Dermatological Practice in Nepal during COVID-19 Crisis: Recommendations of National Panel of Experts

Introduction: Novel Coronavirus disease has caused a substantial halt to the ongoing world in every aspect. There are medical and social implications of the disease. Cutaneous manifestations have been reported to be a part of the disease as well. Dermatologists globally are in dilemma with the clinical practice because of the fear of acquiring the disease. Objectives: This article aims to recommend best practice measures that can be followed in local scenario for re-opening of dermatological services in the context of Nepal. Materials and Methods: A preliminary draft for guidance on Dermatological services based on recommendations of American Academy of Dermatology, International league of Dermatological societies, National recommendations from Ministry of Health, Nepal was sent to a panel of national experts to determine the level of consensus in first week of April, 2020. A preliminary survey was sent to all the members of Society of Dermatologists, Venereologists, and leprologists of Nepal on first week of June and a second draft was subsequently formed which was sent again to experts and revised based on the opinions of national experts. Results: A total of 19 experts participated in the preparation of draft and reached a national consensus after a series of revisions in preliminary draft. Conclusion: Agreements regarding the opening of practice in dermatology discipline have been summarized. Recommendations have been made for opening of dermatological services – opening of outpatient department, performing dermatosurgical and cosmetic procedures as well as strategies on triage of patients and use of masks.


Introduction
W e have lately seen this passionate world motionless for months as if the nature has pressed a reset button. The World Health Organization (WHO) on December 31, 2019 received reports of patients with atypical pneumonia from Wuhan, Hubei Province, China caused by a new virus; Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2); currently designated as Coronavirus disease . 1 The infection promptly spread all over the world escalating the condition and WHO eventually declared COVID-19 as a global pandemic on March 11, 2020. 2 The data regarding the new cases detection and death rate is increasing day by day. Also, we should believe that such data could only be the "tip of an iceberg". Social life of people throughout the world has been disrupted with thousands of people losing their job. In Nepal, the first case of Corona virus was detected on 23rd January, 2020. 3 Since then, cases have been increasing and the government has requested stayat-home order in Nepal since 24 th March, 2020. 4 As the modalities of lockdown order have been changed by the government, the clinical practice has started opening up. In view of high transmission rates of SARS-CoV-2 virus, reopening dermatological services remains a challenge. This article reviews available literatures on SARS-CoV-2 and has developed recommendations for opening up Dermatological services in our set up.

Materials and Methods
A first draft for guidance on Dermatological services based on recommendations of American Academy of Dermatology, International league of Dermatological societies, National recommendations from Ministry of Health, Nepal was delivered via email to panel of 19 national experts to determine the level of consensus in first week of April, 2020. At the same time the Government of Nepal first issued "Stay -at -home order". 3 These 19 national experts were selected based on representation and expertise from different (Eastern part of Nepal to Western region of Nepal) parts of countries. This draft was circulated to all the members of Society of Dermatologists, Venereologists and Leprologists of Nepal. A second survey was sent to all the members of Society of Dermatologists, Venereologists, and Leprologists of Nepal on first week of June for feedback on first draft. A second draft was subsequently formed based on this feedback and sent again to panel of 19 experts via e-mail. The final draft and recommendations was formulated based on the opinions of majority of national experts. The survey was done using online google form and Microsoft excel was used to record the surveyed data.

Virology
Coronaviruses belong to the subfamily Orthocoronavirinae in the family Coronaviridae, Order Nidovirales. 5 The genome of the virus is an enveloped, positive-sense, single-stranded RNA with fluctuating size between 26 kb and 32 kb, the largest genome of known RNA viruses. Two latest outbreaks in this decade of viral pneumonia caused by β-CoVs are severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). 5

Modes of transmission
Till date, it has become a well-known fact that this viral disease can be transmitted by droplets primarily, although surface contact transmissions from objects have also been reported. 6 The average incubation period of SARS-CoV-2 is projected to be around 3-7 days (range, 2-14 days) representing a long transmission period of the virus. 5,6 Vaccines against SARS-CoV-2 The development of vaccines against SARS-CoV-2 has been a priority worldwide to prevent Covid-19. Jackson et al 7 reported preliminary report from phase1 trial evaluating safety and efficacy of mRNA SARS-CoV-2 vaccine and the results have been promising. The dosing regimen of this vaccine is still under study and the authors indicate that planned phase 3 trial of this vaccine is imminent. 7 If there is answer yes to any of the above question, refer them to fever clinic of nearby COVID designated hospital for further evaluation and attend them after clearance from those clinics.

Patients' consultation:
a. Designate specific well ventilated rooms for consultation of patients depending upon the availability of rooms in hospital/clinic. Avoid air condition as far as possible.
b. Provide alcohol based hand sanitizer and disinfection solution in every consulting room and at the reception; ask patients to sanitize prior to entry and exit from the consulting room. providing pre-procedure instructions through telecommunication e.g. to trim/shave the area for laser hair reduction, apply topical anesthesia one hour before procedure which can be done easily at home if given proper instructions. 5. Allow maximum of one to two patients in the waiting area of procedure room with strict social distancing; air-conditioning should be avoided in waiting areas with proper cross-ventilation and exhaust fan. 6. Ask the patients to sign a coronavirus selfdeclaration form stating their travel history, any symptoms of fever/cold/cough or shortness of breath 7. The consent form for procedure should include a statement regarding disinfection measures being taken during Covid-19 and should be duly signed by the patient before initiating any procedure. 8. General aesthetic procedures which can be carried out in Nepal during this pandemic can be divided in three categories and are summarized in Table 1. Hair transplantation Vitiligo Surgery 9. If you are planning to do procedures, minimal level of protection required will be as depicted in Table 2. iii. Discard the sheet after each procedure.
iv. Clean the body of the machine, machine tubes, articulated arm with sodium hypochlorite 1% or 70% ethyl alcohol.
v. Touch screen, lens optics, cooling tip can be cleansed using 70% ethyl alcohol.
vi. Use disposable spatulas. In case spatulas are to be reused, clean with 70% ethyl alcohol.
vii. Eye Shields-Clean eye shields with 70% ethyl alcohol along with the strap.
viii. Laser gel -Take out gel in disposable cups for each procedure and discard after each procedure.
ix. Tattoo removal -Postpone if not urgent.
x. Use low power settings where possible to reduce the production of plumes.
xi. Ablative lasers, Q-switched laser, Laser hair removal generates more plumes as compared to non-ablative lasers or Light emitting diodes -perform with proper precautions including personal protective equipments (PPEs), adequate ventilation and smoke evacuation. 11. Using Injectable (Botulinum toxin /fillers) i.
Double pair of gloves should be worn.
ii. Area to be injected should be cleansed thoroughly.
iii. Disposal of syringes and needles using a needle destroyer should be done immediately post-procedure.
iv. Suitable dressing to be used to seal injection points. 12. Use of N-95 masks i.
Extended use -N-95 mask use can be safely extended for up to 8 hours (including between patients). Wearing a face-shield over the N-95 mask decreases the chances of soiling of mask.
ii. Re-use -CDC recommends that assuming there is no soiling and minimal to no viral contamination the N-95 mask can be reused for up to 5 times with use of following strategies: • Acquire a set of at-least five N-95 masks and rotate their use each day assuring that there is no soiling of mask and minimal to no contamination with virus. Masks should be allowed to dry for a time period longer than the viability of the virus i.e. 72 hours. Each mask should be stored in a clean breathable paper bags separately without coming in contact with each other.
• Methods approved by CDC for reprocessing/ decontamination includes use of steam or liquid hydrogen peroxide. Moist heat at a temperature of 60-70° C and 80-85% relative humidity or dry heat at 70° C for 30 minutes has been shown to adequately kill the virus while preserving the filter integrity and fit.  Table 3. iv. Use disposable instruments as far as possible.
v. Use absorbable sutures as far as possible in order to reduce number of visits.
vi. Electrocautery and laser ablation generate aerosols; hence, droplet precautions need to be taken. Use the machines under lower settings.
C. Keep track of department of health services, Ministry of health for updates on transmission of COVID-19 cases. If cases begin to increase, have a strategy in place to determine whether your practice will need to again temporarily reduce the service. D. Have a plan in place for dermatology patients who appear with COVID-19 symptoms and require testing. Consider finding testing locations where you can recommend patients can go for testing or refer the patient to COVID designated hospitals.

Conclusions
In summary, this article presented the summary arising from recommendations involving 19 national experts. We have made recommendations for opening of Dermatological services -opening of outpatient department, performing dermatosurgical and cosmetic procedures as well as strategies on triage of patients and use of masks during crisis of COVID-19.