Inpatient dermatology consultations during COVID 19 pandemic in a tertiary referral center.

Since the COVID-19 infection first appeared in December 2019, patient profile of outpatient and inpatient clinics has changed. Various cutaneous findings associated with COVID-19 have been reported in the literature. The main objective of this study was to describe and analyze the profile of the consultations requested from dermatology department during the COVID pandemic. Retrospective, cohort study. In this study, we observed the dermatology consultations of the hospitalized patients over a period of 2 months, corresponding to the peak of COVID outbreak in a tertiary care hospital in Turkey. We reviewed the inpatient dermatology consult database retrospectively. Both pediatric and adult dermatology inpatient consultations were evaluated. A total of 166 inpatient dermatology consultations were requested from dermatology department during March-May, 2020. The mean age of the patients was 53.12 (1-89) years. Almost 32.5% (n = 54) of dermatology consultations were requested from the COVID wards and the COVID intensive care unit. The second most common consultations were requested from internal medicine departments (n = 46, 27.7%). The most common indications for the consultations were cutaneous infections (36%), followed by inflammatory disorders (32%), and urticaria (11%). Dermatology consultations have an essential role on the management of hospitalized patients, especially at that pandemic time. Careful dermatological examination improves diagnostic accuracy in skin disorders and skin manifestations of COVID-19 infection that provides an early diagnosis and treatment, helps to improve the quality of the patient care and management.

INTRODUCTION

Although the dermatology practice mainly depends on the outpatient clinics, several systemic diseases, infections and medications may present with skin manifestations. Dermatology consultations have a large impact on the management of these disorders. Since the COVID‐19 (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) first appeared in December 2019 in China, various observations about the cutaneous findings of COVID‐19 infection have been reported, some of which were also linked to the disease prognosis. , Dermatology consultations have a great importance especially during this pandemic period regarding to the wide spectrum of cutaneous findings of COVID infection. During COVID pandemic our hospital provided health care services both in routine hospital wards and separately in the COVID services. In this study, we want to investigate the dermatology consultations both in the hospital wards and the COVID services during the pandemic, retrospectively.

MATERIALS AND METHODS

This study was conducted in the dermatology clinic of Istanbul University Cerrahpasa Medical Faculty and approved by the local Institutional Review Board. The inpatient dermatology consult database was reviewed retrospectively. In this study of both pediatric and adult dermatology inpatient consultations were evaluated for the last 2 months starting after the first case of COVID infection was reported in Turkey. For both groups we reviewed patient demographic characteristics of the patients including age, sex, consult requesting service and reason for dermatology consultation from March 10 to May 10, 2020. Patients who have more than one consultation or admission for different indications, were conducted for a separate diagnosis.

Diseases were classified into seven groups according to etiology including cutaneous infections (viral eruption, cellulitis, herpes zoster, tinea pedis), urticaria, inflammatory disorders (dermatitis, psoriasis, rosacea), drug eruptions, wounds and ulcers, benign tumors, malignant tumors. Purpuric‐petechial eruption which is thought be related to COVID‐19 infection was classified in the cutaneous infection subgroup.

Departments were classified into 13 groups including emergency, internal medicine, intensive care, pediatrics, infectious disease, physical medicine and rehabilitation, cardiology, neurology, COVID wards, COVID intensive care unit, surgery and surgical subspecialties, and psychiatry. In this study only face‐to‐face, standard consultations were included, teleconsultations were excluded.

STATISTICAL ANALYSIS

Data analysis was performed using the NCSS statistical package (Number Cruncher Statistical System) 2007 (Kaysville, Utah). The results were analyzed by using mean ± SD, percentile values and Chi‐square tests. Statistical significance was set at the .5% level.

RESULTS

A total of 166 consultations were reviewed between March and May 2020. Of these patients, 57% (n = 94) were male. The mean age of the patients was 53.12 (range: 1‐89 years) (Table 1).

TABLE 1

Demographic characteristics of the patients

	Number	Minimum	Maximum	Mean	SD
Female	72 (43.3%)	1	89	52.750	23.4165
Male	94 (56.7%)	1	85	53.404	19.6553
Total	166 (100%)	1	89	53.120	21.3027

Among these consultations requested by subspecialties and services, 46 requests (27.7%) from internal medicine, 41 requests (24.9%) from COVID wards, 22(13.2%) from surgery and surgical subspecialties,13 (7.8%) COVID intensive care unit, 11 (6.6%) pediatrics, 9 (5.4%) emergency room, 7 (4.2%) from infectious disease, 4 (2.4%) from intensive care unit, 4 (2.4%) from cardiology, 4 (2.4%) from neurology, 3 (1.8%) from physical medicine and rehabilitation, 2 (1 2%) from psychiatry (Table 2).

TABLE 2

Disease distribution according to sex

	Infections	Urticaria	Inflammatory disorders	Drug eruption	Ulcers	Benign tumor	Malignant tumor	Total
Emergency
Female	4 (66.7%)	1 (16.7%)	1 (16.7%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	6 (100%)
Male	2 (66.7%)	1 (33.3%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	3 (100%)
Total	6 (66.7%)	2 (22.2%)	1 (11.1%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	9 (100%)
Internal medicine
Female	6 (30%)	1 (5%)	8 (40%)	2 (10%)	2 (10%)	0 (0%)	1 (5%)	20 (100%)
Male	7 (26.9%)	1 (3.8%)	9 (34.6%)	4 (15.4%)	3 (11.5%)	1 (3.8%)	1 (3.8%)	26 (100%)
Total	13 (28.3%)	2 (4.3%)	17 (37%)	6 (13%)	5 (10.9%)	1 (2.2%)	2 (4.3%)	46 (100%)
Intensive care
Female	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (100%)	0 (0%)	0 (0%)	2 (100%)
Male	2 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (100%)
Total	2 (50%)	0 (0%)	0 (0%)	0 (0%)	2 (50%)	0 (0%)	0 (0%)	4 (100%)
Pediatrics
Female	3 (60%)	0 (0%)	1820%)	0 (0%)	1 (20%)	0 (0%)	0 (0%)	5 (100%)
Male	2 (40%)	0 (0%)	3 (60%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	5 (100%)
Total	5 (50%)	0 (0%)	4 (40%)	0 (0%)	1 (10%)	0 (0%)	0 (0%)	10 (100%)
Pediatric ICU
Female	1 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (100%)
Male	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
Total	1 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (100%)
Infectious disease
Female	1 (50%)	0 (0%)	1 (50%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (100%)
Male	3 (60%)	0 (0%)	1 (20%)	0 (0%)	0 (0%)	0 (0%)	1 (20%)	5 (100%)
Total	4 (57.1%)	0 (0%)	2 (28.6%)	0 (0%)	0 (0%)	0 (0%)	1 (14.3%)	7 (100%)
Physical medicine and rehabilitation
Female	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (100%)
Male	0 (0%)	0 (0%)	0 (0%)	1 (33.3%)	1 (33.3%)	0 (0%)	1 (33.3%)	3 (100%)
Total	0 (0%)	0 (0%)	0 (0%)	1 (33.3%)	1 (33.3%)	0 (0%)	1 (33.3%)	3 (100%)
Cardiology
Female	1 (50%)	0 (0%)	1 (50%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (100%)
Male	0 (0%)	0 (0%)	2 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (100%)
Total	1 (25%)	0 (0%)	3 (75%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	4 (100%)
Neurology
Female	1 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (100%)
Male	2 (66.7%)	0 (0%)	1 (33.3%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	3 (100%)
Total	3 (75%)	0 (0%)	1 (25%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	4 (100%)
COVID ward
Female	4 (22.2%)	4 (22.2%)	9 (50%)	1 (5.6%)	0 (0%)	0 (0%)	0 (0%)	18 (100%)
Male	11 (47.8%)	5 (21.7%)	4 (17.4%)	2 (8.7%)	1 (4.3%)	0 (0%)	0 (0%)	23 (100%)
Total	15 (36.6%)	9 (22%)	13 (31.7%)	3 (7.3%)	1 (2.4%)	0 (0%)	0 (0%)	41 (100%)
COVID ICU
Female	2 (40%)	0 (0%)	3 (60%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	5 (100%)
Male	4 (50%)	1 (12.5%)	2 (25%)	0 (0%)	1 (12.5%)	0 (0%)	0 (0%)	8 (100%)
Total	6 (46.2%)	1 (7.7%)	5 (38.5%)	0 (0%)	1 (7.7%)	0 (0%)	0 (0%)	13 (100%)
Surgery
Female	1 (11.1%)	1 (11.1%)	3 (33.3%)	2 (22.2%)	1 (11.1%)	0 (0%)	1 (11.1%)	9 (100%)
Male	4 (30.8%)	3 (23.1%)	3 (23.1%)	1 (7.7%)	2 (15.4%)	0 (0%)	0 (0%)	13 (100%)
Total	5 (22.7%)	4 (18.2%)	6 (27.3%)	3 (13.6%)	3 (13.6%)	0 (0%)	1 (4.5%)	22 (100%)
Psychiatry
Female	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (100%)	0 (0%)	0 (0%)	1 (100%)
Male	0 (0%)	0 (0%)	1 (100%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (100%)
Total	0 (0%)	0 (0%)	1 (50%)	0 (0%)	1 (100%)	0 (0%)	0 (0%)	2 (100%)

The most common indications seen by the dermatology consulting services were cutaneous infections (n = 61, 36%), followed by inflammatory skin disorders (n = 53, 32%), urticaria (n = 18, 11%), wound and ulcers (n = 15, 9%) drug eruptions (n = 13, 8%), malignant tumors (n = 5, 3%), and benign tumor (n = 1, 1%). In infection group, maculopapular viral eruption (n = 13, 21%) was the most common cutaneous finding followed by herpes zoster infection (n = 8, 13%) (Table 2).

DISCUSSION

In the present study, the indications for dermatology consultation requests and the distribution of consult requesting services at a tertiary referral center during COVID pandemic were reviewed. The most common conditions seen by our dermatology consulting services were cutaneous infections (n = 61, 36.7%), inflammatory skin disorders (n = 53, 31.9%), urticaria (n = 18, 10.8%), and drug eruptions (n = 13, 7.8%). Almost all of these indications were common skin disorders, none of them were rare diagnosis. The inflammatory skin disorders and cutaneous infections have been reported to be most common clinical diagnoses in dermatology consultations in most of the large hospital series before COVID pandemic similar with our study.

The role of dermatology consultations have been reviewed in many large hospital centers either in different departments such as emergency, hematology and transplantation units or in different indications selecting only one category such as inflammatory disorders or cutaneous infections , , , In our study skin disorders were classified into several subgroups according to their etiology and it was seen that the most common consultation requests were made by COVID services including wards and intensive care unit (n = 54, 32.5%).

Several observations about the cutaneous findings of COVID‐19 infection including urticarial, purpuric, erythema multiforme‐like, chickenpox like rash, acro‐ischemia, chilblain‐like eruptions and pityriasis rosea like eruptions have been reported in the literature. Some of these findings were also linked to disease prognosis and increased mortality. In our study, in female patients with COVID‐19, inflammatory skin disorders (50%) were the most common indications for consultations and in male patients cutaneous infections (47.8%) were the most common indication. In general, cutaneous infections including viral maculopapular eruption, cellulitis, herpes zoster were the most common disorders in all COVID‐19 patients (38.8%, n = 21), followed by inflammatory skin disorders (33.3%, n = 18) and urticarial eruption (18.5%, n = 10). Dermatitis was the most common individual diagnosis in inflammatory disease group (n = 8, 44.4%). Drug eruptions made the 0.5% (n = 3) of the consultations in COVID patients and were more common in COVID wards. Wound and ulcers made the 0.3% (n = 2) of the dermatology consultations requested for COVID patients. Purpuric eruption was detected in 16.6% (n = 9) of the COVID patients (Figures 1 and 2). Purpuric eruptions were more common in male (n = 7) and majority of the patients were elderly patients (60<), hospitalized in COVID intensive care unit reflecting the disease severity and increased thrombotic pattern in COVID‐19 infection (Figures 1 and 2). Morbiliform skin rash was detected in 16% (n = 9) of the COVID patients and more common in COVID‐19 wards. Chickenpox‐like vesicular eruption was also detected in 7% (n = 4) of the COVID‐19 patients and all of the patients were in COVID intensive care unit representing a more severe disease course. Almost 50% of the consultations for urticaria were requested from COVID wards which was the most common cutaneous finding in first admission to the hospital in COVID patients (n = 9).

FIGURE 1

Multiple livedoid, purpuric eruption on forehead, nose, and malar region

FIGURE 2

Multiple petechial, purpuric eruption on dorsal aspect of the upper extremities

The second most common department requested consultation from dermatology was internal medicine (n = 46, 27.7%) reflecting the high volume of patients cared for by this department. The most common indications of the consultations were inflammatory skin disorders, cutaneous infections and drug eruptions for both sex (37%, 28.3%, and 13%) compatibly with the previous studies in the literature. ,

Dermatology consultations from pediatrics were reported to be the 11% to 33% of the all consultations in prepandemic period in previous studies. Temiz et al reported that almost 19.7% of the dermatology consultations were requested from pediatric patients during COVID‐19 pandemic. In our study 6.6% (n = 11) of the dermatology consultations were requested from the department of pediatrics which is most probably related to quarantine, reflecting the change in patient profile during pandemic. Infections (n = 6, 54%) were similarly the most common indication in dermatology consultations requested from pediatric patient group.

Limitations

Limitations of our study include its retrospective nature and the fact that in many cases, primary teams do not accurately record a preliminary diagnosis, skin physical exam findings or a treatment plan once a consultation to dermatology has been placed.

CONCLUSIONS

During COVID‐19 pandemic, the majority of dermatology consultations were requested from COVID wards and COVID intensive care unit in our hospital. These results support that dermatology consultations may have an essential role in the early diagnosis and differential diagnosis of cutaneous manifestations of COVID‐19 which may also affect the risk stratification of patients with COVID‐19. Further training of ward clinicians on common dermatologic conditions and cutaneous manifestation of COVID‐19 will improve the management of skin disorders, hospitalization duration, and life quality of the hospitalized patients.

CONFLICT OF INTEREST

There are no conflicts of interest among all authors regarding this article.

AUTHOR CONTRIBUTIONS

Tugba Kevser Uzuncakmak, Samet Bayazit, and Zekayi Kutlubay involved in conception and design of study; Tugba Kevser Uzuncakmak, Samet Bayazit, and Ozge Askin involved in acquisition of data; and Tugba Kevser Uzuncakmak, Burhan Engin, and Zekayi Kutlubay involved in analysis and/or interpretation of data.

ETHICS STATEMENT

The study was carried out in accordance with the World Medical Association Declaration of Helsinki and was approved by the local ethics committee.