SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 34 COVID CONCEPTS New Cases of Syphilis and Molluscum Contagiosum in the COVID- 19 Pandemic: A Sign That Social Distancing Guidelines Are Not Being Adhered to? Haley D. Heibel, MD1, Parneet Dhaliwal, DO2, Clay J. Cockerell, MD, MBA1,3 1Cockerell Dermatopathology, Dallas, TX 2Department of Pathology, Baylor University Medical Center, Dallas, TX 3Departments of Dermatology and Pathology, UT Southwestern Medical Center, Dallas, TX To the Editor: Social distancing has played an important role in reducing the transmission of COVID-19. However, in the COVID-19 era, we have diagnosed multiple cases of syphilis and molluscum contagiosum histopathologically, the vast majority of which were not suspected by referring clinicians. As syphilis is spread by direct sexual contact and molluscum contagiosum by close physical contact (including sexual contact),1 if the general public had been uniformly adhering to social distancing and hand hygiene recommendations from the Centers for Disease Control and Prevention (CDC),2 we would theoretically expect no new diagnoses of these diseases. However, the number of syphilis (8) and molluscum contagiosum (88) cases were greater between the dates of March 1 to August 28, 2020, compared with number of cases of syphilis (5) and molluscum contagiosum (87) diagnosed between March 1 to August 28, 2019. The incidence of both of these diagnoses increased as the volume of specimens had decreased in 2020 (83,227) from 2019 (107,435) during this time period. ABSTRACT Social distancing has played an important role in reducing the transmission of COVID-19, and, if the general public uniformly followed social distancing guidelines, we would theoretically expect no new diagnoses of sexually transmitted diseases (STDs) during this time period. However, during the COVID-19 era, we have diagnosed multiple cases of syphilis and molluscum contagiosum histopathologically with an increased incidence in our practice from the dates of March 1 to August 28, 2020, compared with these dates in 2019. The vast majority of these cases were not suspected by referring clinicians. Dermatologists are experts in the recognition of the cutaneous manifestations of venereal diseases which is critical to appropriate diagnosis and management, and they should continue to provide care during this pandemic. Individuals who acquire STDs during this time may increase the strain on already limited health care resources by disregarding social distancing recommendations. All medical providers must consider how we can better encourage individuals to abide by social distancing recommendations, optimize care for patients during the pandemic, and prevent the misallocation of valued health care resources. SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 35 This evidence suggests that, despite the consistent message regarding social distancing provided by the CDC, health care providers, and others, a proportion of the population is not abiding by these recommendations as well as engaging in unsafe risky sexual behavior. As primary syphilis occurs about 3 weeks after infection, and secondary syphilis occurs approximately 2 to 10 weeks after the primary chancre, some of these cases of syphilis may have been contracted prior to implementation of social distancing guidelines although this is unlikely.3 We theorize that quarantine and social distancing restrictions as well as stress from the pandemic itself and consequences of it (such as losing one’s job) may have led to a sensation of isolation, which influenced individuals to seek out human interaction in an ill-advised manner, including unsafe sexual practices. According to Karen Surita, acting sexually transmitted disease program (STD) manager for the Texas Department of State Health Services (oral communication, September 2020), resources for contract tracing for STDs in the Texas Department of State Health Services have been deployed to cases of COVID-19 during the pandemic. Therefore, these cases may not be traced as they normally would be. Contact tracing for syphilis and other reportable diseases continues to be important to ensure appropriate treatment and evaluation of sexual contacts and to prevent spread of these diseases. COVID-19 is bringing to the forefront the difficulties STD public health programs have experienced for years. Individuals who acquire STDs during this time may increase the strain on already limited health care resources by disregarding social distancing recommendations. Limited access to care and resources, especially in rural communities, has been a difficulty faced by public health programs in Texas. Therefore, education of the community, including patients, health care providers, and others, regarding testing guidelines for individuals who may be at risk for STDs, as well as treatment and reporting of these conditions has been priority the Texas Department of State Health Services. This is becoming increasingly important with more limited staff and clinic availability in the context of COVID-19 and social distancing guidelines. As many dermatology practices reduced in- office patient visits during the pandemic, it is possible that venereal diseases with cutaneous manifestations were not evaluated by dermatologists, misdiagnosed or unrecognized, and that the incidence of these conditions is likely higher than we observed in our practice. Dermatologists are experts in the recognition of the cutaneous manifestations of STDs, which is critical to appropriate diagnosis and management, and they should continue to provide care during this pandemic. If patients sought care elsewhere and were misdiagnosed, this could have led to a delay in treatment for both patients and their partners as well as complications from progression of the disease process. Dermatologists may play an integral role in the prevention, early recognition, and treatment of STDs through routinely discussing safe sex practices with patients, appropriately screening patients who are suspected to be at risk for an STD by obtaining a complete sexual history and testing them, and remaining up to date on the guidelines for the recommendations of testing and treatments for STDs. All medical providers must consider how we can better encourage individuals to practice social SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 36 distancing not only to prevent the spread of COVID-19 but also to prevent misallocation of valued health care resources. Abbreviations Used: Centers for Disease Control and Prevention (CDC), sexually transmitted disease (STD) Conflict of Interest Disclosures: None Funding: None Corresponding Author: Haley D. Heibel, MD 2110 Research Row Suite 100 Dallas, TX 75235 Phone: 214-530-5200 Email: hheibel@dermpath.com References: 1. Murray, PR, Rosenthal, KS, Pfaller MA. Medical Microbiology. 7th ed. Philadelpha, PA: Saunders Elsevier; 2013. 2. Social distancing keep a safe distance and slow the spread. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/coronavirus/2019- ncov/prevent-getting-sick/social-distancing.html. Updated July 15, 2020. Accessed July 24, 2020. 3. McAdam, AJ, Milner, DA, Sharpe AH. Infectious diseases. In: Kumar, V, Abbas AK, Aster JC, eds. Robbins and Contran Pathologic Basis of Disease. 9th ed. Philadelpha, PA: Saunders Elsevier; 2015: 341-402. mailto:hheibel@dermpath.com https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html