Creating dermatology guidelines for COVID-19: The pitfalls of applying evidence-based medicine to an emerging infectious disease

Bottom Line:

Although the guidelines for an emerging infectious disease are more reliant on expert advice as opposed to evidence-based medicine, efforts must be made to create amendable guidelines based on the best available information at a time.


Freeman, E.E. et al. Creating dermatology guidelines for COVID-19: The pitfalls of applying evidence-based medicine to an emerging infectious disease. J AM Acad Dermatol (2020). DOI: 10.1016/j.jaad.2020.04.002

Date Published:

9 April 2020


The authors have recently published an article regarding the modifications to improve the evidence-based clinical guidelines developed by the American Academy of Dermatology (AAD). The AAD’s rapid-advice guidelines protocol relies on evaluating evidence, and is thus of limited use for COVID-19. In response to this limitation, AAD has developed the COVID-19 Taskforce which has declared an interim guidance. Even though this advice is essential, it is made on limited and rapidly evolving evidence and must be individualized for each patient. Ongoing issues include how to grade evidence from gray literature (e.g. literature not made by commercial publishers), risks and benefits of anecdotal and indirect evidence, and ensuring the guidelines correlate with those made by other organizations. A recent study, for instance, examined the occurrence of upper respiratory infection (URI) for patients treated with biologic therapies (treatment that uses substance from living organisms) to assess the risk of COVID-19 infection while on a biologic. The issues with indirect evidence in this study include the comparison of biologic therapies with placebo, the outcome of URI was not taken into account, and it is unclear whether the URI data can be transferred to COVID-19. The challenge of balancing no information with too much information has persisted in other fields as well. For instance, there has been debate over the use of blood pressure medications called angiotensin-converting enzyme inhibitors, and the American Academy of Cardiology has currently issued a suggestion to continue taking these medications until more certain evidence is obtained. Being place in uncertain circumstances, the authors thus suggest that we shift from using evidence-based guidance to guidance that relies on expert advice, with potential for adjustments in the future.

Summary by: Sheida Naderi-Azad