by Adam Schmitt, MD
Is this skin growth dangerous? How can I get refills of my medications? Is this rash a sign of something more serious? What should I do about my recently diagnosed skin cancer?
As the SARS-CoV-2 virus continues its march across the globe, and the number of COVID-19 cases surges throughout the United States, healthcare workers and patients alike are making daily judgements of what constitutes “essential” medical care. It has many of us asking “Should I keep my doctor’s appointment?” Because the pandemic is changing daily, we will grapple with this question for many months to come. Dermatology is no exception.
When to See a Dermatologist
There are still many reasons to see a dermatologist during the COVID-19 pandemic, and for this reason most Dermatology offices are remaining open on a limited basis. Some conditions will require an office visit while others can be handled via teledermatology (see below). Dermatology is a visual specialty that is perfect for telemedicine consultation and dermatologists have been performing this type of care for decades. By visiting your dermatologist via teledermatology we can help divert care away from overburdened urgent and emergency care facilities.
Conditions Needing Immediate Care
As a general rule, if a lesion is growing rapidly (i.e., significant change over a 1-3 month period), bleeding spontaneously, or painful, it is worth further evaluation. During this time, your dermatologist may advise a preliminary telemedicine visit as an initial evaluation, and may either provide reassurance or recommend a clinic appointment for a possible biopsy. Similarly, if you notice a mole that is changing in size, shape, color, or symptoms, or is showing features of the ABCDEs of melanoma, it should be evaluated by a dermatologist, especially if you have a personal history or strong family history of melanoma.
While many rashes can be managed very well via a tele-dermatology visit, a rapidly expanding rash or a rash with other symptoms (such as fever or abdominal pain) will likely warrant an in-person visit. Additionally, any concern for an active infection that would require intervention – such as an infected cyst that needs drainage – may necessitate a clinic visit.
What Can Wait
The American Academy of Dermatology (AAD) has communicated continuously with its members over the past several weeks. They have provided practical guidance on topics encountered daily by dermatologists. Among these guidelines is a recognition that each clinic will have to address their particular situation differently, based on patient population, acuity of disease, and prevalence of COVID-19 in their area. However, certain restrictions are widely advised during the pandemic. For instance, if not already mandated by local government authorities, all elective procedures should be deferred.
Examples of elective procedures include neuromodulator injections (e.g., Botox), filler injections, laser treatments, non-invasive fat removal (e.g., CoolSculpting), elective/cosmetic mole removals, and others. Non-urgent medical conditions such as precancers (actinic keratoses), cysts, acne, rosacea, and hair loss are also being routinely deferred, as are chronic skin conditions, such as psoriasis and eczema. Furthermore, in-person evaluation of limited rashes and stable skin lesions should be delayed. We are also pushing back regular skin checks for patients without a history of melanoma or aggressive skin cancers.
We understand that the issues above, while not life threatening, are very concerning for many of our patients. To that end, we are scheduling concerns involving skin, hair, or nails for a teledermatology visit. Over 90% of the time this type of visit will address the problem; for the rest, we will get them in to our clinic to see one of our dermatologists in person. This allows us to safely address all of our patients’ needs during this time of social distancing.
What About Skin Cancer?
You or someone you know may have recently received a skin cancer diagnosis. Fortunately, the majority of skin cancers are low-risk basal cell or squamous cell carcinomas. The American College of Mohs Surgery, the preeminent professional society for fellowship-trained skin cancer surgeons (Mohs surgeons), has been in close contact with its members over the past several weeks and has provided informed, thoughtful guidance for its members. The recommendation is to delay treatment of nearly all basal cell carcinomas, as the majority are slow-growing. Adelay in treatment is unlikely to impact the treatment course (the surgery to clear the tumor and the subsequent reconstruction).
Some of these can be treated with prescription topical creams and may not need surgery. Treatment of most squamous cell carcinomas can also be deferred, as long as no high-risk features are present. Your dermatologist can assess and discuss this option on a tele-dermatology consult. The urgency of melanoma treatment varies by depth of tumor invasion and presence of high-risk features, as well. We are addressing these on a case-by-case basis.
Telemedicine is “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.” With an eye towards public safety, mitigating unnecessary exposure to potential disease carriers, and preservation of personal protective equipment, Medicare and Medicaid are encouraging a transition to telemedicine, and private insurers are following suit.
These remote visits can take two main forms: synchronous and asynchronous. Synchronous encounters are live visits with a real-time provider-patient conversation and evaluation. Asynchronous visits are sometimes referred to as “store-and-forward” visits. The patient uploads a history and photographs. The provider reviews the photos and asks questions as necessary via a secure messaging system. Then the provider renders a diagnosis and treatment plan.
In several ways, Dermatology is especially amenable to telemedicine. Many Dermatology practices already had some form of telemedicine service in place prior to the emergence of COVID-19. With restrictions on in-office visits combined with loosening of both telemedicine regulations and medication monitoring requirements, practices are ramping up their telemedicine capabilities. Routine follow-ups, medication refills, initial evaluation of lesions, and evaluation of limited dermatologic diseases are well-managed with telemedicine. We still have the option to recommend a clinic visit for a possible biopsy or more urgent intervention.
What You Can Do
First and foremost, if you have symptoms of COVID-19, either stay at home or seek emergent care, depending on the severity of your symptoms. If a healthcare provider comes in contact with a contagious patient, each subsequent patient is at risk. Unchecked, disease incidence will continue to rise.
Monitor your skin for any of the concerning findings discussed above. Contact your dermatologist if you feel anything needs immediate attention.
If you have a biopsy-confirmed skin cancer, your dermatologic surgeon should be in contact with specific treatment recommendations based on the type of skin cancer, microscopic features, and location. If you have not heard from your provider, reach out for clarification.
Utilize telemedicine services whenever possible. Check your dermatologist’s website to see if they offer telemedicine visits. Many skin disorders can be evaluated and managed remotely, and insurers are likely to cover telemedicine as the pandemic continues.
If in doubt about your skin condition, call your provider. They will advise you and get you the care you need, even if care may be postponed for now. Keep in mind that recommendations and regulations are evolving daily – sometimes by the hour. The clinic staff and healthcare providers are doing their best to accommodate patient needs while prioritizing public safety and adhering to both government mandates and medical society recommendations. Remember: Your providers are as eager to see you as you are to see them. While difficult for patients and providers alike, temporary delays are necessary for the public’s health during this challenging time.
About the Author
Adam Schmitt, MD, MS is a board-certified Dermatologist and fellowship-trained Mohs surgeon with Zel Skin and Laser Specialists in the Twin Cities. He has a Master of Science in Epidemiology from the Harvard TH Chan School of Public Health and a Medical Doctorate from Case Western Reserve University School of Medicine. He completed his residency in Dermatology and fellowship in Micrographic Surgery and Cutaneous Oncology (Mohs surgery) at the Mayo Clinic in Rochester, MN.