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

in-office patient contacts should be approached as potentially infectious.12 The virus can remain viable and infectious in aerosols for hours and on surfaces up to several days (depending on the inoculum shed and surface material).13 Exposure distance less than 6 feet, duration greater than 15 minutes, and/or contact with a contaminated surface or airborne particles presents high risk for infection. Given these facts, physical space needs to be redesigned to reduce the risk of contamination and contact for both staff and patients. Prior to the pandemic, the modern medical office had transformed from the traditional cold, clinical setting to a warm, welcoming environment where patients were encouraged to relax prior to the visit, with refreshments, samples, and reading materials at their disposal. In the COVID-19 era however, the physical space must be stripped from anything redundant and separated into clearly demarcated areas:

• Barriers, such as glass or acrylic ‘sneeze shields’ may be placed to protect reception staff from incoming and outgoing patients.
• Hand sanitizers should be prominently placed for patient use on office entry and throughout the office including utilized areas of the waiting room, lavatories, and treatment rooms. Hands-free units (electronic or foot pedal) are ideal to avoid cross contamination.
• Remove magazines, pens, blankets, pillows, toys, promotional or any reading materials, and skincare samples, and block off refreshment areas and coat closets to discourage contamination by patient contact.
• Patient waiting areas should be closed, or, if in use, provide seating separated by standards of physical distancing.
• All workstations must be rearranged to provide safe physical distance between staff members.
• Adding an air circulation and filtering system such as one including HEPA filters and UVC irradiation in current HVAC systems or adding portable devices may be useful in some environments.
• Decontamination and disinfection supplies should be accessible in every room to facilitate sanitizing surfaces before and after each patient visit. Lipid solvents such as ether, 75% ethanol, and disinfectants containing chlorine (hypochlorous acid), peracetic acid, and chloroform are recommended to inactivate and destroy pathogens from any surface. A list of disinfectants approved against SARS-CoV-2 can be found online in each countries environmental protection agency website.14
• Treatment room contents must be minimized. Remove brochures, extra pillows, blankets, and other non-essential items that cannot be stored within a closed cabinet or drawer. These materials may be brought into the room on an as needed basis for individual patients. If office space is limited, disposable covers are an option to protect equipment not in use.
• Invest in smoke evacuator units for procedures that produce a plume such as electrocauterization, laser (including ablative and non-ablative resurfacing, laser hair removal, tattoo removal). The smoke capture device should be held less than 1 inch away from the treatment site to achieve efficient evacuation.
• Provide no-touch waste containers with disposable liners in all reception, waiting, patient care, and restroom areas. All waste receptacles should be clearly labeled as biohazard or regular per government regulations.

PPE Staff/Physician Considerations
The type of PPE (masks, gloves, goggles, shoe covers, face shields, jackets, or other body coverings) required for each staff member will depend on the anticipated risk of exposure while performing their job responsibilities. In the USA, every office must have written Occupational Safety and Health Administration (OSHA) regulations and document employee training. Employees may use a higher level of protection but cannot use less than the minimum required to prevent occupational exposure to transmissible pathogens.15 In the USA, the American Society of Testing and Materials (ASTM) rating system is a useful guide to face mask selection and use.16 Government health agencies should be used as a guide in other areas.
• Surgical masks (SMs) can filter particles of 0.04–1.3 μm and are commonly used to physically block particles such as droplets. Their principal limitation is due to poor quality of face fit and the consequent possibility of aerosol aspiration. However, these can be worn by support staff or in all eventualities where there is contact between the patient and other people less than 2 meters away and for more than 15 minutes. These may also be worn by patients to avoid their contaminating environment. The level mask used and whether a ‘home made’ cloth mask is sufficient must be determined based upon the employees' responsibilities
• Filtering-face piece respirators (FFP) such as N95 (USA), KN95 (ASIA), and SPP3 (EUROPE) have filtration efficiencies ranging from 80%–99% and are the most appropriate barriers against aerosol because they provide a tight seal to the facial skin. Staff working in close proximity to or over long duration at the patient’s side need to wear an FFP mask as a minimum. If patient is not wearing a mask because of the treatment performed, the additional use of single use gowns or washable upper body coverage, gloves, and full coverage goggles or a plastic full-face shield is recommended.

Disinfection routines must be rigorously followed including handwashing and changing of contaminated PPE and thorough cleansing of equipment as well as all high-touch areas (bed, chair, tables, door handles, light switches, etc) before and after direct contact with a patient, before any aseptic procedure, after potential exposure to body fluids, and after direct contact to potentially contaminated items or surfaces. In addition to PPE, it is recommended that surgical scrubs or other dedicated office uniforms be worn by all providers and staff in close proximity to