Cutaneous Manifestation in COVID-19: A Lesson Over 2 Years Into the Pandemic.

Cutaneous manifestations related to Coronavirus Disease-19 (COVID-19) have been reported over 2 years since the pandemic began. This research aimed to review articles published in English that describe cutaneous manifestations related to COVID-19/SARS-CoV-2. A data search for case reports, original studies, and review articles from the onset of the current COVID-19 pandemic to December 31, 2022, was performed using PUBMED, Cochrane Library, ResearchGate, and Google search engines. Keywords were "coronavirus", "novel coronavirus 2019", "COVID-19", "SARS-CoV-2", and "2019-nCoV" in combination with "cutaneous", "skin" and "dermatology" The extracted data included authors, region, sex, age, number of participants with skin signs, cutaneous signs, its location, symptoms, extracutaneous/associated symptoms, suspected or confirmed status for COVID-19, timeline, and healing duration. Six authors independently reviewed the abstracts and full-texts to identify publications providing these details concerning cutaneous manifestations related to COVID-19. A total of 139 publications with full text (122 case reports, 10 case series, and 7 review articles) that reported cutaneous manifestations were identified, and reviewed from 5 continents. The most common cutaneous manifestations of COVID-19 were maculopapular, followed by chilblain-like lesion, urticarial, livedoid/necrotic, vesicular, and other/non-descript rashes/skin lesions. After 2 years into the COVID-19 pandemic, we can conclude that there is no pathognomonic cutaneous manifestation of COVID-19, since it can be also found in other viral infections.

Presentation and Management of Cutaneous Manifestations of COVID-19.

INTRODUCTION: The spread of the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has instigated a fervent race of the medical community to identify its manifestations, the patients at risk, and optimal disease management. While the COVID-19 illness is largely associated with respiratory consequences, there is increased reporting of other organ-specific disease sequelae that include the skin. OBJECTIVE: To identify, describe, and classify the main skin manifestations of COVID-19 and associated protocols for management. METHODS: Forty-five patients from three clinical centers in North and South America with positive COVID-19 PCR and/or serology presenting cutaneous manifestations were included in this retrospective chart review. Medical history, biopsies, dermoscopy, laboratory findings, clinical photography, and disease management were documented. RESULTS: Seven main types of cutaneous manifestations were identified: exanthema/molbilliform, urticaria, papular/pustular/vesicular, petechiae/purpura, livedo reticularis, chilblains, and alopecia. Histopathogical analysis from skin biopsies and/or dermoscopy highlighted an inflammatory or vascular pathophysiology depending on the type of manifestation. While the first three types of COVID-19 skin manifestations preceded or coincided with other symptoms such as anosmia, fever, chills, chilblains, and livedo were found in later disease stages. All cases had a positive resolution with appropriate treatment. CONCLUSIONS: Cutaneous symptoms are part of the COVID-19 disease spectrum. Early identification, diagnosis, and management through a multidisciplinary approach can facilitate safe disease resolution for patients. J Drugs Dermatol. 2021;20(1):76-83. doi:10.36849/JDD5676.

Impact of COVID-19 pandemic on acute dermatology referrals in a secondary and tertiary care Central London hospital. A retrospective comparison review of pre-COVID-19 era and COVID-19 pandemic.

BACKGROUND: Although Dermatology is largely considered an outpatient specialty, there is an increasing need for Dermatology input in the acute and inpatient setting. During the COVID-19 pandemic, Dermatology services had to be reorganized to facilitate staff redeployment and minimize the risk of exposure to COVID-19 for patients and staff. This led to an unprecedented increase in teleconsultations aided by clinical images. OBJECTIVES: The main aim of our retrospective study was to analyse the acute Dermatology referrals received in the pre-COVID-19 era and during COVID-19 pandemic. METHODS: We retrospectively analysed acute Dermatology referrals using the acute referral log. RESULTS: We retrospectively analysed 500 and 110 acute Dermatology referrals received in the pre-COVID-19 period and during COVID-19 pandemic, respectively. In the pre-COVID-19 era, consultations were most commonly requested by Oncology/Haemato-Oncology, Emergency Departments and General Practice, while during the COVID-19 pandemic General Practice was the most common source of referrals. A wide variety of dermatological conditions were encountered with the most common been eczematous dermatoses. CONCLUSIONS: Although Dermatology is largely an outpatient-based specialty, this study shows the demand for urgent Dermatology input the care of sick patients with severe skin diseases and in the management of skin problems in patients admitted or receiving treatment for other diseases. Re-organization of Dermatology services during the COVID-19 pandemic resulted in a marked increase in teleconsultations (28% versus 84.5%) and highlighted the importance of complete skin-directed physical examination by the referring clinician as well as procurement of good quality clinical images.

Development and Clinical Evaluation of an Artificial Intelligence Support Tool for Improving Telemedicine Photo Quality.

Importance: Telemedicine use accelerated during the COVID-19 pandemic, and skin conditions were a common use case. However, many images submitted may be of insufficient quality for making a clinical determination. Objective: To determine whether an artificial intelligence (AI) decision support tool, a machine learning algorithm, could improve the quality of images submitted for telemedicine by providing real-time feedback and explanations to patients. Design, Setting, and Participants: This quality improvement study with an AI performance component and single-arm clinical pilot study component was conducted from March 2020 to October 2021. After training, the AI decision support tool was tested on 357 retrospectively collected telemedicine images from Stanford telemedicine from March 2020 to June 2021. Subsequently, a single-arm clinical pilot study was conducted to assess feasibility with 98 patients in the Stanford Department of Dermatology across 2 clinical sites from July 2021 to October 2021. For the clinical pilot study, inclusion criteria for patients included being adults (aged ≥18 years), presenting to clinic for a skin condition, and being able to photograph their own skin with a smartphone. Interventions: During the clinical pilot study, patients were given a handheld smartphone device with a machine learning algorithm interface loaded and were asked to take images of any lesions of concern. Patients were able to review and retake photos prior to submitting, so each submitted photo met the patient's assumed standard of clinical acceptability. A machine learning algorithm then gave the patient feedback on whether the image was acceptable. If the image was rejected, the patient was provided a reason by the AI decision support tool and allowed to retake the photos. Main Outcomes and Measures: The main outcome of the retrospective image analysis was the receiver operator curve area under the curve (ROC-AUC). The main outcome of the clinical pilot study was the image quality difference between the baseline images and the images approved by AI decision support. Results: Of the 98 patients included, the mean (SD) age was 49.8 (17.6) years, and 50 (51%) of the patients were male. On retrospective telemedicine images, the machine learning algorithm effectively identified poor-quality images (ROC-AUC of 0.78) and the reason for poor quality (blurry ROC-AUC of 0.84; lighting issues ROC-AUC of 0.70). The performance was consistent across age and sex. In the clinical pilot study, patient use of the machine learning algorithm was associated with improved image quality. An AI algorithm was associated with reduction in the number of patients with a poor-quality image by 68.0%. Conclusions and Relevance: In this quality improvement study, patients use of the AI decision support with a machine learning algorithm was associated with improved quality of skin disease photographs submitted for telemedicine use.

How to differentiate skin rash in covid, mononucleosis, chickenpox, sixth disease and measles.

PURPOSE OF REVIEW: Skin rashes seen during COVID-19 usually feature maculopapular or vesicular morphology, thus mimicking cutaneous eruptions occurring in other common infectious dermatoses, such as mononucleosis, chickenpox, sixth disease and measles, with possible diagnostic mistakes. In this review article, we sought to provide a practical overview about clinical appearance of skin rashes related to SARS-CoV-2 infection. RECENT FINDINGS: The study summarizes literature evidence on clinical patterns of COVID-19-associated maculopapular or vesicular rash, with a particular emphasis on the principal points of differentiation with possible mimickers. SUMMARY: Several differences do exist between rashes due to SARS-CoV-2 infection and other viral eruptions, mainly including lesions morphology, spreading pattern, symptoms and mucosal involvement. The increase of awareness of such features among clinicians may help promptly recognize COVID-19-related exanthemas in order to take proper action to manage the infection.

SYMPTOMATOLOGY AND TREATMENT OF COVID-19 AFFECTING SKIN APPENDAGES: A NARRATIVE REVIEW BEYOND COVID-TOES.

SARS-CoV-2 is the cause of COVID-19 disease and responsible for a pandemic since the 2020. Multiple organ involvement has been described including cutaneous symptoms. Affection of skin appendages, however, seems to be under-reported except for COVID-toes. We performed a PUBMED research for "COVID-19" OR "SARS-CoV-2" AND "skin appendages", "hair", "nails", and "skin glands" from January 2020 to April 2022. COVID toes were excluded since this symptom had extensively been discussed. The focus of this narrative review was laid on clinical presentation, association to the course of COVID-19 disease and treatment options. Skin appendages can be affected by COVID-19 disease beyond COVID-toes, both by symptomatic and asymptomatic course. Telogen effluvium, androgenetic alopecia, and alopecia areata are the most common hair disorders in COVID-19 patients. Nails are less commonly affected by COVID-19 than hair. Splinter hemorrhages and leukonychia are the most frequent findings. While sebaceous glands seem to be uninvolved, SARS-CoV-2 spike proteins have been identified in eccrine sweat glands. Alopecia areata is often seen among asymptomatic COVID-19 patients while telogen effluvium is observed in symptomatic and asymptomatic patients. The half-moon sign on the nails could be a red flag for a more severe course of COVID-19. Treatment options are summarized. Skin appendages are not spared by COVID-19. Their knowledge will help to identify asymptomatic patients and patients at risk for a more severe course of the viral disease.

Characteristic Distinctions Between Pre-/Post-COVID-19 Teledermatology Adoptees: A Cross-Sectional United States-based Analysis and the Implications for Dermatologic Healthcare Equity.

BACKGROUND: Studies suggest potential heterogeneity in telemedicine adoption with potential to exacerbate healthcare access inequity. METHODS: A pre-validated survey was electronically sent to a proprietary listserv of practicing US-based dermatologists. Results were stratified by when teledermatology was adopted. Chi-square and odds ratios (OR) with 95% confidence intervals (95%CI) were used to analyze categorical data while single-factor ANOVA with posthoc Tukey-Kramer was used for continuous data. RESULTS: 338 practicing US-based dermatologists completed the questionnaire. Academic/Government dermatologists were 4-times more likely (OR 4.08, 95%CI 2.37-7.03) to adopt teledermatology pre-COVID than private-practice dermatologists. Dermatologists with ≤10 years of experience were 1.8-times (OR 1.8, 95%CI 1.01-3.18) and 2.82-times more likely (OR 2.82, 95%CI 0.78-10.25) to adopt teledermatology pre-COVID-19 or at all, respectively, compared to dermatologists with ≥20 years of experience. Teledermatology adopters practiced more medical-dermatology (P<.0001) than non-adopters, who reported practicing more dermatologic surgery (P=.003; Tukey-Kramer α<.05) and dermatopathology (P<.0001; Tukey-Kramer α<.05). Pre-COVID-19 adopters were 4-times more likely (OR 4.69, 95%CI 1.46-15.07) to switch/incorporate live-interactive-only teledermatology (LI) post-COVID-19. Post-COVID-19 adopters were 6-times more likely (OR 6.09, 95%CI 3.36-11.06) to utilize LI than Pre-COVID-19 adopters. Pre-COVID-19 adopters use teledermatology for a larger proportion of patient visits than Post-COVID-19 adopters (19.6% v 10.4%, P<.0001), but also are 3.43-times more likely (OR 3.43, 95%CI 1.82-6.46) to report future decreases in usage. LIMITATIONS: Cross-sectional retrospective survey and potential response bias. CONCLUSION: Current teledermatology usage may be a suitable tool for medical-dermatology-focused practices. Material hurdles still exist for procedurally-oriented practices and future studies should investigate these barriers to maximize equitable access to dermatological care. J Drugs Dermatol. 2023;21(1):101-104. doi:10.36849/JDD.7169.

Comparison of Pediatric Dermatology Conditions Across Telehealth and In-Person Visits During the COVID-19 Pandemic.

Understanding the utility of virtual visits in pediatric dermatology practice has become increasingly important in the telehealth era. We compared the conditions diagnosed in pediatric dermatology between traditional in-person visits and virtual telehealth visits during the initial 8-month phase of the COVID-19 pandemic at an urban medical institution. When given the option, pediatric dermatology patients and their families were more likely to choose telehealth visits for the diagnosis and/or management of acne, hemangiomas, and contact dermatitis; however, they were more likely to choose in-person visits for atopic dermatitis, viral warts, and alopecia areata. These differences may be attributed to clinical features of pediatric skin conditions, treatment options, and other factors which may influence patient preference for telehealth or in-person care for their condition. J Drugs Dermatol. 2022;21(11):1260-1263. doi:10.36849/JDD.6843.

Teledermatology in South Dakota: Uses and Patient Centered Improvement in a Rural Setting.

Dermatologic conditions account for a large proportion of healthcare visits in the United States, yet there continues to be barriers to dermatologic care particularly among the rural and underserved populations. Patients among these populations are particularly vulnerable to poor outcomes and increased morbidity. Teledermatology offers a potential solution to increase access to high-quality dermatologic care. Studies have previously examined the convenience, cost-effectiveness, and clinical efficacy of teledermatology compared to in-person dermatology visits. There is a need to assess which populations are appropriate and in what settings teledermatology can be most effective. We surveyed patients of a South Dakota dermatology practice to assess perceptions and experiences with teledermatology visits in the context of the COVID-19 pandemic. Significant factors leading patients to prefer in-person visits compared to teledermatology were being over the age 65 (OR 2.9 95 percent CI 1.9,3.8 and p-value 0.036) or experiencing technical difficulties during the visit (OR 2.9 95 percent CI 1.9,3.9 and p-value 0.048). We found the chief complaint played an important role in patient preference for visit modality. Patients with acne or acne follow up compared to all other chief complaints had a strong preference for teledermatologic visits (OR 4.7 95 percent CI 4.0,5.4 and p-value 0.000018) whereas patients with possible malignant lesions strongly preferred having an in-person visit (OR 6.6 95 percent CI 5.5,7.8 and p-value 0.0004). Based on these results, we suggest a targeted use of teledermatology with pre-visit screening measures to maintain a patient center approach and avoid redundant visits.

Can a Correct Diagnosis Be Established Using the Teledermatology Method?

Teledermatology is a remote method of diagnosis, treatment, and follow-up of the patient with visual communication technologies. It has been a research subject for many years, but its reliability has not been fully explained. With the emergence of the coronavirus disease-19 (COVID-19) pandemic in 2019, the need for teledermatology increased. This study aimed to evaluate the reliability of teledermatology. Material and Method: A total of 595 lesions of 546 patients who visited the dermatology outpatient clinic were included in the study. Two physicians evaluated the patients, one face-to-face and the other via multimedia messaging, and the diagnoses were compared with each other. Diagnoses were in total agreement if the first diagnoses were the same, in partial agreement if the second and third diagnoses were the same, and in no agreement if all diagnoses differed. The first diagnoses of Physicians 1 and 2 matched in 468 (total agreement rate: 76.8%) patients, and the second and third diagnoses matched in 44 and 8 patients, respectively (partial agreement rate: 8.7%). There was no agreement in the diagnoses of 75 patients (12.7%). In total, an agreement was reached in 520 patients (87.3%). Common diseases in dermatology practice, such as papulopustular and urticarial lesions, nails and hair diseases, infectious diseases, erythematous squamous diseases, those with pruritus, and skin malignancies, were diagnosed teledermatologically at a high rate of accuracy. In contrast, eczematous diseases, premalignant lesions, and other groups of diseases were less accurately diagnosed. In the last year, the importance of teledermatology has greatly increased with the COVID-19 pandemic. Our study shows that the store and forward (asynchronous) method of teledermatology can diagnose dermatological diseases with a high rate of accuracy.

SARS-CoV-2 and Skin: New Insights and Perspectives.

The SARS-CoV-2 pandemic has disrupted global health systems and brought the entire globe to its knees. Although born as a disease of the respiratory system, COVID-19 can affect different parts of the body, including the skin. Reports of ongoing skin manifestations of COVID-19 have gradually multiplied, pushing researchers to investigate the etiopathogenic mechanisms underlying these phenomena in more depth. In an attempt to investigate the possible association between SARS-CoV-2, ACE2, TMPRSS2 and skin manifestations, we performed immunohistochemical investigations of the ACE2 receptor and TMPRSS2 in nine skin samples from SARS-CoV-2-positive patients compared to a cohort of healthy controls. Furthermore, after consulting public databases regarding ACE2 mRNA expression in various cell populations resident in the skin, we conducted a literature review aimed at outlining the current state of this topic. We did not find statistically different immuno-expression of ACE2 and TMPRSS2 between the group of SARS-CoV-2-positive patients (nine skin biopsies) and the control group. Regarding ACE2, major immunolabeling was present in the epidermal keratinocytes and, rarely, in the fibroblasts and in the adenomeres of the eccrine sweat glands. Regarding the immune expression of TMPRSS2, we found no significant differences between the two groups, with a weak immune staining only in some skin cytotypes. From the review of the literature, we isolated 35 relevant articles according to the inclusion criteria adopted. ACE2 appears to be a target of SARS-CoV-2, although, other receptor molecules may potentially be implicated, such as TMPRSS2. Future studies with large cases and different molecular investigative methods are needed to further elucidate the mechanisms underlying the skin manifestations of SARS-CoV-2.

The Utilization and Impact of Live Interactive and Store-and-Forward Teledermatology in a Veterans Affairs Medical Center During the COVID-19 Pandemic.

Introduction: Teledermatology has emerged as a promising method of continuing dermatologic care during the coronavirus 2019 (COVID-19) pandemic, including in the Department of Veterans Affairs (VA). Analysis of the utilization and impact of teledermatology within the San Francisco Veterans Affairs Health Care System (SFVAHCS) may elucidate the ways that teledermatology programs can continue to be optimized. Methods: We conducted a retrospective analysis of live interactive encounters, Veterans Affairs Video Connect (VVC), store-and-forward telehealth (SFT), and face-to-face (FTF) consultations, performed within the SFVAHCS from March 2020 to December 2020. To assess utilization, we analyzed numbers of encounters throughout 2020. To assess impact, we analyzed primary diagnoses for each encounter and rates of recommendations for medications and lesion biopsies. Additionally, we assessed diagnostic accuracy associated with each teledermatology type by measuring concordance between teledermatologists' clinical diagnoses and histopathological diagnoses. Results: Two thousand two hundred fifty FTF, 347 VVC, and 470 SFT encounters were conducted from March to December 2020. More female patients utilized VVC, and patients who utilized VVC were younger than SFT and FTF users (p < 0.01). SFT was utilized more by patients from rural areas (p < 0.01). Diagnoses addressed were significantly different between VVC and SFT. A majority of VVC encounters involved referrals for inflammatory conditions; primary diagnoses associated with SFT consultations were most frequently neoplasms. Comparison of VVC and SFT outcomes showed that more VVC visits resulted in a medication recommendation, while more SFT consultations resulted in a biopsy recommendation. Conclusions: Teledermatology contributed to meeting patient needs throughout 2020 and created an impact on clinical management. Patient characteristics, diagnoses, and type of impact associated with encounters varied between SFT and VVC. This analysis provides insight into teledermatology utilization within the VA system and can contribute to efforts to improve the quality of teledermatology care for veterans.

The impact of the first COVID-19 wave on office-based dermatological care in Germany: a focus on diagnosis, therapy and prescription of biologics

Background: The COVID-19 pandemic has led to widespread changes in medical care. However, it is still unclear to what extent the care of patients suffering from moderate-to-severe psoriasis, chronic spontaneous urticaria or atopic dermatitis has been affected. Objectives: This study was conducted to determine the impact of the SARS-CoV-2 pandemic on medical care in dermatological practices, focusing on physicians' concerns related to susceptibility to infections in combination with different treatment modalities. Materials & Methods: Dermatologists working in medical offices in the German federal states of Bavaria and Lower Saxony participated in a cross-sectional, non-interventional, questionnaire-based study investigating the influence of COVID-19 on dermatological care. The study was performed after the first wave of the coronavirus pandemic in July/August, 2020. Results: A total of 195 dermatologists participated in the study. Almost one in five practices were closed for at least one week during the pandemic. The care of patients with chronic inflammatory skin diseases was impaired, affecting diagnostic investigation. Physicians stated that the pandemic substantially influenced systemic therapy. Nearly half of physicians surveyed were concerned about increased susceptibility to infections under biological therapy. No significant differences were identified between the German federal states of Bavaria and Lower Saxony in the south and north of Germany, respectively. Conclusion: This study reveals a significant impact of the COVID-19 pandemic on the care of dermatological patients in medical offices in Germany. New management modalities and continuous education are needed to improve care in pandemic situations.