key: cord-305234-nclk7bbo authors: do, mytrang h.; minkis, kira; petukhova, tatyana a.; lipner, shari r. title: strategies to prevent sars-cov-2 transmission during dermatologic head and neck surgery date: 2020-06-27 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.983 sha: doc_id: 305234 cord_uid: nclk7bbo nan . furthermore, the patient's mouth and nose are often exposed we hope that these suggestions provide the best possible protection for dermatologic efficiency particle air, rt-pcr, reverse transcription-polymerase chain reaction, sars-cov-2, 81 severe acute respiratory syndrome coronavirus 2 head and neck surgery is a high-risk procedure for covid-19 87 transmission and there is a need for a preventive strategy to protect professionals detection of sars-cov-2 in different types of clinical 4. american college of surgeons. covid-19: considerations for optimum surgeon 19/clinical-guidance/surgeon-protection american academy of dermatology. reopening the dermatologic surgery office in the key: cord-285691-pceenwb6 authors: falo, louis d. title: advances in skin science enable the development of a covid-19 vaccine date: 2020-05-30 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.126 sha: doc_id: 285691 cord_uid: pceenwb6 nan expressing adenovectors and adjuvant in the same mnas resulting in a vaccine that induced both antibody responses and enhanced cytotoxic cellular immunity that is likely important for "universal" vaccines and cancer immunotherapies. taken together, these and studies by others demonstrate the potential for the development of cutaneous immune engineering strategies to control systemic immune responses including the potential for developing novel vaccine strategies and immunotherapies, and even negative immunization strategies to treat systemic allergy and autoimmune diseases. advances in skin biology are making important contributions to the fight against the covid-19 pandemic demonstrating once again that dermatology is more than skin deep. the immunological anatomy of the skin antigen-presenting cells in the skin microneedles for drug and vaccine delivery microneedle array delivered recombinant coronavirus vaccines: immunogenicity and rapid translational development improved cutaneous genetic immunization by microneedle array delivery of an adjuvanted adenovirus vaccine key: cord-301478-j4b2534p authors: gisondi, paolo; zaza, gianluigi; del giglio, micol; rossi, mattia; iacono, valentina; girolomoni, giampiero title: 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 date: 2020-04-21 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.085 sha: doc_id: 301478 cord_uid: j4b2534p nan manuscript words: 493 13 we performed a retrospective observational study in order to determine whether hospital and compared to the verona population (n=257,353) ( table 1 ). the overall study 60 population is resident in verona, so that its reference hospital is the same. data of verona 61 residents were derived from national public database. 4 data are expressed as means ± 62 sd or percentages. statistical analyses for comparison between patients and general 63 population included the unpaired-t test, and theχ2-test. 64 as of april 10, 2020, the total number of covid 19-positive patients (including 65 those that did not require hospitalization or die) in verona was 3,199 (1.2% of population). -legend: * asymptomatic individuals were not tested so the true number of covid-19 positive patients is unknown; cni: calcineurin inhibitors; mtori mammalian target of rapamaycin; psa: psoriatic arthritis; pso: psoriasis data of psoriasis and transplant patients are derived from electronic medical record of the hospital. data of general population are derived from https://www.azero.veneto.it/-/emergenza-coronavirus and https://www.epicentro.iss.it and http://demo.istat.it accessed on 10th april 2020. guidance on the use of biologic agents during covid-19 outbreak american academy of 93 dermatology should patients stop their biologic treatment during the 95 covid-19 pandemic should biologics for psoriasis be 97 interrupted in the era of covid-19? key: cord-276147-30buoweg authors: avancini, joao; miyamoto, denise; arnone, marcelo; villas-boas gabbi, tatiana; ferreira, paula silva; neta, cyro festa; sanches, jose antonio title: absence of specific cutaneous manifestations of sars-cov-2 in a reference center in brazil date: 2020-09-15 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.09.030 sha: doc_id: 276147 cord_uid: 30buoweg nan contents of the manuscript have not been previously published and are not currently submitted elsewhere. i accept responsibility for the scientific integrity of the work described in this manuscript. all listed authors have seen and approved of the manuscript and will sign off on any subsequent manuscript revisions. j o u r n a l p r e -p r o o f (clean version) to the editor: we read with interest the letters from the new york city report regarding the absence of covid toes lesions on their patients and the recommendation of caution when concluding that cutaneous findings are specifically due to the severe acute respiratory syndrome coronavirus 2 (sars-cov-2). 1, 2 since the global pandemic of sars-cov-2, the university of sao paulo medical school hospital -a reference center and one of the largest university hospitals in latin america -re-organized its structure, offering about 300 intensive care units and 500 nursery beds fully dedicated to sars-cov-2. five staff members of the dermatology department were exclusively assigned to assist the admitted patients that covid toes: phenomenon or epiphenomenon? caution in the time of rashes and covid-19 cutaneous manifestations in patients with covid-19: a preliminary review of an emerging issue classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases key: cord-262311-vdbk50pl authors: grant-kels, jane m. title: response to “risks of hydroxychloroquine use for covid-19 prophylaxis” date: 2020-04-26 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.112 sha: doc_id: 262311 cord_uid: vdbk50pl nan prophylaxis" hcq has been demonstrated to be anti-viral but is also known for its successful antiinflammatory actions that has resulted in it being used extensively in autoimmune diseases; it can significantly decrease the production of cytokines and, in particular, proinflammatory factors. 7. although the rheumatologic literature has demonstrated that hcq is less toxic than chloroquine and a very safe medication, prolonged use and overdosing can still cause problems for our patients; major concerns surround the potential for ventricular arrhythmias, qt prolongation, and other cardiac toxicities. i applaud those at the front line trying desperately to help those suffering with this virus. a recent wall street journal article reported data compiled from the global rheumatology alliance (a coalition of rheumatologists) that more than five dozen "people taking hydroxychloroquine and other treatments for chronic rheumatologic diseases have become infected with covid-19, according to an analysis of emerging data that is a sign the drugs may not protect people from the new coronavirus." 8. these findings cast doubt on the effectiveness of hcz prophylaxis. risks of hydroxychloroquine use for covid-19 prophylaxis does hydroxychloroquine combat covid-19? a timeline of evidence hydroxychloroquine in the management of critically ill patients with covid-19: the need for an evidence base hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: an observational study efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial bell cl hydroxychloroquine in the treatment of rheumatoid arthritis hydroxychloroquine and other autoimmune drugs don't fully protect against coronavirus, early data suggest key: cord-011451-nnunjora authors: kolitz, elysha; smith, austin; taylor, oliver; mauskar, melissa m.; goff, heather title: “considerable unreimbursed medical care is delivered through electronic patient portals: a retrospective review” date: 2020-05-19 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.054 sha: doc_id: 11451 cord_uid: nnunjora nan we conducted a retrospective review to assess patient-initiated messages on the online portal 37 used in the dermatology clinic at ut southwestern medical center called "mychart. and medical history questionnaires. the message type was verified, and medical advice requests 50 were reviewed independently by each author. encounters where physicians managed the entire 51 patient complaint through the mychart portal were considered as separate electronic e&m 52 services of the patient's concern utilizing the cms guidelines and thus potentially eligible for 53 provider reimbursement. 54 55 there was a steady rise in patient-initiated mychart encounters each year (figure 1 ). contact 56 hours and patient clinic encounters also rose during this same time period, but the rise in 57 messages outpaced the time spent in face-to-face care (figure 2 ). in our sample, 58% of the 58 messages were medical advice requests and 30.75% of all messages met criteria for separate 59 e&m services via the portal. other categories of messages included 22% for appointment 60 changes, 13.50% for history questionnaires, and 6.5% for medication refill requests. 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 the new england journal of medicine sampling techniques. 2 nd ed medicare telemedicine health care provider fact sheet cpt® codes (99421-99423) -and payment for -online digital evaluation and 126 management (e/m) services. codingintel covid-19 public health emergency key: cord-263664-isgcm4lj authors: lee, justin; yousaf, ahmed; fang, wei; kolodney, michael title: male balding is a major risk factor for severe covid-19. date: 2020-07-22 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.062 sha: doc_id: 263664 cord_uid: isgcm4lj nan this manuscript is original, has not been published before, and is not being considered for publication elsewhere. we know of no conflicts of interest associated with this publication and there has been no financial incentive for this work that could have influenced results. as the corresponding author, i can confirm that the manuscript has been read and approved for submission by the other named authors. informed consent was obtained from all participants registered with the uk biobank. 3 options included the following text: pattern 1 "no hair loss," pattern 2 "slight hair loss," pattern 3 "moderate hair loss," pattern 4 "severe hair loss." 4 covid-19 testing was carried out on symptomatic patients per national health service guidelines 5 . descriptive frequencies for covid-19 results, balding patterns, age, and bmi are reported in our study compared a large sample of hospitalized covid-19 positive patients to a control group of hospitalized covid-19 negative patients and thus builds upon and supports the observations of wambier 1 and coauthors. a notable limitation of our work is that balding data was self-reported. while the exact mechanism remains unknown, severe androgenic alopecia seems to be associated with hospitalization for covid-19. the large effect of baldness on the risk of covid-19 suggests that the presence of severe baldness may help clinicians and public health authorities identify and protect those at greatest risk. figure 1. descriptive frequencies for covid-19 testing results, balding patterns, age, and bmi. androgenetic alopecia present in the majority of hospitalized covid-19 patients -the "gabrin sign a preliminary observation: male pattern hair loss among hospitalized covid-19 patients in spain -a potential clue to the role of androgens in covid-19 severity male pattern baldness: classification and incidence resource 100423 screenshot from touchscreen questionnaire used to capture field 2395. uk biobank coronavirus staff guidance inpatient testing protocol key: cord-261929-x688qqdr authors: geskin, larisa j.; trager, megan h.; aasi, sumaira z.; bickers, david r.; carvajal, richard d.; nghiem, paul; taback, bret; zeitouni, nathalie c.; samie, faramarz h. title: perspectives on the recommendations for skin cancer management during the covid-19 pandemic date: 2020-05-06 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.002 sha: doc_id: 261929 cord_uid: x688qqdr nan therapy-related travel for the high-risk category (high-risk cscc, invasive, thick and 56 ulcerated melanoma, mcc, tumors with aggressive histology or in sensitive areas) must be 57 weighed against each patient's risks. for rapidly growing cscc, particularly of the head and 58 neck (eyes, ears, lips, mouth) and symptomatic lesions, more immediate treatment may be 59 considered. mms may be utilized for high-risk scc and rare cancers (including undifferentiated 60 pleiomorphic sarcoma and adnexal tumors with concern for rapidly developing metastasis). to telemedicine visits should be prioritized, limiting in-person visits for biopsies of highly 71 suspicious lesions and for in-office therapies for the highest-risk cancers. this pandemic presents 72 evolving challenges, and we must continue to provide optimal treatment for our patients while 73 preventing global spread of the disease and preserving resources. managing cancer care during the covid-79 19 pandemic: agility and collaboration toward a common goal a new evidence-based risk 82 stratification system for cutaneous squamous cell carcinoma into low, intermediate, and high risk 83 groups with implications for management key: cord-318033-vlwlgp82 authors: su, mack y.; das, shinjita title: expansion of asynchronous teledermatology during the covid-19 pandemic date: 2020-08-18 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.08.054 sha: doc_id: 318033 cord_uid: vlwlgp82 nan person visits at our institution in april 2020 (n=67) represented less than 1% of the volume in april 2019 (n=7919; table 1 ). meanwhile, 1564 virtual visits were conducted in april 2020 compared to 0 in april 2019. asynchronous teledermatology visits also increased, driven primarily by evisits. in april 2020, 197 evisits were conducted compared to only 3 in april 2019, when the program was in a pre-pilot phase with only one dermatologist testing evisits. despite significant nationwide reductions in ambulatory visits 5 , provider-to-provider dermatology econsults increased by more than 20% from april 2019 to april 2020. importantly, the growth of evisits and econsults resulted in asynchronous teledermatology accounting for 1 in 5 of all dermatology visits conducted at our institution in april 2020 ( figure 1 ). teledermatology was our lifeline for maintaining patient care while physical clinics were closed. even as clinics re-open, we encourage dermatologists to consider maintaining teledermatology as part of their practice in order to improve patient access and staff productivity and remain at the forefront of the changing healthcare delivery landscape. more specifically, our experience shows that asynchronous teledermatology has the potential to facilitate routine dermatology care and thus open in-office availability for more urgent issues. currently, limited reimbursement and efficacy data for asynchronous teledermatology have prohibited its widespread adoption. to address this, we advocate for more investigation of asynchronous teledermatology, including patient/provider satisfaction and patient outcomes. dermatology practices as vectors for covid-19 transmission: a call for immediate cessation of nonemergent dermatology visits teledermatology in the era of covid-19: experience of an academic department of dermatology clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial implementation and evaluation of stanford health care direct-care teledermatology program the impact of the covid-19 pandemic on outpatient visits: a rebound emerges key: cord-274696-h7kihj9w authors: piccolo, vincenzo; bassi, andrea title: acral findings during the covid-19 outbreak: chilblain-like lesions should be preferred to acro-ischemic lesions date: 2020-05-22 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.077 sha: doc_id: 274696 cord_uid: h7kihj9w nan we read with great interest the recent paper by fernandez-nieto et al published in jaad 1 . the authors report a case series of 132 patients with acute acro-ischemic lesions affecting nonhospitalized patients during the covid-19 outbreak. the same cutaneous findings have been described all over the world, including a preliminary study conducted by ourselves 2 . in their paper, fernandez-nieto et al repeatedly use the appellative "acro-ischemic" for this cutaneous manifestation. moreover, they hypothesize a relationship between a covid-19-related altered coagulation profile and these acral lesions. as the authors state, true ischemic lesions have been reported in severely-ill patients with proven coronavirus infection 3 . although the comparison between acral lesions in asymptomatic patients and ischemic lesions in severe cases is important, we find the term "acute acro-ischemic lesions" not accurate. patients present with painful or itchy erythematous-edematous lesions of the extremities, sometimes evolving to blistering. this presentation is similar to what it is commonly seen in chilblains. the word "chilblains" itself etymologically refers to cold exposure (chill = cold, blain = sore). the term chilblain-like lesions, in our opinion, therefore would be preferable for the lesions that present in these patients rather than acro-ischemic lesions. in addition, histopathology of these lesions is quite similar to chilblains, with an absence of true necrosis; this is different to what it is typically found in hospitalized patients 4 . although the exact pathogenesis of this cutaneous sign is not known yet, a worldwide common nomenclature would in our opinion be a good starting point in order to avoid confusion among clinicians. characterization of acute acroischemic 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 covid-19) infectioninduced chilblains: a case report with histopathological findings key: cord-252521-m7asfqva authors: shah, monica; naik, haley b.; alhusayen, raed title: hidradenitis suppurativa: the importance of virtual outpatient care during covid-19 pandemic date: 2020-05-01 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.142 sha: doc_id: 252521 cord_uid: m7asfqva nan division of dermatology, department of medicine 12 1 in addition to preventing the spread of infection, the role of the dermatologist is also to provide 33 appropriate care to patients with skin disease to prevent complications, and to lower the burden on the consulted with ed physicians for hs symptoms (of which, 36% consulted with more than 10 ed 45 physicians), and 30% made 10 or more trips to the ed in the pre-diagnosis stage. 2 therefore, we strongly 46 disagree with categorizing hs follow-up as "non-urgent/reschedule", as outlined by price et al. 1 , as this 47 approach would likely contribute to increased ed visits. studies have also demonstrated increased risk of antidepressant drug use (p < .0001) and 57 completed suicide (p = .0334) in the hs population after adjusting for confounding factors. 5 we caution 58 against interruption in care for hs patients due to the potential for increased severity and/or frequency of 59 suicidal behaviours, depression and anxiety, especially considering the additive stress and anxiety 60 resulting from the current socially-isolating quarantine climate. 2 61 62 in our complex medical dermatology practices, we have implemented a similar triage system to 64 price et al. with 3 categories: 1. in-person, 2. virtual/phone, 3. cancel/reschedule. we find that the follow-65 up of both hs and autoimmune bullous diseases through virtual visits is quite effective in a large 66 proportion of patients, during which we utilize patient-reported outcomes such as pain scores, treatment 67 satisfaction scores, and patient global assessments. virtual visits also allow us to counsel patients 68 regarding maintenance regimens for the prevention of disease flares, hs action plans informing steps to 69 take during hs exacerbations and when to contact a provider, and methods to improve overall mental 70 health, including maintaining a healthy diet, utilizing warm compresses and engaging in support groups 71 through the cspa. 2 72 operations during covid-19 pandemic health care utilization patterns and costs for patients 80 impact of sars on healthcare utilization by disease categories: 83 implications for delivery of healthcare services. health policy increased suicide risk in patients with 86 key: cord-304330-egvdvvtx authors: damsky, william; peterson, danielle; king, brett title: when interferon tiptoes through covid-19: pernio-like lesions and their prognostic implications during sars-cov-2 infection date: 2020-06-19 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.052 sha: doc_id: 304330 cord_uid: egvdvvtx nan william damsky md, phd 1,* , danielle peterson md 1 brett king md, phd 1,* 4 5 has suggested that sars-cov-2 infection is sometimes characterized by a muted anti-40 viral type i and iii interferon (ifn) response, 6,7 which may explain progression to 41 severe clinical manifestations in some patients; a robust type i ifn response was 42 associated with rapid viral clearance and bland disease course. 6 here, we describe 43 pernio-like lesions as they have been reported in the literature and consider other 44 settings where pernio is observed, including familial chilblains lupus, an 45 interferonopathy syndrome. together, these data suggest that covid toes may be a 46 marker of patients that are able to mount a robust anti-viral immune response to sars-cov-2 and prognosticate a milder course of covid-19. 48 sporadic pernio (also known as chilblains) is an idiopathic cold-sensitive inflammatory 50 disorder that presents with red-to-violaceous macules or papules on acral sites; 51 vesiculation and ulceration may occur. these lesions are typically located on the distal 52 toes, but can also occur on fingers, heels, and even the nose and ears. histopathology 53 reveals edema in the superficial dermis and marked superficial and deep perivascular 54 and peri-eccrine lymphocytic inflammation (figure 1a) . interface change and/or 55 vasculopathic changes (e.g. focal thrombosis) may be present. type i ifn response is associated with early viral control and a mild course, while an 79 insufficient type i ifn response may be associated with progression to more severe 80 disease ( figure 1b) . 6,7 therefore, we hypothesize that pernio-like lesions, which can 81 occur with elevated type i ifn signaling, are the result of a robust anti-viral response in patients with covid-19, and, therefore, are associated with a favorable disease course, 83 as observed in these patients. characterization of 87 acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 88 patients during the covid-19 outbreak chilblains in children in 91 the setting of covid 19 pandemic covid-19) infection-94 induced chilblains: a case report with histopathologic findings classification of the 97 cutaneous manifestations of covid 19: a rapid prospective nationwide 98 consensus study in spain with 375 cases pernio-like skin lesions associated 101 with covid-19: a case series of 318 patients from 8 countries type i ifn immunoprofiling in 104 covid-19 patients imbalanced host response to key: cord-336450-2ndan331 authors: shaw, katharina s.; karagounis, theodora k.; yin, lu; gibbon, grace; betensky, rebecca a.; lo sicco, kristen i.; femia, alisa n. title: response to “patient preference for cellulitis treatment: at-home care is preferred to hospital-based treatment” date: 2020-08-07 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.120 sha: doc_id: 336450 cord_uid: 2ndan331 nan preference of patients for at-home treatment of cellulitis rather than hospital-based care. 35 notably, these results reflected patient preferences well before the onset of the covid-19 36 pandemic. in light of recent reports linking patient anxiety over covid-19 to delayed and 37 decreased hospital presentations for acute medical problems such as myocardial infarction 2 and 38 stroke 3 , we examined whether a similar trend was observed for patients presenting with skin and 39 soft tissue infections (sstis) at an urban tertiary care center in the epicenter of the covid-19 40 after obtaining irb approval, we queried emergency department (ed) visits at nyu langone 42 2020 and 2019, respectively) . 62 our findings highlight a similar pattern observed by our cardiology 2 and neurology 3 colleagues -63 namely, that fewer patients sought hospital-based care for acute dermatologic problems like 64 sstis during the height of the covid-19 pandemic. these results suggest that some patients 65 with sstis may have avoided hospital-based evaluation and treatment due to fear of covid-19. 66 while we can neither comment on whether these patients sought evaluation elsewhere (such as in 67 an outpatient or telemedicine setting) nor on the outcomes of patients who may have foregone 68 hospital evaluation for sstis, the findings of gabel et al 1 have proven prescient. thus, we argue 69 for careful risk stratification of patients diagnosed with cellulitis in outpatient, urgent care and 70 ed settings going forward. in the context of growing outbreaks in other states and concern for 71 heightened incidence of covid-19 in the fall, we encourage outpatient treatment of cellulitis -72 including parenteral antimicrobial therapy when feasible -for those patients without relevant 73 risk factors for poor outcomes. moreover, given that patients may be reluctant to seek hospital-74 based care, we highlight the need to remain accessible to patients in the outpatient setting or 75 through virtual visits, particularly during periods of stress on local hospital systems. patient preference 79 for cellulitis treatment: at-home care is preferred to hospital-based treatment st-segment elevation cardiac catheterization laboratory activations in the united states during 83 covid-19 pandemic eerie emptiness of ers worries doctors: where are the heart attacks and 85 key: cord-274750-fynxciwg authors: peterson, danielle; damsky, william; king, brett title: calm before the storm: understanding the role of jak inhibitors in covid-19 date: 2020-04-25 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.097 sha: doc_id: 274750 cord_uid: fynxciwg nan inhibit proteins potentially involved in sars-cov-2 entry into cells. 1 not only is that work theoretical, 46 that this potential inhibition might provide clinical benefit to patients infected with sars-cov-2 is even 47 further unknown. also, based on in vitro assays, the concentration of baricitinib needed to inhibit 48 aak1 and clathrin-mediated endocytosis would likely require doses far above the fda approved dose 49 of baricitinib 2mg daily. 2 lastly, the theoretical effect against viral endocytosis only applies to 50 baricitinib; this is not a known property of other jak inhibitors, including upadacitinib. based on these 51 considerations, we believe there is insufficient evidence to recommend continuing jak inhibitors in 52 patients who are acutely infected with sars-cov-2. 53 54 napolitano et al suggest that baricitinib and upadacitinib might be useful in treating the cytokine 55 release syndrome (crs) that can occur in sars-cov-2 infection. we strongly agree that there may be a 56 role for jak inhibitors in treating sars-cov-2-associated crs. however, it is important to note that this 57 is typically a late manifestation of disease that occurs only in a subset of patients. furthermore, there is 58 evidence in both rhesus macaques and mice infected with the original sars virus, sars-cov, that a 59 suboptimal early anti-viral type i interferon response may predispose to this late manifestation. 3,4 jak 60 cytokines including il-2, interferon gamma, gm-csf, and g-csf. important to note is that the 64 theoretical benefit of jak inhibitors in this setting is not limited to upadacitinib and baricitinib but also 65 applies to other jak inhibitors including ruxolitinib and tofacitinib. we and others are undertaking 66 clinical trials to evaluate jak inhibitors for sars-cov-2-associated crs, and it will be interesting to see 67 what they show. 68 in summary, we believe there is insufficient evidence to recommend that jak inhibitors be continued in 70 all patients taking these medications who are acutely infected with sars-cov-2. while jak inhibitors 71 may prove useful in the treatment of sars-cov-2-associated crs, this is a separate consideration of a 72 relatively uncommon manifestation of this viral infection that occurs late in disease course. 73 74 75 76 baricitinib as potential treatment for 2019-ncov acute 78 respiratory disease covid-19: combining antiviral and anti-inflammatory 80 treatments dysregulated type i interferon and inflammatory 82 responses cause lethal pneumonia in sars-cov-infected mice microbe exacerbated innate host response to sars-cov in 85 aged non-human primates. baric rs key: cord-273493-xsroivzj authors: manalo, iviensan f.; smith, molly k.; cheeley, justin; jacobs, randy title: a dermatologic manifestation of covid-19: transient livedo reticularis date: 2020-04-10 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.018 sha: doc_id: 273493 cord_uid: xsroivzj nan we read with great interest "covid-19 can present with a rash and be mistaken for dengue." to date, other described covid-19-associated rashes include: nondescript erythematous rash, urticaria, and vesicles in italy, 1 and dusky acrocyanosis and dry gangrene in critical intensive care unit (icu) patients in wuhan, china. 2 no photos were available for the first two reports. we present two cases of transient unilateral livedo reticularis (lr) in covid-19-positive non-icu subjects to bring awareness to a dermatologic manifestation. a 67-year-old caucasian male was hospitalized for covid-19 (nasopharyngeal swab pcrconfirmed) management. his symptoms began 10 days prior with low-grade fever, nasal congestion, post-nasal drip, and cough without shortness of breath. seven days into his symptoms, he noted a transient non-pruritic blanching unilateral livedoid patch on the right anterior thigh resembling lr ( figure 1 ). the eruption lasted for 19 hours and resolved by the time dermatology evaluated the patient; thus no biopsy was taken. concurrent with the lacy patches on the leg, the patient also noted gross hematuria and generalized weakness. in concert with the netlike exanthem, the hematuria resolved within 24 hours. he was eventually discharged home stable on supplemental oxygen. a 47-year-old caucasian female with history of celiac disease, hashimoto's thyroiditis, and portal vein thrombosis in 2017 with negative work-up for a hypercoagulable state (attributed to a long plane flight combined with prior oral contraceptive) tested covid-19-positive. symptoms began with a mild headache, sinus pressure, anosmia, and fever, with highest recorded temperature of 37.9°c. ten days after testing positive, and with complete clinical convalescence of covid-19 symptoms, she was sitting outside in long pants under direct sunlight for approximately 20-30 minutes. a unilateral asymptomatic rash on her right leg resembling lr was noticed incidentally immediately upon moving indoors (figure 2 ) despite an equal amount of sun exposure on both legs. the rash lasted approximately 20 minutes and did not recur upon re-challenge with sun exposure the following day. livedo reticularis is caused by conditions, including disseminated intravascular coagulation (dic), that reduce blood flow through the cutaneous microvasculature system leading to deoxygenated blood accumulation in the venous plexus. 3 we hypothesize that the microthromboses that manifest in other organs (e.g. cardiopulmonary) 4 for 20 minutes; and did not recur upon rechallenge with re-exposure to the sunlight the next day. cutaneous manifestations in covid-19: a first perspective livedo reticularis: an update acute pulmonary embolism and covid-19 pneumonia: a random association? abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia key: cord-304874-pjdedw7w authors: grant-kels, jane m. title: invited response to the comment on “dermatology residents and the care of covid-19 patients” date: 2020-04-21 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.072 sha: doc_id: 304874 cord_uid: pjdedw7w nan i am greatly appreciative to dr. basil patel for his comments 1 on the dermatoethic's piece entitled "dermatology residents and the care of covid-19 patients" 2. as someone who is intimately involved with dermatology residents at two universities, i am personally very aware of residency concern and fear over this pandemic. i will address each of the issues raised by dr. patel. although the fatality rate for those aged 20-49 is lower, i recognize that any risk, when it is personal, is terrifying. i did not mean to imply that fear was not appropriate. your assertion that theoretically upholding the hippocratic oath should make the fatality rate irrelevant has some merit. although physicians, as you state, do not need to be martyrs, they need to fulfill their professional responsibility the same as a fireman running into a burning building. there is now personal protective equipment (ppe) that reduces the infectivity rate substantially which if worn properly should be reassuring. i agree that having ppe available is crucial. peggy noonan penned an editorial in the wall street journal published april 11-12, 2020. she reflects upon the "…selflessness of doctors and nurses, for instance, and how they do their jobs because it's a calling. this tells us what bravery looks like, but also what a vocation is, and how a vocation is a spiritual event." 3. i am very sensitive to the fact that many residents are young with spouses and children. the risk of returning home after caring for infectious patients is something i did not mention but was acutely aware of. the need to be concise and conform to the word limit of a letter prevented me from raising this issue. finally, you raised the issue of power dynamics and that residents have little leverage. this implies that attendings are not fulfilling their obligation to care for these infectious patients. emergency room and hospital attendings (many of whom ,at many hospitals, include called-up dermatology attendings) are potentially jeopardizing their well-being just as you are. i hope that all are pitching in during this national emergency not out of fear that their contract will not be renewed but "to fulfill the key human desire to be part of something -'to be part of team humanity, to be useful." 3 i am pleased that you are proud to be helping your community and i am confidant your community is grateful to you. those at the front line caring for these patients are heroes. this pandemic has tested all of us. i am hopeful that out of this trial we will grow as physicians and human beings. thank you for your service. comment on dermatology residents and the care of covid-19 dermatology residents and the care of covid-19 a holy week amid a national tribulation key: cord-309914-1lpl26eo authors: peterson, danielle; damsky, william; king, brett title: the use of janus kinase inhibitors in the time of sars-cov-2 date: 2020-04-09 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.03.099 sha: doc_id: 309914 cord_uid: 1lpl26eo nan during the time of the sars-cov-2 pandemic, questions arise regarding patients being treated with 37 immunomodulatory therapies. in particular, is there an increased risk of acquiring the infection or 38 experiencing a worse outcome from sars-cov-2? while this exact question is presently unanswerable, 39 we can look at safety data from clinical trials to try to understand patient susceptibility to different 40 infections. while others have addressed this in the context of biologic 1 or classical small molecule 41 therapy 2 , the risk of janus kinase inhibitor (jaki) treatment has not been addressed. in light of the 42 growing off-label use of jaki in dermatology in addition to pharmaceutical industry sponsored clinical 43 trials of jaki for alopecia areata, atopic dermatitis, vitiligo, etc, dermatologists need data to better 44 understand the risks of jaki treatment in order to best manage and counsel our patients during this 45 unique time. 46 we analyzed and collated adverse events data from jaki clinical trials. in particular, we focused on 48 infections and pulmonary toxicities observed across the different fda-approved jaki for their fda-49 approved indications. when available, data from phase ii or iii clinical trials for dermatological 50 indications was included. table 1 shows the rates of various infections, including upper respiratory 51 infections, nasopharyngitis and influenza, for jaki-treated groups versus placebo groups. overall, rates 52 of infectious events are only mildly increased in jaki-treated patients. we also collated pulmonary 53 toxicities of jaki to identify potential risks of worsening severe respiratory disease from sars-cov-2, and 54 such toxicities are all but absent. 55 56 in order to understand the infection data, it is helpful to understand the mechanism and 57 pharmacokinetics of jaki. cytokines can drive autoimmunity when their activity is exaggerated ( figure 3 1a). jaki, which are taken orally 1-2 times per day, largely impact pathogenically elevated cytokine 59 activity, with relative sparing of normal cytokine activity because drug concentrations are sub-60 therapeutic for part of the day ( figure 1b in this time of the sars-cov-2 pandemic, we must be as informed as possible regarding the risks of the 75 treatments we prescribe our patients. of course, shared decision-making reigns supreme, but without 76 data we, as physicians, will be unable to provide our patients the guidance they rely on us for. should biologics for psoriasis be interrupted in the era of inflammatory diseases liver abscess (1), pleural effusion (1), pyelonephritis (1) 117 2. 10 mg dose-anal abscess (1), cellulitis (1), febrile infection (1), otitis externa (1), pneumonia (1) 118 3. 10 mg dose -furuncle (1) 119 4. 1mg dose -peri-tonsillitis pna (8), 122 sinusitis (1), sepsis (1), lower respiratory infection (1) 123 7. 15mg dose-viral infection (1) key: cord-256565-59bnifxm authors: lebwohl, mark; rivera-oyola, ryan; murrell, dedee f. title: reply to: “covid-19, syphilis, and biologic therapies for psoriasis and psoriatic arthritis: a word of caution” date: 2020-04-10 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.03.103 sha: doc_id: 256565 cord_uid: 59bnifxm nan reply to: ''covid-19, syphilis, and biologic therapies for psoriasis and psoriatic arthritis: a word of caution'' to the editor: we thank dr kansal 1 from the all india institute of medical sciences for her pertinent comments in response to our publication on the use of biologic agents for psoriasis patients in the current covid-19 pandemic. 2 certainly, there are other diseases for which screening could be considered in particular populations before starting a biologic, such as syphilis, as dr kansal makes a point about in her study. strongyloides and leprosy are others. these screening tests apply to all immunosuppressants, not just biologic immunomodulators. there will always be exceptions to the clinical trial data, but even with 10 to 20 years of real-world data reporting of many of these biologics, we have not seen alarming rates of influenza or other viral infections in the non-tumor necrosis factor inhibitor classes of biologics that would warrant advice to discontinue treatment. there are several reasons why biologic agents are different from traditional immunosuppressive drugs such as methotrexate or cyclosporine. they are very targeted and do not affect the entire immune system. most relevant to our current times, many do not impact host defenses against viral infection. for example, individuals born with deficiencies in molecules like interleukin 17 or p40 are prone to chronic mucocutaneous candidiasis or to mycobacterial and salmonella infections. 3,4 they do not have increased rates of viral infections. moreover, the skin itself is a vector for spreading covid-19, and the impact of active skin disease on transmission is unknown. in addition, there has been speculation that reducing overall inflammation in patients with covid-19 infection protects against the deadly pneumonia that has caused the demise of so many. 5 finally, we know that dupilumab, in addition to treating atopic dermatitis, which in itself can be debilitating, also treats asthma, which could be a complicating factor in covid-19 infection. to be clear, we cannot know the long-term impact of biologic agents on patients with suspected or confirmed covid-19 until more time passes and we have more data. for now, the most medical organizations, including the american academy of dermatology, the national psoriasis foundation, and the international eczema council, among others, have advocated not discontinuing biologics in patients who are not infected. of course, these agents should be discontinued in patients with active infection. covid-19, syphilis and biologic therapies for psoriasis andpsoriatic arthritis: a word of caution should biologics for psoriasis be interrupted in the era of covid-19? inborn errors of human il-17 immunity underlie chronic mucocutaneous candidiasis mendelian susceptibility to mycobacterial infection in man 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 key: cord-282355-urys21ry authors: ortega-quijano, daniel; jimenez-cauhe, juan; burgos-blasco, patricia; jimenez-gomez, natalia; fernandez-nieto, diego title: reply to “varicella-like exanthem as a specific covid-19-associated skin manifestation: multicenter case series of 22 patients”: discussing specificity date: 2020-05-04 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.156 sha: doc_id: 282355 cord_uid: urys21ry nan title: reply to "varicella-like exanthem as a specific covid-19-associated skin manifestation: multicenter case series of 22 patients": discussing specificity daniel ortega-quijano, md 1 , juan jimenez-cauhe, md 1 , patricia burgos-blasco, md 1 , natalia jimenez-gomez, md 1 , diego fernandez-nieto, md 1 . dear editor, we read with interest the article by marzano and colleagues addressing the specificity of varicella-like exanthem to diagnose coronavirus disease (covid-19) 1 . although this type of covid-19 associated rash is rare, the authors claim that it is more specific than others without having performed a diagnostic accuracy study 2 . this type of study would calculate the association of covid-19 status (yes/no) with the type of exanthem (varicella-like/non varicella-like) in a predetermined number of patients (to ensure sufficient statistical power) and in a defined population with a known prevalence of covid-19 disease. starting from the assumption that the data is not sufficient to draw such a robust conclusion, we would like to contribute our vision of such an important issue. firstly, for clinicians, specificity is of little value. the positive predictive value, that is, the probability that a person with a varicella-like rash has covid-19, is much more relevant, as a high value would justify sars-cov-2 testing. the positive predictive value is affected by the prevalence of the disease. consequently, as we are going through the peak of the covid-19 pandemic, it is evident by applying bayes' theorem that the conditional probability of covid-19 given a varicella-like rash is enormous. however, this probability is as high given a dengue-like, erythematous or urticarial rash. therefore, the positive predictive value for covid-19 of skin rashes, regardless of which, is high. for us, the main contribution of the study by marzano and colleagues is that, with all exanthems currently having a high positive predictive value for covid-19, that of varicella-like rash is probably the highest since vesicular rash is more specific for viral disease than others 3 . in addition, at the current stage of the pandemic, covid-19 is more frequent in adults, where varicella is not. this gives varicella-like rash additional covid-19 positive predictive value compared to the rest of the rashes. the main factor that at this moment reduces the positive predictive value of rashes for covid-19 is adverse drug reactions. unfortunately, this topic is being less discussed in the literature. to conclude, since things will change fast as the pandemic progresses, it is expected that as the adult population become infected the age at diagnosis of covid-19 will decrease 4 . at that time, this rash will be an important differential diagnosis of varicella itself. in this context, tzank test and varicella-zoster pcr should be subjected to new diagnostic accuracy studies. varicella-like exanthem as a specific covid-19-associated skin manifestation: multicenter case series of 22 patients cutaneous manifestations in covid-19: a first perspective the challenge of diagnosing atypical exanthems: a clinico-laboratory study modeling infectious diseases in humans and animals key: cord-034195-yiv8rp7y authors: guhan, samantha m.; nathan, neera r.; raef, haya; cavanaugh-hussey, margaret; tan, jennifer k. title: covid-19 and healthcare disparities: innovative ways to meet the dermatologic needs of patients experiencing homelessness date: 2020-10-23 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.10.042 sha: doc_id: 34195 cord_uid: yiv8rp7y nan covid-19 and healthcare disparities: innovative ways to meet the dermatologic needs of 1 patients experiencing homelessness 2 3 samantha m. guhan, ba 1 , neera r. nathan, md, mshs 2 , haya raef, ba 3 , margaret 4 cavanaugh-hussey, md, mph 4,6 and jennifer k. tan, md 5,6 5 6 1 the medical community has taken multiple steps to increase access to care for this vulnerable 55 population, such as creating facilities that offer isolation and treatment for peh suffering from 56 covid-19. we hypothesized that dermatologists can further aid this population by mobilizing 57 critical supplies commonly found in our offices and using the generosity of local companies to 58 create covid-19 care kits, which contain items necessary to protect peh from disease. goals of 59 distribution included not only increased access to basic hygienic products, but also 60 acknowledgement of our common humanity during a time of crisis. 61 62 prior to supply collection, local shelters were contacted to identify the most useful items to 63 patients. as dermatologists, we were especially well positioned to obtain products, such as soap 64 and hand sanitizer, due to pre-existing relationships with skin care companies. local volunteers 65 contributed facemasks and donors provided additional funds for entertainment items, covid-19 66 safety brochures, and packaging. the final kits contained soap, hand sanitizer, moisturizer, 67 the 2019 annual 89 homeless assessment report (ahar) to congress assessment of 92 sars-cov-2 infection prevalence in homeless shelters -four covid-19 and racial disparities dental care products, puzzles, headphones, a covid-19 informational pamphlet, and other 68 personal hygiene items ( figure 1 ). in order to minimize the number of people in contact with 69 patients, kits were delivered to a contact person at each shelter, who later distributed the kits. 70 the success of this endeavor was measured by the number of kits distributed to local shelters. 72over 1000 kits were assembled between the months of march and june. this program is 73 sustainable through the generosity of skin care companies, fund-raising efforts, and the 74 incorporation of staff and trainees into the collection and assembly process. limitations include 75 distribution to a single geographic area and variation in supply of donated items. 76 77 building upon relationships we already have as dermatologists, we were able to create a covid-78 19 kit donation program that provided peh with necessary supplies to minimize the spread of 79 disease. in the post-covid era, this effort will be expanded to involve the assembly of kits 80 containing over-the-counter products to treat common skin conditions including acne, atopic 81 dermatitis, and xerosis. we propose a call to action for the dermatology community to create 82 similar programs in order to aid this critically marginalized population. to identify a clinic or 83 shelter with which to partner, the following resources may be useful: national health care for 84 the homeless council respite and grantee directories (nhchc.org), findahealthcenter.hrsa.gov, 85 and www.homelessshelterdirectory.org. 86 87 references: 88 key: cord-294262-yvbufnf4 authors: fernandez-nieto, d.; ortega-quijano, d.; suarez-valle, a.; burgos-blasco, p.; jimenez-cauhe, j.; fernandez-guarino, m. title: comment on: “to consider varicella-like exanthem associated with covid-19, virus varicella zoster and virus herpes simplex must be ruled out. characterization of herpetic lesions in hospitalized covid-19 patients.” date: 2020-06-22 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.063 sha: doc_id: 294262 cord_uid: yvbufnf4 nan be performed in order to rule out other viral infections. marzano and genovese 2 were 32 not able to perform pcr tests in their previous study of varicella-like exanthem 3 due to 33 logistic reasons, but also due to clinical presentation not being suggestive of varicella. 34 we previously conducted a prospective study of vesicular covid-19 rashes (all with 35 positive nasopharyngeal swab for sars-cov-2) in our hospital from march 1st to 36 april 20th, 2020 4 . out of a total of 53 patients, 15 were excluded because of an 37 alternative herpes simplex/zoster clinical diagnosis (clinical data are summarized in 38 table 1 ). all 15 patients presented typical clinical lesions and symptoms of herpes 39 simplex/zoster. only one patient (6.7%) had a previous history of immunosuppression. 40 latency time between covid-19 symptoms and herpetic lesions was variable (median 41 time 16 days, range 6-32). in spite of performing pcr tests for sars-cov-2 from the 42 content of the vesicles in only three patients, the results were all negative. 43 regarding vesicular rashes or varicella-like covid-19 exanthems 3 , we previously 44 reported four cases in which we performed both pcr multiplex for herpesvirus and rt-45 pcr for sars-cov-2, directly from the content of the vesicles. interestingly, both 46 techniques were negative in all four cases 4 . this reasonably rules out a role of herpes 47 viruses 3 , and a potential infective ability of sars-cov-2 through the vesicles. 48 we agree with the authors that there is a potential role for herpetic viral infections and 49 super-infections in covid-19 patients. in fact, some presumed covid-19 vesicular 50 lesions have been later proven to be caused by herpetic infections 1,5 . in our prospective 51 study, 4 from a total of 96 covid-19 dermatological consultations in the reported 52 period, 15.6% corresponded to herpes simplex/zoster diagnoses. however, we cannot 53 categorically affirm that there is an incidence increase of these diagnoses in covid-19 54 patients, due to the lack of a control group. in our current experience, the diagnosis of 55 herpesvirus infection in covid-19 patients does not usually involve diagnostic doubts, 56 due to the clinical presentation and reported symptoms being typical of the disease, 57 even when lesions are extensive (figure 1) . 58 in conclusion, complementary diagnostic tests for herpesvirus and even sars-cov-2 59 may prove useful for clinical research, and should be encouraged if the necessary 60 resources are available. however, we believe that, regarding clinical practice, we should 61 reserve these techniques for atypical clinical presentations or cases where therapeutic 62 management would change significantly. figure 1: a) a 69-year-old male with covid-19 pneumonia and extensive orolabial hsv-1 reactivation. b) a 56-year-old female with covid-101 19 pneumonia and herpes zoster on the trunk key: cord-267357-7aap2cte authors: elston, dirk m. title: the coronavirus (covid-19) epidemic and patient safety date: 2020-02-16 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.02.031 sha: doc_id: 267357 cord_uid: 7aap2cte nan the coronavirus (covid-19) epidemic and patient safety dirk m. elston, md charleston, south carolina i n this issue of the jaad, chen et al 1 discuss patient safety measures in a chinese dermatology clinic during the coronavirus outbreak (2019-ncov acute respiratory disease), including patient screening, respiratory precautions, and telemedicine consultations. the steps they enacted serve as a reminder that we should have policies in place for infection control in every dermatology clinic. patients with varicella, measles, and other viral exanthems present to the dermatologist and may pose a risk to patients and office staff. employees should receive all appropriate vaccinations, and testing should be available for employees to determine their immune status. this is especially important for women of child-bearing age who may be exposed to diseases such as varicella and erythema infectiosum. if available, a negative pressure room should be designated as an isolation room for patients with respiratory pathogens, and exposed susceptible individuals should be furloughed during the incubation period. 2, 3 large health care organizations often address these issues during in-processing of employees, but many dermatologists practice in private clinics and should review existing policies to prepare for the inevitability of contagious patients entering the clinic. this is not the first outbreak of a severe coronavirus. prior outbreaks of virulent coronavirus strains have also been associated with severe respiratory syndromes and patient deaths. individuals who are asymptomatic or who have only mild symptoms may spread the virus. however, superspreading eventsd instances where an index patient transmitted disease to $5 subsequent patientsdwere typically associated with patients who were severely ill, initially not recognized as severe respiratory syndromecoronavirus cases, and subsequently died. delays in implementation of control measures contributed to secondary transmission, but contact tracing, testing, employee furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission. 4 our responsibility for patient and employee safety is not limited to respiratory pathogens. virulent streptococcal infections associated with necrotizing fasciitis and death have been spread during liposuction in outpatient facilities. 5 the procedures were performed by a single surgical team that traveled between locations, and 2 team members were colonized by the organism. substandard infection control, including errors in equipment sterilization and standard precautions, contributed to the outbreak. prevention of transmission of blood-borne infections deserves special mention, and readers should review the jaad continuing medical education articles that focused on patient safety and blood-borne pathogens (https://www.jaad. org/article/s0190-9622(09)00603-3/fulltext and https://www.jaad.org/article/s0190-9622(09)00602-1/fulltext). [6] [7] [8] standard precautions should be enforced, and policies should be in place for postexposure prophylaxis. as captains of our individual ships, it falls to us to put policies in place to prevent the spread of disease and prepare for the needle-stick injuries and transmissible diseases that are part of the practice of medicine. what are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus? infection control in the outpatient setting nosocomial varicella. worth preventing, but how? scope and extent of healthcare-associated middle east respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in riyadh, saudi arabia invasive group a streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation patient safety: part ii. opportunities for improvement in patient safety patient safety: part i. patient safety and the dermatologist managing sharps injuries and other occupational exposures to hiv, hbv, and hcv in the dermatology office key: cord-350317-a9qd3xdr authors: xu, qiannan; chen, lihong; li, xia; zheng, jie title: if skin is a potential host of sars-cov-2, il-17 antibody could reduce the risk of covid-19 date: 2020-11-05 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.10.084 sha: doc_id: 350317 cord_uid: a9qd3xdr nan to the editor: in the era of the coronavirus disease 2019 pandemic, debates have emerged on whether biologics might increase the risk of contracting the disease 1 . il-17 is a biologic that is widely used in dermatology. there were reports that viral reactivation, although extremely low, could be detected during the use of il-17 antibody 2 . this led to concerns in using the il-17 antibody because it was believed that it could make patients more susceptible to severe acute respiratory syndrome coronavirus 2 (sars-cov-2). when we read the article named skin is a potential host of sars-cov-2: a clinical, single-cell transcriptome-profiling and histological study in a recently published issue 3 , a question occurred to us: if skin is a target of sars-cov-2, what might be the consequence of using the il-17 antibody? ace2 is the main entrance receptor for sars-cov-2. the expression of ace2 is associated with the potential risk of making the target tissue susceptible to infection by sars-cov-2. therefore, downregulating the expression of ace2 could lower the risk of covid-19. to evaluate the influence of il-17 antibody on skin ace2 expression, we randomly selected five psoriasis patients who were treated with il-17 antibody (taltz, eli lilly and company). the skin lesions of these patients were biopsied on week 0 and week 8 and prepared for rna sequencing. the skin ace2 expression of patients who underwent the antibody therapy for 8 weeks (0.36 ± 0.10, n=5) was downregulated when compared with that at week 0 (1.24 ± 0.50, n=5), when the il-17 antibody treatment was just started (p < 0.05, paired t-test). to confirm the result, we also selected three patients to compare the skin ace2 expression at weeks 0 and 8 with immunofluorescence. immunofluorescence staining revealed that the fluorescence intensity of ace2 was downregulated in the skin at week 8 (0.84 ± 0.26, n=3) when compared to that before the il-17 antibody treatment (9.23 ± 2.33, n=3, p＜0.05; unpaired t-test). hence, either the mrna or protein of ace2 obtained from psoriasis patients can reveal that il-17 antibody treatmentremarkably reduces ace2 expression. our work above proves that the il-17 antibody treatment during the covid-19 pandemic is not contraindicated. elevated ace2 expression and detection of sars-cov-2 in the skin 4 of covid-19 patients implied skin was a potential host of sars-cov-2. after il-17 antibody treatment, the skin ace2 expression was downregulated which meant il-17 antibody could lower the risk of covid-19 through lessening the cells which could interact with sars-cov-2. additionally, il-17 antibody could reverse the deteriorated barrier and inflammatory status in the skin of psoriasis patient which meant less microbe infection.herein, the specific microbe could be sars-cov-2. till now there is no evidence that covid-19 can be spread by contact with skin. however, sars-cov-2 could survive on skin for 9h 5 , which indicated that sars-cov-2 might transmit through skin in the certain skin status like psoriasis. thus, whether il-17 antibody could reduce the covid-19 risk through reversing the inflammatory skin status with deteriorated barrier and preventing sars-cov-2 transmitting should be further discussed. should biologics for psoriasis be interrupted in the era of covid-19? risk for hepatitis b and c virus reactivation in patients with psoriasis on biologic therapies: a retrospective cohort study and systematic review of the literature skin is a potential host of sars-cov-2: a clinical, single-cell transcriptome-profiling and histological study epub ahead of print sars-cov-2 endothelial infection causes covid-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases survival of sars-cov-2 and influenza virus on the human skin: importance of hand hygiene in covid-19 the authors have declared that no conflict of interest exists. none of the authors has any financial interest in any products, devices or drugs used in the manuscript. there is also no conflict of interest related to any commercial associations or financial relationships. key: cord-278754-vy5c7411 authors: mcgee, jean s.; reynolds, rachel v.; olbricht, suzanne m. title: fighting covid-19: early teledermatology lessons learned date: 2020-06-15 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.027 sha: doc_id: 278754 cord_uid: vy5c7411 nan covid-19 has exacerbated the unequal access to medical care experienced by historically marginalized patient populations. 1 early data demonstrate that the infection and death rates of predominantly black neighborhoods are 3-fold and 6-fold higher, respectively, than in predominantly white neighborhoods. 2 in response to the pandemic, both academic and private dermatology practices have quickly rolled out teledermatology service in an effort to continue access to care. our study aimed to evaluate early practice patterns to identify any variations in the quality of and access to teledermatology service. we randomly selected 274 teledermatology visits conducted during the month of april 2020 in the department of dermatology at beth israel deaconess medical center. we reviewed each visit and extracted the following information including age, preferred language, diagnoses, disposition, visit type (telephone versus video), and visit duration. in addition, we randomly selected 250 in-person visits conducted during the month of february 2020 for a pre-pandemic comparison. prior to the pandemic, 32% of patients seen in person were older than 65 years and 7% of patients seen in person were non-english speaking, those defined as necessitating interpreter service (table 1) . during the pandemic, 23% of patients seen in teledermatology were older than 65 years and 3% of patient seen in teledermatology were non-english speaking ( table 1 ). the two most common diagnoses seen in teledermatology, other than a lesion of concern, were acne and dermatitis at 52% and 49% of total visits, respectively ( table 2 ). nearly all teledermatology visits with these diagnoses led to a recommendation for either discharge or follow-up via subsequent teledermatology visits. in contrast, 60% of teledermatology visits for evaluation of lesion(s) lead to a recommendation to follow up in person for re-evaluation and/or biopsy. lastly, 75% of teledermatology visits with durations of 20 minutes or greater were conducted via telephone, rather than a video-based platform. limitations of this study include a small sample size, narrow scope, and a single institution. our study suggests that elderly patients and non-english speaking patients may be experiencing unequal access to teledermatology care during the pandemic. limited proficiency with technology, administrative burden to mobilize an interpreter service, and hesitancy on the part of patients to receive medical care via virtual platforms can all contribute to these findings. our study also suggests that teledermatology is best suited for acne and non-specific dermatitis. on the other hand, evaluations of lesion(s) may be best suited for in-person visits, as not to generate extra visits and unnecessary costs. lastly, our study found that longer visits were more likely to be conducted by telephone, rather than video. this finding raises a possibility that visual cues may be an important consideration in teledermatology visits. moving forward, we are tasked with creating a new practice model that is likely to be a hybrid of both in-person and teledermatology. our early data support allocating teledermatology resources for certain diagnoses including acne and rashes. however, we need further studies to understand the operational and financial implications of having extra teledermatology visits for the evaluation of lesion(s). racial, economic and health inequality and covid-19 infection in the united states covid-19 and african americans key: cord-294871-bqw48zi5 authors: wambier, carlos gustavo; vaño-galván, sergio; mccoy, john; pai, suraj; dhurat, rachita; goren, andy title: androgenetic alopecia in covid-19: compared to age-matched epidemiologic studies and hospital outcomes with or without the gabrin sign date: 2020-07-29 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.099 sha: doc_id: 294871 cord_uid: bqw48zi5 nan we would like to motivate other groups to evaluate aga in their populations, specifically 55 comparing outcomes in covid-19 positive individuals. for example, our indian colleagues, in a 56 pilot observational prospective study (raw data available at doi.org/10.17632/jdkx76y8fz.1), 57 examined outcomes in admitted covid-19 patients by aga severity. in their cohort of 44 men 58 admitted for severe covid-19, all patients had clinically significant androgenetic alopecia. 59 however, the most severe outcomes (respiratory failure requiring ventilators or fatal 60 outcomes) happened when hns was greater than 2. one patient was 45 years-old, and had no 61 previous co-morbidities; he required prolonged icu stay due to ventilator use, and had hns=3v. 62 study 3 show an increase of relative proportions for hns=2-7 of 7%, hns=3-7 of 26%, and 67 hns=4-7 of 33%. this gap becomes particularly obvious when comparing the frequencies of 68 hns=4-7 in the age range of 55-69 years (fig.2) , 4 which is the age group that contains the 69 median age of the 122 covid-19 hospitalized men. 1 severe aga in young men also confers 70 increased vulnerability. to further exemplify that, we present in this reply letter one of our 71 unpublished patients from brazil: a previously healthy 37-year-old physician (hns=5, depicted 72 in fig1), with no previous co-morbidities; he required hospitalization for 21 days, which 73 included 16 days in the icu (ventilator for 10 days and hemodialysis for 5 days). 74 since vaccines are still not available, and the epidemic is affecting men disproportionately, 75 particularly bald individuals, more emphasis could be given to investigations directed at anti-76 androgen therapies which are routinely prescribed both for hair loss and benign prostatic 77 hyperplasia as standard of care (such as dutasteride and finasteride). finally, severe aga, 78 (hns=3-7) -the gabrin sign -is an objective phenotype, which reflects the individual androgen 79 sensitivity throughout decades of life. aga is associated with individual vulnerability to severe 80 sars-cov-2 infection through the androgen gateway. 5 it is remarkable that severe outcomes 81 such as requirement for ventilator and/or fatalities have occurred in men with this phenotype 82 without other known co-morbidities at younger age groups, such as 35-45 years. 83 androgenetic alopecia present in the 86 majority of hospitalized covid-19 patients -the "gabrin sign androgenetic alopecia in covid-19: compared to what? male pattern baldness: classification and incidence androgenetic alopecia in men 93 aged 40 -69 years : prevalence and risk factors androgen sensitivity gateway to covid-19 95 disease severity photograph of a 100 37 year-old survivor hospitalized in brazil for severe covid-19, without co-morbidities; required 101 ventilator for 10 days. the bars depict outcomes of a pilot study performed in india in may 102 2020 among 44 men who had aga scored with hns. gabrin sign was associated with worse 103 hospital outcomes (use of ventilator and deaths only men with gabrin sign had worse outcomes (red and black bars) age-matched comparison of aga, of very severe baldness between the australian 108 2003 data (general population) versus the spanish 2020 data (hospitalized men with severe 109 covid-19 patients showed higher frequencies of very severe baldness at all age 110 groups. the gap significantly increases after 55 years. the majority of hospitalized patients due 111 to severe covid-19 over 55 years presented with very severe baldness. *very severe baldness 112 accounted for "frontal and vertex" in data from severi et data from wambier et al. more details available at key: cord-347293-fp8phk0p authors: kearns, donovan g.; chat, vipawee s.; uppal, shelley; wu, jashin j. title: assessing the risk of adalimumab use for hidradenitis suppurativa during the covid-19 pandemic date: 2020-07-28 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.086 sha: doc_id: 347293 cord_uid: fp8phk0p nan despite prolonged quarantines and social restrictions, the covid-19 pandemic continues to persist in the united states and globally. questions still remain regarding the safety of various immunosuppressive medications for those with chronic conditions. with limited real-life data from covid-19 infection in patients with hidradenitis suppurativa (hs) receiving adalimumab, we can use previous drug trials to extrapolate the potential risk to patients, based upon the change in infection rate when compared to placebo. adalimumab, a tumor necrosis factor alpha (tnf-α) antagonist, is the only fda approved biologic treatment for patients >12 years with for moderate to severe hs. tnf-α is a pleiotropic cytokine with pro-inflammatory functions that serves to protect against bacterial, fungal and viral infection. primary infection or reactivation of hiv, varicella zoster virus, epstein-barr virus, hepatitis, cytomegalovirus, jc and human papillomavirus have all been reported in patients receiving tnf-α therapy. 1 tnf-α has been shown to be significantly elevated in patients with the sars-cov-2 infection, and serum levels are positively correlated with disease severity. 2 it is currently uncertain whether elevated tnfα is necessary for resolution of sars-cov-2 infection or if it plays a pathological role in the development of "cytokine storm". in two placebo-controlled phase iii clinical trials (pioneer i/ii), 633 adults with moderate-tosevere hs were randomized to receive adalimumab (40 mg), or placebo. the trials were divided into two periods. in period 1, patients' receiver either 40 mg of adalimumab weekly (qw) or placebo for 12 weeks. in period 2, patients received adalimumab (40 mg) weekly, every-otherweek (q2w) or placebo for 24 weeks. at the end of period 1, infection developed in 24.8% and 25.2% of those receiving adalimumab qw, compared to 28.3% and 32.5% of patients receiving placebo, in pioneer 1 and 2, respectively. at the end of period 2, infection occurred in 29.2% and 35.3% of patients receiving adalimumab qw, 25.0 and 35.8 of patients receiving the medication q2w and 32.7 and 25.5% of patients in the placebo control group, in pioneer 1 and 2, respectively. 3 there was no increase in serious infection or nasopharyngitis observed in active treatment groups. in both trials, it was concluded that the rate of infection was not increased in adalimumab-treated patients compared to placebo ( table 1) . this study's analysis was limited by the original research from the adalimumab trials, as the authors of the trials did not specify the whether the cause of infection was bacterial or viral. however, the findings support the notion that healthy hs patients, without risk factors, who use adalimumab during the covid-19 pandemic are not predisposed to infection or nasopharyngitis ( table 1) . this is consistent with a recent case series documenting mild, uncomplicated disease in a small cohort of hs patients receiving adalimumab. 4 clinicians considering discontinuing adalimumab in high-risk patients should be aware that discontinuation of biologics has been shown to result in decreased response to treatment and the development of antidrug antibodies. *this data is a combined average of two-phase iii trials. the adalimumab group is a combined average of two treatment schedules (once per week or once per two weeks) tumor necrosis factor blockade and the risk of viral infection clinical features of patients infected with 2019 novel coronavirus in wuhan two phase 3 trials of adalimumab for hidradenitis suppurativa experience in patients with hidradenitis suppurativa and covid-19 symptoms key: cord-323241-1twnqr4k authors: patrì, angela; gallo, lucia; guarino, maria; fabbrocini, gabriella title: sexual transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2): a new possible route of infection? date: 2020-04-09 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.03.098 sha: doc_id: 323241 cord_uid: 1twnqr4k nan to the editor: the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is the virus responsible for the coronavirus disease (covid-19), first identified in wuhan, china, in december 2019, and that has now actually spread worldwide. the human-tohuman transmission routes hitherto recognized include direct transmission, through cough, sneeze, droplet inhalation, and contact transmission, comprising contact with oral, nasal, and eye mucous membranes. to date, covid-19 has not been reported to be sexually transmitted. however, a series of data raises the possibility that sexual intercourse could be an additional direct way of infection. this hypothesis mainly derives from the recent evidence of a likely fecal-oral transmission. 1 the exact mechanisms by which sars-cov-2 interacts with the gastrointestinal tract is unknown. however, angiotensin-converting enzyme ii (ace2) seems to be used by the virus as a receptor to enter cells. ace2 messenger rna is highly expressed in the gastrointestinal system, and immunofluorescent data show that the ace2 protein is abundantly present in the glandular cells of rectal epithelia. 2, 3 in addition, sars-cov-2 rna identification and intracellular staining of viral nucleocapsid protein in rectal epithelia demonstrated that the virus infects such epithelial cells. [2] [3] [4] the recognition of viral rna from feces indicates that virions are secreted from the virus-infected cells. [2] [3] [4] moreover, sars-cov-2 can also be transmitted through the saliva, and ace2 has been detected on the mucosa of oral cavity, which is rich in epithelial cells. 4 therefore, if saliva and feces are both capable of carrying the virus and ace2 is expressed both in the glandular cells of rectal epithelia and oral mucosa, how can we be sure that sexual intercourse does not represent another way of contagion? we thus hypothesize that practice of certain sexual behaviors could constitute an additional way for the contagion, both directly (eg through oral-anal contacts), or indirectly (eg with exposure of the rectal mucosa to the saliva for lubrication during anal sex). this issue could be particularly noteworthy if considering that a patient with covid-19 is actually considered cured after at least 2 upper respiratory tract samples negative for sars-cov-2 are collected at $24-hour intervals. nevertheless, it has been demonstrated that patients can persistently test positive on rectal swabs even after negative results for nasopharyngeal testing. 5 this means that the gastrointestinal tract may continue shedding the virus and that fecal-oral, or eventually sexual, transmission may be possible despite the apparent recovery. indeed, some authors recommend that real-time reverse transcription polymerase chain reaction be routinely performed to test for sars-cov-2 from feces. 3 patients' sexual habits are often not investigated. these observations highlight the need for physicians, and dermatologists in particular, to strongly discourage sexual practices if infected during the pandemic covid-19. indeed, beyond the hypothesized possibility of a direct sexual transmission, sexual intercourse involves close contact that inevitably expose individuals to the risk of contagion. refining the questions in epidemiologic surveys and conducting extensive studies of the mucosal sites ( genitals included) of sars-cov-2 shedding may perhaps confirm our hypothesis, allowing for a greater understanding about sars-cov-2 transmission routes and effective strategies to control infection spread. funding sources: none. transmission routes of 2019-ncov and controls in dental practice covid-19: faecal-oral transmission? nat rev gastroenterol hepatol evidence for gastrointestinal infection of sars-cov-2 high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa characteristics of pediatric sars-cov-2 infection and potential evidence for persistent fecal viral shedding key: cord-353247-swex393r authors: brumfiel, caitlin m.; jefferson, itisha s.; wu, albert g.; strunck, jennifer l.; veerabagu, surya; lin, krysta; brodell, robert t.; rosman, ilana s. title: a national webinar for dermatology applicants during the covid-19 pandemic date: 2020-09-17 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.09.043 sha: doc_id: 353247 cord_uid: swex393r nan diga is a national student-run organization composed of 120 medical school chapters 49 that serves as a forum for the exchange of information among students interested in 50 dermatology. with support from the apd, a webinar titled 'the shifting landscape of the 2020-51 2021 dermatology application cycle in the era of the covid-19 pandemic' was developed. six 52 u.s. residency program director panelists participated in the event. 53 a total of 996 viewers attended the webinar. an optional poll was administered; only 54 medical students were asked to respond. of 679 respondents, 62% were fourth year students 55 (19% third year, 14% preclinical, and 4% identified as other). minorities underrepresented in 56 medicine accounted for 31% of respondents; 25% of respondents reported attending an 57 institution not affiliated with a dermatology residency program. during the webinar, panelists 58 collectively addressed this year's residency application process via questions prompted by 59 physician moderators (table 2) . these questions had been collected from medical students via 60 google questionnaires administered by diga in the weeks prior to the event. additional "real-61 time" questions from viewers were answered both verbally and in written form within zoom's 62 question and answer and chat functions. 63 program director panelists also presented highlights from the apd consensus 64 statement, 2 such as promoting application to fewer programs to allow for holistic review. 65 panelists emphasized one recommendation letter may be written by any faculty member with 66 whom a student has worked closely, regardless of specialty. this is important given one quarter 67 of our attendees interested in dermatology do not have a home program. virtual away 68 rotations were described as opportunities to learn more about specific programs but should not 69 be perceived as necessary to match into dermatology. the webinar was recorded and is freely 70 available for reference. 5 the covid-19 pandemic has presented significant challenges for graduate medical 72 education. fortunately, the broad adoption of video conference communication has translated 73 into unique opportunities for medical students to stay informed on issues of significant value to 74 them. the large number of webinar viewers suggests acute interest in this format and 75 discussions for a future webinar on virtual interviews have begun. underrepresented minorities 76 and students without home dermatology programs constituted a significant portion of the 77 webinar audience, demonstrating the need and opportunity to fill gaps in recruitment and 78 mentorship for these groups. beyond covid-19 and the resumption of the traditional residency 79 application process, large-scale webinars may continue to be invaluable resources for 80 dermatology applicants. 81 82 j o u r n a l p r e -p r o o f approaching the dermatology 84 residency application process during a pandemic 951206e7f726/updated_dermatology_program_director_statement_on_2020-89 the residency application process amid the covid-19 crisis. 2020 advice for the ophthalmology residency match season the shifting landscape of the 2020-21 dermatology application cycle in the era of the 96 • students submit no more than 60 applications to dermatology programs (recommended 40-60) • students accept no more than 15 interviews (recommended 12-15) • programs do not offer in-person away rotations, except for students without home dermatology residency programs • programs conduct virtual interviews for all applicants 110 how should students express interest in specific programs given most dermatology away rotations are cancelled? who should i contact in the department/division? (program director? chief resident?) how do i find contact information? should a mentor advocate for me or make calls on my behalf? should i tailor my personal statement to specific programs? should i have a region-specific strategy? how should students without a home dermatology program approach away rotations? are test scores weighted differently this year and if so, how? how will different application components be weighted (e.g., letters of recommendation, personal statement, clerkship grades)? how can applicants strengthen their applications (especially those with weaker test scores and those who have had opportunities cancelled)? how should i address "red flags" on my application (e.g., lowstep 1 score, personal leave of absence, repeating clinical rotations)? how should applicants prepare for virtual interviews? are programs going to be coordinating virtual interview dates? how should applicants get the best feel for programs now that in-person meet-and-greets, away rotations, and interviews are cancelled? is it beneficial to take a year off to do research in dermatology? how should i include research experiences and projects that have been delayed or cancelled on my application? how can international medical students strengthen their applications this year? will virtual rotations accept international medical students? 136 table 2 . questions directed to six dermatology residency program director panelists during the webinar. 137 key: cord-305119-y3a1qyi9 authors: price, kyla n.; frew, john w.; hsiao, jennifer l.; shi, vivian y. title: covid-19 and immunomodulator/immunosuppressant use in dermatology date: 2020-03-26 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.03.046 sha: doc_id: 305119 cord_uid: y3a1qyi9 nan to the editor: we read with great interest the commentary by lebwohl et al 1 recently published in the journal of the american academy of dermatology. the authors provided a pertinent overview of infection risk associated with commonly used biologics to treat psoriasis in light of the current coronavirus disease 2019 (covid-19) outbreak. we agree that this time has been particularly concerning for patients taking immunomodulators/immunosuppressants who are unsure of their risk for severe disease. in response to the previous commentary, the goal of this letter is to expand and provide the latest information about covid-19 along with considerations for addressing patient concerns surrounding dermatology-related immunomodulator/immunosuppressant use. theoretical data from previous coronavirus outbreaks has suggested a strong role for type i interferon, b-cellereleased antibodies, tumor necrosis factor-, and other cytokines in the viral immune response (fig 1) . [2] [3] [4] interleukin (il) 17 cytokines are important for immune cell recruitment to infection sites to promote clearance, while also activating downstream cascades of cytokines and chemokines. 4 il-1 promotes fever and the differentiation of t-helper cells to il-17eproducing t cells. tumor necrosis factor-promotes dendritic cell differentiation, leukocyte recruitment, and mediates fever. 4 antibodies produced by plasma cells help to neutralize the virus, limit infection, and prevent future infections. disruption of b-cell differentiation into plasma cells could limit antibody production. 3 broad immunosuppression across multiple cytokine axes with immunosuppressants has the potential to increase susceptibility, persistence, and reactivation of viral infections. immunosuppressants decrease cytokines that recruit and differentiate immune cells needed to clear the infection. in addition, inflammatory mediators can become hyperactivated, resulting in a ''cytokine storm,'' which is the primary cause of death in severe disease. 3 whether withdrawal of broadly immunosuppressive therapies may increase the risk of precipitating cytokine storm is unknown. therefore, classic immunosuppressants may present the most concerning risk for those affected by covid-19 (table i) . immunomodulators, such as biologics, that do not target vital domains within the viral immune response may dampen, but not significantly affect viral clearance. currently, there are no data describing the benefits or risks of stopping immunomodulators/ immunosuppressants during the covid-19 outbreak. however, each medication's mechanism of action, administration method/frequency, and pharmacokinetics/pharmacodynamics are important to consider. nonbiologic medications, including small molecule inhibitors and immunosuppressants, are typically easier to stop and restart within days to weeks due to shorter half-life. meanwhile, biologics generally have a longer half-life and include a risk of antidrug antibody formation with treatment cessation and subsequent continuation. however, biologics also tend to be more targeted and less involved in the previously mentioned components of the viral immune response. general medication considerations are included in table i . although patient dependent, clinicians may consider weaning patients with stable disease off of immunosuppressants. shared decision making is needed when deciding on a treatment plan that includes immunomodulators/immunosuppressants during the covid-19 outbreak. patients with existing comorbidities may require more conservative measures. 5 physicians should continue to consult with the centers for disease control and prevention information for healthcare providers, which is updated daily (https://www.cdc.gov/coronavirus/2019-ncov/hc p/index.html). once again, we thank the authors for raising awareness of patient concerns during this evolving outbreak. the resulting inflammatory cytokines and antibodies continue to stimulate the production of additional cytokines and antibodies, which may contribute to the ''cytokine storm'' noted in those with severe disease. (8) the inflammatory cytokines and antibodies also promote the influx of neutrophils, monocytes, and macrophages along with additional inflammatory cytokines. (right) the drug targets for common dermatologic immunomodulators and immunosuppressants have also been included in this diagram. fgf, basic fibroblast growth factor; gcsf, granulocyte-colony stimulating factor; gmcsf, granulocyte-macrophage colonystimulating factor; il, interleukin; ip10, interferon -induced protein 10; irf, interferon regulatory factor; mcp1, monocyte chemoattractant protein 1; mip1a, macrophage inflammatory protein 1-; nfat, nuclear factor of activated t cells; nf-b, nuclear factor-b; pde4, phosphodiesterase 4; pdgf, platelet-derived growth factor; pka, protein kinase a; t h , t-helper cell; tnf, tumor necrosis factor; vegfa, vascular endothelial growth factor a. created with biorender.com. bees, gpskin, altus labs, and skin actives scientific. there were no incentives or transactions, financial or otherwise, relevant to this manuscript. kyla n. price and drs frew and hsiao have no conflicts of interest to declare. irb approval status: not applicable. accepted for publication march 20, 2020. reprints not available from the authors. should biologics for psoriasis be interrupted in the era of covid-19? the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak immune responses in covid-19 and potential vaccines: lessons learned from sars and mers epidemic coronavirus infections and immune responses centers for disease control and prevention. coronavirus (covid-19). available at key: cord-309230-4f5frlr5 authors: yu, jiade; chen, jennifer k.; mowad, christen m.; reeder, margo; hylwa, sara; chisolm, sarah; dunnick, cory a.; goldminz, ari m.; jacob, sharon e.; wu, peggy a.; zippin, jonathan; atwater, amber reck title: occupational dermatitis to facial personal protective equipment in healthcare workers: a systematic review date: 2020-10-01 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.09.074 sha: doc_id: 309230 cord_uid: 4f5frlr5 background prolonged wear of facial protective equipment can lead to occupational dermatoses. objective to identify important causes of occupational dermatoses from facial protective equipment. methods a systematic review following prisma guidelines was performed using pubmed and embase databases. articles were included if they reported occupational dermatoses caused by surgical/procedure masks and/or n95 respirators. results 344 articles were identified; 16 were suitable for inclusion in this review. selected articles focused on facial occupational dermatoses in healthcare workers. allergic contact dermatitis was reported to the elastic straps, glue, and formaldehyde released from the mask fabric. irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (greater than 6 hours). acneiform eruption was reported due to prolonged wear and occlusion. contact urticaria was rare. limitations only publications listed in pubmed or embase were included. most publications were case reports and retrospective studies. conclusions this systematic review from members of the american contact dermatitis society highlights cases of occupational dermatitis to facial protective equipment including potential offending allergens. this work may help in the diagnosis and treatment of healthcare workers with facial occupational dermatitis. personal protective equipment (ppe), including medical face masks, is essential to the safety of 29 healthcare workers (hcws). there are two primary types of face masks: surgical/procedure 30 masks and n95 respirators. surgical/procedure masks (also referred to as medical face masks) 31 are designed to block large-particle droplets and provide varying levels of protection based on 32 the masks' materials. n95 respirators block at least 95% of 0.3-micron test particles. identified. after removal of duplicates and those that did not meet inclusion criteria (table 1) , 29 49 j o u r n a l p r e -p r o o f areas of involvement in these studies included cheeks, nasal bridge and forehead; these could be 73 potential areas of focus for preventative workplace strategies. hcws at greater risk for adverse 74 reaction during covid-19 wore ppe >6 hours/day. 4,5 length of wear could be a potential 75 workplace modification to assist hcws experiencing mask-related adverse cutaneous reactions. 76 two studies on hcws not in epidemics or pandemics described facial contact dermatitis 6 and 77 facial skin concerns, some of which may have been related to masks. 7 while facial contact 78 dermatitis typically refers to acd or icd, it is difficult to conceptualize a diagnosis with the 79 term "skin concern". it would be advantageous if future studies on cutaneous face mask reactions 80 included specific descriptive symptoms and signs. adhesive chemicals are used in the construction of medical face masks and n95 respirators. a 100 case report described acd to mdbgn in the adhesive material beneath the mask polyester foam 101 strip. 12 mdbgn is a preservative that is used in some adhesives. formaldehyde has been described as an allergen in n95 respirators. 13, 14 formaldehyde is a 104 preservative and is used in the production of resins, plastics, plywood, and paper products. in one 105 case report, chemical evaluation of an n95 respirator identified formaldehyde, possibly a 106 byproduct of polypropylene degradation during production of the mask. 14,15-17 other potential 107 sources of undisclosed formaldehyde include its presence in raw materials or as a contaminant 108 released from product packaging. 18, 19 aside from the possible risk of formaldehyde release from 109 polypropylene degradation, polypropylene itself poses a low risk of acd. identified. after removal of duplicates and those that did not meet inclusion criteria (table 1) formaldehyde has been described as an allergen in n95 respirators. 13, 14 formaldehyde is a 361 preservative and is used in the production of resins, plastics, plywood, and paper products. in one 362 case report, chemical evaluation of an n95 respirator identified formaldehyde, possibly a 363 byproduct of polypropylene degradation during production of the mask. 14,15-17 other potential j o u r n a l p r e -p r o o f following use of n95 facial masks allergic contact dermatitis from formaldehyde textile 200 resins in surgical uniforms and nonwoven textile masks autoxidation of polyoxyethylenic non-ionic 203 surfactants and of polyethylene glycols peroxides in polyethylene glycols and polyethylene glycol derivatives contact allergenic activity of tween 207 80 before and after air exposure adverse skin reactions to personal protective 422 equipment against severe acute respiratory syndrome--a descriptive study occupational contact dermatitis preferred reporting items for systematic 427 reviews and meta-analyses: the prisma statement adverse skin reactions among healthcare workers during 430 the coronavirus disease 2019 outbreak: a survey in wuhan and its surrounding 431 skin damage among health care workers managing 433 coronavirus disease-2019 self-report occupational-related contact 436 dermatitis: prevalence and risk factors among healthcare workers in gondar town 2018-a cross-sectional study safety equipment: when protection 443 becomes a problem occupational allergic contact dermatitis in an 445 obstetrics and gynecology resident allergic contact dermatitis in dental professionals: 447 effective diagnosis and treatment a review of non-glove personal 450 protective equipment-related occupational dermatoses reported to epiderm between 451 1993 and 2013 surgical mask contact dermatitis and epidemiology of contact dermatitis following use of n95 facial masks allergic contact dermatitis from formaldehyde textile 457 resins in surgical uniforms and nonwoven textile masks autoxidation of polyoxyethylenic non-ionic 460 surfactants and of polyethylene glycols peroxides in polyethylene glycols and polyethylene glycol derivatives contact allergenic activity of tween 464 80 before and after air exposure key: cord-338597-aq80vius authors: baniandrés-rodríguez, o.; vilar-alejo, j.; rivera, r.; carrascosa, j. m.; daudén, e.; herrera-acosta, e.; sahuquillo-torralba, a.; gómez-garcía, f. j.; nieto-benito, l. m.; de la cueva, p.; lópez-estebaranz, j. l.; belinchón, i.; ferrán, m.; alsina, m.; rodriguez, l.; carretero, g.; garcía-donoso, c.; ballescá, f.; llamas-velasco, m.; herrera-ceballos, e.; botella-estrada, r.; ruiz-genao, d. p.; riera-monroig, j.; descalzo, m. a.; garcía-doval, i. title: incidence of severe covid-19 outcomes in psoriatic patients treated with systemic therapies during the pandemic: a biobadaderm cohort analysis date: 2020-10-26 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.10.046 sha: doc_id: 338597 cord_uid: aq80vius nan the biobadaderm project is promoted by the fundación piel sana academia española de dermatología y venereología, which receives financial support from the spanish medicines and health products agency (agencia española de medicamentos y productos sanitarios) and from pharmaceutical companies (abbott/abbvie, almirall, janssen, leo pharma, lilly, novartis and ucb). the following companies have also collaborated in the past (msd and pfizer). collaborating pharmaceutical companies were not involved in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; decision to submit the manuscript for publication. • dr baniandrés-rodríguez acted as a consultant and/or speaker for janssen-cilag, abbvie, pfizer, novartis, lilly, celgene, leo pharma and almirall. • dr vilar-alejo participated as ab from janssen, novartis, abbvie, almirall and celgene. • dr rivera acted as consultant and/or speaker for and/or participated in clinical trials as ip for abbvie, almirall, celgene, janssen, leo pharma, lilly, novartis, msd and pfizer-wyeth. • dr carrascosa has participated as speaker and/or advisor for celgene, janssen, lilly, novartis, leo pharma, pfizer, msd, abbvie, biogen amgen. • dr dauden acted as consultant for abbott, amgen, astellas, centocor ortho biotech inc, galderma, glaxo, jansenn-cilag, leo pharma, novartis, pfizer, msd and celgene, received honoraria form abbott, amgen, janssen-cilag, leo pharma, novartis, pfizer, msd, celgene, participated in a speakers bureau for abbott, pfizer, msd and janssen and received grants from pfizer, abbott, janssen and msd. • dr herrera-acosta has served as consultant and/or speaker with leo pharma, novartis, janssen, lilly, celgene y abbvie. • dr sahuquillo has served as a consultant and/or paid speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis, including abbvie, celgene, janssen-cilag, leo pharma, lilly, novartis and pfizer. • dr de la cueva acted as a consultant and/or speaker for janssen-cilag, abbvie, msd, pfizer, novartis, lilly, almirall, ucb, biogen, celgene, amgen, sandoz, sanofi and leo-pharma. • dr lópez-estebaranz participated as ab and received educational grants from janssen, abbvie, msd, lilly, novartis, leopharma, pfizer. • dr belinchón acted as a consultant and/or speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis, j o u r n a l p r e -p r o o f the use of systemic treatments in psoriatic patients during the pandemic has been the subject of extensive debate. in march 2020, we performed a specific study within the cohort of biobadaderm registry, a previously described national, multicenter, prospective cohort [1] . our primary objective was to analyze the incidence of covid-19 infections and severe outcomes in a cohort of psoriatic patients treated with systemic therapies and to compare it to the general population. we reviewed all biobadaderm patient records and contacted the patients when needed. we collected information about current comorbidities related to outcomes in all active patients of the registry. we used the latest data updated on 6 july 2020. we estimated the age and sex standardized incidence ratio (sir) defined as the ratio of the observed cases to the expected number of cases according to the spanish population. the main analysis examined hospitalization, icu and death in pcr-confirmed patients included in biobadaderm as compared to pcr-confirmed cases published by the spanish ministry of health [2] . also 95% ci were calculated for each sir to compare significance between the spanish figures and biobadaderm. in our study, we found that out of 2329 current active patients with systemic therapy, 73 patients (3.13%) had suffered from covid-19, 13 patients (0.56%) required hospitalization, 1 patient (0.04%) needed icu and 1 (0.04%) patient died. patient characteristics are detailed in table 1 . the profile of covid-19 cases was similar to that of the population of origin (biobadaderm) in age and sex [3] , but with higher percentages of comorbidities like hypertension (27% vs 22%) or diabetes mellitus (16% vs 11%). in our main analysis ( [3] that suggests that psoriatic patients receiving biologic treatments are not associated with worse outcomes. a strength of this study is that we analyzed a prospective cohort, that we know the base population and that we can calculate the incidences. this study therefore avoids problems of other ongoing international registries based on case notifications, which do not have a welldefined base population and likely suffer from selection bias [4] . although the first data were reassuring at the start of the pandemic, some authors consider that it is necessary to confirm them using prospective studies of incidence with adequate denominators [5] . the limitations of this study include the lack of serological or molecular confirmations for the diagnosis of covid-19 of all possible cases, which is because in cases of mild courses of the disease testing was often not done during the period of the study. in conclusion, this prospective cohort study suggests that classic systemic or biologic treatments increase neither the susceptibility nor the severity of covid-19. (97) 15 (94) 19 (90) 12 (92) 1 (100) 1 (100) 69 (95) psoriatic arthritis, yes 2 (6) 2 (13) 5 (24) 4 (31) 1 (100) 0 (0) 9 (12) treatment anti-tnf 6 (16) 5 (31) 2 (10) ( the biobadaderm project is promoted by the fundación piel sana academia española de dermatología y venereología, which receives financial support from the spanish medicines and health products agency (agencia española de medicamentos y productos sanitarios) and from pharmaceutical companies (abbott/abbvie, almirall, janssen, leo pharma, lilly, novartis and ucb). the following companies have also collaborated in the past (msd and pfizer). collaborating pharmaceutical companies were not involved in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; decision to submit the manuscript for publication. 1 (8) 0 (0) 0 (0) 13 (18) classic systemics treatments 3 (9) 2 (12) 4 (19) 2 (15) 0 (0) 0 (0) 9 (12) anti-il-12/il-23 9 (25) 4 (25) 3 (14) 4 (31) 0 (0) 0 (0) 16 (22) anti-il17 6 (17) 5 (32) 2 (10) 1 (8) 0 (0) 0 (0) 13 (18) apremilast 6 (17) 0 (0) 6 (29) 2 (15) 0 (0) 1 (100) 12 (16) fumarates 1 (3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) anti-il-23p19 5 (14) 0 (0) 4( the use of systemic treatments in psoriatic patients during the pandemic has been the subject of extensive debate. in march 2020, we performed a specific study within the cohort of biobadaderm registry, a previously described national, multicenter, prospective cohort [1] . our primary objective was to analyze the incidence of covid-19 infections and severe outcomes in a cohort of psoriatic patients treated with systemic therapies and to compare it to the general population. we reviewed all biobadaderm patient records and contacted the patients when needed. we collected information about current comorbidities related to outcomes in all active patients of the registry. we used the latest data updated on 6 july 2020. we estimated the age and sex standardized incidence ratio (sir) defined as the ratio of the observed cases to the expected number of cases according to the spanish population. the main analysis examined hospitalization, icu and death in pcr-confirmed patients included in biobadaderm as compared to pcr-confirmed cases published by the spanish ministry of health [2] . also 95% ci were calculated for each sir to compare significance between the spanish figures and biobadaderm. in our study, we found that out of 2329 current active patients with systemic therapy, 73 patients (3.13%) had suffered from covid-19, 13 patients (0.56%) required hospitalization, 1 patient (0.04%) needed icu and 1 (0.04%) patient died. patient characteristics are detailed in table 1 . the profile of covid-19 cases was similar to that of the population of origin (biobadaderm) in age and sex [3] , but with higher percentages of comorbidities like hypertension (27% vs 22%) or diabetes mellitus (16% vs 11%). in our main analysis ( the results are consistent with the article published by gisondi et al. during the peak of the italian pandemic [3] that suggests that psoriatic patients receiving biologic treatments are not associated with worse outcomes. a strength of this study is that we analyzed a prospective cohort, that we know the base population and that we can calculate the incidences. this study therefore avoids problems of other ongoing international registries based on case notifications, which do not have a welldefined base population and likely suffer from selection bias [4] . although the first data were reassuring at the start of the pandemic, some authors consider that it is necessary to confirm them using prospective studies of incidence with adequate denominators [5] . the limitations of this study include the lack of serological or molecular confirmations for the diagnosis of covid-19 of all possible cases, which is because in cases of mild courses of the disease testing was often not done during the period of the study. in conclusion, this prospective cohort study suggests that classic systemic or biologic treatments increase neither the susceptibility nor the severity of covid-19. 13 (100) 0 (0) 0 (0) 13 (18) icu admission or similar 0 (0) 0 (0) 1 (5) 0 (0) 1 (100) 0 (0) 1 (1) death 0 (0) 0 (0) 1 (5) 0 (0) 0 (0) 1 (100) 1 (1) • dr herrera-ceballos has served as a consultant and/or speaker for and/or participated in clinical trials as ip and sponsored by companies that manufacture drugs used for the treatment of psoriasis, including abbvie, janssen-cilag, leo pharma, lilly, novartis and pfizer. • dr botella-estrada has served as a consultant and/or paid speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treatment of psoriasis verónica massó lópez marina sáez belló (hospital universitario dr. peset), ángeles flórez menéndez miguel ángel descalzo gallego infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the biobadaderm registry • dr carretero has been reimbursed by janssen, abbvie, novartis, pfizer, msd and celgene for advisory service and conference. • dr garcía-donoso participated as ab from abbvie, almirall and speaker for janssen, lilly and celgene. • dr llamas-velasco acted as a consultant and speaker and participated in clinical trials for janssen-cilag verónica massó lópez marina sáez belló (hospital universitario dr. peset), ángeles flórez menéndez miguel ángel descalzo gallego infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the biobadaderm registry institute of health carlos. covid-19 cases in spain nº 33 the impact of the covid-19 pandemic on patients with chronic plaque psoriasis being treated with biological therapy: the northern italy experience international collaboration and rapid harmonization across dermatologic covid-19 registries more on covid-19 in immune-mediated inflammatory diseases this work was conducted within the biobadaderm study group. the following members participated in acquisition of data and review of the manuscript: esteban daudén, mar llamas-velasco, cristina santamaría (hospital universitario de la princesa); gregorio carretero, jaime vilar-alejo, blanca madrid álvarez (hospital universitario de gran canaria dr. negrín); raquel rivera, carmen garcía-donoso, mª del mar onteniente gomis, diana batista cabrera (hospital key: cord-286132-ag2l1xa7 authors: akiyama, shintaro; yamada, akihiro; micic, dejan; sakuraba, atsushi title: the risk of respiratory tract infections and interstitial lung disease with il-12/23 and il-23 antagonists in patients with autoimmune diseases: a systematic review and meta-analysis date: 2020-08-11 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.08.026 sha: doc_id: 286132 cord_uid: ag2l1xa7 abstract background respiratory tract infections (rtis) and interstitial lung disease (ild) secondary to interleukin (il)-12/23 or il-23 antagonists have been reported in autoimmune diseases. objective to assess the risk of rtis and non-infectious ild with these drugs. methods we conducted a systematic review and meta-analysis of randomized controlled trials (rcts). risk of rtis and non-infectious ild was compared to placebo by mantel-haenszel (mh) risk difference (rd). we divided rtis into upper rtis (urti), viral urtis, and lower rtis (lrtis) including infectious pneumonia. non-infectious ild included ild, eosinophilic pneumonia, and pneumonitis. results we identified 54 rcts including 10,907 patients with six il-12/23 or il-23 antagonists and 5,175 patients with placebo. these drugs significantly increased the risk of rtis (mh rd 0.019, 95% confidence interval 0.005-0.033, p = 0.007) which was attributed to urtis, but not viral urtis or lrtis. there was no significant difference in infectious pneumonia and non-infectious ild between two groups. limitations due to the rarity of infectious pneumonia and ild, sensitivity analysis was required. conclusion the use of il-12/23 or il-23 antagonists for autoimmune diseases increased the risk of urtis, but not viral urtis, lrtis, and non-infectious ild. the clinical benefit of interleukin (il)-12 and il-23 inhibition has been demonstrated in psoriasis 2 and crohn's disease (cd) by briakinumab 1, 2 or ustekinumab. 3, 4 furthermore, il-23-specific antagonists, such 3 as tildrakizumab, 5, 6 risankizumab, 7, 8 guselkumab, 9, 10 and brazikumab, 11 have completed phase 2 or 3 trials. 4 currently, il-12/23 or il-23 antagonists are the second most commonly prescribed category of biologics for 5 psoriasis and cd, behind anti-tumor necrosis factor agents. 12 6 however, randomized controlled trials (rcts) of these drugs reported respiratory tract infections 7 (rtis) as the most common adverse events. 13 furthermore, the surveillance conducted by food and drug 8 administration (fda) reported the development of non-infectious interstitial lung disease (ild) following 9 ustekinumab. 14 hence, physicians need evidences to decide whether to continue or hold these drugs 10 particularly during the current covid-19 pandemic. 15-17 11 this systematic review and meta-analysis aimed to determine the risk of rtis and non-infectious 12 we evaluated the presence of heterogeneity across trials by using the i 2 statistic. an i 2 value of <25% 1 indicated low heterogeneity, 25-75% as moderate heterogeneity and >75% as considerable heterogeneity, 2 respectively. 29 heterogeneity was evaluated by using cochran's q-statistics with a significance level of 3 p<0. 10 . 30 begg's and egger's tests were performed to access publication bias and funnel plots were 4 constructed to visualize possible asymmetry when three or more studies were available. 31, 32 5 statistical analyses were performed using the comprehensive meta-analysis software (version 2.0; 6 biostat, englewood, nj, usa). all statistical tests used a two-sided a value of 0.05 for significance. characteristics and outcomes of the included studies are summarized in table 1 the percentage of studies which permitted to use concomitant drugs (e.g. corticosteroids, budesonide, 13 thiopurines, methotrexate, calcineurin inhibitors, or aminosalicylates) during the trials was 40.0% for 14 risankizumab, 38.5% for ustekinumab, 37.5% for briakinumab, 0% for guselkumab, and 0% for tildrakizumab. 15 as for brazikumab, one study for cd was included in this analysis and permitted concomitant drugs (table 1) . 16 meta-analysis with a random-effects model showed that the overall risk of rtis with 1 anti-il-12/il-23 or anti-il-23 agents was significantly higher than that of placebo (mh rd 0.019, 95% 2 confidence interval [ci] 0.005-0.033, p = 0.007) ( figure 2 ). the number needed to harm of rtis was 58.8. 3 subgroup analysis revealed a significantly increased risk of rtis with briakinumab (mh rd 0.021, 95% ci 4 0.001-0.041, p = 0.036) and risankizumab (mh rd 0.040, 95% ci 0.005-0.076, p = 0.026). heterogeneity 5 was absent (i 2 = 0%) in overall and subgroup analyses except for briakinumab (i 2 = 31%). funnel plot 6 demonstrated no asymmetry, therefore suggesting there was no small-study effects or publication bias, which 7 was supported by begg's and egger's tests ( figure s1 ). we also assessed the differential risk of rtis by 8 underlying disease and showed a significantly increased risk of rtis in psoriasis (mh rd 0.023, 95% ci we divided rtis into urtis, viral urtis, and lrtis and investigated each risk with il-12/23 or 12 il-23 inhibitors. the overall risk of urtis was significantly higher in the treatment group compared to anti-il-12/il-23 or anti-il-23 agents did not increase the overall risks of viral urtis (mh rd 17 0.001, 95% ci -0.002-0.003, p = 0.60) and lrtis (mh rd 0, 95% ci -0.002-0.002, p = 0.71) ( figure s4a , 18 s5a). heterogeneity was absent (i 2 = 0%) in these analyses. publication bias was indicated in the analysis of 19 viral urtis (begg: p < 0.001, egger: p = 0.019) ( figure s4b ) and lrtis (begg: p < 0.001, egger: p = 0.55) 1 ( figure s5b ), but the funnel plots did not appear asymmetric on visual inspection. 2 3 the total numbers of infectious pneumonia were 9 and 4 cases in the treatment group and placebo, 5 respectively. mycobacterium tuberculosis and viral pneumonia were not reported. the overall risk of 6 infectious pneumonia was not significantly increased in the treatment group compared to placebo (mh rd 0, 7 95% ci -0.002-0.002, p = 0.87) ( figure 3 ). heterogeneity was absent (i 2 = 0%). the funnel plot was not 8 asymmetric, indicating no publication bias, which was supported by egger's test (p = 0.93) but not begg's test 9 (p < 0.001) ( figure s6 ). 10 in terms of non-infectious ild, 2 and 1 cases were identified in the treatment group and placebo, 11 respectively. all 3 cases were reported in the trials of ustekinumab and occurred within 16 weeks after 12 initiation of the trial. [33] [34] [35] the overall risk of ild was not significantly increased in the treatment group (mh 13 rd 0, 95% ci -0.002-0.002, p = 0.99) ( figure 4 ). heterogeneity was absent (i 2 = 0%). begg's (p < 0.001), but 14 not egger's (p = 0.69), test was suggestive of publication bias, but the funnel plot was not asymmetric ( the sensitivity analysis revealed consistent results (table s1-2, s4-5, s6, s8) except the analysis 17 with 0.5 constant correction of zero-event studies showed a lower risk of infectious pneumonia (table s3) and based on the grade, an overall quality of evidence for this analysis was moderate as infectious 3 pneumonia and ild were rare events (tables s9 and s10). 4 our meta-analysis showed that il-12/23 or il-23 inhibitors increased the risk of rtis, especially 2 urtis, but not viral urtis and lrtis, and non-infectious ild in autoimmune diseases. 3 we found that risankizumab and briakinumab particularly enhanced the risk of rtis and 4 hypothesized that concomitant therapies during the trials might differentiate the risk of rtis. in terms of 5 anti-il-23 agents, risankizumab showed a higher rate of rcts which permitted concomitant therapies (40.0%) 6 compared with guselkumab (0%) and tildrakizumab (0%). among rcts of risankizumab, the only study 7 reporting an increased risk of rtis was performed in patients with ankylosing spondylitis who were permitted 8 to use conventional disease-modifying antirheumatic drugs or low-dose systemic steroids. 36 this suggests that 9 combination therapy of anti-il-23 agents with immunosuppressants might work synergistically to surface the 10 risk of rtis. as for anti-il-12/il-23 agents, each of briakinumab and ustekinumab has a similar percentage of 11 rcts which permitted concomitant drugs (37.5% for briakinumab and 38.5% for ustekinumab). other 12 potential risk factors such as age and sex were not different among the drugs. given that briakinumab has 13 been withdrawn from the application with fda due to severe adverse events, 1 the difference in risk of rtis 14 among two drugs would be explained by different properties of these drugs. 15 our study might support that anti-il-12/23 and anti-il-23 therapies can be safely used for 16 autoimmune diseases even during the current covid-19 pandemic. however, given that influenza respiratory syndrome coronavirus showed that a patient with a poor outcome had an increased level of il17 15 expression in the lung. 41 these data suggest that il-12/23 or il-23 inhibitors might theoretically be preventive 16 for sars-cov-2-induced pneumonia rather than detrimental in autoimmune diseases during the covid19 17 pandemic. 18 first, this study did not assess the long-term effect of il-12/23 or il-23 antagonists on rtis and 2 ild. however, 92.6 % (50/54) of included studies reported rtis during placebo-controlled phases. fda 3 reported the onset of ild was acute or subacute, 14 so our data would most likely include the incidence of these 4 events. second, regarding infectious pneumonia and ild, many studies had both-armed zero-event (87% 5 (47/54) and 94% (51/54), respectively). thus, we undertook comprehensive analyses that either included or 6 excluded double-zero-event studies. the analysis with 0.5 constant correction showed a lower risk of these 7 events in the treatment group. we also used treatment arm correction because this method performed better 8 than 0.5 constant correction to examine rare events. 46 third, our study may not reflect the risk in patients at 9 high risk for rtis due to the possible exclusion of patients with recent rtis or chronic lung disease in clinical 10 trials. fourth, we categorized rtis into urtis, viral urtis, and lrtis based on meddra which is widely 11 used in clinical trials, but not so much in clinical research. furthermore, the included studies have been 12 conducted before the pandemic. hence, it does not provide evidences whether there is an increase in rtis or 13 ild during the pandemic in patients receiving il-12/23 or il-23 antagonists, nor whether these agents can be 14 autoimmune diseases is needed. 20 nemoto et al 2018 48 blauvelt et al 2017 49 reich et al 2017 10 gordon et al 2015 9 sofen et al 2014 50 terui et al 2018 51 [wt>100kg] at wk 0,4 45 s.c.at wk 0,4 33 tsai et al 2011 63 papp et al 2008 3 leonardi et al 2008 64 krueger et al 2007 65 ritchlin et al 2014 34 mclnne et al 2013 66 gottlieb et al 2009 67 feagan et al 2016 68 feagan et al 2016 68 sandborn et al 2012 4 sandborn et al 2008 69 khattri et al 2017 70 saeki (s) 130, 6mg/kg i.v. (s) 1, 3, 6mg/kg i.v. (s) 90 s.c a phase iii, randomized mab briakinumab in moderate-to-severe psoriasis briakinumab for treatment of crohn's disease: results of a randomized trial efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (phoenix 2) ustekinumab induction and maintenance therapy in refractory crohn's disease tildrakizumab versus placebo or etanercept for chronic plaque psoriasis (resurface 1 and resurface 2): results from two randomised controlled, phase 3 trials mk-3222), an anti-interleukin-23p19 monoclonal antibody, improves psoriasis in a phase iib randomized placebo-controlled trial efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (ultimma-1 and ultimma-2): results from two double-blind, randomised, placebo-controlled and ustekinumab-controlled phase 3 trials induction therapy with the selective interleukin-23 inhibitor risankizumab in patients with moderate-to-severe crohn's disease: a randomised, double-blind, placebo-controlled phase 2 study a phase 2 trial of guselkumab versus adalimumab for plaque psoriasis 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 efficacy and safety of medi2070, an patients with moderate to severe crohn's disease: a phase 2a study crohn's disease disease coverage the safety of ustekinumab for the treatment of psoriatic arthritis association of noninfectious pneumonia with ustekinumab use editorial: the explosive epidemic outbreak of novel coronavirus disease covid-19) and the persistent threat of respiratory tract infectious diseases to global health security should biologics for psoriasis be interrupted in the era of covid-19? are patients with inflammatory bowel disease at increased risk for covid-19 infection? preferred reporting items for systematic reviews and meta-analyses: the prisma statement prospero's progress and activities 2012/13 efficacy and safety of guselkumab, administered with a novel patient-controlled injector (one-press), for moderate-to-severe psoriasis: results from the phase 3 orion study in vivo il-12/il-23p40 neutralization blocks th1/th17 response after allogeneic hematopoietic cell transplantation assessing the quality of reports of randomized clinical trials: is blinding necessary? the cochrane collaboration's tool for assessing risk of bias in randomised trials grade guidelines: 4. rating the quality of evidence--study limitations (risk of bias) inclusion of zero total event trials in meta-analyses maintains analytic consistency and incorporates all available data the peto odds ratio viewed as a new effect measure methods for pooled analyses of epidemiologic studies anti-tnf antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials measuring inconsistency in meta-analyses cochrane handbook for systematic reviews of interventions, version 5.1. 0. london the cochrane collaboration operating characteristics of a rank correlation test for publication bias bias in meta-analysis detected by a simple, graphical test efficacy and safety of ustekinumab in japanese patients with moderate-to-severe plaque-type psoriasis: long-term results from a phase 2/3 clinical trial efficacy and safety of the anti-il-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised psummit 2 trial safety and efficacy of ustekinumab or golimumab in patients with chronic sarcoidosis risankizumab, an il-23 inhibitor, for ankylosing spondylitis: results of a randomised, double-blind, placebo-controlled, proof-of-concept, dose-finding phase 2 study vaccination recommendations for the adult immunosuppressed patient: a systematic review and comprehensive field synopsis interstitial pneumonia in psoriasis management of interstitial lung disease associated with connective tissue disease thoracic manifestations of inflammatory bowel disease distinct immune response in two mers-cov-infected patients: can we go from bench to bedside? immunology taught by human genetics il-23 is essential for t cell-mediated colitis and promotes inflammation via il-17 and il-6 il-12 and il-23 cytokines: from discovery to targeted therapies for immune-mediated inflammatory diseases critical role of il-17ra in immunopathology of influenza infection what to add to nothing? use and avoidance of continuity corrections in meta-analysis of sparse data an anti-interleukin-23 monoclonal antibody, for the treatment of moderate to severe plaque-type psoriasis in japanese patients: efficacy and safety results from a phase 3, randomized, double-blind, placebo-controlled study safety and efficacy of guselkumab in japanese patients with moderate-to-severe plaque psoriasis: a randomized, placebo-controlled, ascending-dose study efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: results from the phase iii, double-blinded, placebo-and active comparator-controlled voyage 1 trial guselkumab (an il-23-specific mab) demonstrates clinical and molecular response in patients with moderate-to-severe psoriasis efficacy and safety of guselkumab, an anti-interleukin 23 monoclonal antibody, for palmoplantar pustulosis: a randomized clinical trial first-in-human study to assess guselkumab (anti-il-23 mab) pharmacokinetics/safety in healthy subjects and patients with moderate-to-severe psoriasis anti-il-23a mab bi 655066 for treatment of moderate-to-severe psoriasis: safety, efficacy, pharmacokinetics, and biomarker results of a single-rising-dose, randomized, double-blind, placebo-controlled trial pharmacokinetics of tildrakizumab (mk-3222), an anti-il-23 monoclonal after intravenous or subcutaneous administration in healthy subjects efficacy and safety of briakinumab vs. etanercept and placebo in patients with moderate to severe chronic plaque psoriasis efficacy and safety results from a phase iii, randomized controlled trial comparing the safety and efficacy of briakinumab with etanercept and placebo in patients with moderate to severe chronic plaque psoriasis safety and efficacy of abt-874 monoclonal antibody, in the treatment of moderate to severe chronic plaque psoriasis: results of a randomized, placebo-controlled, phase 2 trial anti-interleukin-12 antibody for active crohn's disease a phase 2, 24-week, randomized, placebo-controlled, double-blind study examining the efficacy and safety of an anti-interleukin-12 and -23 monoclonal antibody in patients with relapsing-remitting or secondary progressive multiple sclerosis ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 cadmus study phase 3 studies comparing brodalumab with ustekinumab in psoriasis efficacy and safety of ustekinumab in chinese patients with moderate to severe plaque-type psoriasis: results from a phase 3 clinical trial (lotus) efficacy and safety of ustekinumab for the treatment of moderate-to-severe psoriasis: a phase iii, randomized, placebo-controlled trial in taiwanese and korean patients (pearl) efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (phoenix 1) a human interleukin-12/23 monoclonal antibody for the treatment of psoriasis efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled psummit 1 trial ustekinumab, a human interleukin 12/23 monoclonal antibody, for psoriatic arthritis: randomised, double-blind, placebo-controlled, crossover trial ustekinumab as induction and maintenance therapy for crohn's disease a randomized trial of ustekinumab monoclonal antibody, in patients with moderate-to-severe crohn's disease efficacy and safety of ustekinumab treatment in adults with moderate-to-severe atopic dermatitis efficacy and safety of ustekinumab in japanese patients with severe atopic dermatitis: a randomized, double-blind, placebo-controlled, phase ii study efficacy and safety of ustekinumab inhibitor, in patients with active systemic lupus erythematosus: results of a multicentre, double-blind, phase 2, randomised, controlled study repeated subcutaneous injections of il12/23 p40 neutralising antibody, ustekinumab, in patients with relapsing-remitting multiple sclerosis: a phase ii, double-blind, placebo-controlled, randomised, dose-ranging study key: cord-346287-xg176mi7 authors: wan, marilyn t.; shin, daniel b.; winthrop, kevin l.; gelfand, joel m. title: in response to: “reply to research letter.” date: 2020-07-29 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.097 sha: doc_id: 346287 cord_uid: xg176mi7 nan letter to the editor 1 2 to the editor: we appreciate the interest of rivera-oyola, koschitzky, and lebwohl 1 in our 3 meta-estimate evaluating the risk of respiratory tract infections (rtis) and symptoms in patients 4 with psoriasis treated with interleukin(il)-17 pathway inhibiting biologics. 2 the authors make a 5 cogent case for the importance of not cherry-picking data when evaluating drug safety by 6 selecting a few examples in which perhaps patients treated with il-17 inhibitors have a lower 7 risk of rtis compared to placebo. the examples they provided are precisely why one needs to 8 look at all the data through an unbiased meta-estimate approach. as we noted in our initial 9 publication, 2 the results demonstrated a statistically significant 31-56% increased risk of rti in 10 il-17 targeting biologic treated patients compared to placebo. sensitivity analyses varying the 11 definition of rti yielded similar findings. the interpretation of these results is that there is a 12 potential safety signal for rti associated with il-17 inhibition. a safety signal is simply defined 13 as a hypothesis between exposure to a drug and an adverse event that warrants further 14 investigation. 3 taking the same analytical approach, we did not find a safety signal for rti 15 associated with il-23 inhibitors. 4 as we pointed out, in the il-17 analysis, the risk of rti in 16 clinical trials is difficult to classify because the diagnosis is made clinically, without objective 17 testing. therefore, the etiology of these symptoms, be they viral, bacterial, fungal, or allergic, is 18 unknown. in the il-23 analysis, we also noted that the confidence intervals overlap, and 19 therefore, we cannot conclude with certainty that there is a true difference in rti risk between 20 biologics that target il-17 versus il-23. current data is insufficient to reliably distinguish the 21 risk of becoming infected with sars-cov-2 and having worse outcomes from covid-19 22 illness between our various biologic treatment options for psoriasis. 23 reply to research letter the risk of respiratory tract infections and symptoms in psoriasis patients treated with il-17-pathway inhibiting biologics: a metaestimate of pivotal trials relevant to decision-making during the covid-19 pandemic characteristics of drugs safety signals that predict safety related product information update the risk of respiratory tract infections in psoriasis patients treated with il-23-pathway inhibiting biologics: a meta-estimate of pivotal trials relevant to decision-making during the covid-19 pandemic key: cord-316793-clshw9v2 authors: sethy, mitanjali; krishna, vamshi; srinivas, chakravarthi r. title: cling film for mobile phone to prevent cross-infection during covid-19 pandemic date: 2020-07-02 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.1008 sha: doc_id: 316793 cord_uid: clshw9v2 nan mobile phone has become an inseparable part of dermatology practice and dermatologists use mobile phones in various ways while clinically examining the patients. the same often used as a torch or a camera to click images of the lesions. in this covid-19 pandemic era, mobile phones are more likely to be contaminated with the virus in health-care settings, need to be sanitized properly after use as it can be a possible carrier of the virus. 1 however, it's practically not feasible to sanitize mobile phones with alcohol-containing sanitizer or chlorine solutions as there may be an ill effect of these chemical solutions on the mobile screen. cling film roll can be a better solution for this challenge. these are thin transparent plastic wraps with smooth surfaces, can be used to wrap mobile thoroughly before reaching the hospital aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 key: cord-285030-ecsa83kf authors: jimenez-cauhe, juan; ortega-quijano, daniel; prieto-barrios, marta; moreno-arrones, oscar m.; fernandez-nieto, diego title: reply to “covid-19 can present with a rash and be mistaken for dengue”: petechial rash in a patient with covid-19 infection date: 2020-04-10 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.016 sha: doc_id: 285030 cord_uid: ecsa83kf nan dermatologists have a unique opportunity to study covid-19 cutaneous manifestations during this pandemic, and illustrative images are the first step for other colleagues to start looking for them. a golden principle of medicine becomes now more important: "the more you see, the more you know; and the more you know is the more you see". covid-19 can present with a rash and be mistaken for dengue cutaneous manifestations in covid-19: a first perspective key: cord-296013-6ej3pd0u authors: trinidad, john; kroshinksy, daniela; kaffenberger, benjamin h.; rojek, nathan title: telemedicine for inpatient dermatology consultations in response to the covid-19 pandemic date: 2020-04-24 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.096 sha: doc_id: 296013 cord_uid: 6ej3pd0u nan to chemotherapy, and other diseases that complicate and extend hospitalizations. 3 inpatient 46 dermatology services will continue to provide impactful care throughout the covid-19 crisis 47 with a particular need to help allocate scarce resources. hospital bed space, isolation rooms, and 48 equipment is/will be limited during this pandemic, and dermatologists will play an important role 49 in triaging and identifying conditions such as varicella-zoster mimics that can be safely managed 50 outside of isolation rooms or pseudocellulitis that can be managed outside of the hospital setting. 51 however, proper protocols and safety measures are necessary to protect the health of patients, 52 trainees, consultants, and family members. 53 54 telemedicine has already begun to revolutionize how we provide care to patients. outpatient 55 teledermatology services have the potential to increase access to dermatology care, and to 56 address health care disparities for urban-underserved and rural populations. 4 inpatient 57 teledermatology is emerging as a safe and effective option as well. 5 dermatologists are poised to 58 utilize teledermatology to increase access to dermatologic care for hospitalized patients, reduce 59 the risk of infection of patients, trainees and staff, and reduce the use of precious resources such 60 as personal protective equipment (ppe) and medical supplies. distinguishing stevens-johnson syndrome/toxic 104 epidermal necrolysis from clinical mimickers during inpatient dermatologic 105 consultation-a retrospective chart review characterisation and diagnosis of ulcers in 108 inpatient dermatology consultation services: a multi-centre study improved patient access and outcomes with the 111 integration of an econsult program (teledermatology) within a large academic medical 112 center a survey-based study of diagnostic and 114 treatment concordance in standardized cases of cellulitis and pseudocellulitis via 115 teledermatology key: cord-344361-amhc0ryh authors: ruggiero, giuseppe; arcangeli, fabio; lotti, torello; ametrano, orsola; ruggiero, cosimo; cucchiara, salvatore; oliva, salvatore title: reply to: “characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak” date: 2020-06-01 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.122 sha: doc_id: 344361 cord_uid: amhc0ryh nan we read with interest "characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak" [1] . cutaneous manifestations of covid-19 are rarely reported. fernandez-nieto et al. in their letter described an increased number of acro-ischemic lesions in young patients from spain [1] . most patients were asymptomatic or mildly symptomatic, and none of them developed covid-19 pneumonia or any other complication. it is very intriguing that in italy we are observing the same uncommon increase. italy and spain are the two european countries with the highest incidence of covid-19 [2] . in italy, after the outbreak onset, many general pediatricians reported on our pediatric dermatology network unusual foot injuries, similar to chilblains and without any other symptoms. these lesions have never been described with this frequency before, being usually rare. thus, we table 1 ). the spanish authors found 132 cases in 41 days, while our patients were collected in 10 days. even in our cohort, lesions were mostly located in the extremities of the limbs, with only two cases involving the face. we found a lower rate of systemic symptoms (16% vs 25%), but our population was slightly younger (mean age 12.5 vs 23.4 years), being likely less symptomatic [3] . almost the same number of positive sars-cov-2 tests (1 vs 2 patients) was described in both cohorts. our positive patient had also extra-cutaneous symptoms (fever and pharyngodynia). he was exposed to positive covid-19 subjects (family members) as in the spanish positive ones. this confirms that the chance of finding infected children increases if all cohabiting family members are tested after an index case. indeed, only 11% in our cohort were tested for sars-cov-2, due to the rigid testing policy in italy. the spanish group tested only 8%, thus confirming the difficulty in having testing in overwhelmed public health systems. we did not differentiate between chilblains-like and erythema multiforme-like lesions. we observed and collected only lesions appearing as circumscribed erythematous edematous elements with a purplish red color, thus defined "erythema pernio-like lesions" (figure 1) . a local and/or systemic therapy was considered only in 74/100 cases (74%) ( table 1 ). up to 80% of cases at day 12 had a favorable outcome regardless of the therapy used. this observation is additional evidence for a covid-19 etiology. indeed, it is known that chilblains can be secondary to viral infections. the likelihood of other seasonal non-covid-19 infections was extremely low since children were having contact only with their family members due to the national lockdown [4] . pernio-like" acrolocated lesions onset and covid-19. general pediatricians all over the world should pay attention to skin lesions during the covid-19 pandemic. pediatric gastroenterology and liver unit, maternal and child health department characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the covid-19 outbreak epidemiological characteristics of 2143pediatric patients with 2019 coronavirus disease in china delayed access or provision of care in italy resulting from fear of covid-19 the authors would like to especially thank the following key persons for contributing in data key: cord-308212-l8flyso7 authors: kong, ha eun; grant-kels, jane m.; stoff, benjamin k. title: applying the ethical principles of resource allocation to drugs in limited supply during a public health crisis date: 2020-04-21 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.078 sha: doc_id: 308212 cord_uid: l8flyso7 nan saving the most lives/life-years is the highest priority. random selection can be used for selecting among patients with comparable prognoses. healthcare workers should be prioritized. with other factors equal, give priority to covid-19 research participants. aligns with maximizing benefits e.g. saving most years of life or preventing further spread of virus. 45 during a pandemic, priority should be given to those whose survival would benefit most from 46 treatment in order to maximize benefit to society. applying this principle to antimalarials, severe 47 covid-19 patients as well as patients with malaria or severe rheumatologic disease, for whom 48 other effective treatments are unavailable, should be favored. if dermatology patients eligible for 49 antimalarials have other, comparably-effective treatment options, dermatologists should 50 recommend alternatives, particularly for mild-to-moderate disease. finally, providers should 51 not prescribe these drugs to the "worried well," who may be hoarding medication in case of 52 illness. clinicians must reassess allocation strategies as new data emerge. the efficacy of 55 antimalarials for covid-19 should be assessed via randomized clinical trials (rcts), which are 56 ongoing. for example, a small open-label french study demonstrated reduction in viral load, 57 but did not assess mortality or morbidity 1 . in contrast, for systemic lupus erythematosus (sle) 58 patients, a rct showed that discontinuing hydroxychloroquine leads to a 2.5x increased 59 relative risk of clinically-relevant flares and a 6x increased relative risk of severe exacerbation 60 compared to placebo 4 . while the benefit of antimalarials to covid-19 patients remains 61 uncertain, high-quality evidence supports continuing treatment in patients with severe sle. 62 what is the role of patient autonomy in public health emergencies? under normal 63 circumstances, if a reasonable patient prefers antimalarials for skin disease, and the treatment 64 is indicated, then the drugs should be prescribed. however, patient autonomy is diminished in 65 public health emergencies, as healthcare ethics shifts priority to populations over individuals 5 . 66 currently, many states in the us have limited prescribing of hydroxychloroquine, but these 67 limitations generally don't apply to patients on drug for approved indications 6 . in applying the 68 ethical principles of resource allocation (table i) table 1 . "application of ethical principles of resource allocation in the covid-19 pandemic" 107 (adapted from emanuel et al. 3 ) 108 saving the most lives/life-years is the highest priority. random selection can be used for selecting among patients with comparable prognoses. healthcare workers should be prioritized. with other factors equal, give priority to covid-19 research participants. aligns with maximizing benefits e.g. saving most years of life or preventing further spread of virus. 109 hydroxychloroquine and azithromycin as a 86 treatment of covid-19: results of an open-label non-randomized clinical trial potential shortages of hydroxychloroquine for patients 89 with lupus during the coronavirus disease fair allocation of scarce medical resources in 92 the time of covid-19 a randomized study of the effect of withdrawing 95 hydroxychloroquine sulfate in systemic lupus erythematosus ethical framework for health care institutions & guidelines for institutional ethics 98 services responding to the coronavirus pandemic -the hastings center key: cord-295371-ccqne6nu authors: stoj, victoria j.; grant-kels, jane m. title: dermatology residents and the care of patients with coronavirus disease 2019 (covid-19) date: 2020-04-04 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.03.086 sha: doc_id: 295371 cord_uid: ccqne6nu nan dear dr dermatoethicist: i am a dermatology resident. recently, i was notified that i might be pulled from dermatology to work in the emergency department or on the hospital floors to help with patients with coronavirus disease 2019. can i refuse, and even consider litigation? my contract with the hospital states that i will be practicing dermatology, with no mention of general medicine. ereluctant resident dear reluctant resident: as if prescient, a 2016 dermatoethics publication in this journal discussed this very topic, except that the dermatologist was requested to consult on a rash in a patient with ebola. 1 the good news is that covid-19 is far less fatal, particularly for young, healthy residents 2 (tables i and ii) . therefore, your fear of dying should be tempered with facts. most importantly, as a physician who cited the hippocratic oath at graduation, you have sworn to solemnly serve your patient as your first consideration before your own interests. 3 you are therefore ethically (because of professionalism, beneficence, nonmaleficence, justice, and dignity) and morally bound to perform your duty when called upon, especially in a medical crisis, as we are presently living through. additionally, there is an american academy of dermatology code of medical ethics that states, ''it is .unethical for a dermatologist .to refuse the management of a patient because of medical risk, real or imagined (page 18, section 1c).'' 4 subsequently, in the current pandemic, it is a dermatologist's duty to treat patients in the clinic, in the hospital, in the emergency room, and in the intensive care unit if called upon. your concern is understandable. in the current covid-19 pandemic, reports of exponential increases of confirmed cases; the rising death toll; and limited resources for testing, treatment, and personal protective equipment can cause an overwhelming sense of anxiety, even for health care workers. health care workers in italy make up approximately 9% of confirmed covid-19 cases in that country as of march 10, 2020. 5 there is no question that physicians are at high risk of exposure and infection. however, as already noted, the cases of infection in adults younger than 65 years have been less severe, resulting in significantly fewer intensive care unit admissions and case fatality rates in the united states, ranging between 0.1 and 0.2 in patients 20 to 44 years old. 6 thus, you need to behave professionally and do whatever is required in our joint effort to mitigate this outbreak. historically, the physician's duty to treat has been an accepted obligation of the profession, akin to police officers or firefighters willing to place themselves in danger to help others. the current covid-19 pandemic is a public health crisis that requires physicians, of all specialties, to step up and help. the bottom line is that to fulfill your obligation as a professional in the house of medicine, ensure medical care is delivered to those in need (distributive justice), help patients, and do no harm (beneficence and nonmaleficence,) and for your own dignity, do not call a lawyer! instead, grab your stethoscope and do the right thing! edr dermatoethicist. i didn't sign on to die'': the dermatologist's ethical obligations during a deadly epidemic global covid-19 case fatality rates the revised declaration of geneva: a modern-day physician's pledge code of medical ethics for dermatologists, article 1b, page 18, section 1c available at coronavirus disease 2019 (covid-19) in italy covid-19)-united states key: cord-274517-9lewc581 authors: litchman, graham h.; rigel, darrell s. title: the immediate impact of covid-19 on us dermatology practices date: 2020-05-16 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.048 sha: doc_id: 274517 cord_uid: 9lewc581 nan nothing has yet been assessed for the us. 2 the purpose of this study was to determine the magnitude of 33 the initial impact of covid-19 on us dermatology outpatient care. 34 after pre-validation, a survey comparing outpatient volumes and scheduling issues for the week of 35 february 17th versus the week of march 16th, 2020 and for estimation of trends in the next several 36 weeks was emailed to us dermatologists on 3/21 (table s1 ) and the first 1,000 responses were 37 tabulated. 30 responses were removed due to ineligible geography or errors in survey entry, leaving 970 38 for the analysis. respondent demographics were analyzed (table 1) . representativeness with regards to 39 geographic location and practice experience compared to aad membership data was confirmed (table 40 s2). statistical significance was calculated using chi-square, difference-of-proportions, and two-tailed 41 independent t-tests. 42 covid-19 impact was material (table 2) . from the 3rd week in february to the 3rd week in march, the 43 average number of patients seen fell from 149.4 to 63.4(p<0.0001), practice days from 4.2 to 44 3.1(p<0.0001) and biopsies from 19.8 to 7.7(p<0.0001). although by 3/16 there were only 24.6k cases 45 nationally 3 , the early-phase decrease in patient volume and office days suggests the magnitude of 46 disease concern impact was greater than actual prevalence. postponement of non-essential 47 appointments increased from 35.5% to 79.4%(p<0.00001). 66.3% of respondents estimated a >50% 48 decrease in patient volume in the coming 2 weeks (18.9% completely closing practices). 54.6% of 49 postponed appointments were for >4 weeks with an additional 25.4% not rescheduled. 50 a greater negative impact was found in us "hotspot" regions 4 (36% of respondentsfigure s1 ) for week 51 3/16-20 for practice days (3.0 hotspots vs. 3.3 non-hotspots) and patients seen (56.2 in hotspots vs. 70.0 52 in non-hotspots). no significant differing telemedicine usage (39.5% hotspots vs 37.2% non-hotspots) or 53 overall for the next 2 weeks was 37.8%. university/academic/government dermatologists were 55 significantly more likely to use telemedicine (57.1%) than private practitioners (35.5%). telemedicine 56 usage was less likely for dermatologists with >30 practice years (>30=32.4% vs 40.0%). however, 57 telemedicine usage does not have an impact on the deferred/postponed biopsies that had already 58 occurred during the march week (mean=10.7) as well as those predicted to be subsequently postponed. 59 limitations include that this study reflects a "snapshot" which could materially change given the 60 dynamically evolving situation. estimations could have led to recall bias and the methodology could 61 have introduced sampling and non-response bias. those with lower work volumes could have been 62 more likely to have time to respond, but this bias was minimized by weekend-only data collection. 63 however, the large sample size and representative distribution mitigate selection bias and standard 64 statistical testing demonstrated significance. 65 our findings demonstrate the significant early impact of covid-19 on us dermatologic care and can help 66 better understand national trends. with an estimated 49.9 million annual us dermatology office visits 5 , 67 the 50%+ decrease in predicted visits could be devastating. beyond telemedicine, other innovative 68 approaches will need to be developed and implemented to help delivery of essential dermatology care 69 during this crisis. 70 71 fair allocation of scarce medical resources in the time of 74 what are we doing in the dermatology outpatient department amidst 76 the raging of the 2019 novel coronavirus cases of coronavirus disease 2019 (covid-19) in the u.s. by centers for disease control html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-81 ncov%2fcases-in-us.html#anchor_1586790730. accessed coronavirus covid-19 global cases by the center for systems science and engineering at johns 83 national ambulatory medical care survey: 2016 national summary tables key: cord-325992-qik2w1f1 authors: torres, angeli eloise; ozog, david m.; hamzavi, iltefat h.; lim, henry w. title: notes and comments on “proposed approach for re-using surgical masks in covid-19 pandemic” date: 2020-05-21 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.083 sha: doc_id: 325992 cord_uid: qik2w1f1 nan angeli eloise torres, md, dpds 1 its effect on n95 respirator integrity rather than a quantification of its virucidal activity. 2 this 24 makes it difficult to compare its virucidal advantage over ultraviolet c (uvc) and other 25 methods. 2 dry heating requires direct supervision during its delivery, as too high a temperature 26 (>100°c) is known to decrease the filtering capacity of respirators and masks. 2 in addition, the 27 effect of dry heating on respirator -and possibly mask -integrity varies significantly depending 28 on the approach used (laboratory oven, dry microwaving, or rice cooker without water) 2 and the 29 specific respirator or mask model. for n95 respirators, failure of fit-testing after 30 decontamination would have potential catastrophic effects on healthcare providers. 3 31 the authors' statement pertaining to uvc having "less penetration" and being "less proposed approach for reusing surgical masks in covid-19 51 pandemic other methods of decontamination of filtering facepiece n-95 respirators during the covid-54 the importance of form 56 fit testing in decontamination of n95 respirators: a cautionary note ultraviolet 59 germicidal irradiation: possible method for respirator disinfection to facilitate reuse during 60 covid-19 pandemic efficacy of an automated multiple emitter whole-62 room ultraviolet-c disinfection system against coronaviruses mhv and mers-cov ultraviolet 65 germicidal irradiation of influenza-contaminated n95 filtering facepiece respirators key: cord-354902-t9df8vhc authors: kearns, donovan g.; uppal, shelley; chat, vipawee s.; wu, jashin j. title: assessing the risk of dupilumab use for atopic dermatitis during the covid-19 pandemic date: 2020-06-10 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.015 sha: doc_id: 354902 cord_uid: t9df8vhc nan in the midst of the covid-19 pandemic, physicians are using what's known of the sars-cov-2 2 virus to establish practice guidelines for dermatologic conditions, particularly in regard to the 3 use of immunosuppressive medications. 1 the effect of immunosuppressive medications on the 4 clinical course of covid-19 infection is currently unclear. while there is some evidence to 5 support the use of targeted immunosuppressive medications against cytokine storm, there is 6 concern that patients treated with biologic medications may have worse outcomes. 1 though 7 knowledge regarding the risk of biologic use during the covid-19 pandemic is extremely 8 limited, we can use data from previous trials to extrapolate a medication's potential risk based on 9 its infection rate when compared to placebo. 10 dupilumab, an interleukin 4 alpha receptor antagonist that inhibits il-4 and il-13 signaling, is a 11 treatment for patients >12 years with moderate to severe atopic dermatitis (ad). interleukin-4 12 (il-4) is critical in mediating th2 polarization and regulating humoral immunity. 2 given that il-13 4 and il-13 are significant in orchestrating and maintaining adaptive immunity, we sought to 14 identify and address the risks associated with dupilumab use during the covid-19 pandemic. 15 16 in three randomized, placebo-controlled phase iii clinical trials (solo 1, solo 2, and 18 chronos), adults with moderate-to-severe ad received dupilumab (300 mg) weekly (qw), 19 dupilumab 300 mg every 2 weeks (q2w), or placebo. by week 16, "infection or infestations," as 20 classified by medical dictionary for regulatory activities, developed in 35% of the patients 21 receiving dupilumab q2w and in 34% of those receiving dupilumab qw, compared to 28% of 22 patients receiving placebo in solo 1 and in 28%, 29%, and 32% of patients, respectively, in 23 solo 2. in chronos, where all three groups were allowed the use of concomitant topical 24 corticosteroids (tcs) with or without topical calcineurin inhibitors (tcis), infection or 25 infestations developed in 57% of the patients receiving dupilumab q2w and in 53% of those 26 receiving dupilumab qw, compared to 58% of patients receiving placebo. nasopharyngitis was 27 the most commonly reported infection among all treatment groups ( table 1) . 3 furthermore, in 28 all three trials, it was concluded that the rate of infection was not increased in dupilumab-treated 29 patients compared to placebo. 4 30 31 this study's analysis was limited to the data from the original dupilumab trials, as the authors 32 did not specify whether infections were bacterial or viral. however, these findings support the 33 notion that healthy ad patients without risk factors using dupilumab during the covid-19 34 pandemic should not be predisposed to infection, upper respiratory tract infection, or 35 nasopharyngitis ( should biologics for psoriasis be interrupted in 54 the era of covid-19? evolution and function of interleukin-4 receptor 56 signaling in adaptive immunity and neutrophils two phase 3 trials of dupilumab versus 58 placebo in atopic dermatitis long-term management of 60 moderate-to-severe atopic dermatitis with dupilumab and concomitant topical 61 corticosteroids (liberty ad chronos): a 1-year, randomised, double-blinded, placebo-62 controlled, phase 3 trial efficacy and safety of multiple dupilumab dose 64 regimens after initial successful treatment in patients with atopic dermatitis: a 65 randomized clinical trial key: cord-302993-t4quwfva authors: loh, tiffany y.; hsiao, jennifer l.; shi, vivian y. title: covid-19 and its impact on medical student education in dermatology date: 2020-05-12 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.026 sha: doc_id: 302993 cord_uid: t4quwfva nan dermatology is a visual field, and repetitive patient encounters are required in order for 65 clinicians to develop the skills necessary for diagnosing and managing dermatologic conditions. 66 teledermatology offers a potential solution to medical student education during the covid-19 67 pandemic. herein, we discuss methods of implementing teledermatology in order to optimize 68 medical student learning. optimizing teledermatology for medical student education 71 although many dermatology appointments have been transitioned to virtual visits, medical 72 students can still participate in these encounters. medical students may join video conferencing 73 patient care encounters at the patient's and attending's discretion (table 1 ). this allows medical 74 students to learn fundamental dermatologic concepts while participating in patient care, which 75 can help optimize their learning in the absence of in-person visits. other online resources can also be helpful for supplementing medical education (table 2) . many 78 dermatology residency programs hold online lectures, kodachrome sessions, and journal clubs, 79 and residents nationwide are often invited to join. virtual dermatology society conferences, 80 webinars, and podcasts are also available to most residencies. although it is commendable that 81 these resources are often available free of charge to residents, it may also be beneficial to extend 82 the invitation to medical students. although telemedicine is useful, it is also important to recognize that there are elements of 85 dermatology education that cannot be replaced virtually, such as the ability to assess texture, 86 perform biopsies, or use tools such as dermoscopy, wood's lamp, and koh scraping. 87 ultimately, in-person visits are still needed. for the time being however, it is important to 88 optimize tele-education and to involve medical students as much as possible. conclusions 91 medical education has changed drastically during the covid-19 pandemic, and teledermatology 92 has become essential for educational continuity. dermatology education is important for all 93 medical students, as the majority will likely continue to encounter dermatologic problems 94 throughout their careers, and it is our responsibility to include them in our educational endeavors 95 to the best of our ability. 96 97 optimizing teledermatology visits for dermatology resident 100 education during the covid-19 pandemic important guidance for medical students on clinical rotations during the coronavirus 103 (covid-19) outbreak medical student core curriculum in 107 dermatology survey assessment of medical students' proficiency in 109 dermatology: are medical students adequately prepared to diagnose and treat common 110 dermatologic conditions in the united states? dermatology in primary care: 112 prevalence and patient disposition key: cord-266589-oj76ol8v authors: wan, marilyn t.; shin, daniel b.; winthrop, kevin l.; gelfand, joel m. title: the risk of respiratory tract infections and symptoms in psoriasis patients treated with il-17-pathway inhibiting biologics: a meta-estimate of pivotal trials relevant to decision-making during the covid-19 pandemic date: 2020-05-19 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.05.035 sha: doc_id: 266589 cord_uid: oj76ol8v nan biologic agents have revolutionized psoriasis treatment. 1 however, they are considered 2 "immunosuppressive," and thus safety assessments focus on infection, particularly those which 3 are serious and/or opportunistic. the sars-cov-2 pandemic has focused attention on 4 respiratory track infections (rtis). 2 the conceptual model of covid-19 is that 5 immunosuppression early in disease may be harmful, yet may be helpful in "late" severe 6 covid-19 illness; which may be mediated by a dysregulated hyperimmune response 7 characterized by pro-inflammatory cytokines including interleukin(il)-17. 3 the effect of il-17 8 inhibitors on covid-19 is unknown, neither the risk of initial infection nor the risk of 9 progression to worse disease. current understanding of viral immunology suggests that il-17 is 10 not a dominant cytokine in viral immunity; however, il-17 is important to mucosal immunity, 11 raising the hypothesis that biologics targeting il-17 could potentially increase rti risk. 4 12 to test this hypothesis, we calculated a meta-estimate from the placebo-controlled period 13 of phase 3 pivotal il-17 trials of terms consistent with rti of secukinumab, ixekizumab, and 14 brodalumab abstracted from fda prescribing information. rti is a broad term classified by 15 clinical judgment. the medical dictionary for regulatory activities (meddra), used to classify 16 adverse events (aes), has multiple terms for rtis. to assess for rtis, we summed the number 17 of aes that are associated with rtis, divided by the total number of subjects in each study, and 18 then calculated a meta-estimate. we found an increased risk of rtis in the il-17 groups as 19 compared to placebo (odds ratio 1.56, 95% confidence interval 1.04-2.33; table 1 ). since 20 prescribing information is not inclusive of all respiratory aes from the pivotal trials that 21 supported approval of interleukin-17 inhibitors, we conducted a summary risk estimate using 22 data from the placebo-controlled period of these studies obtained from clinicaltrials.gov. this 23 more detailed analysis yielded similar findings to our meta-estimate of prescribing information 24 data (odds ratio 1.31, 95% confidence interval 1.05-1.62; table 2 ). sensitivity analyses varying 25 the terms analyzed yielded similar findings but with loss of statistical significance. 26 evaluating the risk of rti in clinical trials is difficult as the diagnosis is made clinically 27 without objective testing, and therefore the etiology of these symptoms, be they viral, bacterial, 28 fungal, or allergic, is unknown. furthermore, there is substantial variation in the rates of rtis in 29 the placebo groups across the trials demonstrating a lack of precision in measuring this outcome. 30 for example, rates of "upper rti" ranged from 0.0% to 7.44% in the placebo groups evaluated. 31 additionally, due to variation in reporting of meddra terms, the events were unevenly pooled 32 as terms are reported inconsistently. it is also possible that patients may have had more than one 33 rti event, which could impact our estimates. these findings highlight the need for more 34 meticulous evaluation of the impact of il-17 inhibitors on rtis in the setting of the novel 35 coronavirus pandemic. nevertheless, our meta-estimate demonstrates a potential safety signal for 36 rti associated with il-17 inhibition and supports guidance issued by aad that clinicians 37 should use their clinical judgment to continue or discontinue patients on these drugs in patients 38 who have not tested positive or exhibited symptoms of covid-19 and to discontinue these 39 agents in patients who test positive for covid-19 symptoms. 5 40 table 1 . meta-estimate of respiratory tract infections (includes "upper respiratory tract infections," "nasopharyngitis," "rhinorrhea," "influenza," "oropharyngitis," "pharyngitis," "pharyngolaryngeal pain") from prescribing information adverse events tables. doses used in this meta-estimate: secukinumab 300mg; brodalumab 210mg; ixekizumab 80mg every 2 weeks as these doses are indicated for moderate-to-severe psoriasis. table 2 . meta-estimate of respiratory tract infections (includes: "upper respiratory tract infections," "viral respiratory tract infections," "influenza," "influenza-like illness," "sinusitis," "pharyngitis," "bronchitis," "cough," "nasopharyngitis," "oropharyngeal pain," "pneumonia") from clinicaltrials.gov in the phase 3 randomized control trials that were submitted for fda approval. doses used in this meta-estimate: secukinumab 300mg; brodalumab 210mg; ixekizumab 80mg every 2 weeks as these doses are indicated for moderate-to-severe psoriasis. joint aad-npf guidelines of care for the management and treatment of psoriasis with biologics should biologics for psoriasis be interrupted in the era of covid-19? covid-19: risk for cytokine targeting in chronic inflammatory diseases? yin and yang of interleukin-17 in host immunity to infection guidance on the use of immunosuppressive agents key: cord-332859-j10n38ah authors: muzumdar, sonal; grant-kels, jane m.; feng, hao title: dear dermatoethicist: medical student dermatology rotations in the context of covid-19 date: 2020-06-24 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.06.070 sha: doc_id: 332859 cord_uid: j10n38ah nan we frequently have medical students rotate through our department but, due to the covid-19 pandemic, we are hesitant to accept rotating students at this time. while we want to optimize the educational opportunities these students receive, we do not want to endanger trainees, staff and our patients. additionally, we are concerned about the impact that this may have on students interested in applying to dermatology. what should we do? dear program director, deciding whether to accept medical students in your department is challenging. beneficence is at play as rotating through dermatology benefits medical students as it is an excellent way for students to learn more about the field and help them determine if dermatology is in fact the specialty they would like to pursue. additionally, rotations help students obtain letters of recommendation from academic dermatologists. since the start of the pandemic, medical students rotating in dermatology have been temporarily sidelined as clinics have closed and are only seeing emergencies. as we reopen, far fewer in-person patient visits are being scheduled and many appointments are now virutal. 1 as a result, students may not benefit significantly from in-person rotations and creative solutions are needed. non-maleficence, or the avoidance of intentional harm, must also be considered. with the covid-19 pandemic, there is a risk that medical students may become infected themselves and subsequently infect their patients and fellow health care workers if allowed to participate in clinical rotations. 2 as medical students are learners, and not considered essential personnel, limiting their exposure to infectious patients is paramount. regarding the ethical principle of justice, limiting student rotations will harm certain groups of students more than others. dermatology is a competitive specialty and rotations and specialty-specific letters of recommendation have been cited as important factors in resident selection. 3 limiting rotations may thus disproportionately affect those with limited or no prior experience in the field. similarly, students without home dermatology departments, who typically rely on away rotations to secure letters of recommendation, are likely to be disadvantaged as well. follow the guidance of your medical school and institution when deciding whether to allow medical students to rotate in-person and ensure they have access to appropriate ppe during in-person encounters if allowed. prioritize safety while optimizing medical student education. creative options include 1) sitting in on virtual lectures and grand rounds sessions, 2) participating in teledermatology care, 3) engaging in case-based learning, and 4) performing scholarly activities. organizations, such as the association of program directors, are devising novel ways to involve students in learning experiences at different institutions. because many students will not have the opportunity to rotate at various dermatology programs or obtain dermatology letters of recommendation prior to applying, this is an opportune time to endeavor to evaluate the applicants based more upon intrinsic values beyond their academic achievements and credentials including their backgrounds and challenges overcome, whether their school has fewer dermatology opportunities, ties to a particular region, unique skills or interests, and aspirations. an assessment of united states dermatology practices during the covid-19 outbreak online ahead of print the role of medical students during the covid-19 pandemic nrmp program director survey. national resident matching program web site key: cord-343704-td1aheay authors: rosman, ilana s.; schadt, courtney r.; samimi, sara s.; rosenbach, misha title: approaching the dermatology residency application process during a pandemic date: 2020-07-21 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.066 sha: doc_id: 343704 cord_uid: td1aheay nan approaching the dermatology residency application process during a pandemic 1 ilana s. rosman, md, faad, 1 courtney r. schadt, md, faad, 2 sara s. samimi, md, faad, 3 given the ongoing crisis, we suggest changes to the application and recruitment process for 53 academic dermatology programs around the country to consider. 54 • away rotations: we recommend dermatology programs reserve away rotation 55 opportunities for students without home-institution dermatology options and 56 encourage such students to seek rotations with the closest dermatology practice or 57 program. additionally, we encourage creation of "virtual" experiences to allow for 58 recruitment of students from other institutions. these may be non-credit bearing, 59 shorter in length than typical rotations, and include a variety of activities, including but 60 not limited to: participation in virtual educational conferences, remote panels or 61 meetings with selected faculty and residents, teledermatology clinical care, and virtual 62 tours of facilities. 63 • interview process: we strongly recommend that programs develop plans for remote 64 interviews via currently available videoconferencing platforms. the capacity to conduct 65 remote interviews will be critical moving forward, even beyond the current pandemic 66 situation by reducing student costs (which may aid in recruiting applicants from broader 67 socioeconomic backgrounds), allowing for greater scheduling flexibility, and aligning 68 with environmentally sound practices in light of the climate crisis. 69 as program directors, we understand the difficulty in enacting novel and possibly temporary 71 policies. we also sympathize with the inclination for a "wait and see" approach as parts of the 72 country relax physical distancing and shelter-in-place orders. however, application season is 73 upon us, and with the likelihood of the pandemic continuing in some capacity for the next 74 5 several months, it is imperative that we take a proactive approach. expecting students to travel 75 during an overlapping covid-19 and influenza season risks their health, and risks exposure and 76 transmission of infection to faculty and residents. we propose the above suggestions be 77 adopted broadly to alleviate medical student concerns, address potential inequities in applicant 78 opportunities, and implement socially responsible measures that will position us well for future 79 challenges. 80 81 outcomes-in-the-match-2018-seniors.pdf. chart 3, page 5 national resident matching program. results of the figure d-1 and d-2 specialty response to covid-19 coalition for physician accountability publishes recommendations on movement across 92 institutional for 2020-2021 details/articleid/10252/coalition-for-physician-accountability-publishes-94 key: cord-322798-5r3kf9wa authors: freeman, esther e.; mcmahon, devon e. title: creating dermatology guidelines for covid-19: the pitfalls of applying evidence based medicine to an emerging infectious disease date: 2020-04-09 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.002 sha: doc_id: 322798 cord_uid: 5r3kf9wa nan to the editor: we recently co-authored a piece in the jaad about modifications the american academy of dermatology (aad) implemented to enhance the rigor of evidence-based clinical practice guidelines. 1 although we believe this change will serve the aad well in the future, we must be flexible about guideline generation during the coronavirus disease-2019 (covid-19) outbreak. like the who, the aad already adopted a rapid advice guidelines protocol, but this process relies on evaluating a body of evidence, which does not yet exist for covid-19. to address this gap, the aad established the covid-19 taskforce, which published interim guidance within five days of establishment. although this advice is essential, it is by necessity made on limited and rapidly evolving evidence, and must be tailored to individual patients. issues include how to grade evidence from gray literature, risks and benefits of use of anecdotal experiences and indirect evidence, and harmonizing guidance simultaneously produced by other organizations. the harms of potentially issuing incorrect guidance must be balanced with the ethical risks of issuing no guidance at all. 2 one example of this challenge is managing patients on immunosuppressives during covid-19. a recent jaad study examined the occurrence of upper respiratory infection (uri) for patients treated with various classes of biologic therapies for psoriasis, as a proxy for risk of covid-19 infection while on a biologic. 3 while we commend the authors for compiling this data, there are several issues with indirect evidence: i) these trials compared biologics to placebo, ii) they were not powered for the outcome of uri, and iii) the similarity of covid-19 to uri is unknown. due in part to these concerns, the aad covid-19 taskforce published interim guidance that did not distinguish among biologic classes. dermatology societies are not struggling alone with creating interim guidelines. in cardiology, there has been concern over the use of angiotensin converting enzyme (ace)-inhibitors due to an observational study that many patients with hypertension admitted for covid-19 were on ace-inhibitors. 4 in the face of uncertainty, societies including the american college of cardiology took a stance to keep patients on ace-inhibitors while they await more evidence. 5 when guidelines can no longer be based on the highest level of evidence, then indirect studies, gray literature, case-reports and expert consensus may be the only tools left in our arsenal. we need 3 guidance not just on biologics, but many topics, including scaling up teledermatology programs and managing patients with invasive skin cancers. these changes to dermatology guidelines do not exist in a vacuum; important ethical implications include patient outcomes such as missed melanomas and the loss of employment for practice staff. with so much uncertainty in our medical practice, guidance is needed now more than ever. we should acknowledge the shift from evidence based medicine to reliance on expert guidance, and appreciate the potential for guideline reversal. but in a time of rapidly changing evidence, we must be willing to take on these risks to guide with the goal of maintaining the highest standard of patient care. modernizing clinical practice guidelines for the american academy of dermatology fair allocation of scarce medical resources in the time of covid-19 should biologics for psoriasis be interrupted in the era of covid-19? are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? patients taking ace-i and arbs who contract covid-19 should continue treatment, unless otherwise advised by their physician: statement from the american heart association, the heart failure society of america and the american college of cardiology the authors would like to acknowledge dr. benjamin stoff for his advice regarding the ethics of clinical practice guideline generation, as well as dr. george hruza and dr. bruce thiers for their comments on a preliminary draft of this manuscript. key: cord-303800-h3lvbldz authors: schultz, brittney; pearson, david r.; mansh, matthew title: reply to “treatment considerations for patients with pemphigus during the covid-19 pandemic” date: 2020-09-04 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.07.132 sha: doc_id: 303800 cord_uid: h3lvbldz nan individual basis through shared decision-making. in particular, rituximab should be considered 43 for patients with severe disease and without active covid-19 illness after discussion of specific 44 individual-level risks (age, comorbidities, occupation) and benefits of rituximab. we would also 45 consider rituximab for younger patients without comorbidities and with less severe disease. 46 first, rituximab is an effective and targeted therapy for pemphigus. we have limited data directly 47 comparing adverse events in those treated with rituximab versus other therapies but compared to 48 prednisone alone, individuals treated with rituximab plus short-term prednisone had decreased 49 cumulative exposure to prednisone and fewer adverse effects, 2 including known risk factors for conversely, physicians should discuss that rituximab may reduce immune response to 63 vaccination, 5 which may decrease the ability of patients to effectively receive a covid-19 64 vaccine. the response to vaccination appears to improve when given 6 months or more after 65 rituximab dosing. 5 immune response to infection itself may similarly be blunted, theoretically 66 leading to risk of re-infection. 67 in summary, we agree with careful consideration of rituximab for patients during the covid-19 68 pandemic. however, with an unknown peak of covid-19, it may not be feasible or beneficial to 69 delay rituximab. on an individualized basis through shared decision making, dermatologists 70 should consider rituximab for select patients. our approach is to discuss rituximab in patients 71 with severe disease, who might otherwise require high doses of prednisone or more broadly 72 immunosuppressive agents over an extended time period, and those with less severe disease but 73 fewer comorbidities and younger age. rheumatologic dosing of rituximab, rather than 74 hematologic, can be considered to decrease healthcare exposures, and we would recommend 75 against maintenance dosing in stable patients where the risk of disease flare is deemed low. 2 76 prior to rituximab, we recommend discussing vaccination concerns and general infection control 77 guidance, including social distancing, frequent hand-washing, and use of masks. 78 j o u r n a l p r e -p r o o f treatment considerations for patients 80 with pemphigus during the covid-19 pandemic first-line rituximab combined with short-82 term prednisone versus prednisone alone for the treatment of pemphigus multicentre, parallel-group, open-label randomised trial risk factors associated with clinical outcomes hospitalized patients in wuhan, china. clin infect dis mild course of coronavirus disease 2019 and spontaneous 87 severe acute respiratory syndrome coronavirus 2 clearance in a patient with depleted peripheral 88 blood b-cells due to treatment with rituximab. arthritis rheumatol vaccines and disease-modifying antirheumatic drugs: practical 90 implications for the rheumatologist none. key: cord-329353-0pwgzeec authors: wambier, carlos gustavo; mccoy, john; goren, andy title: male balding as a major risk factor for severe covid-19: a possible role for targeting androgens and transmembrane protease serine 2 to protect vulnerable individuals date: 2020-09-11 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.09.015 sha: doc_id: 329353 cord_uid: 0pwgzeec nan united states. 7 2 applied biology, inc. irvine, ca, united states 8 9 *twitter handle @wambiermd 10 11 tables: 0 27 supplementary tables: 0 28 keywords: covid-19; sars-cov-2; gabrin sign; vulnerability; androgen receptor; androgenetic 29 alopecia; anti-androgen therapy; transmembrane protease serine 2; tmprss2; dutasteride; 7. 2 they further demonstrated in multivariate logistic regression that very severe baldness had 41 a higher odds-ratio for covid-19 positivity than hypertension, dyslipidemia, diabetes, obesity 42 per body mass index, or age. 1 it is noteworthy that severe baldness was reported to be a better 43 predictor of test positivity than obesity, as there are many reports linking obesity to covid-19 44 disease severity. 3 this underscores the need for further studies and to communicate these 45 findings beyond the dermatology community. 46 in the context of symptomatic presentations reported in lee et al., the baldness survey was 47 conducted many years ago. some patients who initially self-reported as having frontal baldness 48 or vertex baldness (patterns 2 or 3, respectively) could have developed pattern 4 by 2020. 49 therefore, we believe the numbers with "very severe baldness" may be even greater than what 50 was reported. the main evidence of vulnerability is the clinical outcome during the course of 51 covid-19, particularly intensive care unit (icu) admission and fatality rates. severe baldness, 52 the gabrin sign (nhs=3-7), has been associated with both increased icu admissions and 53 increased death rates. 2 54 understanding the mechanisms leading to host susceptibility provides an opportunity for 55 pharmacological interventions to protect vulnerable individuals. we have proposed that 56 androgen sensitivity is associated with sars-cov-2 infection, possibly, through androgen-57 promoted transmembrane protease serine 2 (tmprss2). 4 recently, results of a study using 58 j o u r n a l p r e -p r o o f bromhexine hydrochloride, a common cough over-the-counter medication only available 59 outside the united states were reported. bromhexine was the first drug identified to be a 60 tmprss2 inhibitor. the open-label randomized, standard protocol-controlled trial enrolled 78 61 patients for treatment of clinical and radiologic pneumonia suspected to be due to covid-19. 5 62 the arm with bromhexine was superior to the standard protocol, with only 2 patients admitted 63 to the icu and 0 deaths versus 11 patients admitted to the icu (p=0.006) and 5 deaths in the 64 standard protocol arm (p=0.027). 5 65 reduced expression of tmprss2 is also achieved by blocking androgens with medications 66 commonly used in dermatology. 4 results of our recent covid-19 prospective cohort study 67 involving 77 hospitalized men were also particularly encouraging: only 1 out of 12 individuals 68 were admitted to the icu (8%) in the cohort of men using 5-alpha-reductase inhibitors or other 69 anti-androgen drugs (dutasteride=9, finasteride=2, and spironolactone=1), versus 38 out of 65 70 men (58%) not taking anti-androgens (p=0.0015). the full study is currently under peer review, 71 raw data available at https://data.mendeley.com/datasets/6gpc32dyy7/2. 72 medications that target tmprss2 have demonstrated improved covid-19 outcomes in clinical 73 studies, and have the potential to protect vulnerable individuals during the pandemic. we hope 74 that in the near future more data will be available regarding interventions focused on inhibiting 75 host factors that increase susceptibility to sars-cov-2, such as the androgen-tmprss2 76 pathway. 77 78 j o u r n a l p r e -p r o o f male balding is a major risk factor for severe 80 covid-19: compared to age-matched epidemiologic studies and hospital outcomes with 83 or without the gabrin sign individuals with obesity and covid-19: a global 86 perspective on the epidemiology and biological relationships severe acute respiratory syndrome coronavirus 2 (sars-cov-2) 89 infection is likely to be androgen mediated effect of bromhexine on clinical outcomes and 92 mortality in covid-19 patients: a randomized clinical trial key: cord-268072-pt2u6608 authors: oranges, teresa; janowska, agata; dini, valentina title: reply to: “skin damage among health care workers managing coronavirus disease-2019” date: 2020-04-10 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.04.003 sha: doc_id: 268072 cord_uid: pt2u6608 nan reply to: ''skin damage among health care workers managing coronavirus disease-2019'' to the editor: we read with interest the article ''skin damage among health care workers managing coronavirus disease-2019'' written by lan et al. 1 the main skin problems in health care managing covid-19 and using medical devices are the hand eczema and the skin damage affecting the nasal bridge, cheek, and forehead. lan et al 1 reported that the health care workers who wore medical devices for more than 6 hours showed higher risks of skin damage, with desquamation in more than 60% of cases, and other signs, such as erythema, maceration, and ulcers, in a smaller percentage of cases. this skin damage may cause itching and pain 1 and further impair the quality of life among health care workers. the world health organization recommends performing correct hand hygiene with alcoholbased hand rub ( preferred in case of not visibly soiled hands) or water and soap, in particular, before touching a patient, before any clean or aseptic procedure, after exposure to body fluid, after touching a patient, and after touching a patient's surroundings. 2 the frequent hand hygiene, the use of antiseptics, and wearing of double-layers of gloves for a long time may cause the hand eczema. at the sites of application of masks, goggles, and facial shield, pressure injuries may develop, from grade 1 (nonblanchable erythema) to grade 2/3 (erosion or ulceration). the medical deviceerelated pressure injuries may occur on any anatomic location where the medical device is in contact with the skin and particularly where the skin is over bony prominences, such as the forehead, the nasal bridge, and the zygomatic arch. the university of pisa (italy) wound healing unit proposes the topical management of the skin areas at risk of pressure injuries in terms of cleansing, prevention, and treatment (table i) . the no-sting barrier film spray has shown good efficacy in the management of the skin surrounding chronic wounds, with a significant reduction of the transepidermal water loss values. 3 we suggest the use of this product before wearing the medical devices, because the alcohol-free liquid dries quickly after skin application and forms a protective, transparent, and conformable long-lasting barrier film. the use of topical products containing purified omental lipids will help in improving skin barrier function, repairing the epithelial cell membrane, and increasing microcirculation. 4 these products are also useful to prevent the development of pressure injuries and may be used after removing the medical devices as well the nonadherent dressings (soft silicone/paraffin). some authors described the use of thin hydrocolloid dressing to prevent pressure injuries on the nasal bridge in case of acute noninvasive ventilation. 5 nonadherent dressings (soft silicone/paraffin) and extra-thin hydrocolloid may theoretically also be used before the medical devices are worn, but further studies are needed to certify that these advanced dressings do not alter the safety of the devices. skin damage among health care workers managing coronavirus disease-2019 world health organization & who patient safety. who guidelines on hand hygiene in health care: first global patient safety challenge-clean care is safer care. geneva: world health organization instrumental evaluation of the protective effects of a barrier film on surrounding skin in chronic wounds topical purified omental lipid formulations in the prevention of skin ulcers: a narrative review the preventative effect of hydrocolloid dressings on nasal bridge pressure ulceration in acute non-invasive ventilation key: cord-322435-c88tkbnz authors: rekhtman, sergey; tannenbaum, rachel; strunk, andrew; birabaharan, morgan; wright, shari; garg, amit title: mucocutaneous disease and related clinical characteristics in hospitalized children and adolescents with covid-19 and mis-c date: 2020-10-24 journal: j am acad dermatol doi: 10.1016/j.jaad.2020.10.060 sha: doc_id: 322435 cord_uid: c88tkbnz background little is known about mucocutaneous disease in acutely-ill children and adolescents with covid-19 and mis-c. objective to characterize mucocutaneous disease and its relation to clinical course among hospitalized patients with covid-19 and mis-c. methods descriptive cohort study of prospectively and consecutively hospitalized eligible patients between may 11, 2020 and june 5, 2020. results in covid-19 patients, 4/12 (33%) had rash and/or mucositis, including erythema, morbilliform pattern, and lip mucositis. in mis-c patients, 9/19 (47%) had rash and/or mucositis, including erythema, morbilliform, retiform purpura, targetoid and urticarial patterns, along with acral edema, lip mucositis, tongue papillitis, and conjunctivitis. covid-19 patients with rash had less frequent respiratory symptoms, picu admission, and invasive ventilation, as well as shorter stay (vs covid-19 without rash). mis-c patients with rash had less frequent picu admission, shock, ventilation, as well as lower levels of crp, ferritin, d-dimer, and troponin (vs mis-c without rash). neutrophil-to-lymphocyte ratio was similar for patients with and without rash in both groups. none of the mis-c patients met criteria for kawasaki disease. limitations small sample sizes. conclusions mucocutaneous disease is common among children and adolescents with covid-19 and mis-c. laboratory trends observed in patients with rash may prognosticate a less severe course. coronavirus disease 2019 has variability within its constellation of findings among 73 children and adolescents. [1] [2] [3] [4] [5] in addition to fever and respiratory symptoms, pediatric patients infected with 74 severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the pathogen in covid-19, also 75 develop eruptions and mucositis. yet little is understood about the morphologic spectrum of 76 mucocutaneous disease and its relation to outcomes among acutely-ill children and adolescents with 77 covid-19, or its presumed sequela, multisystem inflammatory syndrome in children (mis-c). the new 78 york metropolitan area was an epicenter for the pandemic in the united states, 6 and this provided an 79 opportunity to characterize mucocutaneous disease in pediatric hospitalized patients with covid-19 and 80 mis-c. the purpose of this study was to estimate prevalence of integumentary findings in hospitalized 81 patients with covid-19 and mis-c, to characterize their morphologic patterns, to evaluate whether rash 82 prognosticates clinical course, and to determine how closely features in mis-c align with kawasaki 83 disease (kd). 84 this study was performed at cohen children's hospital (northwell health), a tertiary hospital 86 located in queens, new york. the study sample consisted of all hospitalized patients between may 11, 87 2020 and june 5, 2020 who were aged ≤18 years and who were suspected of having covid-19 or mis-88 c. criteria for confirming the diagnosis of mis-c included age <21 years, fever for ≥24 hours, clinically 89 severe illness requiring hospitalization, multisystem organ involvement, no alternative plausible 90 diagnosis, and exposure to a suspected or confirmed covid-19 case or positive sars-cov-2 infection 91 by pcr/serology testing. 7 the sample was limited to patients who had 1) diagnosis of mis-c based on all 92 six criteria above, and this group comprised the mis-c cohort; or 2) positive covid-19 pcr test among 93 those not meeting the definition of mis-c, and this group comprised the covid-19 cohort. presence of at least one covid-19-related rash. we categorized covid-19 and mis-c patients 104 separately because these diseases have different clinical characteristics and disease courses, and because 105 mis-c is considered to be a later, non-infectious complication of covid-19. 106 given the anticipated sample size, and consequently low statistical power, the intent of our 108 analysis was descriptive and hypothesis generating. medians (iqr) were used to describe continuous 109 variables, and frequencies (percentages) were used to describe categorical variables. this study was 110 approved by the institutional review board at the feinstein institutes of medical research at northwell 111 of 39 hospitalized pediatric patients identified as possible covid-19 or mis-c during the study 114 period, 31 were eligible for inclusion. six patients did not test positive for sars-cov-2 pcr and were 115 also ruled out for mis-c prior to discharge. others excluded were one child whose family deferred skin 116 examination, and one newborn having limb necrosis with negative sars-cov-2 pcr and igm antibody, 117 who was felt to have fetal compartment syndrome. demographic characteristics for 12 patients classified 118 as covid-19 and 19 patients classified as mis-c are listed in table 1 . those with rash were younger. (table i) . only three of 12 (25%) were febrile (≥100.4°f) during 122 type and frequencies of morphologic patterns observed in patients with covid-19 are described 124 in table 1 . none of the hospitalized covid-19 patients with rash had pernio-like lesions of the toes or 125 fingers, and none had conjunctivitis. locations and frequencies of mucocutaneous eruptions in patients 126 with covid-19 are described in figure 1 . 127 compared to covid-19 patients without rash, those with rash were observed to have less 128 frequent respiratory symptoms, admission to the pediatric intensive care unit (picu), and ventilation, as 129 well as shorter length of hospital stay. maximum neutrophil-to-lymphocyte ratio (nlr) observed during 130 hospitalization was similar for patients with and without rash. (table ii) 131 in patients with mis-c, 9/19 (47%) had rash and/or mucositis. (figure 2 ; supplemental figure 133 2) all 19 patients (100%) were febrile during hospitalization. 134 morphologic patterns were heterogeneous. (table i ) lip fissuring or cracking was present in 135 44% (4/9), while papillitis of the tongue was present in 22% (2/9). conjunctivitis was present in 22% 136 (2/9) of patients with rash. locations and frequencies of mucocutaneous eruptions in patients with mis-c 137 are described in figure 1 . 138 compared to mis-c patients without rash, those with rash were observed to have less frequent 139 picu admission, shock, and requirement for invasive mechanical ventilation. patients with rash also had 140 lower levels of inflammatory markers. maximum nlr observed during hospitalization was similar for 141 patients with and without rash. (table ii) we observed that presence of rash appears to prognostic a less severe clinical course. finally, we 157 observed that mis-c and kd may be more dissimilar the presently postulated. and adolescents, and the basis for preferential involvement of skin, warrants further study. 180 the nlrs were similar between covid-19 patients with and without rash, as well as between 181 mis-c patients with and without rash. we did however observe higher nlr in mis-c patients as 182 compared with covid-19 patients, and this may prove to be a useful differentiating marker. in adults, 183 nlr has been observed to distinguish mild from severe cases of covid-19. may and june of 2020 in the new york metropolitan area. as such, we had inadequate power to perform 196 hypothesis tests and we cannot rule out that differences observed between groups were due to chance. 197 however, the finding of less severe course was observed across several indicators among both and mis-c patients with rash. pathology was not obtained as there was no clear indication this could 199 specify diagnoses or change the courses of care. chinese pediatric novel coronavirus study team. sars-cov-2 209 infection in children epidemiology of covid-19 among children in china characteristics of and important lessons from the coronavirus disease 2019 213 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease 214 control and prevention screening and severity of coronavirus disease clinical and epidemiological features of 36 children 219 with coronavirus disease 2019 (covid-19) in zhejiang, china: an observational cohort study department of health. coronavirus disease 2019 (covid-19) multisystem inflammatory syndrome in children disease committee of the council on cardiovascular disease in the young council on cardiovascular and stroke nursing; council on cardiovascular surgery and anesthesia and council on epidemiology and prevention. diagnosis, treatment, and long-term management 229 of kawasaki disease: a scientific statement for health professionals from the an outbreak of severe kawasaki-like disease at the italian 232 epicentre of the sars-cov-2 epidemic: an observational cohort study multisystem inflammatory syndrome related to covid-235 previously healthy children and adolescents in clinical characteristics of 58 children with a pediatric 238 inflammatory multisystem syndrome temporally associated with sars-cov-2 pernio-like skin lesions associated with covid-19: a 241 case series of 318 patients from 8 countries angiogenesis in covid-19 endothelial cell infection and endotheliitis in covid-19 clinical characteristics of 138 hospitalized patients with coronavirus-infected pneumonia in wuhan dysregulation of immune response in patients with coronavirus clinical and immunological features of severe and moderate 253 coronavirus disease 2019