Recommendations for phototherapy during the COVID-19 pandemic

Coronavirus Disease 2019 and Dermatology Practice Changes

The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the "new normal" in various domains of dermatology practice, namely, dermatology consultation, procedural dermatology, and phototherapy, is also provided.

Ultraviolet diagnostic and treatment modalities in the coronavirus disease 2019 pandemic

Ultraviolet (UV) therapy is an effective and well-tolerated therapeutic method for various dermatologic conditions due to its antiproliferative and immunosuppressive effects. Contemporary phototherapy includes broadband UVB, narrowband UVB, UVA1, PUVA, and excimer laser therapy. The coronavirus disease 2019 pandemic has resulted in the closure of many patient care facilities, including phototherapy units worldwide. Home phototherapy, thalassotherapy, and other UV therapy modalities are an alternative for many patients with chronic dermatoses.

We highlighted possible interactions of UV therapy effects and the coronavirus disease 2019 pandemic, and focused on organization and measures against transmission of infections in phototherapy units. Dermatology departments have reopened their units, assessing the risks and benefits for patients, optimizing safety regulations, and adhering to the rules for disinfection.

A cross-sectional questionnaire study in a phototherapy unit during COVID-19

Background

In March 2020, social isolation measures were imposed in Brazil to contain the spread of the novel coronavirus (SARS-CoV-2), requiring health services to implement contingency plans. The main objective of the study was to verify the status of the disease, self-reported by patients who discontinued phototherapy, during a period of social isolation.

Methods

All patients receiving phototherapy at the Santa Casa de Porto Alegre, Brazil, prior to the implementation of social distancing measures were eligible for inclusion in the study. 86 patients answered a questionnaire during a medical evaluation.

Results

95% of patients who stopped phototherapy reported a worsening of disease status. Only 19% of patients continued to attend phototherapy sessions during the social isolation period.

Conclusion

The COVID-19 pandemic led most patients to stop phototherapy, resulting in the perception of increased disease severity in an outpatient sample in southern Brazil.

Impact of treatment delays on vitiligo during the COVID-19 pandemic: A retrospective study

Due to the COVID-19 pandemic, routine treatments are delayed to some extent and their negative impacts have been widely reported. However, virtually nothing is known about vitiligo in the context of COVID-19. Therefore, we analyzed treatment delays and its impact on vitiligo, aiming to provide suggestions on vitiligo management within this special period. We performed a retrospective cohort study on 322 patients who visited our clinics at least 2 times from January to December 2020, and their medical records and photographs were reviewed. Patients were divided into normal (n = 155) and late group (n = 167) based on whether experienced treatment delays. As for the active cases, the late group showed higher progression rate than normal group (35 of 86 [40.7%] vs. 10 of 81 [12.3%]; p = 0.002). Moreover, we observed higher recurrence rate in delay group than those of normal group (26 of 81[32.1%] vs. 9 of 74 [12.2%]; p = 0.018) among stable cases. Further univariate and multivariate analysis determined treatment delays as the most important independent risk factor for disease progression and recurrence, and maintenance therapy (>2 years) as a protective factor against recurrence. This study, for the first time, revealed the independent adverse impact of treatment delays on the progression and recurrence of vitiligo and indicated the significance of continuous treatment for halting progression and long-term maintenance therapy for preventing recurrence for vitiligo, which should be highly valued in the management of vitiligo during the COVID-19 pandemic.

National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: Version 2-Advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments

OBJECTIVE

To update guidance regarding the management of psoriatic disease during the COVID-19 pandemic.

STUDY DESIGN

The task force (TF) includes 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation staff. Clinical questions relevant to the psoriatic disease community were informed by inquiries received by the National Psoriasis Foundation. A Delphi process was conducted.

RESULTS

The TF updated evidence for the original 22 statements and added 5 new recommendations. The average of the votes was within the category of agreement for all statements, 13 with high consensus and 14 with moderate consensus.

LIMITATIONS

The evidence behind many guidance statements is variable in quality and/or quantity.

CONCLUSIONS

These statements provide guidance for the treatment of patients with psoriatic disease on topics including how the disease and its treatments affect COVID-19 risk, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 (including novel vaccination), and what they should do if they develop COVID-19. The guidance is a living document that is continuously updated by the TF as data emerge.

Ultraviolet radiation, vitamin D, and COVID-19

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has become pandemic on March 11^th, 2020. COVID-19 has a range of symptoms that includes fever, fatigue, dry cough, aches, and labored breathing to acute respiratory distress and possibly death. Health systems and hospitals have been completely rearranged since March 2020 in order to limit the high rate of virus spreading. Hence, a great debate on deferrable visits and treatments including phototherapy for skin diseases is developing. In particular, as regards phototherapy very few data are currently available regarding the chance to continue it, even if it may be a useful resource for treating numerous dermatological patients. However, phototherapy has an immunosuppressive action possibly facilitating virus infection. In the context of COVID-19 infection risk it is important to pointed out whether sunlight, phototherapy and in particular ultraviolet radiation (UV-R) constitute or not a risk for patients. In this review we aimed to focus on the relationship between UV-R, sunlight, phototherapy, and viral infections particularly focusing on COVID-19.

Dermatology practice in the times of the COVID-19 pandemic

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is implicated in the ongoing pandemic across the globe since December 2019. It was first notified by China from Wuhan on 31 December 2020 and transmission to healthcare workers was first reported on 20 January 2020. Human-to-human transmission is mainly by droplet infection. At present no effective vaccine is available. Our speciality needs to collectively address the urgent issue of risk of transmission in dermatology practice. A case series of Coronavirus Disease 2019 (COVID-19) from Wuhan described that 41.3% of their patients may have acquired the infection from the hospital. Of all the infected health care workers, 77.5% worked in general wards and departments. These data highlight the significant risk of nosocomial transmission of COVID-19 and also the higher risk in general wards and departments compared to the emergency room or intensive care unit. Dermatology patients are generally seen in clinics and in outpatient departments in hospitals. Patients wait together in the waiting area, intermingle and then are seen by the physician in their chamber. This can cause transmission of the pathogen among patients and from patient to physician. Social distancing, hand hygiene and the use of personal protective equipment are important for preventing the spread of infection and dermatology practices also have to incorporate these aspects. Telemedicine is becoming an important tool for the management of dermatology patients in these times. At-risk patients in dermatology also need to be given priority care. Protocols for the use of immunosuppressants and biologics in dermatology during the pandemic are being developed.

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.

COVID-19: The experience from Iran

The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology.

Investigating the Potential for Ultraviolet Light to Modulate Morbidity and Mortality From COVID-19: A Narrative Review and Update

During the COVID-19 (coronavirus disease of 2019) pandemic, researchers have been seeking low-cost and accessible means of providing protection from its harms, particularly for at-risk individuals such as those with cardiovascular disease, diabetes and obesity. One possible way is via safe sun exposure, and/or dietary supplementation with induced beneficial mediators (e.g., vitamin D). In this narrative review, we provide rationale and updated evidence on the potential benefits and harms of sun exposure and ultraviolet (UV) light that may impact COVID-19. We review recent studies that provide new evidence for any benefits (or otherwise) of UV light, sun exposure, and the induced mediators, vitamin D and nitric oxide, and their potential to modulate morbidity and mortality induced by infection with SARS-CoV-2 (severe acute respiratory disease coronavirus-2). We identified substantial interest in this research area, with many commentaries and reviews already published; however, most of these have focused on vitamin D, with less consideration of UV light (or sun exposure) or other mediators such as nitric oxide. Data collected to-date suggest that ambient levels of both UVA and UVB may be beneficial for reducing severity or mortality due to COVID-19, with some inconsistent findings. Currently unresolved are the nature of the associations between blood 25-hydroxyvitamin D and COVID-19 measures, with more prospective data needed that better consider lifestyle factors, such as physical activity and personal sun exposure levels. Another short-coming has been a lack of measurement of sun exposure, and its potential to influence COVID-19 outcomes. We also discuss possible mechanisms by which sun exposure, UV light and induced mediators could affect COVID-19 morbidity and mortality, by focusing on likely effects on viral pathogenesis, immunity and inflammation, and potential cardiometabolic protective mechanisms. Finally, we explore potential issues including the impacts of exposure to high dose UV radiation on COVID-19 and vaccination, and effective and safe doses for vitamin D supplementation.

Cutaneous lymphomas and COVID-19: What is known so far?

The Coronavirus disease 2019 (COVID-19) pandemic spreads quickly all over the world. There are no sufficient data in the literature about COVID-19 infection and cutaneous lymphomas. This review sheds the light on what is known so far about COVID-19 with a cutaneous lymphoma perspective. Cutaneous T-cell lymphoma (CTCL) diagnosis does not represent a predisposing factor to viral infections and most of CTCL patients have indolent disease. However, physicians should be cautious with patients with aggressive primary cutaneous lymphomas and advanced CTCL. Different treatment strategies for cutaneous lymphomas should be taken into consideration during the COVID-19 pandemic. Thus, it is highly needed to estimate the benefit-to-risk ratio on a case-by-case basis.

Covid-19 pandemic and the skin

In the beginning of the COVID-19 outbreak, skin manifestations, if present, were not paid enough attention. Then, the focus moved toward the impact of the prolonged use of personal protective measures in both healthcare workers and patients. In the meantime, attention is increasingly paid to dermatology as a result of the concern for certain groups of dermatologic patients, including those whose condition may worsen by the thorough disinfection measures and those treated with immunosuppressants or immunomodulators. Following patients with psoriasis on biological therapy, as well as other inflammatory and autoimmune cutaneous disorders such as atopic dermatitis, pemphigus, pemphigoid diseases, and skin cancer provoked the interest of dermatologists. Finally, an intriguing question to the dermatologic society was whether skin changes during COVID-19 infection exist and what could be their diagnostic or prognostic value. Here, we summarize skin conditions during the COVID-19 pandemic, patient information, and expert recommendations and give an overview about the registries launched to document skin changes during COVID-19, as well as details about certain patient groups infected with SARS-CoV-2, for example, psoriasis, atopic dermatitis, and autoimmune bullous diseases.

Dermatological Manifestations of COVID-19: A Brief Review

The emphasis so far during the COVID-19 pandemic has been on the respiratory manifestations with little attention being paid to cutaneous manifestations. The novel coronavirus has a wide spectrum of cutaneous manifestations which are broadly divided into exanthematous and vasculopathic type of lesions. The effects of this novel virus on the integumentary system cannot be underestimated as it can mimic various types of viral skin lesions. Thus, dermatologists should have knowledge about COVID-19 disease presentations and which differential diagnosis to consider if they encounter skin lesions in a patient who is known or suspected to have COVID-19. Patient evaluation and workup also needs to be modified during the time of this pandemic. Immunosuppressive/immunomodulatory drugs which are rampantly used in dermatological practice, must be used only after weighing their risks and benefits during the COVID-19 era. Personal Protective Equipment has to be worn when coming in contact with a suspected or a proven case of COVID-19. However, its use itself is associated with dermatological side effects which should be known to dermatologist practising during the COVID-19 era. Teledermatology can go a long way in circumventing these issues and it should be made more accessible, especially in remote areas. Another future recommendation could be setting up of a national level organization or group for recording dermatological data related to COVID-19.

Changing trends in dermatology practice during COVID-19 pandemic: A single tertiary center experience

The aim of this study was to evaluate the changing trends in dermatology clinical practice at a tertiary center during the coronavirus disease 2019 (COVID‐19) pandemic. This retrospective cohort study was conducted on patients who were admitted to Ufuk University Hospital with dermatologic complaints/diseases before and during the pandemic. The patients were divided into two groups: (a) the pre‐pandemic period (March‐May 2019) and (b) the Pandemic period (March‐May 2020). Demographic features, clinical characteristics, dermatologic diseases/complaints, dermatologic procedures/interventions, hospitalization rate, and use of biologic agents were compared between the two groups. Total number of hospital admissions have decreased from 1165 to 717. Admission rates for acne, dermatophytosis, and benign neoplasm of the skin significantly lower during the pandemic period (P values were .02, .04, and .006, respectively). Contact dermatitis, acne accompanying dermatitis, cicatricial hair loss, lichen planus, and zona zoster infection rates were significantly higher (P values were .007, <.001, .009, .04, and .03, respectively). Rates of biopsy and electrocautery procedures were decreased significantly (P values were <.001 and .002, respectively). The hospitalization rate was similar between the groups (P = .51). However, the use of biologic agents significantly decreased during the pandemic period (P = .01). Updated clinical protocols should be established for the new normal period in accordance with these findings.

National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1. J Am Acad Dermatol. 2020;83:1704-1716. [PMID: 32891785 PMCID: PMC7471802 DOI: 10.1016/j.jaad.2020.09.001]

Objective

To provide guidance about management of psoriatic disease during the coronavirus disease 2019 (COVID-19) pandemic.

Study design

A task force (TF) of 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care was convened. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation (NPF) staff. Clinical questions relevant to the psoriatic disease community were informed by questions received by the NPF. A Delphi process was conducted.

Results

The TF approved 22 guidance statements. The average of the votes was within the category of agreement for all statements. All guidance statements proposed were recommended, 9 with high consensus and 13 with moderate consensus.

Limitations

The evidence behind many guidance statements is limited in quality.

Conclusion

These statements provide guidance for the management of patients with psoriatic disease on topics ranging from how the disease and its treatments impact COVID-19 risk and outcome, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 and what they should do if they develop COVID-19. The guidance is intended to be a living document that will be updated by the TF as data emerge.

COVID-19 infection alters kynurenine and fatty acid metabolism, correlating with IL-6 levels and renal status

BACKGROUNDReprogramming of host metabolism supports viral pathogenesis by fueling viral proliferation, by providing, for example, free amino acids and fatty acids as building blocks.METHODSTo investigate metabolic effects of SARS-CoV-2 infection, we evaluated serum metabolites of patients with COVID-19 (n = 33; diagnosed by nucleic acid testing), as compared with COVID-19-negative controls (n = 16).RESULTSTargeted and untargeted metabolomics analyses identified altered tryptophan metabolism into the kynurenine pathway, which regulates inflammation and immunity. Indeed, these changes in tryptophan metabolism correlated with interleukin-6 (IL-6) levels. Widespread dysregulation of nitrogen metabolism was also seen in infected patients, with altered levels of most amino acids, along with increased markers of oxidant stress (e.g., methionine sulfoxide, cystine), proteolysis, and renal dysfunction (e.g., creatine, creatinine, polyamines). Increased circulating levels of glucose and free fatty acids were also observed, consistent with altered carbon homeostasis. Interestingly, metabolite levels in these pathways correlated with clinical laboratory markers of inflammation (i.e., IL-6 and C-reactive protein) and renal function (i.e., blood urea nitrogen).CONCLUSIONIn conclusion, this initial observational study identified amino acid and fatty acid metabolism as correlates of COVID-19, providing mechanistic insights, potential markers of clinical severity, and potential therapeutic targets.FUNDINGBoettcher Foundation Webb-Waring Biomedical Research Award; National Institute of General and Medical Sciences, NIH; and National Heart, Lung, and Blood Institute, NIH.

Spectrum of virucidal activity from ultraviolet to infrared radiation

The COVID-19 pandemic has sparked a demand for safe and highly effective decontamination techniques for both personal protective equipment (PPE) and hospital and operating rooms. The gradual lifting of lockdown restrictions warrants the expansion of these measures into the outpatient arena. Ultraviolet C (UVC) radiation has well-known germicidal properties and is among the most frequently reported decontamination techniques used today. However, there is evidence that wavelengths beyond the traditional 254 nm UVC - namely far UVC (222 nm), ultraviolet B, ultraviolet A, visible light, and infrared radiation - have germicidal properties as well. This review will cover current literature regarding the germicidal effects of wavelengths ranging from UVC through the infrared waveband with an emphasis on their activity against viruses, and their potential applicability in the healthcare setting for general decontamination during an infectious outbreak.