Management of Vitiligo Amidst the COVID-19 Pandemic: A Survey and Resulting Consensus.

BACKGROUND: COVID-19 pandemic has changed the approach of dermatologists, with respect to management of numerous conditions, vitiligo being one of them. However, there is a lack of consensus on how to deal with patients of vitiligo, as we battle this pandemic. AIM: To conduct a questionnaire-based survey, amongst expert dermatologists; in order to understand the impact of COVID-19 on the management of vitiligo.
MATERIALS AND METHODS: An online semi-structured English questionnaire was prepared and the link was circulated among 50 pan-Indian expert dermatologists, through various platforms (snowball sampling). Confidentiality and anonymity were strictly maintained. Responses were analyzed at the end of the study and a consensus statement was generated.
RESULTS: 42.22% of the respondents believed that teleconsultation is adequate for the diagnosis and management of most cases of vitiligo. 64.44% were found to be comfortable in prescribing oral medications, even during the COVID-19 pandemic; of which 62% would prefer to prescribe systemic steroids; followed by 17%, 11%, 7%, and 3% who would prefer cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate, respectively. 64.44% respondents would recommend phototherapy in their office and 80% would prefer home-based phototherapy (PUVAsol or handheld NBUVB devices). 86.67% would prefer to stop the oral immunosuppressive drugs, till the COVID-19 RTPCR positive patients are tested negative. LIMITATIONS: The results are based on a survey of a small albeit selected group of dermatologists who decided on the currently available information on COVID-19. The same may change depending on the nature of further available information on the virus and its effect on how we manage the patients.
CONCLUSIONS: Cases for initial consultation may be seen physically, and those for follow-up may be scheduled for teleconsultation. Topical therapy may be used without any hesitation. Phototherapy may be best advised with either PUVAsol or home-based phototherapy units (handheld NBUVB devices). With regards to systemic immunosuppressives, oral minipulse therapy may be preferable in view of lesser requirement of monitoring. Surgery for vitiligo should be performed only if the psychological well-being is severely affected. Copyright:

Introduction

COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020.[1] In an attempt to control the spread of the disease, nationwide lockdown was announced by the Government of India, as also, several other countries. All the specialities of medicine, including and especially dermatology, have been affected, in terms of examination of patients, diagnosis, treatment, and follow-up visits.[2] Dermatologists are preferring teleconsultations over face-to-face consultation, in order to minimize the chances of exposure to the virus.[3] Since most of the dermatological conditions do not require emergency consultation, patients are not in dire need of urgent therapy.[45] However, the ongoing pandemic and the psychological component associated with the same is gradually having its effect on some of the chronic dermatoses like acne vulgaris, telogen effluvium and vitiligo, to name a few.

Vitiligo, being a chronic disease, requires a multitude of therapies, individualized for every patient. With this background, we intended to conduct a questionnaire-based survey, amongst expert dermatologists; in order to understand the impact of COVID-19 on the management of vitiligo.

Materials and Methods

An online semi-structured English questionnaire was prepared on the Google-forms platform and the link was circulated among 50 expert dermatologists across India, through WhatsApp messenger, Telegram, and other social media to the contacts of the investigators (snowball sampling). It commenced on July 15, 2020 at 1000 hrs and closed on 21st July 2020 at 1000 hrs. On receiving and clicking the link, the participants were auto-directed to the information about the study and informed consent. Following this, a set of questions appeared sequentially, which the experts were supposed to answer. The questionnaire was composed of 15 questions pertaining to diagnosis and treatment of vitiligo, with special reference to teleconsultation and comfort to prescribe oral immunosuppressive drugs as well as phototherapy and surgical therapy amidst the COVID-19 pandemic.

Results

The questionnaire was circulated to 50 experienced dermatologists of India, of which 45 responses were taken into consideration (5 were discarded due to incomplete responses). 19 (42.22%) believed that teleconsultation is adequate for the diagnosis and management of vitiligo in most of the cases, whereas 12 (26.67%) opined that teleconsultation is enough in few cases only [Figure 1]. 18 (40%) experts believe that dermoscopy should be performed, to rule out close differential diagnoses in some cases. However, 16 respondents (35.56%) feel that dermoscopy is not required. 17 (37.78%) respondents would not recommend Wood's lamp examination for diagnosing vitiligo, against 16 (35.56%) experts who felt hat Wood's lamp helps in ambiguous cases, needing a face-to-face consultation. Majority (43, 95.56%) do not recommend skin biopsy for diagnosing vitiligo. The respondents were asked several questions pertaining to management of vitiligo. 29 (64.44%) of the respondents were found to be comfortable in prescribing oral medications, even during the ongoing pandemic, of which 62% would prefer to prescribe systemic steroids, as against 17%, 11%, 7% and 3% in favor of cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate respectively [Figure 2]. 33 (73.33%) experts were comfortable in treating childhood vitiligo through teleconsultation, and 24 respondents (53.33%) responded in affirmative, when asked about their willingness to treat a pregnant lady with vitiligo, via teleconsultation. 29 (64.44%) and 36 (80%) respondents would recommend phototherapy in their office and home-based phototherapy (PUVAsol or handheld NBUVB device), respectively. When asked about follow-up visits during COVID-19 pandemic, 20 respondents (44.44%) would request their patients to come for follow-up after 4 weeks; as against 11 experts (24.44%) who recommend follow-up visits after 8 weeks [Figure 3]. Respondents were asked about their opinion regarding continuing oral immunosuppressives on follow-up patients who have been recently tested positive for COVID-19. 39 of them (86.67%) would prefer to stop the oral immunosuppressive drugs, till the patients are tested negative. 34 experts (75.56%) feel that counseling can be done adequately, through teleconsultation. Similarly, 34 (75.56%) respondents would be comfortable performing surgeries for vitiligo, if absolutely indicated. We received some interesting suggestions from the experts regarding the management of vitiligo, during the pandemic, like forwarding e-information brochures to patients along with prescription on tele-consultation. Many respondents are of the opinion that it is better to rely on topical drugs during this pandemic, and if there is poor response, systemic drugs may be initiated following thorough investigations. Moreover, it has been mentioned that there is no need to be aggressive in managing the condition at this time.

Figure 1

Pie chart showing the response regarding the adequateness of teledermatology for consultation of vitiligo

Figure 2

Pie chart showing the preference of oral immunosuppressives to treat vitiligo

Figure 3

Pie chart showing the preference of experts regarding the interval of follow-up visits

Discussion

The COVID-19 pandemic has changed the outlook towards healthcare delivery system globally.[6] Medical consultations for not so serious and emergency conditions are increasingly being done through teleconsultations.[7] Vitiligo is not a life-threatening condition and most of the cases can be managed, without direct contact with the patient and physical examination, especially those who are already on treatment and due for review. This is evident from our survey, wherein, 42% of the respondents believed that teledermatology is adequate for diagnosis and management of vitiligo. However, in case of a first consultation where doubt on the diagnosis or stability exists on a video consultation, a face-to-face consultation may be needed to resolve these issues. Also, with regard to choice of systemic agent, there can be situations where the patients might be suffering from comorbid conditions like hypertension, diabetes and other disorders, which may necessitate a face to face consultation and physical examination, to be sure of the appropriateness of prescription and in order to avoid medicolegal issues in future. Therefore, the appropriateness of teledermatology with respect to vitiligo, needs to be tailored to the situation.

Dermoscopy is one of the most fascinating tools in dermatology now.[8] 18% of the respondents are of the opinion that dermoscopy is required in the diagnosis of vitiligo. However, it is important to remember that dermoscopy can act as a possible source of nosocomial spread of infections and may also act as a potential source of SARS-CoV-2, as evident from published literature.[9] According to the recently published recommendations of SIG Dermoscopy (IADVL Academy), it is prudent to avoid or postpone dermoscopy on COVID-19 positive individuals; patients with clinical features suspicious of COVID-19; patients from containment zones; and those with family history/close contact history of COVID-19. It has also been recommended to avoid dermoscopy wherever clinical examination is sufficient to reach a diagnosis. Since vitiligo is diagnosed clinically in majority of the cases, we believe that the use of a dermoscope is not usually warranted. If dermoscopy is unavoidable, the dermoscope should be wiped with 70% isopropyl alcohol wipes for at least 1 min, the doctor should follow all universal precautions advised by WHO, wear gloves and mask, and patient should wear a facemask and both doctor and patient should practice handwashing or handsanitization prior to and after the procedure.[10]

Wood's lamp examination is often found to be helpful in the diagnosis of vitiligo. We believe that Wood's lamp examination is best avoided in this scenario, taking into consideration the increasing number of COVID-19 positive cases and disadvantage of the need to negate social distancing vis-à -vis the role of this instrument should be considered consciously.

Management of vitiligo revolves around administration of immunosuppressive medications, both topical and oral.[11] Amidst the ongoing pandemic, most of the physicians have been found to be wary and skeptical regarding prescription of oral immunosuppressives. In our survey, 29 out of 45 respondents were comfortable in prescribing oral immunosuppressives to patients of vitiligo. However, it is interesting to note that 26 out of those 29 patients were in favor of using systemic steroids only. There is no doubt that steroid-sparing immunosuppressive drugs like methotrexate, cyclosporine, azathioprine and mycophenolate mofetil give satisfactory results in the management of vitiligo. But, considering the situation of the pandemic, we believe that it is prudent to avoid prescribing these drugs through teleconsultation. We can prescribe these drugs after examining the patient physically (maintaining all the precautions) and considering the risk-benefit ratio, on an individual basis.[12] It is prudent to mention here that immunosuppression itself has not been shown to either increase propensity to acquiring or increased severity or herald poorer prognosis in COVID-19 infection[13] and the avoidance of immunosuppressives in a teleconsultation in this case is a matter of abundant caution. Moreover, vitiligo being a chronic dermatological condition, follow-up visits are mandatory to assess the response to treatment. Most of our respondents (44%) were comfortable in calling their patients for follow-up visits every 4 weeks. In this case, we suggest that follow-up in vitiligo is best managed on an online consultation rather than face-to-face, unless an unexpected change requires a face-to-face consultation.

64% of our respondents were found to be comfortable in advising office phototherapy. However, it must be noted that the decision to continue or resume phototherapy operations in the office (clinic) should be made on the basis of public health recommendations.[14] 80% of our respondents were comfortable in advising phototherapy at home. We strongly believe that office phototherapy (if at all required) should be performed under the blanket of strict precautionary measures (maintenance of social distancing, screening the patients for symptoms of COVID-19; restricting the entry of family members, friends and caregivers unless the patient is a minor; mandatory use of face masks and individual goggles; application of hand sanitizers before and after entering the phototherapy unit). It is important to mention that the staff of phototherapy unit and the clinic should consider maintaining adequate precautions (scheduling patient appointments at least 25-30 minutes apart, ensuring social distancing in the waiting area, giving instructions to patients using loudspeakers, remote controlling the phototherapy unit, disinfection of the changing area and the phototherapy unit after each patient).[14] In this context, it may be worthwhile to mention that patients may not be willing to receive phototherapy in the office (clinic) and home based phototherapy procedures (PUVAsol or handheld NBUVB devices) may be a more acceptable option, since sanitizing phototherapy equipment including tubes is a cumbersome process at best. In a recent study conducted in China, it was found that 75% of vitiligo patients did not come to receive the scheduled phototherapy, due to the fear of COVID-19 infection.[15] It is worthwhile to mention that handheld NBUVB devices are readily available in online portals (accessible to any patient), and some of the metro cities as well. Considering the pandemic situation, it is prudent to recommend home-based phototherapy procedures to the patients.

Amidst the pandemic, vitiligo surgeries may be postponed unless absolutely indicated in terms of a social engagement or severe patient concern. 75% of our respondents were found to be comfortable in performing surgeries, if required. It is to be remembered that COVID-19 testing prior to surgery is advisable, especially if it is envisaged to continue beyond 15 minutes. During surgery, only essential and minimal staff should be allowed to participate, all participating healthcare workers should use PPE and disposable instruments should be used as far as possible. Following the surgery, long-term post-operative medications may be advised to minimize follow-up visits and sutures best be absorbable if at all needed, also keeping avoidance of hospital/clinic visits as far as possible.[16]

We would also like to mention that the impact of vitiligo extends beyond the skin, and therefore, dermatologists should consider the role of adjuvant therapies to adequately address impairments in self-esteem, body image, and quality of life. Psychological management including cognitive behavioral therapy, antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), talk therapy, and support groups play a significant role in the psychological improvement in patients with vitiligo. An emphatic doctor–patient relationship is pivotal (apart from the standard care) for holistic management of vitiligo, especially in the background of the pandemic.[17]

Conclusion

It would be prudent for us to continue to treat vitiligo in the current COVID scenario. It is best that cases for initial consultation be seen physically with sparing use of tools such as dermoscopy whenever inescapable, and those for follow-up may be scheduled for teleconsultation or online consultation. Topical therapy may be used in an unrestricted manner but phototherapy be best advised with either PUVAsol or home-based phototherapy units if feasible, unless clinic/hospital phototherapy is possible to be handled as mentioned above. Systemic therapy if needed is best with agents requiring minimum follow-up monitoring in terms of laboratory investigations or clinical examinations. In this regard, agents such as oral minipulse therapy may be preferable in view of lesser requirement of rigorous monitoring.[18] It is worthwhile to note that pulse therapy with corticosteroids has been used in the management of COVID-19 itself.[19] Surgery for vitiligo should be only performed in case, in the opinion of the treating dermatologist, the same is unavoidable either due to an upcoming social engagement or the postponement of surgery would severely impact the patient's psychological or emotional well-being. In all other cases, a discussion with the patient on the prudence of postponing surgery till the current pandemic is over is warranted to allay anxiety and offer hope to the patient. This does not, however, preclude the performance of a short procedure (of less than 15 min OT time) in non-facial areas with suitable precautions as mentioned above, in the hands of a skilled dermatologic surgeon, if the same would significantly improve a suitable patient's quality of life in these generally depressing times.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.