Indian Journal of Dermatology
IJDŽ SYMPOSIUM
Year
: 2021  |  Volume : 66  |  Issue : 3  |  Page : 256--263

Procedural dermatology during COVID 19 pandemic


Anwita Sinha, Shekhar Neema, Biju Vasudevan 
 From the Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India

Correspondence Address:
Shekhar Neema
Department of Dermatology, AFMC and Command Hospital, Pune, Maharashtra
India

Abstract

The Corona virus disease of 2019 (COVID-19) pandemic has imposed unprecedented challenges on the healthcare system including the specialty of dermatology. Procedural dermatology being an integral part of the specialty has also been profoundly affected where all elective and cosmetic procedures are presently being deferred, giving priority only to urgent and inescapable dermatologic procedures to curb down the risk of SARS-CoV-2 transmission in hospitals. With no certainty as to when the pandemic is going to end, procedural dermatology will be resumed in times to come, which must be taken up with cautious precautions. Dermatosurgeons must formulate protocols, restructure their facilities, and implement stringent measures with the aim to limit the spread of SARS-CoV-2, providing, at the same time, essential surgical care to patients. This review highlights the salient precautions to be observed in a dermatosurgery facility based on the current recommendations. The situation, however, remains fluid and as the pandemic is evolving, dermatosurgeons should remain vigilant and acquaint themselves with the latest guidelines.



How to cite this article:
Sinha A, Neema S, Vasudevan B. Procedural dermatology during COVID 19 pandemic.Indian J Dermatol 2021;66:256-263


How to cite this URL:
Sinha A, Neema S, Vasudevan B. Procedural dermatology during COVID 19 pandemic. Indian J Dermatol [serial online] 2021 [cited 2021 Sep 18 ];66:256-263
Available from: https://www.e-ijd.org/text.asp?2021/66/3/256/321321


Full Text



 Introduction



The COVID-19 pandemic has challenged the entire healthcare system including dermatology, cutaneous, and aesthetic surgeries. As on May 18, 2020; 162,773,940 confirmed cases of COVID-19, including 3,375,573 deaths, have been recorded worldwide.[1] As India is grappling under the second wave of the pandemic, the challenge remains to balance high-quality services for patients with COVID-19, along with the management of other non-COVID ailments. The specialty of dermatology has been drastically reorganized during the pandemic by triaging patients and ensuring emergent care. In the specific context of dermatologic surgery, the choice to defer elective surgeries is being followed the world over to decrease the risk of SARS-CoV-2 transmission.[2] The end of the COVID pandemic appears nowhere in sight[3] and it seems inevitable that elective procedures will be restarted at some point in time with the pandemic still around in some form. With no evidence-based recommendations for the same, elective surgeries must be taken up with utmost caution avoiding nosocomial transmission. This review aims at adopting best practices in procedural dermatology with the aim to mitigate the spread of SARS-CoV-2, at the same time providing essential surgical care. The recommendations in this review are based on updated recommendations by the Ministry of Health and Family Welfare, Government of India (MOHFW),[4] Centre for Disease Control and Prevention (CDC),[5] World Health Organization (WHO),[6] and prominent dermatological societies across the world.[2],[7],[8],[9]

 Background



SARS-CoV-2 is transmitted through respiratory droplets (size, >5–10 μ) and physical contact routes.[10] A person in close contact with a patient having symptoms such as sneezing and/or coughing is at risk of being exposed to infective droplets.[11] Aerosols harboring SARS-CoV-2 can remain suspended for a long period, especially in closed environments, and can gain entry into the respiratory tract.[12] Risk is higher in the hospital environment due to higher viral load and repeated exposures. Moreover, confined and ill-ventilated clinics and procedure rooms can turn into hot spots of covid transmission in the absence of adequate precautions.

Dermatologists have been found to have the ninth highest COVID-19 risk score based on contact and physical proximity with patients and exposure to disease and infection.[13] In the setting of the COVID pandemic, scheduling patients for elective dermatologic and cosmetic surgery increases the risk of transmission of SARS-CoV-2, necessitates utilization of healthcare staff working in COVID care wards, and uses limited healthcare resources such as personal protective equipment (PPE). At the same time, deferring surgery in certain conditions may delay the diagnosis, causing disease progression and resulting in a further complex surgery or increasing the risk of metastasis in cutaneous tumors and the ultimate burden on the healthcare system. Dermatologists must adopt a case-based approach in prioritizing the patient's requirement of procedure based on the COVID prevalence in the community ensuring optimum allocation of healthcare resources and manpower. A key objective in undertaking any procedure must be to minimize the transmission of COVID-19 infection within hospitals by following stringent precautions.

Universal precautions for COVID-19 in dermatologic surgery facilities

Consider the possibility of COVID-19 infection in every patient and follow appropriate precautions as a vast majority of the cases are mild or asymptomatic or maybe in incubation period.Limit entry points for all patients, regardless of symptoms. Screening of patients is of pivotal importance to detect patients with suspected COVID-19 infection at the first point of contact. All patients before entering the clinic should be screened with a contactless infrared thermometer (body temperature must be <37.5°C) and complete a declaration form declaring to have had no flu-like symptoms, neither contact with COVID-19-positive individuals in the past 2 weeks.[14]The staff manning the reception should be adequate, PPE comprising of N95 or FFP2 mask, gloves, and face shield. The reception area should be having a barrier with a window maintaining distance between patients and staff of at least 1 m which can be enforced by mechanical barriers or chains.[15]Patients are advised to compulsorily wear a mask when attending the clinic.[16]Hand sanitization stations with alcohol solutions containing at least 60% ethyl alcohol or 70% isopropyl alcohol should be kept at the entry of the clinic and procedure rooms. A portable elbow or foot-operated handwashing facility should be established at the entry to the clinic.[17] Contaminated hands touching the oral or nasal mucosa, or eyes are potent modes of contact transmission; the virus can also be transferred from one surface to another by contaminated hands, which facilitates indirect contact transmission.[10]Triage patients and give appointments for inescapable and crucial dermatologic procedures only during high COVID prevalence in the community.[2] The choice and timing of the procedure should consider the risk of SARS-CoV-2 transmission, urgency/need of the procedure, and risk of aerosol generation during the procedure.[15] A few important dermatological conditions which require urgent intervention on priority and cannot be delayed have been outlined in [Table 1].Appointments should be staggered to minimize the number of patients in the waiting room at a given time. Ensure physical distancing in the waiting room of at least 2 m (6 ft).[17]Paperwork should be minimized. Utilize digital tools such as electronic patient records, online payment of bills, and electronic prescriptions. Minimize fomites in the waiting area which are potential sources of infection like magazines, newspapers, TV remotes, and flower vases. Use plastic or metallic chairs instead of cloth or leather chairs in the waiting area wherever possible which can be disinfected easily.[15] The patient seating area enforcing physical distancing should be marked with red adhesive tapes.[18]Limit the number of staff on duty. Divide clinical staff into rotational shifts to avoid putting the entire staff at risk in case of inadvertent exposure to a COVID-19-infected patient.Ensure adequate ventilation in the waiting areas and limit the number of patients waiting at a given time.[12] Air conditioners favor recirculation of virus indoors and should be kept off as far as possible in the waiting as well as procedure rooms.[19]High-risk procedures like procedures involving head and neck, intraoral or intranasal procedures, or aerosol-generating procedures should be ideally tested for COVID by reverse transcription-polymerase chain reaction (RT-PCR) prior to the procedure.[20]Avoid aerosol- and plume-generating procedures as far as possible. Viral particles have been found to be present in plumes of smoke emitted by several dermatologic devices such as electrocautery machines and lasers (e.g., CO2 and Nd: YAG lasers).[21]Defer all elective dermatologic procedures like excision of asymptomatic benign lesions, such as cysts, lipomas, acrochordons, scars, and keloids. All cosmetic procedures like acne surgeries, chemical peeling, botulinum toxin, fillers, cosmetic laser procedures, and hair transplantation surgeries should also be deferred.[2],[15]Elective procedures can be taken up with precautions on sustained reduction of COVID cases in the community or downward trajectory in the prevalence rate of new COVID-19 cases for at least 14 days.[22] Dermatologists should be abreast with the fluidity of the situation and be well-versed with the prevailing national and state guidelines.Phototherapy chambers are high-risk areas for COVID-19. The patient should be wearing double masks and individual's own protective goggles inside the phototherapy chamber. Hand sanitization should be followed on entering and leaving the phototherapy facility. High-touch areas like buttons and handles should be wiped with disinfectants between sessions. Space out phototherapy appointments and triage only inescapable phototherapy sessions.[15]Disinfection practices should be followed stringently for all surfaces in concurrence with the US Environmental Protection Agency (EPA)-approved disinfectants for COVID-19.[23] Disinfection measures to be adopted in dermatology facilities have been listed in [Table 2]. Hypochlorite-based products are effective for COVID-19 and include liquid (sodium hypochlorite), solid, or powdered (calcium hypochlorite) formulations. These formulations dissolve in water to create a dilute aqueous chlorine solution in which undissociated hypochlorous acid (HOCl) is active as the antimicrobial compound.[24] The cleaning staff should wear appropriate PPE in the form of disposable rubber boots, gloves, and a triple layer mask and proceed from low-touch or clean to high-touch or dirtier areas.Patients should be encouraged to avoid frequent patient visits to the hospital and resort to virtual consultation via telemedicine wherever feasible to curb COVID transmission.[28]Display boards depicting hand hygiene, cough etiquettes, physical distancing, and other precautions for COVID-19 should be displayed vividly in the reception area.[29]Educate healthcare staff and ancillary staff like housekeepers on appropriate infection control practices for COVID-19 simultaneously ensuring adequate PPE for all staff. Ensure vaccination of all healthcare staff.{Table 1}{Table 2}

Use of PPE during dermatologic surgery

SARS-CoV-2 is a novel virus and despite screening or testing, some patients will be harboring the infection. The screening tests are not 100% sensitive and it is reported that asymptomatic patients or those testing negative might be incubating the virus and are capable of disease transmission.[30] Often dermatologists will be working in close proximity to the patients for a prolonged time. It is prudent to consider every case as a potential covid carrier while doing procedures.

PPEs are protective clothing and equipment designed to protect both the healthcare workers (HCWs) and patients from exposure to infectious agents, and to reduce the transmission of infectious microorganisms in the healthcare facilities.[5] The components of PPE from top to bottom are headcover, goggles, face shield, masks or respirators, gloves, coverall/gowns, and shoe cover or boots. The order for putting on is gown/coverall followed by mask/respirator, eye protection, and gloves. When the gown/coverall is put on, no skin should be exposed. The order to remove is to remove gloves, followed by hand hygiene with alcohol rub, followed by removal of gown, eye protection, respirator/mask, and followed by hand hygiene again with soap and water.[31] Discard disposable items in a closed bin; put reusable items in a dry closed container. It should be noted that a full PPE kit is not necessary for all dermatosurgical procedures, but for high-risk procedures. Adequate PPE should be made available for all HCWs in the operating room with a separate donning and doffing area.

CDC recommends N95 masks or FFP2 masks to be worn by all healthcare workers in hospitals.[32] N95 masks or respirators, named for their ability to filter 95% or more of tiny 0.3-μm particles, are the mainstay of protection against SARS-CoV-2.[33] Such masks are designed to achieve a very close facial fit providing the requisite facial seal to the wearer. The use of cotton cloth masks or medical masks as an alternative is not considered appropriate for the protection of the HCWs. The patient should also be wearing a mask preferably an N95 mask in the procedure room. In the absence of an N95 mask, CDC encourages a double mask for the general public wherein a medical procedure mask can be layered underneath a cloth mask for improved fit and filtration and enhance mask performance.[34],[35] It should be remembered that mask or any other component of PPE does not work in isolation and the correct combination of PPE along with other measures like physical distancing and sanitization is of paramount importance in individual protection. Recommended PPE based on the risk of exposure in dermatologic surgery and best practices while wearing an N95 mask have been outlined in [Table 3] and [Table 4], respectively.{Table 3}{Table 4}

Pre-procedure precautions

Screen patients again on the day of surgery for fever, upper respiratory symptoms, history of travel, or exposure to COVID-19 in the past 14 days. Patients should sign a declaration form mentioning the same.[37]Patients who turn up without masks should be provided a three-layered surgical mask at the entry.[15]Obtain consent from the patient including the possible risk of hospital-acquired COVID-19 infection.[38]Avoid accompanying attendants with the patient, and if required, only one attendant may be allowed.[22]

Standard precautions in the operating room

Both doctor and patient should avoid carrying wallets, mobile phones, watches, belts, rings, and bangles to procedure rooms.[15]Limit the number of medical assistants during the procedure. All participating healthcare workers should use recommended PPE based on the risk of exposure.[39]Ensure that the patient is wearing a well-fitted three-layered surgical mask during the surgical procedure unless the procedure is on the face or oral or nasal mucosa.[37]Use disposable linen and drapes for each patient.[40]To minimize fomite transmission, the operating room should have only essential equipment needed for the procedure. All other nonessential equipment and furniture should be removed.[41]The operation theaters should be negative pressure rooms. If negative pressure rooms are not available, the air conditioning must be turned off and exhaust fans should be working.[42]While using smoke-generating devices like electrocautery machine or laser in the operating room; the use of negative pressure ventilation, smoke evacuator, and ultra-low particulate air filters have been recommended.[43]Aerosolized particles of SARS-CoV-2 remain suspended in the air for minutes to hours.[44] Wherever possible, schedule one procedure in a day in a procedure room. In case of multiple procedures, space out procedures after thorough disinfection of the procedure room and surfaces.It is ideal to cover machine surfaces and handpieces of devices in plastic wraps to avoid contamination. Put a fresh plastic covering on the handpiece after each patient.[14]Use disposable instruments as far as possible. Surgical equipment used for known COVID-19 positive or those under investigation should be cleaned separately from other surgical equipment. These can be disinfected with 0.1% sodium hypochlorite or 60–70% ethanol, which significantly reduces coronavirus viral count on surfaces within 1 min exposure time, followed by routine autoclaving.[15] Coronaviruses do not remain active at temperatures higher than 86°F (30°C), which makes standard autoclaving procedures admissible.[45]Prefer dissolving sutures and cyanoacrylate glue for surgical closure to minimize multiple presentations to the hospital in the postoperative period.[43]Use long-lasting dressings like silver-impregnated or hydrocolloid dressings with proper patient education regarding wound care procedures to avoid repeated hospital visits.[46]In case of a suspected or confirmed COVID-19 patient, take up the case preferably last in the list. The operating room should be closed after the procedure and appropriately disinfected.One should always be aware of the inflammable nature of hand rubs as the use of electrocautery, radiofrequency, or carbon dioxide laser in presence of inflammable materials can result in a fire accident.

Postoperative

Virtual or online consultations for postoperative consultations should be resorted to, whenever feasible; including addressing any postoperative complication or delivering the patient's reports.Disinfect the procedure room with EPA-approved disinfectants as outlined in [Table 2]. SARS-CoV-2 is stable for hours on surfaces such as metal, glass, paper, or plastic for as long as 5 days, even reported up to 9 days.[14] Hence, the dermatosurgery operation theater including equipment will need thorough disinfection in between patients.[43]The disposal of biomedical waste and used materials should be strictly followed as per the Biomedical Waste Management Rules 2016.[47]Chemical disinfection of the waste bins using hypochlorite solution (1–2%) should be done frequently at a separate washing facility in the clinic, preferably daily or at least once a week.[15]

 Conclusion



With the uncertainty of the COVID-19 pandemic and the absence of evidence-based recommendations; the role of dermatologists has to be dynamic to evolve and adapt in this unprecedented time. Procedural dermatology and cutaneous aesthetic surgery is a significant component of practice. Many dermatology procedures are day-care elective procedures of short duration and relatively low risk; with the exception of procedures in cutaneous oncology or labor-intensive procedures like hair transplant or plume-generating procedures. Most dermatology departments have their own dedicated outpatient theaters or procedural rooms, and with appropriate infection control practices, restructuring of services, and the correct PPE, safe dermatosurgical care can be delivered to patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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