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

o All disposable sheets are removed, and surfaces are disinfected (treatment bed, as well as everything touched by the patient: eg, hand mirror, chair, desk, pen used for signature of the consent form).
o Disposable bed sheets/pillowcase are changed and underlying examination table and manual controls sanitized. o Doorknobs, light switches, tray tables, mayo stands, patient chairs, and all other potential surface areas of contact are sanitized (these areas are sanitized/disinfected – they are not sterilized).
o Surfaces of equipment such as energy-based device surfaces are disinfected.
o All contaminated PPE must be properly removed, cleaned, or disposed of properly with office biohazardous waste and labelled accordingly.
o Rigorous hand hygiene must be performed after glove removal. o The dermatologic surgery theater is disinfected and air is allowed to circulate.
o Staff change uniforms each day (or protective cover/ gown).

Dermatologic Treatments and Risk Tiering
As practices resume operations, the question arises whether dermatologists will be able to provide their full offering of medical and aesthetic care safely and effectively. These offerings must now be perceived through a new lens: the risk of COVID-19. High risk procedures are any aerosol-generating procedures (AGPs), such as those that involve breach of mucosa, and laser-generated plume.18 Until new safety protocols have become smooth, practices may wish to defer procedures that involve the oropharyngeal and nasopharyngeal area, since this is the main route of COVID19 transmission from patient to provider.19 For procedures involving the nasal and/or oral cavity, pre-procedural irrigation with an oral disinfectant solution (1.5% hydrogen peroxide, 0.2% povidone iodine or hypochlorous acid) is advised.20 All providers and staff present during those procedures should be wearing the highest level of PPE described above. In high risk or longer procedures, it might be wise to ask patients to get tested for COVID-19. Some institutions are requiring patients have two negative COVID-19 tests within 24 hours immediately prior to such procedures.

Conclusion and Dermatologic Insights from Around the World
As the pandemic subsides, dermatologists like the rest of society face resumption of previously usual routines now in the most unusual of circumstances. Since the situation will continue to be fluid with ongoing publication of new regulations and guidance from professional societies, federal, state, and local authorities, it is crucial that dermatologists remain alert in order to protect their patients, staff and practice. We must not become over-confident: only time will tell if these safeguards are sufficient. However, experts feel optimistic that overcoming the current challenges will provide the safe and efficient environment our patients expect for dermatologic care. Preparation now will also serve us and our communities if we are every faced with similar circumstances in the future.

United States, Beverly Hills, CA – Ava Shamban
Patients are screened by telephone for prior exposure and any risk factors. A telemedicine appointment is conducted to ascertain exact nature of visit and consents are sent electronically.

Patient arrives and notifies front desk by text or phone call. When patient arrives at the door thermal thermometer is used, hands sanitized, mask is given if not already on. Patients are escorted immediately to their room. Visit is conducted with both patient and provider wearing masks except when perioral area is treated. Checkout, payment, product sales, and future appointment are made in the exam room. Patient departs. Staff is properly screened as described in other protocols. PPE includes cloth hair bonnet, safety googles, N95, scrubs, and disposable shoe coverings. Clothing is removed at the end of the workday and taken home to be laundered. Disposable bed and pillow covers are in place. Medical grade air purifiers are in rooms with appropriate filter and air recirculation frequency. Building to provide superior air filters in building air conditioner. At the end of the visit, Lysol wipes or equivalent are used. Hypochlorous mouth wash is used before perioral injectables. Smoke evacuation to be used with every ablative or fractionated ablative procedure.

United States, New York, NY – Neil Sadick
Sadick Dermatology has two ground-floor clinics and research centers in Manhattan. Since NYC is the US epicenter of the COVID- 19 outbreak in the US, many guidelines and restrictions have been put into place by our state officials. Our focus is to support NYC healthcare and our patients that do not have COVID-19 but still need dermatologic care. For example, complicated cases of psoriasis, infections, and skin cancers with health risks still need in person visits, so we operate with a skeleton staff to serve them. We take safety seriously and follow the OSHA standards to sanitize and clean our offices during the day and between patients. Our staff are up-to-date with the latest guidelines published by the local public health authorities. On a day-to-day basis, patients are swiftly taken to the treatment rooms and they spend minimal, if any, time in the waiting room. We limit the number of patients in the practice, and direct patients to the bathroom to wash hands prior to their visit. Masks are required at all times in the office. We’ve ensured a supply of PPE for our vendors, so we can keep our doors open to our patients that need care. For all other patients, we offer telemedicine consultations, which has been a great success as our patients can make appointments, and get advice and prescriptions filled without coming into the office. Our research group also continues to be busy; we abide to the FDA COVID-19 guidance document for the conduct of clinical trials and keep moving forward by having close communication with our study monitors and sponsors.