatment (20) . erythematous rash appeared 4 days after fever and asthenia in a 64 years old woman used oral paracetamol, the erythematous rash extended to the both antecubital fossa, axillary area and the trunk. the rash disappeared in 5 days with no specific treatment while continuing paracetamol intake .the patient's covid19 infection confirmed with positive rt-pcr (19) . malar eruption, a 26 years old man, a known case of crohn disease, who had a history of close contact to a covid19 patient, developed sore throat, anosmia, ageusia, mild dry cough, malaise and chest congestion in the past 2-3 week , who presented with asymptomatic red and edematous malar eruption on his face with a low grade fever and mildly tender large cervical lymph node (25) . c. galván casas summarized prevalence of different skin lesions of covid19 based on a study among 375 patients in spain: maculopapular lesions 47%, urticarial eruption 19%, acral erythematous lesions with pustule or vesicle (chilblain like lesion) 19%, other vesicular lesions 9%, and livedo reticularis 6% (1). there were several drug regimens used for treatment of covid-19 patients, some of which could result in cutaneous side effects like presence of a new dermatoses or flare/aggravation of a previous dermatologic disorder. till to the last update of this systematic review, generalized pustular reaction and exacerbation of psoriasis due to hydroxychloroquine were the reported cases of cutaneous adverse reaction of covid-19 treatment (35, 36) (supplementary table 7 ). the following is the most common adverse reactions found in the publications irrespective of this pandemic, yhat could be in mind for better dermatologic disease approaching (supplementary table 8 ). hydroxychloroquine; despite the inconclusive result over the implication of anti-malarial drugs; it is used widely for treating covid-19 patients. in a study by sharma et al., a total of 21 unique dermatologic reactions were reported in 3578 patients had hydroxychloroquine cutaneous adverse drug reactions. the most common was drug eruptions as in maculopapular, erythematous, and urticarial dermatosis. hyperpigmentation came second followed by pruritis, sjs/ten and agep(acute generalized exanthematous pustulosis) (2) . dermatologists should consider the covid-19 cutaneous manifestations such as erythematous rash, petechia, urticaria as differential diagnosis while assessing the possible hydroxychloroquine drug reactions (29) . azithromycin; azithromycin is another drug used in combination with hydroxychloroquine in covid-19 treatment regimens. skin adverse events of it may include cutaneous severe skin reaction associated fever, generalized red or purple skin rashes, angioedema, blisters, skin peeling, burning sensation in eyes or painful skin (76) . antiviral drugs; several antiviral drugs are used for its treatment as well; including oseltamivir which could result in sjs/ten, angioedema and idiosyncratic cutaneous drug reactions. ribavirin also may cause alopecia, acneiform eruptions, maculopapular and eczematous lesions, localized scleroderma, skin dryness and rash. other anitiviral drugs such as antiretrovirals are also used in some patient including lopinavir and ritanavir. their adverse effects my presented as maculopapular drug eruptions, exfoliative erythroderma, sjs/ten, severe cutaneous drug reactions, injection site reactions (8, 77) . in overall, non-infected non-at risk patients with immune-medicated dermatologic disorders under usage of immunosuppressive immunomodulator drugs like biologic agents are not needed to be alter regimen or discontine the therapies during pandemic, even these drugs may control the deteriorating cytokine storms also prevented disease flare-ups which both were associated with poorer outcomes and more complications in covid-19 course, although strict adherence to quarantine and personal-social preventive hygiene performances are highly recommended especially in these groups of patients. but in patients who are living in highly prevalent disease area, showing flu like or covid-19 specific symptoms (anosmia or asthenia) or who are highly suspected to having had any positive exposures, based on the consult with their physician and considering all circumstances, it is better to have changing in their therapeutic regimens as dose reduction, dose interval increase or temporary discontinuation. patients with an active covid-19 infection should hold the biologic or non-biologic immunosuppressants until the complete recovery (at least 4 weeks). in patients who were symptomatic but were no definite cases, therapies should stop for at least 2 weeks. most of skin diseases which were treated with systemic immunomodolators were usually associated with more severe covid-19 morbidity. dermatologic disorders which were associated with metabolic syndrome, older age or vital organ comorbidities in particular respiratory disorders like patients with psoriasis, hidradenitis suppurativa and atopic tendencies may have poorer prognosis if become infected. patients with more severe skin disorders (e.g. severe psoriasis) were in higher risk for developing pneumonias by any cause that is of great importance in this pandemic. in overall these group of patients may benefit more from future sars-cov-2 vaccination. since the chronic nature of this pandemic, specialists should decide based on recent evidence with regard to case-by case variations considering cost-benefit ratio and also disease psychological burden (48, 56, 65, 78, 79) . biologic immunomodulators especially tnf-a inhibitors, janus kinase (jak) inhibitors, anti-il 6 (tocilizumab) may capable to control cytokine storms and it was systemic consequences like ards and etc in covid-19 course and some trials were conducted to evaluate their efficacy in disease management, so patients who are using these drugs do not be needed to disrupt (80) . here in we discuss about experts' recommendations of management of specific cutaneous diseases during pandemic: *virus could act as target mimicry in immunobullous disorders and may trigger or aggravate disease course but it is not recommended to do not treat properly, since poor disease control have its own consequences; even probable more severe and complicated covid-19 infection; due to deregulated inflammatory storms. *there were not exact data about incidence of covid-19 in psoriatic patients who are under treatment *risk of hospitalization or death is were not higher than normal population in psoriasis patients under treatment with immunomodulators by itself, but psoriasis may be associated with comorbidities like metabolic syndrome especially in elderly people that is associated with higher mortality rate of covid-19 infection * monotherapy with immunosuppressives, targeted therapies and lack of comorbidities predict the lower associated risk of covid-19 complications in psoriatic patients classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases. the british journal of dermatology characterizing the adverse dermatologic effects of hydroxychloroquine: a systematic review should patients stop their biologic treatment during the covid-19 pandemic the prompt use of rituximab could decrease adverse effects in patient with pemphigus vulgaris: a preliminary evaluation occupational skin disease among health care workers during the coronavirus (covid-19) epidemic an assessment of united states dermatology practices during the covid-19 outbreak teledermatology: a useful tool to fight covid-19 cutaneous side-effects of the potential covid-19 drugs potential of chloroquine and hydroxychloroquine to treat covid-19 causes fears of shortages among people with systemic lupus erythematosus cutaneous manifestations in covid-19: a new contribution urticarial eruption in covid-19 infection cutaneous lesions in a patient with covid-19: are they related? the british journal of dermatology a case of covid-19 presenting in clinical picture resembling chilblains disease. first report from the middle east chilblain-like lesions on feet and hands during the covid-19 pandemic a child confirmed covid-19 with only symptoms of conjunctivitis and eyelid dermatitis. graefe's archive for cutaneous manifestations of covid-19: report of three cases and a review of literature dermatologic findings in two patients with covid-19 a dermatologic manifestation of covid-19: transient livedo reticularis a distinctive skin rash associated with coronavirus disease journal of medical virology. 2020. 21. hunt m, koziatek c. a case of covid-19 pneumonia in a young male with full body rash as a presenting symptom. clinical practice and cases in emergency medicine complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases. translational research : the journal of laboratory and clinical medicine infants born to mothers with a new coronavirus (covid-19). front pediatr. 2020;8:104. 24. najarian dj. morbilliform exanthem associated with covid-19 covid-19 can present with a rash and be mistaken for dengue": petechial rash in a patient with covid-19 infection cutaneous manifestations in the current pandemic of coronavirus infection disease (covid 2019) cutaneous manifestations in covid-19: a first perspective characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak clinical and histopathological study of skin dermatoses in patients affected by covid-19 infection in the northern part of italy chilblain-like lesions during covid-19 epidemic: a preliminary study on 63 patients cutaneous manifestations in covid-19: a first perspective " by 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experience antipsoriatic treatments during covid-19 outbreak successful guselkumab treatment in a psoriatic patient affected with cornelia de lange syndrome, and prosecution during the covid-19 pandemic biologic therapy for psoriasis during the covid-19 outbreak: the choice is to weigh risks and benefits no evidence of increased risk for covid-19 infection in patients treated with dupilumab for atopic dermatitis in a high-epidemic area systemic isotretinoin therapy in the era of covid19 the authors contribute equally to all stages of this study. the team has reviewed the manuscript and the data, and all contributors were in full agreement. the authors declare there is no conflict of interest in this study.funding: this study had no funding. key: cord-344566-r75o7ips authors: temiz, selami aykut; dursun, recep; daye, munise; ataseven, arzu title: evaluation of dermatology consultations in the era of covid19 date: 2020-05-22 journal: dermatol ther doi: 10.1111/dth.13642 sha: doc_id: 344566 cord_uid: r75o7ips it has been reported that dermatology practices may be a vector for sars‐cov‐2 transmission and elective cases should be postponed during the pandemic period. in this context, studies on the change of patient profile in dermatology outpatient clinic have been conducted. however, there was no study in the literature about dermatology consultations during the pandemic period. 147 dermatology consultation cases in the era of covid‐19 pandemic between march 11, 2020 and may 4, 2020 were retrospectively evaluated. 24 patients (16.3%) had suspicion and signs of covid during consultation (fever, cough, shortness of breath, etc.). 9 (37.5%) of these patients also had accompanying covid‐19 skin lesions (2 urticarial lesions, 2 livedo and necrosis, 2 maculopapular eruption, 2 vesicular rashes, 1 pseudo‐chilblain). the number of cases that were suspected to have covid‐19 was statistically significantly higher in consultations requested by the emergency department and intensive care unit, while there were no suspected cases in outpatient clinic consultations (p = 0.001). 2 (1.4%) of these patients were diagnosed with covid‐19 confirmed by pcr within 2 weeks. we acknowledge that daily practice changes frequently during this period, but still our study provides a perspective to other dermatology clinics in terms of the requested dermatology consultations during the pandemic. this article is protected by copyright. all rights reserved. in december 2019, unexplained cases of viral pneumonia began to be reported in china, after which it was identified as a new coronavirus pathogen (sars-cov-2) and the disease was called coronavirus disease 2019 (covid-19) (1). on march 11, 2020 , world health organization (who) reported covid-19 as a pandemic. as of may 4, 2020, the who reported nearly 3,559,225 cases and 249,520 deaths attributed to covid-19 worldwide (2) . in the literature, disease-related skin lesions have been reported in approximately 20% of covid-19 patients (3) . it has been reported that dermatology practices may be a vector for sars-cov-2 transmission and elective cases should be postponed during the pandemic period (4) . in this context, studies on the change of patient profile in dermatology outpatient clinic have been conducted (5, 6) . during the pandemic period, the use of teledermatology was recommended in dermatology consultations (7) . however, there was no study in the literature about dermatology consultations during the pandemic period. in our study, we wanted to evaluate the features such as how dermatology consultations were affected during the covid-19 pandemic, which is well established in our daily practice, features of the patients consulted, and skin findings in patients with suspected disease. this study was conducted at the necmettin erbakan university hospital, a major tertiary hospital and sees over 1,200,000 patients per year. dermatology consultation cases in the era of covid-19 pandemic between 11 march 2020 and 4 may 2020 were retrospectively evaluated. all consultations were done in a standard face-to-face examination. the age, gender, the clinic asking for the consultation, reasons for consultation, examination findings, the symptoms, recommended therapies, covid-19 suspicion, and urgency of cases were recorded by searching the hospital automation system and patient files. then, these patients were followed up from their medical records and checked for sars-cov-2 positivity at this incubation period. our study was approved by the ethics committee of the commission for scientific research of the ministry of health of the republic of turkey, required for covid 19 studies in turkey. local ethics committee approval was also obtained for the study. data analysis was performed using the spss 22.0 program. mean ± standard deviation and percentage were used for descriptive statistics. chi-square test was performed and the p value of less than 0.05 was accepted as statistically significant. over the period from march 11th 2020 to may 4th 2020, 147 dermatology consultations were evaluated. the mean age of patients was 46.2±26.1 (1 month-90 years old). female patients had a slight predominance (52,4%vs47,6%). 29 patients (19.7%) were referred from pediatrics units and 118 patients (80.3%) from departments concerning adult diseases. consultations were requested for 72 patients (49%) from inpatient clinics, 43 patients (29.3%) from outpatient clinics, 17 patients (11.5%) from intensive care unit and 15 patients (10.2%) from emergency department. distribution of the clinics that requested a consultation is provided in table 1 . considering the diagnosis groups in consultations, skin infections were found in 41 patients (27.9%). the diagnoses made during consultations are provided in table 2 . as a result of these consultations, 82 patients (55.8%) were offered systemic treatment and 63 patients (42.9%) were recommended local treatment. a total of 35 patients (23.8%) underwent invasive procedures including 16 patients who underwent skin biopsy, 10 patients who underwent native examination, 8 patients who underwent a pathergy test and 1 patient who underwent cryotherapy. 24 patients (16.3%) had suspicion and signs of covid during consultation (fever, cough, shortness of breath, etc.). 9 (37.5%) of these patients also had accompanying covid-19 skin lesions(2 urticarial lesions, 2 livedo, 2 maculopapular eruption, 2 vesicular rashes, 1 pseudochilblain). the number of cases that were suspected to have covid-19 was statistically significantly higher in consultations requested by the emergency department and intensive care unit, while there were no suspected cases in outpatient clinic consultations (p=0.001). table 3 shows the distribution of cases suspected of having covid-19 according to the consultation locations. 2 (1.4%) of these patients were diagnosed with covid-19 confirmed by pcr within 2 weeks. teledermatology was suitable for 107 patients (72.8%), and 40 patients (27.2%) needed a standard face-to-face examination due to the requirement of invasive and face-to-face procedures. only 11 patients (7.5%) required urgent intervention. the aim of dermatology consultation is to identify skin diseases, identify skin lesions secondary to treatment and diseases and to warn the concerned clinician about the skin lesions that can be a part of the diagnosis of a systemic disease (8) . according to the studies involving dermatology consultations before the pandemic in the literature, jack et al. (9) reported that the mean patient age was 43±14 and mirkamali and al. (10) reported the same to be 40±21. in our study, the mean age of the patients was 46±26, which was higher compared to the studies performed before the pandemic. this was thought to be due to the fact that elective patients were discharged during the pandemic period and patients who required urgent care, elderly patients and those who had comorbidities remained in the hospital. similar to pre-pandemic dermatology consultations, the ratio of males and females were found to be nearly the same in our study (8, 9, 10, 11) . considering the dermatology consultations that took place before the pandemic, it was reported that pediatric patients constituted nearly 11 to 33% of all dermatology consultations (8, 12) . 19.7% of our cases were dermatology consultations requested from pediatric departments. once again, considering the dermatology consultations requested in the pre-pandemic period, nearly 60-70% were outpatient clinic consultations (8, 11, 12) . only 29.3% of our cases were outpatient clinic consultations, wherein consultations were mostly requested by the inpatient clinics (49%) and intensive care unit (11.5%). this was also thought to be due to the lower number of elective patients and operational outpatient clinics during the pandemic period. it was reported that skin infections constituted approximately one-third of the diagnoses made during dermatology consultations before the pandemic (8, 9, 10, 11) . according to our findings, the most common consultation result was skin infection (27.9%), which was consistent with pre-pandemic literature, but there was a noticeable reduction in the said rate.drug reactions accounted for nearly 10% of the cases according to the pre-pandemic literature (8, 9, 10, 11, 12) . the same rate was found to be 18.4% in our study, showing that the rate of drug reactions increased during the pandemic. with respect to the dermatology consultations in the pre-pandemic literature, it was found that a skin biopsy was performed on 4-13% of the patients (8, 9, 10, 11, 12, 13) . 10.9% of our patients underwent a biopsy, which was consistent with the pre-pandemic literature. an invasive procedure (biopsy, native, pathergy, cryotherapy) was performed in 23.8% of our cases. while examination of the skin and mucosa already constitutes a risk for covid-19 infection, the risk is significantly higher in case of invasive procedures. of all consultations, 24 (16.3%) patients were suspected of having covid-19. the number of such cases was significantly higher in emergency department and intensive care unit consultations. this data shows that dermatologists should be more careful in the pandemic period, especially in emergency department and intensive care consultations. in a study conducted in italy, cutaneous symptoms were detected in 18 (20.4%) patients among 88 patients with covid-19 (14) . cutaneous symptoms can be classified under five main categories (urticarial lesions, livedo and necrosis, maculopapular eruption, vesicular rash, pseudo-chilblain) (3). in our study, cutaneous symptoms were present in 9 (37.5%) of the 19 patients who were suspected of having covid-19. however, it would not be accurate to make a comparison with the literature, since only two of our patients had covid-19 confirmed by pcr. teledermatology is the evaluation of patient images and clinical information via electronic transfer without face-to-face interviews. it is recommended to use teledermatology in dermatology practices during the covid-19 pandemic (7) . use of face-to-face interviews for each patient instead of teledermatology increases the risk of infection for both patients and physicians. unfortunately, teledermatology is not yet fully implemented in our country, and its legal infrastructure is not fully formed. teledermatology was suitable in 72.8% of our cases, and this high rate suggested that teledermatology could significantly reduce the risk of disease transmission when used in dermatology consultations. further studies to be conducted after the end of the covid-19 outbreak will help us better understand the outcomes of teledermatology and standard face-to-face examination in terms of the risk of infection in dermatology consultations. during the covid-19 pandemic, dermatology consultations continue to guide many clinics in terms of diagnosis, treatment and complication follow-up. our study is important in that it is the first study in the literature that investigated dermatology consultations during the covid-19 pandemic. we acknowledge that daily practice changes frequently during this period, but still our study provides a perspective to other dermatology clinics in terms of the requested dermatology consultations during the pandemic. this article is protected by copyright. all rights reserved. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases dermatology practices as vectors for covid-19 transmission: a call for immediate cessation of non-emergent dermatolgy visits which dermatology patients attend to dermatology outpatient clinics during the sars-cov-2 outbreak in turkey and what happened to them global coronavirus pandemic (2019-ncov): implication for an italian medium size dermatological clinic of a ii level hospital teledermatology: a useful tool to fight covid-19 analysis of consultation cases referred from pediatrics department to dermatology outpatient clinic: retrospective study cutaneous conditions leading to dermatology consultations in the emergency department dermatological emergencies: a comparative study of activity in 2000 and 2010 dermatologists in hospital wards: an 8-year study of dermatology consultations analysis of pediatric dermatology inpatient consultations in a pediatric teaching hospital.arch argent pediatr evaluation of emergency dermatological consultations in a tertiary care centre in north india cutaneous manifestations in covid-19: a new contribution key: cord-323965-6mzzibj8 authors: kapoor, krishan mohan; chatrath, vandana; boxley, sarah gillian; nurlin, iman; snozzi, philippe; demosthenous, nestor; belo, victoria; chan, wai man; kanaris, nicole; kapoor, puneet title: covid‐19 pandemic: consensus guidelines for preferred practices in an aesthetic clinic date: 2020-05-16 journal: dermatol ther doi: 10.1111/dth.13597 sha: doc_id: 323965 cord_uid: 6mzzibj8 background: strict infection control measures in response to the current covid‐19 pandemic are expected to remain for an extended period. in aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. in such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. methods: an online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. the meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from sars‐cov‐2 infection. results: consensus guidelines for ‘preferred practices' were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. procedures were categorized into low‐risk, moderate risk, and high‐risk based on the likelihood of transmission of sars‐cov‐2 virus from the patient to the treating physician or therapist. conclusions: while not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. since guidelines regarding safety measures and use of ppes may vary from country to country, the local guidelines should also be followed to prevent covid‐19 infection in aesthetic clinics. this article is protected by copyright. all rights reserved. the current global pandemic of the sars-cov-2 virus that causes covid-19 respiratory tract infection 1 2 3 is likely to last for a long time. most of the countries have imposed lockdowns 4 and introduced strict infection control measures. the reopening of society is likely to happen slowly and in a phased manner while keeping a focus on the strict infection control measures in the times ahead 5 . appropriate precautions, up to date knowledge, and strict safety measures will be needed, not just when the lockdowns are eased in most countries 6 but also for the entire duration of the pandemic. there is a likelihood of patient overload during this period, and staying prepared is going to be the right strategy for this situation 7 . the safety precautions need to be extended much beyond the lockdown period in every country. no laxity in these precautions should be allowed to happen even if the curve of covid-19 cases flattens or falls near the baseline. while many medical practices are being run with online consultations 8 , aesthetic clinics come in a category of medical services where most of the procedures are provided on one to one basis by a doctor/ therapist. many countries have decided to allow the opening of practices requiring one-on-one contact like dental, physiotherapy, aesthetics, provided they strictly follow the guidelines detailing the infection control measures 9 10 . aesthetic clinics across the world are uncertain about the safe reopening and running of their businesses and the safety measures needed to protect their staff and patients from covid-19 infection. a set of consensus guidelines for 'preferred practices' in aesthetic clinics is proposed in this paper for maintaining a high level of safety for the patients coming to the clinic for treatment as well as for the doctors/ therapists performing the procedures. multiple factors could lead to transmission of covid-19 from a patient to the healthcare worker and vice versa, especially in an aesthetic clinic. • coughing or sneezing by patients and accompanying persons in the waiting areas 11 . speaking loudly or deep breaths also generate aerosols. • small procedure rooms 12 with limited or no natural ventilation • central air conditioning having a single cooling unit and multiple room vents in most aesthetic clinics, without hepa (high efficiency particulate air) filtration as present in most operating rooms 13 • inadequate distance between the patient and treating doctor or therapist 14 • some of the procedures could take a long time with a patient, e.g., full face ultherapy treatment, whole body laser hair reduction • repeated handling of equipment like touch screen, desktop, patient chairs by doctor/therapist and initial screening and handling of patient forms, cash, credit card by the front office staff the consensus group comprised of ten experts in the field of aesthetic medicine (one plastic surgeon, four dermatologists, and five aesthetic physicians), having experience in the working and administration of an aesthetic clinic. the participating members of the consensus group were from india, united kingdom, philippines, australia, sweden, norway, switzerland, and south africa. an online meeting of the consensus group members was held on april 27, 2020, using zoom online app. following items were proposed to all the participants, and a consensus was sought to establish the 'preferred practices' guidelines during the meeting.: guidelines for patient scheduling 2. patient evaluation and triaging; patient categorization 3. guidelines for risk categorization and safety precautions for the aesthetic procedures 4. guidelines for staffing in the aesthetic clinics guidelines for general housekeeping in the aesthetic clinics a 'consensus reached' was considered when at least 70% of participants agreed on the points discussed. the consensus group decided to provide guidelines on ways to reorganize the aesthetic practices while simultaneously instituting safety measures. the government and the health authorities in each country are likely to review the infection control strategy and measures regularly, and new updates may come in the future 16 . although cases of covid-19 infection can happen despite strict measures, the infection is less likely to spread in aesthetic practices with the proposed infection prevention measures. each aesthetic clinic must assess its business model and local conditions and accordingly adopt these guidelines into its daily functioning. in addition to the infection control measures listed in this article, the requirements and precautions advised by the public health authority of their respective country must be followed by the clinic patient scheduling is a critical step for the safety of patients, doctors, therapists, and clinic support staff. sticking to the guidelines for 'social distancing' will ensure safety for everyone present in the clinic. advance scheduling should be made compulsory and walk-in patients should be discouraged. the the staff should be trained to take the necessary information on the phone at the time of giving an appointment. this information should be rechecked when the patient arrives in the clinic. for unscheduled walk-ins, history taking becomes even more critical and must be done at the time of arrival. temperature recording with handheld, non-contact thermometers can be used for screening. however, they could be impractical not only due to a shortage of locally available equipment, and patients taking paracetamol to bring down the fever before arrival but also for suspected covid-19 patients who do not exhibit any fever 18 . experienced staff should be deputed to take the patient's history of travel, occupation, contact, and cluster (tocc), and a declaration form along with a written informed consent document (table 1) can be used to ascertain the following points 19 . t-travel history including a detailed itinerary, transit locations and date of return o -occupation of the patient and spouse/ partner to be asked to check if it is a high-risk profession c-a history of exposure to a test positive covid-19 case should be asked after categorization of the patients based on tocc history and presence or absence of signs/symptoms, only patients in category a are to be taken up for an elective aesthetic procedure with due precautions, as shown in figure 1 . the procedures performed in an aesthetic clinic (office-practice) have been categorized by the expert panel as low-risk, moderate-risk, and high-risk based on the likelihood of transmission of the sars-cov-2 virus from the patient to the treating physician/therapist while performing the procedure. this categorization is based on the assumption that all the patients seen in the aesthetic clinic could be asymptomatic carriers until proven otherwise. this assumption has to be made until the time covid-19 testing of all patients coming to the aesthetic clinics is done as part of the initial screening process. this article is protected by copyright. all rights reserved. the factors taken into account by consensus group for the risk categorization of the procedures werethe type of procedure (aerosol-generating procedure versus non-aerosol generating procedure), body part on which the procedure is being performed (face/body)and the duration of the procedure. contact with mucosa/saliva, body secretions during the procedure, minimally invasive or non-invasive nature of the procedure, and ability of the patient to be masked or not were also considered as important factors for risk categorization (table 2 ) ( figure 5 ). the aerosol producing procedures have the highest risk 20 21 22 , and the long duration of a procedure also increases the risk due to longer contact time with the patient 23 . similarly, procedures involving the middle and lower part of the face would not allow the patient to be masked at the time of the procedure, thus increasing the potential for transmission to the treating physician 22 . based on the categorization, guidelines for ppe were also given ( table 3) . the general guidelines for aesthetic procedures also included minimum conversations with the patient during the procedure, not allowing the patient attendant to be in the procedure room, and also avoid the helping staff/nurse to be in the procedure room while the procedure is being performed, if possible. try to minimize the duration of the procedure where possible to reduce exposure time 24 . cleaning of all surfaces (procedure chair/bed, inspection lights, instrument tray/trolley) and the apparatus being used with sterilizing solution should be done after each procedure 25 . for lhr, all the patients should be asked to shave at home and come for the procedure to reduce contact time with the staff. lip injections with soft-tissue fillers would require that patients be asked to rinse the mouth with 1.5% hydrogen peroxide or 0.2% povidone-iodine for 1 minute right before the procedure 26 . the high-risk procedures may be deferred for sometime after lockdown is lifted in the respective countries 24 . however, when the high-risk procedures are performed, certain procedure-specific steps will be required in addition to the recommendations provided for the moderate risk procedures. for example, when aerosol-generating lasers are used, a cover with a transparent membrane such as polyvinyl clingfilm should be encouraged to reduce the splatter of the aerosolized cellular debris (like for tattoo removal with q-switched lasers), keeping in mind the potential power loss when the laser passes through the membrane 27 . additionally, one can use plume evacuation systems with filters that remove particulates up to 0.1micrometer, known as a ulpa ( ultra-low particulate air) filter. 28 the consensus was that the older staff members (>60 years) or those with associated comorbidities like diabetes, pulmonary conditions, cardiac conditions should be given leave or given work in areas with limited patient contact 29 . staff can be posted for shorter working hours than usual and should be called in rotation 30 . at any given time, 33% to 50% of staff should be working at the clinic 31 . staff must get training in donning and doffing of personal protective equipment and should be provided with appropriate ppe 32 33 . the staff should be encouraged to do frequent hand washing with soap and water for at least 20 seconds. in between, hands disinfectants can also be used. the staff should get training for phone booking, patient interviews on the phone, documentation of patient details and history, getting informed consent signed, social distancing, and hand hygiene 34 (figure 2 ). the following guidelines apply to sanitation and logistics for aesthetic clinics. • security desk: security guards at the entrance should wear surgical masks and maintain a two-hourly handwash protocol. the physical distance of at least 1 m should be maintained 36 . • sanitizing stations: special stations should be installed at clinic entrances, registration counters, and other high contact surfaces for hand sanitization (preferably contact-less) ( figure 4 ). shoe-covers should be available for clients at the clinic entrance so that they do not bring in the fomites with their shoe soles. surgical masks and caps should also be provided at the entrance for clients who come in without wearing a mask 37 . • seating arrangement: chairs in the waiting area should be spaced about 2 meter apart ( figure 3 ). in case of joined seating, distance seating could be maintained by strapping down alternate seats in the middle using ribbons or tape, making them unfit for use 38 . • waiting area decongestion: waiting area congestion can be avoided by scheduling appointments with appropriate turnaround time between two patients. the clients could also be asked to wait in their vehicles if they arrive before the appointed time or until the doctor is ready to see them. • • non-essential material: care must be taken to remove all non-essential material like brochures, magazines, and newspapers from the offices and waiting rooms, as these could be a potential source of contamination. the staff should be trained to use electronic modes of information sharing like e-mail, this article is protected by copyright. all rights reserved. o outdoor areas: outdoor areas of the clinic would need less intense disinfection by being exposed to sunlight and air currents. however, cleaning and disinfection of frequently touched surfaces should be carried out here as well. o patient examination tables or procedure chairs: these should preferably be covered with disposable sheets, which must be discarded after each use 49 . in case disposable sheets are not available, cotton sheets could be used and machine-washed with a regular detergent after every use. mattresses and edges of the tables and examination/procedure chairs must be sanitized using a 60-70% alcoholbased sanitizer. if that is not available, then a 1% sodium hypochlorite solution could be used. • food/beverages & pantry: pantry utensils for the staff should be disposable. clients should be encouraged to carry their water bottles with them. the practice of serving tea, coffee, and other beverages should be discouraged. pantry area should be disinfected every two hours, and items like tea kettle handles and external surfaces should be disinfected after each use. during covid-19 pandemic, strict patient screening, social distancing, use of ppes, and taking extra precaution during 'high risk' aesthetic procedures can help in keeping patients as well the clinic staff safe from covid-19 infection. the patients with minimum risk of transmitting covid-19, based on the risk categorization, can be taken for elective aesthetic procedures. appropriate use of ppes and other precautions can be taken by treating clinic staff as per the risk category of the aesthetic procedure. the 'preferred practices' suggested by the consensus group provide the basis for sound infection control for aesthetic clinics, though these may not be complete or exhaustive. in addition to the consensus guidelines, those provided by the health authorities in each country should also be followed. this article is protected by copyright. all rights reserved. protective equipment as per the consensus recommendations for a "low-risk" procedure. in this instance, as the treatment area is the upper face, the patient is also able to wear a face mask (contributed by wai man chan) footer-* the site at which the procedure is being performed, especially mid and lower face, prohibits the use of a mask by the patient. since social distancing can also not be maintained, it potentially increases the probability of transmission. **contact with oral mucosa/ secretions and genital mucosa/ secretions. ems-electromagnetic muscle stimulation, lhr-laser hair reduction, prp-platelet-rich plasma, agp-aerosol generating procedure, hifu-high intensity 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and its influence on the development of new antiseptic strategies stability and inactivation of sars coronavirus disinfection and sterilization in healthcare facilities. bennett brachman's hosp infect sixth ed aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents name & address of the clinic name of the patient: age of the patient: name of spouse/ partner: name of accompanying person/ persons present residential address: permanent residential address: occupation of the patient: occupation of the patient's partner: ., hereby declare that the information provided is complete and accurate. i fully understand that any false information can put the healthcare workers attending to me at a high risk of contracting covid-19 disease. i fully agree to follow all the instructions regarding precautionary steps by dr……………………………… and the staff at the clinic. i am visiting the clinic with full knowledge that we are going through a covid-19 global pandemic. there is always a risk of contracting this virus when i am visiting a place during this pandemic. there is a possible risk of getting this virus by visiting any place during this pandemic. i have been fully explained the content of this declaration form in a language that i can understand. 