Covid-19

The COVID-19 pandemic caused by the SARS-CoV-2 infection has affected 208 million people globally, with an average mortality rate of 2.16%. The disease manifests with a wide spectrum of symptoms, affecting multiple organs. In addition to respiratory symptoms, some COVID-19 patients experience gastrointestinal symptoms, neurological symptoms, odynophagia, and chest pain amongst others. In addition, cutaneous manifestations have also been seen.
Even in symptomatic patients, the disease ranges from very mild cold-like symptoms to severe complications and death. Furthermore, the evidence suggests that not all people exposed to SARS-CoV-2 get infected. The cause of these variations is undoubtedly multifactorial, and this is valid also for the wide spectrum of skin manifestations that have been associated with SARS-CoV-2 infection. The cutaneous manifestations can be classified into three large groups with respect to their pathological mechanisms: (i) secondary to an immune response to viral nucleotides, (ii) due to the direct viral cytopathic effect on keratinocytes and endothelial cells, (iii) secondary to the systemic consequences caused by COVID-19, especially vasculitis and thrombotic vasculopathy, and secondary to adverse drug reactions during the course of the disease.

COVID-19 is also responsible for skin lesions related to personal hygiene measures due to the SARS-CoV-2 infection and spread prevention principles imposed on both physicians and patients. Preventative strategies that employ hand sanitizers, gloves, masks, and disposable protective suits increase the overall burden of dermatological conditions. This data was originally discovered in the healthcare worker population that was forced to adopt measures to protect themselves and patients from SARS-CoV-2 infection. Thus, an increase in allergic and non-allergic dermatoses increased on face (mask and goggle related), hands (gloves and/or hand sanitizers related) and body (protective suits related). The current knowledge merely focuses on de novo dermatoses, whilst the relationship between pre-existent dermatoses and personal protective equipment (PPE) was poorly investigated.
Remarkably, new findings suggest that both SARS-CoV-2 and PPE are responsible for flares of pre-existing diseases, from psoriatic arthritis to acne (“maskne”) or mask rosacea. In literature, several studies had highlighted the increased severity of hand eczema after hand sanitizers, flares of facial dermatoses (i.e. seborrheic dermatoses) and oral inflammatory diseases (i.e. geographic tongue). Beside the well-known Koebner phenomenon, the underlying mechanisms still remain elusive.

Besides the well-known risk factors for severe COVID-19 (age >60, non-white ethnicity, obesity, diabetes, hypertension, lung disease), disease-related or iatrogenic suppression have been recognized as risk factors for hospitalization. The aforementioned comorbidities are known to be more prevalent in patients with moderate-to-severe psoriasis, and it has been reassuring to know that biologic treatment has proved to be protective for COVID-19 related hospitalization or mortality, perhaps in combination with increased risk-mitigating behavior. The use of oral methotrexate was associated with increased odds of COVID-associated hospitalization, whereas the use of biologic drugs was not associated with worse outcomes of COVID-19 among patients with psoriasis. Increased demand for less frequent monitoring, drug administrations and follow-up appointments may have contributed to a shift in therapeutic preferences.
In other diseases, systemic corticosteroid or immunosuppressive treatment (e.g. methotrexate, cyclosporin, rituximab, or JAK inhibitors) can be considered to be risk factors; these should probably be withheld from patients with COVID-19 or close exposure to the disease, even though dexamethasone and tocilizumab have been useful in patients with cytokine storm and severe disease. On the other hand, flares of psoriasis and psoriatic arthritis have been reported to occur following COVID-19 infection and vaccination, perhaps related to type 1 interferon mediated responses.

Moreover, from a broader point of view, what about the new normality in dermatological practice after the COVID-19 pandemic? The pandemic outbreak caused the closure of many dermatological offices, leaving patients with no possibility to be examined face-to-face. Tele-dermatology, which has indeed proven to be convenient and safe for both doctors and patients, suddenly became the sole tool for providing clinical care, and hybrid models have become more and more frequent. In the future AI will help select patients requiring face-to-face visits, thus saving specialists’ time by supporting the diagnosis of simpler conditions.
Despite the benefits of these types of advances, we will also meet new challenges including cybersecurity, system backups and energy shortage.