A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring.

BACKGROUND: In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. OBJECTIVE: The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. METHODS: The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. RESULTS: From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. LIMITATIONS: Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. DISCUSSION: These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

COVID-19 Pandemic: Impact on Healthcare in Missouri

Most elective and non-essential procedures and in-person visits were deferred in Missouri based on CDC and CMS recommendations in order to preserve PPE, and free up equipment, ORs, hospital beds, ICUs and ventilators for an expected surge of COVID-19 cases (as was seen in Italy and New York City), and to prevent the spread of the virus in the healthcare setting. A trip to the supermarket, hardware store, or gas station may well be riskier than going to the doctors office or an outpatient surgery center, which are much better controlled environments. By having a detailed, written COVID-19 pandemic preparedness plan in place, we have been able to bring back staff who were leery of working during these uncertain times. [...]there is a vaccine or some highly effective treatment, COVID-19 will be with us.

Unintended Consequences of Prior Authorization

There are a number of ways that PAs could reduce burden on physicians, interfere less with patient care, save administrative costs for both sides and allow payors to focus on areas of overuse, waste and abuse of scarce healthcare resources. Development of "best practices" by physician organizations and payors working together to eliminate the need for prior authorization when such best practices are followed.2 The Missouri State Medical Association has been able to, through its advocacy on behalf of Missouri physicians and their patients, get S.B. 514 passed in 2019 and signed into law. The COVID-19 pandemic has led the Centers for Medicare and Medicaid Services to allow waivers of PAs by Medicare Advantage (MA) Plans and Medicare Part D to facilitate healthcare access for beneficiaries during the public health emergency.3 It is not clear if the MA Plans have taken advantage of this flexibility.

Who You Gonna Call?

MSMA has successfully spearheaded additional reforms to reduce lawsuit abuse: expert witness reforms that require testimony to be based on evidence widely accepted by the scientific community, updates to the collateral source rule so plaintiffs can only recover actual monetary damages instead of billed charges and increasing the standard of proof for punitive damage claims. There are many groups, including the state's trial attorneys, the hospitals, integrated healthcare systems, pharmacy benefit managers, pharmacy chains, health insurers, and many others that are in Jefferson City every day often pushing positions that are at odds with what is best for our patients. Select Legislation important for Physicians and Patients that MSMA Passed or Blocked 2010 * Insurance company prompt pay (signed into law) * Naturopath licensure and scope expansion (blocked) * Private Medicaid fraud lawsuits (blocked) * Statute of limitations expansion for medical malpractice cases and weakening of the collateral source rule (blocked) * Tiering of physicians (blocked) * Autism insurance coverage (signed into law) 2011 * Drug testing of surgeons (blocked) * Chiropractors Medicaid payment (blocked) * Allowing professional counselors to diagnose (blocked) * Board of Healing Arts civil penalties (blocked) * Implementation of concussion protocols for student athletes (signed into law) * Preemption of local tobacco laws (blocked) 2012 * Increased use of ignition interlock devices (signed into law) * Regulations on the creation and operation of HIEs (signed into law) * Lay midwife licensure (blocked) * CRNA scope expansion (blocked) * Co-pay equity between primary care physicians and physical therapists (blocked) 2013 * Prompt credentialing improvements (signed into law) * Telehealth reimbursement parity (signed into law) * Repeal of collaborative practice act (blocked) * Volunteer physician malpractice immunity (signed into law) * Updating of newborn screening requirements (signed into law) * Mandatory arbitration for claims over 30 days unpaid (blocked) 2014 * Non-physician clinicians scope expansion (blocked) * Tanning bed parental permission (signed into law) * Establishment of ECHO telehealth distance learning program (signed into law) * Statewide Medicaid managed care implementation (blocked) 2015 * Tort reform (signed into law) * Establishment of direct primary care services (blocked) * Expansion of APRN scope-of-practice (blocked) * Parental notification of immunization exemptions (signed into law) 2016 * Telehealth expansion (signed into law) * Prohibit MOC/MOL for licensure (signed into law) * Licensure not conditioned on participating in any health insurance plan (signed into law) * Step therapy reform (signed into law) * Insurance contracts gag clauses banned (signed into law) * APRN, athletic trainers, physical therapists, radiology technicians scope expansion (blocked) 2017 * Expert witness reform (signed into law) * Collateral source rule updated (signed into law) * Tort reform fix for hospital non-employees (signed into law) * Requirements for medical student mental health and wellbeing (signed into law) * APRN opioid prescriptive authority expansion (blocked) * Implementation of statewide naloxone protocol (signed into law) 2018 * Protection of prudent layperson standard in the ER (signed into law) * Prohibit pharmacy gag clauses (signed into law) * Non-physician clinicians, physical therapists, radiology technicians scope expansion (blocked) * Implementation of workers compensation fee schedule (blocked) * Increased Medicaid post-partum benefits (signed into law) 2019 * Prior authorization reform (signed into law) * Prohibit use of virtual credit cards by insurers (signed into law) * Establishment of pregnancy-associated mortality review board (signed into law) * Implementation of statewide MAT insurance coverage for opioid disorders (blocked) * Defeat of various anti-vaccination requirements for physicians (blocked) * Independent pharmacist prescribing (blocked) 2020 * Punitive damages only for intentional or malicious act (signed into law) * Prompt credentialing to pay from the date of application (signed into law) * Overpayment transparency (signed into law) * Vaping prohibitions (signed into law) * Criminal penalties for gender dysmorphia treatments (blocked)

The American Academy of Dermatology and International League of Dermatological Societies Monkeypox Registry: Expanding the COVID-19 registry to emerging infections.

The World Health Organization declared the global monkeypox outbreak a public health emergency of international concern in July 2022. In response, the American Academy of Dermatology and International League of Dermatological Societies expanded the existing COVID-19 Dermatology Registry to become the "AAD/ILDS Dermatology COVID-19, Monkeypox, and Emerging Infections Registry." The goal of the registry is to rapidly collate cases of monkeypox and other emerging infections and enable prompt dissemination of findings to front-line healthcare workers and other members of the medical community. The registry is now accepting reports of monkeypox cases and cutaneous reactions to monkeypox/smallpox vaccines. The success of this collaborative effort will depend on active case entry by the global dermatology community.

Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study.

BACKGROUND: Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized. METHODS: We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns. RESULTS: Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym "V-REPP" (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5). LIMITATIONS: Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence. CONCLUSION: Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

Coronavirus Disease 2019 and Dermatology Practice Changes.

The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the "new normal" in various domains of dermatology practice, namely, dermatology consultation, procedural dermatology, and phototherapy, is also provided.

Learning from disease registries during a pandemic: Moving toward an international federation of patient registries.

High-quality dermatology patient registries often require considerable time to develop and produce meaningful data. Development time is influenced by registry complexity and regulatory hurdles that vary significantly nationally and institutionally. The rapid emergence of the coronavirus disease 2019 (COVID-19) global pandemic has challenged health services in an unprecedented manner. Mobilization of the dermatology community in response has included rapid development and deployment of multiple, partially harmonized, international patient registries, reinventing established patient registry timelines. Partnership with patient organizations has demonstrated the critical nature of inclusive patient involvement. This global effort has demonstrated the value, capacity, and necessity for the dermatology community to adopt a more cohesive approach to patient registry development and data sharing that can lead to myriad benefits. These include improved utilization of limited resources, increased data interoperability, improved ability to rapidly collect meaningful data, and shortened response times to generate real-world evidence. We call on the global dermatology community to support the development of an international federation of patient registries to consolidate and operationalize the lessons learned during this pandemic. This will provide an enduring means of applying this knowledge to the maintenance and development of sustainable, coherent, and impactful patient registries of benefit now and in the future.

Dermatology COVID-19 Registries: Updates and Future Directions.

During the COVID-19 pandemic, rapid, real-world evidence is essential for the development of knowledge and subsequent public health response. In dermatology, provider-facing and patient-facing registries focused on COVID-19 have been important sources of research and new information aimed at guiding optimal patient care. The 7 dermatology registries included in this update now include more than 8000 case reports sourced from physicians and patients from countries all over the world.

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases.

BACKGROUND: Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized. OBJECTIVE: To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines. METHODS: A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination. RESULTS: From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions. LIMITATIONS: Registry analysis does not measure incidence. Morphologic misclassification is possible. CONCLUSIONS: We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has associated cutaneous manifestations. OBJECTIVE: To characterize the diversity of cutaneous manifestations of COVID-19 and facilitate understanding of the underlying pathophysiology. METHODS: Case series from an international registry from the American Academy of Dermatology and International League of Dermatological Societies. RESULTS: The registry collected 716 cases of new-onset dermatologic symptoms in patients with confirmed/suspected COVID-19. Of the 171 patients in the registry with laboratory-confirmed COVID-19, the most common morphologies were morbilliform (22%), pernio-like (18%), urticarial (16%), macular erythema (13%), vesicular (11%), papulosquamous (9.9%), and retiform purpura (6.4%). Pernio-like lesions were common in patients with mild disease, whereas retiform purpura presented exclusively in ill, hospitalized patients. LIMITATIONS: We cannot estimate incidence or prevalence. Confirmation bias is possible. CONCLUSIONS: This study highlights the array of cutaneous manifestations associated with COVID-19. Many morphologies were nonspecific, whereas others may provide insight into potential immune or inflammatory pathways in COVID-19 pathophysiology.