December 2019 was the starting point of the ongoing coronavirus pandemic. The disease caused by the novel coronavirus strain, known as COVID-19, was first observed in Wuhan, a major city in central China. In just a few months, the virus reached virtually every country, wreaking havoc on society. Major hot spots of the pandemic are the United States, India, Brazil, Russia and Spain. Recent statistics show that there are almost 20 million cases worldwide, and the pandemic doesn't show any signs of slowing down.

Preventing the spread of the new coronavirus in dermatology care

All hospitals are required to monitor each patient for COVID-19 symptoms. The main symptoms to monitor are fever, dry cough, fatigue, diarrhea, headache, dyspnea, hemoptysis and rhinorrhea. The diagnosis is confirmed via special laboratory tests.

The dermatology section of every hospital has to be reorganized. The challenges of dermatology during the pandemic are very serious, particularly for emergency and cancer patients. Because of this aspect, the triage of patients should be performed in the ambulance, before the patient is admitted.

The novel coronavirus has been shown to be very resistant, especially on inanimate surfaces, like glass, plastic or metal. The virus survives for up to 9 days, according to numerous laboratory trials. Surface disinfection should be done with ethanol (with a concentration of 62 to 72 percent), 0.5 percent hydrogen peroxide or 0.1 percent sodium hypochlorite – these solutions effectively inactivate the virus particles within 1 minute.

The challenges of dermatology – how should doctors protect themselves?

Because the virus is so resistant, doctors and nurses must be protected at all times. Goggles and sanitary masks can dramatically reduce the risk of viral transmission. This is very important for dermatologists, who routinely work close to patients. Teledermatology visits are a great alternative for dermatologists who want to work remotely. Fortunately, dermatology is a highly visual specialty, so a reliable diagnosis can be done via digital visits.

When it comes to physical visits, several safety measures should be enforced. Disinfection of the medical staff is mandatory before and after each new patient visit. Disinfection should also be done after any aseptic procedure, potential exposure to body fluids or any other type of direct contact. This is very important, as dermatologists come into contact with tens of different patients every day.

Doctors should always use personal protective equipment during visits. Although this type of equipment can cause skin disorders or can aggravate pre existing skin conditions, the equipment should be worn by medical professionals. Common problems caused by protective equipment include the aggravation of acne, rosacea or seborrheic dermatitis; similarly, inflammatory papules have been observed after prolonged wearing protective goggles; urticaria has also been observed. Similarly, excessive, intensive hand washing can cause irritant contact dermatitis by interrupting epidermal barrier functions.

Protective gloves should also be worn by dermatologists. The hands should be clean, properly disinfected and dry before putting the gloves on. Wearing gloves can cause hyperhidrosis or hyperhydration, especially if the skin is particularly sensitive. In severe cases or after long-term use, maceration or disturbances of the epidermal barrier function or skin erosion can occur. Gloves can also increase the risk of allergic contact dermatitis. Always wash hands after changing gloves – also, use a skin care product for extra protection.

Cutaneous eruptions and the risk of COVID-19

Multiple studies have shown that cancer patients and patients with immunosuppression issues belong to a high-risk group for COVID-19. These patients can react negatively to various drug eruptions, increasing the risk of infections.

COVID-19 patients can be treated with antiviral substances and antibiotics – some of these drugs may cause eruptions as well. What's more, viral infections like dengue fever, rubella or measles can cause general eruptions. Lymphophenia (about 75 percent) and eosinopenia (about 53 percent) were observed among patients. Cutaneous symptoms were also observed in 18 of the 88 patients in an intensive care unit in a hospital in Lombardia, Italy. The diagnoses were only clinical, and they are not confirmed by a laboratory.

Dermatologists working in a hospital with active COVID-19 cases are often challenged to differentiate among various types of skin conditions and infections. What's more, other related conditions are present, like miliaria rubra or other non-allergic diseases. Data suggests that skin conditions may be associated with COVID-19 patients, but some experts don't believe that COVID-19 patients are at a higher risk of drug-related skin diseases.

Fortunately, teledermatology is an effective alternative for dermatologists who want to continue their activity safely. Diagnoses can be done remotely, especially if patients provide relevant information about their condition (such as high-quality photographs).

Skin cancer patients and COVID-19

Skin cancer can be a risk factor for COVID-19 patients, according to multiple studies. Nonmelanoma skin cancer is considered the most frequent malignancy. Because of this, surgery for the primary tumors is critical and should not be delayed or postponed under any circumstances. Both skin cancer and COVID-19 patients should be prioritized.

On the other hand, malignant melanoma is far more aggressive. Early complete surgical removal is the main way to treat malignant melanoma. For serious cases, such as metastatic skin cancer, systemic treatment is advised and should continue even if the patient is confirmed with COVID-19. Data suggests that there is a significant prolongation of survival for many responders. For patients with metastatic melanoma treatment should continue as normal. If not, the window to treat may be lost, often with tragic consequences. Solid tumor patients should follow adjuvant therapy with curative intent.

Challenges of dermatology during the pandemic – the conclusions

Dermatologists cannot be excluded from the fight against the COVID-19 pandemic. They must be prepared and must take part in the fight. Dermatology patients must continue therapy. Patients must receive their drugs and dermatologists should continue to give advice for patients with inflammatory skin diseases or systemic drug therapy. Consultations can be done via teledermatology or physical clinic visits, depending on each specific situation. Ethical care for advanced skin cancer patients is another major challenge for dermatologists, specifically during this difficult period.

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