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Forming ranks

On the frontlines of the COVID-19 pandemic, dermatologists stand with their medical colleagues to help where most needed


Forming ranks

On the frontlines of the COVID-19 pandemic, dermatologists stand with their medical colleagues to help where most needed


By Emily Margosian, assistant editor

“I knew I wasn’t going to be able to live with myself if I hadn’t participated in the biggest medical crisis of my lifetime,” said Massachusetts dermatologist Sarita Nori, MD, of her decision to volunteer at a Boston field hospital dedicated entirely to the care of COVID-19 patients. “I didn’t want to get to the end of my career, look back, and think, ‘Oh yeah, that COVID thing happened, and all I did was a couple of punch biopsies.’ I wanted to scientifically see what this disease looked like in a patient, and I felt useless sitting on the sidelines.”

Since the novel coronavirus first emerged in December 2019, it has fundamentally altered the human landscape. Globally, cases have surpassed over 15 million, and the disease has impacted about five million Americans to date. Amid great social and economic cost, policymakers and public health officials have struggled to reach a unified response halting the pandemic’s spread. Despite these pressures, medical professionals worldwide have stepped beyond their specialties to support frontline health care workers. “It’s been a long time since I stayed up all night on an overnight shift,” said Linda Stein Gold, MD, the AAD’s next vice president-elect and division head of dermatology at the Henry Ford Health System, who voluntarily re-deployed to the ER to assist COVID-19 testing. “The emergency room staff is so appreciative of the help, and they couldn’t be more welcoming to us. Everyone is there to help, and we are all in this together.”

This month, Dermatology World talks with dermatologists from across the country about their efforts assisting on the frontlines of the COVID-19 crisis, including:

• Direct COVID-relief efforts and testing

• Collaboration with local government

• PPE conservation techniques

• Innovative patient care

• Identification of cutaneous COVID-19 symptoms

• Partnership with infectious disease experts 

Boots on the ground

The Boston Convention and Exhibition Center was a familiar, yet unfamiliar sight to Dr. Nori in early April. Converted into the “Boston Hope,” the facility had been reconfigured to relieve local hospital systems experiencing a surge of COVID-19 cases. “If you can imagine the exhibit hall for the AAD conference — they converted that into rows and rows of 10- by six-foot cubicles, erecting approximately 1,000 rooms in five days,” she said. While the pop-up hospital was intended for stabilized patients to help clear beds in ICU wards, Dr. Nori says the reality was more unpredictable. Despite the presence of intensivists on-staff to assist with escalating cases, on more than one occasion, Dr. Nori had to draw on past training to help stabilize struggling patients. “I had one patient who was de-satting, and I knew to put him prone on his belly to increase the number of alveoli that were being recruited,” she explained. “I finished an internal medicine residency 18 years ago, and some of it came back, but I definitely relied on my hospitalist app to look up some things. I also got to pull out my stethoscope to listen to lungs, which was a little nerve-wracking.”

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Although Dr. Nori admits that the experience at times has been “very scary,” she says volunteering at Boston Hope has proved to be a rewarding opportunity to flex her strengths as a dermatologist in a new setting. On her first night, instead of going to sleep, Dr. Nori wanted to keep working instead of going to sleep. “I thought, I’m going to get into the EMR and start prepping discharge summaries for the next day. That’s a typical derm thing to do. Any of us would have done that; we wouldn’t have just gone to sleep when there was something that needed to be taken care of, because nobody is more efficient than dermatologists.”

Dr. Stein Gold agrees that dermatologists have not shied away from lending a hand in COVID-relief efforts. Since March, she and her colleagues have been administering COVID-19 tests to patients to alleviate the burden on emergency room staff. “There were a number of us who were re-deployed to the ER. We weren’t drafted; we were given the option to help out. Our first-year residents have been working in the emergency room and are fully immersed there, assisting in every way,” she said. “We work full shifts in the ER, and with Detroit being one of the hot spots in the country, the help is really desperately needed.”

Outside the ER, dermatologists have also taken a direct role in shaping public health responses to the ongoing crisis. Dermatologist Col. Philip Latham, MD, currently serves as the State Air Surgeon for the South Carolina National Guard and has taken an active role in the state’s COVID Response Task Force. “My first job was to assist with medical surge planning. So liaising with almost every hospital throughout the state to determine how many beds they have and how many beds they could accommodate if they get overwhelmed,” he explained. “We’re also planning a medical strike team where Guard members will be set up throughout the state to go in and respond if, for example, a nursing home or a factory starts having a sudden outbreak. Ideally, we can come in and test staff within 24 to 48 hours’ notice.”

Despite his many years of service as a dermatologist and National Guardsman, Dr. Latham says the pandemic has proved to be an unprecedented challenge. “Normally in the National Guard, we are responding to natural disasters, but so far this has proved to be one of the longest missions we’ve ever participated in,” he said. “I know the virus will drag on longer than I had hoped, but at least I can say that I’m doing something that’s making a difference.”

PPE preservation

Of the many challenges produced by the sudden onslaught of the virus, widespread shortages of personal protective equipment (PPE) posed the most immediate danger to frontline medical providers. To help alleviate the shortage, dermatologists took the lead on several innovative methods for preserving PPE. Sherry Yu, MD, who at the time was serving as a dermatology resident in Harvard’s Combined University Training program and Deland Fellow in Health Care and Society at Brigham and Women’s Hospital (BWH), led PPE innovation and conservation within the logistics branch of the Incident Command structure at BWH. Dr. Yu, who is now a Mohs micrographic surgery fellow in the dermatology department at the Yale School of Medicine, was inspired by a photo of a hands-free COVID-testing booth prototype developed in South Korea. “The model used a physical plexiglass partition with holes for a provider wearing gloves to swab patients for testing,” she explained. “That made me think about a free-standing booth where a provider didn’t need to wear any PPE. The goal is to make sure everyone stays safe while preserving as much PPE as possible.”

Within the span of four days, Dr. Yu worked with hospital leadership, the engineering team, and infection control and safety experts to design and produce the first prototype which was deployed immediately. Shortly thereafter, an additional nine testing booths were created and have since been deployed across BWH and other hospital systems and community centers, including hard-hit virus hotspots. The opportunity to help address the current PPE shortage has been a rewarding one, said Dr. Yu. “You’re collaborating not only within your own hospital, across departments, divisions, and roles — but you’re collaborating with the broader community as well. It’s really heartwarming to see how everyone’s creative energy is being directed at solving the PPE shortage issue.”

Likewise frustrated by the PPE shortage, Detroit-based dermatologist Iltefat Hamzavi, MD, used his phototherapy expertise to tackle the issue in a unique way. “We’ve known for decades that UVC light can inhibit the growth of certain bacteria and viruses,” said Dr. Hamzavi, who is part of the photomedicine unit at the Henry Ford Health System. Working closely with a phototherapy technology manufacturer, Daavlin, Dr. Hamzavi and his team were able to produce a device prototype for sanitizing N95 masks for reuse by medical professionals. “We were able to do experiments proving that the entire mask could be irradiated with UVC. Dermatologists are very good at dosing light to make sure the entire surface of the skin receives it, so we applied those same ideas to this concept,” he explained.

Dr. Hamzavi’s team further coordinated with the infection control group at Henry Ford to develop a process for accepting and decontaminating masks within the hospital system. “We’ve decontaminated over 1,400 masks at this point. The device has been deployed to three hospitals in our system, and about 15 throughout the country,” he said. Dr. Hamzavi’s team has also been working to gain FDA-approval for their device, in addition to collaborating with other manufacturers to improve their products for PPE decontamination. “We’re going to rapidly work on the science until we’ve got it right, but right now we’ve got something that’s better than using a bandana or a contaminated mask,” he said. 

First responders

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Innovative patient care in a time of pandemic

Massachusetts dermatologist Helen Raynham, MD, has taken an unexpected approach to accommodating patients during the COVID-19 crisis. Although Dr. Raynham’s practice was able to launch teledermatology services within roughly a week after businesses began to close their doors, some patients were struggling to adapt to the new system. “It was frustrating for some of our older patients who cannot get telehealth visuals to work at all,” she said. “They were very relieved when I said to them, don’t worry, I have another solution.”

After securing permission from her town’s Department of Public Health, Dr. Raynham erected a drive-thru dermatology clinic in her office’s parking lot. “We have a commercial grade tent there and have made it clear that this is not the same thing as going to Dunkin Donuts. Patients have to try telehealth options first, and if they are still struggling, they have the option of the drive-thru. We want to flatten the curve, and that involves making sure that our drive-thru dermatology clinic is safe.”

Dr. Raynham says the drive-thru clinic has been a hit with patients so far. “I had one patient, a very elderly gentleman, who needed a biopsy. I have an exam set-up where I have a table, chair, and my little biopsy kit I usually take to the hospital when I’m on-call. He was quite anxious about coming inside the office, and in the privacy of the tent I was able to do a quick biopsy in a way that he felt comfortable.”

Dr. Raynham has also taken a creative approach to assessing patients while maintaining social distancing through the use of high-grade binoculars. “I’m currently waiting on a new pair specifically for viewing butterflies, but right now I’m using the ones I have when I go on safari,” she said. “I’m originally from South Africa, so I’m very familiar with using binoculars for wildlife. Now I used them this morning to see a patient!”

An open invitation

Despite widespread support from public health experts, mandatory masks during COVID-19 remain controversial. Prior to the pandemic, experts observed an “unprecedented” reemergence of infectious disease due to cultural factors. Learn more about what’s driving their return. 

Identifying cutaneous signs of COVID-19

While investigation remains ongoing, there is evolving evidence suggesting that skin manifestations may occur in some COVID-19 patients. One such manifestation, pernio-like lesions found on the feet and hands of some COVID-19 patients, dubbed “COVID toes,” has garnered significant media coverage. However, other related rashes have since emerged in conjunction with the virus. Dr. Nori first took note of the phenomenon in early March, reaching out to international colleagues with a several weeks’ head start on observing the effects of the virus’s spread in their countries. “By early March I had seen a whole bunch of pernio/chilblains cases, which is very odd to have such a cluster,” she said. “I managed to get in contact with some French and Italian dermatologists to find out what they had been seeing and learned that they had collected about 250 COVID-related rashes in their informal registry, and shortly after that they published anecdotal reports about the ‘COVID toes.’”

Dr. Nori assembled these accumulated anecdotal reports from across the globe into a preliminary triage protocol, concerned that pre- or asymptomatic COVID patients with dermatologic manifestations might be unknowingly seen by providers without sufficient PPE. “I started talking to the incident command team at my group, and it took about 10 days working with the infectious disease and dermatology chiefs to come up with a triage protocol,” she said. The protocol, which has been adopted by dermatologists in other health systems, homes in on vascular rashes, livedo reticularis, and pernio/chilblains in patients with no prior history of Raynaud’s or any known trauma.

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Further collaboration among dermatologists throughout the global community has been fostered with the development of the COVID-19 Dermatology Registry. Esther Freeman, MD, PhD, assistant professor at Harvard Medical School and director of Global Health Dermatology at Massachusetts General Hospital, was one of the principal drivers behind the registry and likens it to the historic early efforts of dermatologists who helped identify the emerging HIV/AIDS crisis through collaborative reporting of unusual Kaposi sarcoma clusters. “A registry can be very helpful, especially in the beginning of an outbreak or an epidemic, by helping us gather these different clinical observations and really start to form hypotheses,” she explained. According to Dr. Freeman, the registry highlights the ability of transatlantic teams to work together, with the project taking nine days from conception to the collection of its first data set — a process normally requiring a minimum of six months. “The main goal is trying to feed information back, not just to the dermatology community, but to all of those on the front lines,” she said.

The registry, which is open to any health provider anywhere in the world, currently houses data from over 38 different countries. At its launch, the database was collecting information on 20-30 cases per day of dermatologic manifestations of COVID-19, a number that has since expanded to a total of 1,000 cases. This collaboration has not only spanned national borders, but across specialty lines as well, according to Dr. Freeman. “When we were just starting the Dermatology COVID-19 Registry, we reached out to rheumatologists. They were about two weeks ahead of us, and were extremely willing to share their best practices and lessons learned from launching their registries. These registry efforts have really been about everyone pulling together to learn as much as we can, and quickly, about this virus.”

According to Dr. Freeman, to date, documented dermatologic manifestations of lab-proven COVID-19 commonly include:

• Morbilliform rash

• Pernio-like rashes

• Varicella-like eruptions

• Urticaria

• Livedo reticularis

• Retiform purpura

Current AAD recommendations on skin manifestations of COVID-19 advise that in the absence of any other clear cause, dermatologists should engage patients in case-by-case discussions of the appropriateness of self-isolation, following CDC guidelines, as well as COVID-19 testing by PCR and/or IgM and IgG serology. “We certainly don’t want patients to panic unnecessarily,” cautioned Dr. Freeman, who advises that patients who display suspected skin manifestations of COVID-19 without any other related indications for urgent evaluation should be managed with careful consideration of not overburdening local emergency room resources, particularly in hard-hit or surging areas. “The last thing we want to do is bring people into the ER unless absolutely necessary,” she said.