Dermatology plays a prominent role on the COVID-19 world stage

Speakers provide update on dermatology's role with COVID-19

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Skin, hair, and nail disorders continue to present as major manifestations of COVID-19. “About 10% of people with COVID-19 will have skin manifestations (accompanied by other symptoms) and about 20% will have only skin manifestations. We truly are on the front line,” said Esther Ellen Freeman, MD, PhD, FAAD, director of global health dermatology at Massachusetts General Hospital and principal investigator of the COVID-19 Dermatology Registry, who moderated Saturday’s S021 – COVID-19 Dermatology and Vaccines. The presentation featured a comprehensive overview of key dermatology-related conditions associated with COVID-19, anchored by fellow expert speakers from the AAD Ad Hoc Task Force on COVID-19.

COVID-19, psoriasis, and biologics

Are patients with psoriasis who are treated with tumor necrosis factor inhibitors (TNFi) or IL17 inhibitors at increased risk of adverse COVID-19-related outcomes? These patients do not have an increased rate of COVID-19 hospitalization or mortality, compared with patients who did not receive TNFi exposure, said April W. Armstrong, MD, MPH, FAAD, associate dean of research and professor of dermatology at the University of Southern California. Dr. Armstrong presented real-world data on COVID-19 infections and vaccine considerations.

What about COVID-19 vaccine recommendations for psoriasis patients? According to CDC guidelines, patients 12 and older who are severely immunocompromised should receive four doses of an mRNA vaccine and one booster dose five months after the primary series.

“Most psoriasis patients are not severely immunocompromised and aren’t required to have the third dose, but we do recommend a booster,” Dr. Armstrong said. If patients are scheduled to get the COVID-19 vaccine the same week as their biologic dose, consider delaying the biologic by a week. “My psoriasis patients have done well with that,” Dr. Armstrong said.

COVID toes and other COVID skin lesions

“Pernio-like/chilblains-like ‘COVID toes’ may be related to the COVID infection or not. Both can be true at the same time,” said Lindy Peta Fox, MD, FAAD, professor of clinical dermatology and director of the hospital consultation services at the University of California, San Francisco. Generally, though, skin lesions associated with COVID-19 are benign and self-limited.

Depending on the skin lesion, however, they can have prognostic significance. “In the inpatient setting, COVID-associated skin signs portend a worse prognosis and provide insight into the immune system’s response to SARS-CoV-2 infection,” Dr. Fox said.

Detecting rashes in skin of color

Cutaneous manifestations of COVID-19 are present in 0.2% to 20.5% of people with COVID, said Jenna Lester, MD, FAAD, director of Skin of Color Program at the USCF Department of Dermatology. “We saw the majority of these rashes occurring in light skin.” Because skin rashes could be the only sign of COVID, it’s important to recognize erythema in all skin tones. To identify erythema in skin of color, “look for dark brown and purple discoloration,” Dr. Lester said. “Training your eye to see that purpura brown color is important and looking at the edges of eruption to see if you can pick up on what would be a primary color can be helpful.”

COVID-19 and kids

As of early March 2022, there have been over 12 million cases of COVID in children. Although vaccines have been approved in children ages five and older, with a booster recommendation for children 12 and older, only 33% of 5-11 year-olds have received one dose, said Elena B. Hawryluk, MD, PhD, FAAD, faculty director of pediatric dermatology at the Harvard combined dermatology residency program. “One selling point for the vaccine is that multisystem inflammatory syndrome, a serious COVID complication, is more common in unvaccinated children,” Dr. Hawryluk said.

The digital divide

Pre-pandemic, only 14.1% of dermatologists used telemedicine. Since COVID, it’s up to 96.9%. Still, only 58% of dermatologists surveyed by the AAD said they intend to use teledermatology after COVID-19, said Jules Lipoff, MD, FAAD, assistant professor in the department of dermatology at the University of Pennsylvania. Common barriers to implementing telemedicine include technology/connectivity issues, low reimbursement, concerns regarding malpractice liability, and government regulations, Dr. Lipoff said.