Changes in UK dermatological surgery during the COVID-19 pandemic.

COVID‐19 has resulted in 1.5 million cases and over 66 000 deaths (on 28 November 2020) in the UK with ‘lockdown’ introduced in March 2020. The British Society for Dermatological Surgery (BSDS) published guidance to dermatologists on 30 March 2020, with recommendations of ‘avoid, restrict and abbreviate’: avoid non‐urgent clinics/surgeries; restrict number of visits, staff and aerosol generation; and abbreviate waiting and treatment times. UK Dermatology departments have experienced severe effects across their services. We sought to determine the impact of COVID‐19 on UK Dermatological Surgery through anonymous surveys electronically distributed to all BSDS members in May–June 2020.

In total, 51 recipients responded: 21 (41%) general dermatology consultants, 19 (35%) Mohs surgeons and 11 (24%) registrars/other dermatology doctors from at least 30 departments, with 87% working in England.

Of the respondents, 87% reported cancelling some or all routine/noncancer work and > 90% reported cancelling some/all non‐head and neck basal cell carcinomas (BCCs). By contrast, almost 90% continued all/some 2‐week‐wait (2WW) activity. Head and neck BCCs and cases requiring Mohs surgery were most subject to case‐by‐case assessment, with respondents regarding symptomatic lesions as the most important triaging factor. Other key prioritization factors were patient age, comorbidities and lack of immunosuppression, although the latter did not affect 2WW activity. Most (68%) respondents reported deferring ‘less urgent’ cases, e.g. melanoma in situ, wide local excisions and low‐risk squamous cell carcinomas, and 17 (33%) respondents increased referrals to other surgical specialities, particularly plastic surgery (77%). These case management strategies corresponds with recommendations by Der Sarkissian and colleagues.

Other strategies employed were one‐stop clinics (13/51; 25%) and teledermatology (28/51; 55%). The use of teledermatology increased markedly (Fig. 1), with 29/51 (57%) using it to manage over half their patients.

Figure 1

Use of teledermatology in different stages of the COVID‐19 pandemic.

Methods to reduce surgical patient visits included almost all respondents increasing their use of absorbable sutures and decreasing their use of secondary intention healing. Measures to reduce the risk of COVID‐19 spread included increased cleaning time between patients (10/51; 20%) limiting staff numbers in theatre (15/51; 29%) and reducing numbers of patients in waiting areas (24/51; 47%).

Usage of personal protective equipment (Fig. 2) was high, with surgical masks, visors, and aprons always used by 89%, 95% and 95% of respondents respectively. Use of filtering facepiece (FFP)3 masks was relatively low; ‘always used’ by only one‐third of respondents, and ‘never used’ by almost 50%. Several respondents stated FFP3 masks were not available and/or their trust ‘did not recognize guidelines on skin surgery from the BAD’, or ‘dermatology was not a priority area’. Almost two‐thirds of respondents always used bipolar cautery to try to reduce the plume; only one‐third always used smoke extractors.

Figure 2

Use of personal protective equipment (PPE) in dermatological surgery. FFP, filtering facepiece.

Respondents described different challenges at different stages of the pandemic (Table 1).

Table 1

Challenges during the COVID‐19 pandemic.

Time of challenge	Effects
Beginning of lockdown	Uncertainty in case triaging
	Patients not wishing to attend consultations
	Correct PPE use
	Staff redeployment to the front line
	Lack of consensus: ‘ … even within units, there were differences of opinion’
End of lockdown	Service restart with a need to prioritize patients
	Poor IT infrastructure and limited administration support for remote consultation
	A struggle with the quality of care
	Inability to make accurate diagnoses on video/telephone
	Risk of missing key diagnoses, e.g. melanomas
	Severe delays in treatment
	‘ … sense a drive to push down quality … by those who do not understand’
Future	A ‘tsunami’ backlog of patients, worsened by decreased throughput due to social distancing and increased cleaning times
	Reduced workforce due to occupational health concerns or at‐risk staff
	Safety of vulnerable patients, particularly with the poor availability to staff of appropriate PPE: ‘ … without (correct) PPE we put them at risk every time they come to the hospital’
	‘Careful balance between the need to remove an individual skin cancer against the risks associated’.
	Conducting surgery with PPE: … ‘it’s hot, sticky, more tiring, and more time‐consuming’
	Anxiety regarding the possibility of further redeployment with potential second/third waves

In the coming months, over half of respondents plan to screen patients with at least symptom questionnaires, and ideally pre‐operative antigen swabbing and advising patients to self‐isolate prior to surgery. Many respondents felt staff themselves should also undergo regular testing.

The pandemic has significantly reduced face‐to‐face opportunities for dermatologists to discuss, understand and develop practices with other dermatology departments. This survey highlights the common themes many dermatologists have faced during the pandemic and potential solutions (Table 2).

Table 2

Commonly adopted solutions to deal with the COVID‐19 pandemic.

Solution	Method
Reduce visits	Teledermatology for a significant proportion of follow‐up patients
	One‐stop clinics combining assessment and surgery where possible
	Dissolvable sutures; less complex repairs
Reduce the spread of COVID‐19	Increased appointment times to allow cleaning between patients and reduce the risk of pooling of patients in waiting areas
	Essential staff only in theatre
	Antigen testing of both staff and patients
Screening for COVID‐19 infection	Use of appropriate symptom questionnaires
	Temperature checks on arrival to clinic (for staff and patients)
	Antigen swabbing of patients when capacity allows