key: cord-0880125-6zygcpv2 authors: Musumeci, Maria Letizia; Nasca, Maria Rita; Micali, Giuseppe title: COVID-19: The Italian Experience date: 2021-02-01 journal: Clin Dermatol DOI: 10.1016/j.clindermatol.2021.01.013 sha: fa0402243b27615ad65ee24e142838d97ade7bf2 doc_id: 880125 cord_uid: 6zygcpv2 Italy was among the most and earlier affected countries by COVID-19 in the world. We report the Italian experience with the pandemic. The dermatologic community immediately reduced any type of activities to 80-90% of outpatient consultations both in the public hospitals and in private offices. The Italian Society of Dermatology and Sexually Transmitted Diseases (SIDeMaST) and the Italian Forensic Dermatologic Society (SIDeLF) supported the dermatologic community by recommendations available as newsletters (vademecum) for routine management of dermatologic patients either in the hospital or private setting. We have provided an overview of the skin manifestations from the pandemic, including those consequents to the misuse of safety measures. We also have evaluated the recently developed research projects on patients treated with biologics for psoriasis (PSO-BIO-COVID), atopic dermatitis (DA-COVID), and hidradenitis suppurativa (HS-ada-COVID19), as well as the registries (SKIN-COVID-19, PED-COVID-19) for various skin diseases impacted by COVID-19. After the China outbreak, by early March 2020, Italy had become one the most affected countries in the world by COVID-19 ( Figure 1 ). The dissemination of the virus hit quite strongly Northern Italy, especially the Lombardy region, and on March 9 the Italian government issued a lockdown that lasted until June 3. The Italian health system was heavily challenged by this unexpected pandemic that represented the first health priority for the following months. As of May 26, 2020, 126 physicians among general practitioners and physicians who were in the front line died of COVID-19 infection 1 . As a result of the pandemic, the dermatologic community consistently diminished most activities, reducing by 80-90% the outpatient consultation both in public hospitals and in private offices 2, 3 . Dermatology settings were considered at serious risk for contagion for several reasons: the close contact required for an accurate skin evaluation, the lack of office facilities with adequate biosafety requirements, and the shortage of supplies for personal protection equipment. On February 2020, an Italian dermatologist was reported among the first physicians positive for COVID-19 and was hospitalized at the Policlinic of Milan, where he presented with changes in taste and smell and an unusual trunk eruption with varicelliform microvesicles 4, 5 . Most public dermatology clinics postponed appointments for elective surgery and non-urgent visits to avoid people commuting and overcrowding. This restriction was in line with the legislative decree from the Italian prime minister "I stay at home" (IoRestoaCasa), recommending the closure of any commercial activities with the exception of such essential services as pharmacies and grocery stores 6 . People were not allowed to leave their homes unless there was the need for working (health workers), for urgent health reasons, or the purchase of necessary goods. Fortunately, many people could work virtually. The vademecum addressed to dermatologists indicates that, in accordance with the indications provided by IMS and ISS, they are required to follow strict rules: 1) always wear a protective mask; 2) limit the number of patients in the waiting room; 3) wash with water and soap or sanitize hands with hydro alcoholic gel before and after each visit; 4) do not wear jewelry or wristwatch during the visit; 5) use disposable gloves ; 6) clean/disinfect examination tables with chlorine derivatives and medical devices with 70% ethyl alcohol; 7) refrain from work in case of fever, cough, cold, and flu-like symptoms; 8) sanitize systematically all the medical instruments (manual or digital dermatoscope or any other non-disposable tool used during the visit) after each examination. In the vademecum addressed to patients, in addition to reminding them that the most effective preventive measures are wearing a protective mask, frequent hand washing, and use of alcohol-based and gel prior to and after entering the medical office, some information for specific dermatologic situations were provided: 1) non-urgent skin consultations should be avoided in case of fever, cough, cold, or flu-like symptoms; 2) priority for dermatologic consultations and/or investigations in public institutions is generally established by general practitioners and/or the dermatologists; 3) no accompanying person is generally allowed during the visit or in the waiting room, unless a parent/tutor (for minors) or a caregiver (for non-self-sufficient patients), and all attending subjects must comply with inter-personal distance and be willing to undergo temperature check by infrared remote thermometer; 4) surgery for a suspected skin cancer (melanoma, squamous and basal cell carcinomas) is usually warranted and scheduled according to the availability of operating rooms. An additional challenge concerned dermatologic patients requiring systemic treatment, in particular those with an impaired immunologic status 7 . According to the SIDeMaST recommendation, patients receiving topical steroids, calcineurin inhibitors, or oral isotretinoin are not exposed to a higher risk of COVID-19; therefore, they should not discontinue treatment, unless on dermatologist advice. SIDeMast also released eight vademecum related to specific dermatoses, such as chronic inflammatory (psoriasis and/or psoriatic arthropathy, atopic dermatitis, hidradenitis suppurativa), neoplastic (melanoma, squamous cell carcinoma, basal cell carcinoma, primary cutaneous lymphoma) and bullous and autoimmune disorders, treated with traditional systemic drugs or with biologic agents. These vademecum confirm that for such disorders there is no need to stop the treatment with biologics or traditional drugs, especially if there are no clinical and laboratory signs of COVID-19, as there is no evidence that treatment discontinuation protects against an infection. In addition, any interruption in therapy might result in a loss of response when treatment is reintroduced. These recommendations were later adopted by several international societies, such as those representing rheumatologists, gastroenterologists, and dermatology societies, including the American Academy of Dermatology (AAD) 8 . During the pandemic, another challenge was represented by the prevention of negative COVID-19 patients with advanced skin cancer to be exposed to viral infection. Another limited to the essential, adopting strategies for social distancing. The S-MDTB assigned a priority to advanced skin tumors and classified them, according to their biologic aggressiveness, into three main categories (melanoma, squamous cell carcinoma, and basal cell carcinoma) labeled through a "triage" system using different colors (red, yellow, green, and white). There was also a risk ladder useful to prioritize the management of both oncologic and COVID-19 risk patients. The "triage" color system had the following characteristics: red: when the COVID-19 risk may be higher than the oncologic risk, the patient visit or treatment must be postponed; Finally, another emerging problem with the application of these safety procedures has been the occurrence of skin damage among health workers, including dermatologists, either due to repeated or incorrect and frequent cleansing or to prolonged contact with protective devices such as clothing, gloves, masks, glasses, and visors 32 PSO-BIO-COVID is a national observational study to evaluate the management of patients on biologic therapy during the current pandemic and to track the potential development of COVID-19 in this category of patients. In particular, a 6-month study was planned from February 20, 2020 through September30, 2020. Subsequent monthly data will also be collected: 1. data on the medical management of psoriatic patients and actions put in place by dermatologists; 2. the incidence of COVID-19 in these patients and their subsequent course; 3. the collection of the above data (e.g. age, comorbidities, etc.), the incidence of symptomatic or asymptomatic COVID-19, and their correlation with age, sex, ongoing therapy, co-medications or comorbidities, and close contact with SARS-CoV2+ subjects 33 . DA-COVID19 registry is an observational multicenter, national, retrospective and prospective, non-profit study designed to describe the management during the current pandemic of adult patients with moderate/severe atopic dermatitis treated with traditional systemic immunosuppressive drugs, biologics and phototherapy, and to track the development of COVID-19 infections in these populations by interview and questionnaire administration. The data would collected from February 2020 through December 2020. The data will be analyzed according to age, comorbidity, and concurrent medications, etc. to identify specific groups of patients at higher risk for adverse events. HS-ada-COVID-19 is a multicenter, observational study for suppurative hidradenitis (HS) patients treated with adalimumab to estimate the prevalence and incidence of COVID-19 in these patients and to evaluate the safety and the possible impact of adalimumab on COVID-19 course. SKIN-COVID-19 is a multicenter, observational study regarding the skin events associated with COVID-19 aimed to assess their incidence and prevalence as well as to disclose their Patients should be asked to fill up and sign a questionnaire stating the lack of COVID-19 related symptoms and/or reporting on recent contacts with infected individuals. They should also undergo body temperature check by an infrared remote thermometer and sanitize hands before entering the visiting room. examination gloves) should be used by all office staff members, washing hands for at least 60 seconds prior to wearing, changing them after each visit, and properly disposing of them in unsorted waste after each use. Eye, face and head protection with special reusable equipment (glasses, visors or face shields) should be used to avoid operator's contamination by aerosols and respiratory droplets, blood, body fluids or excretions. Finally, it is important to check personal protection equipment availability in adequate amount for the next working day 34 . The COVID-19 pandemic is still far from its end. Learning about the Italian experience may be significant for the development of preventive and therapeutic measures for other countries. Legend for figure Increased Risk of COVID-19-Related Deaths among General Practitioners in Italy. 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