Patients with bullous disorders during COVID‐19 period: Management and adherence to treatment

Dear Editor,

Pemphigoid is included in the group of rare autoimmune bullous disorders affecting the skin and the mucous membrane. It mainly occurs in elderly patients that usually present other comorbidities such as cardiovascular and respiratory problems. This bullous disorder is characterized by an alteration of T‐cell immune response, leading to the production of pathogenetic autoantibodies directed against different proteins of the desmosome, and by the release of pro‐inflammatory cytokines. This immune alteration clinically manifests with vescicles and erosions on the epithelium of the mucous membrane and of the skin, exposing patients to a higher risk of comorbidities and secondary infections. ¹ SARS‐CoV2 infection has now spread all over the world and higher mortality rates have been reported among elderly and comorbid (diabetes, cardiovascular disease, and immunosuppression) patients. In this scenario, patients with bullous pemphigoid are part of the high‐risk population and preventive measures in order to minimize the risk of infection must be implemented.

We want to share our experience about the management of patients with bullous disorders, in particular pemphigoid disease in our outpatient clinic during COVID‐19 pandemic.

Since the beginning of March 2020, in our Dermatological clinic, outpatient visits have been suspended with the postposition of all nonurgent visits, except for oncological dermatology and emergencies. Ten patients (six women and four men) with a median age of 68.5 years, affected by bullous pemphigoid, all histologically confirmed, were already followed in our Day‐Hospital service before the COVID‐19 pandemic spread. Then, 7/10 (70%) patients had a mild‐moderate grade of the disease, whereas, 3/10 (30%) presented a severe grade of the disease. Diabetes and hypertension were the two comorbidities most frequently reported. Only 3three patients (30%) presented other malignancies: one patient had breast cancer, one gastrointestinal cancer and one presented multiple basal cell carcinomas. All patients were treated with glucocorticoids, in particular: two patients (20%) were in treatment only with topical high potency corticosteroids (CCS), two patients (20%) with oral CCS, three patients (30%) with both topical and systemic CCS, and three patients (30%) with azathioprine in addition to topical and systemic CCS. Different dosage of CCS were administered according to patients comorbidities. Almost all patients (80%) had a good control of their bullous disease and routine blood exams, performed in external laboratories and then transmitted to physicians were within the normal limits.

It has been widely recognized that the use of immunosuppressive agents, such as oral CCS is associated with an increased mortality in patients with coronavirus pneumonia, ² but, on the other hand, there are no evidences suggesting the preventive discontinuation of CCS in patients on long‐term treatment with these drugs, especially for the risk of acute adrenal insufficiency. ³ Weekly telephonic consultations were performed in order to control patients adherence to treatment and to avoid the risk of COVID‐19 infection. Patients received information about the importance of home isolation and the early identification of COVID‐19‐related symptoms. Video‐call visits were performed and CCS dosages were tapered in case of adverse events and according to the reported skin condition, showing good results and without discontinuing their treatment. In literature, several articles suggesting the use of teledermatology services, such as video‐call visits, email, and mobile applications as useful tool to take care of patients during this pandemic period have already been reported. ⁴ , ⁵ This tele‐service resulted to be effective also in the follow‐up of our patients with rare autoimmune disorders; nevertheless reports on larger sample size are needed.

CONFLICT OF INTEREST

None declared.