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Practicing cosmetic dermatology during COVID-19

Answers in Practice

By Victoria Houghton, managing editor, November 1, 2020

DermWorld talks with Sean Wu, MD, Monica Boen, MD, Douglas C. Wu, MD, PhD, and Mitchel P. Goldman, MD, from Cosmetic Laser Dermatology in San Diego, about best practices for offering cosmetic dermatology during COVID-19.

DermWorld: How has the COVID-19 public health emergency (PHE) affected cosmetic practices in the U.S.?

Dr. Wu et al: At the time of writing, more than four million confirmed cases of the novel coronavirus have been identified in the United States, resulting in 150,000 deaths. While acute care medical facilities risk being overwhelmed in epicenters of disease, outpatient care has declined drastically across the country. Analysis conducted by the Commonwealth Fund of 50,000 U.S. health care providers estimates that, on April 4, in-person ambulatory visits had decreased by 69% from baseline, with a gradual recovery since this nadir. Practicing cosmetic dermatology in this environment is a challenging but possible endeavor. As offices reopen, new protocols and careful monitoring are necessary to keep patients and staff safe.

DermWorld: How has the COVID-19 PHE affected Cosmetic Laser Dermatology?

Dr. Wu et al: Due to a statewide “Stay-at-Home” mandate, our practice closed on March 20, except for urgent post-operative visits as well as cysts and/or cutaneous infections requiring drainage or antibiotics. At the start of the closure, all employees were given an additional two weeks of vacation or sick time in order to minimize furloughing. However, due to extended duration of closure, we had to furlough staff in late April. Since reopening on May 1, we have reduced patient volume by 25% to allow for more social/physical distancing and minimize waiting room time. Fortunately, we have been able to bring back almost all employees, excluding a few who did not wish to return due to family concerns.

DermWorld: What has Cosmetic Laser Dermatology done to ensure patient safety and office sterility, while continuing to operate during the PHE?

Dr. Wu et al: Since re-opening for cosmetic procedures, our practice of 46 staff has instituted measures recommended in the American Society for Dermatologic Surgery (ASDS) guidance for cosmetic practices, including requiring all employees to have temperature checks and attest to not being ill, wearing face masks and eye protection, and to wash hands before and after each visit. Additional social/physical distancing measures implemented include separating workstations by six feet, limiting non-patient visitors, decreasing the number of visit slots, minimizing time spent in the waiting room, and placing visible educational signs throughout the clinic. Patient rooms are disinfected after each visit while common areas are disinfected multiple times throughout the day. All patients are screened for symptoms and temperature prior to entering the clinic.

DermWorld: What evidence is available regarding the efficacy of social distancing and the use of personal protective equipment?

Dr. Wu et al: A recent metanalysis pooling data from 172 observational studies on SARS, MERS, and COVID-19 showed a clear benefit to social/physical distancing and wearing face masks (Lancet. 2020. 395; 10242:1973-1987). Social/physical distancing of at least one meter reduced transmission risk from 12.8% to 2.6%. Further reductions are likely if greater distances are used. Face masks reduced transmission risk from 17.4% to 3.1%. N95 filtering facepiece particulate respirators showed possible stronger protection over surgical masks, while both N95 respirators and surgical masks were more effective than single-layer masks. Though data on the effect of eye protection on COVID-19 transmission is very limited, pooled data from all three viruses suggested a risk reduction from 16.0% to 5.5%. Not addressed in this metanalysis is whether the combination of the three protective strategies is more effective than any strategy alone.

DermWorld: Describe what occurred after you learned that one staff member and one patient tested positive for COVID-19.

Dr. Wu et al: In early July, COVID-19 antibody tests were offered to all clinical and research staff in our practice. A total of 34 of 46 active employees at the time of testing were voluntarily screened, resulting in one positive test.

The staff member with positive antibodies was asymptomatic at the time of the test. However, he showed flu-like symptoms in April, when the clinic was closed during mandated quarantine, and his family members had similar symptoms. He subsequently had two reverse transcriptase polymerase chain reaction (RT-PCR) tests, of which the first test was negative, but the second test performed one week later was positive. His six contacts within his work area screened negative with RT-PCR tests three days after exposure and have remained without symptoms for over three weeks.

Several weeks later, a patient who had received ablative laser resurfacing informed the clinic that she had tested positive for COVID-19 4 days later after she developed symptoms. The three asymptomatic members of her treatment team were screened with PCR tests five days after exposure, again all negative. Finally, two clinic staff members (who had no contact with the infected patient or initial infected staff) tested positive for COVID-19 on RT-PCR tests, presumed to be secondary to exposures outside clinic. All eight staff in contact with these two individuals had PCR and/or serological testing five days post-exposure, all of which were negative.

DermWorld: What challenges still exist with regard to safely operating during COVID-19?

Dr. Wu et al: It is imperative to have a plan in place to prevent spread of COVID-19 within outpatient medical offices. Evidence-based algorithms on screening of health care workers at baseline and after exposures are lacking (Lancet Infect Dis. 2020;S1473-3099(20):30458-8). Furthermore, a systematic review showed that RT-PCR tests have a false negative rate of 2-29%, which may lead to delayed diagnosis and a false sense of security (medRxiv. 2020.04.16.20066787).

DermWorld: What procedures has Cosmetic Laser Dermatology put in place regarding containment of COVID-positive individuals?

Dr. Wu et al: Our clinic has adopted a containment approach in accordance with the latest CDC guidelines. If an employee develops COVID-19 symptoms, they must stay home and take a rapid RT-PCR test immediately. If this test is positive, the entire staff is informed and anyone with prolonged close contact with this employee within the previous 48 hours without proper personal protective equipment is required to take a RT-PCR test or be quarantined at home for 10 days. These individuals are isolated from the clinic while awaiting test results. Patients in contact with this COVID-positive employee 48 hours prior to symptom onset or positive test are contacted. The clinic will also undergo extra sterilization protocols. Any RT-PCR confirmed cases of COVID-19 are isolated from clinic for a period of 10 days and must be completely asymptomatic before returning to work. A repeat test at this time is not performed in accordance with current CDC guidelines.

By implementing mask-wearing and social/physical distancing protocols and adopting the rigorous containment measures of rapid identification, isolation, and contact tracing, cosmetic dermatology practices can maintain optimal safety within their clinics for both patients and staff in this new era of COVID-19. The lack of spread of COVID-19 within our clinic of over 40 staff and eight physicians due to prevention and containment protocols in place is promising.

Sean Wu, MD, Monica Boen, MD, Douglas C. Wu, MD, PhD, and Mitchel P. Goldman, MD, practice at Cosmetic Laser Dermatology in San Diego.