Dermoscopy Practice during COVID-19 Pandemic: Recommendations by SIG Dermoscopy (IADVL Academy)

Coronavirus disease (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease originated in China in December 2019 and has now been declared pandemic by the world health organization (WHO).[1] The studies on the human-to-human and fomite-to-human transmission of SARS-CoV-2 suggest that the virus can stay on the surface of plastics, cardboard, stainless steel, copper, door handles, mobile phones, and other daily routine commodities.[2,3] These findings are important keeping in mind that dermatologists also use certain instruments in daily clinical practice, which can potentially act as a source of nosocomial spread of COVID-19.

It is important to note that dermatology outpatient clinics are running in many countries even at these times of pandemic.[4,5] Aggravation of previous skin diseases such as rosacea, eczema, atopic dermatitis, and neurodermatitis has been seen in Covid-19 patients.[4,5] In addition, urticarial lesions, chicken-pox like vesicles, livedoid, and erythematous rash has also been noticed.[6] However, the most common scenario in the coming days would be asymptomatic shedders visiting dermatology clinics for a preexisting dermatosis and dermatology practice may act as a vector for COVID-19 transmission.[7] Over past few years, dermoscopy using a dermatoscope, has become one of the most frequently performed examination procedures in dermatology clinics. Existing literature suggests that a dermatoscope can act as a possible source of nosocomial spread of infections and may also act as a potential source of SARS-CoV-2.[8] Therefore it is important that we remain vigilant while performing dermoscopy. Nevertheless, it may also serve as an important investigative tool in such times when invasive procedures like skin biopsy are best avoided.

In view of COVID-19, it is only wise to avoid or postpone doing dermoscopy on COVID-19 positive cases; patients showing signs and symptoms related to COVID-19; patients with history of travel in the past 2 weeks, especially to high risk countries; patients from red zones or high risk areas; and patients with family history/close contact history of COVID-19. Dermoscopy may be better avoided wherever clinical examination is sufficient to reach a diagnosis or other modalities (with lesser risk of transmission) can be used. The importance of social distancing to minimize the transmission of COVID-19, should be kept in mind during clinical as well as dermoscopic evaluation. Wherever possible, for COVID-19 suspected patients, standardized protocol of wearing personalized protective equipments (PPE) and examination in negative pressure rooms should be followed.[9] In the coming months, after the nationwide lockdown is over, the risk of random patient with asymptomatic COVID-19 infection may still prevail, therefore we recommend certain precautions in the dermatology OPDs and clinics to be followed.

It is important to make sure that dermatoscope should be wiped with 70% isopropyl alcohol wipes for at least 1 min. The dermatologist performing dermoscopy should follow all universal precautions advised by WHO[1] and wear gloves before performing dermoscopy. Patient should be advised to wear a facemask and clean the hands (with soap and water for at least 20 s or sanitization with 60-90% isopropyl alcohol).[1]

Various methods have been described in literature to decrease the chances of nosocomial spread through a dermatoscope:

• Disposable dermoscopic lens cover: provided with most dermatoscopes now-a-days

• Plastic bottle cap: a disposable plastic bottle cap fitting the size of the dermatoscope may be used[10]

• Polyvinyl chloride (PVC) food wrap: a PVC film is placed (with or without mineral oil on both sides of it) between the dermatoscope lens and the lesion[11]

• Transparent adhesive tape: after placing the immersion fluid, a transparent adhesive tape is applied to assist contact dermoscopy[10]

• Microscopic glass slide: a glass slide can be placed over the lesion in front of the dermatoscope[8]

• Polyethylene tube for mucoscopy: a disposable polyethylene tube can be used with a USB dermatoscope for performing mucoscopy[12]

• Car phone holder for oculoscopy.[13]

The dermatologist while performing dermoscopy may use these methods. The lesion to be scoped should be cleaned with alcohol swabs (60-90% isopropyl alcohol) and alcohol-containing solutions should be used as interface medium. Noncontact dermoscopy is preferable over contact dermoscopy and use of a video dermatoscope or universal serial bus (USB) dermatoscope may be preferred over hand-held dermatoscope. Dermoscopy of mucosal lesions and oozy/fissured lesions is better avoided. The patient should be made to turn his head to the other side and adequate distance to be maintained so that there is minimal chance of spread through aerosol.

Postdermoscopy, especially in COVID-19 suspected cases, the dermatoscope and all other surfaces exposed to the patients should be cleaned with 60-90% isopropyl alcohol. It is advisable to clean the mobile phone, if used for the visualization of the images using the dermatoscope. As a paperless approach is better, a digital dermoscopy report is preferable. All materials used for dermoscopic examination should be disposed as per biomedical waste guidelines.

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Conflicts of interest

There are no conflicts of interest.