Box 1: Special features of dermatosurgical procedures

1. Most dermatosurgical procedures are day care procedures and often less invasive

2. Often, they need multiple sessions and hence repeated visits to the clinic

3. Only few are considered essential (e.g., biopsy, skin cancer, treatment of infectious conditions such as viral warts, molluscum contagiosum, and abscess)

4. Many are considered as cosmetic treatments

5. Some are associated with plumes and aerosol (e.g., electrocautery, ablative radiofrequency [RF], ablative laser, dermabrasion, and follicular unit extraction [FUE] hair transplantation)

6. Many of them are on the face and hence exposure to nose and throat is likely

7. Many of them need prolonged period, even hours (e.g., vitiligo surgery, hair transplantation, liposuction, and autologous fat graft)

8. Some surgeries need multiple assistants (e.g., hair transplantation)

It is also important to understand that although dermatosurgical procedures may be minor, emergencies can occur during any procedure, which may need interventions such as resuscitation and intubation. These need to be considered seriously while choosing to perform such procedures.

Objectives of this document and disclaimer

This document aimed to outline best practices that can be followed in the scenario of COVID-19 pandemic to perform procedures. It is important to note that these recommendations are being drafted in the light of limited Indian experience and based on the experience in other countries, and hence need to be considered provisional and could change in future. These will serve only as a guide and do not include every possible measure needed. The treating dermatosurgeon will have to consider each case on its merit and take precautions and adopt procedures as needed. These recommendations will not limit the dermatosurgeon from taking any additional precautions for the patient as he/she deems necessary or as advised by the local health authorities. In summary, these recommendations are minimum recommendations, in the light of current evidence available or based on expert opinion, but subject to change and modifications. Also, these guidelines are subject to guidelines and instructions issued by appropriate governmental agencies in that particular geographical COVID zones, and where these guidelines are in conflict, the governmental guidelines will take precedence. Neither the authors nor Association of Cutaneous Surgeons (India) (ACS(I)) nor Journal of Cutaneous and Aesthetic Surgery (JCAS) will be liable for any medicolegal issues that may arise out of adopting these recommendations.

Mode of virus transmission

SARS-CoV2 is transmitted through respiratory droplets (size, >5–10 microns) and physical contact routes.[45] A person in close contact (<1 m) with a patient having symptoms such as sneezing and/or coughing is at risk, with the possibility of his/her oronasal mucosae and conjunctivae getting exposed to potentially infective droplets. Fomites and the immediate environment of the infected person can also transmit the infection.[6] Airborne transmission is not proven yet. According to a recent publication in the New England Journal of Medicine (NEJM), experimentally generated aerosol in the COVID-19 patient’s vicinity showed persistence of virus for 3h.[7] Being an experimentally generated aerosol, this finding does not reflect the clinical setting, in which aerosol generating procedures are performed. Transmission via skin has not been documented.

Risk of viral transmission in dermatology clinics

The virus is not dermatotropic and transmission via skin has not been documented. However, viral transmission can occur during performance of dermatosurgical procedure by the above routes. Hence dermatology clinics and outpatient departments should develop appropriate preventive measures.[8] The fomites, which may transmit the virus in the clinic or hospital, are enumerated in Box 2. Table 1 shows the persistence of the virus on different surfaces.[9]

Box 2: Fomites, which may transmit the virus in the clinic or hospital

• Reception desk, landline, and mobile phones at the reception

• Currency, card swipe machine

• Armrests of chairs–sofa, magazines, newspapers, brochures

• Old prescriptions or files that patients carry

• Examination bed, bedcover, and so on

• Patient chair in waiting areas and consultation rooms

• Magnifying glass, dermatoscope, headlights

• Laptop, desktop

• Remote controls

• Devices and their keys

• Elevator panel, staircase handle bars, door knobs

• Electrical switch board

• Employee biometric machines

• Doors and the mesh of ultraviolet (UV) chambers

• And many such things, where there is a possibility of patient touching with hands

Office procedures in the clinic, minor, and major operating theaters (OT) pose additional risks, both for the healthcare worker (HCW) and the patient undergoing the procedure. This risk is due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. Aerosols with diameter of 5 microns can remain suspended for long period, especially in closed environments and in high viral concentrations, and can gain entry into respiratory tract.

Most dermatosurgical procedures are minor and done in day care theater. Some procedures need magnification such as hair transplantation, which poses additional challenge, necessitating modifications in the face shield for the surgeon. These can be performed with proper PPE and risk stratification, to be explained later.

Major surgeries needing general anesthesia and intubation are rarely performed in dermatosurgical practice. However, if they are planned, these should be performed in a major theater, as dermatosurgical theater is not equipped in the same way as a standard theater in a tertiary care hospital. High-efficiency particulate air (HEPA) respirators/filters are at least 99.97% efficient in removing particles ≥0.3 μm in diameter.[10] Social distancing is difficult to adopt and using shields or even masks may not be feasible when major surgeries are to be done on the face.

Social (physical) distancing

Social distancing means keeping space between yourself and other people outside of your home.[1213] The authors feel this is better termed as physical distancing in the context of procedures. Physical (social) distancing helps limit contact with infected people and contaminated surfaces. New study, published in the journal Science, documents that for every confirmed case of COVID-19 there are likely another five to 10 people with undetected infections.[14]

To practice social or physical distancing stay at least 1 m (3 feet) from other people.[15]

Physical (social) distancing practice at different places of clinic is mentioned as following:

Box 3: List of disinfectants approved for use for COVID-19

1. 70% ethyl alcohol

2. Isopropyl alcohol

3. Sodium hypochlorite solution, 0.5%–1% (5000ppm to disinfect surfaces)

4. Hydrogen peroxide

5. Quaternary ammonium

6. Citric acid

7. Chlorine dioxide

8. Peroxyacetic acid

9. Glutaraldehyde

   • High contact surfaces such as elevator buttons, handrails/handles and call buttons, public counters, intercom systems, equipment such as telephone, printers/scanners, and other office machines should be cleaned twice daily by mopping with a linen/absorbable cloth soaked in 1% sodium hypochlorite. Frequently touched areas such as tabletops, chair handles, pens, diary files, keyboards, mouse, mouse pad, and tea/coffee dispensing machines should specially be cleaned.

   • For metallic surfaces such as door handles, security locks, and keys, 70% alcohol can be used to wipe down the surfaces where the use of bleach is not suitable.

   • Carefully clean the equipment used in cleaning at the end of the cleaning process.

   • If available or feasible, it is preferable to fumigate all patient contact areas, like it is done for operation theater.

Disposal of biomedical waste

The disposal of biomedical waste should be strictly followed as per the Biomedical Waste Management Rules 2016.[17] The bags used for storing and transporting biomedical waste shall be in compliance with the Bureau of Indian Standards. Yellow, blue, red, and translucent bags/bins/containers are marked with biohazard symbol, hospital logo, and with bar coding to be supplied by common biomedical waste treatment and disposal facility. Chemical disinfection of the waste bins using hypochlorite solution (1%–2%) should be done frequently at a separate washing facility in the clinic, daily preferably, at least once a week.

Sanitary (housekeeping) workers must use separate set of cleaning equipment for toilets (mops and nylon scrubber) and separate set for sink and commode. They should always wear disposable protective gloves while cleaning a toilet. It is advisable to use sodium hypochlorite 1% and detergent soap powder with long handle angular brush for cleaning the toilet area. Always use freshly prepared 1% sodium hypochlorite as it becomes almost ineffective 24h after preparation.

Daily all the clothes, cloth masks should be soaked in 0.5% sodium hypochlorite solution for 15 min, and then immediately washed with soap and water. They should be dried in open terrace. Face shield should be dipped in soap water for 10 min, and washed and dried for use on next day.

Sodium hypochlorite is available in the strength of 5% solution. To prepare 1% sodium hypochlorite solution, add 10 mL of 5% sodium hypochlorite solution to 1L of cold water. Do not expose the solution to sunlight as it is rendered ineffective. Do not mix sodium hypochlorite to soap water or detergent as toxic gases may be produced.

Hand hygiene

Contact transmission occurs when contaminated hands touch the mucosa of the mouth, nose, or eyes; the virus can also be transferred from one surface to another by contaminated hands, which facilitates indirect contact transmission. Consequently, hand hygiene is extremely important to prevent the spread of the COVID-19 virus. It also interrupts the transmission of other viruses and bacteria causing common cold, flu, and pneumonia, thus reducing the general burden of disease. Hand hygiene is the most effective single measure to reduce the spread of infections through multimodal strategies. HCWs should perform hand hygiene using the proper technique and according to the instructions known as “My 5 moments for hand hygiene,” in particular,

• Before putting on PPE and after removing it

• When changing gloves

• After any contact with a patient with suspected or confirmed COVID-19 virus, their waste, or the environment in the patients’ immediate surroundings, after contact with any respiratory secretions

• Before food preparation and eating

• After using the toilet[18]

Hand sanitizers

Centers for Disease Control and Prevention (CDC) recommends the use of alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol as the preferred form of hand hygiene in HCWs.[19] Apply the label-recommended amount of the product into the palm of your hand and rub your hands together, covering all surfaces, as you would do normally when washing. Allow the sanitizer to dry completely before you touch anything [Figure 1]. Hand sanitizing stations should be installed in reception area (especially at the entry) and near high contact surfaces.

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Figure 1

Hand sanitizing method with sanitizer. (Image adopted from https://www.who.int/gpsc/5may/hh-relay-procedure.pdf?ua=1)

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PPE

PPE are protective clothing and equipment designed to protect both HCWs and patients from exposure to infectious agents, and to reduce the transmission of infectious microorganisms in healthcare facilities. PPE should be South India Textile Research Association (SITRA) tested and certified.

Components of PPE

Components of PPE from top to bottom are head cover, goggles, face shield, masks or respirators, gloves, coverall/gowns (with or without aprons), and shoe cover or boots. It also includes drapes for covering the patients.

Masks: They are the most important component of PPE because SARS-CoV2 targets the upper and lower respiratory tract. Triple-layer fluid-resistant medical mask and N95 respirator mask are the recommended masks. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit. The use of cotton cloth masks as an alternative is not considered appropriate for protection of HCWs as the quality differs widely.[20] CDC[21] and Government of India[22] advise even homemade cloth face coverings to overcome shortages. Hence, patients attending the clinic or hospital should be advised or instructed to wear them before entering the healthcare facility. There is no uniform opinion as to what kind of masks are to be used and how long they can be used. N95 masks are recommended, but are in short supply; hence, an additional cheaper mask can be used on top of the N95 mask so that N95 mask can be reused. Figure 2 presents the right way to wear and remove N95 masks.

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Figure 2

How to wear and remove N95 masks

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Gloves: Latex gloves are adequate for examination and performance of procedures. Nitrile gloves are preferred for housekeeping staff, over latex gloves, as they are resistant to damage by chemicals such as chlorine, which may be used as disinfectants, and are hypoallergenic. Avoid powdered gloves.

Face shield and goggles: Aerosol-generating procedures in dermatology such as dermabrasion, RF ablation, and ablative laser surgery can cause contamination of mucous membranes of the eyes, nose, and mouth of the HCW, and transmit infection. A full-face shield or visor or a surgical mask with integrated visor should be used in such a scenario. However, inadvertently touching the eyes/nose/mouth with a contaminated hand is a likely scenario. Hence, protection of the mucous membranes of the eyes/nose/mouth by using face shields/goggles is recommended as an integral part of standard and contact precautions.

Coverall gowns: They are to be used if there is a risk of fluids or blood from the patient splashing onto the HCW’s body, and hence they are not routinely needed. A plastic apron can also be worn over the gown for the entire time the health worker is in the treatment area if splashes are expected. In dermatology clinics, gowns/overall may be used for aerosol-generating procedures.

Head covers: Coveralls usually cover the head. Hair and hair extensions should fit inside the head cover. This is needed only if a COVID-19-positive patient is being treated.

Shoe covers/boots: Shoe covers should be made up of impermeable fabric and should be used over shoes to facilitate personal protection and decontamination.

How to put on PPE—donning

Before donning, the HCW should have eaten, should be well hydrated, and should have gone to the washroom.[2526] All jewelry should be removed. The hair should be tied back. Check if the correct size of PPE is available. The donning should be done before entering the patient’s room. The order for putting on is gown/coverall followed by mask/respirator, eye protection, and gloves [Figure 3]. When the gown/coverall is put on, no skin should be exposed. If the respirator is not a good fit, DO NOT PROCEED.

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Figure 3

Donning of PPE. (Adapted from www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures.)

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How to remove PPE—doffing

The PPE should be removed in such a way that contamination is minimized.[2526] It should be done either before exiting the patient’s room or in a dedicated room for doffing. Remove plastic apron, if worn. The order 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 [Figure 4]. Discard disposable items in a closed rubbish bin; put reusable items in a dry closed container.

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Figure 4

Doffing of PPE. (Adapted from www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures)

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Disinfection of instruments

Use disposable equipment wherever and whenever feasible such as disposable biopsy punches and ear buds for the application of peels or for chemical cautery. Table 3 enumerates the preferred disinfection methods of various instruments used in dermatology clinic.

Training the clinic staff

Educate the staff about COVID-19, and why it is important to contain the outbreak. They have to be trained on the policies and practices to minimize the spread of infection. A task-specific training can be given to them on preventing spread of infectious agents. Educate staff on how to advise patients about changes in office procedures (e.g., calling before arrival if the patient has any signs of a respiratory infection and taking appropriate preventive actions). Ensure that the clinical assistants know the right way to use and take off PPE safely.

Staff should be made aware about them being quarantined if they are exposed to COVID-19.

Risk of SARS-CoV2 transmission

Below is the general risk stratification for different cutaneous procedures and surgeries. It has to be stated here that all cutaneous procedures are of considerably low risk as compared to surgeries in other specialties such as dental, ENT, and general surgery, so the categories mentioned below are not comparable to the terminologies used in other specialties, and this should be taken in this context. This categorization is specific only for cutaneous surgeries.

Urgency of the procedures

1. Surgery for minimally symptomatic or asymptomatic benign lesions, such as cysts, lipomas, acrochordons, scars, and keloids, should be deferred till governmental agencies state that elective surgeries can be performed.[29]

2. Non-life-threatening skin cancers (e.g., BCC, DFSP), which are slowly progressive and are not likely to cause severe functioning impairments, may be either treated by cryosurgery or noninvasive means or postponed if feasible based on the individual situation.

3. Skin cancers needing urgent intervention include squamous cell carcinoma and melanoma. These should be taken up as early as possible with all protective measures and protocols.

Risk of aerosol generation during the procedure

The procedures, which generate aerosol in the minor operating room, should be performed with appropriate PPE. These procedures include RF ablation, dermabrasion, microdermabrasion, and ablative lasers. Wherever feasible, these procedures can be replaced by cryosurgery or scalpel excision or nonablative procedures. Where minor aerosol is generated, such as a small wart, a smoke evacuator should be used and the treating doctor should wear a shield. The power setting of RF machine should be as low as possible.[30]

Patient selection

All patients symptomatic for flu symptoms should not be taken for surgery even if negative for SARS-CoV2.

All the patients taken up for procedures should be screened for SARS-CoV2. Patient will have to be screened for:

1. COVID-19 symptoms[31]

2. Exposure to a proven case of COVID-19

3. Travel to a hotspot of COVID-19

Any patient having a positive history to any of the aforementioned would have to have their procedure deferred for 3 weeks. Negative patients can be considered for the procedure and be taken for testing. Aarogya Setu app has also been recommended by the Government of India as a method of screening.

Testing options

As stated earlier, dermatosurgical practice has to adapt to the challenge like it did in the Hepatitis B and HIV scenarios. One way to do is to perform proper testing before conducting the procedure. However, rapid testing is either not available freely or is expensive. However, in the near future, it is expected that rapid testing becomes more easily available and accessible. In such a scenario, it would be possible to perform procedures after appropriate testing. Testing is subject to governmental regulations and are subject to changes. Surgeons are advised to follow their concerned state governmental guidelines.

Polymerase chain reaction testing: PCR tests the antigen or viral load. It is taken from a nasal swab or cough expectorant. It is positive in the first week of the illness and then becomes negative as the patient recovers. It is a sign of active infection. In one study, asymptomatic patients had swab positivity for a total duration of 18 days.[32] Diagnostic test sensitivity was shown to be 54% at 8–14 days by PCR technique [Table 4].[33] Strategy for COVID-19 testing in India recommended by ICMR[34]:

1. All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days.

2. All symptomatic (ILI symptoms) contacts of laboratory confirmed cases.

3. All symptomatic (ILI symptoms) health care workers/frontline workers involved in containment and mitigation of COVID-19.

4. All patients of Severe Acute Respiratory Infection (SARI).

5. Asymptomatic direct and high-risk contacts of a confirmed case to be tested once between day 5 and day 10 of coming into contact.

6. All symptomatic ILI within hotspots/containment zones.

7. All hospitalised patients who develop ILI symptoms.

8. All symptomatic ILI among returnees and migrants within 7 days of illness.

9. No emergency procedure (including deliveries) should be delayed for lack of testing.

NB: ILI case is defined as one with acute respiratory infection with fever = 38°C AND cough. SARI case is defined as one with acute respiratory infection with fever = 38°C AND cough AND requiring hospitalization. All testing in the above categories is recommended by real time RT-PCR test only.

Once this test becomes available freely, PCR immediately before the procedure can be considered for taking up the patient for surgery. However, the current cost of this test precludes its use for minor surgeries where cost of testing may be more than or equal to the cost of the procedure itself. However, for procedures such as hair transplantation, vitiligo surgery, extensive body hair removal, and liposuction, such testing can be considered, in areas where governmental regulations allow nonessential procedures to be performed.

Special informed consent will have to be obtained both for surgery and for testing. Table 4 shows the sensitivities of different tests.

HCWs

Testing for clinic staff has not been recommended by ICMR. Hence, proper screening as aforementioned should be done.

General safety recommendations

• Paperwork should be minimized, and all forms should be preferably electronic.

• Patient should be counseled and prepped for the procedure.

• Minimum essential manpower should be inside the minor operating room. Trainee doctors should be in another room where a television set may be provided connected with Wi-Fi. The livestreaming of the procedure on television screen is possible using an ordinary smartphone.

• Procedures to be performed in well-ventilated room, avoiding air-conditioned (AC) rooms. Procedures should be spaced out.

• To minimize fomite transmission, the operating room should have only those equipment, which are needed for the patient. All other nonessential equipment and furniture should be removed.

• All patients should be assumed to be asymptomatic COVID-19 patient and should be given masks even if tested negative for SARS-CoV2, to prevent them getting infection or vice versa if they are in incubation period.

• HCW should wear goggles, mask, and gloves. Wear face shields while performing procedures on the face.

• Both the patient and the doctor should minimize contact with surfaces. Both doctor and patient should avoid carrying wallets, mobile phones, watches, belts, rings, bangles, and bindis to procedure rooms.

• Minimize the use of handheld mirrors and marking pens. Marking pens can be cleaned with spirit in between procedures.

• Use plume evacuation systems, preferably with filters that remove particulates to 0.1 microns known as ultralow particulate air filters (HEPA or ULPA filter). Avoid nonmedical-grade fume evacuators and vacuum cleaners for fume evacuation.

• Follow-up visit can be made infrequent and need-based, patient should be advised sufficiently with all precautions to prevent possible postsurgical complications such as gaping of the wound, wetting of the wound, and excessive use of the operated part. Unless the patient develops some warning signs of complications, such as excessive pain, oozing or pus discharge from surgical site, hematoma formation, bleeding, and excessive swelling, in the follow-up of excisional procedures, the patient can come directly on the day of suture removal.

• All the used materials should be disposed properly according to recommendations.

• In between procedures, examination beds, countertop, doorknobs, and examination light buttons/handles should be wiped with products, which are approved by World Health Organization (WHO) for disinfecting surfaces.

Special considerations for each type of procedure

Box 4: Probable protocols for aesthetic procedures

There are four key factors that need to be addressed to conduct minimally invasive procedure conduction in COVID era, which are as follows:

1. Rule regarding proximity of patient with physician while conducting procedure: This can be addressed by the use of full body cover by physician for any procedure, especially aerosol-generating procedures. Full body cover for assistant in procedure room is also mandatory.

2. Contact of device to the patient: Here all the protocol regarding disinfection of the movable and immovable device to be undertaken as listed in Table 3.

3. Room/chair or bed of procedure has to be sanitized in between patients. Also having multiple procedure rooms would be an added advantage here, as it gives time and space between sanitization.

4. Patient undergoing the procedure: Once the proximity rules with full-body cover, device, and room sterility in between procedures are achieved, then the patient factor is crucial and at the discretion of physician and patient with proper consent to conduct procedures.

Laser procedures

Airborne contaminants are associated with certain lasers such as ablative fractional lasers, high-peak power ultrashort-pulsed lasers such as nano- and picosecond lasers.[40] Apart from airborne contaminants, one has to take care of lasers with contact cooling handpiece such as diode laser where the tip can come in contact near the mucosal areas such as upper lip and chin. It should be clarified here that risk due to aerosol after laser or RF procedures is considerably less than aerosol due to mechanical drilling procedure as the heat generated by the tissue interaction with these devices is likely to be inimical to the virus. Other devices such as excimer lamp and skin-tightening devices, all have probes that come in close contact with the skin. Thorough cleaning of the tip is mandatory in the setting of COVID-19. Microneedle radiofrequency (MNRF) devices do cause pinpoint bleeding, and they can increase the risk to medical personnel.[41]

It is best to postpone cosmetic laser surgery until the governmental agencies allow nonessential procedures to be performed.

1. While performing, modifications such as the use of shield and smoke evacuators need to be used.

2. Sterilize laser handpieces before and after every use. In case of contact lasers such as diode, excimer lamp, or RF, better to use disposable cling wrap for handpiece. The laser body can be sterilized with any one of the approved disinfectants. Considering the cost-effectiveness, sodium hypochlorite solution should be sprayed on laser equipment, but protecting the optics. The laser optics can be cleaned with isopropyl alcohol or 70% ethyl alcohol. Patient bed and laser room should be sprayed with sodium hypochlorite solution in between and after each procedure.

3. It is best to surgically prepare the area to be treated with proper disinfection such as ethyl alcohol. It is best to wait for 15 min after preparation, and clean the area again with water, so as to avoid potential burns because of disinfectants or sanitizers containing alcohol. Risk stratification for energy-based devices is given in Tables 7 and 8.

Phototherapy

Phototherapy using closed chamber poses special risks.

Phototherapy should be by appointment alone. Ask the patient to use mask while entering the chamber and use hand sanitizers before entering and at the time of leaving the cubicle. Patients are encouraged to buy their own protective goggles and use them. The staff should disinfect the high touch areas such as handles between the patients. Risk categorization for different types of phototherapy is enumerated in Table 9.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.