Recommendations for personal protective equipment and smoke evacuation for dermatologic surgeries amid the COVID-19 crisis.

Abstract

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has significantly affected clinical practices. Currently, elective dermatologic procedures (ablative laser procedure and laser hair removal) are deferred with only emergency dermatological surgeries being performed to lessen viral spread and preserve personal protective equipment (PPE). As COVID-19 prevalence decreases, postponed procedures will be scheduled. For Mohs micrographic surgery (MMS) and excisions, hemostasis is often achieved by electrosurgery, generating surgical smoke plume. Although data on transmission of SARS-CoV-2 via surgical smoke is unavailable, human immunodeficiency virus, hepatitis B virus, and human papillomavirus have been detected in surgical smoke.1 Since SARS-CoV-2 may be transmitted through aerosols,2 it is critical to reexamine recommended protective measures for dermatologic surgery. The use of fitted respirator or surgical masks and smoke evacuators was recommended to minimize the infectious, inhalation, chemical, and mutagenic risks of surgical smoke prior to COVID-19.1 For smoke evacuators, minimal flow rate, determined by internal diameter and suction strength, nozzle positioning, filtration efficiency, and regular maintenance impact efficacy.1 Since COVID-19 is transmitted through droplets and aerosols,2 it is premature to resume elective laser procedures, including ablative CO2 and hair removal. However, deferred non-elective excisions and MMS for skin cancer will need to be performed in the near future. The Centers for Disease Control and Prevention (CDC) recommends N95 respirator use for health care workers participating in aerosol-generating procedures (AGP).3 Therefore, N95 respirators are essential for dermatologic surgeons and staff operating on mucosal regions and/or generating aerosols with electrocautery (Table 1). The CDC recommends against extended use or reuse of respirators following AGP.3 However, given N95 shortages, particularly in outpatient dermatology practices, following this recommendation may be unrealistic, with extended use unavoidable. A surgical mask covering the N95 respirator may be considered to extend longevity. Decontamination of N95s for reuse3 or 3D-printed masks have also been proposed; testing would be required to ensure effective filtration.4 In an intubation simulation,5 secretions were recovered from exposed skin (ie, neck and ears) and hair of health care providers following two coughing episodes despite use of N95 respirators, eye protection, gowns, and gloves, suggesting that use of standard PPE is likely insufficient. This study raises concern for a similar inoculation pattern from surgical smoke potentially laden with SARS-CoV-2 in the dermatologic surgeon's exposed skin and hair, suggesting that a hood covering hair, ears and neck should be utilized. In addition, this infectious material may be transferred to the eyes, nose, or mouth via self-inoculation, a process that can be prevented with proper hand hygiene. Finally, to minimize smoke production, electrosurgery units should be set to the lowest effective settings for achieving hemostasis. Recommendations for PPE, smoke evacuation, and hand hygiene are shown in Table 1. Many hospitals are adequately supporting redeployed resident and attending dermatologists caring for COVID-19 inpatients. As we are discharged from redeployments and perform increasing numbers of essential outpatient dermatological surgeries, it is incumbent upon hospitals, as well as, state and federal governments to ensure adequate access to PPE for all dermatologists and staff. The authors declare no conflicts of interest.