The emerging COVID-19 virus is phylogenetically linked to viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) . COVID-19 creates variable degrees of illness, ranging from fever, cough, dyspnea, fatigue, and diarrhea to critical cases of severe acute respiratory distress syndrome (2) .
The COVID-19 pandemic has brought the world to a standstill and placed considerable challenges on healthcare workers, including dermatologists.
Telemedicine has gained particular importance, where many of the dermatologic consultations were transitioned into teledermatology services. The current outbreak has led to the ongoing emergence of personal protective equipment (PPE)-related dermatoses and hygiene-related hand dermatitis, particularly among healthcare providers. In addition, due to a shortage of vaccination programs imposed by the COVID-19 lockdown, there is a significant risk for other infectious disease outbreaks, including measles.
A cross-sectional observational study involving two online surveys were conducted for data collection. The purpose of using two questionnaires is twofold:
1. to comprehensively examine the effect of COVID-19 on different aspects of medical practice 2. to concentrate on the virus effect on dermatologic practice.
A 5-item electronic survey was created and sent to 276 randomly selected healthcare providers working in the emergency departments, inpatient wards, and outpatient clinics of the major hospitals in Iraq. The survey assessed the frequency of occupational skin diseases due to hygienic work practices and PPE use among healthcare providers working during the current pandemic. The participants were asked about their gender, age, and the frequency of hygienerelated hand dermatitis and skin complications related to PPE use.
For survey 2, a 12-item electronic questionnaire was sent to 156 randomly selected dermatologists practicing within the COVID-19 era. The dermatologists were asked about the impact of the current outbreak on various aspects of dermatology practice, including the provided medical services, infection control
In the first survey, a total of 200 responses were collected from healthcare providers working amid the COVID-19 pandemic with a response rate of (72.46%).
The results of the first survey are summarized in table 1 and 2. Tables 3, 4 , and 5. 
Do you provide online/ phone consultations (teledermatology)?
Did you work at the respiratory triage or any other COVID-19 related unit?
Did you diagnose a case of measles during the current pandemic?
14 86 
We have reviewed the impact of COVID-19 pandemic on the practice of dermatology in Iraq. Although the population of Iraq exceeded 40 million in 2020, based on the latest United Nation data (3) , available statistics indicate that the number of physicians is 7.08 per 10,000 populations which is extremely low when compared to developed countries (4) .
On February 24, 2020, Iraq announced the first confirmed case of SARS-CoV-2 infection. Since then, the spread of COVID-19 has increased. exponentially. By early September, about 260,370 confirmed cases and 7,512 deaths had been reported in Iraq (5) .
The COVID-19 pandemic has targeted every single aspect of medical practice, including dermatology. As Baghdad became the epicenter of the COVID-19
pandemic in mid-March, most dermatology clinics were closed or continued to operate at a minimal capacity. The objective was to provide essential medical care for emergency cases, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, erythroderma, acute angioedema, and lesions worrisome for skin cancer.
With the acute shortage of PPE, medical practitioners clenched their teeth with each patient, wondering if they had been exposed to the virus already. COVID-19
patients may present with a wide range of dermatologic manifestations with or without typical respiratory signs (6) (7).
Of the 100 dermatologists involved in the survey, 20% reported diagnosing one or more COVID-19 related skin manifestations. These have included the most commonly diagnosed diseases: erythematous maculopapular eruption (41.67%), urticaria (37.50%), chilblains (25%), and vasculitis (16.67%) (Figure 1 ). 
The dermatology team tried to reduce face-to-face consultations in both public hospitals and private practice clinics, limiting them to emergency patients. (Figure 2 ).
Flowchart represents the pre-examination triage to decrease the risk of infection spread while attending the dermatology clinic and utilizing teledermatology for initial +/-follow-up assessment.
Due to frequent handwashing, prolonged use of gloves, and overuse of disinfectants, the incidence of hand dermatitis among healthcare staff and the general population has dramatically increased (Figure 3) .
In this survey, hand dermatitis was reported in 83% of healthcare providers working during the current pandemic. Another study reported a comparable result of gloves-related hand dermatitis (88.5%) among healthcare providers working in Hubei Province hospitals amid the outbreak (9) . A pre-outbreak epidemiologic study in mainland China found the frequency of hand dermatitis to range from 14.3% to 23.8% across hospital departments, far from those recorded during the COVID-19 outbreak (10) .
Several measures can be used to decrease the incidence of hand dermatitis, including the use of mild soaps (syndets) that are equally effective in preventing the viral spread and frequent use of moisturizers and physical barriers, especially after handwashing to protect the skin and decrease irritation. Depending on the severity of the lesions, established hand dermatitis should be treated with emollients and/or topical steroids (11) .
Prolonged contact with PPE such as masks, protective gowns, face shields, and goggles has led to an unprecedented emergence of PPE-related dermatoses among healthcare providers working amidst the current pandemic. PPE-induced skin injuries are attributed to mechanical friction, long-term occlusion, maceration, and allergic contact reactions (12) .
Among the surveyed healthcare providers, 147 (73.5%) reported PPE-related dermatoses. Of these, 111 (75.5%) occurred in women and 36 (24.9%) in men.
The median age was 31 years (range 24-47 years; standard deviation 4.94 years).
The frequency of PPE-related dermatosis reported in this survey includes:
pressure injuries (51.9%), acne (33.1%), non-gloves contact dermatitis (29.9%), nonspecific dermatitis and itching (17.5%), urticaria (9.1%), and skin infections (3.2%) (Figure 4) . Folliculitis can occur at the site of skin friction, and the inflamed follicles may become infected with bacteria, especially Staphylococcus aureus.
Friction caused by surgical masks can also trigger reactivation of the Herpes simplex virus. 
It is currently enigmatic how COVID-19 can affect those with chronic skin conditions such as psoriasis and how it can affect these individuals' treatment.
The psychologic impact of the crisis, patients' reluctance to attend a clinic appointment, limited use of immunosuppressive drugs, and shortage of drugs lead to a perceptible increase in the rate of relapse and exacerbation of several chronic skin diseases (17) . Relapse rates of psoriasis, atopic dermatitis, rosacea, vitiligo, and alopecia areata were noticeably increased as observed by 64.70%, 58.82%, 17.64% 9.80%, and 5.88% of dermatologists, respectively.
Patients should be strongly advised against stopping their medications without consulting their physicians (18) . The importance of supporting patients with chronic dermatologic conditions during the current crisis cannot be overemphasized.
The WHO expressed great concern about the spread of previously controllable infectious diseases like measles. Derangement of immunization services caused by the ongoing COVID-19 pandemic is likely to further to decrease measles vaccination coverage by an additional 20%, leaving the most susceptible children at risk for highly infectious disease outbreak (19) . About 14% of the surveyed dermatologists recorded new cases of measles amid the current pandemic;
hence, health authorities are called to emphasize the importance of identifying and reaching children with missed vaccine doses to avoid an inevitable outbreak.
Several expert opinions have recommended restricting the use of immunosuppressive agents during the current pandemic (20) (21) (23) .
Most of the non-essential dermatological procedures and biopsies were postponed to minimize the risk of spreading COVID-19 infection. Skin surgery was limited to a few undeferrable biopsies and high-risk skin cancer removal when the risk of delay exceeded the risk of exposure to the virus ( Figure 5 ). Some hospitals have applied specific internal protocols to protect their patients and staff, including testing patients for COVID-19 before their scheduled surgeries and procedures, providing full PPE to all operating staff, and solicitous intraoperative environment sterilization and waste disposal (24) .
A dramatic decrease in the number of skin biopsies at Baghdad Teaching Hospital in response to the increasing numbers of COVID-19 patients.
Baghdad has been hit particularly hard by COVID-19, where almost half of the confirmed cases were recorded. The dermatology staff felt the call of duty and were actively involved in the respiratory triage at the emergency department, where they continued to help patients and support their fellow physicians.
Nineteen percent of the dermatologists surveyed reported working in the respiratory triage or other COVID-19 related units.
The Flowchart representing pre-examination triage to decrease the risk of infection spread while attending the dermatology clinic and utilizing teledermatology for initial +/-follow-up assessment. 