1. How Should I Protect Myself?

To minimize the risk of transmission of infection to healthcare workers (HCW), the following precautions are recommended to be taken:

Self-Protection:
It should be the practitioners’ top priority during their practice nowadays as increased rate of HCW infections will yield more burden on the health care system and services providers in these hard times, in addition to the importance of their own safety

• Practitioners who fit high risk criteria of being age 60 or older, immunocompromised, or pregnant should be prohibited from evaluating patients.
• Trainee exposure (residents/fellows) should be minimized and staggered to protect the health care workforce.
• Women who are less than 28 weeks pregnant should practice social distancing but can continue working in a patient-facing role, provided the necessary precautions are taken.
• Women who are more than 28 weeks pregnant, or have underlying health conditions, should avoid direct patient contact.

The WHO also paid great attention for health workers with high and low risk of infection and here are some of its recommendations.

Recommendations for health workers with high risk for infection:

• Stop all health care interaction with patients for a period of 14 days after the last day of exposure to a confirmed Covid-19 patient.
• Be tested for Covid-19 virus infection.
• Quarantine for 14 days in a designated setting.

Recommendations for health workers with low risk for infection:

• Self-monitor temperature and respiratory symptoms daily for 14 days after the last day of exposure to a Covid-19 patient.
• Health workers should be advised to call health care facility if he/she develop any symptoms suggestive of Covid-19.

Self-Protection for dermatologists who are getting redeployed:
The American Academy of Dermatology (AAD) agrees with the American Medical Association and the Joint Commission that physicians should be allowed to use Personal Protective Equipment (PPE) from their office or home, if PPE is not being routinely supplied by the hospital or care facility.

2. How Can I Educate My Patients?

Patient education comes in second place and is very important to minimize spread of infection in the form of continuous and repeated education of the patients regarding the following issues:

• Avoid touching of face, eyes or mouth with unwashed hands
• Covering mouth and nose whilst coughing or sneezing
• Avoiding overseas or interstate travel
• Staying at home unless for medical care or necessary work
• Avoid sharing of household items such as cutlery and towels
• Regular cleaning of high-touch everyday objects
• Wearing a face mask is not necessary if you are well
• Practice good social-distancing techniques
• Stop shaking hands, hongi, kissing, or hugging as a greeting
• Avoiding large gatherings, crowded or enclosed places (e.g. lifts)
• For cleaning around the house, any usual household detergent should be effective

The National Health Service of the United Kingdom (NHS) has categorized patients taking immunosuppressants according to risk profile of Covid-19, taking into account their effect on body immunity into high and moderate risk groups and high-risk groups receiving immunosuppressive therapy for any medical condition should follow strict measures in order to decrease risk of infection in the form of the following:

1. Shielding, not leaving home for 12 weeks
This shall be practiced by extremely vulnerable people (high risk) who are taking:

• Two or more immunosuppressive or biologic medicines (except the combination of a biologic with methotrexate, hydroxychloroquine or sulphasalazine).
• Systemic prednisolone orally 20 mgs or more each day for > 4 weeks.
• Corticosteroid > 5mg each day for > 4 weeks plus at least one other immunosuppressive or biologic medication.
• Cyclophosphamide, rituximab or infliximab.

2. Very Careful Social Distancing:
This shall be practiced by vulnerable people (moderate risk) who are taking only one immunosuppressive or biologic medicine or a biologic combined with methotrexate, hydroxychloroquine or sulphasalazine, except for those who are over the age of 70, pregnant or have another medical problem who should practice Shielding.

3. Patients shall also be educated on Dry Skin & Frequent Handwashing to Reduce Covid-19 Risk by stressing on the following hygienic points as recommended by the British Association of Dermatologists (BAD):

• Wash hands using soap and water! During handwashing, overly hot water can lead to contact dermatitis and should be avoided.
• Dry your hands fully after washing by patting them dry, not rubbing.
• Moisturizers are an essential part of treating hand dermatitis. They should be applied generously after handwashing, repeatedly throughout the day and whenever the skin feels dry. Hypoallergenic moisturizers, gloves, and alcoholic hand sanitizers are vital to prevent hand eczema. Some people find overnight moisturizing treatments beneficial.
• When hands are going to come into contact with water or detergents but not specifically for handwashing (i.e. washing up, shampooing a child's hair, or using cleaning products), wearing gloves that provide a barrier (such as nitrile gloves) will help to keep the skin's barrier intact.
• Frequent hand hygiene was associated with a higher incidence of hand dermatitis.

4. Some of our patients are our colleagues working at the front lines of combating this virus. Here is some of the advice that is geared towards their practice:

• Cutaneous lesions mostly affect the nasal bridge, hands, cheek & forehead.
• Length of time wearing the face shield is not significantly associated with the risk of facial lesions.
• Goggles are implicated more than N95 masks in most injuries.
• Simple interventions, including frequent rotations and the use of adhesive barrier films prior to donning protective gear.
• It may be difficult to continue wearing protective gear in the face of cutaneous ulceration and attempts to shift points of pressure and abrasion may reduce the effectiveness of the protective mask.

There has been also a Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against Covid-19 which stated certain measures for protection of hands, face, eyes, nasal and oral mucosa, external ear and hair, and also against UV related & hidrosis related skin conditions.

3. What Should I Do to Keep My Patients Safe?

The International League of Dermatological Societies (ILDS) raised early Covid-19 pandemic alerts that stated that:

• Elective and cosmetic procedures such as laser hair removal, soft tissue augmentation with injectables, chemical peels, etc. performed in health facilities shall be postponed for a later date to prevent transmission.
• Elective dermatosurgery procedures (defined as skin lesions which will not be of imminent danger to the patient if not surgically treated within 3-months) shall be postponed to a later date based on regular clinical evaluation and those that can not be postponed (e.g. melanoma) should be evaluated case by case and treated promptly.
• Optimal safety protocols should be implemented in the medical facility to prevent the risk of transmission of the SARS-CoV-2 virus.
• The use of patient questionnaires for patient-triage (ideally by phone for private practices, onsite for hospitals) and/or telemedicine is recommended in order to reduce exposure of patients and employees to patients who may potentially be contagious.

But in spite of that, there were other contradictory reports released from China as the following two:

1. First report was from the Department of Dermatology, West China Hospital of Sichuan University who reported running the dermatology clinic full capacity by the following means:

• They performed a triage: Feverish persons referred to Fever Clinic.
• Increased Tele and telephone consultations.
• During the skin clinic: Patients are not allowed to take off their masks except on indications of facial lesions.
• Doctors must wear masks, surgical caps, protective suits, gloves, and goggles at work; they take off their PPE only after their work in a designated disposable area.
• Educational programs and activities of West China Hospital have come to a halt; graduate students and interns are prohibited from returning to school and work. Also, West China Hospital established special psychologic intervention counseling via a telephone and network platform to help those in need and published a psychologic protection handbook for free download.

Second report was from the Third Affiliated Hospital of Sun-Yat sen University, Guangzhou, China, a national designated hospital for diagnosing, receiving and treating Covid-19 patients, who did the same by the following means:

• The dermatology staff never stop to help the patients during the period of Covid-19.
• They established a set of procedures which included subarea administration, cautionary symbol and periodic disinfection in clinic working area, dermatology staff’s training and protection, patient reception procedures, skin surgery and skin laser treatment process and equipment disinfection.
• From February 3 to February 18, 1756 patients were received in our dermatology out-patient department. 44 dermatology staff participate in the clinical work. The Covid-19 infection rate of 0% was achieved until today in our department.

4. What’s the Current Role of Tele-Dermatology?

Telehealth or using technology for a remote medical encounter has become an efficient solution for safe patient care during the Covid-19 pandemic. This medium allows patient immediate healthcare access without the need for an in-person visit

The BAD published Clinical Guidelines for The Management of Dermatology Patients Remotely:

• Streamline skin cancer patients on 2WW pathways, using tele dermatology to triage referrals and book patients directly to surgery where possible.
• Manage urgent / on-call patients and in-patient referrals using secure nhs.net email or mobile messaging apps where possible.
• Redirect new patients through Advice and Guidance services where possible rather than referral.

There have been also recommendations for colleagues who shall use tele dermatology but not in a so official form:

• Allow time to work out technical kinks. Once you start using telemedicine, you will quickly figure out the pitfalls of your own system and your patient population (poor at-home video technology, poor lighting, etc.).
• Allow extra time to do a proper consult.
• The camera on the back of the phone is usually the best.
• The patient may have to hold the camera up in order to allow the lightest to fall on the lesion.

5. Patients’ Psychological Aspects Considerations.

During such times of anxiety, special consideration shall be made to our patients needs and requests, we have to understand that and show them more compassion to their concerns and grant them more time to understand their complaints and discuss the treatment plans.

6. Which Cutaneous Manifestations of Covid-19 I Should Be Aware of?

Skin manifestations may accompany Covid-19 and may be used as a prognostic sign of the disease. The first report published on this issue was from Italy and mentioned that of the 88 Covid-19 patients, 20.5% developed skin manifestations. Eight of the 18 (44%) had skin eruptions at symptom onset, and the rest after hospitalization. Fourteen (78%) had red rashes, three had widespread urticaria, and one had chickenpox-like vesicles. The most commonly affected area was the trunk. Itching was mild or absent & lesions usually healed up in a few days. Skin manifestations did not correlate with disease severity.

The second report was from China which described 7 critical Covid-19 patients with acro-ischemia in a single center in Wuhan, 4 of them were men & 3 of them with underlying comorbidities. All patients had acro-ischemia presentations including finger/toe cyanosis, skin bulla and dry gangrene. D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients. Prothrombin time were prolonged in 4 patients. D-dimer and FDP levels increased progressively when Covid-19 exacerbated, and 4 patients were diagnosed with definite DIC. 6 patients received low molecular weight heparin treatment, after which their D-dimer and FDP decreased, but there was no significant improvement in clinical symptoms. 5 patients died finally and the median time from acro-ischemia to death was 12 days and they recommended that the existence of hypercoagulation status in critical Covid-19 patients should be monitored closely, and anticoagulation therapy can be considered in selected patients.

Skin manifestations of Covid-19 positive patients can be classified into:

• Dengue like rash
• Erythematous rash, urticaria and vesicles
• Dusky acrocyanosis and dry gangrene
• Transient livedo reticularis-like exanthem

  In addition to that, one of the authors has reported on warts eruption in an Egyptian patient.

  
  

  7. How Far Should I Reconsider Therapeutic Agents?

  Dermatologists should Re-Consider Therapeutics that may impair immunity.

  The European Academy of Dermatology & Venereology Atopic Dermatitis Task Force was the first to issue a statement on this which recommended the following:
  

  • Continue all immune-modulating treatments, including immuno-suppressive therapy, since exacerbations of underlying diseases can have a large negative impact on patients’ immunity.
  • Strictly follow the recommendations for patients at risk issued by the local health authorities in each European country.
  • Carefully observe hygienic procedures using hand wash and disinfectants. Moisturizers should be applied afterwards.
  • Patients diagnosed with Covid-19 should undergo interdisciplinary risk assessment first. Immune-modulating therapy may or may not be paused afterwards, in accordance with current guidelines on active infections and systemic therapy.

  The AAD has also published its guidance for the use of immunosuppressives during the Covid-19 era, which stated the following:
  

  • Patients on systemic immunosuppressive agents who have not tested positive or exhibited signs/symptoms of Covid-19: There is insufficient evidence to recommend discontinuation of systemic immunosuppressive agents at this time. Physicians should use their clinical judgments to stop or continue the patients on these drugs.
  • Patients on systemic immunosuppressive agents who have tested positive for Covid-19 or exhibit signs/symptoms of Covid-19: We recommend physicians discontinue or postpone the systemic immunosuppressive agents until the patient recovers from Covid-19, consistent with guidelines on the management of patients with active infections on systemic non-biologic and biologics therapy.
  • Patients who have halted systemic immunosuppressive therapy after testing positive for Covid-19: We recommend physicians can re-initiate the systemic immunosuppressive therapy after ensuring the patients have completely recovered from Covid-19.
  • Patients being considered for systemic immunosuppressive agents: We recommend physicians assess the risk vs. benefits in lower-risk patients before initiating immunosuppressive agents on a case-by-case basis, recognizing that anyone may develop serious complications from Covid-19 infection.
  
  

  8. How Should I Run My Business?

  Based on the AAD Recommendations, the following steps shall be followed to run one’s practice:
  

  • Understand your community's Covid-19 prevalence.
    
  • Prepare your practice
    
  • Set your patient schedule including telemedicine visits
    
  • Organize your staff
    
  • Determine your pre-visit workflow along with Covid-19 screening questionnaire and steps to minimize patient contact
    
  • Communicate to patients when you are reopening and your schedule
    
  • In addition to taking care of the following: Preserving & Donating PPE, Employee & Family Sick Leave Requirements and Local Regulatory Considerations.