The COVID-19 pandemic has now grown to colossal proportions, affecting nearly 233 million cases, with 4.7 million deaths (WHO dashboard 1-10-2021). How vitiligo management has changed during the pandemic has not been explored.
A cross-sectional Google form (Google LLC) based questionnaire was developed by a group of 4 consultants of our institutional pigmentary clinic (later updated by Delphi group of 15 members) [Annexure 1] and disseminated, via email to a few national and international experts who had five or more years in managing vitiligo and had been the first or corresponding authors of articles published on the same.
Totally 103 participants responded to the survey. Most worked in private clinics (35; 33.9%), followed by university hospitals (30; 29.1%), public hospitals (21; 20.4%), and corporate hospitals’ centers of excellence (17; 16.5%). All questions were answered by the participants.
The approximate number of both stable (80.2 ± 26.4/month to 10.4 ± 8.6/month, P < 0.05) and unstable vitiligo cases (60.4 ± 32.8/month to 7.5 ± 7.2/month, P < 0.05) seen by study participants decreased during the lockdown [Figure 1]. A gross decrease in number of face-to-face consultations during the lockdown (74.7% to 13.5%; P < 0.05) was noted [Figure 1].
Those who presented during the pandemic phase predominantly had unstable disease and nearly 10% presented with an unstable disease for the first time during the pandemic.
There was a gross reduction in the usage of almost all scoring systems [Table 1].
Thirty-five percent of respondents had been posted in care of COVID-19 patients, of them 14 (40%) agreed that these assignments had negatively impacted the care of their vitiligo patients due to unavailability and less time. A few (1.9%) of the participants had vitiligo patients who were COVID-19 positive [Table 2].
The majority of participants (65; 63.1%) felt pandemic had a negative impact on the quality of life of vitiligo patients (VITIQoL and by physician perception). Twenty participants (19.4%) advocated switch over from previous systemic treatment to topical therapies, and disfavored the use of systemic immunosuppressants, phototherapy, and immunomodulators [Table 3].
For patients affected with COVID-19, 60 (58.25%) wished to continue only oral mini pulse with dexamethasone at the same dose, whereas 70 (67.9%) felt that the dose of agents like oral cyclosporine, azathioprine, and mycophenolate mofetil should be reduced by 25%–50%. The majority (78; 75.7%) felt that phototherapy can be continued at the same dose and frequency, if feasible.
There was hesitation in the initiation of systemic immunosuppressive therapy. The highest level of safety so far appears to be with low dose mini pulse of dexamethasone and with apremilast. The risk is moderate with methotrexate, and high with mycophenolate mofetil and JAK inhibitors. Xu et al. had found that delay in initiation of systemic immunosuppressants was the most significant risk factor for recurrence of vitiligo during the pandemic.
Now even though there is a lesser number of cases, the unstable cases constitute a higher proportion. We had observed a trend of hesitancy in the initiation of immunosuppression. Steps need to be taken by the vitiligo task force to regularize the role of adequate immunosuppressive treatment, especially in patients with unstable vitiligo.
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1. Sarkar R, Nayak P Novel corona virus infection:A dermatologist's perspective Pigment Int 2020 7 5 11
2. Mehta H, Soufila K, Kumar S, Sarkar R, Kumaran M Use of immunosuppressants in vitiligo during COVID-19 pandemic:A quick review Pigment Int 2021 8 8 13
3. Xu X, Zhang C, Jiang M, Xiang LF Impact of treatment delays on vitiligo during the COVID-19 pandemic:A retrospective study Dermatol Ther 2021 34 e15014