The COVID-19 pandemic has challenged health care, and particularly the dermatologic industry, in many ways. Although increased attention to personal hygiene during the COVID-19 pandemic may have had some positive effects on reducing the spread of skin infections, data points to an association between COVID-19 infection and cutaneous manifestations. Viral infections such as COVID-19 frequently cause skin lesions, and certain medications used to treat COVID-19 may increase the risk of infections and other cutaneous side effects. Read more about the intersection between COVID-19 and skin infections in this week’s Derm Appeal Blog.
Incidence of skin infections pre- and mid-pandemic
In the decades before the onset of the COVID-19 pandemic the U.S. saw a steady uptick in the number of diagnosed skin infections, burdening an already resource-deficient health system. Nearly 14 million people per year were estimated to be affected by viral, bacterial, and fungal skin conditions. Industry efforts to better understand and manage skin infections gained traction, but challenges such as treatment-resistant bacteria infections remained problematic. Then, the onset of the COVID-19 pandemic in 2020 and its resulting implications on overall health care underscored the need for better management strategies for a virus-driven dermatologic health crisis.
Interestingly, a retrospective study that assessed hospital visits between 2018 and 2020 demonstrated that the number of patients diagnosed with certain skin diseases has trended downwards as the COVID-19 pandemic continues. The lower incidence of certain contagious skin diseases such as scabies, varicella, impetigo, and molluscum contagiosum may be related to increased hand hygiene during the pandemic. However, researchers are careful to note that this phenomenon could instead be attributed to delayed diagnoses due to social distancing measures and patients seeking less frequent nonemergency dermatologic care.
The COVID-19 pandemic has challenged the industry’s understanding of skin infection incidence and management, underscoring a need for greater research and insight into the effects of virus-driven health crises in dermatologic care. Not only can COVID-19 infection have cutaneous manifestations such as erythematous rash, acute hemorrhagic edema, petechiae, morbilliform rash, chickenpox‐like vesicles, livedoid lesions, localized or widespread urticaria confluent erythematous‐yellowish papules and plaques, but many potential COVID-19 therapies can have dermatologic side effects, as well.
Tocilizumab, a humanized anti-interleukin 6 receptor monoclonal antibody that was given Emergency Use Authorization by the U.S. Food and Drug Administration (FDA) to treat hospitalized adults and pediatric patients with COVID-19, may be associated with an increased risk of skin infection, along with other cutaneous side effects. The drug’s warning label states that patients treated with tocilizumab “are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections.” This presents a significant problem if infections do develop in a hospitalized patient, not only because he or she also has an active COVID-19 infection, but also because tocilizumab itself is an immunosuppressant.
The overuse of antibiotics has led to a worldwide increase in antibiotic resistance – due to the surviving microbes multiplying and passing on their resistant traits. According to many experts, the number one challenge surrounds infections that have become resistant to antibiotic therapy, such as infections caused by Staphylococcus aureus (staph infections). These common bacteria are the leading cause of skin and soft tissue infections and are now resistant to several antibiotics. The rise of these antibiotic-resistant strains of staph are often described as methicillin-resistant S. aureus (MRSA) and are much more challenging to treat.
Another significant challenge is determining the cause of the skin infection. Many different bacteria and sometimes fungi can cause skin rashes that become infected; if treatment must be initiated before a provider can obtain lab results, they may risk prescribing inappropriate or insufficient treatment and losing valuable time in which the infection can advance. More research is needed to develop timely and efficient testing to determine the nature of cutaneous infections.
Antibiotics that target certain types of treatment-resistant fungus or bacteria are the cornerstone of new developments in skin infection therapy. Recent approvals from the FDA include:
- Delafloxacin. A fourth-generation fluoroquinolone for treating adults with acute bacterial skin and skin structure infections caused by designated susceptible bacteria.
- Oritavancin. A long-acting lipoglycopeptide antibiotic, for the treatment of adults with acute bacterial skin and skin structure infections resulting from susceptible isolates of designated gram-positive microorganisms.
Skin infections, especially those that have become treatment-resistant, necessitate further research into more optimal therapies. Experts can’t say for sure whether COVID-19 has contributed significantly to any specific skin infection; it has resulted in skin manifestations in some patients, but further research would be necessary to implicate a direct relationship between skin infections and COVID-19. Dermatology providers should stay updated on the pipeline of novel and targeted agents, and the latest data on cutaneous manifestations of COVID-19 infection and treatment, allowing for prompt diagnosis and effective management of these conditions.