Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 1 Comparative Evaluation of Dermatological Emergency Consultations in the Coronavirus Pandemic Era: Tertiary Clinic Experience Berkay Temel1, Ozge Mine Orenay1, Nermin Karaosmanoglu1 1 Department of Dermatology, Ministry of Health, Ankara Training and Research Hospital, Ankara, Turkey Key words: covid, consultation, emergency, dermatology Citation: Temel B, Orenay OM, Karaosmanoglu N. Comparative evaluation of dermatological emergency consultations in the coronavirus pandemic era: Tertiary clinic experience. Dermatol Pract Concept. 2023;13(1):e20230112. DOI: https://doi.org/10.5826/dpc.1301a112 Accepted: June 16, 2022; Published: January 2023 Copyright: ©2023 Temel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Berkay Temel, MD, Adress: Department of Dermatology, Ministry of Health, Ankara Training and Research, Hospital. Sakarya Mahallesi, 89, Ulucanlar Caddesi, 06230, Altındağ/ Ankara, Turkey. Phone number: +905058190789 E-mail: berkaytemel42@gmail.com Introduction: Due to the increase in COVID-19 patients during the pandemic, the workload of emergency departments has increased. The profile of patients seeking non-COVID medical care has changed significantly because of the pandemic; this includes dermatological emergencies. Objective: The aim was to evaluate and compare adult dermatological emergency consultations during the COVID-19 period with the pre-pandemic period. Methods: Consulted patients from ED to dermatology between March 11, 2019, and March 11, 2021 were included (Pre-pandemic and pandemic). Age, gender, zone of triage, consultation hour, consulta- tion date, consultation response time, ICD-10 codes were recorded. Results: The total number of consultations was 639. The mean age of the patients was 44.4 in the pre-pandemic period and 46.1 in the pandemic period. The mean consultation response time was 44.4  minutes in the pre-pandemic period and 60.3 minutes in the pandemic. In the pre-pandemic period, the most common consulted diseases were herpes zoster, urticaria, and allergic contact derma- titis. During the pandemic, the most common consulted diseases were herpes zoster, other dermatitis, and urticaria. There was a statistically significant difference in the incidence of other dermatitis, impe- tigo/folliculitis, cutaneous vasculitis, and pruritus (p<0.05) Conclusions: Emergency departments are the busiest and fastest areas of the hospital. Pandemics such as COVID-19 may also occur in the coming years. Informing society about dermatological emergencies and adding adequate dermatology training to the training of emergency physicians will facilitate appropriate patient management in emergency departments. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 Introduction On March 11, 2020, the World Health Organization de- clared the Coronavirus disease 19 (COVID-19) outbreak as a pandemic, reporting more than 118,000 cases and 4,291 deaths in 114 countries [1]. The rapid spread of COVID-19 all over the world hit health systems hard and prompted many countries to take various measures that aimed to limit the spread of the virus and reduce the number of patients and deaths [2]. The health system, which was rebuilt under the influence of the pandemic, affected every medical depart- ment including the dermatology and emergency departments (ED). Almost most of the dermatology inpatient services were reserved for COVID-19 patients, and the number of patients in dermatology outpatient clinics was restricted by health authorities to reduce the spread of the virus [3]. Therefore, the number of dermatologic patients who applied to clinics during the pandemic period decreased, and in ad- dition to this decrease, fear of contracting COVID-19 and skin conditions related to COVID-19 (vesicular eruptions, petechial/purpuric rashes, acral lesions, livedoid lesions, urti- carial rash, and maculopapular-erythematous rash) changed the profile of faced dermatological diseases [3-5]. During the pandemic, many COVID-19 patients were first evaluated in hospital EDs. Because of this, the workload in ED increased significantly. There have been many studies investigating the impact of the pandemic on the ED. These studies showed that the number of non-COVID-19 patients admitted to the ED decreased and their disease profiles changed [6,7]. Despite these studies, studies on dermatolog- ical diseases consulted from emergency services were limited [8,9]. This study aimed to evaluate adult dermatological emergency consultations during the COVID-19 period and to compare them with the pre-pandemic period. Material and Methods Study Design, Patient Selection and Variables Patients who were consulted to the dermatology clinic by the adult emergency department between March 11, 2020, and March 11, 2021 (pandemic period) and the same dates of the previous year (pre-pandemic period) were included in this study. The dividing point for the pre-pandemic and pan- demic period was chosen on March 11, 2020, the day when COVID-19 was declared as a pandemic all over the world. This study was conducted in the Dermatology Clinic of An- kara Training and Research Hospital, which is a tertiary clinic in Turkey. Local ethical approval was obtained for this study. Age, gender, zone of triage, consultation hour, consul- tation date, consultation response time, and International Classification of Diseases, Tenth Revision (ICD-10) codes were recorded from hospital electronic medical records. Zone of triage was determined as green (simple health con- ditions that present as an outpatient, are stable in general condition and can be treated on an outpatient basis), yel- low (conditions with potentially life-threatening, risk of limb loss and significant morbidity) red (conditions that are life-threatening and require a rapid aggressive approach and urgent simultaneous evaluation and treatment). In our center, consultations requested from the adult emergency between 08:00 and 16:00 are evaluated in outpatient clinics. Between 16.00-08.00, a doctor is assigned to the inpatient clinic for consultation. Consultation time was divided into three time periods 08.00-16.00, 16.00-00.00, and 00.00-08.00. The consulted diseases were classified according to ICD-10 codes. These were dermatitis, infection diseases, hypersensi- tivity diseases, inflammatory diseases, autoimmune bullous disease, and others. The subgroup disease profile was also determined under these headings one by one. Bullous disor- ders with extensive involvement, angioedema, erythroderma, toxic epidermal necrolysis, Steven Johnson’s syndrome, pus- tular psoriasis with metabolic complications were accepted as true dermatological emergencies [10]. These data were evaluated and compared according to pre-pandemic and pandemic periods retrospectively. Statistical Analysis Research data was evaluated via Statistical Package for the Social Sciences (SPSS.22, IBM SPSS Statistics for Windows, Version 22.0. Armonk, New York: IBM Corp.). Descriptive statistics were recorded as mean (±) standard deviation, fre- quency distribution, and percentage. Normality analyses of the data were carried out with the Shapiro-Wilk test. For cat- egorical variables, whether there is a difference in frequency between groups was compared using Pearson chi-square. The t-test was used to evaluate normally distributed means. Mann-Whitney U test was used to evaluate not normally distributed means. The statistical significance value of this study was accepted as p<0.05. Results Main Characteristics of Pre-Pandemic and Pandemic Period Consultations The total number of consultations during the pre-pandemic and pandemic period was 639. It was determined that 467 consultations were requested in the pre-pandemic 1-year period, while 172 consultations were requested in the pan- demic 1-year period. It was found that consultations de- creased by 63.1% during the pandemic period. The mean age of the patients in the pre-pandemic period was calculated as 44.4±18.6. In the pandemic period, the mean age was cal- culated as 46.1±18.2. There was no statistically significant difference between the periods in terms of mean age (p=0.31) Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 3 (Table 1). 47.3% (n=221) of the patients evaluated in the pre-pandemic period were male and 52.7% (n=246) were fe- male. During the pandemic period, 51.2% (n=88) were men and 48.8% (n=84) were women. There was no statistically significant difference in terms of gender (p=0.38) (Table 1). In the pre-pandemic period, 40.3% (n=18) of the consulta- tions were requested from the green zone, 50.7% (n=237) from the yellow zone and 9% (n=42) from the red zone. In the pandemic period, 25% (n=43) were requested from the green zone, 64.5% (n=111) from the yellow zone and 10.5% (n=18) from the red zone. There was a statistically significant difference between the periods in terms of green and yellow triage zones (p=0.01) (Table 1). In the pre-pandemic period, 40% (n=187) of the con- sultations were requested between 08.00- 16.00, 51.2% (n=239) between 16.00-00.00 and 8.8% (n=41) between 00.00-08.00. In the pandemic period, 45.9% (n=79) of the consultations were requested between 08.00-16.00, 41.3% (n=71) between 16.00-00.00 and 12.8% (n=22) between 00.00-08.00. There was a statistically significant difference between the periods in terms of 16.00-00.00 consultation time (p=0.04) (Table 1). The mean consultation response time in the pre-pandemic period was 44.4 minutes. It was 60.3 minutes during the pandemic period. There was no sta- tistically significant difference between the periods in terms of consultation response time (p=0.52) (Table 1). 6 (1.3%) of the patients in the pre-pandemic period and 1 (0.6%) of the patients in the pandemic period were hospitalized. There was no statistically significant difference between the peri- ods in terms of hospitalization rates (p=0.34) (Table 1). In the pre-pandemic period, consultation was most requested in August 2019 (n=55) and least in September 2019 (n=25). During the pandemic period, consultation was most re- quested in July 2020 (n=35) and least in January 2021 (n=2) (Figure 1). Comparison of Pre-Pandemic and Pandemic Period Disease Profiles In the pre-pandemic period, the three most commonly con- sulted diseases were herpes zoster, urticaria, and allergic contact dermatitis. In the pandemic period, the three most consulted diseases were herpes zoster, other dermatitis, and urticaria. There was a statistically significant differ- ence between the periods in terms of the incidence of other dermatitis, impetigo/folliculitis, cutaneous vasculitis, and pruritus (p=0.01, 0.02, 0.03, 0.01) (Table 2). True dermato- logical emergencies were detected in 37 (7.9%) patients in the pre-pandemic period and 13 (7.6%) patients in the pan- demic period. There was no statistically significant difference between the periods in terms of dermatological emergencies (p=0.86) (Table 1). Discussion The COVID-19 pandemic has deeply affected the health sys- tem of every country. During the pandemic period, emergency departments became the first points of contact for COVID-19 patients. Therefore, the number and profile of non-COVID-19 patients admitted to the emergency department changed. In this study, the dermatology consultations requested from the adult emergency department during the pandemic period were examined and compared with the pre-pandemic period. Table 1. Characteristics of study. Pre-Pandemic (n=467) Pandemic (n=172) pvalue Age, mean ±Std 44.4±18.6 46.1±18.2 0.31* Gender, n (%) Male Female 221 (47.3) 246 (52.7) 88 (51.2) 84 (48.8) 0.38** Triage Zones, n (%) Green Yellow Red 118 (40.3)a 237 (50.7)a 42 (9)a 43 (25)b 111 (64.5)b 18 (10.5)a 0.01** <0.05 <0.05 >0.05 Consultation time 08.00-16.00 16.00-00.00 00.00-08.00 187 (40)a 239 (51.2)a 41 (8.8)a 79 (45.9)a 71 (41.3)b 22 (12.8)a 0.04** >0.05 <0.05 >0.05 Consultation response time, min 44.4 60.3 0.52*** Hospitalization, n(%) 6 (1.3) 1 (0.6) 0.34* True Dermatological Emergency,n (%) 37 (7.9) 13 (7.6) 0.86* Std: Standart Deviation, min: minute, *: T-test, **: Chi-square test, ***: Mann Whitney Utesta,b: Each subscript letter denotes a subset of pandemic status categories whose column proportions do not differ significantly from each other at the 0.5 levels. 4 Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 0 10 20 30 40 50 60 M ar ch 2 01 9 A p ri l 2 01 9 M ay .2 01 9 Ju n e 20 19 Ju ly 2 01 9 A u g u st 2 01 9 Se p te m b er 2 01 9 O ct o b er 2 01 9 N o ve m b er 2 01 9 D ec em b er 2 01 9 Ja n u ar y 20 20 Fe b ru ar y 20 20 M ar ch 2 02 0 A p ri l 2 02 0 M ay .2 02 0 Ju n e 20 20 Ju ly 2 02 0 A u g u st 2 02 0 Se p te m b er 2 02 0 O ct o b er 2 02 0 N o ve m b er 2 02 0 D ec em b er 2 02 0 Ja n u ar y 20 21 Fe b ru ar y 20 21 M ar ch 2 02 1 Number of Patients Figure 1. Distribution of the Number of Patients by Month. Table 2. Comparison of Diseases Profile. Diseases, n (%) Pre-Pandemic Pandemic P-value* Dermatitis Irrıtant contact dermatitis Allergic contact dermatitis Dermatitis, others 73 (15.6) 13 (2.8) 39 (8.4) 21 (4.5) 35 (20.3) 4 (2.3) 8 (4.7) 23 (13.4) 0.3 0.96 0.11 0.01 Infection Diseases Impetigo/folliculitis Cellulitis Dermatophytosis Herpes Simplex Herpes Zoster Leishmaniasis Scabies Syphilis 223 (47.7) 28 (6) 25 (5.4) 12 (2.6) 8 (1.7) 125 (20.8) 1 (0.2) 22 (4.7) 2 (0.4) 84 (48.8) 3 (1.7) 13 (7.6) 5 (2.9) 0 (0) 50 (29.1) 1 (0.6) 12 (7) 0 (0) 0.96 0.02 0.29 0.81 0.08 0.56 0.46 0.25 0.39 Hypersensitivity Diseases Urticaria Angioedema Insect Bite Maculopapular Drug Eruption Erythema Multiforme 115 (24.6) 53 (11.3) 29 (6.2) 11 (2.4) 14 (3) 8 (1.7) 42 (24.4) 16 (9.3) 13 (7.6) 7 (4.1) 6 (3.5) 0 (0) 0.9 0.46 0.54 0.24 0.5 0.08 Inflammatory Diseases Psoriasis Pityriasis Rosea Cutaneous Vasculitis Behcet Disease 25 (5.3) 8 (1.7) 10 (2.1) 5 (1.1) 2 (0.4) 8 (4.6) 1 (0.6) 1 (0.6) 6 (3.5) 0 (0) 0.87 0.28 0.17 0.03 0.54 Autoimmune Bullous Disease 8 (1.7) 0 (0) 0.08 Others Leg Ulcer Alopecia Areata Acne Vulgaris Pruritus 23 (4.9) 1 (0.2) 2 (0.4) 3 (0.6) 17 (3.6) 2 (1.2) 2 (1.2) 0 (0) 0 (0) 0 (0) 0.32 0.12 0.39 0.290.01 Total 467 (100) 172 (100) *: Chi-squaretest Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 5 compared to the pre-pandemic period. Similar results were obtained by Neslihan Ogut et al. [8]. During the COVID-19 pandemic, countries started to take measures quickly, the most important of which was the curfew. The curfew was im- posed on all weekends and weekdays between 21.00-05.00 in our country. We thought that this situation caused a change in consultation hours. Emergency departments are one of the most crowded places in hospitals that work 7 days and 24 hours. Turkey has the world’s highest number of emergency department visits annually: some 100 million. The high number of pa- tients, especially in our country, is one of the risk factors for transmission during the COVID-19 pandemic. In our study, it was found that consultation response time increased during the pandemic period compared to the pre-pandemic period (44.4 minutes vs 60.3 minutes). Both the working of dermatology physicians in the COVID departments and the increase of COVID patient load on emergency departments should have increased the consultation response time. The prolongation of the consultation response time increased the length of stay of the patients in emergency departments and this situation could have increased the non-COVID patient burden on emergency departments. Along with the pandemic, the distribution of the number of patients by month also changed. Demirel Ogut et al. [8] reported that the number of patients decreased in March 2020, April 2020, and May 2020 compared to 2019, and the number of patients started to increase as of June 2020. A similar trend was obtained in our study. Interestingly, in our study, the number of patients decreased as of July 2020, and the number of patients in 2019 could never be reached. In our country, full or partial curfews were implemented to coincide with the periods when the number of patients de- creased. We thought that this result was caused by the cur- fews and travel bans during the pandemic period Pandemic period studies showed that the profile of the disease consulted from emergency departments has changed  [8,9]. In Isoletta et al.’s study, although urticaria, atopic eczema and acute onset infections were reported to be the most frequently consulted diseases during the pan- demic period, urticaria, vasculopathic lesions and scabies were found to be statistically significantly higher compared to the pre-pandemic period [9]. In Demirel Ogut et al’s study, although contact dermatitis, scabies and urticaria were re- ported to be the most frequently consulted diseases during the pandemic period, scabies and pityriasis rosea were found to be statistically significantly higher and herpes zoster was found statistically significantly lower compared to the pre-pandemic period [8]. In addition to obtaining similar re- sults, the rate of pruritus and impetigo/folliculitis was statis- tically significantly lower in our study. These results showed that non-urgent situations decreased during the pandemic There were numerous published studies evaluating der- matologic emergency consultations in the pre-pandemic pe- riod. The mean age of the patients included in these studies was between 43-51. The rate of male patients was between 47-62% [11-15]. As expected, similar findings were found in the pre-pandemic period of our study. In pre-pandemic period studies, the most frequently con- sulted diseases were non-specific dermatitis, scabies, con- tact dermatitis, herpes zoster, superficial fungal infections, maculopapular drug eruptions, urticaria, erysipelas/cellulitis and cutaneous vasculitis [11-15]. However, the incidence of the aforementioned diseases varied in these studies. Similar diseases were also consulted in the pre-pandemic period of our study. Bullous disorders with extensive involvement, an- gioedema, erythroderma, toxic epidermal necrolysis, Steven Johnson’s syndrome, pustular psoriasis with metabolic com- plications were defined as a true dermatological emergency in Gupta et al’s study [10]. On the other hand, Murr et al. defined diseases that started or flared up for 5 days as der- matological emergencies [16]. In pre-pandemic period stud- ies, similar to our results, true dermatological emergencies were between 6-24.7% of the consulted diseases [11,12,15]. It was clearly seen that the rate of real dermatological emer- gencies among the diseases consulted from the emergency department to dermatology was quite low. We thought that this situation was caused by the fact that public and emer- gency physicians did not know which dermatological disease was a true emergency. There were few studies investigating the impact of the COVID-19 pandemic on dermatology consultations re- quested from emergency departments [8,9]. These studies showed that the number and mean age of consulted patients decreased and the rate of male patients increased during the pandemic period [8,9]. However, our study showed that the mean age of the patients during the pandemic period was higher. On the other hand, Demirel Ogut et al. [8] reported that the rate of hospitalizations and true dermatological emergencies decreased during the pandemic period. Similar results were obtained in our study. Emergency department triage systems facilitate the categorization of emergency pa- tients according to their disease severity and determine both treatment priority and treatment location [17]. In our study, while the rate of patients consulted from the yellow zone increased during the pandemic period, the rate of patients consulted from the green zone decreased. This showed that the number of unnecessary consultations decreased during the pandemic period. We thought that these situations were caused by the fear of infection and the curfews. In this study, consultations requested between 08.00-16.00 increased and the consultations requested be- tween 16.00-00.00 decreased during the pandemic period 6 Original Article | Dermatol Pract Concept. 2023;13(1):e20230112 period. In our study, as in other studies [8, 9], diseases previ- ously associated with COVID-19 disease and vaccines such as herpes zoster, cutaneous vasculitis and urticaria were listed. Emergency department physicians should be careful about these diseases and COVID-19 should be investigated. Limitations This study had some limitations. The study was retrospec- tively planned from a single care center. The diagnoses of the patients were made according to ICD-10 codes. There may have been person-based errors in adding the diagnostic codes to the system. More than one doctor was evaluating the consultations. In this case, there may be conflicts about the accuracy of the diagnoses. However, to correct this situa- tion, the diagnosis is confirmed by a second doctor. Conclusion This study showed that the prolongation of the consultation response time increased during the COVID-19 pandemic pe- riod. The distribution of the number of patients by month changed, and the number of patients decreased as of July 2020. The profile of dermatological diseases consulted from the emergency department also has changed. During the pan- demic period, non-urgent conditions such as impetigo/fol- liculitis and pruritus decreased. Emergency departments are the busiest and fastest areas of the hospital. Pandemics such as COVID-19 may also occur in the coming years. Inform- ing the public about dermatological emergencies and adding adequate dermatology training to the training of emergency physicians will facilitate appropriate patient management in emergency departments. References 1. 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