Clinical Dermatology Review

DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - REVIEW ARTICLE
Year
: 2021  |  Volume : 5  |  Issue : 1  |  Page : 3--11

Changing the gear of dermatology practice during and after COVID-19 pandemic: Potential problems and their management


BS Chandrashekar, Preethi B Nayak, C Madura 
 Department of Dermatology, CUTIS Academy of Cutaneous Sciences, Bengaluru, Karnataka, India

Correspondence Address:
B S Chandrashekar
Department of Dermatology, CUTIS Academy of Cutaneous Sciences, 5/1, 4th Main MRCR Layout, Vijaya Nagar Bengaluru - 560 040, Karnataka
India

Abstract

COVID-19 since the dawn has changed the way we look at things around us. Medical practice has changed drastically, so is dermatology practice. Clinical and procedural dermatology practice had come to a standstill in India, due to the past COVID-19 situations. With the changing scenario, now it is time for dermatologists as well as dermatology field to sail through these difficult times, with extra care and precautions. According to the latest CDC and ICMR guidelines, we have designed the following proposed guidelines from entrance to exit for the smooth functioning of dermatology institute/hospital/clinic. Potential setbacks related to patient and manpower, their management during COVID-19 pandemic has been reviewed. Potential setbacks related to clinical dermatology practice and procedures, their management during COVID-19 pandemic has been reviewed and briefed. Hard times are usually blessings in disguise; hence, we should utilize this pandemic period to learn and rejuvenate our practice.



How to cite this article:
Chandrashekar B S, Nayak PB, Madura C. Changing the gear of dermatology practice during and after COVID-19 pandemic: Potential problems and their management.Clin Dermatol Rev 2021;5:3-11


How to cite this URL:
Chandrashekar B S, Nayak PB, Madura C. Changing the gear of dermatology practice during and after COVID-19 pandemic: Potential problems and their management. Clin Dermatol Rev [serial online] 2021 [cited 2021 Sep 21 ];5:3-11
Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/3/309751


Full Text



 Introduction



As it goes with famous proverb in Kannada language “Nivaranegintha Nirbandhave Lesu” (Prevention is better than cure!), nowhere it is truer than in today's COVID-19-era.

COVID-19 since the dawn has changed the way we look at things around us. Face masks, social distance, and hand hygiene which were more in books than in practice, has become the new norm. Medical practice has changed drastically, so is dermatology practice. Clinical and procedural dermatology practice had come to a standstill in India, due to the past COVID-19 situations, but with the changing scenario, now it is time for dermatologists as well as dermatology field to sail through these difficult times, with extra care and precautions. Dermatology is considered as a nonemergency branch at one end, but a handful of hair fall or sudden spurt of numerous acne or an irresistible itch to scratch or abrupt eruption of rashes or even weaning off of botox/fillers effect is considered as an emergency by patients at the other end. Out-patient practice and procedural dermatology should go hand in-hand to achieve utmost patient satisfaction, but is it worth putting patient's and our life at stake? or is it ideal to allow quacks to take over dermatology at this time of crisis? If not, how to handle the patients and tackle the present pandemic? These might be the thoughts in the mind of every dermatologist. The aim of this article is to provide a model practice essentials, and to discuss the possible setbacks and hitches which we might face, and its solutions, in turn helping to establish a successful practice in this COVID-19-era.

 Dermatology Practice and COVID-19



It can broadly be classified as

During the pandemicAfter the pandemicLong-term effects of pandemic

 During the Pandemic of COVID-19



The most important measure to be taken during the COVID-19 is strict application of 3-pronged approach in practice.

The 3 prongs in the control of COVID-19 are face mask, hand hygiene, and social distancing:

Face mask: Surgical/N95 mask for hospital staff along with face shield, and cloth mask for patients. There are reports of cloth mask and surgical mask being effective. Hence, we should use our resources rightly; while sitting in outpatient department surgical mask is adequate, cloth mask is sufficient in community and N95 mask should be used only when in contact with aerosol generating procedure and for procedures on the face, neck and scalpHand Hygiene: Use hand rub/wash hands on contact with any items of other person/any other objects, every 1 h use hand rub and every 4–6 h use hand washSocial distancing: Distance of approximately 6 feet (at least 3 feet) should be compulsory, especially when:

Close contact can occur while caring for, visiting, or sharing a healthcare waiting area or room with a patientDirect contact with infectious secretions of a person such as being coughed/sneezed on.

All the doctors, staff, and associated persons should install the Arogya Setu application on their mobile phones which will alert the user about the threat or in case of contact with COVID-19 patient.

 Dermatology Practice COVID-19 Proposed Guidelines



According to the latest CDC and ICMR guidelines, we have designed the following proposed guidelines from entrance to exit for the smooth functioning of dermatology institute/hospital/clinic [Figure 1].{Figure 1}

 Entrance



STRICTLY NO TOUCH policy, no touching of gates/railings/leaning against walls/unnecessary talks after entering hospital premisesNO PATIENT ATTENDER/ACCOMPANYING PERSON except for patients below age of 18 years or very old patients requiring assistance with whom 1 attendant allowed.NO CASE SHEETS/PREVIOUS RECORDS/BAGS (Preferable no mobile phones). The patient can take photograph of previous prescription and mail it prior to the appointment time or show it in mobile phones during the appointmentProviding visual alerts (signs, posters) at entrancesLimiting building access to minimal people at a time, with a door monitor allowing one person inside for each person that exitsImplementing a process of screening staff for fever or respiratory symptoms before entering the facility at the screening deskCreate a clear path from the main door to the clinic, with partitions or other physical barriers (if feasible), to minimize contact with other patients.

 Screening



Symptom and temperature screening, triage of patients at the entrance of the clinic and provision of respiratory protection (masks) and hand rub to patients [Figure 2]Barriers installed to limit contact with patients at triageUSE of N95 masks, FACE-SHIELD, nonsterile gloves and USE HANDRUB while screening every patientPostsigns at the door instructing clinic patients with respiratory illness to return to their vehicles (or remain outside if pedestrians) and call the telephone number of the clinic so that proper triage can be performed before they enter the hospital.{Figure 2}

 Reception



STRICT NO TOUCH POLICYUSE of surgical/N95 mask, FACE-SHIELD, nonsterile gloves, and USE HANDRUBEnsuring supplies are available (tissues, waste receptacles, alcohol-based hand sanitizer)Include text or automated telephone messages/RECPETIONTIONIST SHOULD PERSONALLY SPEAK TO PATIENT and specifically ask sick patients to stay home and request home delivery or send a well family member or friend to pick up their medicineAvoid using other employees' phones, desks, offices, or other work tools and equipment, when possible. If necessary, clean and disinfect them before and after useCreate a barrier of minimum 3 feet distance at the receptionist desk.

 Billing



Use of tape and signs on the groundMaintain social distance while standing in queueONLINE PAYMENT preferredAvoid handling insurance or benefit cards. Instead, have the patients take a picture of the card for processing or read aloud the information that is neededFour box technique to collect cash (use one box for each day and rotate on every 4th day - the virus gets eliminated in 4 days from hard surface).

 Waiting Area/Photography



Patients to be seated in designated area only as instructed by hospital staffArea for spatially separating patients by providing space so that patients would be >6 feet (at least 3 feet) apart in waiting areas [Figure 3]Providing visual alerts (signs, posters) at waiting area, providing instruction on hand hygiene, respiratory hygiene, and cough etiquetteAudio and video instructions of hand wash, social distancing and wearing of mask to staff as well as patients can be played hereReducing crowding in waiting rooms; consider asking patients waiting to be seen to stay outside and away from others or in their vehicles (if appropriate) until they are called into the facility for their appointmentMinimize the patient movement areaWaiting area only for patientSTRICT NO UNNECESSARY TALKS among patientsThe use of Sodium hypochlorite spray in area where the patient was sitting. For hard nonporous surfaces, clean with detergent or soap and water if the surfaces are visibly dirty prior to disinfectant application. Frequently clean and disinfect all patient service counters and patient contact areas. Clean and disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, and doorknobsDiscontinue the use of magazines, mobile charging stations, and other shared items in pharmacy waiting areas. Ensure that the waiting area is cleaned regularlyPromote the use of self-serve checkout registers and clean and disinfect them frequently. Encourage the use of, and have hand sanitizer and disinfectant wipes available at register locations for use by patientsWashroom/Toilet: It has to be sanitized frequently.{Figure 3}

 OPD Consultation Room



USE of surgical/N95 mask and face shield, eye protection goggles (if required), nonsterile glovesUse hand rub between each patient/wash hand on contact with patient/patient articlesSingle patient sitting arrangement/preference to make patient standUse of sodium hypochlorite after each patientMINIMIZE PATIENT CONTACT TIME TO LESS THAN 5 MINSDIGITAL PRESCRIPTION should be preferredTOUCH patient only when necessaryIf dermoscope is used, to sanitize it before and after every patient.Discourage contact/placement of any patient articles on the table/patient bed/chair.

 Procedure Area



Formulate and follow the policies and procedures of your hospital related to illness, cleaning and disinfectionAdvice staff to stay at home if sick, and to get medical care and inform hospital supervisor if you/any staff have a sick family member at home with COVID-19It is preferable to provide disposable caps, masks and shoe cover to all the patientsWash your hands often with soap and water for at least 20 s. Use hand sanitizer with at least 60% alcohol if soap and water are not availableAvoid touching your eyes, nose, and mouth with unwashed hands – face shield prevents thisUse of face shield during procedure should be compulsoryCover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow. Throw used tissues in the trash and immediately wash hands or use hand sanitizerClean AND disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, handrails, and doorknobs. Dirty surfaces can be cleaned with soap and water prior to disinfectionPractice social distancing by avoiding large gatherings and maintaining distance (approximately 6 feet or 2 m) from others when possibleStrategize the movement of hospital staff to procedure rooms, reception area, OT complex, and canteen. Manage social distancing, so that no 2 people is in the same area during a given periodIn procedure rooms, a MAXIMUM OF ONE DOCTOR, ONE TECHNICIAN AND ONE PATIENT at a timeMinimize usage of air conditioners (except for laser rooms) and allow fresh air to circulate if provision is there.

 Laboratory



Follow Standard Precautions when handling clinical specimens, all of which may contain potentially infectious materials. Standard Precautions include hand hygiene and the use of personal protective equipment, such as laboratory coats or gowns, gloves, and eye protectionFollow routine laboratory practices and procedures for decontamination of work surfaces and management of laboratory wasteMinimize patient contact and contact with specimen time.

 Pharmacy



Pharmacists and pharmacy technicians should always wear a facemask while they are in the pharmacy for source controlEveryone entering the pharmacy should wear a face covering, regardless of symptomsFREQUENT USE OF HAND RUBProvide hand sanitizer containing at least 60% alcohol on counters for use by patients and have sufficient and easy access to soap and water or hand sanitizer for staffAvoid touching objects that have been handled by patients. If transfer of items must occur, pharmacy staff should wash their hands afterward with soap and water for at least 20 s or use an alcohol-based hand sanitizer containing at least 60% alcohol. They should always avoid touching their eyes, nose, or mouth with unwashed handsThe pharmacy should develop procedures to avoid handling paper prescriptions or they can ask the patient TO READ PRESCRIPTION ALOUDMinimize physical contact with patients and between patients. Maintain social distancing (6 feet between individuals) for people entering the pharmacy as much as possible. Use signage/barriers and floor markers to instruct waiting patients to remain 6 feet back from the counter, from other patient interfaces, and from other patients and pharmacy staffTo shield against droplets from coughs or sneezes, install a section of clear plastic at the patients contact area to provide barrier protection (e.g., Plexiglas type material or clear plastic sheet). Configure with a pass-through opening at the bottom of the barrier for people to speak through or to provide pharmacy items, if feasibleLimit the number of patients in the pharmacy at any given time to prevent crowding at the pharmacy counter or checkout areasPharmacists who are providing patients with chronic disease management services, medication management services, and other services that do not require face-to-face encounters should make every effort to use telephone, tele-health, or tele-pharmacy strategiesPlace packaged medication on the counter for patients instead of handing it to themFour-box technique can be used for handling cash.Potential setbacks related to patients and manpower, their management during COVID-19 pandemic is discussed in [Table 1]Potential setbacks related to clinical dermatology practice and procedures, their management during COVID-19 pandemic is discussed in [Table 2][Table 3] provides insight on Dermatology procedures and COVID-19 risk{Table 1}{Table 2}{Table 3}

 Safety Considerations for Laser Therapy in COVID-19 Back Drop



A separate consent form regarding COVID 19 infection explaining about history of travel, any contact with positive patient, any history of fever or sore throat should be taken before the laser procedureParticular attention to be paid to prepping and draping of patients and operator to reduce and remove any virus particles as much as possibleIt 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 alcoholSterilize laser hand pieces before and after every use, use of cling film wherever the laser probes come in contact with skinFrequent and thorough hand washing after touching instruments and machinesWear goggles, mask, gloves, and face shield during the procedureUse high filtration media masks when dry, on usage the dampness from breathing will make them ineffectivePatients should wear surgical/cloth mask during the procedureUse plume evacuation systems with filters that remove particulates to 0.1 microns known as ultra-low particulate air filters (HEPA or ULPA filter). Nonmedical grade smoke evacuators such as vacuum cleaners must be avoidedPlace all used material in biohazard disposal binsA dedicated air conditioning unit with an air handling unit (AHU) with air filtration system if possibleConsidering the cost effectiveness, sodium hypochlorite solution should be sprayed on body of laser equipment but protecting the optics. The laser optics must be cleaned with Isopropyl alcohol or 70% ethyl alcoholPatient bed and laser room should be sprayed with sodium hypochlorite solution in between and after each procedure.

 List of Disinfectants Approved for Use for COVID-19



Seventy percent ethyl alcoholIsopropyl alcoholSodium hypochlorite solution 0.5%–1% (5000 ppm to disinfect surfaces)Hydrogen peroxideQuaternary ammoniumCitric acidChlorine dioxidePeroxyacetic acidQuaternary ammonium compoundGlutaraldehyde.

 After the Pandemic



This pandemic is going to change the way we practice dermatology. Clinical dermatology which had taken a back seat till now, especially in 3 tier/2 tier cities will be the bread-winner for the dermatologists. Reasonable numbers of patients who approach dermatologist are going to prefer simple oral/topical treatment over quicker procedural results, due to financial constraint or the fear of acquiring infection. Many dermatologists would practice virtual dermatology and touch the patient only when necessary. The use of bed-side tests for diagnosis may decrease. Procedural dermatology will be the worst hit for few months to couple of years from now, and will entirely depend on how the dermatologist will shape his/her practice.

 Long Term Effects of Pandemic



This pandemic will stay for long time in the minds of the patients and doctors, and will teach us to live with it. It will cause lifestyle modification of doctors, patients, and community at large. The dermatology clinics/institutes will also see the difference in practice. Busy OPDs will be replaced with patients preferring social distancing. Digital prescription and tele-consultation will rise. If the dermatologist does not change with these changing times may make a way for the rise in quacks/other specialties taking over. Hence, adaptation is the rule and passion to practice dermatology is the key.

 Conclusion



Hard times are usually blessings in disguise; hence we should utilize this pandemic period to learn and rejuvenate our practice. A dermatologist can start slowly and steadily both clinical dermatology and procedural dermatology, foreseeing the setbacks and its timely management.[1],[2],[3],[4],[5],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2Indian Association of Dermatologists, Venereologists and Leprologists (IADVL). Online Consultation Guidelines. Available from: https://www.iadvl.org/announcements.php?AnnouncementId=5e8ad48a9f2d29172f769522. [Last accessed on 2020 May 15].
3Indian Council of Medical Research. COVID-19. Available from: https://main.icmr.nic.in/content/COVID-19. [Last accessed on 2020 May 15].
4Indian Association of Dermatologists, Venereologists and Leprologists (IADVL). IADVL Position Statement on our Dermatology Clinical Practice in the Evolving COVID-19 Scenario. Available from: https://iadvl.org/announcements.php?AnnouncementId=5e78b21b9f2d2924fc186d02. [Last accessed on 2020 May 15].
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6Liang T. Handbook of COVID-19 prevention and treatment. The First Affiliated Hospital, Zhejiang University School of Medicine. Compiled According to Clinical Experience. 2020 Mar;68.