Recommendations on dermatologic surgery during the COVID-19 pandemic
Authors: Samuel Antranig Der Sarkissian, Leo Kim, Michael Veness, Eleni Yiasemides, Deshan Frank Sebaratnam
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We read with interest the article by Chen et al1Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar reporting the experience of a dermatology department at the center of the COVID-19 pandemic. As doctors, we have a responsibility to support measures that mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but at the same time, to provide essential medical care to our patients. Cutaneous oncology poses a unique set of challenges. Having patients attend dermatologic surgery clinics increases the risk of transmission of SARS-CoV-2, takes medical staff away from other settings (including upskilling in critical care), and uses limited health care resources such as personal protective equipment. Deferring planned surgery may allow for disease progression, increasing tumor burden, which may result in more complex surgery and reconstruction, increasing the risk of metastasis, and the ultimate burden on the health care system. There is no certainty regarding when the pandemic is likely to subside and no evidence-based recommendation regarding when deferred procedures should be undertaken. Several institutions have proposed an approach to dermatologic surgery during the pandemic.2British Association of Dermatologists and British Society for Dermatological SurgeryCOVID-19 – Skin cancer surgery guidance. Clinical Guidance for the Management of Skin Cancer Patients During the Coronavirus Pandemic.http://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6658Date accessed: March 30, 2020Google Scholar, 3Melanoma Institute AustraliaImportant notice regarding the management of clinically suspected primary melanoma during the COVID-19 crisis.https://mcusercontent.com/88a3bd528a963791abea7c880/files/b853272a-052d-4eeb-b62a-ea0bd2cbce60/Melanoma_Management__Covid_FINAL.pdfDate accessed: April 7, 2020Google Scholar, 4National Comprehensive Cancer NetworkCOVID-19 resources. Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community.https://www.nccn.org/covid-19/default.aspxDate accessed: April 7, 2020Google Scholar We propose the following guidelines (Table I).5Skulsky S.L. O'Sullivan B. McArdle O. et al.Review of high-risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology.Head Neck. 2017; 39: 578Crossref PubMed Scopus (83) Google Scholar Where possible, clinics should be triaged so that only urgent patients are reviewed in person, with telehealth used where appropriate.Table IRecommendations regarding dermatologic surgery during the COVID-19 pandemicAreaRecommendationClinic structureTriage clinics, rebooking according to clinical priority and use telehealth where possibleWaiting roomsScreen patients before attendance to prevent high-risk cases from entering the practiceStagger appointment times to minimize patients in waiting room togetherPatient chairs spaced a minimum of 1.5 m apartLimit support persons to 1Remove possible sources of infection (such as magazines) in the waiting roomEnsure all attendees hand sanitize on arrivalProceduresPPE being rationed to allow for the best protective practices while also preventing a complete shortage. This is a dynamic process dependent on supplyConsider N95 masks for perioroficial surgeryUse dissolving sutures to minimize multiple presentationsBenign lesionsCysts, lipomas, cosmetic procedures: defer for nowProcedures that alleviate significant morbidity (eg incision and drainage of hidradenitis suppurativa abscesses) may proceed as soon as feasibleBCCSuperficial: defer treatment for 6 monthsAll other: defer surgery for 3 to 6 monthsSCCActinic keratosis and SCC in situ: defer for nowSCC: guided by prognostic variables: location, size >2 cm, depth >2 mm, differentiation, perineural or lymphovascular invasion, recurrence immunosuppression5Skulsky S.L. O'Sullivan B. McArdle O. et al.Review of high-risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology.Head Neck. 2017; 39: 578Crossref PubMed Scopus (83) Google ScholarMelanomaExcisional biopsy with 2-mm border when melanoma suspectedMelanoma in situ: defer treatment for 3 monthsInvasive melanoma: if histologic clearance obtained, defer wide excision and/or sentinel lymph node biopsy for 3 monthsOther tumorsBenign tumors: defer for now, where medical investigation required (for fibrofolliculoma, tricholemmoma, sebaceous carcinoma, etc), this may be deferredLocally aggressive tumors (eg, dermatofibroma sarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, etc): proceed as soon as feasibly possible with consideration of patient and tumor variablesBCC, Basal cell carcinoma; PPE, personal protective equipment; SCC, squamous cell carcinoma. Open table in a new tab BCC, Basal cell carcinoma; PPE, personal protective equipment; SCC, squamous cell carcinoma. Elective surgery, such as excision of benign lesions and cosmetic procedures, should be postponed. For conditions such as hidradenitis suppurativa, where minimally invasive dermatologic procedures, such as incisional and drainage, may relieve debilitating morbidity, should be pursued as soon as feasible. For superficial basal cell carcinoma, we recommend deferring treatment for 6 months, except where this may lead to significant morbidity, and for all other forms of basal cell carcinoma, deferring surgery for 3 to 6 months. For squamous tumors, we recommend deferring treatment of actinic keratosis and squamous cell carcinoma in situ. Treatment for invasive squamous cell carcinoma will require triage according to prognostic factors such as differentiation, location, depth, perineural invasion, and patient variables (eg, immunosuppression).5Skulsky S.L. O'Sullivan B. McArdle O. et al.Review of high-risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology.Head Neck. 2017; 39: 578Crossref PubMed Scopus (83) Google Scholar Alternative treatments, such as radiotherapy, carry their own set of logistical issues. For suspected melanoma we recommend excisional biopsies over shave or incision biopsies given the uncertainty about when definitive treatment will take place, should it be needed. Treatment of melanoma in situ may be deferred for 3 months. Where histologic clearance of a melanoma has been achieved, wide excision may also be deferred for 3 months. Wide excision does not influence survival but decreases the risk of local recurrence.4National Comprehensive Cancer NetworkCOVID-19 resources. Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community.https://www.nccn.org/covid-19/default.aspxDate accessed: April 7, 2020Google Scholar Given the spectrum of tumors encompassed by cutaneous oncology, treatment of rarer aggressive or indeterminate malignancies needs to be individualized according to tumor, patient, and health care resource considerations. We acknowledge that any recommendations we propose are likely to shift in the coming weeks as the COVID-19 pandemic evolves, and we welcome feedback from our colleagues given the paucity of evidence in this unprecedented time. The set point of the equilibrium between minimizing morbidity and mortality from infection and from malignancy will be mercurial, and our response as doctors will have to be equally dynamic. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?Journal of the American Academy of DermatologyVol. 82Issue 4PreviewIn late December 2019, several individuals with unexplained pneumonia were reported in Wuhan, China. A novel coronavirus was subsequently identified as the causative pathogen and provisionally designated 2019 novel coronavirus (2019-nCoV).1 As of February 10, 2020, 42,638 cases of 2019-nCoV infection have been confirmed in China, with 21,675 suspected cases and 1016 deaths. There are still more than 3000 confirmed cases every day, involving people living in or visiting Wuhan, as a subsequent characteristic of human-to-human transmission. Full-Text PDF