|Year : 2022 | Volume
| Issue : 3 | Page : 143-147
Coronavirus disease 2019 in dermatology practice: Perspective of three levels of prevention on public health
Chengwen Luo1, Cai-Zheng Geng2, Yung-Hsien Tung3, Bing-Long Wang4, Tao-Hsin Tung1
1 Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
2 Department of Radiology; Department of Nuclear Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
3 Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
4 Department of Healthcare Leadership and Management, School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
|Date of Submission||06-Apr-2022|
|Date of Decision||19-May-2022|
|Date of Acceptance||28-May-2022|
|Date of Web Publication||14-Sep-2022|
Dr. Tao-Hsin Tung
Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has become a major public exigency of international concern. The COVID-19 epidemic has spread rapidly around the world, profoundly impacting people's lives. Patients are among those most affected by the pandemic. COVID-19 has adversely affected health-care systems, and the effects are long-lasting and devastating. Most medical institutions in the impacted countries and regions have been imbued with COVID-19 cases, both confirmed and suspected, leading to an overburdened health-care workforce like never before. While most of the critical situations involved internal medicine departments, such as infectious diseases, and intensive care units, other specialties, including dermatology, have also been profoundly affected by this pandemic. Dermatoepidemiology, the application of epidemiological methods to dermatology practice, is an important emerging discipline in dermatology. In this review, we discussed the influence of the COVID-19 epidemic on dermatology practice, as well as the application of public health strategies in dermatology. These findings from genetic epidemiological research, clinical trial networks, and pharmacovigilance research suggested that further research in dermatology requires collaborative studies across different fields, institutions, and countries. To solve the highly complex unsolved problems that we face, dermatologists and epidemiologists should be dynamic team members with multiple approach skills.
Keywords: Coronavirus disease 2019, dermatology practice, psoriasis, public health, teledermatology
|How to cite this article:|
Luo C, Geng CZ, Tung YH, Wang BL, Tung TH. Coronavirus disease 2019 in dermatology practice: Perspective of three levels of prevention on public health. Dermatol Sin 2022;40:143-7
|How to cite this URL:|
Luo C, Geng CZ, Tung YH, Wang BL, Tung TH. Coronavirus disease 2019 in dermatology practice: Perspective of three levels of prevention on public health. Dermatol Sin [serial online] 2022 [cited 2023 Feb 6];40:143-7. Available from: https://www.dermsinica.org/text.asp?2022/40/3/143/356071
| Introduction|| |
In December 2019, coronavirus disease 2019 (COVID-19) broke out and spread rapidly around the world, directly and indirectly causing great concern among patients and doctors. The impact of COVID-19 on health-care systems has been long-lasting and devastating. Most medical institutions in the impacted countries and regions were imbued with COVID-19 cases, leading to an overburden of health-care workers. Although the emergencies primarily involve internal medicine departments, such as infectious diseases, and intensive care units, other specialties, including dermatology, have also been profoundly affected by this pandemic. For example, dermatology consultations in outpatient clinics have decreased dramatically. This decline in attendance is due to patient fear, and dermatologists advising patients to postpone nonurgent visits.
Dermatological consultation requires close contact with patients. The risk of infection may trigger anxiety among health-care workers and, as a result, compromise the quality of medical services. Countermeasures have been adopted by dermatologists as a powerful way to control the transmission of the virus, and preventive strategies, such as hand hygiene practices, social distancing, and patient education, are being prioritized. A web-based global investigation of dermatologists identified that there was a decline in hospital services, in-person consultations, and procedures, while teledermatology use increased by 3-fold. The same study further showed that the COVID-19 pandemic had an immediate influence on how dermatology is being practiced and contributed to the increasing use of teledermatology.
Dermatology practices have been dramatically affected by the COVID-19 pandemic. For example, there has been a decrease in the number of clinical visits and caused uncertainties concerning the utilization of biological and immunosuppressive treatment.,, Importantly, the reduced quality of care, and reduced job satisfaction, are major concerns for dermatologists. Significant changes to how dermatology will be practiced in future, including novel methods, are needed and must be embraced to maintain dermatology care throughout the COVID-19 crisis and beyond. Adaptive education and measures are mandatory for ensuring the effectiveness and safety of dermatological services. A survey conducted in Taipei showed that there was a significant association between decreased dermatology clinic visits during COVID-19 and increased nonemergent dermatoses, including fungal infections, parasitic infections, and vitiligo. Considering that most dermatology patients have ailments that are not life-threatening, some experts have recommended canceling nonurgent face-to-face appointments to minimize the risk of COVID-19 spreading., Furthermore, recent research has also demonstrated an increased risk of hand eczema during the COVID-19 epidemic because of frequent handwashing.
Wearing masks is one of the important means of personal protection against the epidemic. Although the use of masks could prevent disease spread, the prolonged use can also result in certain adverse skin reactions, such as acne, rash, and itching., A study conducted in China found that 98.03% of frontline health-care workers had dermatological problems due to the use of personal protective equipment. A similar study in Thailand that included health-care workers and the general public found that in 54.25% of cases, masks caused adverse skin reactions. In addition to the high incidence of skin injuries related to the use of protective equipment, studies have also reported adverse skin reactions after COVID-19 vaccination.,,,
The COVID-19 pandemic has been the center of attention worldwide, due to the substantial number of patients infected by the novel coronavirus and evidence of person-to-person transmission. The domains of dermatology and procedural dermatology have not been exempted from this global problem. We cannot deny that the epidemic would continue to influence people's health-seeking behaviors. Therefore, dermatologists must identity the potential risks and consider the preventive measures to take when recommencing their practices after the COVID-19 pandemic.
| The principle of Epidemiology to Dermatology Practice|| |
Epidemiology, a branch of clinical science, explores the associated risk factors that may contribute to the causation of diseases via a prospective or retrospective observation. It can determine the complete natural history of a disease and the morbidity or transmission mechanisms of a disease in individuals and investigate preventive and treatment control methods. The use of population-based information for medical decision-making about patients is usually described as clinical epidemiology or, more recently, evidence-based medicine. For observational studies to become “real,” results need to be replicated in other populations, further interpreted by laboratory studies, and evaluated in clinical studies.
Dermatoepidemiology, an important emerging discipline in dermatology, applies epidemiological methods to the practice of dermatology. Dermatoepidemiology is the investigation of skin ailments at the population level. One aspect that dermatoepidemiology focuses on is the worldwide growth of skin diseases. In recent decades, dermatoepidemiology has flourished with the occurrence of numerous novel and scientific studies on this subject.,,,,,
The importance of epidemiology in dermatology practice
Emerging epidemiological evidence has shown an independent association between psoriasis and metabolic syndrome. The higher prevalence of the metabolic syndrome and its components in individuals with psoriasis than in controls, regardless of disease severity, underscored the need for early therapy and follow-up of all psoriasis patients with metabolic disease. These results suggest that environmental factors, including stress and drugs, may play different roles in the exacerbation of psoriasis in different ethnic groups. The risk of cancer in psoriasis patients remains a cause of particular concern. The relationship between cancer and psoriasis was detected in a group of individuals with psoriasis, and this relationship was driven mainly by nonmelanoma skin cancer, lung cancer, and lymphoma.
As mentioned, psoriasis is a chronic inflammatory disease and recent research has shown a link between psoriasis and obesity. A hospital-based retrospective case–control study showed that men are more likely to develop psoriasis if they are mildly obese and middle age or older. Furthermore, psoriasis concomitantly preceded bullous pemphigoid in individuals with bullous pemphigoid. Patients with both diseases were significantly younger than those with solitary bullous pemphigoid. Patients with both entities were more often treated with adjuvant immunosuppressants, possibly to avoid the long-term use of large doses of corticosteroids in patients with psoriasis. Antibiotics disrupted the human microbiome and have been associated with several pediatric autoimmune diseases. However, antibiotics did not appear to significantly increase the risk. Elevated body mass index was a risk factor for psoriasis. The prevalence of obesity was higher in psoriasis individuals than in general population. A dietetic intervention associated with increased physical activities reduced the severity of psoriasis in overweight or obese psoriasis patients treated with systemic therapy.
| The Application of Public Health Strategies in Dermatology Practice|| |
Public health in dermatology
Public health refers to the science and art of preventing diseases, prolonging life, and promoting health, through the organized efforts and informed choices of society, organizations, public and private communities, and individuals. The goal of public health is to provide the greatest benefits to the largest number of people. Public health has three core functions. The first is assessment, which allows for the systematic collection, analysis, and provision of information about healthy communities. The second is policy development, using scientific knowledge as the basis for policy development and decision-making. The third is to ensure that services are available to those in need.
The three levels of prevention are as follows. Primary prevention aims to prevent the onset of a disease. Secondary prevention aims to decrease the influence of a disease that has occurred through early diagnosis and prompt treatment. Tertiary prevention aims to relieve the impact of an ongoing disease that has resulted in lasting clinical effects through rehabilitation.
Public health dermatology promotes skin health, but modern public health dermatology is still relatively backward. Health-care professionals helped individual patients but have little impact on the population health. On the one hand, individuals rarely recognize the impact of large-scale population interventions. When considering the whole population, a little harm that affects a lot of people may be more significant than a lot of harm that affects only a few people. Modern public health dermatology has been successful in reducing the incidence of skin cancer and in controlling infectious diseases. Low-technology educational interventions targeting entire communities could provide more benefits than high-technology drugs targeting only a few patients. It is well known that public health measures to reduce viral transmission, including social distancing, hand hygiene, and cough etiquette, appeared to finally be a priority and may have reduced the severity of resource shortages by closing the gap between medical needs and the available treatment supplies. However, efforts to mitigate the public health impact did not preclude the need to be fully prepared to allocate scarce resources before they became necessary.
Opportunities for dermatology
This is an exceptional time for medical publishing. Articles on COVID-19 are being published at an unprecedented rate. With notable exceptions, in dermatology, the COVID-19 literature consists primarily of case reports, small case series, and opinion articles. It is critically important for dermatologists to conduct rigorous prospective studies to gain an integrative understanding of the natural history, true prevalence, and cutaneous findings associated with COVID-19 infection, identify whether cutaneous manifestations have any systemic associations, and to determine the best management approaches.
Parallel research efforts should address how dermatologists can continue to provide specialized care during global epidemics. Adopting stringent strategies to minimize further gaps in access is also necessary. Identifying opportunities and clarifying priorities in both dermatology research and clinical care is also important. Furthermore, the availability of better or more data could advance patient care and improve the understanding of dermatological conditions, and streamline risk-based therapies, billing, and reimbursement.
Benefits and challenges of teledermatology
The utilization of teledermatology has increased during the COVID-19 pandemic. This is one of the immediate effects of COVID-19 on dermatology practices. Teledermatology can greatly reduce the risk of COVID-19 infection compared to face-to-face treatment. Teledermatology is also time-efficient and enables the proper triage of patients. Moreover, it is helpful to patients who normally need to take time off work to attend appointments. Patients who are elderly, disabled, or living in nursing homes can also receive care without the need to depend on occupational and transportation services. Furthermore, in remote areas with limited access to dermatological care, teledermatology can increase access and, at the same time, reduce the risk of transmission of infectious diseases.
Teledermatology is not without challenges. Limited image quality may affect the dermatologist's ability to diagnose conditions, or the risk of misdiagnosis may be increased. Dermoscopy may be limited unless patients use a dedicated dermoscopic photo capturing software. Moreover, security and privacy may be a concern without secure video conferencing software to ensure cybersafety. There are also limitations to treatment options. For example, surgical procedures, cryotherapy, and laser treatment cannot be performed. Furthermore, the lack of a reliable reimbursement system is also an important factor to consider.
For governments and policy-makers
It is a known fact that public health has not been well-recognized among medical/surgical disciplines. Governments should ensure that individuals suffering from skin anomalies have access to specialized health-care and comprehensive treatment. Optimal treatment of unhealthy skin and its comorbidities requires a shift to a people-centered and integrated model of health-care delivery. Governments and nongovernmental organizations should also provide education to health-care professionals regarding common chronic skin conditions. Governments and policy-makers need to play key roles in reducing the stigma and discrimination associated with skin diseases.
For health systems and health professionals
Health-care professionals working in primary medical care should be aware of the risk of COVID-19 in dermatology practices. Clinicians should notify patients of the possible consequences of the disease and aim for optimal management. Health professionals should also develop consensus on the classification of COVID-19 manifestations in dermatology, standardize the collection of epidemiological data, and develop guidelines regarding the diagnosis and treatment.
For patients' organizations and civil society
Organizations and societies must also advocate for the rights of individuals suffering from COVID-19. Concurrently, organizations should provide support for patients suffering from COVID-19 and establish networks for mutual support and experience exchange. Civil societies can encourage the establishment of patient associations where they currently do not exist.
| Integrated Model for Surveillance of Coronavirus Disease 2019 in Dermatology Practice|| |
The collection and utilization of electronic data in dermatology present both challenges and opportunities. Few dermatologic conditions have outcomes that were quantifiable, standardized, and easily recognized in routinely collected health-care data. Objective vital signs, laboratory tests, and easily recognizable endpoints, including hospital admissions and mortality, are commonly used to improve clinical outcomes in other specialties, but these are rarely accessible for dermatologic conditions. Since relevant dermatologic data cannot be easily collected or quantified, novel approaches for data capture and analyses were needed to ensure that providers do not take on additional burdens. The skin is uniquely available for measurement. Hence, clinical data systems should consider other outcome measures. Obtaining measurements that complement provider-generated data, such as data from digitized photographic images and using validated assessment tools to collect patient-reported signs and symptoms, should be considered., New machine learning technologies have enabled the analysis of large amounts of data. Using machine learning and a large number of clinical practices in dermatology could serve as a model to assess the severity, extent, and impact of skin diseases on the patients. This innovation in routine measurement of outcomes combined with standardized clinical data would push dermatology to the forefront of patient-centered care. Efforts to enhance dermatology data collection and standardization have the potential to benefit the patients, clinical practices, and population health and would demand an inter-disciplinary effort with input from patients, providers, researchers, and administrators.
Atopic dermatitis is common and can be devastating in severe cases. This chronic inflammatory skin disease is part of the atopic syndrome, which includes food allergies, asthma, and hay fever. The field of atopic dermatitis research could benefit from past experience with psoriasis and should not take the same path but commit to a more holistic method from the outset. Genetic and metabolic analyses were performed to assess the susceptibility of individuals with atopic dermatitis to cardiovascular disease. In general, the association between cardiovascular disease and atopic dermatitis was modest. However, in more targeted cohorts, the cardiovascular risk profile and genetic makeup were comparable. A more comprehensive methodology could quickly identify the clinical relevance of cardiovascular disease in patients with atopic dermatitis, and remove the guesswork from patient care, while conserving scientific resources. Dermatological surveillance data for COVID-19 patients are usually based on case reports and small-scale surveillance studies. However, it is difficult to establish a causal relationship between COVID-19 and its diverse symptoms, including skin diseases or atopic dermatitis, that is potentially aggravated by COVID-19. Surveillance alone is difficult. Close observation, investigation, and collection of clinical data, are essential.
| Future Perspectives|| |
The most straightforward problems have been solved by inductive methods, which associate the risk exposure with an outcome. The primary challenge is whether dermatoepidemiology can contribute to a better understanding of complicated processes or diseases. Understanding the epidemiological aspects of a certain disease requires a large number of samples, advanced statistical tools, and the availability of genetic data and biological specimens, underscoring the importance of population-based cohorts and biobanks that might form international study unions. Further research in dermatoepidemiology requires collaborative studies across different fields, institutions, and countries, as illustrated by genetic epidemiological research, clinical trial networks, and pharmacovigilance research. To solve the highly complex unsolved problems that we face, epidemiologists should be dynamic team members with multiple approach skills.
| Conclusion|| |
In the era of the COVID-19 pandemic, dermatologists should not only dedicate their knowledge and expertise to medical care but also seize the opportunity to explore the underlying pathogenesis of dermatoses and apply the findings to clinical practice. The continued development of optimized telemedicine and artificial intelligence in hospital information systems may also provide an excellent academic and clinical platform for dermatologists to contribute to academic, regional, and global communities in fighting the novel coronavirus.
Financial support and sponsorship
Conflicts of interest
Dr. Tao-Hsin Tung, a statistical editor at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
| References|| |
Piccolo V, Argenziano G. The impact of novel coronavirus on dermatology. Dermatol Pract Concept 2020;10:e2020049.
Bhat YJ, Aslam A, Hassan I, Dogra S. Impact of COVID-19 pandemic on dermatologists and dermatology practice. Indian Dermatol Online J 2020;11:328-32. [Full text]
Bhargava S, McKeever C, Kroumpouzos G. Impact of COVID-19 pandemic on dermatology practices: Results of a web-based, global survey. Int J Womens Dermatol 2021;7:217-23.
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al.
Fair allocation of scarce medical resources in the time of covid-19. N Engl J Med 2020;382:2049-55.
Leis M, Fleming P, Lynde CW. Impacts of COVID-19 on dermatologic practice, disease presentation, and immunomodulator prescriptions. J Cutan Med Surg 2021;25:106-8.
Gisondi P, Piaserico S, Conti A, Naldi L. Dermatologists and SARS-CoV-2: The impact of the pandemic on daily practice. J Eur Acad Dermatol Venereol 2020;34:1196-201.
Lee C. Role of dermatologists in the uprising of the novel corona virus (COVID19): Perspectives and opportunities. Dermatol Sin 2020;38:1-2. [Full text]
Ma S, Tai Y, Dai Y, Chen C, Chang Y. Impact of the COVID-19 pandemic on dermatology clinic visits: Experience from a tertiary medical center in Taiwan. Dermatol Sin 2020;38:180-1. [Full text]
Pathoulas JT, Stoff BK, Lee KC, Farah RS. Ethical outpatient dermatology care during the coronavirus (COVID-19) pandemic. J Am Acad Dermatol 2020;82:1272-3.
Kwatra SG, Sweren RJ, Grossberg AL. Dermatology practices as vectors for COVID-19 transmission: A call for immediate cessation of nonemergent dermatology visits. J Am Acad Dermatol 2020;82:e179-80.
Singh M, Pawar M, Bothra A, Choudhary N. Overzealous hand hygiene during the COVID 19 pandemic causing an increased incidence of hand eczema among general population. J Am Acad Dermatol 2020;83:e37-41.
Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore) 2020;99:e20603.
Krajewski PK, Matusiak Ł, Szepietowska M, Białynicki-Birula R, Szepietowski JC. Increased prevalence of face mask-induced itch in health care workers. Biology (Basel) 2020;9:451.
Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al
. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol 2020;82:1215-6.
Techasatian L, Lebsing S, Uppala R, Thaowandee W, Chaiyarit J, Supakunpinyo C, et al.
The effects of the face mask on the skin underneath: A prospective survey during the COVID-19 pandemic. J Prim Care Community Health 2020;11:2150132720966167.
Fernandez-Nieto D, Hammerle J, Fernandez-Escribano M, Moreno-Del Real CM, Garcia-Abellas P, Carretero-Barrio I, et al
. Skin manifestations of the BNT162b2 mRNA COVID-19 vaccine in healthcare workers. 'COVID-arm': A clinical and histological characterization. J Eur Acad Dermatol Venereol 2021;35:e425-7.
Burlando M, Russo R, Cozzani E, Parodi A. COVID-19 “second wave” and vaccines: The dermatologists' perspective. Int J Dermatol 2021;60:889-90.
Cyrenne BM, Al-Mohammedi F, DeKoven JG, Alhusayen R. Pityriasis rosea-like eruptions following vaccination with BNT162b2 mRNA COVID-19 vaccine. J Eur Acad Dermatol Venereol 2021;35:e546-8.
Busto-Leis JM, Servera-Negre G, Mayor-Ibarguren A, Sendagorta-Cudós E, Feito-Rodríguez M, Nuño-González A, et al.
Pityriasis rosea, COVID-19 and vaccination: New keys to understand an old acquaintance. J Eur Acad Dermatol Venereol 2021;35:e489-91.
Ng JN, Cembrano KA, Wanitphakdeedecha R, Manuskiatti W. The aftermath of COVID-19 in dermatology practice: What's next? J Cosmet Dermatol 2020;19:1826-7.
Nijsten T, Apfelbacher C, Gisondi P, Silverberg J, Cohen A, Barbarot S, et al.
Dermatoepidemiology; what's up people? Br J Dermatol 2015;173:881-3.
Barzilai DA, Freiman A, Dellavalle RP, Weinstock MA, Mostow EN. Dermatoepidemiology. J Am Acad Dermatol 2005;52:559-73.
Williams HC. Beyond the year 2000: How may epidemiology influence future clinical practice in dermatology? Clin Dermatol 2001;19:55-8.
Marks R. Dermatoepidemiology: Wherefore art thou in this perilous time of need? Int J Dermatol 2001;40:167-8.
Weinstock M. Dermatoepidemiology. Dermatol Clin 1995;13:505-716.
Chuang TY, Reizner GT. Dermatoepidemiology. Part I: Epidemiologic methods. Int J Dermatol 1993;32:251-6.
Chuang TY, Faust HB, Farmer ER. Dermatoepidemiology. II: Causal inference established by a rule called “ASSOCIATED”. Int J Dermatol 1997;36:412-5.
Chuang TY, Mirowski GW, Reizner GT. Dermatoepidemiology. III. ABC principles for a critical review of the literature. Int J Dermatol 1998;37:1-6.
Milčić D, Janković S, Vesić S, Milinković M, Marinković J, Ćirković A, et al.
Prevalence of metabolic syndrome in patients with psoriasis: A hospital-based cross-sectional study. An Bras Dermatol 2017;92:46-51.
Yan D, Afifi L, Jeon C, Cordoro KM, Liao W. A cross-sectional study of psoriasis triggers among different ethno-racial groups. J Am Acad Dermatol 2017;77:756-8.e1.
Chiesa Fuxench ZC, Shin DB, Ogdie Beatty A, Gelfand JM. The risk of cancer in patients with psoriasis: A population-based cohort study in the health improvement network. JAMA Dermatol 2016;152:282-90.
Naito R, Imafuku S. Distinguishing features of body mass index and psoriasis in men and women in Japan: A hospital-based case-control study. J Dermatol 2016;43:1406-11.
Kridin K, Bergman R. Association between bullous pemphigoid and psoriasis: A case-control study. J Am Acad Dermatol 2017;77:370-2.
Horton DB, Scott FI, Haynes K, Putt ME, Rose CD, Lewis JD, et al.
Antibiotic exposure, infection, and the development of pediatric psoriasis: A nested case-control study. JAMA Dermatol 2016;152:191-9.
Naldi L, Conti A, Cazzaniga S, Patrizi A, Pazzaglia M, Lanzoni A, et al
. Diet and physical exercise in psoriasis: A randomized controlled trial. Br J Dermatol 2014;170:634-42.
Winslow C. The untilled field of public health. Mod Med 1920;2:183-91.
Abuabara K, Asgari MM, Chen SC, Dellavalle RP, Kalia S, Secrest AM, et al.
How data can deliver for dermatology. J Am Acad Dermatol 2018;79:400-2.
Snyder CF, Aaronson NK, Choucair AK, Elliott TE, Greenhalgh J, Halyard MY, et al
. Implementing patient-reported outcomes assessment in clinical practice: A review of the options and considerations. Qual Life Res 2012;21:1305-14.
Bingham CO 3rd
, Bartlett SJ, Merkel PA, Mielenz TJ, Pilkonis PA, Edmundson L, et al
. Using patient-reported outcomes and PROMIS in research and clinical applications: Experiences from the PCORI pilot projects. Qual Life Res 2016;25:2109-16.
Nijsten T. Atopic dermatitis and comorbidities: Added value of comprehensive dermatoepidemiology. J Invest Dermatol 2017;137:1009-11.
Nijsten T, Stern RS. How epidemiology has contributed to a better understanding of skin disease. J Invest Dermatol 2012;132:994-1002.