Effective Role of Teledermatology in Managing Chronic Urticaria Patients during the COVID-19 Pandemic

Abstract

Sir, Chronic urticaria (CU) is a common dermatological disorder characterized by pruritus and weals with or without angioedema. More than 50 million patients are affected globally by CU.[1] Coronavirus disease 2019 (COVID-19) continues to be a threat even today, disrupting the healthcare systems and patient care. Patients with CU are also affected by the variable durations of lockdowns, social distancing measures, and travel restrictions. CU may be severe at times, requiring immediate medical care. However, usual patients of CU can be managed through teledermatology effectively. Teledermatology is a way of communication where personal information such as age, gender, medical history, and images of the skin lesions are shared by a patient to a physician. It can have real-time online consultation (synchronous) with a physician or can undertake sharing personal information through E-mails and messaging platforms (store-and forward technique, asynchronous), which is the most widely used method. Teledermatology can also be hybrid where both asynchronous and synchronous can be combined.[2] A multicenter study by Kocatürk et al.[1] which shared the experiences of Urticaria centers of Reference and Excellence (UCAREs) during this pandemic in managing CU found that there was a significant decrease in the face-to-face consultations during the pandemic due to obvious reasons and simultaneous increase in the teleconsultations by 600%. They have also mentioned that remote consultations have been a useful tool during the COVID-19 pandemic, but the long-term consequences of remote care of CU patients are yet to be characterized. There have been a few studies regarding the long-term outcomes of telehealth especially for allergy consultations. Waibel[3] found that both new and follow-up visits to the allergist were well complied by patients and demonstrated significant monetary savings. In another multicenter study by Waibel et al.,[4] tele-allergy supported most of the patients without in-person consultation with high patient satisfaction and significant time and cost savings. We have been interviewing and providing consultations to CU patients during the pandemic. Most of the old patients under follow-up are satisfied by the teledermatology. However, new-onset urticaria with fever needs attention and face-to-face consultation in lieu of early manifestation of COVID-19. CU patients do not require vigorous mucocutaneous examinations to be performed at every visit in face-to-face consultations. Patient’s disease exacerbations or control can be objectively calculated through the valid Urticaria Activity Scores over 7 days and Urticaria Control Test, which can well be filled and discussed through telephonic consultations or Internet and communication technologies (ICTs). Moreover, antihistamines dosages can also be titrated in CU patients with disease exacerbations or remissions through teledermatology and may alleviate the need to visit the centers amidst the pandemic. Patients have been treating using teledermatology with updosing of antihistamines or short course of corticosteroids to control CU. A recent study during the COVID-19 pandemic by Thomas et al.[5] which was performed in a tertiary allergy center with 23.2% of urticaria/angioedema referrals found that teleconsultation-based allergy service models may be more time and cost-effective and also improve patient accessibility to a specialized care. None of the studies during the literature search demonstrated any counter to remote consultation of urticaria/angioedema during the pandemic. It is also recommended to maintain the ongoing treatments with antihistamines and omalizumab during the present pandemic, but to be cautious with the use of immunosuppressives for CU.[1] This can well be monitored through teledermatology. However, in a resistant-CU patient, short courses of low-dose oral corticosteroids and cyclosporine may be utilized for disease control. Treating dermatologists or allergists should be cautious and should not forbid their use. Recalcitrant or refractory CU in the COVID-19 pandemic may be treated with short courses of corticosteroids and cyclosporine as there are reports of improved clinical outcomes with cyclosporine and low-dose corticosteroids treatment in patients with moderate-to-severe COVID-19.[6] The experience with teleconsultation or ICTs has been satisfactory as per various studies. Moreover, in our experience also, it provided a great relief and satisfaction to the urticaria patients especially who required tailoring of dosages and counseling regularly. Monitoring patients with CU on treatment may be well managed by teledermatology as there is no requirement of repeated clinical examination in already-established cases of CU. Validated scores and questionnaires are sufficient to assess the disease severity or disease control in CU patients and can be obtained through teleconsultation or ICTs. Non-face-to-face consultations during COVID-19 in CU patients may be more time saving and cost effective; moreover, it may also significantly decrease the chances of contracting severe acute respiratory syndrome-coronavirus-2 infection. However, face-to-face consultations may not be replaced fully by teleconsultations using ICTs, but it may be an effective alternative during the present pandemic. Further, large and long-term studies are required in future to provide much improved and validated results. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.