Dermatology and the COVID-19 Pandemic

In this issue, we have articles on multimedia use in resident education (page 35), the microbiome and acne (page 44), the potential role of the natural killer cell in eczema (page 25), and tips for correcting signs of aging (page 23). It’s a real hodgepodge of stuff!  Normally, we would try to find some common factor to write about, but there isn’t one, and even if there were, the only possible topic for us is the coronavirus.

This issue does have one article on IL-23 biologics for psoriasis (page 27), and that gives us a natural segue into discussing the coronavirus disease (COVID-19) because many patients—and their dermatologists—want to know if biologic therapy should be stopped during this time. While the data we have are limited and there are no clear answers, the bottom line is to say no, we don’t need to stop our patients’ biologics.

There is currently no reliable evidence that patients on biologics are at a meaningfully increased risk of SARS-CoV-2 infection. Additionally, there is some theoretical evidence that tumor necrosis factor alpha and IL-17 inhibitors may actually improve outcomes during the cytokine storm-mediated pulmonary injury phase of COVID-19 pneumonia.^1-4 Accordingly, a clinical trial for the use of adalimumab (Humira) in treating severe COVID-19 pneumonia is currently underway.⁵

The answer to whether it is appropriate to use systemic corticosteroids for skin disease flares at this time is also unknown. However, the Centers for Disease Control and Prevention (CDC) recommends against corticosteroid use in active infection as this may prolong the duration of viral shedding.^6,7

Realistically, dermatologic disease care may suffer in the wake of this pandemic. Patients may fear “immunosuppression” and discontinue medications, whether rational or not. If so, we can expect poorer disease control and increased rates of flares.  

We should adhere closely to the CDC interim infection control guidelines for health care providers⁸ and any institutional specific guidelines. Our dermatology colleagues in China have provided a snapshot of what they are doing to maintain care while taking the utmost precaution.^9,10 We can learn from their experiences to make the best of a difficult situation:

• Practice smart hand hygiene: washing hands, use of alcohol-based hand sanitizer, and avoid touching face;
• Take respiratory precautions, including use of personal protection equipment; 
• Review institutional infection control policies ahead of time;
• Screen and separate patients in the waiting room;
• Keep a distance from others and limit time in public places;
• Avoid nonessential travel; and
• Plan for telemedicine and remote consultation.

We should not take COVID-19 lightly—it is preferable to react with an overabundance of caution with so many unknowns. Just as we went to publish this issue, the American Academy of Dermatology canceled the 2020 Annual Meeting.¹¹ Hopefully, we can look back on this time and think that we overreacted rather than looking back and thinking that we could have been better prepared. At the time of writing, it appears not to be a question of if COVID-19 will affect our patients, but rather when. In the meantime, wash those hands and don’t touch that face. We’ll be bumping elbows with our patients.

References
1. Tobinick E. TNF- inhibition for potential therapeutic modulattion of SARS coronavirus infection. Curr Med Res Opin. 2004;20(1):39-40. doi:10.1185/030079903125002757

2. Hussell T, Pennycook A, Openshaw PJ. Inhibition of tumor necrosis factor reduces the severity of virus-specific lung immunopathology. Eur J Immunol. 2001;31(9):2566-2573. doi:10.1002/1521-4141(200109)31:9<2566::aid-immu2566>3.0.co;2-l

3. Shi X, Zhou W, Huang H, et al. Inhibition of the inflammatory cytokine tumor necrosis factor-alpha with etanercept provides protection against lethal H1N1 influenza infection in mice. Crit Care. 2013;17(6):R301. doi:10.1186/cc13171

4. Zumla A, Hui DS, Azhar EI, Memish ZA, Maeurer M. Reducing mortality from 2019-nCoV: host-directed therapies should be an option. Lancet. 2020;395(10224):e35-e36. doi:10.1016/S0140-6736(20)30305-6

5. A clinical study for the efficacy and safety of adalimumab injection in the treatment of patients with severe novel coronavirus pneumonia (COVID-19) Chinese Clinical Trial Registry: ChiCTR2000030089. Updated February 23, 2020. Accessed March 10, 2020. https://www.chictr.org.cn/showprojen.aspx?proj=49889

6. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020;395(10223):473-475. doi:10.1016/S0140-6736(20)30317-2

7. Interim Clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). Centers for Disease Control and Prevention website. Updated March 7, 2020. Accessed March 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

8. Interim infection prevention and control recommendations for patients with confirmed coronavirus disease 2019 (COVID-19) or persons under investigation for COVID-19 in healthcare settings. Centers for Disease Control and Prevention website. Updated February 21 2020. Accessed March 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

9. Tao J, Song Z, Yang L, Huang C, Feng A, Man X. Emergency management for preventing and controlling nosocomial infection of 2019 novel coronavirus: implications for the dermatology department. Br J Dermatol. Published online March 5, 2020. doi:10.1111/bjd.19011

10. Chen Y, Pradhan S, Xue S. What are we doing in the dermatology outpatient department amidst the raging of 2019-nCoV? J Am Acad Dermatol. Published online February 17, 2020. doi:10.1016/j.jaad.2020.02.030

11. Hruza GJ. 2020 AAD annual meeting is canceled due to COVID-19 outbreak. American Academy of Dermatology website. Published March 9, 2020. Accessed March 10, 2020. https://www.aad.org/member/meetings/am2020