Overview

The purpose of this guideline is to maximise the safety of children and adults who have dermatological conditions treated with drugs affecting the immune response during the COVID-19 pandemic. It also aims to protect staff from infection and enable services to make the best use of NHS resources.

On 9 April 2021,we updated recommendations on treatment considerations for patients not known to have COVID-19 to take into account COVID-19 vaccination status.

This guideline focuses on what you need to stop or start doing during the pandemic. Follow the usual professional guidelines, standards and laws (including those on equalities, safeguarding, communication and mental capacity), as described in making decisions using NICE guidelines.

This guideline is for:

• health and care practitioners
• health and care staff involved in planning and delivering services
• commissioners.

The recommendations bring together:

• existing national and international guidance and policies
• advice from specialists working in the NHS from across the UK. These include people with expertise and experience of treating patients for the specific health conditions covered by the guidance during the current COVID-19 pandemic.

NICE has also produced COVID-19 rapid guidelines on children and young people who are immunocompromised and arranging planned care in hospitals and diagnostic services, which should be read alongside this guideline.

We developed this guideline using the interim process and methods for developing rapid guidelines on COVID-19 in response to the rapidly evolving situation. We will review and update the recommendations as the knowledge base develops using the interim process and methods for guidelines developed in response to health and social care emergencies.

1. Communicating with patients and minimising risk

1.1.

Communicate with patients, their families and carers, and support their mental health and wellbeing to help alleviate any anxiety and fear they may have about COVID-19. Signpost to sources of online information (such as the British Association of Dermatologists’ patient hub), support groups (including NHS Volunteer Responders) and UK government guidance on the mental health and wellbeing aspects of COVID-19.

1.2.

Some patients will have received a letter telling them they are at high risk of severe illness from COVID-19. Tell them, or their parent or carer, to follow the advice on shielding in UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable to COVID-19.

1.3.

Telephone, email or send a text message to patients booked for a dermatology appointment, or their parents or carers. Tell them that if they have been advised to self-isolate they should follow the UK government stay at home advice for households with possible coronavirus (COVID-19) infection. They should:

• not attend their appointment
• contact the dermatology department for advice on their ongoing care.

1.4.

Minimise face-to-face contact by:

• avoiding non-essential face-to-face consultations
• using electronic prescriptions rather than paper
• using different methods to deliver prescriptions and medicines, for example, postal services, NHS Volunteer Responders or drive-through pick-up points for medicines
• contacting patients via text message, telephone or email
• optimising the use of teledermatology, such as telephone and video consultations
• making use of departmental pages on local NHS trust websites, which should include FAQs on COVID-19 if possible
• extending intervals between drug monitoring (see recommendation 3.3 in the section on treatment considerations) and using local services for blood tests if possible.

1.5.

If patients need to attend face-to-face appointments, ask them to help reduce the risk of contracting or spreading infection with COVID-19 by:

• coming to the appointment alone
• having only 1 parent or carer accompany a child or adult who cannot come alone
• avoiding public transport if possible.

1.6.

Tell patients, or their families and carers, that they should contact the NHS 111 online coronavirus service, or call NHS 111 if they don’t have internet access, if they think they have COVID-19. In an emergency they should call 999 if they are seriously ill. They should also inform their dermatology team, to get advice about their immunosuppressive therapies.

1.7.

Advise patients, or their parents or carers, to write down a list of the medicines they take and the conditions they have, to give to healthcare staff if they need to seek treatment for COVID-19.

1.8.

Tell patients who still need to attend services, or their parents or carers, to follow relevant parts of government advice on social distancing (this differs across the UK), or UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.

2. Supplying medicines

2.1.

Think about the resources that are available to make treatment changes during the COVID-19 pandemic and how these changes will be delivered. Be aware that the supply of medicines through normal routes, for example homecare medicines delivery services, may become disrupted during the pandemic and have plans in place to manage this.

2.2.

Prescribe usual quantities of medicines to meet the patient’s clinical needs. Prescribing larger quantities of medicines puts the supply chain at risk.

3. Patients not known to have COVID-19

3.1.

If patients need to attend hospital appointments, minimise their potential exposure to the virus by:

• encouraging them not to arrive early
• texting them when staff are ready to see them, so that they can wait outside the building, for example in their car
• providing a ‘clean route’ through the hospital to the department
• reducing, and ideally eliminating, the time they spend in waiting areas through careful scheduling
• delivering investigations, procedures and treatment promptly and in 1 stop when feasible
• ensuring prescriptions are dispensed rapidly and ideally without visiting hospital pharmacies, for example by use of home delivery or NHS volunteers, where available.

4. Patients known or suspected to have COVID-19

4.1.

Be aware that patients taking drugs that affect the immune system may have atypical presentations of COVID-19. For example, patients taking prednisolone may not develop a fever.

4.2.

If patients with known or suspected COVID-19 need to attend the dermatology department, follow appropriate UK government guidance on infection prevention and control. This includes recommendations on patient transfers and options for outpatient settings.

4.3.

If COVID-19 is later diagnosed in a patient not isolated from admission or presentation, follow UK government guidance for health professionals.

5. Modifications to usual care

5.1.

If necessary, only continue core services, including:

• dermatology department advice lines
• essential parenteral day-case treatment
• blood tests for drug monitoring where necessary
• services for urgent inpatient and outpatient review (both new and follow up)
• facilities to enable face-to-face review to manage disease flares and complications of therapy.

5.2.

Provide acute and emergency dermatology advice to GPs to avoid unnecessary emergency department attendances and admissions, using advice and guidance services and teletriage where possible.

5.3.

Think about pooling resources with other specialities and NHS trusts to provide services such as drug monitoring and telephone and email advice.

6. Healthcare workers

6.1.

All healthcare workers involved in receiving, assessing and caring for patients who have known or suspected COVID-19 should follow UK government guidance for infection prevention and control. This contains information on using personal protective equipment (PPE), including visual and quick guides for putting on and taking off PPE.

6.2.

If a healthcare professional needs to self-isolate, ensure that they can continue to help by:

• enabling telephone or video consultations, and attendance at virtual multidisciplinary team meetings
• identifying patients who are suitable for remote monitoring and follow up, and those who are vulnerable and need support
• carrying out tasks that can be done remotely, such as entering data.

6.3.

Take account of the information on the NHS Employers website about good partnership working and issues to consider when developing local plans to combat COVID-19.

Update information

9 April 2021: In section 3 we added a recommendation to follow advice on COVID-19 vaccination for patients having or going to be having immunosuppressive treatments. We also added a question on COVID-19 vaccination to recommendation 3.2.

30 April 2020: We added information to recommendation 4.5 to highlight that the half-life of some drugs means that immunosuppression will continue for some time after stopping treatment.

Your responsibility: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.