LetterEditor

Dear Editors: 

It has been around seven months since the closure of the non-emergency healthcare services across Kurdistan region, Iraq and many countries around the world amongst the evolving COVID-19 pandemic. 

All non-emergent outpatient visits and minor surgical across the Kurdistan region have been temporarily suspended by the healthcare authorities, with the exception of urgent outpatient consultations such as invasive malignancy. The decision was made as a precautionary measure to avoid public gatherings and mitigate the spread of the virus. Several dermatologists have called for implementation of a similar policy in the United States (1), partly because certain dermatology patients like psoriasis and atopic dermatitis are recognized as high risk for infection due to possible impaired skin barrier (2) and/or immunosuppression from long term use of immunosuppressant (3).

While the Kurdistan region may not be a perfect environment to fulfill Teledermatology, nonetheless, similar to any other part of the globalized world, there is a wide spread use of telecommunication and information technologies in the region. As such, utilization of the telecommunication in the healthcare and especially visual oriented specialties like dermatology in the region is imminent.

Since the beginning of social distancing and indoor self-isolation from the unprecedented lockdown in Kurdistan, we have been receiving more than usual consultations. A common anecdotal explanation for this is while people are staying at home, they have more time focusing on their personal issues among them skin illnesses rendering them to overreact and seek dermatologist’s advice. COVID-19 can show itself through several cutaneous presentations, majority as a nonspecific maculopapular eruption, urticarial lesions, pseudochilblain, vesicular lesions and livedo-necrosis (4). However, worsening of their symptoms might actually have indirect link with COVID-19 since some protective measures against SARS-CoV-2 like frequent hand washing and wearing mask & gloves might be irritant for certain skin diseases worsening their symptoms. Many COVID-19- related skin lesions have been reported in the literature believed to have emerged secondary to the precautionary measures against the notorious virus (5).

From the early days of the outbreak, most skin doctors in the region have announced that they are willing to respond to any dermatological consultation voluntarily through their social media and other telecommunication devices, among which Viber messaging app, the most widely used app in the region. 

Viber is a well-known communication apps installed on the smart phones for free. In contrast to many modern sophisticated apps, it is very simple and easy to use even by illiterate people. It allows all sorts of real time communications from texting to voice messaging to video chat, and accessible by almost every adult in the region. Throughout the lockdown period of almost six weeks started since March 1,2020 to date, Viber has considerably filled the healthcare gap created by the closure of non-emergency offices.

Teledermatology can be delivered via two methods, either real time video/audio consultation (RT-TD), or sending texts and photographs by the patient as store-and-forward method (SAF) to be responded by dermatologists later. Viber has both features, the live-interactive method which can be done using Viber app, shows comparable results with standard care in terms of accuracy and efficacy (6). Teledermatology is applied increasingly and would be incorporated with traditional skin disorders treatment services (7).

Kurdistan as a part of the developing world may not be the best example to run tele dermatology, however, the immense use of smartphones in the region could play a key role for its success enabling thousands of concerned patients seeks advice easily no matter how far they are.

Dermatology, in contrast to most of other medical and surgical specialties, is a highly visual oriented specialty (8). Poor photo quality from smartphone limitations needs improvement, to maintain the legal rights of both dermatologists and the patients, proper regulations should be developed regarding the trend of tele dermatology (9, 10) ,with patient confidentiality and emergent ethical issues to be given the top priority and preserved by law.

To date, the termination of the lockdown is unclear and current situation may linger. Dermatologists should be mindful on the seriousness of COVID-19 and advice their patients to avoid unnecessary hospital visits (11).

If they decide to reopen their clinics, they should wear PPEs including the N95 mask during the patient visits. Once outpatient dermatology or private skin & cosmetic clinics began to receive patients, it is prudent to start triaging of patients at the entrance of the clinic to maintain proper social distancing during the outbreak (12, 13).

Despite standard self-precautionary measures like wearing mask and goggles, Special attention should be paid on laser surgeries. Advanced evacuation system must be set for the laser rooms to minimize potential laser hazards of airborne contaminations, laser hand pieces must be sterilized, only disposable materials should be used and they need to be discarded immediately after patient using safe biohazard boxes (14).

The story of Covid-19 so far, means that Dermatology departments as the rest of everyday life have had to change the way they interact with patients. Local guidelines should be prepared regarding how to recommencing outpatient dermatology services, performing skin surgeries and doing follow up and even the referral system should be revised. Kurdistan society of Dermatologists alongside health ministry could contribute in this regard as British association of Dermatologists updated guidelines to cope dermatological services with the novel virus, even guidance on how to take a photo for the patients to be used in Teledermatology (15).

Teledermatology is safe, easy to use, affordable and accessible to absolute majority of the region’s population. While it effectively limits the spread of the virus amid the COVID-19 outbreak, likewise remarkably increases healthcare access by overcoming the barrier of transportation and lowers the cost by avoiding traveling risks & fees, this would be invaluable gain especially for the countryside and rural communities

 While face to face (FTF) traditional practice is the gold standard consultation method, Teledermatology could be a potential alternative, during such pandemic in particular.  The Viber is helping us outstandingly in preventing unnecessary crowds amid the outbreak control, it is also teaching us a lesson; time for Teledermatology in the region has arrived and its administration is not impossible. Although the logistic issues associated with ways of communication like poor photo quality & network connection are easy to address, the medico-legal aspect of the novel method requires careful decision making. This can only be done through enacting comprehensive endorsed realistic adaptable policies which meticulously highlight step by step application of the technology in order to preserve both parties’ rights and responsibilities. Failure to do so may result in adverse consequences such as abusing doctor’s rights and breaching patient’s confidentiality among many others.

References

1. Kwatra SG, Sweren RJ, Grossberg AL. Dermatology practices as vectors for COVID-19 transmission: a call for immediate cessation of non-emergent dermatology visits. J Am Acad Dermatol [Internet]. 2020; Available from: https://doi.org/10.1016/j.jaad.2020.03.037

2. Tao J, Song Z, Yang L, Huang C, Feng A, Man X. Emergency management for preventing and controlling nosocomial infection of 2019 novel coronavirus: implications for the dermatology department. Br J Dermatol. 2020; 

3 Conforti C, Giuffrida R, Dianzani C, Di Meo N, Zalaudek I. COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? A call for action. Dermatologic Therapy. 2020. 

4. Galván Casas, C., A. C. H. G. Catala, G. Carretero Hernández, P. Rodríguez‐Jiménez, D. Fernández‐Nieto, A. Rodríguez‐Villa Lario, I. Navarro Fernández et al. "Classification of the cutaneous manifestations of COVID‐19: a rapid prospective nationwide consensus study in Spain with 375 cases." British Journal of Dermatology 183, no. 1 (2020): 71-77.

5. Darlenski R, Tsankov N. Covid-19 pandemic and the skin - What should dermatologists know? Clin Dermatol [Internet]. 2020; Available from: https://doi.org/10.1016/j.clindermatol.2020.03.012

6. Lee JJ, English JC. Teledermatology: A Review and Update. Am J Clin Dermatol. 2018;19(2):253–60. 

7. Eedy DJ, Wootton R. Teledermatology: A review. British Journal of Dermatology. 2001. 

8. Specialty spotlight – dermatology [Internet]. Available from: https://www.rcplondon.ac.uk/education-practice/advice/specialty-spotlight-dermatology

9. Lee K, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018; 

10. Buabbas AJ, Sharma P, Al-Abdulrazaq A, Shehab H. Smartphone use by government dermatology practitioners in Kuwait: A self-reported questionnaire based cross-sectional study. BMC Med Inform Decis Mak. 2019;19(1):1–11. 

11. Taylor P. Ce Pt Ed Us Cr. J Dermatolog Treat [Internet]. 2012;0(December):37–41. Available from: http://dx.doi.org/10.1080/09546634.2020.1751040

12. Elston DM. Letter from the Editor: Occupational skin disease among healthcare workers during the Coronavirus (COVID-19) epidemic. J Am Acad Dermatol. 2020; 

13. Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: a useful tool to fight COVID-19. J Dermatolog Treat [Internet]. 2020;0(0):1–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32238000

14. Seyed-Naser Emadi BA-N. Coronavirus Disease 2019 (COVID-19) and dermatologists: Potential biological hazards of laser surgery in epidemic area. Ecotoxicol Environ Saf. 

15. https://www.bad.org.uk/healthcare-professionals/covid-19

a Dept. of Dermatology, College of Medicine, University of Sulaimani, Kurdistan Region/Iraq

b KBMS Trainee, Dermatology Teaching Center, Sulaimani, Kurdistan region/Iraq

c Department of Dermatology , Kalar General Teaching hospital, Kurdistan Region/Iraq