Dermatologic surgery during the COVID-19 pandemic: Experience of a large academic center
Authors: Michael W. Tee, Claire Stewart, Saud Aliessa, Max Polansky, Kalee Shah, Tatyana Petukhova, Anthony Rossi, Shari R. Lipner, Kira Minkis
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: The novel coronavirus disease 2019 (COVID-19) pandemic has required significant modifications to clinical practice.1Elston D.M. The coronavirus (COVID-19) epidemic and patient safety.J Am Acad Dermatol. 2020; 82: 819-820Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In the hardest-hit areas, such as New York City, triaging of personnel and supplies, as well as prioritization of certain skin cancers, was required in dermatology practices. Although clinical judgment should be used to evaluate patients on a case-by-case basis, general guidelines from the National Comprehensive Cancer Network recommend postponing treatment for low-risk lesions by 3 months, except in cases in which "debilitating progression within 3 months" was estimated by the physician.2Geskin L.J. Trager M.H. Aasi S.Z. et al.Perspectives on the recommendations for skin cancer management during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 83: 295-296Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,3National Comprehensive Cancer Network. Advisory statement for non-melanoma skin cancer care during the COVID-19 pandemic, 2020.https://www.nccn.org/covid-19/pdf/NCCN-NMSC.pdfGoogle Scholar However, for certain skin cancers types, including invasive melanoma, Merkel cell carcinoma, and high-risk cutaneous squamous cell carcinoma, the decision to delay care is of higher risk.2Geskin L.J. Trager M.H. Aasi S.Z. et al.Perspectives on the recommendations for skin cancer management during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 83: 295-296Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,3National Comprehensive Cancer Network. Advisory statement for non-melanoma skin cancer care during the COVID-19 pandemic, 2020.https://www.nccn.org/covid-19/pdf/NCCN-NMSC.pdfGoogle Scholar Prior studies have reported that delays to treatment for stage 1 melanomas may increase the risk of poor prognosis and decrease overall survival.4Conic R.Z. Cabrera C.I. Khorana A.A. Gastman B.R. Determination of the impact of melanoma surgical timing on survival using the National Cancer Database.J Am Acad Dermatol. 2018; 78: 40-46.e7Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar Providers must also weigh the significant anxiety faced by patients who have received a diagnosis of skin cancer but are unable to receive definitive treatment. As such, for patients who require surgery during the pandemic via Mohs micrographic surgery or wide local excision, it is crucial that dermatology practices have protocols in place to provide necessary care while protecting patients and health care personnel from COVID-19. Our goal is to share our experience in practicing dermatologic surgery in the heart of the COVID-19 pandemic with an abundance of caution. Dermatologic societies have created a living document to grade evidence regarding measures to minimize the transmission risk of COVID-19, covering topics including hand washing, personal protective equipment, risk of aerosolizing COVID-19, ventilation, and eye protection.5Shanthi N. Alam M. Ozog D.M. et al.American Society of Dermatologic Surgery Association (ASDSA) and American Society for Laser Medicine & Surgery (ASLMS) guidance for cosmetic dermatology practices during COVID-19.https://www.asds.net/skin-experts/news-room/press-releases/asdsa-and-aslms-partner-to-develop-guidance-for-cosmetic-dermatology-practices-during-covid-19Google Scholar To add to this work, we summarize measures taken at New York Presbyterian–Weill Cornell Medicine, a large academic center greatly affected by the pandemic (Table I). We also summarize our approach to handling COVID-19–positive patients who require care (Fig 1). From March 1, 2020, to July 14, 2020, 235 nonmelanoma skin cancers and 27 melanoma excisions were performed at Weill Cornell Dermatology. With our measures, there has been no known transmission of COVID-19 associated with dermatologic surgery, even when COVID-19–positive patients were treated.Table ICurrent coronavirus disease 2019 precautions taken at Weill Cornell dermatologyVisitLocationPreventive measures takenPreoperativeTelevisitPrioritizing surgical cases via telemedicinePatient taking a self-photograph to help identify surgical sitePhotographic instructions sentCOVID-19 screening for symptoms and instructing patients to self-monitor and report any symptoms before surgerySince mid-June, presurgical COVID-19 PCR testing for surgical sites in mask zone or other high-risk situations24–72 h before surgeryEnsure test turnover and result time appropriateOperation dayIn personScreening for COVID-19Symptom screening and temperature checkWaiting room avoidancePatients scheduled so that they can go directly to procedure rooms and remain in the roomVisitors not allowed to be with the patient aside from special circumstances, including for minors and when there is a medical or legal necessityOperation precautionsPPE for patient: provide patient with surgical maskPPE for provider: mask (N95 + surgical mask), goggles or face shield, hair and shoe covering, and gownUse of smoke evacuator during electrocauteryDissolvable sutures and cyanoacrylate for surgical closure to prevent need for additional visitWritten and oral wound care instructions regarding wound careSanitation steps (disinfecting room between patient encounters)Sanitary wipes to disinfect all room surfaces and any objects touched by patientsCOVID-19, Coronavirus disease 2019; PCR, polymerase chain reaction; PPE, personal protective equipment. Open table in a new tab COVID-19, Coronavirus disease 2019; PCR, polymerase chain reaction; PPE, personal protective equipment. With regional variability in the prevalence of COVID-19, personal protective equipment shortages, and hospital policies, we acknowledge the complexity of this issue and that our solution may not be a one-size-fits-all solution. We appreciate that alternative methods for transmission prevention, including a "pod system" in which staff work in small, unchanging groups to limit the number of exposures, may be a better option for other facilities or regions. We also appreciate that in some situations, practices have to temporarily pause surgeries. We foresee COVID-19 to be a long-term issue, particularly in New York City, where there has been a secondary increase in cases. Given the lack of proven treatments or vaccines for COVID-19, the paucity of information on practice standards for dermatologic surgery, and concerns about how delays can affect patients, we hope that sharing our experience will add to the body of information and may enable other practices to continue to serve their patients during this difficult situation. None disclosed.