Consensus on Pre-examination and Triage in Clinic of Dermatology During Outbreak of COVID-19 From Chinese Experts^#

Abstract

The 2019 novel coronavirus infection has brought a great challenge in prevention and control of the national epidemic of coronavirus disease 2019 (COVID-19) in China. During the fight against the epidemic of COVID-19, properly carrying out pre-examination and triage for patients with skin lesions and fever has been a practical problem encountered in hospitals for skin diseases as well as clinics of dermatology in general hospitals. Considering that certain skin diseases may have symptom of fever, and some of the carriers of 2019 novel coronavirus and patients with COVID-19 at their early stage may do not present any symptoms of COVID-19, to properly deal with the visitors to clinics of dermatology, the Chinese Society of Dermatology organized experts to formulate the principles and procedures for pre-examination and triage of visitors to clinics of dermatology during the epidemic of COVID-19.

Introduction

There are extensive concerns around the novel coronavirus (2019-nCoV) as the viral infection is spreading all around the world. As the members of the family of coronaviridae, the severe acute respiratory syndrome coronavirus¹ and Middle East respiratory syndrome coronavirus,² have caused more than 10,000 cumulative cases in the past two decades. Also, 2019-nCoV has led to more than 80,000 patients of novel coronavirus pneumonia and nearly 3000 deaths in the world, mainly in Hubei province of China. Health care workers and the public are facing an unprecedented challenge in prevention of these viral infections and cross infections. Considering the most common symptom of coronavirus disease 2019 (COVID-19) is fever, and many kinds of skin diseases are also accompanied by fever, properly carrying out pre-examination and triage for patients with skin lesions and fever has been a practical problem encountered in the hospitals for skin diseases and dermatology clinics in general hospitals. The Chinese Society of Dermatology organized experts to formulate the principles and procedures for pre-examination and triage of visitors to clinic of dermatology during outbreak of the 2019 novel coronavirus infection, so as to properly deal with the visitors to clinics of dermatology.

Set-up of pre-examination and personnel prospective measures of workers carrying in pre-examination and triage

A separate pre-examination should be set up for visitors to clinic of dermatology in hospitals for skin diseases and general hospitals with large number of visitors to dermatology clinics. Dermatologist should be involved in the pre-examination of patients presented with skin lesions and fever. The protective measures for personnel carrying in pre-examination include properly wearing disposable hat, work clothes, medical surgical masks or particulate protective masks, goggles, barrier gowns, and gloves.

Pre-examination

Each patient should be allowed at most one accompanying person when entering the clinic and mandatory masks are required for both patient and accompanying person. All patients and accompany persons should be tested for body temperature and investigated for the following information: (1) whether they have or had symptoms of fever, cough, and dyspnea in the past 2 weeks; (2) whether they had history of close contact with confirmed patients infected with 2019-nCoV or suspected cases, or a suspicious environmental exposure within 14 days before the visit; (3) whether there is a clustering onset of similar symptoms around the visitor. All visitors and accompanying persons should sign a letter of commitment of honest and be emphasized that they may bear legal consequences if they provide false information or conceal any medical history, exposure history, and other needed information.

Triage

All visitors to dermatology clinics with any positive history of close contact and exposure to confirmed or suspected COVID-19 should be instructed to the fever clinic immediately before visiting dermatology clinics. For visitors to dermatology clinics with negative history of history of exposure to COVID-19, but have symptoms of fever (body temperature higher than 37.3°C), dermatologist should be involved in triage according to the following principles.

As we have already known, a variety of skin diseases may be accompanied by fever, which can be categorized into the three following types:

1) Skin diseases almost always accompanied by fever including: (1) viral infectious diseases, such as measles, rubella, exanthem subitem, hand-foot-mouth disease, infectious mononucleosis, chicken pox, and Kaposi varicelliform eruption; (2) bacterial infectious diseases, such as scarlet fever, staphylococcal scalded skin syndrome, erysipelas, cellulitis, and other serious infections of skin and soft tissues; (3) noninfectious diseases of the skin, such as severe drug eruption: acute generalized exanthematous pustulosis, Stevens-Johnson syndrome, toxic epidermal necrolysis and drug-induced hypersensitivity syndrome, generalized pustule psoriasis and erythrodermic psoriasis, Sweet disease, adult Still disease, Kawasaki disease, febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta, and so on.

For these visitors with symptoms of have fever, they should be allowed to first visit a dermatology clinic, but only if they have negative of history of exposure to COVID-19. Considering possibility of drug eruptions in patients infected with 2019-nCoV after taking drugs, a more detailed history should be screened to exclude infection of 2019-nCoV including the reasons of taking drugs, the symptoms before taking medicine and the process of diagnosis and treatment, besides the history of exposure to COVID-19.

2) Skin diseases possibly accompanied by fever including: erythema infectiosum, mild to moderate drug eruption, erythema multiforme, erythrodermic atopic dermatitis, severe contact dermatitis, secondary bacterial infection in pemphigus and bullous pemphigoid, connective tissue disease such as systemic lupus erythematosus and dermatomyositis, Behcet disease, panniculitis and vasculitis, and so on.

For these visitors who have symptoms of fever, they should be allowed to visit dermatology clinic under extensive monitor, but only if they have negative of history of exposure to COVID-19. Also considering possibility of drug eruptions in patients infected with 2019-nCoV after taking drugs, a more detailed history should be screened to exclude infection of 2019-nCoV including the reasons of taking drugs, the symptoms before taking medicine and the process of diagnosis and treatment, besides the history of exposure to COVID-19.

3) Skin diseases rarely accompanied by fever including: primary herpes simplex, herpes zoster, and some subtypes of urticaria such as serum sickness-like reaction, and so on.

For these visitors who have fever comparable with the diseases of the skin, they could be allowed to visit dermatology clinics, only if they have negative of history of exposure to COVID-19. Otherwise, they should be guided before fever clinic.

Previous study has shown that common symptoms of COVID-19 include fever (98%), cough (76%), dyspnoea (55%), and myalgia or fatigue (44%); less common symptoms are sputum production (28%), headache (8%), haemoptysis (5%), and diarrhoea (3%).³ There has never been a reported case of skin lesions of symptoms related to COVID-19 in the published literature.^4–6 Although someone diagnosed a case of 2019-nCoV infection presented with fever and urticaria (not published). Therefore, we should pay attention to the rashes related to 2019-nCoV infection.

Considering some patients of COVID-19 may have uncertain or negative history of exposure to epidemic area or confirmed and suspected cases,⁷ all the dermatologists should recheck the patients’ body temperature and make a thorough inquiry into their history of exposure to 2019-nCoV infection when they interview a patient. Furthermore, all the medical staffs should always be vigilant to prevent 2019-nCoV infection during the process of pre-examination, triage, and medication in clinic.