Impact of the COVID-19 pandemic on dermatology practice in the Philippines: A cross-sectional study.

Dear Editors,

Since the first local case of COVID‐19 was reported in the Philippines in March 2020, varying degrees of community quarantine have been implemented by the national government. In the most restrictive enhanced community quarantine (ECQ), essential medical services were prioritised and only non‐aesthetic dermatology clinics were allowed. Aesthetic services were allowed after 5 months (August 2020) in areas under the less restrictive general community quarantine (GCQ) and modified GCQ (MGCQ). Safety guidelines in outpatient clinics were prescribed by local authorities and specialty societies. , , The impact of these changes on dermatology practice in the country has not been evaluated.

To assess the impact of the COVID‐19 pandemic on dermatology practice, we conducted an analytical cross‐sectional study using an online questionnaire among members of the Philippine Dermatological Society (PDS) from September 25 to December 31 2020. At this time, new cases ranged from 700 to 3500 per day and most areas were under GCQ or MGCQ. Results were analysed using Stata version 14. Comparative analyses were done using paired t‐test or Mann–Whitney U‐test for quantitative variables, and chi‐square test or Fisher exact test for qualitative variables. Normalcy of data was tested using Shapiro–Wilk test. Significance levels were set at P‐value < 0.05.

Of 1037 PDS members, 305 completed our questionnaire. Table 1 shows the demographic profile of the respondents. Table 2 shows the changes in consultation practices before and during the pandemic. During the pandemic, 15% saw patients purely via teledermatology (TD), 15% saw all their patients face‐to‐face (FTF) and 70% utilised both. Our respondents reported more than 50% decrease in clinic hours and number of patients seen during the pandemic. Those utilising TD increased 6‐fold. There were no changes in the three most seen pathologic and aesthetic concerns before and during the pandemic (Supplemental S1). Our results parallel the findings of previous studies documenting the impact of the pandemic on dermatology practice, including a decrease in clinic days, decrease in patients seen FTF and an increase in TD utilisation. , , , , The 6‐fold increase in TD utilisation in our study is notable, which may be due to the extended period of restrictions. Most physicians used Viber and Facebook messenger for TD consults, reflecting their primary considerations in choosing TD platforms. Similarly, other reports reflect the use of ‘informal’ TD platforms, such as WhatsApp, Zoom, Skype, Facetime, Facebook and Viber. ,

Table 1

Demographic profile of the respondents

	n (%) or mean (SD) n = 305
Age, in years	48.05 (±9.63)
30–39	74 (24%)
40–49	88 (29%)
50–59	106 (35%)
≥60	37 (12%)
Gender
Male	26 (8.52%)
Female	279 (91.48%)
Geographic location of practice
Luzon	260 (85.25%)
National Capital Region (NCR)	241 (79%)
Outside NCR	19 (6.23%)
Visayas	18 (5.90%)
Mindanao	27 (8.85%)
Clinic location*
Mall	108 (35.41%)
Government hospital	41 (13.44%)
Private hospital	170 (55.74%)
Stand‐alone clinic	132 (43.28%)
Multispecialty clinic	11 (3.61%)
Others	5 (1.64%)
Type of practice
Aesthetic	1 (0.33%)
Pathologic	37 (12.13%)
Aesthetic and pathologic	267 (87.54%)

Respondents were instructed to select all that apply.

Table 2

Consultation practices before and during the COVID‐19 pandemic

	Before COVID‐19 pandemic n = 260	During COVID‐19 pandemic n = 260	P‐value
Clinic hours per week [mean (SD)]	26.02 (±12.46)	12.23 (±8.47)	<0.0001
Patients seen per week [median (IQR)]	40 (IQR 25–60)	15 (IQR 8–25)	<0.0001
% of patients seen by appointment [mean (SD)]	34 (±30.80)	73 (±32.52)	<0.0001
Duration of patient consultation [n (%)]
Decreased		176 (68)
Increased		13 (5)
No change		71 (27)
Respondents who utilised teledermatology [n (%)]	(n = 305) 43 (14)	(n = 305) 260 (85)	<0.0001
		n (%) n = 260
Type of teledermatology
Hybrid		156 (60)
Real‐time interactive		67 (26)
Store‐and‐forward		37 (14)
Considerations in selecting teledermatology platform*
Ease of use for patients		209 (80)
Ease of use for dermatologist		181 (70)
Cost		161 (62)
Data privacy		83 (32)
Technical support		23 (9)
Other		4 (2)
Teledermatology platform**
Viber		161 (63)
Facebook messenger		149 (57)
Zoom		48 (18)
SeriousMD***		45 (17)
Medifi***		37 (14)
Google Meet		28 (11)
Doxy.me***		26 (10)
Hospital‐provided platform		9 (3)
Other		3 (1)
Factors considered to see patient face‐to‐face instead of teledermatology**		(n = 215)
Difficulty in online patient assessment		156 (73)
Patient’s request		134 (62)
Perform urgent procedure		115 (53)
Local government unit has allowed clinic operation		94 (44)
Rapidly progressing disease		85 (40)
Not responding to treatment		77 (36)
Perform aesthetic procedure		69 (32)
Patient does not have access to teledermatology		8 (4)
Other		6 (3)

IQR, interquartile range; SD, standard deviation.

Respondents were instructed to select up to 3 considerations.

Respondents were instructed to select all that apply.

SeriousMD is an electronic medical record and practice management software which has teleconsultation function. Medifi and Doxy.me are dedicated teleconsultation platforms.

Half of those who saw inpatients before ceased to do so during the pandemic which may be due to their fear of acquiring COVID‐19 in the hospital or due to fewer dermatology admissions as hospital beds were diverted to COVID‐19 patients. To augment the overwhelmed workforce, 8% went on duty in COVID‐19 facilities. Similarly, Conforti and colleagues reported that 11% of their respondents worked in COVID‐19 departments.

Table 3 shows the changes in procedural practices before and during the pandemic. During the pandemic, 95% and 90% of our respondents still performed non‐aesthetic and aesthetic procedures respectively. This may be due to the timing of our survey during which safety protocols for dermatology clinics were more established and quarantine protocols were less restrictive. However, most reported a decrease in procedures performed, with a median decrease of 75% (IQR 50%–90%) and 80% (IQR 50%–90%) in non‐aesthetic and aesthetic procedures respectively. This may be due to the decrease in their clinic hours and allotment of time in between procedures for air flow and disinfection, thus limiting the number of procedures per day.

Table 3

Procedural practices before and during the COVID‐19 pandemic

	Before COVID‐19 pandemic n (%) n = 260	During COVID‐19 pandemic n (%) n = 260	P‐value
Number of non‐aesthetic procedures
Decreased		235 (90)
Increased		10 (4)
No change		8 (3)
Performed non‐aesthetic procedures	260 (100)	248 (95)	<0.0001
Type of non‐aesthetic procedure	(n = 260)	(n = 248)
Electrodessication	251 (97)	140 (56)	<0.0001
Biopsy	229 (88)	138 (56)	<0.0001
Excision	153 (59)	82 (33)	<0.0001
Cryotherapy	70 (27)	37 (15)	<0.001
Mohs’ surgery	7 (3)	5 (3)	0.616
Other	36 (14)	7 (3)	<0.0001
Number of aesthetic procedures
Decreased		241 (93)
Increased		4 (2)
No change		4 (2)
Not applicable*		7 (3)
Performed aesthetic procedures	253 (97)	235 (90)	0.001
Type of aesthetic procedure	(n = 253)	(n = 235)
Acne surgery	244 (96)	124 (53)	<0.0001
Chemical peel	229 (90)	128 (54)	<0.0001
Laser/energy‐based device	186 (74)	112 (48)	<0.0001
Botulinum toxin injection	172 (68)	113 (48)	<0.0001
Microneedling	144 (57)	53 (23)	<0.0001
Sclerotherapy	88 (35)	27 (11)	<0.0001
Soft tissue augmentation	69 (27)	39 (17)	0.005
PRP injection	42 (17)	19 (8)	0.004
Scar revision	42 (17)	17 (7)	0.002
Other	11 (4)	6 (3)	0.028

PRP, platelet‐rich plasma.

Did not perform aesthetic procedures.

Respondents implemented various engineering and administrative control measures (Supplemental S2). Some of the personal protective equipment used significantly differed according to risk of exposure (Supplemental S3).

Ninety‐six per cent of the respondents reported a decrease in weekly income, with a median decrease of 60% (IQR 50%‐75). Twenty‐nine per cent ventured into alternate sources of income: e‐commerce and sales (69%), stocks and investments (24%), real estate (13%), practice of non‐dermatological profession (9%) and others (7%).

Limitations of our study include possible recall and non‐response biases due to the methodology. Another is that 79% practice in the National Capital Region, the region with the most cases. It is possible that respondents who were profoundly affected by the pandemic were more motivated to complete our survey.

Our study shows the profound impact of the COVID‐19 pandemic and the ensuing safety measures on dermatology practice in the Philippines, specifically in terms of consultation practices, hospital practices, procedural practices, infection control and income. In addition, it shows how TD can be utilised to complement FTF consults for dermatologists to continue to provide care to patients in this pandemic.

Ethics approval

This study was approved by the University of the East Ramon Magsaysay Memorial Medical Center Research Institute for Health Sciences Ethics Review Committee (ERC approval number: 0869/H/2020/097).

Table S1. Most common pathologic and aesthetic concerns seen before and during the COVID‐19 pandemic.

Table S2. Engineering and administrative control measures utilized during the COVID‐19 pandemic.

Table S3. Personal protective equipment used according to risk of exposure.

Click here for additional data file.