Update on COVID-19 effects in dermatology specialty.

Dear Editor,

We are fighting a dreaded pandemic, coronavirus disease 2019 (COVID‐19), caused by severe acute respiratory syndrome corona virus 2 (SARS‐CoV‐2). The pathogen is transmitted during an incubation period that can be as long as 14 days via inhalation of contaminated droplets and contact of respiratory secretions with mucous membranes such as the oral and ocular mucosae. The clinical spectrum resembles viral pneumonia ranging in severity from asymptomatic, subclinical infection to mild to moderate disease, acute respiratory distress syndrome, septic shock and multiorgan failure, and ultimately death. ,

Dermatological manifestations of COVID‐19 have been recently reported. In a study performed at Lecco Hospital, Lombardy, Italy, 148 patients affected with COVID‐19 were observed regarding cutaneous manifestations. From the collected data (88 patients), 18 patients (20.4%) developed cutaneous manifestations. Fourteen patients developed a nonspecific eruption, 3 patients developed generalized urticaria, and 1 patient developed a varicella‐like eruption. Trunk was the commonest site of involvement, and minimal itching was noted. Most lesions healed without any sequelae, and there was no correlation with severity of COVID‐19. The weakness of this study is the complete lack of photographic confirmation. In a case report from Thailand, a patient presented with a petechial eruption. The patient had thrombocytopenia and, because dengue is quite common among patients with petechial eruptions in this setting, a clinical diagnosis of dengue was made, and patient was admitted. However, he developed respiratory distress and a diagnosis of COVID‐19 infection was confirmed by a laboratory work‐up including reverse transcription polymerase chain reaction. In China, unspecific eruption and/or urticarial rashes were observed as well in some COVID‐19 patients (Chen et al., personal communication). Taken together, cutaneous manifestations might be more frequent than initially expected in this intriguing disease and should be investigated further. Furthermore, it remains unclear whether the observed manifestations are secondary (ie, due to drug‐related antigens, which are given in almost all hospitalized patients with COVID‐19) or primary, namely direct consequences of the immune response against SARS‐CoV‐2. Based on the abovementioned data, the dermatologist may play a role in picking up cases of COVID‐19 manifesting with eruption. A high index of suspicion for COVID‐19 is currently recommended when examining a patient with constitutional symptoms and an eruption. Since patients visiting outpatient skin clinics can be asymptomatic carriers, it is recommended that during this pandemic the dermatologist should wear an appropriate mask, suitable goggles, and wash hands before and after using gloves. Indeed, dermatologists can play an important role during a COVID‐19 epidemic or local outbreak. First, they should recommend appropriate hand washing to their patients including avoidance of harsh/drying soaps and chemicals and very hot water. Second, they should appropriately advise patients about pharmacologic treatment. As per current guidance by the American Academy of Dermatology, patients should continue their biologic treatment if they have not tested positive or do not exhibit signs or symptoms of COVID‐19. Third, no cosmetic or other elective treatments should be performed during this pandemic as the risks of transmitting COVID‐19 outweigh the benefits, and the personal protective equipment should be reserved for those who need it the most. Furthermore, nonemergency consultations should be conducted over electronic media, that is, virtual visits, when possible, mitigating the need of in‐person consultation.