Commentary

I am not an elite athlete. Never have been, never will be. But as I contemplated how to support my colleagues at my hospital during the COVID-19 pandemic—knowing that we face more weeks of social distancing, probable virus outbreaks as business opens up, and myriad changes in how we will practice medicine—I wondered how Olympic athletes focus their mental and physical stamina to respond to the challenges of competition.

In this article, I offer some pointers, gleaned from techniques used by exceptional athletes, on how we can maintain our stamina during the COVID-19 marathon.

Tinseltown/Shutterstock

Train your mind

Elite athletes understand that what will take them to the top of their sport is less about their physical gifts (all elite athletes have superior athletic talent) and more about how they train their minds to achieve their goals. As basketball great Kareem Abdul-Jabbar said, “Your mind is what makes everything else work.” Not surprisingly, athletes who train to be mentally “tough” have a better chance to reach the podium.

One definition of mental toughness is the “ability to perform toward the upper range of your talent and skill” regardless of external circumstances.¹ Mental toughness involves an unshakable self-belief, resilience, motivation, focus, and ability to perform under pressure and manage physical and emotional pain.

Like me, most of you probably are not elite athletes, but you can train your mind to be tougher and increase your stamina using some of the following techniques.

Think positively

Do you find yourself dealing with an inner monologue of fear, self-doubt, and feelings of worthlessness? That is the Obnoxious Roommate in your head as described in a HuffPost article and based on the pioneering work of psychiatrist Aaron Beck, MD, the father of cognitive-behavioral therapy.^2,3 Such thoughts negatively affect one’s sense of self-efficacy, which is the mental state of believing that you can meet the challenges you face. Elite athletes pay particular attention to their self-talk and replace negative thoughts with positive ones. These may include affirmations of your strengths or cue words that pump you up or help you manage your nerves.

To begin this practice, first observe what you are telling yourself. You may be saying, “I can’t do this. This is too hard.” This is an important step because you may have lived with the Obnoxious Roommate for so long that these thoughts are automatic and seem like a part of you. If, however, you first observe the thought and acknowledge it, you can begin to replace negative thoughts with supportive ones: “This is hard, but I can do this. I am intelligent, strong, capable, and ready.” While practice and repetition are required, thinking positively eventually will become a habit of self-support. Elite athletes know that to reach the top, they need to become their own best friend.⁴

Continue to: Use visualization...

Use visualization

Elite athletes visualize their events in such meticulous detail that they can actually feel their feet on the track, their muscles tensing, the starter pistol going off, the roar of the crowd. Research shows that the part of the brain that is activated in a race is also activated when one visualizes the race. It is as though the race is happening in real time.⁵ Physicians could use this approach to visualize the day ahead, picturing the procedures in detail and the clinical encounters going well.

In the current crisis, we frequently need a way to calm down quickly. One suggestion is to find a quiet space and sit for a few minutes, allowing the chair to support you. Then imagine a beautiful, calm, soothing place. Relax there and take in that feeling. Or, imagine a past achievement when you felt good about yourself. See yourself in that moment, remember how you felt, and take it in.

Plan for setbacks

All elite athletes have setbacks: Marathon runners hit a wall, golfers hit into the rough. But they don’t spin out of control at setbacks. They expect them, and they have practiced skills to restore their confidence and re-center themselves.⁶ For example, some athletes calm themselves by performing a ritualized series of movements. Others use a specific phrase (that positive self-talk again!) that reminds them of their goals or skills, while others play specific songs on their media player, or in their head, to return to their center.

Another technique is to use deep, rhythmic, diaphragmatic breathing for about 30 seconds to bring yourself back to your body.

The point is to have a plan in place to respond to setbacks in a positive manner and get back on track. Don’t waste time on self-criticism.

Continue to: Manage stress...

Manage stress

Not all stress is negative. Everyone has a “sweet spot,” a level of activation from which we operate best.¹ If we go too far over that level, though, we can panic. If we aren’t stressed enough, it is hard to get going at all.

If you need to be pumped up to function at your best, try playing music that energizes you. If you work best when you are calm, take deep breaths and attend to the exhalation while you engage in positive self-talk.

Another way to manage stress levels during the COVID-19 pandemic is to employ the ESCAPE mnemonic:

• Exercise. Research shows that regular aerobic exercise is a potent stress reliever; it raises endorphin levels, provides a general sense of well-being, and improves immune function.⁷ If you exercise regularly, do everything possible to keep doing so. If you do not have an exercise routine, try taking walks. Get out into the fresh air, pay attention to your surroundings, and work to be present in your body as you move.
• Sleep. Getting adequate sleep, 7 to 9 hours a night for most people, is important for maintaining physical and emotional health.⁸ Elite athletes pay particular attention to sleep because they know that their bodies need to recharge. The COVID-19 crisis has affected sleep for many, and we need to consciously attend to sleep hygiene. This includes limiting use of screen time to no more than 2 hours before bed. As well, limit your intake of the news and definitely avoid it right before bedtime. Take a warm shower, drink a cup of herbal tea, or read a less-than-stimulating journal article. Make sure your bedroom is cool and dark. Keep a regular bedtime and wake up at a regular time.
• Connect. Despite the current need for physical distancing, do not neglect your need to connect to those you love and care about. Whatever modality works for you—telephone, e-mail, video conferencing—if you feel lonely, reach out. Friends and families are concerned about us, and it makes them feel useful to support us. Allow that.
• Appreciate/cultivate gratitude. Look for causes for celebration in your life, whether that is your family, friends, or that you have a job and a home. Perhaps it is the cleaner air or the beauty of nature. Whatever you are grateful for, acknowledge it, perhaps by writing it down in a journal. Remembering these things can serve as an antidote to the stress created by the COVID-19 crisis.
• Play. Seek out things that make you laugh.⁹ Find your inner goofiness. Get creative and paint, sing, garden, golf, play an instrument, dance, do puzzles, or play games. We need to remember the pleasures in life when times are dark. Find whatever feels like joy.
• Exhale. If you have a meditation practice continue to do it. If not, consider starting. Try yoga as a way to center yourself in your body. Elite athletes use meditation and yoga to harness their minds and bodies to feel more in control.¹⁰ When so many things feel out of our control and unpredictable, it can be immensely soothing to connect to yourself in this way and realize you can reliably relax.

Self-care is a necessity

While we are in a marathon not of our choosing, we can use the techniques of elite athletes to think positively, visualize scenarios to achieve our goals or to simply relax, plan for setbacks so that we can bounce back, and manage stress productively. Self-care is paramount as we continue to care for others. Let’s not neglect ourselves, and we will cross the finish line together. ●

I am not an elite athlete. Never have been, never will be. But as I contemplated how to support my colleagues at my hospital during the COVID-19 pandemic—knowing that we face more weeks of social distancing, probable virus outbreaks as business opens up, and myriad changes in how we will practice medicine—I wondered how Olympic athletes focus their mental and physical stamina to respond to the challenges of competition.

In this article, I offer some pointers, gleaned from techniques used by exceptional athletes, on how we can maintain our stamina during the COVID-19 marathon.

Tinseltown/Shutterstock

Train your mind

Elite athletes understand that what will take them to the top of their sport is less about their physical gifts (all elite athletes have superior athletic talent) and more about how they train their minds to achieve their goals. As basketball great Kareem Abdul-Jabbar said, “Your mind is what makes everything else work.” Not surprisingly, athletes who train to be mentally “tough” have a better chance to reach the podium.

One definition of mental toughness is the “ability to perform toward the upper range of your talent and skill” regardless of external circumstances.¹ Mental toughness involves an unshakable self-belief, resilience, motivation, focus, and ability to perform under pressure and manage physical and emotional pain.

Like me, most of you probably are not elite athletes, but you can train your mind to be tougher and increase your stamina using some of the following techniques.

Think positively

Do you find yourself dealing with an inner monologue of fear, self-doubt, and feelings of worthlessness? That is the Obnoxious Roommate in your head as described in a HuffPost article and based on the pioneering work of psychiatrist Aaron Beck, MD, the father of cognitive-behavioral therapy.^2,3 Such thoughts negatively affect one’s sense of self-efficacy, which is the mental state of believing that you can meet the challenges you face. Elite athletes pay particular attention to their self-talk and replace negative thoughts with positive ones. These may include affirmations of your strengths or cue words that pump you up or help you manage your nerves.

To begin this practice, first observe what you are telling yourself. You may be saying, “I can’t do this. This is too hard.” This is an important step because you may have lived with the Obnoxious Roommate for so long that these thoughts are automatic and seem like a part of you. If, however, you first observe the thought and acknowledge it, you can begin to replace negative thoughts with supportive ones: “This is hard, but I can do this. I am intelligent, strong, capable, and ready.” While practice and repetition are required, thinking positively eventually will become a habit of self-support. Elite athletes know that to reach the top, they need to become their own best friend.⁴

Continue to: Use visualization...

Use visualization

Elite athletes visualize their events in such meticulous detail that they can actually feel their feet on the track, their muscles tensing, the starter pistol going off, the roar of the crowd. Research shows that the part of the brain that is activated in a race is also activated when one visualizes the race. It is as though the race is happening in real time.⁵ Physicians could use this approach to visualize the day ahead, picturing the procedures in detail and the clinical encounters going well.

In the current crisis, we frequently need a way to calm down quickly. One suggestion is to find a quiet space and sit for a few minutes, allowing the chair to support you. Then imagine a beautiful, calm, soothing place. Relax there and take in that feeling. Or, imagine a past achievement when you felt good about yourself. See yourself in that moment, remember how you felt, and take it in.

Plan for setbacks

All elite athletes have setbacks: Marathon runners hit a wall, golfers hit into the rough. But they don’t spin out of control at setbacks. They expect them, and they have practiced skills to restore their confidence and re-center themselves.⁶ For example, some athletes calm themselves by performing a ritualized series of movements. Others use a specific phrase (that positive self-talk again!) that reminds them of their goals or skills, while others play specific songs on their media player, or in their head, to return to their center.

Another technique is to use deep, rhythmic, diaphragmatic breathing for about 30 seconds to bring yourself back to your body.

The point is to have a plan in place to respond to setbacks in a positive manner and get back on track. Don’t waste time on self-criticism.

Continue to: Manage stress...

Manage stress

Not all stress is negative. Everyone has a “sweet spot,” a level of activation from which we operate best.¹ If we go too far over that level, though, we can panic. If we aren’t stressed enough, it is hard to get going at all.

If you need to be pumped up to function at your best, try playing music that energizes you. If you work best when you are calm, take deep breaths and attend to the exhalation while you engage in positive self-talk.

Another way to manage stress levels during the COVID-19 pandemic is to employ the ESCAPE mnemonic:

• Exercise. Research shows that regular aerobic exercise is a potent stress reliever; it raises endorphin levels, provides a general sense of well-being, and improves immune function.⁷ If you exercise regularly, do everything possible to keep doing so. If you do not have an exercise routine, try taking walks. Get out into the fresh air, pay attention to your surroundings, and work to be present in your body as you move.
• Sleep. Getting adequate sleep, 7 to 9 hours a night for most people, is important for maintaining physical and emotional health.⁸ Elite athletes pay particular attention to sleep because they know that their bodies need to recharge. The COVID-19 crisis has affected sleep for many, and we need to consciously attend to sleep hygiene. This includes limiting use of screen time to no more than 2 hours before bed. As well, limit your intake of the news and definitely avoid it right before bedtime. Take a warm shower, drink a cup of herbal tea, or read a less-than-stimulating journal article. Make sure your bedroom is cool and dark. Keep a regular bedtime and wake up at a regular time.
• Connect. Despite the current need for physical distancing, do not neglect your need to connect to those you love and care about. Whatever modality works for you—telephone, e-mail, video conferencing—if you feel lonely, reach out. Friends and families are concerned about us, and it makes them feel useful to support us. Allow that.
• Appreciate/cultivate gratitude. Look for causes for celebration in your life, whether that is your family, friends, or that you have a job and a home. Perhaps it is the cleaner air or the beauty of nature. Whatever you are grateful for, acknowledge it, perhaps by writing it down in a journal. Remembering these things can serve as an antidote to the stress created by the COVID-19 crisis.
• Play. Seek out things that make you laugh.⁹ Find your inner goofiness. Get creative and paint, sing, garden, golf, play an instrument, dance, do puzzles, or play games. We need to remember the pleasures in life when times are dark. Find whatever feels like joy.
• Exhale. If you have a meditation practice continue to do it. If not, consider starting. Try yoga as a way to center yourself in your body. Elite athletes use meditation and yoga to harness their minds and bodies to feel more in control.¹⁰ When so many things feel out of our control and unpredictable, it can be immensely soothing to connect to yourself in this way and realize you can reliably relax.

Self-care is a necessity

While we are in a marathon not of our choosing, we can use the techniques of elite athletes to think positively, visualize scenarios to achieve our goals or to simply relax, plan for setbacks so that we can bounce back, and manage stress productively. Self-care is paramount as we continue to care for others. Let’s not neglect ourselves, and we will cross the finish line together. ●

I am not an elite athlete. Never have been, never will be. But as I contemplated how to support my colleagues at my hospital during the COVID-19 pandemic—knowing that we face more weeks of social distancing, probable virus outbreaks as business opens up, and myriad changes in how we will practice medicine—I wondered how Olympic athletes focus their mental and physical stamina to respond to the challenges of competition.

In this article, I offer some pointers, gleaned from techniques used by exceptional athletes, on how we can maintain our stamina during the COVID-19 marathon.

Tinseltown/Shutterstock

Train your mind

Elite athletes understand that what will take them to the top of their sport is less about their physical gifts (all elite athletes have superior athletic talent) and more about how they train their minds to achieve their goals. As basketball great Kareem Abdul-Jabbar said, “Your mind is what makes everything else work.” Not surprisingly, athletes who train to be mentally “tough” have a better chance to reach the podium.

One definition of mental toughness is the “ability to perform toward the upper range of your talent and skill” regardless of external circumstances.¹ Mental toughness involves an unshakable self-belief, resilience, motivation, focus, and ability to perform under pressure and manage physical and emotional pain.

Like me, most of you probably are not elite athletes, but you can train your mind to be tougher and increase your stamina using some of the following techniques.

Think positively

Do you find yourself dealing with an inner monologue of fear, self-doubt, and feelings of worthlessness? That is the Obnoxious Roommate in your head as described in a HuffPost article and based on the pioneering work of psychiatrist Aaron Beck, MD, the father of cognitive-behavioral therapy.^2,3 Such thoughts negatively affect one’s sense of self-efficacy, which is the mental state of believing that you can meet the challenges you face. Elite athletes pay particular attention to their self-talk and replace negative thoughts with positive ones. These may include affirmations of your strengths or cue words that pump you up or help you manage your nerves.

To begin this practice, first observe what you are telling yourself. You may be saying, “I can’t do this. This is too hard.” This is an important step because you may have lived with the Obnoxious Roommate for so long that these thoughts are automatic and seem like a part of you. If, however, you first observe the thought and acknowledge it, you can begin to replace negative thoughts with supportive ones: “This is hard, but I can do this. I am intelligent, strong, capable, and ready.” While practice and repetition are required, thinking positively eventually will become a habit of self-support. Elite athletes know that to reach the top, they need to become their own best friend.⁴

Continue to: Use visualization...

Use visualization

Elite athletes visualize their events in such meticulous detail that they can actually feel their feet on the track, their muscles tensing, the starter pistol going off, the roar of the crowd. Research shows that the part of the brain that is activated in a race is also activated when one visualizes the race. It is as though the race is happening in real time.⁵ Physicians could use this approach to visualize the day ahead, picturing the procedures in detail and the clinical encounters going well.

In the current crisis, we frequently need a way to calm down quickly. One suggestion is to find a quiet space and sit for a few minutes, allowing the chair to support you. Then imagine a beautiful, calm, soothing place. Relax there and take in that feeling. Or, imagine a past achievement when you felt good about yourself. See yourself in that moment, remember how you felt, and take it in.

Plan for setbacks

All elite athletes have setbacks: Marathon runners hit a wall, golfers hit into the rough. But they don’t spin out of control at setbacks. They expect them, and they have practiced skills to restore their confidence and re-center themselves.⁶ For example, some athletes calm themselves by performing a ritualized series of movements. Others use a specific phrase (that positive self-talk again!) that reminds them of their goals or skills, while others play specific songs on their media player, or in their head, to return to their center.

Another technique is to use deep, rhythmic, diaphragmatic breathing for about 30 seconds to bring yourself back to your body.

The point is to have a plan in place to respond to setbacks in a positive manner and get back on track. Don’t waste time on self-criticism.

Continue to: Manage stress...

Manage stress

Not all stress is negative. Everyone has a “sweet spot,” a level of activation from which we operate best.¹ If we go too far over that level, though, we can panic. If we aren’t stressed enough, it is hard to get going at all.

If you need to be pumped up to function at your best, try playing music that energizes you. If you work best when you are calm, take deep breaths and attend to the exhalation while you engage in positive self-talk.

Another way to manage stress levels during the COVID-19 pandemic is to employ the ESCAPE mnemonic:

• Exercise. Research shows that regular aerobic exercise is a potent stress reliever; it raises endorphin levels, provides a general sense of well-being, and improves immune function.⁷ If you exercise regularly, do everything possible to keep doing so. If you do not have an exercise routine, try taking walks. Get out into the fresh air, pay attention to your surroundings, and work to be present in your body as you move.
• Sleep. Getting adequate sleep, 7 to 9 hours a night for most people, is important for maintaining physical and emotional health.⁸ Elite athletes pay particular attention to sleep because they know that their bodies need to recharge. The COVID-19 crisis has affected sleep for many, and we need to consciously attend to sleep hygiene. This includes limiting use of screen time to no more than 2 hours before bed. As well, limit your intake of the news and definitely avoid it right before bedtime. Take a warm shower, drink a cup of herbal tea, or read a less-than-stimulating journal article. Make sure your bedroom is cool and dark. Keep a regular bedtime and wake up at a regular time.
• Connect. Despite the current need for physical distancing, do not neglect your need to connect to those you love and care about. Whatever modality works for you—telephone, e-mail, video conferencing—if you feel lonely, reach out. Friends and families are concerned about us, and it makes them feel useful to support us. Allow that.
• Appreciate/cultivate gratitude. Look for causes for celebration in your life, whether that is your family, friends, or that you have a job and a home. Perhaps it is the cleaner air or the beauty of nature. Whatever you are grateful for, acknowledge it, perhaps by writing it down in a journal. Remembering these things can serve as an antidote to the stress created by the COVID-19 crisis.
• Play. Seek out things that make you laugh.⁹ Find your inner goofiness. Get creative and paint, sing, garden, golf, play an instrument, dance, do puzzles, or play games. We need to remember the pleasures in life when times are dark. Find whatever feels like joy.
• Exhale. If you have a meditation practice continue to do it. If not, consider starting. Try yoga as a way to center yourself in your body. Elite athletes use meditation and yoga to harness their minds and bodies to feel more in control.¹⁰ When so many things feel out of our control and unpredictable, it can be immensely soothing to connect to yourself in this way and realize you can reliably relax.

Self-care is a necessity

While we are in a marathon not of our choosing, we can use the techniques of elite athletes to think positively, visualize scenarios to achieve our goals or to simply relax, plan for setbacks so that we can bounce back, and manage stress productively. Self-care is paramount as we continue to care for others. Let’s not neglect ourselves, and we will cross the finish line together. ●

To the Editor:

It is with great interest that I read the article by Ware et al,¹ “Racial Limitations of Fitzpatrick Skin Type.” Within my own department, the issue of the appropriateness of using Fitzpatrick skin type (FST) as a surrogate to describe skin color has been raised with mixed responses.

As in many dermatology residency programs across the country, first-year dermatology residents are asked to describe the morphology of a lesion/eruption seen on a patient during Grand Rounds. Preceding the morphologic description, many providers describe the appearance of the patient including their skin color, as constitutive skin color can impact understanding of the morphologic descriptions, favor different diagnoses based on disease epidemiology, and guide subsequent treatment recommendations.^2,3 During one of my first Grand Rounds as an early dermatology resident, a patient was described as a “well-appearing brown boy,” which led to a lively discussion regarding the terms that should be used to describe skin color, with some in the audience preferring FST, others including myself preferring degree of pigmentation (eg, light, moderate, dark), and lastly others preferring an inferred ethnicity based on the patient’s appearance. One audience member commented, “I am brown, therefore I think it is fine to say ‘brown boy,’” which adds to findings from Ware et al¹ that there may be differences in what providers prefer to utilize to describe a patient’s skin color based on their own constitutive skin color.

I inquired with 2 other first-year dermatology residents with skin of color at other programs. When asked what terminology they use to describe a patient for Grand Rounds or in clinic, one resident replied, “It’s stylistic but if it’s your one liner [for assessment and plan] use their ethnicity [whereas] if it’s [for] a physical exam use their Fitzpatrick skin type.” The other resident replied, “I use Fitzpatrick skin type even though it’s technically subjective and therefore not appropriate for use within objective data, such as the physical exam, however it’s a language that most colleagues understand as a substitute for skin color.” I also raised the same question to an attending dermatologist at a primarily skin-of-color community hospital. She replied, “I think when unsure about ethnicity, Fitzpatrick type is an appropriate way to describe someone. It’s not really correct to say [a patient’s ethnicity] when you don’t know for sure.”

Unfortunately, as Ware and colleagues¹ indicated, there is no consensus by which to objectively classify nonwhite skin color. Within the dermatology literature, it has been proposed that race should not be used to express skin color, and this article proposes that FST is an inappropriate surrogate for race/ethnicity.⁴ Although I agree that appropriate use of FST should be emphasized in training, is there a vocabulary that Ware et al¹ recommend we use instead? Does the Skin of Color Society have suggestions on preferred language among its members? Finally, what efforts are being made to develop “culturally appropriate and clinically relevant methods for describing skin of color,” as the authors stated, within our own Skin of Color Society, or to whom does this responsibility ultimately fall?

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Sachdeva S. Fitzpatrick skin typing: applications in dermatology. Indian J Dermatol Venereol Leprol. 2009;75:93-96.

3. Kelly AP, Taylor SC, Lim HW, et al. Taylor and Kelly’s Dermatology for Skin of Color. 2nd ed. New York, NY: McGraw-Hill Education; 2016.

4. Bigby M, Thaler D. Describing patients’ “race” in clinical presentations should be abandoned. J Am Acad Dermatol. 2006;54:1074-1076.

Author’s Response

My colleagues and I thank Dr. Pimentel for his insights regarding the article, “Racial Limitations of Fitzpatrick Skin Type.”¹ The conundrum on how to appropriately categorize skin color for descriptive and epidemiologic purposes continues to remain unsolved today. However, attempts have been made in the past. For example, in September 2006, Dr. Susan C. Taylor (Philadelphia, Pennsylvania), formed and chaired a workshop session titled “A New Classification System for All Skin Types.” Dermatology leaders with skin of color expertise were invited from around the world for a weekend in New York, New York, to brainstorm a new skin color classification system. This endeavor did not produce any successful alternatives, but it has remained a pertinent topic of discussion in academic dermatology, including the Skin of Color Society, since then.

When unsure about ethnicity, my colleagues and I continue to advocate that the Fitzpatrick scale is not an appropriate substitute to describe skin color. This usage of Fitzpatrick skin type (FST) perpetuates the idea that the Fitzpatrick scale is a suitable proxy to describe ethnicity or race, which it is not. It is important to remember that race is a social classification construct, not a biological one.² The topic of race in contemporary culture undoubtedly invokes strong emotional connotations. The language around race is constantly evolving. I would argue that fear and discomfort of using incorrect racial language promotes the inappropriate use of FST, as the FST may be perceived as a more scientific and pseudoapplicable form of classification. To gain knowledge about a patient’s ethnicity/race to assess epidemiologic ethnic trends, we recommend asking the patient in an intake form or during consultation to self-identify his/her ethnicity or race,³ which takes the guesswork out for providers. However, caution must be exercised to avoid using race and ethnicity to later describe skin color.

Until a more culturally and medically relevant method of skin color classification is created, my colleagues and I recommend using basic color adjectives such as brown, black, pink, tan, or white supplemented with light, medium, or dark predescriptors. For example, “A 35-year-old self-identified African American woman with a dark brown skin hue presents with a 2-week flare of itchy, dark purple plaques with white scale on the scalp and extensor surfaces of the knees and elbows.” These basic descriptions for constitutive skin color conjure ample visual information for the listener/reader to understand morphologic descriptions, presentation of erythema, changes in pigmentation, and more. For a more specific skin color classification, we recommend developing a user-friendly Pantone-like color system to classify constitutive skin color.⁴

Jessica E. Dawson, MD

From the University of Washington School of Medicine, Seattle.

The author reports no conflict of interest.

Correspondence: Jessica E. Dawson, MD, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 ([email protected]).

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Ifekwunigwe JO, Wagner JK, Yu JH, et al. A qualitative analysis of how anthropologists interpret the race construct. Am Anthropol. 2017;119:422-434.

3. Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41:1501-1518.

4. What is the Pantone color system? Pantone website. https://www.pantone.com/color-systems/pantone-color-systems-explained. Accesed May 13, 2020.

To the Editor:

It is with great interest that I read the article by Ware et al,¹ “Racial Limitations of Fitzpatrick Skin Type.” Within my own department, the issue of the appropriateness of using Fitzpatrick skin type (FST) as a surrogate to describe skin color has been raised with mixed responses.

As in many dermatology residency programs across the country, first-year dermatology residents are asked to describe the morphology of a lesion/eruption seen on a patient during Grand Rounds. Preceding the morphologic description, many providers describe the appearance of the patient including their skin color, as constitutive skin color can impact understanding of the morphologic descriptions, favor different diagnoses based on disease epidemiology, and guide subsequent treatment recommendations.^2,3 During one of my first Grand Rounds as an early dermatology resident, a patient was described as a “well-appearing brown boy,” which led to a lively discussion regarding the terms that should be used to describe skin color, with some in the audience preferring FST, others including myself preferring degree of pigmentation (eg, light, moderate, dark), and lastly others preferring an inferred ethnicity based on the patient’s appearance. One audience member commented, “I am brown, therefore I think it is fine to say ‘brown boy,’” which adds to findings from Ware et al¹ that there may be differences in what providers prefer to utilize to describe a patient’s skin color based on their own constitutive skin color.

I inquired with 2 other first-year dermatology residents with skin of color at other programs. When asked what terminology they use to describe a patient for Grand Rounds or in clinic, one resident replied, “It’s stylistic but if it’s your one liner [for assessment and plan] use their ethnicity [whereas] if it’s [for] a physical exam use their Fitzpatrick skin type.” The other resident replied, “I use Fitzpatrick skin type even though it’s technically subjective and therefore not appropriate for use within objective data, such as the physical exam, however it’s a language that most colleagues understand as a substitute for skin color.” I also raised the same question to an attending dermatologist at a primarily skin-of-color community hospital. She replied, “I think when unsure about ethnicity, Fitzpatrick type is an appropriate way to describe someone. It’s not really correct to say [a patient’s ethnicity] when you don’t know for sure.”

Unfortunately, as Ware and colleagues¹ indicated, there is no consensus by which to objectively classify nonwhite skin color. Within the dermatology literature, it has been proposed that race should not be used to express skin color, and this article proposes that FST is an inappropriate surrogate for race/ethnicity.⁴ Although I agree that appropriate use of FST should be emphasized in training, is there a vocabulary that Ware et al¹ recommend we use instead? Does the Skin of Color Society have suggestions on preferred language among its members? Finally, what efforts are being made to develop “culturally appropriate and clinically relevant methods for describing skin of color,” as the authors stated, within our own Skin of Color Society, or to whom does this responsibility ultimately fall?

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Sachdeva S. Fitzpatrick skin typing: applications in dermatology. Indian J Dermatol Venereol Leprol. 2009;75:93-96.

3. Kelly AP, Taylor SC, Lim HW, et al. Taylor and Kelly’s Dermatology for Skin of Color. 2nd ed. New York, NY: McGraw-Hill Education; 2016.

4. Bigby M, Thaler D. Describing patients’ “race” in clinical presentations should be abandoned. J Am Acad Dermatol. 2006;54:1074-1076.

Author’s Response

My colleagues and I thank Dr. Pimentel for his insights regarding the article, “Racial Limitations of Fitzpatrick Skin Type.”¹ The conundrum on how to appropriately categorize skin color for descriptive and epidemiologic purposes continues to remain unsolved today. However, attempts have been made in the past. For example, in September 2006, Dr. Susan C. Taylor (Philadelphia, Pennsylvania), formed and chaired a workshop session titled “A New Classification System for All Skin Types.” Dermatology leaders with skin of color expertise were invited from around the world for a weekend in New York, New York, to brainstorm a new skin color classification system. This endeavor did not produce any successful alternatives, but it has remained a pertinent topic of discussion in academic dermatology, including the Skin of Color Society, since then.

When unsure about ethnicity, my colleagues and I continue to advocate that the Fitzpatrick scale is not an appropriate substitute to describe skin color. This usage of Fitzpatrick skin type (FST) perpetuates the idea that the Fitzpatrick scale is a suitable proxy to describe ethnicity or race, which it is not. It is important to remember that race is a social classification construct, not a biological one.² The topic of race in contemporary culture undoubtedly invokes strong emotional connotations. The language around race is constantly evolving. I would argue that fear and discomfort of using incorrect racial language promotes the inappropriate use of FST, as the FST may be perceived as a more scientific and pseudoapplicable form of classification. To gain knowledge about a patient’s ethnicity/race to assess epidemiologic ethnic trends, we recommend asking the patient in an intake form or during consultation to self-identify his/her ethnicity or race,³ which takes the guesswork out for providers. However, caution must be exercised to avoid using race and ethnicity to later describe skin color.

Until a more culturally and medically relevant method of skin color classification is created, my colleagues and I recommend using basic color adjectives such as brown, black, pink, tan, or white supplemented with light, medium, or dark predescriptors. For example, “A 35-year-old self-identified African American woman with a dark brown skin hue presents with a 2-week flare of itchy, dark purple plaques with white scale on the scalp and extensor surfaces of the knees and elbows.” These basic descriptions for constitutive skin color conjure ample visual information for the listener/reader to understand morphologic descriptions, presentation of erythema, changes in pigmentation, and more. For a more specific skin color classification, we recommend developing a user-friendly Pantone-like color system to classify constitutive skin color.⁴

Jessica E. Dawson, MD

From the University of Washington School of Medicine, Seattle.

The author reports no conflict of interest.

Correspondence: Jessica E. Dawson, MD, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 ([email protected]).

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Ifekwunigwe JO, Wagner JK, Yu JH, et al. A qualitative analysis of how anthropologists interpret the race construct. Am Anthropol. 2017;119:422-434.

3. Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41:1501-1518.

4. What is the Pantone color system? Pantone website. https://www.pantone.com/color-systems/pantone-color-systems-explained. Accesed May 13, 2020.

To the Editor:

It is with great interest that I read the article by Ware et al,¹ “Racial Limitations of Fitzpatrick Skin Type.” Within my own department, the issue of the appropriateness of using Fitzpatrick skin type (FST) as a surrogate to describe skin color has been raised with mixed responses.

As in many dermatology residency programs across the country, first-year dermatology residents are asked to describe the morphology of a lesion/eruption seen on a patient during Grand Rounds. Preceding the morphologic description, many providers describe the appearance of the patient including their skin color, as constitutive skin color can impact understanding of the morphologic descriptions, favor different diagnoses based on disease epidemiology, and guide subsequent treatment recommendations.^2,3 During one of my first Grand Rounds as an early dermatology resident, a patient was described as a “well-appearing brown boy,” which led to a lively discussion regarding the terms that should be used to describe skin color, with some in the audience preferring FST, others including myself preferring degree of pigmentation (eg, light, moderate, dark), and lastly others preferring an inferred ethnicity based on the patient’s appearance. One audience member commented, “I am brown, therefore I think it is fine to say ‘brown boy,’” which adds to findings from Ware et al¹ that there may be differences in what providers prefer to utilize to describe a patient’s skin color based on their own constitutive skin color.

I inquired with 2 other first-year dermatology residents with skin of color at other programs. When asked what terminology they use to describe a patient for Grand Rounds or in clinic, one resident replied, “It’s stylistic but if it’s your one liner [for assessment and plan] use their ethnicity [whereas] if it’s [for] a physical exam use their Fitzpatrick skin type.” The other resident replied, “I use Fitzpatrick skin type even though it’s technically subjective and therefore not appropriate for use within objective data, such as the physical exam, however it’s a language that most colleagues understand as a substitute for skin color.” I also raised the same question to an attending dermatologist at a primarily skin-of-color community hospital. She replied, “I think when unsure about ethnicity, Fitzpatrick type is an appropriate way to describe someone. It’s not really correct to say [a patient’s ethnicity] when you don’t know for sure.”

Unfortunately, as Ware and colleagues¹ indicated, there is no consensus by which to objectively classify nonwhite skin color. Within the dermatology literature, it has been proposed that race should not be used to express skin color, and this article proposes that FST is an inappropriate surrogate for race/ethnicity.⁴ Although I agree that appropriate use of FST should be emphasized in training, is there a vocabulary that Ware et al¹ recommend we use instead? Does the Skin of Color Society have suggestions on preferred language among its members? Finally, what efforts are being made to develop “culturally appropriate and clinically relevant methods for describing skin of color,” as the authors stated, within our own Skin of Color Society, or to whom does this responsibility ultimately fall?

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Sachdeva S. Fitzpatrick skin typing: applications in dermatology. Indian J Dermatol Venereol Leprol. 2009;75:93-96.

3. Kelly AP, Taylor SC, Lim HW, et al. Taylor and Kelly’s Dermatology for Skin of Color. 2nd ed. New York, NY: McGraw-Hill Education; 2016.

4. Bigby M, Thaler D. Describing patients’ “race” in clinical presentations should be abandoned. J Am Acad Dermatol. 2006;54:1074-1076.

Author’s Response

My colleagues and I thank Dr. Pimentel for his insights regarding the article, “Racial Limitations of Fitzpatrick Skin Type.”¹ The conundrum on how to appropriately categorize skin color for descriptive and epidemiologic purposes continues to remain unsolved today. However, attempts have been made in the past. For example, in September 2006, Dr. Susan C. Taylor (Philadelphia, Pennsylvania), formed and chaired a workshop session titled “A New Classification System for All Skin Types.” Dermatology leaders with skin of color expertise were invited from around the world for a weekend in New York, New York, to brainstorm a new skin color classification system. This endeavor did not produce any successful alternatives, but it has remained a pertinent topic of discussion in academic dermatology, including the Skin of Color Society, since then.

When unsure about ethnicity, my colleagues and I continue to advocate that the Fitzpatrick scale is not an appropriate substitute to describe skin color. This usage of Fitzpatrick skin type (FST) perpetuates the idea that the Fitzpatrick scale is a suitable proxy to describe ethnicity or race, which it is not. It is important to remember that race is a social classification construct, not a biological one.² The topic of race in contemporary culture undoubtedly invokes strong emotional connotations. The language around race is constantly evolving. I would argue that fear and discomfort of using incorrect racial language promotes the inappropriate use of FST, as the FST may be perceived as a more scientific and pseudoapplicable form of classification. To gain knowledge about a patient’s ethnicity/race to assess epidemiologic ethnic trends, we recommend asking the patient in an intake form or during consultation to self-identify his/her ethnicity or race,³ which takes the guesswork out for providers. However, caution must be exercised to avoid using race and ethnicity to later describe skin color.

Until a more culturally and medically relevant method of skin color classification is created, my colleagues and I recommend using basic color adjectives such as brown, black, pink, tan, or white supplemented with light, medium, or dark predescriptors. For example, “A 35-year-old self-identified African American woman with a dark brown skin hue presents with a 2-week flare of itchy, dark purple plaques with white scale on the scalp and extensor surfaces of the knees and elbows.” These basic descriptions for constitutive skin color conjure ample visual information for the listener/reader to understand morphologic descriptions, presentation of erythema, changes in pigmentation, and more. For a more specific skin color classification, we recommend developing a user-friendly Pantone-like color system to classify constitutive skin color.⁴

Jessica E. Dawson, MD

From the University of Washington School of Medicine, Seattle.

The author reports no conflict of interest.

Correspondence: Jessica E. Dawson, MD, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 ([email protected]).

References

1. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

2. Ifekwunigwe JO, Wagner JK, Yu JH, et al. A qualitative analysis of how anthropologists interpret the race construct. Am Anthropol. 2017;119:422-434.

3. Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41:1501-1518.

4. What is the Pantone color system? Pantone website. https://www.pantone.com/color-systems/pantone-color-systems-explained. Accesed May 13, 2020.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease that can have devastating effects on many organs. Despite the considerable morbidity and mortality associated with SLE, treatment options have been largely unchanged since the 1950s.¹ It was not until the last decade that a new biologic medication was approved, and several other promising treatments currently are being evaluated in clinical trials. Dermatologists are most likely to encounter cutaneous lupus erythematosus (CLE) with or without SLE, which can present with a variety of skin manifestations. Cutaneous lupus erythematosus can have devastating effects on quality of life and can be a visible sign of the internal activity and damage of SLE.^2,3 Although many trials have been completed evaluating SLE treatments, few medications have been evaluated specifically for CLE despite the availability of validated measures of CLE skin activity.⁴ There is a recent shortage of antimalarial medications, the current first-line therapy for CLE, due to both an import alert in the United States on quinacrine placed in 2019 as well as the use of hydroxychloroquine and chloroquine in treating coronavirus disease 2019.^5,6 Due to this shortage, the need for new and effective treatments is more critical than ever, as alternatives to first-line therapy frequently require immunosuppression. We review recent drug approvals for SLE and their efficacy in CLE. We also provide an update on new agents currently being studied to treat this disease.

Belimumab

Belimumab is a B-lymphocyte stimulator–specific inhibitor that was first approved for treatment of SLE in 2011. It was the first monoclonal antibody approved to treat SLE.⁷ B-lymphocyte stimulator plays a critical role in B-cell survival; thus, its inhibition increases apoptosis of autoreactive B cells involved in the pathogenesis of SLE. More recently, belimumab was approved for pediatric SLE in April 2019 based on the PLUTO study, a phase 2 randomized, double-blind study of 93 patients.⁸ Although patients with cutaneous manifestations of lupus were included in trials for belimumab, they lacked CLE-specific outcome measurements to truly evaluate the efficacy in treating skin disease.⁹ This medication currently is not approved by the US Food and Drug Administration (FDA) for CLE; however, it is used off label in some cases for recalcitrant disease.¹⁰

Baricitinib

Baricitinib is a selective and reversible inhibitor of JAK1 and JAK2 that was granted fast-track status by the FDA in December 2018. In a phase 2 trial, baricitinib was superior to placebo plus standard of care, primarily for arthritis and lupus nephritis.¹¹ Although improvement of cutaneous disease was measured as an end point, it did not show significant improvement in disease. The presence of skin disease was high, but the activity of disease was low, which can make it difficult to show meaningful improvement, as there is not much room for patients to objectively improve.¹² Showing meaningful improvement in skin disease often is difficult in phase 2 trials, especially when the trial design is focused on SLE rather than CLE activity. Further studies of baricitinib that include more severe patients with CLE disease are needed to truly understand its effects on the skin.

Lenalidomide

There have been several CLE studies in the last several years surrounding lenalidomide, an analog of thalidomide.^13-15 This molecule has a number of immunomodulatory effects including antiangiogenic effects, increased natural killer cell–dependent cytotoxicity, and cytokine and interleukin inhibition. Lenalidomide is of particular interest in treating CLE, as it was shown to be more potent than thalidomide at low doses and with a better side-effect profile. Multiple small, open-label trials have shown lenalidomide to be both safe and efficacious in the treatment of CLE.^13,14 In addition, iberdomide, a derivative of lenalidomide, recently completed a phase 2 dose-escalation study showing improvement in both SLE and CLE end points.¹⁶ A phase 2b proof-of-concept study currently is underway (ClinicalTrials.gov Identifier NCT03161483).

Monoclonal Antibodies

Many developing therapies target specific components of the type I interferon pathway, which is a primary driver of CLE lesions. Innate immune system pathways involving type I interferon were shown to be active in the pathogenesis of CLE, and levels of interferon correlate with skin disease activity.¹⁷ One molecule in development that targets this pathway is BIIB059, a humanized IgG1 monoclonal antibody that binds to blood dendritic cell antigen 2. This cell surface protein is uniquely expressed on plasmacytoid dendritic cells, which are the main source of type I interferon overproduction in SLE. The binding of this antibody to the blood dendritic cell antigen 2 receptor both blocks type I interferon production and decreases the overall number of active plasmacytoid dendritic cells present.¹⁸ In the completed phase 1b study, a response in cutaneous disease was shown through a reduction in the CLE disease area and severity index score following single-dose administration.¹⁹ More recently, a phase 2 study met primary end points in both SLE and CLE compared to placebo.²⁰

Anifrolumab is a human IgG1k monoclonal antibody that binds to type I interferon receptor, blocking all type I interferon signaling. Following a successful phase 2 trial, it failed to meet its primary end point in its first phase 3 trial.²¹ Several secondary end points suggested a clinical benefit. A second phase 3 trial of 362 patients randomized to treatment with anifrolumab or placebo over 48 weeks showed anifrolumab to be superior to placebo for multiple end points, including the overall disease primary end point as well as a notable reduction in skin activity.²²

Final Thoughts

Outside of the approval of belimumab, there have been no new FDA-approved treatments for SLE since the approval of antimalarial agents nearly 50 years ago. For CLE specifically, there is an even greater scarcity of evidence-based treatments. Recently studied medications, such as belimumab and lenalidomide, are available off label for CLE patients when other options have failed. Recent studies have evaluated the efficacy of these agents in the treatment of CLE using the CLE disease area and severity index.^10,13,14 Enrollment in CLE trials is difficult due to the rarity of the disease, and careful attention must be paid to evaluating skin end points. As experts in CLE and the nuances of these assessments, it is critical that dermatologists be involved in clinical trials. Future SLE trials must consider CLE as an important end point for CLE patients to get access to much-needed novel therapies.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease that can have devastating effects on many organs. Despite the considerable morbidity and mortality associated with SLE, treatment options have been largely unchanged since the 1950s.¹ It was not until the last decade that a new biologic medication was approved, and several other promising treatments currently are being evaluated in clinical trials. Dermatologists are most likely to encounter cutaneous lupus erythematosus (CLE) with or without SLE, which can present with a variety of skin manifestations. Cutaneous lupus erythematosus can have devastating effects on quality of life and can be a visible sign of the internal activity and damage of SLE.^2,3 Although many trials have been completed evaluating SLE treatments, few medications have been evaluated specifically for CLE despite the availability of validated measures of CLE skin activity.⁴ There is a recent shortage of antimalarial medications, the current first-line therapy for CLE, due to both an import alert in the United States on quinacrine placed in 2019 as well as the use of hydroxychloroquine and chloroquine in treating coronavirus disease 2019.^5,6 Due to this shortage, the need for new and effective treatments is more critical than ever, as alternatives to first-line therapy frequently require immunosuppression. We review recent drug approvals for SLE and their efficacy in CLE. We also provide an update on new agents currently being studied to treat this disease.

Belimumab

Belimumab is a B-lymphocyte stimulator–specific inhibitor that was first approved for treatment of SLE in 2011. It was the first monoclonal antibody approved to treat SLE.⁷ B-lymphocyte stimulator plays a critical role in B-cell survival; thus, its inhibition increases apoptosis of autoreactive B cells involved in the pathogenesis of SLE. More recently, belimumab was approved for pediatric SLE in April 2019 based on the PLUTO study, a phase 2 randomized, double-blind study of 93 patients.⁸ Although patients with cutaneous manifestations of lupus were included in trials for belimumab, they lacked CLE-specific outcome measurements to truly evaluate the efficacy in treating skin disease.⁹ This medication currently is not approved by the US Food and Drug Administration (FDA) for CLE; however, it is used off label in some cases for recalcitrant disease.¹⁰

Baricitinib

Baricitinib is a selective and reversible inhibitor of JAK1 and JAK2 that was granted fast-track status by the FDA in December 2018. In a phase 2 trial, baricitinib was superior to placebo plus standard of care, primarily for arthritis and lupus nephritis.¹¹ Although improvement of cutaneous disease was measured as an end point, it did not show significant improvement in disease. The presence of skin disease was high, but the activity of disease was low, which can make it difficult to show meaningful improvement, as there is not much room for patients to objectively improve.¹² Showing meaningful improvement in skin disease often is difficult in phase 2 trials, especially when the trial design is focused on SLE rather than CLE activity. Further studies of baricitinib that include more severe patients with CLE disease are needed to truly understand its effects on the skin.

Lenalidomide

There have been several CLE studies in the last several years surrounding lenalidomide, an analog of thalidomide.^13-15 This molecule has a number of immunomodulatory effects including antiangiogenic effects, increased natural killer cell–dependent cytotoxicity, and cytokine and interleukin inhibition. Lenalidomide is of particular interest in treating CLE, as it was shown to be more potent than thalidomide at low doses and with a better side-effect profile. Multiple small, open-label trials have shown lenalidomide to be both safe and efficacious in the treatment of CLE.^13,14 In addition, iberdomide, a derivative of lenalidomide, recently completed a phase 2 dose-escalation study showing improvement in both SLE and CLE end points.¹⁶ A phase 2b proof-of-concept study currently is underway (ClinicalTrials.gov Identifier NCT03161483).

Monoclonal Antibodies

Many developing therapies target specific components of the type I interferon pathway, which is a primary driver of CLE lesions. Innate immune system pathways involving type I interferon were shown to be active in the pathogenesis of CLE, and levels of interferon correlate with skin disease activity.¹⁷ One molecule in development that targets this pathway is BIIB059, a humanized IgG1 monoclonal antibody that binds to blood dendritic cell antigen 2. This cell surface protein is uniquely expressed on plasmacytoid dendritic cells, which are the main source of type I interferon overproduction in SLE. The binding of this antibody to the blood dendritic cell antigen 2 receptor both blocks type I interferon production and decreases the overall number of active plasmacytoid dendritic cells present.¹⁸ In the completed phase 1b study, a response in cutaneous disease was shown through a reduction in the CLE disease area and severity index score following single-dose administration.¹⁹ More recently, a phase 2 study met primary end points in both SLE and CLE compared to placebo.²⁰

Anifrolumab is a human IgG1k monoclonal antibody that binds to type I interferon receptor, blocking all type I interferon signaling. Following a successful phase 2 trial, it failed to meet its primary end point in its first phase 3 trial.²¹ Several secondary end points suggested a clinical benefit. A second phase 3 trial of 362 patients randomized to treatment with anifrolumab or placebo over 48 weeks showed anifrolumab to be superior to placebo for multiple end points, including the overall disease primary end point as well as a notable reduction in skin activity.²²

Final Thoughts

Outside of the approval of belimumab, there have been no new FDA-approved treatments for SLE since the approval of antimalarial agents nearly 50 years ago. For CLE specifically, there is an even greater scarcity of evidence-based treatments. Recently studied medications, such as belimumab and lenalidomide, are available off label for CLE patients when other options have failed. Recent studies have evaluated the efficacy of these agents in the treatment of CLE using the CLE disease area and severity index.^10,13,14 Enrollment in CLE trials is difficult due to the rarity of the disease, and careful attention must be paid to evaluating skin end points. As experts in CLE and the nuances of these assessments, it is critical that dermatologists be involved in clinical trials. Future SLE trials must consider CLE as an important end point for CLE patients to get access to much-needed novel therapies.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease that can have devastating effects on many organs. Despite the considerable morbidity and mortality associated with SLE, treatment options have been largely unchanged since the 1950s.¹ It was not until the last decade that a new biologic medication was approved, and several other promising treatments currently are being evaluated in clinical trials. Dermatologists are most likely to encounter cutaneous lupus erythematosus (CLE) with or without SLE, which can present with a variety of skin manifestations. Cutaneous lupus erythematosus can have devastating effects on quality of life and can be a visible sign of the internal activity and damage of SLE.^2,3 Although many trials have been completed evaluating SLE treatments, few medications have been evaluated specifically for CLE despite the availability of validated measures of CLE skin activity.⁴ There is a recent shortage of antimalarial medications, the current first-line therapy for CLE, due to both an import alert in the United States on quinacrine placed in 2019 as well as the use of hydroxychloroquine and chloroquine in treating coronavirus disease 2019.^5,6 Due to this shortage, the need for new and effective treatments is more critical than ever, as alternatives to first-line therapy frequently require immunosuppression. We review recent drug approvals for SLE and their efficacy in CLE. We also provide an update on new agents currently being studied to treat this disease.

Belimumab

Belimumab is a B-lymphocyte stimulator–specific inhibitor that was first approved for treatment of SLE in 2011. It was the first monoclonal antibody approved to treat SLE.⁷ B-lymphocyte stimulator plays a critical role in B-cell survival; thus, its inhibition increases apoptosis of autoreactive B cells involved in the pathogenesis of SLE. More recently, belimumab was approved for pediatric SLE in April 2019 based on the PLUTO study, a phase 2 randomized, double-blind study of 93 patients.⁸ Although patients with cutaneous manifestations of lupus were included in trials for belimumab, they lacked CLE-specific outcome measurements to truly evaluate the efficacy in treating skin disease.⁹ This medication currently is not approved by the US Food and Drug Administration (FDA) for CLE; however, it is used off label in some cases for recalcitrant disease.¹⁰

Baricitinib

Baricitinib is a selective and reversible inhibitor of JAK1 and JAK2 that was granted fast-track status by the FDA in December 2018. In a phase 2 trial, baricitinib was superior to placebo plus standard of care, primarily for arthritis and lupus nephritis.¹¹ Although improvement of cutaneous disease was measured as an end point, it did not show significant improvement in disease. The presence of skin disease was high, but the activity of disease was low, which can make it difficult to show meaningful improvement, as there is not much room for patients to objectively improve.¹² Showing meaningful improvement in skin disease often is difficult in phase 2 trials, especially when the trial design is focused on SLE rather than CLE activity. Further studies of baricitinib that include more severe patients with CLE disease are needed to truly understand its effects on the skin.

Lenalidomide

There have been several CLE studies in the last several years surrounding lenalidomide, an analog of thalidomide.^13-15 This molecule has a number of immunomodulatory effects including antiangiogenic effects, increased natural killer cell–dependent cytotoxicity, and cytokine and interleukin inhibition. Lenalidomide is of particular interest in treating CLE, as it was shown to be more potent than thalidomide at low doses and with a better side-effect profile. Multiple small, open-label trials have shown lenalidomide to be both safe and efficacious in the treatment of CLE.^13,14 In addition, iberdomide, a derivative of lenalidomide, recently completed a phase 2 dose-escalation study showing improvement in both SLE and CLE end points.¹⁶ A phase 2b proof-of-concept study currently is underway (ClinicalTrials.gov Identifier NCT03161483).

Monoclonal Antibodies

Many developing therapies target specific components of the type I interferon pathway, which is a primary driver of CLE lesions. Innate immune system pathways involving type I interferon were shown to be active in the pathogenesis of CLE, and levels of interferon correlate with skin disease activity.¹⁷ One molecule in development that targets this pathway is BIIB059, a humanized IgG1 monoclonal antibody that binds to blood dendritic cell antigen 2. This cell surface protein is uniquely expressed on plasmacytoid dendritic cells, which are the main source of type I interferon overproduction in SLE. The binding of this antibody to the blood dendritic cell antigen 2 receptor both blocks type I interferon production and decreases the overall number of active plasmacytoid dendritic cells present.¹⁸ In the completed phase 1b study, a response in cutaneous disease was shown through a reduction in the CLE disease area and severity index score following single-dose administration.¹⁹ More recently, a phase 2 study met primary end points in both SLE and CLE compared to placebo.²⁰

Anifrolumab is a human IgG1k monoclonal antibody that binds to type I interferon receptor, blocking all type I interferon signaling. Following a successful phase 2 trial, it failed to meet its primary end point in its first phase 3 trial.²¹ Several secondary end points suggested a clinical benefit. A second phase 3 trial of 362 patients randomized to treatment with anifrolumab or placebo over 48 weeks showed anifrolumab to be superior to placebo for multiple end points, including the overall disease primary end point as well as a notable reduction in skin activity.²²

Final Thoughts

Outside of the approval of belimumab, there have been no new FDA-approved treatments for SLE since the approval of antimalarial agents nearly 50 years ago. For CLE specifically, there is an even greater scarcity of evidence-based treatments. Recently studied medications, such as belimumab and lenalidomide, are available off label for CLE patients when other options have failed. Recent studies have evaluated the efficacy of these agents in the treatment of CLE using the CLE disease area and severity index.^10,13,14 Enrollment in CLE trials is difficult due to the rarity of the disease, and careful attention must be paid to evaluating skin end points. As experts in CLE and the nuances of these assessments, it is critical that dermatologists be involved in clinical trials. Future SLE trials must consider CLE as an important end point for CLE patients to get access to much-needed novel therapies.

I grew up in a family that was pretty much devoid of physical demonstrations of affection. I certainly felt that my folks loved me, but there was no hugging. I don’t recall ever seeing my parents kiss or touch each other. My dad would occasionally physically tease my mother. For example, I can remember one incident at the dinner table when he was playfully and gently laying a hand on my mother’s arm just as she was raising her fork to her mouth. After about three of these gentle holds, she lifted her water glass and tossed its contents in his face. This was the full extent of physicality in our family.

kate_sept2004/thinkstock

It wasn’t just my parents. I can’t remember aunts or uncles or cousins ever hugging us when we met. Grandmothers of course would request a hug. I never knew either of my grandfathers, but I suspect they would not have been the hugging kind.

I never felt I was missing out on anything, because in the generally WASPish atmosphere of the community in which I grew up I saw very few public displays of affection. But somewhere over time, hugging crept into the American repertoire of expression. This incursion may have been a ripple effect from the flower power, free love hippiedom of the ‘60s and ‘70s. Or it may have been a symptom of globalization as Americans became more familiar with other cultures in which physical expression was more common.

Whatever the reason for the more widespread adoption of hugging in our social vocabulary with my somewhat physically impoverished upbringing, it took me longer than most folks to comfortably include it in my greeting options. Although I may have come to the dance late, I have fully adopted hugging as a way to greet people with whom I have more than a passing acquaintance.

In fact, the ability to comfortably hug former coworkers, old friends I haven’t seen in years, and parents with whom I had shared a particularly troublesome child is what I miss most about the restrictions that have come with the COVID-19 pandemic. Now when I meet folks in the grocery store with whom I share a special affection that magnetic spark still leaps between our eyes, just visible over our face masks, but mentally and physically we take a step back and say to ourselves that this hug shouldn’t happen and it isn’t going to happen. And that makes me sad.

One of the great perks of practicing pediatrics in a small town and then remaining there in retirement is that nearly every week I encounter one or two people with whom I have a long and sometimes emotionally charged relationship. Nurses with whom I sweated over difficult delivery room resuscitations. Parents for whom their anxiety was getting in the way of their ability to parent. Parents and caregivers of complex multiply disabled children who are now adults. Peers who have lost a spouse or a child. I’m sure you have your own list of people who send off that we-need-to-hug spark.

I can envision a day sometime in the relatively near future that I will be able to hug my two grandchildren whom I haven’t hugged even though they live a short 10-minute walk away. But I have trouble imagining when I will again be able to enjoy and be enriched by those special grocery store hugs that I have grown to savor.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I grew up in a family that was pretty much devoid of physical demonstrations of affection. I certainly felt that my folks loved me, but there was no hugging. I don’t recall ever seeing my parents kiss or touch each other. My dad would occasionally physically tease my mother. For example, I can remember one incident at the dinner table when he was playfully and gently laying a hand on my mother’s arm just as she was raising her fork to her mouth. After about three of these gentle holds, she lifted her water glass and tossed its contents in his face. This was the full extent of physicality in our family.

kate_sept2004/thinkstock

It wasn’t just my parents. I can’t remember aunts or uncles or cousins ever hugging us when we met. Grandmothers of course would request a hug. I never knew either of my grandfathers, but I suspect they would not have been the hugging kind.

I never felt I was missing out on anything, because in the generally WASPish atmosphere of the community in which I grew up I saw very few public displays of affection. But somewhere over time, hugging crept into the American repertoire of expression. This incursion may have been a ripple effect from the flower power, free love hippiedom of the ‘60s and ‘70s. Or it may have been a symptom of globalization as Americans became more familiar with other cultures in which physical expression was more common.

Whatever the reason for the more widespread adoption of hugging in our social vocabulary with my somewhat physically impoverished upbringing, it took me longer than most folks to comfortably include it in my greeting options. Although I may have come to the dance late, I have fully adopted hugging as a way to greet people with whom I have more than a passing acquaintance.

In fact, the ability to comfortably hug former coworkers, old friends I haven’t seen in years, and parents with whom I had shared a particularly troublesome child is what I miss most about the restrictions that have come with the COVID-19 pandemic. Now when I meet folks in the grocery store with whom I share a special affection that magnetic spark still leaps between our eyes, just visible over our face masks, but mentally and physically we take a step back and say to ourselves that this hug shouldn’t happen and it isn’t going to happen. And that makes me sad.

One of the great perks of practicing pediatrics in a small town and then remaining there in retirement is that nearly every week I encounter one or two people with whom I have a long and sometimes emotionally charged relationship. Nurses with whom I sweated over difficult delivery room resuscitations. Parents for whom their anxiety was getting in the way of their ability to parent. Parents and caregivers of complex multiply disabled children who are now adults. Peers who have lost a spouse or a child. I’m sure you have your own list of people who send off that we-need-to-hug spark.

I can envision a day sometime in the relatively near future that I will be able to hug my two grandchildren whom I haven’t hugged even though they live a short 10-minute walk away. But I have trouble imagining when I will again be able to enjoy and be enriched by those special grocery store hugs that I have grown to savor.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I grew up in a family that was pretty much devoid of physical demonstrations of affection. I certainly felt that my folks loved me, but there was no hugging. I don’t recall ever seeing my parents kiss or touch each other. My dad would occasionally physically tease my mother. For example, I can remember one incident at the dinner table when he was playfully and gently laying a hand on my mother’s arm just as she was raising her fork to her mouth. After about three of these gentle holds, she lifted her water glass and tossed its contents in his face. This was the full extent of physicality in our family.

kate_sept2004/thinkstock

It wasn’t just my parents. I can’t remember aunts or uncles or cousins ever hugging us when we met. Grandmothers of course would request a hug. I never knew either of my grandfathers, but I suspect they would not have been the hugging kind.

I never felt I was missing out on anything, because in the generally WASPish atmosphere of the community in which I grew up I saw very few public displays of affection. But somewhere over time, hugging crept into the American repertoire of expression. This incursion may have been a ripple effect from the flower power, free love hippiedom of the ‘60s and ‘70s. Or it may have been a symptom of globalization as Americans became more familiar with other cultures in which physical expression was more common.

Whatever the reason for the more widespread adoption of hugging in our social vocabulary with my somewhat physically impoverished upbringing, it took me longer than most folks to comfortably include it in my greeting options. Although I may have come to the dance late, I have fully adopted hugging as a way to greet people with whom I have more than a passing acquaintance.

In fact, the ability to comfortably hug former coworkers, old friends I haven’t seen in years, and parents with whom I had shared a particularly troublesome child is what I miss most about the restrictions that have come with the COVID-19 pandemic. Now when I meet folks in the grocery store with whom I share a special affection that magnetic spark still leaps between our eyes, just visible over our face masks, but mentally and physically we take a step back and say to ourselves that this hug shouldn’t happen and it isn’t going to happen. And that makes me sad.

One of the great perks of practicing pediatrics in a small town and then remaining there in retirement is that nearly every week I encounter one or two people with whom I have a long and sometimes emotionally charged relationship. Nurses with whom I sweated over difficult delivery room resuscitations. Parents for whom their anxiety was getting in the way of their ability to parent. Parents and caregivers of complex multiply disabled children who are now adults. Peers who have lost a spouse or a child. I’m sure you have your own list of people who send off that we-need-to-hug spark.

I can envision a day sometime in the relatively near future that I will be able to hug my two grandchildren whom I haven’t hugged even though they live a short 10-minute walk away. But I have trouble imagining when I will again be able to enjoy and be enriched by those special grocery store hugs that I have grown to savor.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In an update of the PREDIX-HER2 trial, trastuzumab emtansine (T-DM1) remained equivalent to standard neoadjuvant chemotherapy plus dual-targeted HER2 therapy in producing pathologic complete remissions (pCRs) among patients with HER2-positive, metastatic breast cancer.

The new data also suggest tumor-infiltrating lymphocytes (TILs) and dramatic improvements in PET-CT scans can predict favorable outcomes in both treatment groups. Though these findings will be useful for research purposes, they likely won’t influence routine clinical practice.

Thomas Hatschek, MD, PhD, of Karolinska Institutet in Stockholm, presented the updated results from PREDIX-HER2 during the European Society for Medical Oncology: Breast Cancer virtual meeting.

PREDIX-HER2 included patients with HER2-positive breast cancer and tumor size greater than 20 mm or lymph node metastases.

Patients received neoadjuvant therapy (NAT) with docetaxel and trastuzumab plus pertuzumab (DTP) or T-DM1 every 3 weeks for a planned total of six courses. The protocol permitted switching to the competing treatment for progression, lack of response, or drug-related severe toxicity.

Postoperatively, all patients received triweekly epirubicin plus cyclophosphamide – four courses for the T-DM1 arm and two courses for the DTP arm. All patients then received triweekly adjuvant trastuzumab for 11 courses. The 62% of patients whose tumors were hormone receptor (HR)–positive received standard endocrine therapy postoperatively.
 

Updated results, predictors of pCR

At the 2019 ASCO annual meeting, PREDIX-HER2 investigators reported that, when compared with DTP, T-DM1 produced the same likelihood of pCR with less toxicity (ASCO 2019, Abstract 501). Updated data presented at ESMO Breast Cancer 2020 showed similar results.

The pCR rate was 45.5% in the DTP arm and 43.9% in the T-DM1 arm (P = .824). pCR rates were higher for HR-negative tumors – 63.6% in the DTP arm and 59% in the T-DM1 arm – than for HR-positive tumors – 36.4% in the DTP arm and 33.9% in the TDM-1 arm.

Three patients had disease progression with T-DM1, and none progressed with DTP. However, almost twice as many patients switched from DTP to T-DM1, compared with the other sequence.

Dr. Hatschek reported that the presence of at least 10% TILs predicted pCR in both treatment groups. Among patients who achieved a pCR, 52.2% had at least 10% TILs in baseline biopsies, and 30.4% had less than 10% TILs.

In addition, a decrease of FDG maximum standardized uptake value by more than 75% on protocol-required PET-CT scans was highly predictive of pCR. Among patients who achieved a pCR, 70.3% had a maximum standardized uptake value decrease of more than 75%, and 22.5% had a decrease of 75% or less.

At median follow-up of 28.5 months, event-free survival was similar between the treatment arms. Overall, there were 13 cases of progression, relapse, contralateral breast cancer, distant metastases, or death from any cause. There were five such events in the DTP arm and eight in the TDM-1 arm.

Dr. Hatschek concluded that neoadjuvant T-DM1 may be as effective as standard NAT in all clinical subgroups evaluated. Both TILs and PET-CT showed the potential to predict pCR and merit further study in the NAT setting.
 

An imperfect surrogate

By definition, a surrogate is “one appointed to act in place of another.” In the case of PREDIX-HER2 and most other NAT studies in HER2-positive breast cancer patients, pCR is a surrogate for the endpoint about which doctors and patients really care – cancer-free survival.

As such, pCR is not a perfect surrogate. Reproducibly, pCR has been highly predictive of disease-free survival and overall survival, especially in the HR-negative subset of HER2-positive patients.

However, despite improvements with dual targeting of HER2 in the TRYPHAENA trial (Eur J Cancer. 2018;89:27-35) and the use of T-DM1 for patients failing to achieve pCR in the immediately practice-changing KATHERINE trial (N Engl J Med. 2019;380:617-28), eventual relapse is seen in 10%-20% of patients in various clinical-pathologic subgroups.

In PREDIX-HER2, the pCR rate for node-positive patients was considerably lower with T-DM1 than with DTP (54.1% vs. 38%), noted Valentina Guarneri, MD, of the University of Padova (Italy), in her discussion of the trial at ESMO Breast Cancer 2020.

Patients with larger initial tumor size and multiple involved axillary nodes at diagnosis remain at increased risk of death because of cancer relapse.

Central nervous system relapse remains a vexing problem. Among patients with triple-positive breast cancer, relapses may occur late, despite pCR.

Patients whose tumors transform from HER2 positive to HER2 negative with NAT, seen in approximately 8% of cases in the KATHERINE trial (ESMO Breast Cancer 2020, Abstract 96O), may be another poor-risk group.
 

Clinical implications

PREDIX-HER2 is an important study. At the early time point of 2.4 years (especially early since most patients were HR-positive), if pCR is achieved, event-free survival is excellent with T-DM1 or an aggressive multiagent cytotoxic combination plus dual HER2 targeting followed by anthracyclines.

It is ideal to have clinical-pathologic tests to distinguish those patients destined to achieve the surrogate endpoint of pCR from those who will not achieve it.

Despite linkage of TILs to improved outcome for triple-negative and HER2-enriched molecular subtypes (Lancet Oncol. 2018 Jan;19[1]:40-50), analysis of TILs is not standard practice in HER2-positive breast cancer in community settings. Optimal cutoffs are not well established, and TILs have not been linked to the choice of particular treatment options.

Currently, PET-CT scans are not part of National Comprehensive Cancer Network guidelines for pretreatment evaluation, except in patients for whom there is clinical suspicion of distant disease.

For those reasons, the main results of PREDIX-HER2 remain research tools that will focus our attention on the clinical-pathologic correlations Dr. Hatschek highlighted, but the results should have no influence on routine clinical practice at this time.

PREDIX-HER2 was funded by the Swedish Cancer Society, Radiumhemmet of Karolinska Institutet, Region Stockholm, and Roche Sweden. Dr. Hatschek disclosed relationships with Roche Sweden, Pfizer Sweden, and Pierre Fabre Sweden. Dr. Guarneri disclosed relationships with Roche, Novartis, and Eli Lilly.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Hatschek T et al. ESMO Breast Cancer 2020, Abstract 97O.

In an update of the PREDIX-HER2 trial, trastuzumab emtansine (T-DM1) remained equivalent to standard neoadjuvant chemotherapy plus dual-targeted HER2 therapy in producing pathologic complete remissions (pCRs) among patients with HER2-positive, metastatic breast cancer.

The new data also suggest tumor-infiltrating lymphocytes (TILs) and dramatic improvements in PET-CT scans can predict favorable outcomes in both treatment groups. Though these findings will be useful for research purposes, they likely won’t influence routine clinical practice.

Thomas Hatschek, MD, PhD, of Karolinska Institutet in Stockholm, presented the updated results from PREDIX-HER2 during the European Society for Medical Oncology: Breast Cancer virtual meeting.

PREDIX-HER2 included patients with HER2-positive breast cancer and tumor size greater than 20 mm or lymph node metastases.

Patients received neoadjuvant therapy (NAT) with docetaxel and trastuzumab plus pertuzumab (DTP) or T-DM1 every 3 weeks for a planned total of six courses. The protocol permitted switching to the competing treatment for progression, lack of response, or drug-related severe toxicity.

Postoperatively, all patients received triweekly epirubicin plus cyclophosphamide – four courses for the T-DM1 arm and two courses for the DTP arm. All patients then received triweekly adjuvant trastuzumab for 11 courses. The 62% of patients whose tumors were hormone receptor (HR)–positive received standard endocrine therapy postoperatively.
 

Updated results, predictors of pCR

At the 2019 ASCO annual meeting, PREDIX-HER2 investigators reported that, when compared with DTP, T-DM1 produced the same likelihood of pCR with less toxicity (ASCO 2019, Abstract 501). Updated data presented at ESMO Breast Cancer 2020 showed similar results.

The pCR rate was 45.5% in the DTP arm and 43.9% in the T-DM1 arm (P = .824). pCR rates were higher for HR-negative tumors – 63.6% in the DTP arm and 59% in the T-DM1 arm – than for HR-positive tumors – 36.4% in the DTP arm and 33.9% in the TDM-1 arm.

Three patients had disease progression with T-DM1, and none progressed with DTP. However, almost twice as many patients switched from DTP to T-DM1, compared with the other sequence.

Dr. Hatschek reported that the presence of at least 10% TILs predicted pCR in both treatment groups. Among patients who achieved a pCR, 52.2% had at least 10% TILs in baseline biopsies, and 30.4% had less than 10% TILs.

In addition, a decrease of FDG maximum standardized uptake value by more than 75% on protocol-required PET-CT scans was highly predictive of pCR. Among patients who achieved a pCR, 70.3% had a maximum standardized uptake value decrease of more than 75%, and 22.5% had a decrease of 75% or less.

At median follow-up of 28.5 months, event-free survival was similar between the treatment arms. Overall, there were 13 cases of progression, relapse, contralateral breast cancer, distant metastases, or death from any cause. There were five such events in the DTP arm and eight in the TDM-1 arm.

Dr. Hatschek concluded that neoadjuvant T-DM1 may be as effective as standard NAT in all clinical subgroups evaluated. Both TILs and PET-CT showed the potential to predict pCR and merit further study in the NAT setting.
 

An imperfect surrogate

By definition, a surrogate is “one appointed to act in place of another.” In the case of PREDIX-HER2 and most other NAT studies in HER2-positive breast cancer patients, pCR is a surrogate for the endpoint about which doctors and patients really care – cancer-free survival.

As such, pCR is not a perfect surrogate. Reproducibly, pCR has been highly predictive of disease-free survival and overall survival, especially in the HR-negative subset of HER2-positive patients.

However, despite improvements with dual targeting of HER2 in the TRYPHAENA trial (Eur J Cancer. 2018;89:27-35) and the use of T-DM1 for patients failing to achieve pCR in the immediately practice-changing KATHERINE trial (N Engl J Med. 2019;380:617-28), eventual relapse is seen in 10%-20% of patients in various clinical-pathologic subgroups.

In PREDIX-HER2, the pCR rate for node-positive patients was considerably lower with T-DM1 than with DTP (54.1% vs. 38%), noted Valentina Guarneri, MD, of the University of Padova (Italy), in her discussion of the trial at ESMO Breast Cancer 2020.

Patients with larger initial tumor size and multiple involved axillary nodes at diagnosis remain at increased risk of death because of cancer relapse.

Central nervous system relapse remains a vexing problem. Among patients with triple-positive breast cancer, relapses may occur late, despite pCR.

Patients whose tumors transform from HER2 positive to HER2 negative with NAT, seen in approximately 8% of cases in the KATHERINE trial (ESMO Breast Cancer 2020, Abstract 96O), may be another poor-risk group.
 

Clinical implications

PREDIX-HER2 is an important study. At the early time point of 2.4 years (especially early since most patients were HR-positive), if pCR is achieved, event-free survival is excellent with T-DM1 or an aggressive multiagent cytotoxic combination plus dual HER2 targeting followed by anthracyclines.

It is ideal to have clinical-pathologic tests to distinguish those patients destined to achieve the surrogate endpoint of pCR from those who will not achieve it.

Despite linkage of TILs to improved outcome for triple-negative and HER2-enriched molecular subtypes (Lancet Oncol. 2018 Jan;19[1]:40-50), analysis of TILs is not standard practice in HER2-positive breast cancer in community settings. Optimal cutoffs are not well established, and TILs have not been linked to the choice of particular treatment options.

Currently, PET-CT scans are not part of National Comprehensive Cancer Network guidelines for pretreatment evaluation, except in patients for whom there is clinical suspicion of distant disease.

For those reasons, the main results of PREDIX-HER2 remain research tools that will focus our attention on the clinical-pathologic correlations Dr. Hatschek highlighted, but the results should have no influence on routine clinical practice at this time.

PREDIX-HER2 was funded by the Swedish Cancer Society, Radiumhemmet of Karolinska Institutet, Region Stockholm, and Roche Sweden. Dr. Hatschek disclosed relationships with Roche Sweden, Pfizer Sweden, and Pierre Fabre Sweden. Dr. Guarneri disclosed relationships with Roche, Novartis, and Eli Lilly.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Hatschek T et al. ESMO Breast Cancer 2020, Abstract 97O.

In an update of the PREDIX-HER2 trial, trastuzumab emtansine (T-DM1) remained equivalent to standard neoadjuvant chemotherapy plus dual-targeted HER2 therapy in producing pathologic complete remissions (pCRs) among patients with HER2-positive, metastatic breast cancer.

The new data also suggest tumor-infiltrating lymphocytes (TILs) and dramatic improvements in PET-CT scans can predict favorable outcomes in both treatment groups. Though these findings will be useful for research purposes, they likely won’t influence routine clinical practice.

Thomas Hatschek, MD, PhD, of Karolinska Institutet in Stockholm, presented the updated results from PREDIX-HER2 during the European Society for Medical Oncology: Breast Cancer virtual meeting.

PREDIX-HER2 included patients with HER2-positive breast cancer and tumor size greater than 20 mm or lymph node metastases.

Patients received neoadjuvant therapy (NAT) with docetaxel and trastuzumab plus pertuzumab (DTP) or T-DM1 every 3 weeks for a planned total of six courses. The protocol permitted switching to the competing treatment for progression, lack of response, or drug-related severe toxicity.

Postoperatively, all patients received triweekly epirubicin plus cyclophosphamide – four courses for the T-DM1 arm and two courses for the DTP arm. All patients then received triweekly adjuvant trastuzumab for 11 courses. The 62% of patients whose tumors were hormone receptor (HR)–positive received standard endocrine therapy postoperatively.
 

Updated results, predictors of pCR

At the 2019 ASCO annual meeting, PREDIX-HER2 investigators reported that, when compared with DTP, T-DM1 produced the same likelihood of pCR with less toxicity (ASCO 2019, Abstract 501). Updated data presented at ESMO Breast Cancer 2020 showed similar results.

The pCR rate was 45.5% in the DTP arm and 43.9% in the T-DM1 arm (P = .824). pCR rates were higher for HR-negative tumors – 63.6% in the DTP arm and 59% in the T-DM1 arm – than for HR-positive tumors – 36.4% in the DTP arm and 33.9% in the TDM-1 arm.

Three patients had disease progression with T-DM1, and none progressed with DTP. However, almost twice as many patients switched from DTP to T-DM1, compared with the other sequence.

Dr. Hatschek reported that the presence of at least 10% TILs predicted pCR in both treatment groups. Among patients who achieved a pCR, 52.2% had at least 10% TILs in baseline biopsies, and 30.4% had less than 10% TILs.

In addition, a decrease of FDG maximum standardized uptake value by more than 75% on protocol-required PET-CT scans was highly predictive of pCR. Among patients who achieved a pCR, 70.3% had a maximum standardized uptake value decrease of more than 75%, and 22.5% had a decrease of 75% or less.

At median follow-up of 28.5 months, event-free survival was similar between the treatment arms. Overall, there were 13 cases of progression, relapse, contralateral breast cancer, distant metastases, or death from any cause. There were five such events in the DTP arm and eight in the TDM-1 arm.

Dr. Hatschek concluded that neoadjuvant T-DM1 may be as effective as standard NAT in all clinical subgroups evaluated. Both TILs and PET-CT showed the potential to predict pCR and merit further study in the NAT setting.
 

An imperfect surrogate

By definition, a surrogate is “one appointed to act in place of another.” In the case of PREDIX-HER2 and most other NAT studies in HER2-positive breast cancer patients, pCR is a surrogate for the endpoint about which doctors and patients really care – cancer-free survival.

As such, pCR is not a perfect surrogate. Reproducibly, pCR has been highly predictive of disease-free survival and overall survival, especially in the HR-negative subset of HER2-positive patients.

However, despite improvements with dual targeting of HER2 in the TRYPHAENA trial (Eur J Cancer. 2018;89:27-35) and the use of T-DM1 for patients failing to achieve pCR in the immediately practice-changing KATHERINE trial (N Engl J Med. 2019;380:617-28), eventual relapse is seen in 10%-20% of patients in various clinical-pathologic subgroups.

In PREDIX-HER2, the pCR rate for node-positive patients was considerably lower with T-DM1 than with DTP (54.1% vs. 38%), noted Valentina Guarneri, MD, of the University of Padova (Italy), in her discussion of the trial at ESMO Breast Cancer 2020.

Patients with larger initial tumor size and multiple involved axillary nodes at diagnosis remain at increased risk of death because of cancer relapse.

Central nervous system relapse remains a vexing problem. Among patients with triple-positive breast cancer, relapses may occur late, despite pCR.

Patients whose tumors transform from HER2 positive to HER2 negative with NAT, seen in approximately 8% of cases in the KATHERINE trial (ESMO Breast Cancer 2020, Abstract 96O), may be another poor-risk group.
 

Clinical implications

PREDIX-HER2 is an important study. At the early time point of 2.4 years (especially early since most patients were HR-positive), if pCR is achieved, event-free survival is excellent with T-DM1 or an aggressive multiagent cytotoxic combination plus dual HER2 targeting followed by anthracyclines.

It is ideal to have clinical-pathologic tests to distinguish those patients destined to achieve the surrogate endpoint of pCR from those who will not achieve it.

Despite linkage of TILs to improved outcome for triple-negative and HER2-enriched molecular subtypes (Lancet Oncol. 2018 Jan;19[1]:40-50), analysis of TILs is not standard practice in HER2-positive breast cancer in community settings. Optimal cutoffs are not well established, and TILs have not been linked to the choice of particular treatment options.

Currently, PET-CT scans are not part of National Comprehensive Cancer Network guidelines for pretreatment evaluation, except in patients for whom there is clinical suspicion of distant disease.

For those reasons, the main results of PREDIX-HER2 remain research tools that will focus our attention on the clinical-pathologic correlations Dr. Hatschek highlighted, but the results should have no influence on routine clinical practice at this time.

PREDIX-HER2 was funded by the Swedish Cancer Society, Radiumhemmet of Karolinska Institutet, Region Stockholm, and Roche Sweden. Dr. Hatschek disclosed relationships with Roche Sweden, Pfizer Sweden, and Pierre Fabre Sweden. Dr. Guarneri disclosed relationships with Roche, Novartis, and Eli Lilly.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Hatschek T et al. ESMO Breast Cancer 2020, Abstract 97O.

Coronaviruses (CoVs) are among the most common causes of the common cold but also can lead to severe respiratory disease.¹ In recent years, CoVs have been responsible for outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), caused by SARS-CoV and MERS-CoV, respectively. Severe acute respiratory syndrome emerged from China in 2002, and MERS started in Saudi Arabia in 2012. In December 2019, several cases of unexplained pneumonia were reported in Wuhan, China.¹ A novel CoV--SARS-CoV-2--was isolated in these patients and is now known to cause coronavirus disease 19 (COVID-19).¹ Coronavirus disease 19 can cause acute respiratory distress and multiorgan failure.^1,2 It spread quickly throughout the world and was declared a pandemic by the World Health Organization on March 11, 2020. According to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html), there were approximately 14,500 COVID-19 cases diagnosed worldwide on February 1, 2020; by May 22, 2020, there were more than 5,159,600 cases. Thus, heightened measures for infection prevention and control were put in place around the globe in an attempt to slow the spread of disease.¹  

In this article, we describe the dermatologic implications of COVID-19, including the clinical manifestations of the disease, risk reduction techniques for patients and providers, personal protective equipment-associated adverse reactions, and the financial impact on dermatologists.  

Clinical Manifestations 

At the start of the COVID-19 outbreak, little was known about the skin manifestations of the disease. Providers speculated that COVID-19 could have nonspecific skin findings similar to many other viral illnesses.^3,4 Research throughout the pandemic has found many cutaneous manifestations of the disease.^3-6 A case report from Thailand described a patient who presented with petechiae in addition to fever and thrombocytopenia, which led to an initial misdiagnosis of Dengue fever; however, when the patient began having respiratory symptoms, the diagnosis of COVID-19 was discovered.⁵ Furthermore, a study from Italy (N=88) showed dermatologic findings in 20.4% (18/88) of patients, including erythematous rash (77.8% [14/18]), widespread urticaria (16.7% [3/18]), and chickenpoxlike vesicles (5.6% [1/18]). A recent study from Spain (N=375) found 5 cutaneous patterns associated with COVID-19: pseudochilblain--acral areas of erythema with vesicles and/or pustules--lesions (19%), vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%), and livedoid/necrotic lesions (6%).⁶ Pseudochilblain lesions appeared in younger patients, occurred later in the disease course, and were associated with less severe disease. Vesicular lesions often were found in middle-aged patients prior to the onset of other COVID-19 symptoms, and they were associated with intermediate disease severity. Urticarial and maculopapular lesions typically paralleled other COVID-19 symptoms in timing and were associated with more severe disease. Likewise, livedoid and necrotic lesions were associated with more severe disease; they occurred more frequently in older patients.⁶ Clinicians at Cleveland Clinic found similar cutaneous lesions in COVID-19 patients, including morbilliform rashes, acral purpura resembling perniosis, and livedoid lesions.³ Initial biopsies of these lesions pointed to viral exanthema and thrombotic vasculopathy as potential etiologies of morbilliform and livedoid lesions, respectively. Interestingly, patients may present with multiple cutaneous morphologies of the disease at the same time.³ The acral lesions ("COVID toes") have been popularized throughout the media and thus may be the best-known cutaneous manifestation of the disease at this time. New findings continuously arise, and further research is warranted as lesions that develop in hospitalized COVID-19 patients could be virus related or secondary to hospital-induced skin irritation, stressors, or medications.³ Importantly, clinicians should be aware of these cutaneous signs of COVID-19, especially when triaging patients.

Risk Reduction

The current health crisis could have a drastic impact on dermatology patients and providers. One factor that may increase COVID-19 risk in dermatology patients is immunosuppression. Many patients are on immunomodulators and biologics for skin conditions, which can cause immunosuppression directly and indirectly. Immunosuppression is a risk factor for severe disease in patients with COVID-19, so this population is at higher risk for serious infection.⁷ Telemedicine for nonemergent cases and follow-ups should be considered to decrease traffic in high-risk hospitals; to limit the number of people in waiting rooms; and to protect staff, providers, and patients alike.¹ Recommendations for teledermatology consultation during this time include the following: First, have patients take photographs of their skin lesions and send them remotely to the consulting physician. If the lesion is easily recognizable, treatment recommendations can be made remotely; if the diagnosis is ambiguous, the dermatologist can set up an in-person appointment.¹  

Personal Protective Equipment

Moreover, the current need to wear personal protective equipment (PPE) and wash hands frequently may lead to skin disease among health care providers. Facial rashes may arise from wearing masks and goggles, and repeated handwashing and wearing gloves may lead to hand dermatitis.⁸ One study examined adverse skin reactions among health care workers (N=322) during the SARS outbreak in 2003. More than one-third (35.5%) of staff members who wore masks regularly during the outbreak reported adverse skin reactions, including acne (59.6%), facial itching (51.4%), and rash (35.8%).⁸ The acne etiology likely is multifactorial. Masks increase heat and humidity in the covered facial region, which can cause acne flare-ups due to increased sebum production and Cutibacterium acnes growth.⁸ Additionally, tight N95 masks may occlude the pilosebaceous glands, causing acne to flare. In the SARS study, facial itchiness and rashes likely were due to irritant contact dermatitis to the N95 masks. All of the respondents with adverse skin reactions from masks developed them after using N95 masks; those who wore surgical masks did not report reactions.⁸ Because N95 masks are recommended for health care workers caring for patients with highly transmissible respiratory infections such as SARS and COVID-19, it will be difficult to avoid wearing them during the current crisis. For this reason, topical retinoids and topical benzoyl peroxide should be the first-line treatment of mask-induced acne, and moisturization and topical corticosteroids should be used for facial erythema. Additionally, 21.4% of respondents reported adverse skin reactions from latex gloves during the SARS outbreak, including dry skin, itchiness, rash, and wheals.⁸ These skin reactions may have been type I IgE-mediated hypersensitivity reactions or irritant contact dermatitis due to latex sensitization and frequent handwashing. No respondents reported skin reactions to plastic gloves.⁸ For this reason, health care providers should consider wearing plastic gloves in lieu of or under latex gloves to prevent hand dermatitis during this time. Moisturization, barrier creams, and topical corticosteroids also can help treat hand dermatitis. Frequently changing PPE may help prevent skin disease among the frontline health care workers,⁸ which posed a problem at the beginning of the COVID-19 outbreak as there was a PPE shortage. With industry and individuals coming together to make and donate PPE, it is now more widely available for our frontline providers.  

Financial Impact

Finally, the pandemic is having an immense financial impact on dermatology.⁹ At the onset of the outbreak, our role as health care providers was to help slow the spread of COVID-19; for this reason, most elective procedures were cancelled, and many outpatient clinics closed. Both elective procedures and outpatient visits are central to dermatology, so many dermatologists worked less or not at all during this time, leading to a loss of revenue. The goals of these measures were to reduce transmissibility of the disease, to prevent the health care system from being overwhelmed with critical COVID-19 cases, and to allocate resources to the frontline providers.⁹ Although these measures were beneficial for slowing the spread of disease, they were detrimental to some providers' and practices' financial stability. Many dermatology practices have begun to reopen with COVID-19 precautions in place. For example, practices are limiting the number of patients that can be in the office at one time, mandating temperature readings upon check-in, and requiring masks be worn throughout the entire visit. With continued recommendations for individuals to stay at home as much as possible, the number of patients being seen in dermatology clinics on a daily basis remains less than normal. One potential solution is telemedicine, which would allow patients' concerns to be addressed while keeping providers practicing with a normal patient volume during this time.⁹ Keeping providers financially afloat is vital for private practices to continue operating after the pandemic. Dermatology appointments are in high demand with long waiting lists during nonpandemic times; without dermatologists practicing at full capacity, there will be an accumulation of patients with dermatologic conditions with even longer waiting times after the pandemic. Telemedicine may help reduce this potential accumulation of patients and allow patients to be treated in a more timely manner while alleviating financial pressures for providers.

Final Thoughts

The COVID-19 pandemic has spread across the world, infecting millions of people. Although the trends have slowed, more than 106,100 cases are still being diagnosed daily according to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html). Patients with COVID-19 may present with a variety of cutaneous lesions. Wearing PPE to take care of COVID-19 patients may lead to skin irritation, so care should be taken to address these adverse skin reactions to maintain the safety of providers. Finally, dermatologists should consider telemedicine during this time to protect high-risk patients, prevent a postpandemic surge of patients, and alleviate financial stressors caused by COVID-19.

Coronaviruses (CoVs) are among the most common causes of the common cold but also can lead to severe respiratory disease.¹ In recent years, CoVs have been responsible for outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), caused by SARS-CoV and MERS-CoV, respectively. Severe acute respiratory syndrome emerged from China in 2002, and MERS started in Saudi Arabia in 2012. In December 2019, several cases of unexplained pneumonia were reported in Wuhan, China.¹ A novel CoV--SARS-CoV-2--was isolated in these patients and is now known to cause coronavirus disease 19 (COVID-19).¹ Coronavirus disease 19 can cause acute respiratory distress and multiorgan failure.^1,2 It spread quickly throughout the world and was declared a pandemic by the World Health Organization on March 11, 2020. According to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html), there were approximately 14,500 COVID-19 cases diagnosed worldwide on February 1, 2020; by May 22, 2020, there were more than 5,159,600 cases. Thus, heightened measures for infection prevention and control were put in place around the globe in an attempt to slow the spread of disease.¹  

In this article, we describe the dermatologic implications of COVID-19, including the clinical manifestations of the disease, risk reduction techniques for patients and providers, personal protective equipment-associated adverse reactions, and the financial impact on dermatologists.  

Clinical Manifestations 

At the start of the COVID-19 outbreak, little was known about the skin manifestations of the disease. Providers speculated that COVID-19 could have nonspecific skin findings similar to many other viral illnesses.^3,4 Research throughout the pandemic has found many cutaneous manifestations of the disease.^3-6 A case report from Thailand described a patient who presented with petechiae in addition to fever and thrombocytopenia, which led to an initial misdiagnosis of Dengue fever; however, when the patient began having respiratory symptoms, the diagnosis of COVID-19 was discovered.⁵ Furthermore, a study from Italy (N=88) showed dermatologic findings in 20.4% (18/88) of patients, including erythematous rash (77.8% [14/18]), widespread urticaria (16.7% [3/18]), and chickenpoxlike vesicles (5.6% [1/18]). A recent study from Spain (N=375) found 5 cutaneous patterns associated with COVID-19: pseudochilblain--acral areas of erythema with vesicles and/or pustules--lesions (19%), vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%), and livedoid/necrotic lesions (6%).⁶ Pseudochilblain lesions appeared in younger patients, occurred later in the disease course, and were associated with less severe disease. Vesicular lesions often were found in middle-aged patients prior to the onset of other COVID-19 symptoms, and they were associated with intermediate disease severity. Urticarial and maculopapular lesions typically paralleled other COVID-19 symptoms in timing and were associated with more severe disease. Likewise, livedoid and necrotic lesions were associated with more severe disease; they occurred more frequently in older patients.⁶ Clinicians at Cleveland Clinic found similar cutaneous lesions in COVID-19 patients, including morbilliform rashes, acral purpura resembling perniosis, and livedoid lesions.³ Initial biopsies of these lesions pointed to viral exanthema and thrombotic vasculopathy as potential etiologies of morbilliform and livedoid lesions, respectively. Interestingly, patients may present with multiple cutaneous morphologies of the disease at the same time.³ The acral lesions ("COVID toes") have been popularized throughout the media and thus may be the best-known cutaneous manifestation of the disease at this time. New findings continuously arise, and further research is warranted as lesions that develop in hospitalized COVID-19 patients could be virus related or secondary to hospital-induced skin irritation, stressors, or medications.³ Importantly, clinicians should be aware of these cutaneous signs of COVID-19, especially when triaging patients.

Risk Reduction

The current health crisis could have a drastic impact on dermatology patients and providers. One factor that may increase COVID-19 risk in dermatology patients is immunosuppression. Many patients are on immunomodulators and biologics for skin conditions, which can cause immunosuppression directly and indirectly. Immunosuppression is a risk factor for severe disease in patients with COVID-19, so this population is at higher risk for serious infection.⁷ Telemedicine for nonemergent cases and follow-ups should be considered to decrease traffic in high-risk hospitals; to limit the number of people in waiting rooms; and to protect staff, providers, and patients alike.¹ Recommendations for teledermatology consultation during this time include the following: First, have patients take photographs of their skin lesions and send them remotely to the consulting physician. If the lesion is easily recognizable, treatment recommendations can be made remotely; if the diagnosis is ambiguous, the dermatologist can set up an in-person appointment.¹  

Personal Protective Equipment

Moreover, the current need to wear personal protective equipment (PPE) and wash hands frequently may lead to skin disease among health care providers. Facial rashes may arise from wearing masks and goggles, and repeated handwashing and wearing gloves may lead to hand dermatitis.⁸ One study examined adverse skin reactions among health care workers (N=322) during the SARS outbreak in 2003. More than one-third (35.5%) of staff members who wore masks regularly during the outbreak reported adverse skin reactions, including acne (59.6%), facial itching (51.4%), and rash (35.8%).⁸ The acne etiology likely is multifactorial. Masks increase heat and humidity in the covered facial region, which can cause acne flare-ups due to increased sebum production and Cutibacterium acnes growth.⁸ Additionally, tight N95 masks may occlude the pilosebaceous glands, causing acne to flare. In the SARS study, facial itchiness and rashes likely were due to irritant contact dermatitis to the N95 masks. All of the respondents with adverse skin reactions from masks developed them after using N95 masks; those who wore surgical masks did not report reactions.⁸ Because N95 masks are recommended for health care workers caring for patients with highly transmissible respiratory infections such as SARS and COVID-19, it will be difficult to avoid wearing them during the current crisis. For this reason, topical retinoids and topical benzoyl peroxide should be the first-line treatment of mask-induced acne, and moisturization and topical corticosteroids should be used for facial erythema. Additionally, 21.4% of respondents reported adverse skin reactions from latex gloves during the SARS outbreak, including dry skin, itchiness, rash, and wheals.⁸ These skin reactions may have been type I IgE-mediated hypersensitivity reactions or irritant contact dermatitis due to latex sensitization and frequent handwashing. No respondents reported skin reactions to plastic gloves.⁸ For this reason, health care providers should consider wearing plastic gloves in lieu of or under latex gloves to prevent hand dermatitis during this time. Moisturization, barrier creams, and topical corticosteroids also can help treat hand dermatitis. Frequently changing PPE may help prevent skin disease among the frontline health care workers,⁸ which posed a problem at the beginning of the COVID-19 outbreak as there was a PPE shortage. With industry and individuals coming together to make and donate PPE, it is now more widely available for our frontline providers.  

Financial Impact

Finally, the pandemic is having an immense financial impact on dermatology.⁹ At the onset of the outbreak, our role as health care providers was to help slow the spread of COVID-19; for this reason, most elective procedures were cancelled, and many outpatient clinics closed. Both elective procedures and outpatient visits are central to dermatology, so many dermatologists worked less or not at all during this time, leading to a loss of revenue. The goals of these measures were to reduce transmissibility of the disease, to prevent the health care system from being overwhelmed with critical COVID-19 cases, and to allocate resources to the frontline providers.⁹ Although these measures were beneficial for slowing the spread of disease, they were detrimental to some providers' and practices' financial stability. Many dermatology practices have begun to reopen with COVID-19 precautions in place. For example, practices are limiting the number of patients that can be in the office at one time, mandating temperature readings upon check-in, and requiring masks be worn throughout the entire visit. With continued recommendations for individuals to stay at home as much as possible, the number of patients being seen in dermatology clinics on a daily basis remains less than normal. One potential solution is telemedicine, which would allow patients' concerns to be addressed while keeping providers practicing with a normal patient volume during this time.⁹ Keeping providers financially afloat is vital for private practices to continue operating after the pandemic. Dermatology appointments are in high demand with long waiting lists during nonpandemic times; without dermatologists practicing at full capacity, there will be an accumulation of patients with dermatologic conditions with even longer waiting times after the pandemic. Telemedicine may help reduce this potential accumulation of patients and allow patients to be treated in a more timely manner while alleviating financial pressures for providers.

Final Thoughts

The COVID-19 pandemic has spread across the world, infecting millions of people. Although the trends have slowed, more than 106,100 cases are still being diagnosed daily according to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html). Patients with COVID-19 may present with a variety of cutaneous lesions. Wearing PPE to take care of COVID-19 patients may lead to skin irritation, so care should be taken to address these adverse skin reactions to maintain the safety of providers. Finally, dermatologists should consider telemedicine during this time to protect high-risk patients, prevent a postpandemic surge of patients, and alleviate financial stressors caused by COVID-19.

Coronaviruses (CoVs) are among the most common causes of the common cold but also can lead to severe respiratory disease.¹ In recent years, CoVs have been responsible for outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), caused by SARS-CoV and MERS-CoV, respectively. Severe acute respiratory syndrome emerged from China in 2002, and MERS started in Saudi Arabia in 2012. In December 2019, several cases of unexplained pneumonia were reported in Wuhan, China.¹ A novel CoV--SARS-CoV-2--was isolated in these patients and is now known to cause coronavirus disease 19 (COVID-19).¹ Coronavirus disease 19 can cause acute respiratory distress and multiorgan failure.^1,2 It spread quickly throughout the world and was declared a pandemic by the World Health Organization on March 11, 2020. According to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html), there were approximately 14,500 COVID-19 cases diagnosed worldwide on February 1, 2020; by May 22, 2020, there were more than 5,159,600 cases. Thus, heightened measures for infection prevention and control were put in place around the globe in an attempt to slow the spread of disease.¹  

In this article, we describe the dermatologic implications of COVID-19, including the clinical manifestations of the disease, risk reduction techniques for patients and providers, personal protective equipment-associated adverse reactions, and the financial impact on dermatologists.  

Clinical Manifestations 

At the start of the COVID-19 outbreak, little was known about the skin manifestations of the disease. Providers speculated that COVID-19 could have nonspecific skin findings similar to many other viral illnesses.^3,4 Research throughout the pandemic has found many cutaneous manifestations of the disease.^3-6 A case report from Thailand described a patient who presented with petechiae in addition to fever and thrombocytopenia, which led to an initial misdiagnosis of Dengue fever; however, when the patient began having respiratory symptoms, the diagnosis of COVID-19 was discovered.⁵ Furthermore, a study from Italy (N=88) showed dermatologic findings in 20.4% (18/88) of patients, including erythematous rash (77.8% [14/18]), widespread urticaria (16.7% [3/18]), and chickenpoxlike vesicles (5.6% [1/18]). A recent study from Spain (N=375) found 5 cutaneous patterns associated with COVID-19: pseudochilblain--acral areas of erythema with vesicles and/or pustules--lesions (19%), vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%), and livedoid/necrotic lesions (6%).⁶ Pseudochilblain lesions appeared in younger patients, occurred later in the disease course, and were associated with less severe disease. Vesicular lesions often were found in middle-aged patients prior to the onset of other COVID-19 symptoms, and they were associated with intermediate disease severity. Urticarial and maculopapular lesions typically paralleled other COVID-19 symptoms in timing and were associated with more severe disease. Likewise, livedoid and necrotic lesions were associated with more severe disease; they occurred more frequently in older patients.⁶ Clinicians at Cleveland Clinic found similar cutaneous lesions in COVID-19 patients, including morbilliform rashes, acral purpura resembling perniosis, and livedoid lesions.³ Initial biopsies of these lesions pointed to viral exanthema and thrombotic vasculopathy as potential etiologies of morbilliform and livedoid lesions, respectively. Interestingly, patients may present with multiple cutaneous morphologies of the disease at the same time.³ The acral lesions ("COVID toes") have been popularized throughout the media and thus may be the best-known cutaneous manifestation of the disease at this time. New findings continuously arise, and further research is warranted as lesions that develop in hospitalized COVID-19 patients could be virus related or secondary to hospital-induced skin irritation, stressors, or medications.³ Importantly, clinicians should be aware of these cutaneous signs of COVID-19, especially when triaging patients.

Risk Reduction

The current health crisis could have a drastic impact on dermatology patients and providers. One factor that may increase COVID-19 risk in dermatology patients is immunosuppression. Many patients are on immunomodulators and biologics for skin conditions, which can cause immunosuppression directly and indirectly. Immunosuppression is a risk factor for severe disease in patients with COVID-19, so this population is at higher risk for serious infection.⁷ Telemedicine for nonemergent cases and follow-ups should be considered to decrease traffic in high-risk hospitals; to limit the number of people in waiting rooms; and to protect staff, providers, and patients alike.¹ Recommendations for teledermatology consultation during this time include the following: First, have patients take photographs of their skin lesions and send them remotely to the consulting physician. If the lesion is easily recognizable, treatment recommendations can be made remotely; if the diagnosis is ambiguous, the dermatologist can set up an in-person appointment.¹  

Personal Protective Equipment

Moreover, the current need to wear personal protective equipment (PPE) and wash hands frequently may lead to skin disease among health care providers. Facial rashes may arise from wearing masks and goggles, and repeated handwashing and wearing gloves may lead to hand dermatitis.⁸ One study examined adverse skin reactions among health care workers (N=322) during the SARS outbreak in 2003. More than one-third (35.5%) of staff members who wore masks regularly during the outbreak reported adverse skin reactions, including acne (59.6%), facial itching (51.4%), and rash (35.8%).⁸ The acne etiology likely is multifactorial. Masks increase heat and humidity in the covered facial region, which can cause acne flare-ups due to increased sebum production and Cutibacterium acnes growth.⁸ Additionally, tight N95 masks may occlude the pilosebaceous glands, causing acne to flare. In the SARS study, facial itchiness and rashes likely were due to irritant contact dermatitis to the N95 masks. All of the respondents with adverse skin reactions from masks developed them after using N95 masks; those who wore surgical masks did not report reactions.⁸ Because N95 masks are recommended for health care workers caring for patients with highly transmissible respiratory infections such as SARS and COVID-19, it will be difficult to avoid wearing them during the current crisis. For this reason, topical retinoids and topical benzoyl peroxide should be the first-line treatment of mask-induced acne, and moisturization and topical corticosteroids should be used for facial erythema. Additionally, 21.4% of respondents reported adverse skin reactions from latex gloves during the SARS outbreak, including dry skin, itchiness, rash, and wheals.⁸ These skin reactions may have been type I IgE-mediated hypersensitivity reactions or irritant contact dermatitis due to latex sensitization and frequent handwashing. No respondents reported skin reactions to plastic gloves.⁸ For this reason, health care providers should consider wearing plastic gloves in lieu of or under latex gloves to prevent hand dermatitis during this time. Moisturization, barrier creams, and topical corticosteroids also can help treat hand dermatitis. Frequently changing PPE may help prevent skin disease among the frontline health care workers,⁸ which posed a problem at the beginning of the COVID-19 outbreak as there was a PPE shortage. With industry and individuals coming together to make and donate PPE, it is now more widely available for our frontline providers.  

Financial Impact

Finally, the pandemic is having an immense financial impact on dermatology.⁹ At the onset of the outbreak, our role as health care providers was to help slow the spread of COVID-19; for this reason, most elective procedures were cancelled, and many outpatient clinics closed. Both elective procedures and outpatient visits are central to dermatology, so many dermatologists worked less or not at all during this time, leading to a loss of revenue. The goals of these measures were to reduce transmissibility of the disease, to prevent the health care system from being overwhelmed with critical COVID-19 cases, and to allocate resources to the frontline providers.⁹ Although these measures were beneficial for slowing the spread of disease, they were detrimental to some providers' and practices' financial stability. Many dermatology practices have begun to reopen with COVID-19 precautions in place. For example, practices are limiting the number of patients that can be in the office at one time, mandating temperature readings upon check-in, and requiring masks be worn throughout the entire visit. With continued recommendations for individuals to stay at home as much as possible, the number of patients being seen in dermatology clinics on a daily basis remains less than normal. One potential solution is telemedicine, which would allow patients' concerns to be addressed while keeping providers practicing with a normal patient volume during this time.⁹ Keeping providers financially afloat is vital for private practices to continue operating after the pandemic. Dermatology appointments are in high demand with long waiting lists during nonpandemic times; without dermatologists practicing at full capacity, there will be an accumulation of patients with dermatologic conditions with even longer waiting times after the pandemic. Telemedicine may help reduce this potential accumulation of patients and allow patients to be treated in a more timely manner while alleviating financial pressures for providers.

Final Thoughts

The COVID-19 pandemic has spread across the world, infecting millions of people. Although the trends have slowed, more than 106,100 cases are still being diagnosed daily according to the Johns Hopkins University Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html). Patients with COVID-19 may present with a variety of cutaneous lesions. Wearing PPE to take care of COVID-19 patients may lead to skin irritation, so care should be taken to address these adverse skin reactions to maintain the safety of providers. Finally, dermatologists should consider telemedicine during this time to protect high-risk patients, prevent a postpandemic surge of patients, and alleviate financial stressors caused by COVID-19.

The Navajo people have dealt with adversity that has tested our strength and resilience since our creation. In Navajo culture, the Holy People or gods challenged us with Naayee (monsters). We endured and learned from each Naayee, hunger, and death to name a few adversities. The COVID-19 pandemic, or “Big Cough” (Dikos Nitsaa’igii -19 in Navajo language) is a monster confronting the Navajo today. It has had significant impact on our nation and people.

The Navajo have the most cases of the COVID-19 virus of any tribe in the United States, and numbers as of May 31, 2020, are 5,348, with 246 confirmed deaths.¹ The Navajo Nation, which once lagged behind New York, has reported the largest per-capita infection rate in the United States.

These devastating numbers, which might be leveling off, are associated with Navajo people having higher-than-average numbers of diabetes, heart disease, and cancer. This is compounded with 30%-40% of homes having no electricity or running water, and a poverty rate of about 38%.²

Geographical and cultural factors also contribute to the inability to gain a foothold in mitigating the number of cases. The Navajo Nation is the largest tribe in the United States, covering 27,000 square miles over an arid, red rock expanse with canyons and mountains. The population is over 250,000,³ and Navajo have traditionally lived in matrilineal clan units throughout the reservation, the size of West Virginia. The family traditional dwelling, called a “hogan,” often is clustered together. Multiple generations live together in these units. The COVID-19 virus inflicted many Navajo and rapidly spread to the elderly in these close-proximity living quarters.

Most Navajo live away from services and grocery stores and travel back and forth for food and water, which contributes to the virus rapidly being transmitted among the community members. Education aimed at curbing travel and spread of the virus was issued with curfews, commands to stay at home and keep social distance, and protect elders. The Navajo leadership and traditional medicine people, meanwhile, advised the people to follow their cultural values by caring for family and community members and providing a safe environment.
 

Resources are spread out

There are only 13 stores in this expansive reservation,⁴ so tribal members rely on traveling to border towns, such as Farmington and Gallup, N.M., Families usually travel to these towns on weekends to replenish food and supplies. There has been a cluster of cases in Gallup, N.M., so to reduce the numbers, the town shut itself off from outsiders – including the Navajo people coming to buy food, do laundry, and get water and feed for livestock. This has affected and stressed the Navajo further in attempting to access necessities.

Access to health care is already challenging because of lack of transportation and distance. This has made it more difficult to access COVID-19 testing and more challenging to get the results back. The Indian Health Service has been the designated health care system for the Navajo since 1955. The Treaty of Bosque Redondo, signed by the Navajo in 1868, included the provision of health care, as well as education in exchange for tracts of land, that included the Navajo homeland or Dinetah.⁵

The Indian Health Service provides care with hospitals and clinics throughout the reservation. Some of the IHS facilities have been taken over by the Navajo, so there are four Navajo tribally controlled hospitals, along with one private hospital. Coordination of care for a pandemic is, therefore, more challenging to coordinate. This contributes to problems with coordination of the health care, establishing alternate care sites, accessing personal protective equipment, and providing testing sites. The Navajo Nation Council is working hard to equitably distribute the $600 million from the CARES Act.⁶

Dealing with the pandemic is compromised by chronic underfunding from the U.S. government. The treaty obligation of the U.S. government is to provide health care to all federally recognized Native Americans. The IHS, which has been designated to provide that care for a tribal person, gets one-third the Medicare dollars for health care provided for a person in the general population.⁷ Health factors have led to the public health issues of poorly controlled diabetes, obesity, and coronary artery disease, which is related to this underfunding and the high rate of COVID-19 cases. Parts of the reservation are also exposed to high levels of pollution from oil and gas wells from the coal-fueled power plants. Those exposed to these high levels of pollutions have a higher than average number of cases of COVID-19, higher than in areas where the pollution is markedly lower.⁸

The Navajo are having to rely on the strength and resilience of traditional Navajo culture and philosophy to confront this monster, Dikos Nitsaa’igii’ 19. We have relied on Western medicine and its limited resources but now need to empower the strength from our traditional ways of knowing. We have used this knowledge in times of adversity for hundreds of years. The Navajo elders and medicine people have reminded us we have dealt with monsters and know how to endure hardship and be resilient. This helps to ameliorate mental health conditions, but there are still issues that remain challenging.

Those having the virus go through times of shortness of breath, which produces anxiety and panic. The risk of death adds further stress, and for a family-oriented culture, the need to isolate from family adds further stress. For the elderly and young people with more serious disease having to go to the hospital alone without family, often far from home, is so challenging. Connecting family by phone or social media with those stricken is essential to decrease anxiety and isolation. Those infected with the virus can learn breathing exercises, which can help the damage from the virus and decrease emotional activation and triggers. Specific breathing techniques can be taught by medical providers. An effective breathing technique to reduce anxiety is coherent breathing, which is done by inhaling 6 seconds and exhaling for 6 seconds without holding your breath. Behavioral health practitioners are available in the tribal and IHS mental health clinics to refer patients to therapy support to manage anxiety and are available by telemedicine. Many of these programs are offering social media informational sessions for the Navajo community. Navajo people often access traditional healing for protection prayers and ceremonies. Some of the tribal and IHS programs provide traditional counselors to talk to. The Navajo access healing that focuses on restoring balance to the body, mind, and spirit.

Taking action against the virus by social distancing, hand washing, and wearing masks can go a long way in reducing anxiety and fear about getting the virus. Resources to help the Navajo Nation are coming from all over the world, from as far as Ireland,⁹ Doctors Without Borders, ¹⁰ and University of San Francisco.¹¹

Two resources that provide relief on the reservation are the Navajo Relief Fund and United Natives.
 

References

1. Navaho Times. 2020 May 27.

2. Ingalls A et al. BMC Obes. 2019 May 6. doi: 10.1186/s40608-019-0233-9.

3. U.S. Census 2010, as reported by discovernavajo.com.

4. Gould C et al. “Addressing food insecurity on the Navajo reservation through sustainable greenhouses.” 2018 Aug.

5. Native Knowledge 360. Smithsonian Institution. “Bosque Redondo.”

6. Personal communication, Carl Roessel Slater, Navajo Nation Council delegate.

7. IHS Profile Fact Sheet.

8. Wu X et al. medRxiv. 2020 Apr 27.

9. Carroll R. ”Irish support for Native American COVID-19 relief highlights historic bond.” The Guardian. 2020 May 9.

10. Capatides C. “Doctors Without Borders dispatches team to the Navajo Nation” CBS News. 2020 May 11.

11. Weiler N. “UCSF sends second wave of health workers to Navajo Nation.” UCSF.edu. 2020 May 21.
 

Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo Nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association. She has no disclosures.

The Navajo people have dealt with adversity that has tested our strength and resilience since our creation. In Navajo culture, the Holy People or gods challenged us with Naayee (monsters). We endured and learned from each Naayee, hunger, and death to name a few adversities. The COVID-19 pandemic, or “Big Cough” (Dikos Nitsaa’igii -19 in Navajo language) is a monster confronting the Navajo today. It has had significant impact on our nation and people.

The Navajo have the most cases of the COVID-19 virus of any tribe in the United States, and numbers as of May 31, 2020, are 5,348, with 246 confirmed deaths.¹ The Navajo Nation, which once lagged behind New York, has reported the largest per-capita infection rate in the United States.

These devastating numbers, which might be leveling off, are associated with Navajo people having higher-than-average numbers of diabetes, heart disease, and cancer. This is compounded with 30%-40% of homes having no electricity or running water, and a poverty rate of about 38%.²

Geographical and cultural factors also contribute to the inability to gain a foothold in mitigating the number of cases. The Navajo Nation is the largest tribe in the United States, covering 27,000 square miles over an arid, red rock expanse with canyons and mountains. The population is over 250,000,³ and Navajo have traditionally lived in matrilineal clan units throughout the reservation, the size of West Virginia. The family traditional dwelling, called a “hogan,” often is clustered together. Multiple generations live together in these units. The COVID-19 virus inflicted many Navajo and rapidly spread to the elderly in these close-proximity living quarters.

Most Navajo live away from services and grocery stores and travel back and forth for food and water, which contributes to the virus rapidly being transmitted among the community members. Education aimed at curbing travel and spread of the virus was issued with curfews, commands to stay at home and keep social distance, and protect elders. The Navajo leadership and traditional medicine people, meanwhile, advised the people to follow their cultural values by caring for family and community members and providing a safe environment.
 

Resources are spread out

There are only 13 stores in this expansive reservation,⁴ so tribal members rely on traveling to border towns, such as Farmington and Gallup, N.M., Families usually travel to these towns on weekends to replenish food and supplies. There has been a cluster of cases in Gallup, N.M., so to reduce the numbers, the town shut itself off from outsiders – including the Navajo people coming to buy food, do laundry, and get water and feed for livestock. This has affected and stressed the Navajo further in attempting to access necessities.

Access to health care is already challenging because of lack of transportation and distance. This has made it more difficult to access COVID-19 testing and more challenging to get the results back. The Indian Health Service has been the designated health care system for the Navajo since 1955. The Treaty of Bosque Redondo, signed by the Navajo in 1868, included the provision of health care, as well as education in exchange for tracts of land, that included the Navajo homeland or Dinetah.⁵

The Indian Health Service provides care with hospitals and clinics throughout the reservation. Some of the IHS facilities have been taken over by the Navajo, so there are four Navajo tribally controlled hospitals, along with one private hospital. Coordination of care for a pandemic is, therefore, more challenging to coordinate. This contributes to problems with coordination of the health care, establishing alternate care sites, accessing personal protective equipment, and providing testing sites. The Navajo Nation Council is working hard to equitably distribute the $600 million from the CARES Act.⁶

Dealing with the pandemic is compromised by chronic underfunding from the U.S. government. The treaty obligation of the U.S. government is to provide health care to all federally recognized Native Americans. The IHS, which has been designated to provide that care for a tribal person, gets one-third the Medicare dollars for health care provided for a person in the general population.⁷ Health factors have led to the public health issues of poorly controlled diabetes, obesity, and coronary artery disease, which is related to this underfunding and the high rate of COVID-19 cases. Parts of the reservation are also exposed to high levels of pollution from oil and gas wells from the coal-fueled power plants. Those exposed to these high levels of pollutions have a higher than average number of cases of COVID-19, higher than in areas where the pollution is markedly lower.⁸

The Navajo are having to rely on the strength and resilience of traditional Navajo culture and philosophy to confront this monster, Dikos Nitsaa’igii’ 19. We have relied on Western medicine and its limited resources but now need to empower the strength from our traditional ways of knowing. We have used this knowledge in times of adversity for hundreds of years. The Navajo elders and medicine people have reminded us we have dealt with monsters and know how to endure hardship and be resilient. This helps to ameliorate mental health conditions, but there are still issues that remain challenging.

Those having the virus go through times of shortness of breath, which produces anxiety and panic. The risk of death adds further stress, and for a family-oriented culture, the need to isolate from family adds further stress. For the elderly and young people with more serious disease having to go to the hospital alone without family, often far from home, is so challenging. Connecting family by phone or social media with those stricken is essential to decrease anxiety and isolation. Those infected with the virus can learn breathing exercises, which can help the damage from the virus and decrease emotional activation and triggers. Specific breathing techniques can be taught by medical providers. An effective breathing technique to reduce anxiety is coherent breathing, which is done by inhaling 6 seconds and exhaling for 6 seconds without holding your breath. Behavioral health practitioners are available in the tribal and IHS mental health clinics to refer patients to therapy support to manage anxiety and are available by telemedicine. Many of these programs are offering social media informational sessions for the Navajo community. Navajo people often access traditional healing for protection prayers and ceremonies. Some of the tribal and IHS programs provide traditional counselors to talk to. The Navajo access healing that focuses on restoring balance to the body, mind, and spirit.

Taking action against the virus by social distancing, hand washing, and wearing masks can go a long way in reducing anxiety and fear about getting the virus. Resources to help the Navajo Nation are coming from all over the world, from as far as Ireland,⁹ Doctors Without Borders, ¹⁰ and University of San Francisco.¹¹

Two resources that provide relief on the reservation are the Navajo Relief Fund and United Natives.
 

References

1. Navaho Times. 2020 May 27.

2. Ingalls A et al. BMC Obes. 2019 May 6. doi: 10.1186/s40608-019-0233-9.

3. U.S. Census 2010, as reported by discovernavajo.com.

4. Gould C et al. “Addressing food insecurity on the Navajo reservation through sustainable greenhouses.” 2018 Aug.

5. Native Knowledge 360. Smithsonian Institution. “Bosque Redondo.”

6. Personal communication, Carl Roessel Slater, Navajo Nation Council delegate.

7. IHS Profile Fact Sheet.

8. Wu X et al. medRxiv. 2020 Apr 27.

9. Carroll R. ”Irish support for Native American COVID-19 relief highlights historic bond.” The Guardian. 2020 May 9.

10. Capatides C. “Doctors Without Borders dispatches team to the Navajo Nation” CBS News. 2020 May 11.

11. Weiler N. “UCSF sends second wave of health workers to Navajo Nation.” UCSF.edu. 2020 May 21.
 

Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo Nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association. She has no disclosures.

The Navajo people have dealt with adversity that has tested our strength and resilience since our creation. In Navajo culture, the Holy People or gods challenged us with Naayee (monsters). We endured and learned from each Naayee, hunger, and death to name a few adversities. The COVID-19 pandemic, or “Big Cough” (Dikos Nitsaa’igii -19 in Navajo language) is a monster confronting the Navajo today. It has had significant impact on our nation and people.

The Navajo have the most cases of the COVID-19 virus of any tribe in the United States, and numbers as of May 31, 2020, are 5,348, with 246 confirmed deaths.¹ The Navajo Nation, which once lagged behind New York, has reported the largest per-capita infection rate in the United States.

These devastating numbers, which might be leveling off, are associated with Navajo people having higher-than-average numbers of diabetes, heart disease, and cancer. This is compounded with 30%-40% of homes having no electricity or running water, and a poverty rate of about 38%.²

Geographical and cultural factors also contribute to the inability to gain a foothold in mitigating the number of cases. The Navajo Nation is the largest tribe in the United States, covering 27,000 square miles over an arid, red rock expanse with canyons and mountains. The population is over 250,000,³ and Navajo have traditionally lived in matrilineal clan units throughout the reservation, the size of West Virginia. The family traditional dwelling, called a “hogan,” often is clustered together. Multiple generations live together in these units. The COVID-19 virus inflicted many Navajo and rapidly spread to the elderly in these close-proximity living quarters.

Most Navajo live away from services and grocery stores and travel back and forth for food and water, which contributes to the virus rapidly being transmitted among the community members. Education aimed at curbing travel and spread of the virus was issued with curfews, commands to stay at home and keep social distance, and protect elders. The Navajo leadership and traditional medicine people, meanwhile, advised the people to follow their cultural values by caring for family and community members and providing a safe environment.
 

Resources are spread out

There are only 13 stores in this expansive reservation,⁴ so tribal members rely on traveling to border towns, such as Farmington and Gallup, N.M., Families usually travel to these towns on weekends to replenish food and supplies. There has been a cluster of cases in Gallup, N.M., so to reduce the numbers, the town shut itself off from outsiders – including the Navajo people coming to buy food, do laundry, and get water and feed for livestock. This has affected and stressed the Navajo further in attempting to access necessities.

Access to health care is already challenging because of lack of transportation and distance. This has made it more difficult to access COVID-19 testing and more challenging to get the results back. The Indian Health Service has been the designated health care system for the Navajo since 1955. The Treaty of Bosque Redondo, signed by the Navajo in 1868, included the provision of health care, as well as education in exchange for tracts of land, that included the Navajo homeland or Dinetah.⁵

The Indian Health Service provides care with hospitals and clinics throughout the reservation. Some of the IHS facilities have been taken over by the Navajo, so there are four Navajo tribally controlled hospitals, along with one private hospital. Coordination of care for a pandemic is, therefore, more challenging to coordinate. This contributes to problems with coordination of the health care, establishing alternate care sites, accessing personal protective equipment, and providing testing sites. The Navajo Nation Council is working hard to equitably distribute the $600 million from the CARES Act.⁶

Dealing with the pandemic is compromised by chronic underfunding from the U.S. government. The treaty obligation of the U.S. government is to provide health care to all federally recognized Native Americans. The IHS, which has been designated to provide that care for a tribal person, gets one-third the Medicare dollars for health care provided for a person in the general population.⁷ Health factors have led to the public health issues of poorly controlled diabetes, obesity, and coronary artery disease, which is related to this underfunding and the high rate of COVID-19 cases. Parts of the reservation are also exposed to high levels of pollution from oil and gas wells from the coal-fueled power plants. Those exposed to these high levels of pollutions have a higher than average number of cases of COVID-19, higher than in areas where the pollution is markedly lower.⁸

The Navajo are having to rely on the strength and resilience of traditional Navajo culture and philosophy to confront this monster, Dikos Nitsaa’igii’ 19. We have relied on Western medicine and its limited resources but now need to empower the strength from our traditional ways of knowing. We have used this knowledge in times of adversity for hundreds of years. The Navajo elders and medicine people have reminded us we have dealt with monsters and know how to endure hardship and be resilient. This helps to ameliorate mental health conditions, but there are still issues that remain challenging.

Those having the virus go through times of shortness of breath, which produces anxiety and panic. The risk of death adds further stress, and for a family-oriented culture, the need to isolate from family adds further stress. For the elderly and young people with more serious disease having to go to the hospital alone without family, often far from home, is so challenging. Connecting family by phone or social media with those stricken is essential to decrease anxiety and isolation. Those infected with the virus can learn breathing exercises, which can help the damage from the virus and decrease emotional activation and triggers. Specific breathing techniques can be taught by medical providers. An effective breathing technique to reduce anxiety is coherent breathing, which is done by inhaling 6 seconds and exhaling for 6 seconds without holding your breath. Behavioral health practitioners are available in the tribal and IHS mental health clinics to refer patients to therapy support to manage anxiety and are available by telemedicine. Many of these programs are offering social media informational sessions for the Navajo community. Navajo people often access traditional healing for protection prayers and ceremonies. Some of the tribal and IHS programs provide traditional counselors to talk to. The Navajo access healing that focuses on restoring balance to the body, mind, and spirit.

Taking action against the virus by social distancing, hand washing, and wearing masks can go a long way in reducing anxiety and fear about getting the virus. Resources to help the Navajo Nation are coming from all over the world, from as far as Ireland,⁹ Doctors Without Borders, ¹⁰ and University of San Francisco.¹¹

Two resources that provide relief on the reservation are the Navajo Relief Fund and United Natives.
 

References

1. Navaho Times. 2020 May 27.

2. Ingalls A et al. BMC Obes. 2019 May 6. doi: 10.1186/s40608-019-0233-9.

3. U.S. Census 2010, as reported by discovernavajo.com.

4. Gould C et al. “Addressing food insecurity on the Navajo reservation through sustainable greenhouses.” 2018 Aug.

5. Native Knowledge 360. Smithsonian Institution. “Bosque Redondo.”

6. Personal communication, Carl Roessel Slater, Navajo Nation Council delegate.

7. IHS Profile Fact Sheet.

8. Wu X et al. medRxiv. 2020 Apr 27.

9. Carroll R. ”Irish support for Native American COVID-19 relief highlights historic bond.” The Guardian. 2020 May 9.

10. Capatides C. “Doctors Without Borders dispatches team to the Navajo Nation” CBS News. 2020 May 11.

11. Weiler N. “UCSF sends second wave of health workers to Navajo Nation.” UCSF.edu. 2020 May 21.
 

Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo Nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association. She has no disclosures.

While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.

The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.

When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.

Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.

Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”

Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)

Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.

Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.

The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”¹ (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.

Reference

1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.

While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.

The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.

When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.

Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.

Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”

Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)

Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.

Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.

The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”¹ (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.

Reference

1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.

While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.

The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.

When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.

Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.

Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”

Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)

Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.

Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.

The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”¹ (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.

Reference

1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

This morning, Megan A. Adams (a GI & Hepatology News Associate Editor and a Michigan faculty member) and I held an hour-long video conference with all of our Michigan GI fellows. Our four third-year fellows talked about their job search and employment plans for July. Three will join academic centers (UNC, University of Wisconsin, Henry Ford) and one will enter private practice (Atlanta Gastroenterology). I was glad to hear that all had been reassured that their positions were secure despite the COVID-19 impact. As I speak with colleagues across the country, all (whether health system physicians, academic faculty, or community gastroenterologists) are experiencing the financial, emotional, and operational effects of this pandemic. This is an experience that will define our professional careers.

As one of three chief clinical officers at Michigan Medicine, I am part of a four-person team that leads the faculty medical group and the ambulatory portion of our health system. Each of our segments (ambulatory, adult hospital, children’s hospital, and medical school) have targets for sustained cost reductions that total $400 million and Michigan Medicine (as published in the news) plans to reduce our workforce (nonfaculty) by 1,400. We have a hiring freeze, leaders are taking salary reductions, and we have instituted other painful, cost-saving measures. The physician leaders we hired just 12 months ago to oversee a new faculty group structure were thrust into a firestorm. Department chairs, division chiefs, nursing and administrative leaders all are having to make heart-wrenching cost-cutting decisions. Together, we have to make individual reductions in force or retain decisions about people we work with daily. This emotional toll will never truly heal for anyone involved.

There will be little time to recover. We are scrambling to reopen safely, with a planned process. We have a backlog of 12,000 surgeries and 8,000 endoscopy procedures that have been deferred. Eight-hundred children are behind in their well-child medical care, frightened patients are sitting home with critical aortic stenosis, dangerous hypertension, growing cancers, and other urgent medical needs. Private practices are facing the same issues, financial pressures, and emotional toll.

Anna Quindlen once said, “Grief is a whisper in the world, but a clamor within.” Recognize the toll this is taking and don’t be alone with your grief.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This morning, Megan A. Adams (a GI & Hepatology News Associate Editor and a Michigan faculty member) and I held an hour-long video conference with all of our Michigan GI fellows. Our four third-year fellows talked about their job search and employment plans for July. Three will join academic centers (UNC, University of Wisconsin, Henry Ford) and one will enter private practice (Atlanta Gastroenterology). I was glad to hear that all had been reassured that their positions were secure despite the COVID-19 impact. As I speak with colleagues across the country, all (whether health system physicians, academic faculty, or community gastroenterologists) are experiencing the financial, emotional, and operational effects of this pandemic. This is an experience that will define our professional careers.

As one of three chief clinical officers at Michigan Medicine, I am part of a four-person team that leads the faculty medical group and the ambulatory portion of our health system. Each of our segments (ambulatory, adult hospital, children’s hospital, and medical school) have targets for sustained cost reductions that total $400 million and Michigan Medicine (as published in the news) plans to reduce our workforce (nonfaculty) by 1,400. We have a hiring freeze, leaders are taking salary reductions, and we have instituted other painful, cost-saving measures. The physician leaders we hired just 12 months ago to oversee a new faculty group structure were thrust into a firestorm. Department chairs, division chiefs, nursing and administrative leaders all are having to make heart-wrenching cost-cutting decisions. Together, we have to make individual reductions in force or retain decisions about people we work with daily. This emotional toll will never truly heal for anyone involved.

There will be little time to recover. We are scrambling to reopen safely, with a planned process. We have a backlog of 12,000 surgeries and 8,000 endoscopy procedures that have been deferred. Eight-hundred children are behind in their well-child medical care, frightened patients are sitting home with critical aortic stenosis, dangerous hypertension, growing cancers, and other urgent medical needs. Private practices are facing the same issues, financial pressures, and emotional toll.

Anna Quindlen once said, “Grief is a whisper in the world, but a clamor within.” Recognize the toll this is taking and don’t be alone with your grief.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This morning, Megan A. Adams (a GI & Hepatology News Associate Editor and a Michigan faculty member) and I held an hour-long video conference with all of our Michigan GI fellows. Our four third-year fellows talked about their job search and employment plans for July. Three will join academic centers (UNC, University of Wisconsin, Henry Ford) and one will enter private practice (Atlanta Gastroenterology). I was glad to hear that all had been reassured that their positions were secure despite the COVID-19 impact. As I speak with colleagues across the country, all (whether health system physicians, academic faculty, or community gastroenterologists) are experiencing the financial, emotional, and operational effects of this pandemic. This is an experience that will define our professional careers.

As one of three chief clinical officers at Michigan Medicine, I am part of a four-person team that leads the faculty medical group and the ambulatory portion of our health system. Each of our segments (ambulatory, adult hospital, children’s hospital, and medical school) have targets for sustained cost reductions that total $400 million and Michigan Medicine (as published in the news) plans to reduce our workforce (nonfaculty) by 1,400. We have a hiring freeze, leaders are taking salary reductions, and we have instituted other painful, cost-saving measures. The physician leaders we hired just 12 months ago to oversee a new faculty group structure were thrust into a firestorm. Department chairs, division chiefs, nursing and administrative leaders all are having to make heart-wrenching cost-cutting decisions. Together, we have to make individual reductions in force or retain decisions about people we work with daily. This emotional toll will never truly heal for anyone involved.

There will be little time to recover. We are scrambling to reopen safely, with a planned process. We have a backlog of 12,000 surgeries and 8,000 endoscopy procedures that have been deferred. Eight-hundred children are behind in their well-child medical care, frightened patients are sitting home with critical aortic stenosis, dangerous hypertension, growing cancers, and other urgent medical needs. Private practices are facing the same issues, financial pressures, and emotional toll.

Anna Quindlen once said, “Grief is a whisper in the world, but a clamor within.” Recognize the toll this is taking and don’t be alone with your grief.

John I. Allen, MD, MBA, AGAF
Editor in Chief