To the Editor: The COVID-19 pandemic created a global health emergency, forcing infection prevention measures into the clinical routines of patients with skin disorders. Our location in southwest Germany, near Italy, led to COVID-19 cases starting in February 2020. Evidence shows that the elderly and those with comorbidities are more vulnerable for severe SARS-CoV-2 disease, with higher mortality rates. We evaluated the impact of the pandemic on dermatologic patients, including both inpatients and day hospital outpatients, throughout 2020 compared with 2019. We analyzed a total of 6206 patients from January 1, 2019, to December 31, 2020 (Tables I and II ). Diagnoses were recorded with ICD-10 codes for each hospital visit individually, visits referring to both admissions and day hospital visits. Nonmelanoma skin cancer, including Merkel cell carcinoma and malignant melanoma, followed by eczema, leg ulcers, desensitization to allergens, and psoriasis, were the most frequent reasons for admission at our department in 2019, consistent with previous years.1 Pan-German data showed a 13% decrease in inpatients in 2020 compared with 2019.2 Similarly, we noticed an 8% (P < .001) decline in patient admissions (Table I). Proportionally, admissions below the age of 65 years decreased, whereas those above the age of 65 years increased to 58% of all hospitalizations (P > .99, Table I). We had fewer admissions of patients with inflammatory skin diseases (eg, eczema/psoriasis) and patients with lower leg ulcers (P < .001). Interestingly, patients admitted with herpes zoster as main diagnosis and receiving intravenous treatment as per German guidelines increased by 52% (P < .05) and were recorded throughout the year, possibly induced by stress-associated immunosuppression.3 We specifically aimed at not postponing admissions for oncologic patients, but reduced outpatient assessments could have led to delays.4 Although there were no differences in mean T stages in melanoma patients, we observed a higher proportion of sentinel lymph node extirpations in 2020 (2019: 45.6%, 2020: 47.4%; P = .462) (Table I). The increased number of immune-related adverse events (P = .001, Table I) likely mirrors the growing patient numbers treated with combined immunotherapy in stage IV melanoma.
Table I.
Hospital admissions in 2019 compared with those in 2020
| Variable | 2019 | 2020 | P values |
|---|---|---|---|
| Treatment days per year | 17.520 | 15.608 | .140 |
| Total, N | 2.411 | 2.231 | <.001∗ |
| Male, n (%) | 1.302 (54) | 1.206 (54) | >.99 |
| Female, n (%) | 1.109 (46) | 1.025 (45.9) | >.99 |
| Age, mean (SD) in years | 64.78 (19.14) | 64.76 (19.07) | >.99 |
| Stratified by age (years), n in years (%) | |||
| 0-17 | 30 (1.2) | 25 (1.1) | |
| 18-35 | 208 (8.6) | 202 (9.1) | |
| 36-49 | 251 (10.4) | 232 (10.4) | |
| 50-64 | 552 (22.9) | 478 (21.4) | |
| 65-74 | 422 (17.5) | 431 (19.3) | |
| 75-84 | 625 (27) | 617 (28) | |
| 85-94 | 635 (26.3) | 583 (26.1) | |
| 95+ | 23 (1) | 24 (1.1) | |
| <65 vs ≥65 | 1370 (56.8) | 1294 (58) | >.99 |
| Hospital stay, median in days | 6.02 | 5.88 | |
| Disease classification (ICD-10), n (%) | |||
| NMSC (C44) | 684 (28.4) | 615 (27.6) | >.99 |
| Malignant Melanoma (C43) | 265 (10.9) | 253 (11.3) | >.99 |
| Sentinel lymph node extirpation (OPS 05-401) | 120 (5) | 140 (6) | >.99 |
| Radical lymphadenectomy (OPS 05-404) | 17 (<1) | 17 (<1) | >.99 |
| Secondary and unspecified malignant neoplasm of lymph nodes (C77) | 29 (1.2) | 41 (1.8) | >.99 |
| Immunotherapy associated adverse events (K52.1, K71.6, K75.4, E23.1, R50.6) | 6 (0.2) | 29 (1.3) | .001∗ |
| Hidradenitis suppurativa (L73.2) | 56 (2.3) | 59 (2.6) | >.99 |
| Eczema, dermatitis, prurigo (L20, L28, L30) | 185 (7.7) | 156 (7.0) | >.99 |
| Psoriasis (L40) | 158 (6.6) | 115 (5.2) | .798 |
| Herpes zoster (B02) | 59 (2.4) | 93 (4.2) | <.05∗ |
| Erysipelas (A46) | 44 (1.8) | 43 (1.9) | >.99 |
| Ulceration of the lower leg (I83, I89, L97, I70) | 182 (7.5) | 93 (4.2) | <.001∗ |
| Pyoderma gangraenosum (L88) | 23 (1.0) | 19 (0.9) | >.99 |
| Pemphigus foliaceus/vulgaris (L10) | 8 (0.3) | 6 (0.3) | >.99 |
| Bullous pemphigoid (L12) | 60 (2.5) | 55 (2.5) | >.99 |
| Desensitization to allergens (Z51.6) | 176 (7.3) | 138 (6.2) | >.99 |
Statistical analysis was performed with R (version 4.0.4). Categorical variables were tested with the chi-square test, and continuous variables with a t test. The Holm method was used for the P value adjustment.
NMSC, Nonmelanoma skin cancer.
Level of significance is P < .05.
Table II.
Day hospital treatments in 2019 compared with those in 2020
| Variable | 2019 | 2020 | P values |
|---|---|---|---|
| Treatment days | 5.100 | 4.782 | <.05∗ |
| Total, N | 876 | 688 | <.001∗ |
| Male, n (%) | 427 (48.7) | 324 (47.1) | >.99 |
| Female, n (%) | 449 (51.3) | 362 (52.6) | >.99 |
| Age, mean (SD), in years | 46.85 (22.75) | 48.71 (22.68) | .975 |
| Stratified by age (years), n (%) | |||
| 0-17 | 115 (13.1) | 73 (10.6) | |
| 18-35 | 157 (17.9) | 140 (20.3) | |
| 36-49 | 142 (16.2) | 104 (15.1) | |
| 50-64 | 243 (27.7) | 172 (25.0) | |
| 65-74 | 122 (13.9) | 108 (15.7) | |
| 75-84 | 84 (9.6) | 76 (11.0) | |
| 85-94 | 9 (1.0) | 13 (1.9) | |
| 95+ | 4 (0.5) | 2 (0.3) | |
| <65 vs ≥65 | 219 (25.0) | 199 (28.9) | .923 |
| Disease classification (ICD-10), n (%) | |||
| Eczema, dermatitis, prurigo (L20, L28, L30) | 194 (22.1) | 170 (24.7) | >.99 |
| Psoriasis (L40) | 140 (16.0) | 104 (15.1) | >.99 |
| Epidermolysis bullosa (Q81) | 126 (14.4) | 86 (12.5) | >.99 |
| Lichen planus (L43) | 5 (0.6) | 8 (1.2) | >.99 |
| Cutaneous T-cell lymphoma (C84) | 6 (0.7) | 8 (1.2) | >.99 |
| Pemphigus foliaceus (L10) | 1 (<1) | 1 (<1) | >.99 |
| Bullous pemphigoid (L12) | 6 (0.7) | 9 (1.3) | >.99 |
Statistical analysis was performed with R (version 4.0.4). Categorical variables were tested with the chi-square test, continuous variables with a t test. The Holm method was used for the P value adjustment.
Level of significance P < .05
Our day hospital allows patient treatment over several hours for skin disorders of moderate intensity. We had a 6% decline in day hospital visits (P < .05) and reduced patient numbers (P < .001) in almost all diagnosis groups (Table II). We also noticed around 30% (P > .99) fewer day hospital visits for patients with epidermolysis bullosa, a rare, inherited skin fragility disease treated at our Skin Fragility Center, a specialized day hospital (Table II). Our data suggest that the pandemic primarily affected treatment options for patients with inflammatory and rare skin disorders, whereas patients with infectious and oncologic indications were still sufficiently treated. Limitations of this study are its monocentric character and the fact that mildly affected patients were actively short-term postponed in the early phase of the pandemic. Overall, adopting security measures (questionnaires, polymerase chain reaction testing, and visitor restrictions) prevented a significant negative impact for geriatric admissions. Nonetheless, enabling easy access and emphasizing high-quality medical and telemedical care for patients, especially those with inflammatory skin diseases, could reduce long-term complications and prevent irreversible damage.5
Conflicts of interest
None disclosed.
Acknowledgments
We thank Oliver Pfeiffer, Medical Documentary of the Skin Cancer Cente—Comprehensive Cancer Center Freiburg, and Sarah Riechert of the Department of Medical Controlling, both from the Medical Center, University of Freiburg, for providing the anonymized data on patient diagnoses. Language editing was performed by Gillian Marsden, Australia, and Maysa Sarhan, MD, PhD, MBChB, Department of Dermatology, University of Freiburg.
Footnotes
Funding sources: FS and DK are supported by the Berta-Ottenstein Advanced Clinician Scientist Programme of the University of Freiburg. DK is supported by theGerman Research Foundation (DFG) through SFB1160 project B03 and KI1795/2-1, as well as the Fritz Thyssen Foundation.
IRB approval status: No 21-147 of Freiburg Ethics Committee Board and study registration on the German Clinical Trials Register (http://www.drks.de, DRKS-ID DRKS000244633).
Reprints not available from the authors.
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