Management of a case of pemphigus foliaceus in a paraplegic man with palliative dermatology principles during COVID‐19 pandemic

AUTHORS CONTRIBUTION

B.H.: concept, patient consultation, manuscript writing. N.A.U.: concept, patient consulation, manuscript writing. M.J.: Concept, data collection, manuscript writing and editing. M.R.T.: concept, patient consultation, manuscript writing. T.P.A.: concept, patient consultation, manuscript writing. A.A.M.: patient consultation, manuscript editing.

Dear Editor,

COVID‐19 pandemic has crippled regular medical services, including those of dermatology department, worldwide. ¹ In this context medical management of disabled people, especially from lower socioeconomic strata, with chronic life‐threatening diseases become a social problem. We are describing a case of 50 years old man who was paraplegic for last 10 years. He presented by proxy with complaints of severe itching and scaling on trunk and scalp. Due to his physical incapacity he was not able to present himself in hospital due to transport issues. His condition was discussed with local palliative unit and the first author volunteered to visit the patient in his house with a team of palliative volunteer, driver, and nurse (Figure 1). On examination he was having multiple flaccid bullae over the trunk, areas of skin erosions, diffuse erythema, and scaling and crusts including scalp (Figure 2). Mucosa was not affected. Skin biopsy had to be avoided due to financial constraints and a clinical diagnosis of pemphigus foliaceus (PF) was made. Palliative laboratory assistant collected samples for routine tests, such as CBC, ESR, RBS, urine routine, liver, and kidney function test, mantoux test, HIV, HbSAg, etc, at home itself. After getting normal results, treatment was initiated with oral prednisolone 30 mg (tapered the dose by 5 mg in every week), oral cyclophosphamide 50 mg (dose increased to 100 mg in 2 weeks after reassuring the drug tolerability), levocetirizine 10 mg/day, topical clobetasol, and liquid paraffin. The medicines were donated from the drug bank of palliative care since the patient was not supported with any insurance system. A volunteer from the locality visited the house regularly to monitor the treatment compliance and to communicate with the doctor through popular communication platforms. Quality of life of the patient increased significantly within 2 weeks and the follow up was maintained smoothly with teleconsultation methods (Figure 3).

FIGURE 1.

Palliative dermatology team including the dermatologist, nurse, and driver during the home visit in dedicated vehicle

FIGURE 2.

Photo taken by palliative volunteer showing multiple flaccid bullae and erosions with diffuse scaling and crusting over trunk

FIGURE 3.

Photo taken by palliative volunteer showing areas of scaling and crusting with no active bulla or erosions after 2 weeks of treatment

Pemphigus foliaceus (PF) is an acquired autoimmune blistering disease which requires very long term treatment. ² Palliative dermatology (PD) is an emerging branch of palliative care (PC) which deals with dermatololgic conditions in palliative patients and dermatoses which require palliative care as well. ³ , ⁴ Role of dermatologists in PC have shifted from hospices to home care and tele consultation in the context of COVID‐19 pandemic. ⁵ We report this case to describe the working model of PD care during pandemic.

Home care service is an integral part of PC which is done with the help of community volunteers. ⁶ Essential components of a PD team for such services are enlisted below:

1. Dermatologist.

2. Trained palliative nurse who can be given additional role of drug bank.

3. Vehicle possibly donated by philanthropists or NGOs.

4. Driver trained in PC and basic life support who oversees home visit route maps.

5. Volunteers trained in PC.

6. Drug bank to avail commonly used medicines for free of cost.

There are basically three types of house visits in PD. (a) Regular house visits by volunteers in the locality, (b) Monthly visits by palliative nurses, and (c) On demand visit by the dermatologist. Most cases in dermatology can be discussed through telemedicine applications with the help of the volunteers. ⁷ But if the situation demands, the team should arrange the appointment of the dermatologist for home visit which should be done with all the necessary COVID‐19 precautions. Dermatologist should take baseline photos for future reference. Volunteers must ensure treatment compliance regularly and communicate the same with nurses/doctor with the help of serial images and videos. This model which enables a small number of dermatologists to cater services to a larger population beyond institutional affiliations, can be replicated globally with necessary modifications.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.