We performed a cross-sectional study among Chinese patients with skin diseases. A web-based survey link was created and posted on social media platforms (WeChat groups and teledermatology platforms) to facilitate the collection of questionnaires. To avoid repeat submissions, each single IP address was allowed to submit answers only one time. Completion of all questions was required before submission of the questionnaire. All the participants were allowed to quit at any time if any question made them feel uncomfortable. The survey was conducted from April 15 to 27, 2020. The study was reviewed and approved by the institutional research ethics board of Xiangya Hospital, Central South University (Changsha, China; approval number: 202002024). Electronic informed consent was collected from all participants.

Three exposure variables were defined. Outdoor activity restriction was determined by a single question: “During the last month, what measures did you take for isolation?” with the following four responses: “I was not isolated, and my outdoor activity was unaffected,” “I was not isolated, but my outdoor activity was partly affected,” “I was isolated at home and receiving medical observation,” and “I was quarantined in hospital and receiving medical observation or treatment.” Because only one patient reported having COVID-19 and being quarantined in hospital, patients who were quarantined at home or in the hospital were combined into one group in the analysis.

The employment status was determined by a single question: “How is your employment status since the epidemic?” with the following responses: “I am unemployed since the epidemic” and “My employment status has been unaffected since the epidemic.”

Income change was measured by a single question: “Has your monthly income changed since the epidemic of COVID-19?” with the following responses: “I have completely lost my income,” “My monthly income has decreased,” “My monthly income has been unaffected,” and “My monthly income has increased.” Because only two patients reported increased income, they were categorized in the “unaffected” group in the analysis.

The primary outcomes were perceived stress and depression and anxiety, which were measured using some short, simple scales to minimize respondent burden.

The Visual Analog Scale (VAS) was used to assess perceived stress during the past two weeks. The area under the receiver operating characteristic curve of the VAS was 0.9 to 0.93, with a cutoff of 6.8 to 7.2 according to the Perceived Stress Scale-14 (PSS-14) [12,13]. Here, we used a cutoff of ≥7 to define significant perceived stress.

The Generalized Anxiety Disorder-7 (GAD-7) and the 9-item Patient Health Questionnaire (PHQ-9) were applied to examine the symptoms of anxiety and depression during the past two weeks. The cutoff point for both scales was ≥8 [14,15]. The Cronbach α coefficients of the GAD-7 and PHQ-9 in our sample were .93 and .89, respectively.

The Dermatology Life Quality Index (DLQI) was used to assess the respondents’ quality of life during the past two weeks. The cutoff point was ≥10 in our study [16]. The Cronbach α coefficient of the DLQI in our sample was .76. Health utility was mapped using the generic tool EQ-5D-3L according to the method proposed by Liu et al [17].

Demographic and clinical data of the individuals were collected and analyzed as covariates, including gender (male or female), age, marital status (unmarried, married, divorced, or widowed), educational level (primary school and below, middle school, high school, or college and above), annual income (<¥10,000, ¥10,000 to ¥49,999, ¥50,000 to ¥99,999, or ≥¥100,000, equivalent to US $1,464.47, $1,464.4 to $7,322.21, $7,322.36 to $14,644.57, or ≥$14,644.72), type of skin diseases (infectious skin diseases, papulosquamous disorders, allergic skin diseases, disorders of appendages, pigmentary disorders, skin tumors), course of disease (<1 year, 1 to 5 years, 6 to 10 years, >10 years), adherence to treatment, and use of health care services.

The data were exported from the web-based survey system and analyzed with R version 3.4 (R Project). Continuous variables with normal distribution were expressed as mean (SD) and compared with analysis of variance. Continuous data with skewed distributions were presented as median (IQR) and compared with the Wilcoxon rank sum test. Categorical variables were summarized as counts (percentages) and compared using the chi-square test or Fisher exact test. The interaction effects of the exposure variables were examined. The effect sizes of the associations were presented as adjusted odds ratios (aORs) and 95% CIs. A P value <.05 was considered statistically significant. Reporting of the results followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines.

Data are available upon request from JS.

In the current study, we investigated the association of the impact of the COVID-19 pandemic with health-related quality of life in Chinese patients with skin diseases through a web-based survey. Our results indicated that over half of the respondents experienced quarantine and loss of income during the pandemic. These patients reported higher levels of perceived stress, increased symptoms of anxiety and depression, and impaired quality of life. To the best of our knowledge, this is the first impact analysis of the COVID-19 pandemic in patients with skin diseases. Our study reveals considerable proportions of impaired quality of life and mental well-being in these patients. Telemedicine, mental health intervention, and social support are needed for patients with skin diseases during this particular period.

Studies have indicated increases in mental health issues among medical staff [18] and patients with chronic diseases [19] since the outbreak of COVID-19. However, there is little research regarding the impact of the pandemic on patients with skin diseases. Here, we identified isolation, unemployment, and loss of income as significant risk factors for poor mental well-being and quality of life in patients with skin diseases.

Public health efforts to prevent the spread of COVID-19 are having a growing impact on the global economy. A considerable number of individuals are losing their jobs, at least temporarily [20]. It has been estimated that the worldwide unemployment rate will increase from 4.936% to 5.644% due to the COVID-19 pandemic [2]. According to our data, over 20% of participants (109/506, 21.5%) became unemployed, which is notably higher than the reported unemployment rate. Additionally, 208 of the 506 patients (41.1%) experienced reduced income even though they were not unemployed; this also resulted in impaired mental health and quality of life. In addition to the financial impacts, job loss can disrupt health insurance coverage [21]. Although many countries have provided free testing or even treatment for COVID-19, medical costs for other conditions related to the pandemic are generally not covered by these reimbursement policies.

It should be noted that 65% of the respondents’ nonadherence to treatment was related to limited accessibility to health institutions or medications based on our observations. Since the pandemic, many hospitals and health care institutions have temporarily closed their outpatient services to avoid nosocomial infection and better allocate health care resources, which has created unique challenges to health care delivery at present [22]. A previous study described the possibility of using telemedicine in disasters or public health emergencies [23]. Most developed areas have been using telemedicine not only for physical health care, but also for mental health services [24]. However, it is difficult for patients in rural areas who lack internet services and smartphones to use remote health care. Current telemedicine programs in China and some countries enable consultation services but do not provide medication delivery services; this could eventually cause nonadherence to treatment due to lack of medication.

Our study has some limitations. First, the survey was web-based, with low representativeness due to nonprobability sampling. Second, the exposure and outcome variables were self-reported, and recall bias may have been introduced. Third, some relevant outcomes such as sleep quality were not included in our study because a heavy survey burden may lead to fewer responses and lower accuracy. Last, the survey was conducted among Chinese patients and may not fully represent all patients in areas beyond China due to cultural differences as well as variations in reimbursement policies and social systems.

Taken together, our findings indicate that pandemic-related impacts are associated with adverse patient-reported outcomes of skin diseases. Early and timely mental health intervention, telemedicine, and health education are needed for these patients. Preferably, social support and reimbursement policies will further help patients under heavy financial burdens endure this difficult period.