290 © 2021 Indian Dermatology Online Journal | Published by Wolters Kluwer - Medknow

IntroductionSevere acute respiratory syndromecoronavirus2(SARS‑CoV2)isanenvelopedRNAviruswith a genome size of 26 − 32kilobases.[1,2] It is transmitted throughdroplets or contact transmission. Researchhas shown that the receptors required forthe attachment and entry of SARS‑CoV2virus to host cells are transmembraneprotease serine 2 (TMPRSS2) andangiotensin‑converting enzyme 2 (ACE2)receptors.[2] While TMPRSS2 receptorshave not been demonstrated in skin,ACE2 receptors which are necessary forattachment of SARS‑CoV2 after primingwithTMPRSS2have been demonstrated inkeratinocytes (confined mainly to stratumbasale and spinosum), eccrine glands,and to a lesser extent fibroblasts. This hasraisedconcernsabout transmission, throughprocedures, which impair skin barrier,particularlyiftheygenerateaerosols.[3]Thishas affected dermatosurgical practice andhas necessitated safety measures that havebeen published in several guidelines. Inthis article, we outline additional specificsteps practiced at our center tomake theseprocedures“safer”.1. Observation for 2 weeks prior to the

procedure Since the incubation period of COVID

is about 14 days, it is useful to watchthe patient for 2 weeks prior to theprocedure. At first visit, the patientis sensitized about the procedure andadvised about priming of the skin prior

Address for correspondence: Dr. Anuradha Jindal, Venkat Center for Skin, #3437, 1st G Cross Rd, Subbanna Garden, Vijayanagar, Bengaluru, Karnataka ‑ 560 040, India. E‑mail: dr.anu17@gmail.com

Access this article online

Website: www.idoj.in

DOI: 10.4103/idoj.IDOJ_544_20Quick Response Code:

AbstractSARS‑CoV2pandemichasaffecteddermatologypracticegreatly.Inviewoftheriskoftransmission,physiciansneedtodevisemethodstoperformproceduresinasaferway.Ourinstitutehasadoptedanumberofinnovativesafetyprecautionssteps,whicharebeingoutlinedhere.

Keywords: Aesthetic, dermatology, Covid‑19, coronavirus, laser, procedures, radiofrequency

9 Tips and Pearls for Safer Performance of Dermatological Procedures during Covid-19 Pandemic

Brief Report

Venkataram Mysore, Aniketh Venkataram, Anuradha Jindal, Ashwini L Hirevenkangoudar, Deepthi Malayanuru, Malcom Noronha, Sajin AlexanderVenkat Center for Skin and Plastic Surgery, Bangalore, Karnataka, India

H o w t o c i t e t h i s a r t i c l e : M y s o r e V , Venkataram A, Jindal A, Hirevenkangoudar AL, Malayanuru, D, Noronha M, et al. 9 Tips and pearls for safer performance of dermatological procedures during covid‑19 pandemic. Indian Dermatol Online J 2021;12:290‑3.

Received: 23-Jul-2020. Revised: 19-Sep-2020.Accepted: 20-Oct-2020. Published: 02-Mar-2021.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

to the procedure. The patient is alsoadvised to restrict travel/meeting newindividuals and to observe and reportif any signs of cough, sore throat, andfever occur. This 2 weeks period isutilizedtobuildrapportwiththepatient,to get to know the patient better, andto ensure that procedure can be donesafelyinthepatient.

2. Double gloves—Double gloves areuseful, as this allows removal of thesoiledorcontaminatedouterglovesoonafter a procedure, letting one move todocumentation or other patients andthusminimaltimewasted.[4]

3. Povidone‑iodine (PVI) gargles andnasal spray: Salivacontainsahigh loadof SARS‑CoV2 viral load with up to1.2 × 108 infective copies/mL. It hasalso been discovered that viral load ishighest in nasopharynx followed byoropharynx and mouth in descendingorder.[5] Hence, cleaning of oral andnasal cavity with a virucidal solutionprior to procedures might render theprocedure safer for both doctor andpatient. PVI solution for skin cleaningis available as a 10% solution and thelowestconcentrationofpovidone‑iodinefoundtobeeffectiveagainstSARS‑CoVwas 0.23% with an exposure durationof 2 min to reduce viral load to anundetectablelevel.[6]

Preparation:As betadine is available as10% solution, we diluted the solutionusing normal saline to achieve a

[Downloaded free from http://www.idoj.in on Tuesday, March 23, 2021, IP: 106.51.241.161]

Mysore, et al.: Making dermatological procedures safer in Covid‑19

291Indian Dermatology Online Journal | Volume 12 | Issue 2 | March-April 2021

concentration of 0.5%. (9 mL of normal saline to beaddedto1mLof10%betadinesolution).Thissolutioniskeptinasterilebottlewithspraypump.

For nasopharynx cleansing – 0.28‑0.30 ml of 0.5%solution of PVI is sprayed into each nostril (2 spraysin each nostril). Contralateral nostril should be closedwhileadministeringinotherone.Thisgivesatotaldoseof0.33mgofiodine.[6]

For oral cavity–9mLof the0.5%solution is givento the patient and the patient is instructed to garglethe same and keep inside the oral cavity for at least30 seconds. The solution should be held for a fewseconds at the back of the throat before spitting outtoensurethecleansingofposteriororopharynx.Ithasbeenpostulatedthatonly1mLofsolutionisretainedand absorbed giving an estimated dosage of 0.55mgof PVI. If the patient is not able to gargle, 7 sprayscan be used aimed (equivalent dosage) at differentdirections in the oral cavity, and the patient is askedto lick laterremainingPVIin theoralcavity.[7]

4. Modifiedmaskforfacialaestheticprocedures One obstacle in performing procedures over face was

how to spare the area for procedure while assuringadequate coverage of nose and mouth area, forprotection of patient as well as staff and doctor. Wemodifiedthesurgical/3‑plymaskbymarking4points–

Firstpatient isaskedtowear themaskandto lookstraightwitheyesatsamelevel• 1st point ‑ upper edge of themask in line withmedial

pupillarylinesymmetricalonboththesides.• 2nd point ‑ on the outer edge of nasolabial fold at

leveloflowerborderofnasalalae.• 3rd point ‑ 1 cm lateral to angle of mouth on both

thesides• 4thpoint–1cmbelowmento‑labialsulcus.

A margin of 1 cm is kept and edges are sealed with 3M double‑sided sticking tape. Figure 1 shows the imageof a patient wearing a modified mask. Figure 2 shows asimple linediagram for preparing amodifiedmask for thepatient.[8]

However, this method leads to wastage of resources asthat mask cannot be reused after the procedure. Hencean alternativemethod is to fold themask and fix it in thecenter of the face‑covering only nose and mouth withoutcuttingthemask.

Thismethod is not suitable for procedures over the upperlipornose.[8]

The below pearls are specific for aerosol‑generatingproceduressuchasLasers,Radiofrequency,etc.:

5. ClingfilmDuringLaserprocedures:Transmissionmayhappen through fomites particularly metallic surfaceswhere the virus can survive for up to 72 h.[9] Clingfilms can be wrapped around the handpieces while

performing procedures where the handpiece is placedin direct contactwith the skin. In addition, cling filmcan also be applied to the treatment area like fortattoo removal.This technique prevents tissue splatterand hence reduces the generation of aerosols duringprocedures. Catherine Chen et al. performed a studytomeasurethetransmissibilityandlossoflaserenergywhen passed through various transparent surfacesusing Q‑switched Alexandrite laser. Handiwrapcling film showed a 7% loss of energy which wassignificantly less when compared to tegaderm (26%loss)oracudermdressing(41%loss).[10]

6. Glass slides during laser procedures: Laser hairreduction using glass slide, as done for diascopy, isone method to treat difficult to treat hair by laser hairremoval as it removes thecompetingchromophoreoxyhemoglobin by vasoconstriction. The same techniquecan be used for laser hair removal procedures, tominimize the exit of plumes that are generated due toevaporationofshaftduringlaserhairremoval.[11]Alossof8%transmissionofenergyisseenwhenaglassslideisusedasinterface.[10]

7. Gel – Use of transparent USG gel as an interfacebetween the laser handpiece and area to be treatedreduces the number of plumes generated during theprocedure.[12] First skin is cleansedwith spirit followedby saline and gel is applied on the area to be treated.Gel bottle should be kept in the refrigerator upsidedown, cool gel provides added benefit of soothing theskin, and keeping the bottles upside down reduces thechancesofbubbleformationinthebottles.[12,13]

8. Transparent Hood‑ The hood is made of transparentacrylicmaterial and is placed over patient’s head andneck during the procedure.[14] Refer Figures 3 and 4.The hood acts as a physical barrier preventing the

Figure 1: Mask worn by the patient has been modified sparing the area over the cheek for laser. Other measures of protection—doctor N-95 mask, face shield, and surgical cap with surgical gown; smoke evacuator on the left side. Laser probe and arm covered with cling film which is changed for every patient

[Downloaded free from http://www.idoj.in on Tuesday, March 23, 2021, IP: 106.51.241.161]

Mysore, et al.: Making dermatological procedures safer in Covid‑19

292 Indian Dermatology Online Journal | Volume 12 | Issue 2 | March-April 2021

escape of any droplets from the patient or aerosolsgenerated during the procedure. For maneuvering thelaser or RF equipment 2 circular‑shaped apertureshave been created on all sides of the box, exceptfor the front which is covered with the curtain madefrom thickpolyestermaterialpreventing theescapeofplumes. The apertures are lined by a polyester sheeton the inside which can be tightened over the wristafter doctors insert his/her hands through the apertureinto the hood ensuring further added protection andcomplete seal. While conducting the procedure thehose of the smoke evacuator is passed through oneof the apertures and the nozzle is placed near to thetreating area [Figure 4]. One side two apertures areused by the treating dermatologist and the oppositeis occupied by the staff nurse for assistance.[15] Aftereach procedure hood is cleaned using either 1%sodiumhypochloritesolutionor70%isopropylalcoholand allowed to dry for minimum 15 minutes beforethe next procedure.[4] Conducting procedures in awell‑ventilatedroomorroomwithexhaust(atleast12exchangeofairperhour)isencouraged.

Limitations of the hood include slight compromise inthe visibility through the acrylic hood as compared tonakedeyeanddifficultyinmaneuveringduringfineRFandlaserprocedures.

9. Smoke evacuator ‑ Smoke evacuator equipped threestagefilteringmechanismconsistingof–highefficiencyparticulate air (HEPA) pre‑filter, a layer of activatedcharcoalforodorabsorption,andathirdstageUltraLowPenetrationAir(ULPA)filterareconsideredcurrentlythemosteffectivefilterforaerosol‑generatingprocedures.[16]Thenozzleofthesmokeevacuatorisintroducedthroughoneoftheaperturesintothehood.Theplacementofthenozzle iscrucialas thedistancebetween thenozzleandtreating area increases the efficacy of smoke evacuatordecreases.A2.2‑cmwandwhenplaced at a distanceof7.5 cm from the smoke source captured only 53% ofthe smoke in comparison to 99% capture when placedat2.5cm.[17]The smokeevacuator iskepton inside thehoodforatleast2minutesaftertheprocedureisovertovacuumanyremainingplumespresent.

To summarize, all these 9 measures can be dividedinto 4 P’s—physician, patient, procedure, and place ofprocedure—andhavebeensummarizedinTable1.

These measures are in addition to other sine quanon‑measures being taken for COVID‑19—socialdistancing,screening,mask,handhygiene.

Thesemethods show thatwith innovations that are simpleand cheap, it is possible to overcome the challenges facedduringprocedures.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

Figure 2: 1st point (blue dots) - upper edge of the mask in line with medial pupillary line (dotted red line). 2nd point (red dots) - on the outer edge of nasolabial fold at the level of the lower border of nasal alae. 3rd point (green dots) - 1 cm lateral to angle of mouth on both sides. 4th point (purple dot) —1 cm below mento-labial sulcus

Figure 4: Hood from top view being used for laser toning of the face. Red arrow shows the laser handpiece. Smoke evacuator nozzle (yellow arrow). The patient is wearing nasal filter after betadine gargle and nasal spray

Figure 3: Hood being used for laser toning of the face. Smoke evacuator nozzle (yellow arrow) and part of the hose is kept inside the hood near the area being treated

[Downloaded free from http://www.idoj.in on Tuesday, March 23, 2021, IP: 106.51.241.161]

Mysore, et al.: Making dermatological procedures safer in Covid‑19

293Indian Dermatology Online Journal | Volume 12 | Issue 2 | March-April 2021

References1. Chen Y, Liu Q, Guo D. Emerging coronaviruses: Genome

structure, replication, and pathogenesis. J Med Virol2020;92:418‑23.

2. Russo R, Andolfo I, Lasorsa VA, Iolascon A, Capasso M.Genetic analysis of the coronavirus SARS‑CoV‑2 host proteasetmprss2indifferentpopulations.FrontGenet2020;11:872.

3. Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et al. Highexpression of ACE2 receptor of 2019‑nCoV on the epithelialcellsoforalmucosa.IntJOralSci2020;12:8.

4. DhawanS,KumariP,DeA,PallA,PudukadanD,RomiE,et al.Lasers use in dermatology practice in the evolving COVID‑19scenario – Recommendations by SIG lasers (IADVL academy).IndianDermatolOnlineJ2020;11:337‑42.

5. Wu YC, Chen CS, Chan YJ. The outbreak of COVID‑19: Anoverview.JChinMedAssoc2020;83:217‑20.

6. Challacombe S, Kirk‑Bayley J, Sunkaraneni V, Combes J.Povidoneiodine.BrDentJ2020;228:656‑7.

7. Anderson DE, SivalingamV, KangAEZ,AnanthanarayananA,ArumugamH, JenkinsTM, et al. Povidone‑iodine demonstratesrapid in vitro virucidal activity against SARS‑CoV‑2, the viruscausingCOVID‑19disease.InfectDisTher2020;9:669‑75.

8. Noronha M, Jindal A, Mysore V. Modified mask for aestheticprocedures on face during COVID‑19 era: Chiseling ourarmamentarium.DermatolTher2020;e13819.

9. Chin AWH, Chu JTS, Perera MRA, Hui KPY, Yen HL,Chan MCW, et al. Stability of SARS‑CoV‑2 in differentenvironmentalconditions.LancetMicrobe2020;1:e10.

10. PayA,Kenealy J.Laser transmission throughmembranes usingtheQ‑switchedNd:YAGlaser.LasersSurgMed1999;24:48‑54.

11. MurphyMJ.Anovel,simpleandefficacioustechniquefortattooremoval resulting in less pain using the Q‑switched Nd:YAGlaser.LasersMedSci2014;29:1445‑7.

12. Chuang GS, Farinelli W, Christiani DC, Herrick RF, Lee NC,Avram MM. Gaseous and particulate content of laser hairremovalplume.JAMADermatol2016;152:1320‑6.

13. Ross EV, Chuang GS, Ortiz AE, Davenport SA. Airborneparticulateconcentrationduringlaserhairremoval:Acomparisonbetween cold sapphire with aqueous gel and cryogen skincooling.LasersSurgMed2018;50:280‑3.

14. Asokan K, Babu B, JayadevanA. Barrier enclosure for airwaymanagement in COVID‑19 pandemic. Indian J Anaesth2020;64:S153‑4.

15. BabuB,GuptaS,SahniV.Aerosolbox fordentistry.BrDent J2020;228:660.

16. Mowbray NG, Ansell J, Horwood J, Cornish J, Rizkallah P,ParkerAet al.SafemanagementofsurgicalsmokeintheageofCOVID‑19.BrJSurg2020;10.1002/bjs.11679.doi:10.1002/bjs.1167917.

17. KatochS,MysoreV.Surgicalsmokeindermatology:Itshazardsandmanagement.JCutanAesthetSurg2019;12:1‑7.

Table 1: Tips can be divided into 4 Ps ‑ Patient, physician, procedure, place of procedureLevel of protection Measures Comments Patient Betadinenasalspray 0.5%sol,2spraysineachnostril

Betadinegargle 0.5%sol,9mLofsol,tokeepinoropharynxfor30sUVCchamber DisinfectionofpersonalbelongingsGlovesforpatient Avoidscross‑contaminationandtouchingofface

Physician Mask OPD‑surgicalmask+shieldNon‑aerosolprocedures‑N‑95mask+doublegloves+apron(disposable)Aerosolprocedures‑N‑95mask±surgicalmask+doublegloves+GownwithheadcoverorPPE

UVCchamber DisinfectionofpersonalbelongingsPlaceofprocedure Wellventilatedprocedureroom Atleast12airexchangeperhourwithminimumstaffandnoattendersinroom

Smokeevacuator HEPA/UPLAequippedfilterNozzleshouldbekeptclosetotheareabeingtreated

Procedure Hood Allaerosol‑generatingproceduresCleanwith70%isopropylalcoholor1%sodiumhypochloriteaftereachpatient,Gapof15min.minimumbetweenprocedures

Clingfilm/gel/quartzslide Forplumegeneratinglaserprocedures‑Asaninterfacebetweenskinandlaserprobe

[Downloaded free from http://www.idoj.in on Tuesday, March 23, 2021, IP: 106.51.241.161]