Management of urticaria in COVID‐19 patients: A systematic review

The global pandemic COVID‐19 has resulted in significant global morbidity, mortality and increased healthcare demands. There is now emerging evidence of patients experiencing urticaria. We sought to systematically review current evidence, critique the literature, and present our findings. Allowing PRISMA guidelines, a comprehensive literature search was carried out with Medline, EMBASE, Scopus, Cochrane, and Google Scholar, using key MeSH words, which include “COVID‐19,” “Coronavirus,” “SARS‐Cov‐2,” “Urticaria,” “Angioedema,” and “Skin rash” up to 01 August 2020. The key inclusion criteria were articles that reported on urticaria and/or angioedema due to COVID‐19 infection and reported management and outcome. Studies were excluded if no case or cohort outcomes were observed. Our search returned 169 articles, 25 of which met inclusion criteria. All studies were case reports, reporting 26 patients with urticaria and/or angioedema, COVID‐19 infection and their management and/or response. ajority of patients (n = 16, 69%) were over 50 years old. However, urticaria in the younger ages was not uncommon, with reported case of 2 months old infant. Skin lesions resolved from less than 24 hours to up to 2 weeks following treatment with antihistamines and/or steroids. There have been no cases of recurrent urticaria or cases nonresponsive to steroids. Management of urticarial in COVID‐19 patients should involve antihistamines. Low dose prednisolone should be considered on an individualized basis. Further research is required in understanding urticarial pathogenesis in COVID‐19. This will aid early diagnostic assessment in patients with high index of suspicion and subsequent management in the acute phase.     

Azithromycin and COVID‐19: Prompt early use at first signs of this infection in adults and children,an approach worthy of consideration

The devastating effects of the coronavirus designated severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) have led to urgent attempts to find effective therapeutic agents for inpatient and outpatient treatment of COVID‐19. Initial enthusiasm for the combination of hydroxychloroquine and azithromycin has abated. However, as a result of positive clinical experience with azithromycin used alone during the first few days of the flu‐like illness caused by this coronavirus, we recommend formal clinical trials using azithromycin early in the course of a COVID‐19 infection. There is one clinical trial initiated, the individually randomized, telemedicine‐based, “Azithromycin for COVID‐19 Treatment in Outpatients Nationwide” based at the University of California San Francisco. This placebo‐controlled trial is designed to determine the efficacy of a single 1.2‐g dose of oral azithromycin to prevent COVID‐19 patient progression to hospitalization. We recommend formal clinical trials of azithromycin in its prepackaged form at the first sign of COVID‐19 infection in adults and children, using an initial adult dose of 500 mg followed by 250 mg per day for 4 days, a total cumulative dose of 1.5 g, and for children 5 to 18 years of age, 10 mg/kg on the first day followed by 5 mg/kg for 4 days.     

Surveillance of psoriatic patients on biologic treatment during the COVID‐19 pandemic: A single‐center experience

There are few studies on how patients with psoriasis who are on biologic therapy are affected by the COVID‐19 pandemic. We analyzed the impact of the COVID‐19 pandemic on patients with psoriasis receiving biologic therapy, patients' current status at a single center in Turkey. A total of 133 patients (mean age; 44.6 ± 13.5 years) were on maintenance biological treatment for moderate‐to‐severe psoriasis during the pandemic. A standardized questionnaire was administered by phone interviews to determine patients' perceptions, attitudes, and adherence to therapy and identify the frequency of COVID‐19 infection, psoriasis status, and new comorbidities during the pandemic. All patients had been receiving a biological agent including ustekinumab, etanercept, adalimumab, secukinumab, infliximab, ixekizumab, or certolizumab pegol. Ninety‐one patients (68.4%) had at least one comorbid condition, including psoriatic arthritis (35.3%), hypertension (19.5%), diabetes mellitus (16.5%), obesity, coronary artery disease, and dyslipidemia. During the first 3 months of the pandemic, 52 patients (39%) suspended their biological therapies for short (n = 33) or long (n = 19) periods without medical advice for reasons of fear, worry, and anxiety. All but one patient restarted their medications as a result of therapeutic counseling. Five patients reported suspicious symptoms, but only one had PCR‐confirmed COVID‐19. Our findings suggest that biologic treatment for moderate‐to‐severe psoriasis would not pose an additional risk for COVID‐19 infection and its life‐threatening complications, even in the presence of a high frequency of cardiometabolic comorbidities, provided that all patients are informed and necessary pandemic‐directed precautions are well adopted by the patients.     

Contributions of dermatologists to COVID‐19 research: A brief systematic review

Coronavirus disease 2019 (COVID‐19) has been declared a pandemic. We conducted a systematic review to reveal the contribution of dermatologists in COVID‐19 research. Two hundred and ninety‐eight articles were included and classified into cutaneous manifestations of COVID‐19, operating experience against COVID‐19, mechanisms and treatment of COVID‐19, disinfection and personal protective equipment (PPE)‐related skin diseases, and other topics. The value of these articles and their impact on clinical impact were discussed and we hope that dermatologists can have a better understanding of these areas from this study.     

The impact of COVID‐19 in patients with psoriasis: A multicenter study in Istanbul

There is widespread concern about treatment of psoriasis in COVID‐19 pandemic. We aimed to evaluate the epidemiological data, clinical characteristics, treatment features of the psoriasis patients during the pandemic period. We conducted a study in dermatology clinics of seven different tertiary centers. All adult psoriasis patients who were followed up between 11 March 2020 and 28 June 2020, were phone called or questioned in their visit to their follow‐up clinics. A semistructured questionnaire was applied and patients' demographics and disease characteristics were recorded. Of 1322 patients, 52.4% were male, and 47.6% were female. According to the questionnaire responses, 964 (72.9%) of these patients could not communicate with their physician during this period, remained 358 (27.1%) patients contacted the physician by phone, email, or hospital visit. From the patients diagnosed as probable/confirmed COVID‐19, 14 were female, and 9 were male. Nine of 23 (39.1%) patients were using biologic treatment. There was no statistically significant difference in terms of hospitalization from COVID‐19 between the patients using biologics (n = 9) and those who did not (n = 14) (P = 1.00). No mortality was observed among them. Obesity, smoking, age, and accompanying psoriatic arthritis were not among the risk factors affecting the frequency of COVID‐19. We only encountered an increased risk in diabetic patients. Also, an exacerbation of psoriasis was observed with the infection. No difference was found in patients with psoriasis in terms of COVID‐19 infection in patients who use biologics and those who don't.     

Treatment considerations for Behçet disease in the era of COVID‐19: A narrative review

COVID‐19 is a multisystem disease caused by severe acute respiratory syndrome coronavirus 2. It has been declared a pandemic by the World Health Organization in March 2020 and the outbreak still keeps its impacts worldwide. Behçet disease (BD) is a multi‐systemic vasculitis involving the skin, mucosa, eyes, joints, nervous system, cardiovascular system, and gastrointestinal system. The precise etiopathogenesis of the disorder is unknown but autoimmunity is believed to play a key role. A considerable part of patients with BD are susceptible to immunosuppression and are more predisposed to infections than healthy individuals. Hence, the protection and control measures for patients with BD against the COVID‐19 are of the utmost significance. Given the requirement to balance proper treatment of BD with the smallest risk of COVID‐19 associated mortality and morbidity, we aimed to review the management of BD in the era of the pandemic with a special focus on treatment considerations. According to current expert recommendations, there is no reason to discontinue topical treatments, colchicine, and nonsteroidal antiinflammatory drugs. Systemic steroids can be used at the lowest possible dose if needed. Ongoing treatments can be continued unchanged in patients with no suspected or confirmed COVID‐19. In cases with COVID‐19 symptoms, immunosuppressive and biological agents can be temporarily stopped but the decision should be made on a case by case basis. Considering their potential beneficial effects on the course of COVID‐19, colchicine, pentoxifylline, and dapsone can be considered as safe treatment options in BD.     

Suspected COVID‐19‐related reticulated purpura of the soles in an infant

A growing number of skin lesions during the COVID‐19 pandemic are being recognized. Acral ischemic lesions identical to chilblains are most typical in children and young adults. We report an infant girl, aged 1 month and 29 days, with a peculiar reticulated purpuric eruption on her soles, with positive immunohistochemistry for SARS‐CoV‐2 in the endothelia of dermal blood vessels. The patient had an excellent outcome without specific therapy.     

Investigating the spectrum of dermatologic manifestations in COVID‐19 infection in severely ill patients: A series of four cases

COVID‐19, an infectious disease caused by the novel coronavirus, was initially identified in Wuhan, China, in December 2019. By March 2020, it was declared a pandemic by the World Health Organization. Although most findings have been reported in the lungs, primarily due to catastrophic respiratory decline, other organs, including the skin, are affected. Recent reports have been published describing the clinical spectrum of COVID‐19‐related lesions. In addition, recent case series have described a subset of these lesions having underlying thrombotic microangiopathy with increased complement activation characterized by increased C4d deposition within the blood vessel walls. Herein, we describe a series of COVID‐19‐related cutaneous manifestations found at autopsy examination and their underlying histopathologic findings. Although the clinical manifestations seen in these lesions vary widely, the underlying etiology of thrombotic microangiopathy remains consistent and reproducible.     

Dermatologic comorbidities of the patients with severe COVID‐19: A case‐control study

The current studies focus on the association between COVID‐19 and certain comorbidities. To the best of our knowledge, the association between severe COVID‐19 and dermatologic comorbidities has not been reported yet. In this study, we aimed to describe the dermatologic comorbidities of patients with severe COVID‐19 and compare it with the control group. Patients who have died at U?ak Training and Research Hospital due to COVID‐19 and other diseases in the COVID‐19 Intensive Care Units and Internal Medicine Intensive Care Units were recruited into the study. Two groups were compared with each other regarding the most common dermatologic comorbidities. A total of 198 patients including 111 patients with COVID‐19 and 87 age and sex‐matched patients with other diseases were enrolled in the study. The most common dermatologic comorbidities were pruritus (8.1%), eczema (6.3%), skin infections (3.6%), leukocytoclastic vasculitis (1.8%), and urticaria (0.9%) in the COVID‐19 group while they were skin infections (9.2%), eczema (3.4%), pruritus (2.3%), and urticaria (1.1%) in the control group. None of patients in the control group had leukocytoclastic vasculitis. There were no significant differences between COVID‐19 and control groups in terms of pruritus, eczema, skin infections, and urticaria (P values were .117, .517, .181, .505, and 1.000, respectively). In conclusion, although it is not statistically significant, it appears that pruritus and leukocytoclastic vasculitis are more common in severe COVID‐19 patients. These cytokines‐related diseases in the immuno‐cutaneous systems may give some clues on the COVID‐19 severity. Further studies are required to elucidate the relationship between the immuno‐cutaneous system and COVID‐19 severity.     

Rituximab as the treatment of pemphigus vulgaris in the COVID‐19 pandemic era: A narrative review

Pemphigus vulgaris (PV), an autoimmune blistering disease is treated with immunosuppressive medications. As the immunosuppressive effect of rituximab, the first‐line therapy of PV, lasts more than 6 months, many concerns have raised due to the ongoing novel coronavirus disease (COVID‐19) pandemic. With this background, our objective was to review the currently available literature as well as important websites for the evidence related to rituximab, PV and COVID‐19, adverse effects associated with drugs, and relevant guidelines. “PubMed” and “Google Scholar” database were systematically searched for retrieving all articles related to anti‐CD20 therapy in pemphigus vulgaris and COVID‐19 published up to 14 July 2020. A total of seven clinical studies are performed with anti‐CD20 therapy in COVID‐19, three of which are performed on pemphigus patients, and have shown concerns employing rituximab in patients with COVID‐19. Evidence for treating PV patients with rituximab in COVID‐19 pandemic is limited. Until sufficient evidence or guideline for pemphigus and COVID‐19 treatment is available, we advocate caution commencing rituximab in patients with pemphigus, due to the reported adverse outcomes.     

Immunosuppressive drugs for patients with psoriasis during the COVID‐19 pandemic era. A review

The COVID‐19 has been spreading around the world. Concerns about the safety of administration of immunosuppressive drugs have been raised for treatment of psoriasis (PSO), and there is insufficient evidence for the risk of COVID‐19 infection for psoriatic patients using these drugs, so we did a review, focusing on the risk of overall infection associated with the most commonly used immunosuppressive drugs, such as methotrexate, biologics, cyclosporin, Janus kinase inhibitors for the treatment of PSO. The data on the effect of immunosuppressive drugs on this virus may be ever‐changing and remains to be clear. We recommend the initiation and continuation of low‐risk immunomodulating drugs, such as Interleukin (IL)‐17, IL‐12/23, and IL‐23 inhibitors, for treatment of PSO during COVID‐19 era. For psoriatic patients with comorbidities switching to safer modalities such as systemic retinoids, apremilast, and home phototherapy is recommended. Immunosuppressive drugs should be withheld in psoriatic patients with the COVID‐19 infection.     

Coronavirus disease (COVID‐19): An updated review based on current knowledge and existing literature for dermatologists

The world entered the year 2020 with reports of the emergence of a new viral illness in Wuhan city, Hubei province, China. In January 2020, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was identified to be the causative novel coronavirus for the cluster of patients suffering from pneumonia in China. The disease was later named as coronavirus disease (COVID‐19) and was declared a pandemic by the World Health Organization on March 11, 2020. Several studies, since then, have tried to study and explain the origin of SARS‐CoV‐2, its structure and pathogenicity, epidemiology, modes of transmission, spectrum of illness and causes of mortality and morbidity. The current management strategies focus on supportive care and prevention of complications. With no definite treatment, as of now, encouraging reports of some anti‐viral and anti‐malarial drugs in the management of COVID‐19 generate some hope. This review intends to cover the current known aspects of COVID‐19 and SARS‐CoV‐19, based on the available literature.     

Tetracyclines in COVID‐19 patients quarantined at home: Literature evidence supporting real‐world data from a multicenter observational study targeting inflammatory and infectious dermatoses

Tetracyclines (TetraC) are widely used in dermatology for both inflammatory and infectious dermatoses; recently both in vivo and in vitro studies started to suggest also a potential antiviral effect. During COVID‐19 outbreak, several dermatological patients contracted SARS‐CoV‐2 experiencing only mild symptoms, but no protocol were approved. A multicenter prospective observational study that enrolled COVID‐19 patients visited with teledermatology and undergoing TetraC was performed. About 38 adult outpatients (M/F: 20/18, age 42.6 years [21‐67]) were enrolled. During the TetraC treatment, symptoms resolved in all patients within 10 days. Remarkably, ageusia and anosmia disappeared in the first week of TetraC treatment. TetraC seem a promising drug to treat COVID‐19 outpatients with mild symptoms.     

Effect of the COVID‐19 pandemic on the anxiety and depression levels in patients who applied to the cosmetology unit

The relationship between the skin and the brain is based on their origin from the same ectodermal structure, as well as being affected by similar hormones and neurotransmitters. At this point, psychodermatology forms a common field of study based on the relationship and interaction between psychiatry and dermatology. Cosmetology is a special group within dermatology, and the psychosocial needs of this group differ. In this study, it was aimed to examine the moods such as anxiety, fear and depression experienced by the patients during their application to the cosmetology unit during the COVID‐19 pandemic process and to compare them with the control group. A total of 162 cases, 80 cases from the cosmetology unit meeting the specified conditions and 82 cases as the control group, were retrospectively evaluated. In all participants, the Coronavirus Anxiety Scale (CAS) scores decreased significantly compared to the beginning of the pandemic (P = .001). In the study, while depression (HAM‐D) and general anxiety (HAM‐A) were higher in the cosmetology group compared to the control group (P = .049 and P = .001, respectively), there was no difference in coronavirus anxiety scores (CAS) (P = .24). It should be known that patients who underwent cosmetological procedures during the pandemic period may have anxiety and depression. In this patient group, which requires a special psychodermatological approach, pandemic effects should also be considered. In patients who apply to cosmetology units during the pandemic period, attention should be paid to the relationship between surreal cosmetological process requests and their anxiety and depression state.