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

aerosol‐generating procedures

Centers for Disease Control and Prevention

coronavirus disease 2019

Mohs micrographic surgery

personal protective equipment

severe acute respiratory syndrome coronavirus 2

Dear Editor,

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. Since SARS‐CoV‐2 may be transmitted through aerosols, 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. For smoke evacuators, minimal flow rate, determined by internal diameter and suction strength, nozzle positioning, filtration efficiency, and regular maintenance impact efficacy.

Since COVID‐19 is transmitted through droplets and aerosols, 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). 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. 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 reuse or 3D‐printed masks have also been proposed; testing would be required to ensure effective filtration.

TABLE 1

Personal protective equipment and electrosurgery/smoke evacuation system recommendations for dermatologic surgeries during the COVID‐19 crisis

Measures	Comments
PPE	Properly fitted N95 respirators to minimize air leaks (yearly respiratory fit testing is required to ensure appropriately sized respirators) Protect N95 respirator with surgical mask Disposable gloves Disposable surgical gowns (American National Standards Institute/Association for the Advancement of Medical Instrumentation PB70 levels 1‐4) Consider hood that covers hair, ears, and neck Eye protection (ie, goggles or face shield; goggles are preferred for single use N95 respirator) Hair and beard coverings Shoe coverings
Electrosurgery/smoke evacuation system	Use lowest effective setting from electrosurgery units to minimize smoke burden. Minimum airflow of 0.012 m3/s to efficiently capture surgical smoke. Hold smoke collection tip within 5.1 cm of the surgical field. Use evacuators with efficient filter size (0.1 μm). Follow proper filter disposal techniques after each use. Perform regular maintenance as per the manufacturer's instructions.
Hand hygiene	Use an alcohol‐based hand sanitizer immediately after removing all PPE. Wash hands with soap and water if hands are visibly dirty.

In an intubation simulation, 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.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.