Psoriasis health care in the time of the coronavirus pandemic: insights from dedicated centers in Sardinia (Italy)

Abstract

Dear Editor, Psoriasis is a major chronic inflammatory skin disease, affecting about 3% of the population in Italy, whose management requires experienced specialists in order to guarantee high-quality standards of care.1 The pandemic coronavirus (2019-nCoV; COVID-19) has changed the approach to all patients requiring close contact during a visit, including dermatologic consultations. In Italy, true outbreak begun in Lombardy, by 21 February 2020 with exponential contagion, surpassing China in the number of deaths.2 The healthcare system was overwhelmed, and best hospitals in Northern Italy unable to cope with the huge number of desperately ill patients. Concern about the impact on the South was great due to the chronic shortage of facilities and limited intensive care equipment. In Sardinia, with a population of 1 640 000 inhabitants,3 the institutional recognition found only 20 intensive care beds available to welcome COVID-19 cases. A strategic plan will increase the number to 224 beds, but full implementation would require time (Resolution of the Regional Council 11/17 of the 11/03/2020). As isolation is the main weapon to control the spread,4 and on 9 March 2020 a Decree of the President of the Council of Ministers ordered the suspension of all outpatients’ services, including clinics for psoriasis patients. Unfortunately, thousands of patients were suddenly deprived of dermatologic care. The dedicated psoriasis clinics in the major hospital of Cagliari, Nuoro and Sassari account approximately 6890 patients. About 23% of them afflicted with severe psoriasis and psoriatic arthritis, requiring systemic treatments or phototherapy (Table 1). 6890 1586 (23%) We began calling all patients with scheduled visits and programmable procedures to remain at home, providing telephone consultation and counselling. Patients were completely unprepared, upset and disoriented by the lockdown. Some patients could not understand the crisis and demanded full attention, quite aggressively. Other patients were more understanding. Only patients requiring dose adjustment and/or blood chemistry controls were admitted, as well as patients requiring infusions, such as infliximab. The access to the phototherapy service was also maintained for selected cases. On 13 March 2020 the Italian Medicines Agency (AIFA) allowed the automatic renewal of all expiring therapeutic plan, required for biotechnological drugs, preventing patients from referral only to have their prescription renewed. As awareness of the severity of the COVID-19 increased, some patients were concerned about continuing their biologics. We followed the SIDEMAST recommendations5 and advised patients not to dismiss their drugs without consultation, especially biologics. Clinical trials were continued for patients already enrolled, but new screening was discontinued, and prudently, not new treatment was started. Patients were admitted only after a strict triage: body temperature was registered and was required the compilation of a questionnaire, on recent symptoms (fever, cough, breathing difficulties) or travels outside Sardinia. A quarantine of two weeks had become mandatory from 8 March 202. Thankfully, Sardinia COVID-19 cases are small in magnitude, but we hold an unpleasant record. On 26 March 2020, the number of infections among health personnel was higher (40%) than the national average of 7–8%.6 In this uncomfortable setting, a COVID-19 patient indicated the skin consultation at the Dermatology Clinic of Sassari as the possible source of contagion. All the health personnel resulted negative for the infection, but we clearly felt the risk of being considered ‘spreaders’ for the community, instead of essential care providers. We were more exposed to involuntary contagion from asymptomatic patients and not provided with the necessary personal protective equipment. As dermatologists are specialists not directly involved in the management of critical patients, the supply of specific protective equipment against bio-hazards, as well as of environmental sanitizers, was very limited, and the massive consumption from critical care wards depleted all stocks. Thus, all not essential sanitary personnel were placed on vacation, but with the possibility of being called back into service to support other critical specialties. Educational programmes for medical students, graduate and resident have been interrupted. Effects of pandemic coronavirus infection are without precedents. Restrictive measures were mandatory, and dermatologists had to adapt: more counselling to support patients, detect unmet needs and find ways to reassure patients about their disease, to keep them safely home. None. All authors contributed equally to the manuscript and had the opportunity to revise and approve the final text.

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