Which dermatology patients attend to Dermatology Outpatient Clinics during the SARS-CoV-2 outbreak in Turkey and what happened to them?

Coronavirus disease, first emerged in Wuhan, rapidly spread all over the world since December 2019. There are concerns about elective dermatology appointments and its results. Herein, we aimed to find out which type of dermatologic patients attended to dermatology outpatient clinic. The patients visiting the clinics for elective dermatologic diseases between March 11 and 18, 2020, were included in this study. Their age, sex, diagnosis of disease, requirement for emergent intervention, and their medical records about COVID-19 were obtained. There were 390 patients attending to the dermatology outpatient clinic in this period. The most common disease was acne (N: 94, 24%), only 19% of patients need emergent interventions or dose adjustment. There were 40 (10%) patients over the age of 65. After their visits, five patients were diagnosed as COVID-19 in 2weeks. Dermatologic examinations may be a vector for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission since being closed to the patient. Five of our patients were diagnosed as COVID-19 after their elective visit to hospital. Since the asymptomatic course of some young patients, most of our patients were not screened for COVID-19. Our findings support the concerns of elective physician examinations.

INTRODUCTION

In December 2019, several cases with unexplained viral pneumonia were reported in Wuhan, China. A novel coronavirus was identified as the pathogen severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and the disease was named as COVID‐19 (ie coronavirus disease 2019). By February 2020, COVID‐19 has spread throughout China and across the world. As of March 11, 2020, the first case of SARS‐CoV‐2 infection has been confirmed in Turkey. Recent reports demonstrate that the COVID‐19 pandemic is set for exponential growth in Turkey. The Turkish government imposed a partial curfew for citizens over the age of 65 and those with chronic diseases, on March 21, 2020. The government had also banned flights with suspicious countries, closed schools, cafes and bars, mass prayers, and indefinitely postponed matches in its main sports leagues. However, outpatient clinics did not completely halt the services to some patients who need to visit during the SARS‐CoV‐2 outbreak. As reported before, dermatology practices may be a vector for SARS‐CoV‐2 transmission. In this study, we summarized our patients profile and possible risk factors for transmission.

MATERIALS AND METHODS

This study was conducted at Bezmialem Vakif University, Dermatology Outpatient Clinics, a major tertiary hospital in Istanbul, with all major medical and surgical specialties and sees over 500000 patients per year.

The patients admitted to the dermatology outpatient clinic of Bezmialem Vakif University between March 11 and 18, 2020, were included in this study. The patients who had made online and telephone consultations, and the patients who had visited another doctor for any reason, the patients who did not pay attention to social distancing in their daily life were excluded from the study. The age, sex, diagnosis of patients, their medical history, and urgency of cases were recorded. Then, these patients were followed up from their medical records and checked for SARS‐CoV‐2 positivity at this incubation period.

RESULTS

Over the period from March 11 to 18, 2020, there were 390 presentations to the dermatology outpatient clinic of Bezmialem Vakif University. The most common presentations were acne (N: 94, 24%), types of dermatitis (N: 55, 14%), superficial fungal infections (N: 29, 7%), urticaria (N: 23, 5%), psoriasis (N: 21, 5%), and scabies (N: 19, 4%) (Table 1). The mean age of patients was 33.8 ± 17.5 (minimum 2 months of age, maximum 90 years old). Male patients had a slight predominance (51% vs 49%). There were 40 (10%) patients over the age of 65. The most common complaint in this group was superficial fungal infections (N: 10, 25%). A number of 202 patients of presenting complaints were identified as being new, in which 188 patients attended to dermatology clinic for a follow‐up visit. After their visits, five patients were diagnosed as COVID‐19 in 2 weeks. Seventy‐seven patients (19%) need emergent interventions or dose adjustment.

TABLE 1

The diseases of patients attended to dermatology outpatient clinic

Diseases	Frequency	Percent
Acne	94	24.1
Superficial fungal infections	29	7.4
Scabies	19	4.9
Verruca vulgaris	7	1.8
Psoriasis	21	5.4
Telogen effluvium	5	1.3
Pruritus	16	4.1
Types of dermatitis	55	14.1
Urticaria	23	5.9
Vitiligo	3	0.8
Hidradenitis suppurativa	3	0.8
Rosacea	9	2.3
Bacterial infections	5	1.3
Alopecia areata	11	2.8
Zona zoster	5	1.3
Androgenic alopecia	2	0.5
Herpes infections	5	1.3
Hyperhidrosis	1	0.3
Seborrheic keratosis	2	0.5
Nevus	4	1
Lichen planus, lichen pilanopilaris	3	0.8
Anogenital verruca	9	2.3
Drug eruptions	5	1.3
Stomatitis	3	0.8
Melasma	5	1.3
Bullous diseases	3	0.8
Eritema nodosum	4	1
Granulation tissue of nail apparatus	4	1
Dermatofibrosarcoma protuberans	1	0.3
Pytriasis rosea	4	1
Amiloidosis	1	0.3
Granuloma annulare	4	1
Basal cell carcinoma	4	1
Callus	2	0.5
Mycosis fungoides	2	0.5
Lipoma	5	1.3
Xerosis	2	0.5
Nail diseases	2	0.5
Behcet's disease	2	0.5
Pediculus capitis	2	0.5
Actinic keratosis	2	0.5
Autoimmune diseases	2	0.5

DISCUSSION

This is the first article to describe dermatology patients presenting to a dermatology outpatient clinic during the COVID‐19 outbreak in Istanbul, Turkey. The patients who need dose adjustment or interruption in medication administration are 19%.

The number of Dermatology Outpatient Clinics has been reduced from five to one after the confirmation of first case of COVID‐19 in Turkey. In addition, the number of patients attended to Dermatology Outpatient Clinics has been decreased day by day. Some people entering the outpatient clinics wore masks, and they have their body temperature monitored by health professionals. During the skin clinic, patients show their lesions, on all areas of their body. Doctors wore masks, scrubs, and gloves. Dermatologic surgical and cosmetic procedures were postponed to decrease the risk of transmission.

Kwatra et al reported their concern about dermatology practices as vectors for COVID‐19 transmission. As their suggestion, the majority of our outpatient visits were nonemergent. Similar to their suggestion, only 19% of patients need emergent dermatologic intervention, or dose adjustment for their immunosuppresant drugs, biologic agents, systemic treatment. The vast majority of our patients were young, and they might be asymptomatic carriers who could shed viral particles in their prolonged incubation period. Emerging research also suggests that COVID‐19 viral particles remain viable in droplets for several hours and can survive several days on multiple surfaces. Therefore, we cannot predict their risk for transmission. By the way, 40 of patients were over age 65, they were at high risk and severe illness for infection. It was observed that the patients being age 65 and older did not pay attention to the outbreak of COVID‐19. After the partial curfew, they did not come to outpatient clinics.

After the investigation of their SARS‐CoV‐2 status, it was seen that five of these patients were diagnosed as COVID‐19 later. These individuals may be considered to have been exposed after their hospital visit.

In contrast with partial curfew, calls for staying at home, the importance of social distancing, these nonemergent patients carried on to visit the dermatology outpatient clinic. The greatest majority of diagnoses of these patients were acne vulgaris, types of dermatitis, and common superficial tineal infections.

It has been reported that more than one‐third of dermatology patients have some level of psychiatric or psychologic problem, complicating their skin disease. Acne is one of the most common dermatological diagnoses with psychiatric involvement, and anxiety associated with skin disease was common. In addition, acne is a well‐known stress responsive condition and has known psychological percussion in the causation and in the course of the disease.5, 6 This may be clarified with their anxiety that their symptoms will get worse if they do not visit their physician and take their treatment immediately. These patients frequently consider that they will not have COVID‐19 infection due to their young age, even though they are exposed to viral particles of SARS‐CoV‐2. Hu et al showed that 29% asymptomatic COVID‐19 cases showed normal computer tomography (CT) image and had no symptoms during hospitalization; therefore, some of our patients might not have any symptoms, and as a result they were not screened for infection.

Similar to the suggestions of Kwatra et al, we observed that screening patients and cancelling appointments only for those with fevers is not sufficient as there is known asymptomatic viral transmission. This situation was dangerous for both patients and physicians related to transmission. It is uncertain to predict when the COVID‐19 will end, and how the outbreak will affect Turkey. This study was an observation of our dermatology clinic, when the outbreak of COVID‐19 occurred in Istanbul, Turkey. We will figure out the results of noncancellation of the nonemergent appointments following the end of the COVID‐19 outbreak.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.