ABSTRACT
We present the outcomes from the reaudit of an established UK regional teledermatology service, revealing the impact of the COVID-19 pandemic on referrals from primary to secondary care. Our teledermatology service invites general practitioners (GPs) to submit queries with attached clinical photographs regarding adult patients through the National Health Service EReferral Service. While requests in relation to skin lesions are not excluded, GPs are advised to continue referring suspected skin cancers through the usual 2-week-wait (2WW) pathway. The original audit involved data collection over 12 months before the COVID-19 pandemic. It demonstrated a functioning service providing rapid advice and guidance responses to GPs from consultant dermatologists or associate specialists. The service was reaudited over a 1-month period during the COVID-19 pandemic. Data were collected on the time taken to get a response, the types of dermatological problems in question, the quality of photos submitted and the response outcome. In October 2020, 273 requests were submitted to the service, revealing a 4.5-fold increase vs. pre-COVID-19 pandemic queries. The average response time was 0 08 days. Further referral to secondary care was advised in 20% of cases, with 26% of patients ultimately being referred in the subsequent 3 months. Forty per cent of queries related to skin lesions, a further 40% to chronic dermatoses, 14% to acute dermatoses and 4% to provide advice on therapeutic management. Most notably, there was a six-factor increase in skin lesion queries when compared with pre-COVID-19 data. Our reaudit demonstrated a teledermatology service that continues to deliver timely advice, with the vast majority of responses provided on the same day as the request. This both preserves resources in avoiding potential referrals to secondary care and saves patients from long waiting times for an outpatient appointment. The demand for teledermatology advice has risen significantly during the COVID-19 pandemic, particularly with regard to skin lesions. This may be explained by the current reduced capacity for GPs to see their patients face to face or by the initial reduction in 2WW referrals made at the beginning of the pandemic and subsequent catch-up. The proportion of response outcomes advising further referral for an outpatient appointment has also increased during the pandemic. This is often due to inappropriate queries better served by the skin cancer pathway. Furthermore, 60% of requests lacked good-quality photographs or dermoscopic images, which often left the responding clinician unable to make an adequate assessment of a skin lesion, therefore resulting in referral.
ABSTRACT
A 21-year-old woman was admitted with a 3-day history of severe vulval ulceration, oedema and pain. On examination she had large deep necrotic-appearing kissing ulcers on the right and left inner labia minora, with overlying grey eschar and significant surrounding inflammation. The pain was described as agonizing, requiring opioid analgesia and catheterization for micturition. Three weeks prior, she had tested positive for SARS-CoV-2, having had mild symptoms, but her PCR was negative on admission. She had not been sexually active for several months due to dyspareunia. She was initially started on co-amoxiclav and acyclovir due to a raised C-reactive protein of 94, and white cell count of 11. Investigations were negative for Epstein-Barr virus (EBV), HIV and mycoplasma. Bacterial and viral skin swabs were negative. Biopsies were taken under general anaesthesia. Histology revealed ulceration and granulation tissue only. Bacterial and atypical mycobacterial cultures were negative. She was discharged when the ulcers had stabilized and pain was controlled. Follow-up 2 weeks later revealed full healing of the ulceration. Therefore, this is a case of reactive nonsexually acquired acute genital ulceration (AGU), also known as Lipsh€utz ulceration (Sadoghi B, Stary G, Wolf P et al. Ulcus vulvae acutum Lipsch€utz: a systematic literature review and a diagnostic and therapeutic algorithm. J Eur Acad Dermatol Venereol 2020;34 1432-9), which is likely to have developed secondary to COVID -19 in this patient. This rare form of vulval ulceration has been previously linked to infections including EBV, cytomegalovirus and mycoplasma. There have been three case reports of AGU linked to COVID -19 (Krapf JM, Casey RK, Goldstein AT. Reactive non-sexually related acute genital ulcers associated with COVID-19. BMJ Case Rep 2021;14: e242653). This is a rare and dramatic presentation that needs to be recognized by the dermatologist to aid timely diagnosis and treatment.