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These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. 802 CASE AND RESEARCH LETTERS Managing Psoriasis East respiratory syndrome, COVID-19) enable us to suggest that the risk of severe manifestations and complications of Consultations During the COVID-19 is no greater in immunodepressed patients than in COVID-19 Pandemic: the general population. Recommendations From the The main interleukins (IL) involved in the pathogenesis Psoriasis Group of the Spanish of psoriasis (tumor necrosis factor [TNF] alfa, IL-17, and IL- 23) have not been proven to affect the course of the viral Academy of Dermatology and infection, although they could be involved in the onset of Venereology (AEDV)夽 the cytokine storm, which is associated with the severity of the infection. Therefore, at least in terms of pathogenesis, Recomendaciones del Grupo de Psoriasis de la specific inhibition of these proteins does not seem to imply AEDV sobre el manejo de la consulta de a risk with respect to the clinical course of patients taking psoriasis durante la pandemia por COVID-19 specific immunomodulators. The impact of broad-spectrum immunomodulators (methotrexate, ciclosporin) and their To the Editor: inhibition is less well-known.5 Proposals for the management of patients with psoriasis are shown in Table 1. Infection by the coronavirus SARS-CoV-2 and the associ- ated disease, COVID-19, constitute a serious public health Psoriasis Clinic During the SARS-CoV-2 problem. Considerable uncertainty surrounds the way in Pandemic6 which this problem will affect inflammatory diseases such as psoriasis and, in particular, patients treated with selec- tive immunomodulators and immunosuppressants. Based In-person specialist psoriasis clinic on the scarce scientific evidence available and consistent with the position of other national and international sci- The conditioning factors and restrictions affecting in-person entific societies (European Academy of Dermatology and visits to the specialist psoriasis clinic will be those that are Venereology-Skin Inflammation and Psoriasis International appropriate and acknowledged for any in-person visit to the Network, International Psoriasis Council, American Academy dermatology clinic while the pandemic lasts (recommenda- of Dermatology),1---3 the Psoriasis Group of the Spanish tions of the institutions themselves and of the AEDV). Academy of Dermatology and Venereology (AEDV) issued a statement through the AEDV (GPs-COVID-19)4 with the aim Specialist psoriasis clinic online of guiding dermatologists who treat psoriasis, especially in cases where patients are receiving treatment or are about The new situation brought about by the COVID-19 pan- to initiate treatment with selective immunomodulators or demic, where in-person visits are expected to be restricted, immunosuppressants.1,2 could provide an opportunity for the development and The SARS-CoV-2 pandemic has affected, and will con- appropriate adaptation of complementary strategies (e.g., tinue to affect, at least for some time, the management telemedicine, in the screening, management, and follow-up of patients with psoriasis and the functioning of specialist of psoriasis). psoriasis clinics. Given that the situation is gradually com- The activities that each unit will now address online ing under control, it is worth considering the conditions for should preferably be supervised by the professionals who see and limitations to resuming care services in these clinics patients at the in-person visits and have appropriate knowl- in a scenario where the virus continues to circulate, with edge and experience in the management of these patients. occasional or seasonal exacerbations. An in-person approach should continue to be used, at In order to minimize risk for and maximize benefits to least for the initial visits or until the skin disease is well- patients and optimize the functioning of psoriasis clinics, the controlled. Psoriasis Group has developed a series of recommendations Online visits could be alternated with in-person visits for based on scientific evidence and on recommendations from the follow-up of well-managed patients whose disease is other scientific societies. controlled with the treatment prescribed at the in-person In any case, whether or not these recommendations are visits. applied will depend on scientific evidence and the progress Therefore, we believe that it would be of interest to of the pandemic. set out the main uses of teledermatology in the specialist psoriasis clinic (Table 2). Recommendations Patient Management Conflicts of Interest Data available on previous and current outbreaks of coron- Dr. I. Belinchón has acted as a consultant and/or speaker avirus infection (severe acute respiratory syndrome, Middle for and/or has participated in clinical trials sponsored by the following companies: Janssen Pharmaceuticals Inc., Almirall SA, Lilly, AbbVie, Novartis, Celgene, Amgen, LEO Pharma, 夽 Please cite this article as: Belinchón I, Puig L, Ferrándiz L, de Pfizer-Wyeth, UCB, and MSD. la Cueva P, Carrascosa JM. Recomendaciones del Grupo de Psoriasis Dr. Ll. Puig has acted as a consultant and/or speaker de la AEDV sobre el manejo de la consulta de psoriasis durante la for and/or has participated in clinical trials sponsored pandemia por COVID-19. Actas Dermosifiliogr. 2020;111:803---805. by the following companies: AbbVie, Almirall, Amgen, CASE AND RESEARCH LETTERS 803 Table 1 Recommendations for Patients With Psoriasis During the COVID-19 Era. In general, patients with psoriasis can continue their treatment during the COVID-19 pandemic in order to avoid flare-ups that would directly affect the patient and necessitate greater use of health care resources. Small-molecule immunosuppressants and biologics should generally be suspended if a patient is suspected of having active COVID-19 infection. Initiating these treatments in cases of active infection is contraindicated. If a patient lives in areas with a high incidence of COVID-19 or is in close contact with confirmed cases, temporary suspension of some selective immunomodulators or immunosuppressants should be considered----taking into account factors such as age and comorbid conditions----until the infection has been confirmed or ruled out. There is no evidence----or restriction to date----with respect to the use of topical treatments in the management of patients with psoriasis. We currently lack data on the impact of psoriasis therapy on susceptibility to or severity of COVID-19. Therefore, health professionals should be guided by their previous clinical experience and their understanding of the mechanism of action of the treatment they prescribe.5 The new situation brought about by the pandemic may affect the advisability of and restrictions associated with phototherapy as an option for treatment of psoriasis. The Photobiology Group of the Spanish Academy of Dermatology and Venereology has drafted a specific document in this area. Table 2 Main Uses of Teledermatology in a Specialist Psoriasis Unit. Screening of patients in order to evaluate the need for in-person care in the psoriasis unit. The most efficient approach in this case is store-and-forward teledermatology, which is based on clinical images taken in the health center and requested by the family physician. Thus, a virtual screening appointment makes it possible to identify patients with moderate to severe psoriasis who are candidates for systemic treatment or phototherapy and can be seen at an in-person visit. The general evaluation of the patient should take into account the impact on quality of life. Follow-up of the response to therapy via direct teledermatology between physician and patient, with digital images taken by the patient or via a video visit. The optimal approach should include an online history, access to additional tests via the online history, electronic prescription, and basic additional tests in the hospital or primary care center. Reporting of incidents. In the case of chronically ill patients, teledermatology is also useful for early reporting of incidents associated with the disease (e.g., loss of response, early onset of comorbid conditions) or with treatments (e.g., detection of toxicity, dispensing incidents). The patient should be able to contact the psoriasis unit without having to travel, according to well-established protocols, and using any means of communication (e.g., telephone, direct virtual consultation with images sent by the patient, app) that enables a suitable response. Reporting should fulfill the requirements of confidentiality, encryption, and connection with the computer system set out by the individual health service. Teledermatology models should always be supported by guaranteed in-person care. Therefore, irrespective of the stage of care, patients will benefit from in-person or virtual visits depending on the modality that best meets their needs and their personal, occupational, and social situation. Baxalta, Biogen, Boehringer Ingelheim, Celgene, Gebro, 2. https://www.psoriasiscouncil.org/blog/Statement-on-COVID- Janssen, JS BIOCAD, LEO Pharma, Lilly, Merck-Serono, 19-and-Psoriasis.htm. MSD, Mylan, Novartis, Pfizer, Regeneron, Roche, Sandoz, 3. https://assets.ctfassets.net/1ny4yoiyrqia/PicgNuD0IpYd9MSOw Samsung-Bioepis, Sanofi, and UCB. ab47/023ce3cf6eb82cb304b4ad4a8ef50d56/Biologics and COVID- Dr. L. Ferrándiz has acted as a consultant and/or speaker 19.pdf. 4. https://aedv.es/comunicado-del-grupo-de-psoriasis-de-la-aedv- for and/or has participated in clinical trials sponsored by the sobre-la-pandemia-por-covid-19. following companies: Janssen Pharmaceuticals Inc., Almirall 5. Torres T, Puig L. Managing Cutaneous Immune-Mediated SA, Lilly, AbbVie, Novartis, Amgen, LEO Pharma, UCB, and Diseases During the COVID-19 Pandemic [published Gebro Pharma. online ahead of print. Am J Clin Dermatol. 2020:1---5, Dr. P. de la Cueva has acted as a consultant and/or http://dx.doi.org/10.1007/s40257-020-00514-2. researcher for the following companies: AbbVie, Almirall, 6. Wollina U. Challenges of COVID-19 pandemic for dermatology Astellas, Biogen, Boehringer, Celgene, Janssen, LEO Pharma, [published online ahead of print. Dermatol Ther. 2020:e13430, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB. http://dx.doi.org/10.1111/dth.13430. Dr. J.M. Carrascosa has acted as a consultant and/or speaker for and/or has participated in clinical trials spon- I. Belinchóna,∗ , L. Puigb , L. Ferrándizc , P. de la Cuevad , sored by the following companies: Janssen Pharmaceuticals J.M. Carrascosae , en nombre del Grupo de Psoriasis de la Inc., Almirall SA, Lilly, AbbVie, Novartis, Celgene, Amgen, AEDV LEO Pharma, Pfizer-Wyeth, Sandoz, Amgen, Biogen, and a Servicio de Dermatología, Hospital General Universitario Mylan. de Alicante-ISABIAL-UMH, Alicante, Spain b Servicio de Dermatología, Hospital de la Santa Creu i References Sant Pau, Barcelona, Spain c Servicio de Dermatología, Hospital Universitario Virgen 1. https://www.eadv.org/cms-admin/showfile/7 PSORIASIS- Macarena, Sevilla, Spain SPIN%20TF%20Recommandations Covid-Corner.pdf. 804 CASE AND RESEARCH LETTERS d Servicio de Dermatología, Hospital Universitario Infanta ∗ Corresponding author. Leonor, Madrid, Spain E-mail address: belinchon isa@gva.es (I. Belinchón). e Servicio de Dermatología, Hospital Universitari Germans 18 May 2020 26 May 2020 Trias i Pujol, Universitat Autònoma de Barcelona, IGTP, Barcelona, Spain https://doi.org/10.1016/j.adengl.2020.05.001 1578-2190/ © 2020 AEDV. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Eosinophilic Panniculitis She was hospitalized for observation, and began treatment with ceftriaxone, enoxaparin, and hydroxychloro- Associated With COVID-19夽 quine. Betamethasone cream was prescribed for the skin lesions. The patient’s condition improved markedly within a Paniculitis eosinofílica secundaria a infección few days, after which she was discharged from hospital and por COVID-19 isolated at home. Eosinophilic panniculitis is a very rare form of panniculi- To the Editor tis. It affects women more frequently than men (3:1 ratio), and its incidence peaks in the third and sixth decades of Within just 3 months of the detection in Wuhan in December life.2 It is a reactive process secondary to a range of stimuli, 2019 of the first cases of pneumonia caused by a novel coron- avirus, the scale of this outbreak has increased to pandemic proportions. As the number of cases increased, new respi- ratory, neurological, digestive, and dermatological clinical manifestations were also reported.1 A 29-year-old Colombian woman with no relevant his- tory was seen at our emergency department for skin lesions that had appeared 1 week earlier. She had cough and fever that had begun 20 days earlier and for which she was not being treated. She reported no dyspnea and her baseline oxygen saturation was 97%. A laboratory workup revealed the following: D-dimer, 1 790.0 ng/mL; lympho- cytes, 1 500/␮L; lactate dehydrogenase, 202 U/L; C-reactive protein <0.5 mg/L. Chest x-ray was normal. Polymerase chain reaction analysis of a pharyngeal swab was positive for SARS-CoV-2. Physical examination revealed the presence of erythe- matous or brownish subcutaneous nodular lesions (1---4 cm). There were no other irregularities on the skin surface. The Figure 1 Nodular lesion (2 cm in diameter) with a brownish lesions, which were located on the anterior and lateral surface located on the outer aspect of the right leg. aspects of the legs (Fig. 1) and on the thighs, forearms, and left shoulder, were itchy and painful on palpation. Skin biopsy of a lesion on the right leg showed no alterations in the epidermis. The superficial and deep der- mis contained perivascular inflammatory infiltrate (Fig. 2), which reached the subcutaneous tissue and displayed a predominantly lobular pattern (Fig. 3A). This infil- trate consisted of lymphocytes, histiocytes, and numerous eosinophils (Fig. 3B). Leukocytoclasia was evident. Flame figures were absent, and subcutaneous involvement was superficial, without fibrosis. Blood extravasation without vasculitis was observed. Based on these findings, the patient was diagnosed with eosinophilic panniculitis secondary to COVID-19 infection. Figure 2 Panoramic image of the biopsy (hematoxylin-eosin 夽 Please cite this article as: Leis-Dosil VM, Sáenz Vicente A, Lorido- staining). The epidermis is preserved. Note the perivascular and Cortés MM. Paniculitis eosinofílica secundaria a infección por COVID- periadnexal inflammatory infiltrate in the dermis that extends 19. Actas Dermosifiliogr. 2020;111:805---806. to the subcutaneous tissue.