COVID-19 and dermatology: What is in store?
The COVID-19 pandemic has undoubtedly affected not just the health sector, but the entire way of life. The practice of medicine is certainly not spared from repercussions. Many appease themselves with the belief that majority are knee-jerk reactions, and hence transient. However, the disease seems to be here to stay, and the changes could be permanent. In all likelihood, the pandemic will generate a long-standing paradigm shift in medical practice. This article tries to conceptualize how the way we practice and preach dermatology might be transformed.
Numerous guidelines are available outlining the precautions to be followed in clinical practice.[1,2] However, the finer details of how the whole shebang shall impact daily routine is yet to be discerned. At this juncture, a reality check is in store, regarding the realistic aspects of the alterations in practice and teaching in the peri-COVID era.
Dermatology practice: The pre-COVID school of dermatology teaching advocated spending ample time with the patient to obtain a detailed history and to examine closely to elicit clinical findings. However, the dictum of social distancing contradicts this. The present dogma, irrespective of specialty, is to minimize patient contact. This can be executed only at the cost of communication, which previously had much emphasis. The patient-doctor relationship, which was already under strain before the pandemic, may be compromised further in the present and potential future scenario between patients and health care providers. The possible directions it can take are:
Overt lack of trust and reliance on technical methods for diagnosis: Commercial interests might support this, as evidenced by mushrooming of telemedicine applications to replace health-care facilities
The epidemic slowly becoming part of “new normal,” the system recognizing it as part of reality and the extra risk as part of career
The communication through gadgets become routine, and telediagnosis and prescription become normal practice which satisfies patient and doctor alike. Eventually, this can lead to new etiquettes of practice.
COVID could become a potential differential diagnosis in myriad scenarios ranging from viral exanthem to vasculitis. This includes, but is not restricted to, pseudo chilblains (acral areas of erythema–edema with some vesicles or pustules), vesicular eruptions, urticarial lesions, and maculopapular lesions of various morphologies (e.g., pityriasis rosea-like, purpuric, punctate, erythema multiforme-like, and erythema elevatum diutinum-like). The rising popularity of defensive medicine and uncertainty of the diagnosis of a potentially dangerous illness may lead to detailed work-up of cases. Dermatology is a visual specialty and considered the most suited for teledermatology. However, a lesion may appear different on direct observation than when viewed in a photograph or video. A shift to telemedicine consultations may lead to diagnostic difficulties.
PATIENT-CARE AND CARE-SEEKING BEHAVIOR
Delay in seeking care has become the norm. Telemedicine requests through WhatsApp and video calls are a dayto-day affair. Although there are some attempts in regulating such practices, we may have to enforce more directives. Such regulations, though the need of the hour, have not yet materialized satisfactorily. Rapid changes in this area necessitate a quick and appropriate response from regulatory bodies.
We are, or rather were, in an era of procedural dermatology. Suddenly, many procedures, previously considered basic and/ or essential, have become avoidable, or at least “postponable.” If the COVID-19 scare endures, we may have to redefine the indications for procedures. Patients and dermatologists alike may favor medical rather than surgical therapies for conditions which can be managed by either, causing repercussions on the practice, including revenue gained. Most of the procedures are now done with “COVID consent,” a new armamentarium in defensive medicine! However, as COVID becomes the norm and hopefully recedes eventually, such consents can extend to various other situations too.
We, dermatologists, have, at times, been guilty of taking things for granted while enforcing precautions against infections. Now, innovations ranging from “bubble clinics” to non-contact dermatology are being advocated. Perhaps, this should be a wake-up call to develop stricter guidelines for safety. It is also important to ensure safety in using instruments. For instance, using a dermoscope needs special precautions such as opting for non-contact dermoscopy, using protective measures and aids such as disposable dermoscopic lens cover, polyvinyl chloride food wrap, and applying transparent adhesive tape over the immersion fluid. Social distancing using car phone holder or polyethylene tube have become common.
Dermatology is heavily reliant on immunosuppressive therapies. The use of biologicals had become the vogue. The present scenario necessitates the need to reconsider the treatment ladder of several grave maladies. As suggested by recent publications, we may start to advocate less aggressive management, and advise caution while prescribing immunosuppression and even accept less aggressive control of diseases.
How will mask, a mandatory attire all over the world, which keeps the greater part of the face hidden, impact on facial dermatosis and cosmetic dermatology? Although people concern themselves with facial beauty not just to impress others but also for improving self-image and confidence, one may not be as worried about a covered blemish as an exposed one. Meanwhile, cases of PPE-induced/aggravated dermatosis seem to be on the rise.
The fee that we charge is for the time spent with patients, and the trust they place in us, in addition to the correct diagnosis and treatment. Charging an equal fee for telemedicine consultations as for direct ones may not sit well with the patient population. How is it possible to regulate the consultation fee in this scenario?
Case-discussions are the core of dermatology teaching. It requires a practiced eye under proper guidance to pinpoint the correct diagnosis. Seminars and symposiums can be conducted as online teaching, but newer methods will have to be contrived to replace traditional teaching in the current scenario. Furthermore, robotic medicine and artificial intelligence (AI) protocols may have to be included in the dermatology curriculum soon. Postgraduates are increasingly facing difficulties in conducting their thesis studies as only few non-COVID patients are approaching OPDs, and this may change the way these studies are being undertaken in future. The mode of evaluation of students in practical examinations is also changing, with a shift to virtual case scenarios from actual patients-based case taking, and the use of clinical photographs for spotter questions.
Panic-driven acceptance of dubious research has resulted in a few retractions recently. Hopefully, this will stimulate practitioners to learn how to evaluate publications more critically before putting them into practice.
There already exist mobile applications for diagnosing skin lesions, mostly meant for use by doctors. The future may see the rise of more such apps, possibly available for public. Proper coordination can appropriately guide the patient to the doctor. However, a rise in self-diagnosis and treatment may culminate if such facilities are unregulated.
AI AND ROBOTICS
These being the two most rapidly developing fields, AI may try to replace the intellect, and robotics, the skills. Can social distancing and scare of infection lead to the replacement of dermatologists by machines and algorithms?
The far-reaching consequences of the pandemic are beyond predictions. Only time will truly tell whether this too shall pass, or if the reality shall be worse than our fears. What will decide the quantum and pace of change? The duration of the pandemic, its impact on policy, economy, and world order, and the extent of mortality may be some factors. We can merely consider the possible scenarios, remain as prepared as humanly possible, and then await what the future holds.
Declaration of patient consentNot required as there are no patients in this article.
Financial support and sponsorshipNil.
Conflicts of interestDr Kidangazhiathmana Ajithkumar is on the editorial board of the Journal.
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