Chinese Experts Consensus on Pre-examination and Triage in Dermatology Clinics d

Chinese Society of Dermatology, Lin Ma, Gang Wang, Qi-Ri Mu, Yu-Ping Ran, Quan-Zhong Liu,Sheng-Xiang Xiao, Xue-Jun Zhang, Jian-Zhong Zhang, Fu-Ren Zhang, Li He0, Ai-Jun Chen,Xiang Chen, Jie Zheng, Rong-Ya Yang, Zhi-Rong Yao,*, Ping Tu, Yu-Zhen Li,Xing-Hua Gao, Jin-Hua Xu, Heng Gu0, Bo Cheng, Wei Lai, Qian-Jin Lu,*

1Department of Dermatology,Beijing Children's Hospital,Capital Medical University,Beijing 100045,China; 2Department of Dermatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, China; 3Department of Dermatology,Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia 010017, China; 4Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China; 5Department of Dermatology,Tianjin Medical University General Hospital, Tianjin 300052, China; 6Department of Dermatology and Venereology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China; 7Department of Dermatology, Institute of Dermatology, Anhui Medical University, Hefei, Anhui 230032, China; 8Department of Dermatology, Peking University People's Hospital, Beijing 100044, China; 9Skin Disease Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250022,China; 10Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China;11Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China;12Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; 13Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; 14Department of Dermatology, Seventh Medical Center of PLA General Hospital, Beijing 100191, China; 15Department of Dermatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; 16Department of Dermatology, Peking University First Hospital, Beijing 100034, China; 17Department of Dermatology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China; 18Department of Dermatology, The First Hospital of China Medical University,Shenyang, Liaoning 110001, China; 19Department of Dermatology, Huashan Hospital, Fudan University, Shanghai 200040, China;20Hospital for Skin Diseases (Institute of Dermatology), Chinese Academy of Medical Sciences and Peking Union Medical College,Nanjing, Jiangsu 210042, China; 21Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou,Fujian 350005, China; 22Department of Dermatology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou,Guangdong 510630, China; 23Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha,Hunan 410011, China.

Abstract The SARS-CoV-2 infection has brought a great challenge in prevention and control of the national epidemic of coronavirus disease 2019(COVID-19)in China.During the COVID-19 epidemic,properly carrying out pre-examination and triage for patients with skin lesions and fever has become a practical problem encountered in hospitals for skin diseases and dermatology clinics in general hospitals.Some of the carriers of the SARS-CoV-2 and patients with COVID-19 in the early stage may not present with any symptoms of COVID-19,while certain other skin diseases can also cause fever.Therefore,to properly deal with the patients presenting at dermatology clinics,the Chinese Society of Dermatology organized experts to formulate principles and procedures for the pre-examination and triage of patients at dermatology clinics during the COVID-19 epidemic.

Keywords: SARS-CoV-2, COVID-19, fever, skin disease, pre-examination, triage

Introduction

The SARS-CoV-2 has caused extensive concern as the viral infection is spreading world widely.In the past two decades, there have been more than 10,000 cumulative cases of infection with other Coronaviridae family viruses,including severe acute respiratory syndrome coronavirus1and Middle East respiratory syndrome coronavirus.2Health care workers and the public are facing an unprecedented challenge regarding the prevention of these viral infections and cross infections.As the most common symptom of coronavirus disease 2019 (COVID-19) is fever, and many kinds of skin diseases are also accompanied by fever, the proper pre-examination and triage for patients with skin lesions and fever has become a practical problem in hospitals for skin diseases and dermatology clinics in general hospitals.In order to handle this problem,the Chinese Society of Dermatology organized experts to formulate principles and procedures for the pre-examination and triage of patients in dermatology clinics during the COVID-19 outbreak.These principles and procedures are detailed below.

Pre-examination setup and personnel protective measures of workers carrying out pre-examination and triage

A separate pre-examination area should be set up for visitors to dermatology clinics in hospitals for skin diseases and general hospitals with large numbers of patients.A dermatologist should be involved in the pre-examination of patients presenting with skin lesions and fever.The protective measures for personnel carrying out such a preexamination area include a disposable hat, work clothes,medical surgical mask or particulate protective mask,goggles, barrier gowns, and gloves.

Pre-examination

Each patient should be allowed at most one accompanying person when entering the clinic,and masks are mandatory required for both the patient and accompanying person.All patients and accompanying persons should be tested for body temperature and questioned regarding the presence of the following items: (1) symptoms of fever,cough, and dyspnea in the past 2 weeks; (2) a history of close contact with patients confirmed or suspected to be infected with SARS-CoV-2 or a suspected environmental exposure within 14 days before the visit; (3) a clustering onset of similar symptoms around the patient.All patients and accompanying persons should sign a letter of commitment to honesty and must be informed that they may bear legal consequences if they provide false information or conceal any medical history, exposure history, and/or other required information.

Triage

All patients with any positive history of close contact and/or exposure to patients with confirmed or suspected COVID-19 should be immediately directed to the fever clinic before visiting the dermatology clinics.For patients who have no history of exposure to COVID-19 patients,but have symptoms of fever(body temperature higher than 37.3°C), a dermatologist should perform triage based on the following categorization of skin diseases accompanied by fever.

Skin diseases almost always accompanied by fever

This type of diseases includes:(1)viral infectious diseases,such as measles, rubella, exanthem subitem, hand-footmouth disease, infectious mononucleosis, chicken pox,and Kaposi varicelliform eruption;(2)bacterial infectious diseases,such as scarlet fever,staphylococcal scalded skin syndrome, erysipelas, cellulitis, and other serious infections of the skin and soft tissues;(3)noninfectious diseases of the skin,such as severe drug eruption:acute generalized exanthematous pustulosis, Stevens-Johnson syndrome,toxic epidermal necrolysis and drug-induced hypersensitivity syndrome, generalized pustule psoriasis and erythrodermic psoriasis, Sweet disease, adult Still disease,Kawasaki disease, and febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta.

Patients with fever,who are suspected to have the above mentioned diseases should be allowed in dermatology clinic, but only if they have no history of exposure to COVID-19.Considering the possibility of drug eruptions in patients infected with SARS-CoV-2, a more detailed history should be screened including the reasons of taking drugs, the symptoms before taking the medicine and the process of diagnosis and treatment.

Skin diseases possibly accompanied by fever

This type of diseases includes erythema infectiosum, mild to moderate drug eruption, erythema multiforme, erythrodermic atopic dermatitis, severe contact dermatitis,secondary bacterial infection in pemphigus and bullous pemphigoid, connective tissue diseases, such as systemic lupus erythematosus and dermatomyositis,Behcet disease,panniculitis, and vasculitis.

Patients with fever who are suspected to have the above mentioned diseases should be allowed in dermatology clinic under extensive monitoring,but only if they have no history of exposure to COVID-19.Considering the possibility of drug eruptions in patients infected with SARS-CoV-2, a more detailed history should be screened including the reason for drug intake, the symptoms before the drug intake and the process of diagnosis and treatment, besides the history of exposure to SARS-CoV-2.

Skin diseases rarely accompanied by fever

This type of diseases includes primary herpes simplex,herpes zoster, and some subtypes of urticaria such as serum sickness-like reaction.

Patients with fever who are suspected to have the above mentioned diseases diseases should be allowed in the dermatology clinic, but only if they have no history of exposure to SARS-CoV-2.Otherwise,they should be sent to a fever clinic.

Previous research has shown that the common symptoms of COVID-19 include fever (98%), cough (76%),dyspnea (55%), and myalgia or fatigue (44%); less common symptoms include sputum production (28%),headache (8%), hemoptysis (5%), and diarrhoea (3%).3There has never been a reported case of skin lesions of symptoms related to COVID-19 in the published literature.4-6However, SARS-CoV-2 infection was diagnosed in one patient who presented with fever and urticaria(unpublished communication).Therefore, clinicians must pay close attention to the rashes related to SARS-CoV-2 infection.

As some patients with COVID-19 may have an uncertain or negative history of exposure to an epidemic area or confirmed/suspected cases,7all dermatologists should recheck patient's body temperature and make a thorough inquiry into their history of exposure to SARSCoV-2 infection.Furthermore, all medical staff should always be vigilant in preventing SARS-CoV-2 infection during the processes of pre-examination, triage, and medication administration.