The following hierarchy of service adjustments could be considered:
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1)
New patient visits for particularly severe cases of suspected angioedema, in particular events with pharyngeal/laryngeal, abdominal, or genital involvement, can be prioritized for face-to-face visits or telehealth. Such patients may need laboratory workup for hereditary angioedema. Much of the visit could be conducted via virtual care, with orders placed for phlebotomy as appropriate (if available).
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2)
For patients with established hereditary angioedema under good control without any remarkable episodes in the past 6 mo, it would be in their best health care interest to be managed by virtual care.
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3)
Visits for new onset of lesser severity of angioedema can be postponed (consider telehealth).
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4)
Visits for new evaluation of chronic urticaria can be postponed, with referring physicians given instructions to start the patient on every-day-twice-a-day dosing of potent nonsedating antihistamines (eg, cetirizine, fexofenadine, or loratadine), according to best evidence, pending resolution of the COVID-19 pandemic.52 Evidence suggests that laboratory testing can be postponed or deferred in most patients with chronic spontaneous urticaria.53
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54 Patients with refractory urticaria could be considered for telehealth or a face-to-face visit to recommend further evaluation and management, including initiation of omalizumab in properly selected patients.55
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5)
Face-to-face visits for ongoing evaluation of established chronic urticaria can be deferred, in particular if this condition has been well controlled in the past 6 mo, and issues or medication adjustments can be handled through phone triage or telehealth.
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6)
For new evaluation of atopic dermatitis, severity of the illness as assessed by the referring physician should be strongly considered. Visits for mild atopic dermatitis evaluation may be deferred and the patient managed with topical corticosteroids under the direction of the referring provider. A recommendation to escalate potency within a certain range of topical corticosteroids can be provided. For moderate atopic dermatitis, consider telehealth evaluation. For severe disease, in particular in an infant or in a patient with extensive body surface area involvement and a history of superinfection, face-to-face visits may be necessary and should receive priority over any other patient with atopic dermatitis. For return patient visits for atopic dermatitis, the same general principles apply, with extended consideration for the use of telehealth in the more severe patients who have demonstrated improvement in lieu of face-to-face visits.
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7)
In the context of atopic dermatitis without a history of acute food reaction, food allergy screening should be deferred. No skin or serologic allergy testing evaluation without a discernable, probable food trigger is advised, given this is low yield and represents a poor prioritization of services.56, 57, 58, 59, 60
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8)
Initiation of biologic therapy for atopic dermatitis should be weighed very carefully but remains a viable option because this is administered at home and requires limited face-to-face supervision. This can be managed via visiting nurse services or via phone triage.
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