Paucity of COVID-19 dermatology literature from low- and middle-income countries.

Dear Editor, Since emerging in December 2019, coronavirus disease 2019 (COVID‐19) has become a global pandemic with community transmission now reported in most World Health Organization regions. As the pandemic progresses, there have been a growing number of reports of cutaneous manifestations and discussions of how COVID‐19 has impacted clinical practice.– We hypothesized that many such dermatology publications may be authored from high‐income countries, raising questions about case representation and the generalizability and comprehensiveness of COVID‐19‐related insights, discourse and guidance in our field.

To address this question, we assessed authors’ countries of professional affiliation in the published COVID‐19 dermatology literature. We searched PubMed/MEDLINE from 1 November 2019 through 12 June 2020 and Embase from 1 January 2019 through 14 June 2020 using dermatological keywords and a modified search strategy based on the Medical Library Association Clinical Librarians Caucus’ COVID‐19 hedge (search terms available upon request), identifying 988 unique results. Two reviewers independently conducted title and abstract reviews to identify articles related to dermatology and COVID‐19. Categorization discrepancies were discussed to consensus. In total 553 articles met the inclusion criteria and were further classified by article theme and author country affiliation. Country affiliation categorization was based on the World Bank’s income classification scheme (HIC, UMIC, LMIC, LIC – respectively countries with high, upper middle, lower middle and low income), with an additional distinct category for China, which we suspected would be uniquely well represented in the literature. UMIC and LMIC were combined into middle‐income country (MIC) for clarity and pragmatism of analysis.

The most common article theme was cutaneous manifestations of COVID‐19 (190, 34·4%), followed by pandemic impacts on the field of dermatology (139, 25·1%), management of specific dermatological conditions during the pandemic (132, 23·9%), dermatological issues associated with personal protective equipment use and hygiene practices (65, 11·8%), cutaneous adverse effects of COVID‐19 drugs (16, 2·9%), and dermatological drugs and conditions modulating COVID‐19 disease severity (11, 2·0%). The majority of first authors were affiliated with HICs (419, 75·8%), followed by MICs (98, 17·7%), exclusive of China (36, 6·5%). When considering the country affiliation of all authors, 440 (79·6%) papers had an author from an HIC, 117 (21·2%) had an author from an MIC, and 43 (7·8%) had an author from China. Our analysis identified no COVID‐19 dermatology publications listing authors from LICs. A visualization of our results illustrates a lower density of articles describing COVID‐19 cutaneous manifestations originating from countries in Africa and Central and South America, compared with a higher density of articles from European countries and the USA (Figure 1).

Figure 1

Global heat map of published articles regarding cutaneous manifestations of COVID‐19 by the country income status of the first author. HIC, high‐income country; MIC, middle‐income country.

This paucity of published COVID‐19 dermatological articles from MICs and LICs is consistent with COVID‐19 publication trends generally, and likely reflects trends in academia outside of the current pandemic. Nonetheless, it has important implications for current clinical practice and pandemic control. Dermatological manifestations can be the presenting symptom of COVID‐19, and our ability to diagnose and treat these patients rapidly relies on identifying these symptoms, which may vary in presentation based on skin type and geographical region. Consistent with a recent study demonstrating a lack of representation of images of skin of colour in the COVID‐19 dermatological literature, the current paucity of MIC and LIC representation in the literature suggests our understanding of its cutaneous manifestations is incomplete.

Accordingly, dermatology journals must prioritize soliciting and publishing submissions from MICs and LICs on COVID‐19. Inclusion of more cases of COVID‐19 with cutaneous manifestations and discourse about clinical practice in dermatology during the pandemic from more regions of the world and in differently resourced practice settings is integral to the improved management of COVID‐19 and other dermatological conditions. This is true not only in MICs and LICs, but also in all countries and contexts with diverse patient populations and resource settings. Our findings may also reflect a need for the field to invest in promoting dermatology research training and opportunities globally.

Limitations of this study include the use of author country affiliation as a proxy for case country location, which may miss publications based on data registries that include cases from LICs, but are published with only HIC authors, like the recent study published by Freeman et al. We also did not account for differing COVID‐19 caseload or testing capacity by country. However, country caseload and capacity do not change the implications of the paucity of MIC and LIC publications we discussed above.

Despite limitations in our analysis, we believe our findings decisively call for the prioritization of inclusion of COVID‐19 dermatological literature from MICs and LICs to improve our clinical understanding of COVID‐19 and to better inform discussions within our field during this pandemic, which has presented unprecedented challenges to the clinical practice of dermatology.

Acknowledgments

we would like to thank Connie Wong MLIS, MPVM, DVM for her guidance in building the search strategies used to identify relevant articles in PubMed/MEDLINE and Embase. We would also like to thank Vandita Pendse for her support with data visualization.

Author Contribution

Ruchita S. Pendse: Conceptualization (equal); Data curation (supporting); Formal analysis (lead); Investigation (equal); Methodology (equal); Project administration (lead); Resources (equal); Software (equal); Validation (equal); Visualization (equal); Writing‐original draft (lead); Writing‐review & editing (lead). Ben Liad Schwartz: Conceptualization (supporting); Data curation (lead); Formal analysis (supporting); Investigation (lead); Methodology (equal); Project administration (supporting); Resources (equal); Validation (lead); Visualization (supporting); Writing‐original draft (supporting); Writing‐review & editing (supporting). Justin Lee Jia: Conceptualization (equal); Data curation (supporting); Formal analysis (supporting); Investigation (supporting); Methodology (equal); Project administration (supporting); Resources (supporting); Validation (equal); Visualization (lead); Writing‐original draft (supporting); Writing‐review & editing (supporting). Elizabeth Bailey: Conceptualization (equal); Data curation (supporting); Formal analysis (supporting); Investigation (supporting); Methodology (equal); Project administration (supporting); Supervision (lead); Validation (supporting); Visualization (supporting); Writing‐original draft (supporting); Writing‐review & editing (lead).