Hidradenitis suppurativa: The importance of virtual outpatient care during COVID-19 pandemic
Authors: Monica Shah, Haley B. Naik, Raed Alhusayen
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We read with interest "Strategic dermatology clinical operations during COVID-19 pandemic" by Price et al1Price K.N. Thiede R. Shi V.Y. Curiel-Lewandrowski C. Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemic.J Am Acad Dermatol. 2020; 82: e207-e209Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar and greatly appreciate their approach to maintaining successful patient care while limiting risks. In addition to preventing the spread of infection, the role of the dermatologist is also to provide appropriate care to patients with skin disease to prevent complications and to lower the burden on the health care system through emergency department (ED) visits and admissions. Hidradenitis suppurativa (HS) is an extremely painful, debilitating disease that significantly impairs quality of life.2Canadian Skin Patient AllianceHidradenitis Suppurativa: Overview –What is HS.https://www.canadianskin.ca/hidradenitis-suppurativaDate: 2020Date accessed: April 22, 2020Google Scholar Because HS symptom control and lesion resolution are often inconsistent and inadequate, HS patients exhibit greater use of emergency department (ED) and inpatient care than patients with other chronic inflammatory skin conditions.3Kirby J. Miller J. Adams D. Leslie D. Health care utilization patterns and costs for patients with hidradenitis suppurativa.JAMA Dermatol. 2014; 150: 937Crossref PubMed Scopus (87) Google Scholar Kirby et al3Kirby J. Miller J. Adams D. Leslie D. Health care utilization patterns and costs for patients with hidradenitis suppurativa.JAMA Dermatol. 2014; 150: 937Crossref PubMed Scopus (87) Google Scholar reported a mean 3-year ED cost of $2002 for HS patients and a higher proportion of ED visits relative to psoriasis (P = .02) and control groups (P < .001) after adjusting for age, sex, and comorbidities. In addition, of 47 respondents who completed the Canadian Skin Patient Alliance Hidradenitis Suppurativa Patient Experience survey, half consulted with ED physicians for HS symptoms (of which, 36% consulted with more than 10 ED physicians), and 30% made 10 or more trips to the ED in the prediagnosis stage.2Canadian Skin Patient AllianceHidradenitis Suppurativa: Overview –What is HS.https://www.canadianskin.ca/hidradenitis-suppurativaDate: 2020Date accessed: April 22, 2020Google Scholar We therefore strongly disagree with categorizing HS follow-up as "nonurgent/reschedule," as outlined by Price et al,1Price K.N. Thiede R. Shi V.Y. Curiel-Lewandrowski C. Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemic.J Am Acad Dermatol. 2020; 82: e207-e209Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar because this approach would likely contribute to increased ED visits. Furthermore, continued virtual outpatient care for HS patients may reduce ED exposure and minimize risk of infection, which is important for HS patients with significant concomitant comorbidities and those on immunomodulatory therapies. In addition, it would provide dermatologists a platform to explain and emphasize to patients the importance of social distancing while on immunosuppressants, crucial since research after the 2003 severe acute respiratory syndrome outbreak demonstrated higher self-reported compliance with quarantine measures when the rationale was understood (P = .018).4Lu T. Chou Y. Liou C. Impact of SARS on healthcare utilization by disease categories: implications for delivery of healthcare services.Health Policy. 2007; 83: 375-381Crossref Scopus (52) Google Scholar Studies have also demonstrated increased risk of antidepressant drug use (P < .0001) and completed suicide (P = .0334) in the HS population after adjusting for confounding factors.5Thorlacius L. Cohen A. Gislason G. Jemec G. Egeberg A. Increased suicide risk in patients with hidradenitis suppurativa.J Investig Dermatol. 2018; 138: 52-57Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar We caution against interruption in care for HS patients due to the potential for increased severity or frequency of suicidal behaviors, or depression and anxiety, or both, especially considering the additive stress and anxiety resulting from the current socially isolating quarantine climate.2Canadian Skin Patient AllianceHidradenitis Suppurativa: Overview –What is HS.https://www.canadianskin.ca/hidradenitis-suppurativaDate: 2020Date accessed: April 22, 2020Google Scholar In our complex medical dermatology practices, we have implemented a triage system similar to Price et al1Price K.N. Thiede R. Shi V.Y. Curiel-Lewandrowski C. Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemic.J Am Acad Dermatol. 2020; 82: e207-e209Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar with 3 categories: (1) in person, (2) virtual/phone, (3) cancel/reschedule. We find that the follow-up of both HS and autoimmune bullous diseases through virtual visits is quite effective in a large proportion of patients, during which we use patient-reported outcomes such as pain scores, treatment satisfaction scores, and patient global assessments. Virtual visits also allow us to counsel patients regarding maintenance regimens for the prevention of disease flares, HS action plans informing steps to take during HS exacerbations and when to contact a provider, and methods to improve overall mental health, including maintaining a healthy diet, using warm compresses, and engaging in support groups through the Canadian Skin Patient Alliance.2Canadian Skin Patient AllianceHidradenitis Suppurativa: Overview –What is HS.https://www.canadianskin.ca/hidradenitis-suppurativaDate: 2020Date accessed: April 22, 2020Google Scholar Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemicJournal of the American Academy of DermatologyVol. 82Issue 6PreviewTo the Editor: We were very pleased to read Chen et al's commentary1 presenting practical methods for reducing the spread of coronavirus disease 2019 (COVID-19) in the dermatologic setting. Health care teams around the world are working diligently to limit the spread of COVID-19 despite unprecedented challenges. In this letter, we provide additional strategies and a potential framework for maintaining successful patient care while limiting risks for faculty, residents, staff, and the community during the COVID-19 outbreak. Full-Text PDF