As Covid-19 invaded the NHS, we all got ready, we acted on our clinical instincts and the united force of the NHS kicked in. Dermatology and the rest of the non-acute medical specialties prepared to be redeployed to the wards. The dermatology registrars were recruited first and then consultants, albeit a little nervously. We dusted off our stethoscopes and boned up on acute medical pathways and ECGs. We wanted to support our frontline friends and colleagues in any way we could. I have never had more respect for my frontline friends in blues, who took on the pressure and marched into their shifts, as Covid-19 cases flooded into hospitals. Many of my dermatologist friends were called upon to be second consultant on call, buddied with an acute consultant or were happy to play the role of a junior and be an extra pair of sensible hands on medical wards.
Dermatology has always embraced visual technology and many departments have systems in place to adjust to a brave new world of virtual clinics. We had a headstart on many other specialties, who have had to use this new way of conducting outpatient clinics. We continued to manage urgent skin cancer patients face to face in PPE, but we all had to adjust to video conferencing and using clinical photos and a referral letter to diagnose and manage skin rashes and lesions. Virtual dermatology clinics for new patients can be like having 70% of the pieces of a puzzle and relies on clinical acumen to reach a final skin picture/ diagnosis. One positive outcome from this crisis, is that mountains have been moved within days between managers and clinicians and innovative ways of working will change the way we practice medicine and dermatology forever in the NHS.
The skin wellbeing clinic for staff was one practical way we could help. Colleagues came in exhausted, with hand dermatitis and war wounds from PPE, seeking solace in emollients and the peace of outpatients. The pharmaceutical and cosmeceutical industries came to our rescue producing hand sanitisers and donating free emollients for NHS staff. Staff left the clinic a little lighter mentally and heavier with creams.
The skin is often a window into internal disease and we are seeing an array of skin presentations with Covid19. The most characteristic presentation appears to be the ‘Covid toes’, or non-blanching erythema, chilblain like lesions at acral sites, particularly on the toes and sometimes fingers. This presentation appears to be more common in children but can be seen in adults at any stage of the disease. [1]
The underlying pathophysiology is not fully understood but maybe a result of a vasculopathy due to the pro-thrombotic state of Covid19 patients, although further clinicopathological correlation is needed. Classically this presentation is self-limiting. Other cutaneous presentations are less specific and include maculopapular, vesicular, urticarial and livedoid rashes. [2] Although, one also has to consider other diagnoses in patients with Covid-19 such as drug eruptions, or acro-ischaemia due to inotropes. The Italian group have found 20% of Covid19 patients have skin rashes [1], although in China this figure appears to be much lower 0.2%. [3] As dermatology publishes and collates databases internationally, a clearer picture should emerge regarding the association of skin disease and Covid19.
Skin examination should be part of the consultation in a patient with suspected Covid19 and may help identify patients.
Dermatology and all specialties have a role to play in the fight against Covid19. The collaborations, camaraderie and unfailing work ethic are some of the success stories within the NHS.
References
1. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387.
2. Galvan Casas C, Catania A, Carratero Hernandez G et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020 Apr 29. doi: 10.1111/bjd.19163. [Epub ahead of print]
3. Guan WJ , Ni ZY , Hu Y , et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. Published online February 28, 2020. doi:10.1056/NEJMoa2002032
Rapid Response:
Covid-19: Perspective from a dermatologist
Dear Editor
As Covid-19 invaded the NHS, we all got ready, we acted on our clinical instincts and the united force of the NHS kicked in. Dermatology and the rest of the non-acute medical specialties prepared to be redeployed to the wards. The dermatology registrars were recruited first and then consultants, albeit a little nervously. We dusted off our stethoscopes and boned up on acute medical pathways and ECGs. We wanted to support our frontline friends and colleagues in any way we could. I have never had more respect for my frontline friends in blues, who took on the pressure and marched into their shifts, as Covid-19 cases flooded into hospitals. Many of my dermatologist friends were called upon to be second consultant on call, buddied with an acute consultant or were happy to play the role of a junior and be an extra pair of sensible hands on medical wards.
Dermatology has always embraced visual technology and many departments have systems in place to adjust to a brave new world of virtual clinics. We had a headstart on many other specialties, who have had to use this new way of conducting outpatient clinics. We continued to manage urgent skin cancer patients face to face in PPE, but we all had to adjust to video conferencing and using clinical photos and a referral letter to diagnose and manage skin rashes and lesions. Virtual dermatology clinics for new patients can be like having 70% of the pieces of a puzzle and relies on clinical acumen to reach a final skin picture/ diagnosis. One positive outcome from this crisis, is that mountains have been moved within days between managers and clinicians and innovative ways of working will change the way we practice medicine and dermatology forever in the NHS.
The skin wellbeing clinic for staff was one practical way we could help. Colleagues came in exhausted, with hand dermatitis and war wounds from PPE, seeking solace in emollients and the peace of outpatients. The pharmaceutical and cosmeceutical industries came to our rescue producing hand sanitisers and donating free emollients for NHS staff. Staff left the clinic a little lighter mentally and heavier with creams.
The skin is often a window into internal disease and we are seeing an array of skin presentations with Covid19. The most characteristic presentation appears to be the ‘Covid toes’, or non-blanching erythema, chilblain like lesions at acral sites, particularly on the toes and sometimes fingers. This presentation appears to be more common in children but can be seen in adults at any stage of the disease. [1]
The underlying pathophysiology is not fully understood but maybe a result of a vasculopathy due to the pro-thrombotic state of Covid19 patients, although further clinicopathological correlation is needed. Classically this presentation is self-limiting. Other cutaneous presentations are less specific and include maculopapular, vesicular, urticarial and livedoid rashes. [2] Although, one also has to consider other diagnoses in patients with Covid-19 such as drug eruptions, or acro-ischaemia due to inotropes. The Italian group have found 20% of Covid19 patients have skin rashes [1], although in China this figure appears to be much lower 0.2%. [3] As dermatology publishes and collates databases internationally, a clearer picture should emerge regarding the association of skin disease and Covid19.
Skin examination should be part of the consultation in a patient with suspected Covid19 and may help identify patients.
Dermatology and all specialties have a role to play in the fight against Covid19. The collaborations, camaraderie and unfailing work ethic are some of the success stories within the NHS.
References
1. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387.
2. Galvan Casas C, Catania A, Carratero Hernandez G et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020 Apr 29. doi: 10.1111/bjd.19163. [Epub ahead of print]
3. Guan WJ , Ni ZY , Hu Y , et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. Published online February 28, 2020. doi:10.1056/NEJMoa2002032
Competing interests: No competing interests