Impact of the Covid-19 pandemic on skin disease in older people

In March 2020, the World Health Organization (WHO) declared Covid-19 a global pandemic. Covid-19 has affected millions of people worldwide, but in particular, older and vulnerable populations such as those with chronic diseases, including skin disease.¹

Every country in the world is currently experiencing growth in both the absolute number and proportion of older people in the population. By 2030, the number of people aged 60 and older is predicted to rise to 1.4 billion worldwide, accounting for one sixth of the global population.²

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A global ageing population already poses several challenges for dermatologists and healthcare resources, given the increased susceptibility of developing skin pathologies such as pruritus, dermatitis, malignancies and infections.³ The Covid-19 pandemic has not only exacerbated, but has also created many new challenges for delivering skin care for older people. For example, traditional models of healthcare delivery became disrupted in a bid to avoid the spread of infection, with remote consulting and de-prioritisation of non-urgent healthcare services impacting diagnosis and management of skin conditions in older patients in particular.^4,5

Avoidance of infection permeated our daily clinical practice and private lives. Fear of contracting Covid-19 drastically influenced our social and health-seeking behaviours with national lockdowns and new legislation around coronavirus. Discussions around immunosuppression, the consequences of contracting Covid-19, as well as adverse effects of vaccinating against Covid itself, has impacted the manifestation and management of skin disease in older people.

Despite the many ways in which the pandemic has changed the delivery of healthcare in dermatology for older people, it has also provided an opportunity for change and optimisation of healthcare services, particularly when considering the judicious use of technology.

A change in skin disease management: teledermatology

During the Covid-19 pandemic, healthcare systems worldwide rapidly implemented changes to the delivery of services to limit the spread of coronavirus. The use of telecommunications technology (or teledermatology) for the remote diagnosis and treatment of skin disease in patients, enabled the provision of expert assessment by dermatologists without compromising patient safety through exposure to Covid-19.

Whilst teledermatology has been crucial for providing care during the pandemic, this technology has been identified as being less accessible to older patients,⁶ who would need digital skills, access to a camera device and the internet in order to use the service.

Evidence shows that older patients are less likely to have these requirements and are hence ‘digitally excluded’.⁷ As a result, patients may be less likely to engage with healthcare services for skin related concerns.⁸

This has led to delays in the diagnosis and treatment of skin disease, including skin cancer. Indeed, according to the UK Northern Cancer Network, there was a significant reduction in the number of skin biopsies (disproportionately affecting older patients)9 and a significant decrease in skin cancer diagnoses during the national lockdown in 2020.¹⁰

Furthermore, a modelling study demonstrated that for patients in England over the age of 80 with invasive cutaneous melanoma, a three-month delay in diagnosis could result in a 12.56% reduction in 10-year cancer specific net survival.¹¹

Now, as a result of the pandemic, the majority of skin lesions are assessed remotely and in isolation (i.e. a single lesion assessment). If they are deemed to be benign, the majority of patients are discharged without a full skin check, which would have otherwise been conducted in a face-to-face two-week wait clinic. Fewer face-to-face assessments and full skin checks, particularly in the older population who are at increased risk of skin malignancy,¹² may result in a reduction in incidental malignancy identification and opportunities for prevention of skin malignancy through identification and management of pre-cancerous lesions (e.g. actinic keratoses).¹³

Whilst barriers do exist for older patients using technology for their skin disease, the Stanford Skin Scan Programme, a pilot study involving a hybrid model (non-clinical staff helping patients with technology in person, with subsequent dermatology review) demonstrated that with support, older patients can successfully access care using technology.¹⁴

Another study demonstrated that the use of support groups to help older patients with chronic inflammatory dermatoses with technology improved treatment adherence and clinical outcomes.¹⁵

Re-prioritisation of dermatology services

In the peak of the pandemic, NHS resources and members of staff were diverted to the front line. NHS services therefore had to be prioritised according to clinical urgency.¹⁶ Whilst crucial services such as cancer care continued to operate, routine care for chronic skin conditions, many of which affect older patients (such as pruritus and eczematous dermatoses),¹² were postponed. Furthermore, non-urgent dermatology services such as patch testing, phototherapy and elective surgery were also suspended or ran at significantly reduced capacity.

Delayed treatment for chronic dermatoses, particularly in older patients, carries significant physical and psychological morbidity. For example, chronic pruritis can have a substantial impact on patients’ quality of life,¹⁷ and during the Covid-19 pandemic, this was likely compounded by several other issues faced by older patients, such as financial difficulties, loneliness and bereavement. As clinical services are reintroduced, additional capacity is required to address the backlog of routine outpatient appointments and procedures, so as to minimise diagnostic delay and further patient morbidity.

Fears around Covid-19 and skin disease

Uncertainty and high mortality rates at the outset of the Covid-19 pandemic instilled fear worldwide, with a sudden change in health-seeking behaviours, social interactions and even prescribing practices (e.g. immunosuppressants).

Being over 70 years of age is considered a significant risk factor for contracting Covid-19 and for having a more severe form of the illness. Evidence suggests that older patients who were subsequently diagnosed as having skin cancers were initially deterred from seeking help for their suspicious skin lesions during the pandemic, due to fear of being exposed to Covid-19 in healthcare environments, and since these skin lesions often do not cause significant symptoms in the early stages.⁵

Guidance from the British Association of Dermatologists (BAD) regarding continuation of immunosuppressants advises healthcare professionals to take the views and concerns of their patients into account, and to avoid starting immunosuppressant agents where possible, particularly in vulnerable patients.¹⁸ Furthermore, seroconversion rates after Covid-19 vaccination are known to be significantly lower in immunocompromised patients.¹⁹ This information has undoubtedly influenced how clinicians advise and prescribe immunosuppressants to treat dermatological diseases in older patients.

Similarly, given previous government guidance around shielding if clinically extremely vulnerable or immunosuppressed, older patients may be more reluctant to continue or commence immunosuppressant therapy for their dermatological condition, given the impact it would have on their risk of Covid-19 and response to vaccination. Clinicians should continue to be mindful of this, providing accurate evidence for patients to evaluate when deciding together whether immunosuppression is appropriate.

Cutaneous manifestations of Covid-19 and vaccinations

In addition to the changes made in healthcare delivery and fears that have developed during the Covid-19 pandemic, the virus itself has also had a significant impact on skin health in older people. Several cutaneous manifestations have been described in the context of Covid-19.²⁰ In particular, ischaemic manifestations have been associated with older patients, correlating with severity of infection. This is thought to be secondary to systemic hypercoagulability and intravascular thrombosis (e.g. livedo racemosa, retiform purpura and acral ischaemia).²¹

Consideration should also be given to the impact of national lockdowns and fears around social interaction on the physical and psychological morbidity associated with skin disease in older people. For example, eczematous dermatoses are amongst the most common skin diagnoses in the elderly,²² and evidence suggests that the impact of the Covid-19 pandemic (e.g. self-isolation, increased stress and anxiety, frequent hand-washing) can result in exacerbation of atopic dermatitis.²³

There is also growing evidence that Covid-19 vaccinations can cause a variety of skin reactions,²⁴ particularly in the older population, such as bullous pemphigoid,^25,26 Sweet’s syndrome²⁷ and vasculitis.²⁸ Whilst adverse reactions undoubtedly contribute towards vaccine hesitancy amongst all age groups, the use of registries such as the Vaccine Adverse Event Reporting System may help instil confidence in patients regarding vaccinations and help allay fears based on anecdotal reporting of adverse reactions.²⁹

Conclusion

Thankfully, with the introduction of vaccinations and treatments for Covid-19, morbidity and mortality is falling, and there has a been a gradual reintroduction of clinical services in dermatology.³⁰

Our focus should now be on returning services to pre-pandemic levels where possible, with additional capacity to address the backlog of routine outpatient appointments and procedures, so as to minimise diagnostic delay and reduce patient morbidity and mortality.11 Care should be taken to address concerns patients may have around Covid-19 and their skin, be it adverse reactions to vaccination or whether they should commence immunosuppressant treatment. Whilst the older population may be at risk of being disadvantaged in a model which solely relies on teledermatology to identify high-risk lesions, evidence does show that when sufficient support is provided to help patients overcome such digital barriers,14 older patients can benefit from the use of technology to support management of their skin disease.

 

The Kligman Essay Competition is run by the British Society for Geriatric Dermatology and is open to health professionals from any specialty.

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Dr Laksha Bala, GP with a special interest in dermatology

Conflict of interest: none declared

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References

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