The purpose of this Guidelines summary is to maximise the safety of children and adults who have dermatological conditions treated with drugs affecting the immune response during the COVID-19 pandemic. It also aims to enable services to make the best use of NHS resources. For information on protecting staff from infection, please see the full guideline.
Communicating with patients and minimising risk
- Communicate with patients, their families and carers, and support their mental health and wellbeing to help alleviate any anxiety and fear they may have about COVID-19. Signpost to sources of online information (such as the British Association of Dermatologists’ patient hub), support groups (including NHS Volunteer Responders) and UK government guidance on the mental health and wellbeing aspects of COVID-19
- Some patients will have received a letter telling them they are at high risk of severe illness from COVID-19. Tell them, or their parent or carer, to follow the advice on shielding in UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable to COVID-19
- Telephone, email or send a text message to patients booked for a dermatology appointment, or their parents or carers. Tell them that if they have been advised to self-isolate they should follow the UK government stay at home advice for households with possible COVID-19 infection. They should:
- not attend their appointment
- contact the dermatology department for advice on their ongoing care
- Minimise face-to-face contact by:
- avoiding non-essential face-to-face consultations
- using electronic prescriptions rather than paper
- using different methods to deliver prescriptions and medicines, for example, postal services, NHS Volunteer Responders or drive-through pick-up points for medicines
- contacting patients via text message, telephone or email
- optimising the use of teledermatology, such as telephone and video consultations
- making use of departmental pages on local NHS trust websites, which should include FAQs on COVID-19 if possible
- extending intervals between drug monitoring (see the recommendation on the interval between blood tests for drug monitoring in patients who are stable on treatment in the section on treatment considerations) and using local services for blood tests if possible
- If patients need to attend face-to-face appointments, ask them to help reduce the risk of contracting or spreading infection with COVID-19 by:
- coming to the appointment alone
- having only 1 parent or carer accompany a child or adult who cannot come alone
- avoiding public transport if possible
- Tell patients, or their families and carers, that they should contact the NHS 111 online coronavirus service, or call NHS 111 if they don’t have internet access, if they think they have COVID-19. In an emergency they should call 999 if they are seriously ill. They should also inform their dermatology team, to get advice about their immunosuppressive therapies
- Advise patients, or their parents or carers, to write down a list of the medicines they take and the conditions they have, to give to healthcare staff if they need to seek treatment for COVID-19
- Tell patients who still need to attend services, or their parents or carers, to follow relevant parts of UK government guidance on social distancing for everyone in the UK, or UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19
- Think about the resources that are available to make treatment changes during the COVID-19 pandemic and how these changes will be delivered. Be aware that the supply of medicines through normal routes, for example homecare medicines delivery services, may become disrupted during the pandemic and have plans in place to manage this
- Prescribe usual quantities of medicines to meet the patient’s clinical needs. Prescribing larger quantities of medicines puts the supply chain at risk
Patients not known to have COVID-19
- If patients need to attend hospital appointments, minimise their potential exposure to the virus by:
- encouraging them not to arrive early
- texting them when staff are ready to see them, so that they can wait outside the building, for example in their car
- providing a ‘clean route’ through the hospital to the department
- reducing, and ideally eliminating, the time they spend in waiting areas through careful scheduling
- delivering investigations, procedures and treatment promptly and in 1 stop when feasible
- ensuring prescriptions are dispensed rapidly and ideally without visiting hospital pharmacies, for example by use of home delivery or NHS volunteers, where available
- When deciding whether to start or continue treatment with a drug that affects the immune system, discuss the risks and benefits with the patient, their parents or carer, and take into account the following in the context of COVID-19:
- is it essential to start this drug immediately?
- is it essential to continue this drug?
- if treatment is needed, is there an alternative with a better risk profile?
- is the required monitoring and review feasible?
- can monitoring be done remotely or at a frequency that minimises the risk to the patient’s safety and wellbeing?
- are there any changes to the dose, route of administration or mode of delivery that could make hospital attendance or admission less likely?
The British Association of Dermatologists has published a risk stratification grid. It includes a list of drugs affecting the immune response that could put patients at risk of severe infection.
- Assess whether it is safe to increase the time interval between blood tests for drug monitoring in patients who are stable on treatment. Take into account the patient’s age and any comorbidities
- Encourage and support shared care, by helping patients carry out elements of their own care
Patients known or suspected to have COVID-19
- Be aware that patients taking drugs that affect the immune system may have atypical presentations of COVID-19. For example, patients taking prednisolone may not develop a fever
- If patients with known or suspected COVID-19 need to attend the dermatology department, follow appropriate UK government guidance on infection prevention and control. This includes recommendations on patient transfers and options for outpatient settings
- If COVID-19 is later diagnosed in a patient not isolated from admission or presentation, follow UK government guidance for health professionals
- In patients known or suspected to have COVID-19:
- continue topical treatments
- think about treating new-onset dermatological conditions with topical treatments rather than new systemic treatments that affect the immune system
- In patients known or suspected to have COVID‑19:
- do not suddenly stop oral corticosteroids
- continue hydroxychloroquine, chloroquine, mepacrine, dapsone and sulfasalazine
- consider temporarily stopping all other oral immunosuppressive therapies, novel small-molecule immunosuppressants, biological therapies and monoclonal antibodies, and contact the dermatology department for advice on when to restart treatment
The half-life of some drugs means that immunosuppression will continue for some time after stopping treatment. See the BNF and the summaries of product characteristics (SPCs) for specific information about individual drugs
- When deciding whether to stop treatment, discuss the risks and benefits with the patient, or their parent or carer, and take into account:
- whether COVID-19 is confirmed
- the severity of the COVID-19
- the risks and benefits of stopping or continuing treatment
- the severity of the dermatological condition
- the effect of stopping treatment on other conditions, for example the effect on asthma of stopping dupilumab
- other risk factors such as age and comorbidities, for example respiratory or cardiovascular conditions
Modifications to usual care
- If necessary, only continue core services, including:
- dermatology department advice lines
- essential parenteral day-case treatment
- blood tests for drug monitoring where necessary
- services for urgent inpatient and outpatient review (both new and follow up)
- facilities to enable face-to-face review to manage disease flares and complications of therapy
- Provide acute and emergency dermatology advice to GPs to avoid unnecessary emergency department attendances and admissions, using advice and guidance services and teletriage where possible
- Think about pooling resources with other specialities and NHS trusts to provide services such as drug monitoring and telephone and email advice
© NICE 2020. COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response. Available from: www.nice.org.uk/guidance/ng169. All rights reserved. Subject to Notice of rights.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Published date: 09 April 2020.
Last updated: 30 April 2020.