Which are the "emergent" dermatologic practices during COVID-19 pandemic? Report from the lockdown in Milan, Italy.

Dear Editor,

In March 2020, Kwatra launched an international warning about the risk of dermatological practices as vectors for COVID‐19 transmission, emphasizing the necessity of an immediate cessation of nonemergent visits.

Since March 9, only urgent and deferred consultations, i.e. with a 3‐day and 10‐day priority, respectively, were admitted in our Dermatology Unit, upon first evaluation of the general practitioner. During the period corresponding to Italian lockdown, from March 9 to May 4, 203 “priority” patients were admitted (105 males, 98 females) with a median age of 49 years. Pediatric dermatological consultations were carried out in a separated department to avoid overcrowding. Patients' characteristics and their diagnoses are shown in Table 1.

Table 1

Patients' characteristics and diagnoses during Italian lockdown (Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico)

Diagnosis	No of patients <65 years old	No of patients >65 years old	Total
Eczema of any causes	34	20	54
Seborrheic dermatitis	3	0	3
Hand eczema	16	8	24
Psoriasis	11	5	16
Prurigo	2	4	6
Repetitive self‐harm syndrome	1	0	1
Urticaria	7	4	11
Pressure urticaria	1	0	1
Acne	3	0	3
Rosacea	2	2	4
Total inflammatory diseases	60	35	95
Melanoma	2	1	3
Nonmelanoma skin cancer	1	5	6
Benign neoplasms	25	15	40
Total skin neoplasms	28	21	49
Scabies	11	4	15
Herpes zoster	3	3	6
Herpes simplex	4	0	4
Wart	2	0	2
Molluscum contagiosum	2	0	2
Body lice infestation	1	1	2
Folliculitis and furunculosis	4	3	7
Cutaneous abscess	3	1	4
Dermatophytosis	0	2	2
Total infectious diseases	30	14	44
Pityriasis rosea	4	0	4
Leg purpura	0	3	3
Maculopapular exanthema	1	0	1
Total parainfective rash	5	3	8
Blistering diseases	1	2	3
Scleroderma	1	2	3
Annular granuloma	0	1	1
Total immunopathology	2	5	7
Total	125	78	203

The most common diagnosis was dermatitis of any causes (54/203; 26.6%): in particular, 24 patients (11.8%) were diagnosed for hand eczema while 30 (14.8%) presented with diffuse eczema, seborrheic, and atopic dermatitis. The second most common group of diseases were the infectious ones (44/203, 21.7%): scabies (15/203, 7.4%) and herpes zoster (6/203, 3%) were the most frequent. Sixteen patients (7.9%) received a diagnosis of psoriasis, in mild‐severe form, being eligible for systemic therapy. Eleven patients (5.4%) had a diagnosis of acute urticaria, among which a patient, who was a nurse at work, was classified as pressure urticaria related to the use of a filter facial mask. Other diagnoses were prurigo (6 patients, 3%), acne (3 patients, 1.5%), and rosacea (4, 2%), while nine patients (4.4%) had a diagnosis of cutaneous malignancy: three melanomas and six nonmelanoma skin cancers. Finally, we observed eight parainfective rash (3.9%): four with the features of pityriasis rosea, three presenting as purpura of the legs, and one maculopapular exanthema. These dermatological manifestations were also described in association with COVID‐19 infection: three of eight patients reported previous symptoms as asthenia and fever, but none of them had undergone nasopharyngeal swab.

In the lockdown period, we recorded a reduction in more than half of the urgent dermatological consultations, if compared with 419 in the same period of the last year. We also noted a reduction in the mean age of the patients, reflecting the lower concern for contagion of young patients. The most frequent diagnosis was hand dermatitis; there was often an association with repetitive or obsessive hand washing, abuse of sanitizing gel, and improper use of gloves.

Although Yan et al reported an increased number of facial dermatoses (acne, rosacea, seborrheic dermatitis) among healthcare workers due to the use of facial masks, we did not observe an increase in general population. This is related to the different type of masks, usually surgical mask or homemade mask, with less filtering capacity and less adherence on the face. However, considering the new rules of phase 2 that allow visiting relatives and return to work wearing a mask mandatory, we expect an increase also of these diseases because of the occlusive effect of the masks.

Eventually, we want to share some considerations about the clinical practice during lockdown. The use of personal protective equipment and social distancing may affect quality and length of visiting: patients tend to show the affected part of body, goggles and other facial protections can interfere with dermoscopy; elderly patients, with hearing difficulties, struggle to understand the prescription as they do not see the lable. Moreover, both doctors and patients are reluctant to perform inspections of the oral cavity and/or evaluation of facial lesions.

On May 4, the Italian Government moved on phase 2 of pandemic crisis, easing some restrictions in people's daily activities. Our Dermatologic Department is also experiencing a gradual return to normal activities.