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Dermatology and COVID-19 VIEWPOINT Opinion Dermatology and COVID-19 VIEWPOINT Kanade Shinkai, MD, Even early in the coronavirus disease 2019 (COVID-19) multisystemsyndrometemporallyassociatedwithSARS- PhD pandemic, it was clear that dermatologists had an im- CoV-2 infection (also known as multisystem inflamma- Department of portant role in the management of patients. Although tory syndrome in children) because half the children af- Dermatology, initial case series rarely documented skin changes, pos- fected with this syndrome present with characteristic University of California, San Francisco; and sibly due to the inability to perform a complete skin ex- mucocutaneous findings, and to clarify its cutaneous dis- Editor, JAMA amination, subsequent research has suggested signifi- tinctions from Kawasaki disease.5 Dermatology. cantly higher rates of skin involvement.1 The true In addition, the worldwide recognition of acral chil- prevalence of skin findings, the uncertainty of whether blainslike lesions (also known as COVID-19 toes) has gen- Anna L. Bruckner, MD, these represented direct infection or were associated erated both confusion and controversy among MSCS 6 University of Colorado with systemic illness (eg, reactive or due to medica- dermatologists. The finding of chilblainslike lesions in School of Medicine, tions), and how best to manage them were among the multiplecaseseriesofpatientswithdocumentedCOVID- Children’s Hospital many questions challenging the evolving understand- 19, along with early reports of ultrastructural detection Colorado, Aurora; and Deputy Editor, JAMA ing of these cutaneous manifestations. This has been an of SARS-CoV-2 infection and strong type I interferon sig- Dermatology. important opportunity for dermatologists to learn and nal in these skin lesions, suggest a pathophysiological re- contribute.2 What are the current priorities in derma- lationship beyond just temporal association. However, tology research and clinical care as the COVID-19 pan- other large case series of patients presenting with this demic progresses? skin finding have failed to find SARS-CoV-2 infection by Viewpoints either nasopharyngeal swab or serological tests.6 Could pages 1131-1155 and Skin Findings chilblainslike lesions, which tend to affect younger, Editorial page 1159 A broad spectrum of skin manifestations has been re- asymptomatic patients often late in the evolution of ported in association with severe acute respiratory syn- COVID-19 disease, be a late-phase immune response or drome coronavirus 2 (SARS-CoV-2) infection, spanning be associated with failure to trigger humoral immunity?1 almosteveryinflammatorypattern.Thevariabilityofskin Studies have been limited by uncertain case definition findings seen is substantial compared with other viral in- because chilblains affects a similar demographic and may fections that typically present with characteristic skin be associated with other viral or systemic illnesses. patterns. The seemingly high (estimated as high as 20% in one study) prevalence in adults, who rarely present Key Considerations for the Study with viral exanthems, is also notable. Understanding the and Management of Dermatology Patients trueprevalenceofskinfindingsiscomplicatedbythelack COVID-19 has raised many important questions about of testing, as well as likely reporting bias in publication. the current management of patients with cutaneous dis- SARS-CoV-2 infection disproportionately affects people ease. In the earliest days of the pandemic, many expert guidelines were generated on how best to manage patients receiving systemic In addition, the worldwide recognition immunosuppressive therapy indicated of acral chilblainslike lesions for skin disease, such as corticosteroids (also known as COVID-19 toes) and biologic agents. Multiple registries worldwide were created to capture data has generated both confusion and on clinical outcomes in patients with spe- controversy among dermatologists. cific skin conditions. Whether these pa- tients have increased susceptibility to of color yet there have been almost no reports of der- SARS-CoV-2 infection or different outcomes compared matologic findings in this population.3 with the general population is a critical question. Broader Thelargestcaseseriesofskinmanifestationstodate, databases will be needed to determine the relative rates which included 375 patients, highlighted 5 predomi- of infection and mortality in patients with immunosup- nant morphological patterns: maculopapular, urti- pression from therapies for skin disease because these carial, pseudochilblain, vesicular, and livedoid.1 The abil- may differ from patients undergoing immune suppres- Corresponding ity to characterize and categorize skin changes into sion for other indications. Designing research collabo- Author: Kanade morphological patterns will help inform hypotheses and rations and systems for rapid implementation of re- Shinkai, MD, PhD, subsequent studies on the mechanisms involved. For ex- search across different health systems to study the skin Department of Dermatology, ample, livedoid changes signify occlusion of the cuta- findings in COVID-19 infection is another important op- University of Calfornia, neous vessels, and studies in patients with COVID-19 and portunity for dermatologists. San Francisco, 1701 livedoid changes have pointed to likely complement- Whether all patients with COVID-19 skin manifesta- Divisadero St, mediated vasculopathy4 that may portend systemic tions need expert dermatologic care has been debated, San Francisco, CA 94115 (kanade.shinkai@ thrombosis. Dermatologists also may be important in the especially in the cases of likely nonspecific skin reac- jamanetwork.org). diagnosis and understanding of pediatric inflammatory tions such as morbilliform eruptions or urticaria seen in jama.com (Reprinted) JAMA September 22/29, 2020 Volume 324, Number 12 1133 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Opinion Viewpoint association with SARS-CoV-2 infection. During the initial days of the was due to the redeployment of resident physicians. It will be im- pandemic, the presentation of otherwise healthy and asymptom- portant to consider how to provide support for trainees and also atic patients (largely over telemedicine platforms) for evaluation of course correction for residency curricula. Safely reintroducing learn- acralchilblainslikelesionsraisedaclinicaldilemmaofwhethertobring ers into the clinical environment has required tremendous effort by patients into the clinic for SARS-CoV-2 testing. A wealth of informa- dermatology educators and clinical chiefs, and there is an ever- tion has been gained from the study of these patients, including re- changing landscape as upticks in SARS-CoV-2 infections occur across sults of hematologic and rheumatologic testing. However, it is im- the country. portant to acknowledge that these evaluations represent research Another educational problem of utmost importance is the up- and are not yet established as the clinical standard of care. coming residency recruitment season, which will be almost exclu- sively virtual. This change in the resident selection process will force COVID-19 and the Dermatology Workforce and Education residency and fellowship program directors and other faculty to re- COVID-19 has changed the workforce and the way dermatologists flect on what core values are desirable and necessary in the next gen- practice and learn. Reassignment of dermatologists occurred world- eration of dermatologists and to ensure that these core values are wide, most often to COVID-19 screening facilities and to inpatient maintained at the forefront of recruitment. It is paramount to pay hospital wards. Valid institutional restrictions on nonessential in- particular attention to the proactive mentorship and recruitment of person specialty care and elective procedures, shortages of per- underrepresented minority students into dermatology. sonal protective equipment, and the need for dermatology clinics to provide ongoing access had many dermatologists turning to tele- Looking to the Future: Opportunities for Dermatology medicine. Important opportunities were afforded by key changes It has been an extraordinary time for medical publishing with an un- to regulations from the Centers for Medicare & Medicaid Services precedented rapid publication pace of articles related to SARS- in March 2020, including widespread implementation of teleder- CoV-2 infection. With notable exception, the dermatology COVID-19 matology platforms in academic dermatology departments, changes literature is comprised mostly of case reports, small case series, and to the iPledge system for isotretinoin prescribing that align well with opinion articles. It will be important for dermatologists to pursue rig- telemedicine,7 and the possibility of furthering the outreach of der- orous prospective research to achieve a comprehensive understand- matologic care. ing of the true prevalence and natural history of SARS-CoV-2 infec- However, key questions remain. Do virtual visits provide high- tion and skin findings, determine whether cutaneous manifestations quality dermatologic care equivalent to in-person visits? Are the pa- signal important systemic associations, and identify the best man- tients seen via telemedicine the same patients who are the highest agement strategies. In addition, parallel research efforts should ad- priority in needing dermatologic care? Could disparities in access to dress how dermatologists can
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