Recommendations for Dermatology Office Reopening in the Era of COVID-19

July 2020 | Volume 19 | Issue 7 | Original Article | 22 | Copyright © July 2020

Published online June 26, 2020

Suleima Arruda MDa, Doris Hexsel MDb, Tingsong Lim MDc, Heidi A. Waldorf MDd, Ofir Artzi MDe, Whosung Choi MDf, Sahar Ghana MD PhDg, Huang Gaomin MDh, Wilson Ho MDI, Maria Cristina Puyat MDj, Elena Rossi MDk, Ava Shamban MDl, Sonja Sattler MDm, Neil Sadick MDn

aArruda Dermatology, Sao Paulo, Brazil bBrazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil cClique Clinic, Kuala Lumpur, Malaysia dWaldorf Dermatology Aesthetics, Nanuet, NY; Icahn School of Medicine of Mount Sinai, New York, NY eTel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel fPiena Aesthetic Clinic, Seoul, Korea gAlexandria University, Alexandria, Egypt; Sahar Polyclinic, Salmiya, Kuwait hShanghai WanTian Cosmetic Medical Management Consultancy, Shanghai, China iThe Specialists: Lasers, Aesthetic and Plastic Surgery, Central, Hong Kong jRizal Medical Center, Pasig, Philippines kHead and Neck Skin Cancer Service, Modena, Italy; Reggio Emilia University, Modena, Italy lAva MD, Santa Monica, CA; SKIN FIVE, Los Angeles, CA mRosenpark Klinik GmbH, Clinic for Aesthetic Dermatologic Surgery and Plastic Surgery, Darmstadt, Germany, nWeill Cornell College of Medicine, New York, NY

• E-visits, for digital evaluation and medication management. For these visit patients must be established, enrolled, and active in the patient portal and have had an appointment in the past one year.
• Evaluation of recorded video and/or images submitted by an established patient that includes interpretation with follow- up with the patient within 24 business hours. This visit is unrelated to services provided within the previous 7 days and does not lead to an e-visit or in person visit within the next week.
• Virtual consultations for new medical or cosmetic dermatology patients are also an option for some practices. Practices may wish to allow time for a second shorter in-office evaluation immediately before performing an aesthetic procedure on any patient seen only virtually.
• Patients should be advised that virtual visits do not replace the need for an in-office appointment at a time when safety standards allow.

In the experts’ experience, onboarding patients and even physicians on telemedicine platforms has a steep learning curve, which can frustrate patients and support staff. However, minimal training is required to use it for straight forward medical follow ups and counseling. Before the visit, which lasts an average of 15 minutes, medical information and photographs are sent to the physician. After the interaction, the patient chart is completed as it would be during an in-person visit with history, evaluation, assessment, and plan. While telemedicine is currently built as a physician platform, it can also be used by nursing staff within the telemedicine model to mimic a standard in-person encounter. Aesthetic consultations may also be conducted virtually in this manner. Collectively, the experts feel that being an early adopter of telemedicine may have long-term benefits for patients who find it physically difficult to attend routine appointments due to health or distance, and for the practice’s ability to increase the number of patients served. Effective implementation requires clinician and patient enthusiasm and organization but can be leveraged as an effective channel for patient care during this challenging time.

Forms and Questionnaires
Forms and questionnaires including preregistration data collection, health information, preoperative instructions, and informed consent, must be updated to include pertinent information relating to the SARS-CoV-2 virus. In order to avoid unnecessary patient anxiety, these forms should be kept as simple, clear, and concise as possible. Important screening information such as a diagnosis of COVID-19, the presence of COVID-19-like symptoms, recent travel, and the health of contacts is easily captured through simple verbal or written questionnaire and can be used to determine whether a patient can be seen in-office, must reschedule at a later date, or should be switched to a virtual visit (Table 1). These screening questions are generally based upon standard World Health Organization definitions and should be updated with additional signs and symptoms as new knowledge arises.

Per one expert, the Israel health ministry released a “patient risk score scale” to be used prior to scheduling healthcare visits to determine the patient’s risk of morbidity or mortality with a COVID- 19 infection. However, such a measure has not been adopted internationally, and some of the experts feel this is an issue that should be determined by the individual patient and his or her general medicine physician, not dermatologist (Table 2). Certainly, any patient known to be COVID-10 positive or recently exposed to a COVID-19 positive patient, should be rescheduled. However, even asymptomatic and ‘risk-free’ patients should be approached as though they could be COVID-19 positive, just as with other universal precautions.

Physical/Equipment Considerations
SARS-CoV-2 is transmitted through microdroplets and aerosol: its diffusion occurs through coughing, sneezing, and saliva, and infection entry points are the mouth, nose, and eyes.11 Because both asymptomatic patients in the incubation phase and healthy carriers can transmit the virus, even pre-screened