Treatment practices amongst dermatologists in western India during the COVID-19 pandemic: A cross-sectional study

Sir,

India has the second highest number of COVID-19 cases after the United States of America. COVID-19 has affected the mode of consultation and prescription patterns in dermatology worldwide.^1,2 The aim of the study was to study the prescription patterns and practices among dermatologists during COVID-19 pandemic. An online questionnaire was sent via email and WhatsApp groups to dermatologists working in Rajasthan between 28 September 2020 to 1 November 2020. A total of 76 participants responded after giving informed consent. Out of all the questions, there was no response to a few questions (range 1–3 questions), as shown in Tables 1-3. Majority of the dermatologists, 43 (56.6%) were working in educational institutes and government hospitals followed by private hospitals 20 (26.3%). Thirty-three (43.4%) of the total participants were attending more than 50 cases per day before COVID-19, while only 21 (27.6%) participants were attending more than 50 patients per day during the pandemic. In India, telemedicine is not a commonly used mode of consultation, however due to the pandemic 39 (51.3%) dermatologists were using a telemedicine platform along with physical consultations. Dermatologists did not find telemedicine as a good mode of consultation every time. Thirty-one (40.8%) dermatologists found telemedicine consultation good in terms of diagnosis only sometimes (34–66% of time) [Table 1]. Specific reason for this was not asked from the participants but it may be related to poor quality images, mode used, need for systemic evaluation and a need for whole body examination.

COVID-19 can spread through asymptomatic individuals as well and therefore use of protective equipment is important. Forty-six (60.5%) dermatologists were using both mask and face shields, while 27 (35.5%) were using face mask alone during patient examination.

Majority i.e 50 (65.8%) dermatologists agreed that COVID-19 had affected their prescription pattern. Sixty-four (84.2%) dermatologists preferred to use only topical drugs along with oral antihistamines during the pandemic. Thirty-four (44.7%) dermatologists were using immunosuppressives sometimes (24–66% of time) and 73 (96.1%) agreed that we should be more cautious while prescribing these drugs during the COVID-19 pandemic. The main indication to start immunosuppressives was pemphigus followed by eczemas. For the treatment of patients on long term immunosuppressants, 44 (57.9%) dermatologists have reduced the dose of immunosuppressants to minimal to control the disease activity, while 22 (29.0%) had stopped immunosuppressants and have switched to drugs with no or minimal immunosuppression potential such as dapsone and apremilast. Most of them were using oral steroids for lesser duration and lesser dose in comparison to pre-COVID times. Forty-four (57.9%) dermatologists were always (100% of time) taking account of patient’s age and associated comorbidities before prescribing immunosuppressants. Fifty-two (68.4%) dermatologists were giving precautionary advice to patients on immunosuppressive agents to follow preventive measures against COVID-19 [Table 2]. Fifteen (19.7%) dermatologists were using biologics depending on risk-benefit ratio and 23 (30.3%) have currently stopped using them altogether. Due to the pandemic, 41 (54.0%) dermatologists had either completely stopped doing aesthetic procedures or were doing these procedures only in follow-up cases.

Common skin manifestations of COVID-19 are pseudofrost bite like lesions, urticarial rashes and varicella like eruption.³ Forty-six (60.5%) dermatologists were aware of all these manifestations. Six (7.9%) and 21(27.6%) dermatologists were aware of only pseudofrost bite such as lesions and only urticarial rashes as the sole manifestation of COVID-19, respectively. Many dermatological associations have provided recommendations regarding judicious use of immunosupressants and biologics during the COVID pandemic.^4,5 In the present study, 46 (60.5%) dermatologists were aware of guidelines or recommendations on the use of immunosuppresants [Table 3].

The COVID-19 pandemic has made a great impact on dermatology services all around the globe. Muddasani et al. found a reduction in dermatology practice in the United States especially in areas with a high COVID-19 prevalence.⁶ In India, even during the unlocking phase; there was still a reduction in the number of dermatology patients seen per day, as seen in the present survey.

Teledermatology is the first step toward social distancing. Virtual consultations have increased in comparison to face to face consultations in India.⁷ Due to the pandemic, about 51.3% dermatologists were using a telemedicine platform along with physical consultation, 34.2% were doing physical consultations only and no dermatologist was doing tele consultation alone. While in a global survey, 37.3% of dermatologists were using a combination of teledermatology and in-person consultations, 37.8% were doing tele-consultation only and 9.3% were doing physical consultations alone.⁸ The difference may be due to the resources and infrastructure available for teledermatology is still in developing stage in our country. In the present study, 31 (40.8 %) dermatologists found telemedicine consultation good in terms of diagnosis only sometimes (34–66% of time) while in a study by Temiz et al., teledermatology was found suitable in nearly 70% of the patients.⁹ Difference may be due to poor quality of image or mode of teledermatology used.

Around 60% dermatologists are using both mask and face shields, while 35.5% are using face mask alone during patient examination. We were unable to find this observation in the previous studies. These findings have not been studied previously to the best of our knowledge. Correct use of personal protective equipment along with hand hygiene is critical to prevent its transmission.

Immunosuppressive drugs can be continued in patients without COVID-19 infection who are already taking them at a low dose; however, the use of these drugs in new cases should be balanced between the risk and benefit ratio on case-to-case basis.^4,5 Most dermatologists in the present study are now using a lesser dose and lesser duration of oral steroids in comparison to before COVID. For the treatment of patients on long-term immunosuppressants, 44 (57.9%) dermatologists have reduced the dose of immunosuppressants to minimal to control the disease activity while 22 (29.0%) had stopped immunosuppressants and have switched to drugs with no or minimal immunosuppression potential such as dapsone and apremilast. Similar findings were seen in another study where 42.2% dermatologists preferred to decrease the dose of immunosuppressants in a stable disease and 32.5% preferred smaller molecules like apremilast in disease activity.¹⁰

Aesthetic dermatology practices have reduced to a great extent. The risk of spreading infection is more while performing cosmetic treatments over the face area, as mask needs to be removed. Stringent disinfection, cost of full personal protective equipment has decreased the frequency of aesthetic procedures. Furthermore, many patients may not come for aesthetic procedures because of economic setback.^11,12 Due to the pandemic, nearly half of practitioners have either completely stopped aesthetic procedures such as peels, LASER, dermatosurgery procedures or are doing these procedures only in follow-up cases. In a survey from various countries, only 7.4% of participants were doing cosmetic procedures.⁸

Forty-six (60.5%) dermatologists were aware of all three common skin manifestations of COVID-19, that is, pseudofrost bite like lesions, urticarial rashes and varicella like eruptions and guidelines or recommendations on the use of immunosuppresants respectively. This finding was not noted in the previous studies.

The study reflects how COVID-19 pandemic has affected the practices and prescription patterns among dermatologists in the western part of India. It also shows the level of awareness regarding COVID-related cutaneous manifestations and recommendations on use of immunosuppressants in this region. However, because of small sample size, the present study gives only a small snapshot and more studies with large sample size are required.

Limitation of the present study is small sample size, cross-sectional study design and recall bias. Information regarding years of experience and specific reasons for doing physical consultation were not included.