Q&A: Impact of COVID-19 on Patients With Psoriatic Arthritis
It is an understatement to say that COVID-19 pandemic has significantly impacted medicine. If anything, the current pandemic and attempts to “flatten the curve” have forced physicians across the medical field to adapt to stay-at-home policies, shortages of personal protective equipment, and the unknowns regarding reopening, which some states have already begun.
Telemedicine has become the driving force that is keeping dermatologists, rheumatologists, and other physicians connected with most of their patients. While certain conditions can be managed using telemedicine, such as follow ups for acne, some are more difficult to assess and treat. According to Joseph Merola, MD, a dermatologist and rheumatologist at the Brigham and Womens’ Hospital in Boston, the use of telemedicine in his practice has had mixed success.
“For patients who have mostly well-controlled disease, the telemedicine visits have offered a safe and comfortable alternative for routine check-in, medication monitoring, COVID-safety discussions, etc,” said Dr Merola. In these follow-up patients he has been able to assess skin disease activity through history and a combination of video and ‘store and forward’ images requested in advance from patients. Joint disease flares have been assessed mainly through history with emphasis on any impact on function. “Telehealth visits have allowed us to keep patients on medication, where appropriate, adjust medications accordingly, and prevent disease flares.”
However, physical exams remain important for clinical decision making in both dermatology and rheumatology. “The inability to perform a detailed joint exam can be a barrier for appropriate assessment,” he said. This can be particularly challenging for new patients as the true severity of their disease affecting both the skin and joints can be hard to determine via video or telephone.
The quality of the image, either photograph or video, can also negatively impact physicians’ diagnostic capabilities, according to Dr Merola. For example, assessing the extent of a patients’ disease in some common areas of involvement such as the scalp can be nearly impossible, and other areas such as many body folds and genitals are not appropriate for telemedicine.
“In the absence of a detailed exam, we have found some virtual work-arounds, including having patients demonstrate joint range of motion, self-assessment of certain tender areas of interest, observing their gait and other visual or functional clues to suggest a diagnosis,” said Dr Merola. Subtle clues, such as psoriatic nail changes, have been difficult to assess using telehealth unless store-and-forward, high-resolution photos are available, for example, he added.
In addition, Dr Merola added that patients who require a procedure to diagnosis or control the disease, such as a skin biopsy or arthrocentesis, those on medications that require lab monitoring or are administered in the office, such as infusions, still have to come into the office. The need for an in-person visit should be weighed against the risks of exposure, as well as patients’ concerns and comfort.
Joseph Merola, MD, is an associate professor at Harvard Medical School and vice chair of Clinical Trials and Innovation and director of the Center for Skin and Related Musculoskeletal Diseases at the Brigham and Women’s Hospital in Boston.
—Melissa Weiss
