key: cord-0724443-dyqnu121
authors: Esen‐Salman, Kübra; Akın‐Çakıcı, Özlem; Kardeş, Sinan; Salman, Andaç
title: Public interest in dermatologic symptoms, conditions, treatments, and procedures during the COVID‐19 pandemic: Insights from Google Trends
date: 2021-02-25
journal: Dermatol Ther
DOI: 10.1111/dth.14895
sha: ffacd3e67aafb43474aa43e0ba6c721900f8c45f
doc_id: 724443
cord_uid: dyqnu121

Coronavirus disease 2019 (COVID‐19) pandemic had substantial effect both on daily life and medical practice. Internet data have been used to analyze the trends in public interest in various medical conditions and treatments. The aim of this study is to analyze the public interest in dermatologic symptoms, conditions, treatments, and procedures during the COVID‐19 pandemic. Google Trends was queried for a total of 120 dermatological search queries. Three periods of 2020 ([March 15‐May 9], [May 10‐July 4], and [July 5‐October 31]) were compared with the previous 4 years (2016‐2019). A significantly decreased interest in skin cancers and certain dermatologic conditions (eg, pityriasis rosea and scabies) was observed throughout the study period. Whereas a significant increase of interest in dry skin, hair shedding, oily hair, atopic dermatitis, and hand eczema was detected during the study. An initial decrease in interest was followed by a significant increase for acne, comedones, melasma, rosacea, botox, dermaroller, and peeling. The study demonstrated a significant impact of the COVID‐19 pandemic on the public interest in dermatology. The present results would help to create healthcare policies and information sources, which can meet the public demand. The reasons for the observed trends and their effect on patient outcomes might be of interest for future studies.

During recent years, internet data have been increasingly used to analyze the public behavior and interest in various medical conditions. [3] [4] [5] [6] [7] [8] Google Trends is the most popular tool and has been used to explore the interest in dermatologic conditions before and during the COVID-19 pandemic. [8] [9] [10] [11] [12] [13] [14] [15] Previous studies in dermatology have investigated the public interest in common dermatological conditions (eg, acne, seborrheic dermatitis, and warts), cosmetic dermatology procedures, and COVID-19-related acral symptoms during the early phases of the outbreak. [11] [12] [13] [14] In the present study we aimed to analyze the public interest in a wide range of dermatologic symptoms, conditions, treatments, and procedures using a very detailed set of search terms and a longer period of investigation for providing information on impact of different stages of pandemic on the public interest in dermatology. Therefore, the insights generated from this study would expand the knowledge produced in previous studies and increase our understanding in this new pandemic.

Google Trends, a freely available tool, provides information on frequencies of queries that people search on Google search engine. It normalizes the frequency of a search query to all queries, and presents results as a relative search volume ranging from 0 to 100; with larger scores denote greater popularity for the search query.

We determined search queries representing a wide spectrum of dermatologic symptoms, conditions, treatments, and procedures.

Three different dermatologists (K.E.S., Ö.A.Ç., and A.S.) have discussed and decided the search terms through working on a shared online document. The terms were selected from the most frequent conditions, treatments and procedures using dermatology textbooks. The complete list of a total of 120 search queries is presented in Table 1 .

For each query, Google Trends was queried applying filters of "United States," "01/01/2016-11/17/2020," and "All categories." The Google

Trends weekly data were exported for analysis. 

The current study found that public interest in dermatologic symptoms, conditions, treatments, and procedures has significantly changed during different periods of COVID-19 pandemic when compared with the corresponding periods in the previous 4 years.

The interest in search terms including basal cell carcinoma, skin cancer, melanoma, erythema multiforme, scabies, pityriasis rosea, demodex, tinea, and skin candida has been decreased throughout the study period. Accordingly, a decreased interest in skin cancer during the COVID-19 pandemic has also been reported in Italy, Turkey, and the United States. 11, 14 This might be explained by the decrease in hospital/dermatology visits due to a fear to exposure to SARS-COV-2 and the resultant decrease in the diagnosis of these conditions or an increased concern for COVID-19 rather than the dermatologic conditions. A prolonged diagnostic delay might result in more advanced disease, increased morbidity and mortality, particularly in patients with skin cancers (eg, melanoma, non-melanoma skin cancer [NMSC; ie, basal cell carcinoma and squamous cell carcinoma]). 16 In fact, a recent report from the United Kingdom has shown a decrease up to 47% in the number of non-melanoma skin cancer treated and melanoma patients undergoing sentinel lymph node biopsies. 17 Moreover, studies from Italy showed a statistically significant increase in mean Breslow thickness during the post-lockdown phase compared with the pre-lockdown and decreased detection of melanoma during the COVID-19 pandemic. 18, 19 Another study from the United Kingdom has reported that the NMSCs excised in 2020 required significantly larger and more complex surgery than in 2019. 20 Altogether, these findings suggest an increased delay in the diagnosis of skin cancers, which in turn might result in more advanced disease requiring more complex surgical procedures. Implementation of teledermatology might help, at least partially to overcome these issues and effectively prioritize the patients in whom earlier treatment is needed. 21 Unlike our study suggesting a decreased interest in scabies and pruritus, recent studies have reported an outbreak of scabies in Spain and Turkey. 22, 23 The increase of scabies was attributed to the increased transmission due to closer contact among family members and delay in diagnosis during the lockdown. This discrepancy could be attributed to the differences in the socioeconomic status of the study populations or merely to the lack of correlation between the incidence of scabies and public interest in these search terms. Considering the increased global burden of scabies, 24, 25 the future studies investigating the changes in scabies epidemiology during COVID-19 pandemic would be of benefit to prevent potential scabies outbreaks during the lockdowns in the future.

Another important finding of the present study was the increased interest in dry skin, atopic dermatitis, hand eczema, tacrolimus ointment, pimecrolimus cream, and skin care all through the study period.

In line with our findings, a previous study from the United Kingdom has reported a similar trend for hand eczema during the COVID-19 pandemic. 12 It seems possible that these results are due to more strict hygiene practices, that is, more frequent use of soaps and alcoholbased hand sanitizers which might lead to the development of contact dermatitis. 26 Indeed, an increased incidence of dermatitis associated with the hygiene practices and the use of personal protective equipment (PPE) during the pandemic has been reported. 27, 28 Despite the efforts for the prevention of contact dermatitis associated with hygiene practices, 29 there still seems to be room for improvement in community education on safe and effective hygiene practices.

The current study found a continuous increase of interest in dandruff, oily hair, and hair shedding which are most commonly associated with seborrheic dermatitis and telogen effluvium. This result can be well-expected considering that these conditions might exacerbate in response to elevated levels of psychological stress 30 which is a wellcharacterized impact of COVID-19. 31 The stable increase in the interest for the term "purple skin" is also of interest, despite being foreseeable.

Among the various dermatologic manifestations of COVID-19, pseudochilblain lesions involving acral areas (also described as COVID toes) and livedo-like lesions might present as purplish discoloration of the skin. 32 Accordingly with our results, an increased public interest in acral lesions (ie, coronavirus toes, coronavirus fingers) has also been demonstrated in a prior study from France. 13 Another finding of this study was the initially decreased interest in "comedones, acne, melasma, rosacea, Botox, Dermaroller, peeling, showed an increase in appearance-focused behaviors (eg, mirror checking, appearance comparisons) in patients with higher dysmorphic concern during the COVID-19 pandemic due to the closure of beauty services. 33 Moreover, another study reported an association between COVID-19-related stress negative body image in adults. 34 The subsequent increase of interest in cosmetic procedures such as botulinum toxin injections, dermaroller, and chemical peeling may also be explained by these findings. Another possible explanation is the exacerbation of acne and rosacea induced by the use of protective masks. 35 Previous studies have reported a similar trend for cosmetic procedures 11, 12, 14 but in the United Kingdom there was an increased interest in acne during the initial phases of the pandemic which was attributed to public desire for self-treatment of acne. 12 Some limitations of the present study need to be acknowledged.

First, the results should be interpreted cautiously before extrapolating to the general population because the source of data was confined to the population with access to the internet and Google searches.

Nonetheless, the fact that Google's search engine market share of 88% 36 and the internet usage rate among US adults of 90%, 37 enables our study to cover a major segment of the general population.

Another limitation is the lack of information on the reasons for the 

COVID-19) Dashboard j WHO Coronavirus Disease (COVID-19) Dashboard

Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice

Public interest in rheumatic diseases and rheumatologist in the United States during the COVID-19 pandemic: evidence from Google Trends

Population-level interest in anti-rheumatic drugs in the COVID-19 era: insights from Google Trends

Use of Google Trends to investigate loss-of-smell-related searches during the COVID-19 outbreak

Public interest in elective urological procedures in the COVID-19 pandemic: a Google Trends analysis

A Google trends analysis of facial plastic surgery interest during the COVID-19 pandemic

Google trends in infodemiology and infoveillance: methodology framework

Insights into worldwide interest in tattoos using Google Trends

Google search trends and skin cancer: evaluating the US population's interest in skin cancer and its association with melanoma outcomes

Analysis of dermatologic conditions in Turkey and Italy by using Google trends analysis in the era of the COVID-19 pandemic

Dermatological insights from Google trends: what does the public think is important during COVID-19 lockdown?

The use of Google Trends for acral symptoms during COVID-19 outbreak in France

Analysis of dermatology-related search engine trends during the COVID-19 pandemic: implications for patient demand for outpatient services and telehealth

Why are chilblains underreported in Nordic countries during the COVID-19 pandemic? An analysis of Google trends

The danger of neglecting melanoma during the COVID-19 pandemic

The effect of the COVID-19 pandemic on skin cancer surgery in the United Kingdom: a national, multi-Centre, prospective cohort study and survey of plastic surgeons

Delayed melanoma diagnosis in the COVID-19 era: increased breslow thickness in primary melanomas seen after the COVID-19 lockdown

The reduction in the detection of melanoma during the coronavirus disease 2019 (COVID-19) pandemic in a melanoma center of South Italy

Characterising nonmelanoma skin cancer undergoing surgical management during the COVID-19 pandemic

Teledermatology in the times of COVID-19: a systematic review

Scabies outbreak during home confinement due to the SARS-CoV-2 pandemic

The explosion in scabies cases during COVID-19 pandemic

The global burden of scabies: a cross-sectional analysis from the global burden of disease study

Ectoparasites

Occupational and hand dermatitis: a practical approach

Increased occurrence of hand eczema in young children following the Danish hand hygiene recommendations during the COVID-19 pandemic

Iatrogenic dermatitis in times of COVID-19: a pandemic within a pandemic

Hand hygiene during COVID-19: recommendations from the American contact dermatitis society

Dermatological manifestations of stress in normal and psychiatric populations

COVID stress syndrome: concept, structure, and correlates

Classification of the cutaneous manifestations of COVID -19: a rapid prospective nationwide consensus study in Spain with 375 cases

The COVID -19 pandemic: psychological and behavioral responses to the shutdown of the beauty industry

COVID-19-related stress and anxiety are associated with negative body image in adults from the United Kingdom

Facial dermatoses in the general population due to wearing of personal protective masks during the COVID-19 pandemic: first observations after lockdown

Demographics of Internet and Home Broadband Usage in the United States j Pew Research Center

Public interest in dermatologic symptoms, conditions, treatments, and procedures during the COVID-19 pandemic: Insights from Google Trends

The authors declare no conflict of interest.

The data that support the findings of this study are available from the corresponding author upon reasonable request. Andaç Salman https://orcid.org/0000-0002-6407-926X