Recommendations for skin cancer consultation and surgery during COVID-19 pandemic.

As a result of the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and government lockdown measures, healthcare systems were challenged worldwide. Medical doctors were faced with prioritization of non‐COVID19 medical problems in order to reduce potential exposures and to mobilize staff and resources for COVID‐19 care. On the other hand, decreases in some non‐COVID19 health problems have been observed, e.g. myocardial infarction, newly diagnosed cancers among which esp. skin cancer, … and there is concern that delay in these may negatively affect patient outcome. , , In this respect, it is important to define and communicate recommendations on prioritization of non‐COVID19 related health care.

In this position paper, we describe recommendations developed by the Belgian Association of Dermato‐Oncology (BADO) for prioritization of patients in the field of dermato‐oncology during COVID19 pandemic without compromising quality of care and safety. BADO was founded in 2012, and the board consists of a mix of derrmatologists, oncologists and surgeons. Its main goals are to promote multidisciplinary approach of dermato‐oncology, to exchange scientific knowledge about dermato‐oncology and to work on treatment recommendations for different skin cancer types.

These (COVID‐19) recommendations are based on estimated potentially harmful effects by delaying a specific consultation type as also discussed in the letter of Tejera‐Vaquerizo. We categorized dermato‐oncology care into urgent (no delay), semi‐urgent (delay for max 8–12 weeks) and low priority (more than 12 weeks delay acceptable) (Tables 1, 2, 3). In addition, measures for limiting viral transmission during consultation and surgery are described (Tables 4, 5, 6).

Table 1

Urgent care: no postponement

Referral for possible melanoma or other skin cancer Confirmed new melanoma and its surgery Confirmed new SCC Confirmed new other skin cancer, e.g. Merkel cell CA, angiosarcoma Skin cancer with systemic treatment † Excision suspicious nevus Follow‐up stage II and III melanoma within first 2 years of follow‐up Follow‐up SCC: moderate/poor differentiation or prior metastasis or transplant patient or history of multiple SCCs Follow‐up multiple primary melanomas Planned digital dermoscopy follow‐up of specific lesion(s) after 3–4 months Any patient with skin cancer history who is worried (first triage by teleconsultation)

Systemic treatment options with reduced frequency of hospital visits need to be considered.

Table 2

Semi‐urgent care: these indications can be postponed, but need to be replanned within 8–12 weeks

Follow‐up stage II and III melanoma after 2 years of follow‐up Follow‐up stage I melanoma and in situ melanoma Follow‐up low‐risk SCC Confirmed new BCC (for BCC in the face surgery should already be planned) Confirmed Morbus Bowen Follow‐up multiple BCC Dysplastic nevus syndrome with family history of melanoma

Table 3

Low priority indications can be postponed beyond 12 weeks

Follow‐up BCC Follow‐up dysplastic nevus syndrome with negative personal/family history of melanoma (annual check) Follow‐up actinic keratosis

Table 4

Practical planning of the consultation

Consider teleconsultation whenever possible. This is especially important in patients at risk for serious COVID19 infection (e.g. old age – immunosuppressive R/ – other comorbidities) Prior to consultation, ask the patient: if he/she has has (had) any fever‐ or cough‐ or flu‐like symptoms to bring a face mask if he/she has one

Table 5

General precautions during the consultation

Patients should be spaced at least 1.5 m apart while waiting. Patient should clean their hands with soap and water for at least 20 s. Alternatively they can be asked to use alcohol 70% desinfectant If patients have a face mask (or the dermatology practice can provide one) they should be asked to wear it. Patients with fever‐ or cough‐ or flu‐like symptoms in the past 4 weeks or patients who tested COVID19 positive should wear a face mask up to 30 days after the start of their first symptoms/ positive COVID‐19 PCR testing. The dermatologist who performs a total body examination with dermoscopy should wear a face mask and wash/desinfect hands. The dermatologist can consider to wear gloves during examination. The dermatoscope should be desinfected with an 70% alcohol solution. The use of a protective cap or polyvinyl chloride (PVC) food wrap on the dermatoscope should be considered. An alcohol solution or gel can be used as interface medium for dermoscopy 12 Dermoscopy at certain sites like the area under the face mask should be avoided as much as possible 12

Table 6

Precautions during surgery

1. Outpatient intervention outside face mask area

Patient wears face mask

Doctor wears face mask and gloves and normal surgical clothing

When in the face outside the face mask area sterile field protects as much as possible mask area; normal protective clothing (mask, gloves, surgical clothing)

2. Outpatient intervention in mask area of the face

COVID testing (SWAB screening day before) negative

If testing is not available, treat the patients as potentially positive and increase doctor's protection: (FFP2) mask and extra protection (e.g. shield and extra surgical apron over surgical clothing)

3. Inpatient surgery

Consider COVID testing in all patients prior to hospitalization

The dermatoscope should be desinfected with an 70% alcohol solution. The use of a protective cap or polyvinyl chloride (PVC) food wrap on the dermatoscope should be considered. An alcohol solution or gel can be used as interface medium for dermoscopy

Dermoscopy at certain sites like the area under the face mask should be avoided as much as possible

In conclusion, the COVID‐19 outbreak posed significant challenges to medical staff to offer optimal and timely care in non‐COVID19 health problems at the same time keeping the risk of COVID19 spread as low as possible. In the last months, proposals for triage in several health conditions have been published especially in oncology including skin cancer. , , , , , BADO developed recommendations to prioritize dermato‐oncological care on a national level in Belgium. In the circumstances of the COVID19 pandemic, the approval and refunding of tele/videoconsultations by the government was accelerated but for skin cancer treatment and follow‐up teleconsultations are often suboptimal. ,

These recommendations were needed to take on a nationwide similar approach for the different indications in dermato‐oncology; it was also a way to monitor replanning of postponed consultations since acceptable delay period was defined for different indications in dermato‐oncology. Because of the fast changing situation, the introduction of the guidelines mentions that ‘these recommendations could serve as a guidance and are based on a general weighing of pros/cons. They need to be tuned according to the evolving situation and advices for COVID19 by the government and the weighing of the pros/cons for the individual patient’.

For the moment, the lockdown measures in Belgium have been gradually decreased and care has returned to (nearly) normal levels taking into account basic preventive measures described above to avoid spread of infection. Nevertheless, these guidelines may be valuable in case of flare up of COVID‐19 or in other circumstances that require prioritization of dermato‐oncology care.

Conflicts of interest

None declared.

Funding sources

None declared.