As the COVID-19 pandemic gradually comes under control, the members of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) have drawn up a proposed list of the requirements, limitations, and conditioning factors affecting the resumption of work in contact dermatitis units. The assumption is that the severe acute respiratory syndrome coronavirus 2 is still circulating and that occasional or seasonal outbreaks will occur. They recommend that the first step should be to assess how many patch tests each clinic can handle and review the waiting list to prioritize cases according to disease severity and urgency. Digital technologies can, where possible, be used to send and receive the documentation necessary for the patch test (information, instructions, informed consent, etc.). If the necessary infrastructure is available, patients can be offered the option of a remote initial consultation. Likewise, in selected cases, the patch test results can be read in a virtual visit using photographs taken by the patient or a video visit can be scheduled to allow the physician to evaluate the site of application remotely. These measures will reduce the number of face-to-face visits required, but will not affect the time spent on each case, which must be scheduled in the normal manner. All of these recommendations are suggestions and should be adapted to the needs and possibilities of each health centre.
Con el progresivo control de la pandemia por SARS-CoV-2, los miembros del Grupo Español de Investigación en Dermatitis de Contacto y Alergia Cutánea (GEIDAC) realizan una propuesta sobre cuáles van a ser los requisitos, las limitaciones y los condicionantes para reanudar el servicio en las unidades de dermatitis de contacto en un escenario en el que se presume la persistencia del virus, con episodios ocasionales o estacionales de exacerbación. Se aconseja ajustar el número de pruebas epicutáneas (PE) a las posibilidades de cada centro y la revisión de los casos en lista de espera para priorizar a los pacientes en función de la gravedad y la urgencia. Se ofrecerán, si es factible, métodos telemáticos para los documentos relativos a las PE (información, pautas, documentos de consentimiento informado). De estar disponible, puede ofrecerse la opción de realizar una primera visita telemática. Igualmente, en pacientes seleccionados puede llevarse a cabo una televisita en las visitas de lectura a través de imágenes realizadas por el paciente o mediante una videovisita que permita visualizar el resultado de la exploración. Estas acciones permitirán reducir el número de visitas presenciales, aunque no el tiempo dedicado y asignado al facultativo para los actos médicos. Todas estas recomendaciones son sugerencias y se adaptarán a los requisitos y a las posibilidades de cada centro sanitario.
The rapid spread of infection by the coronavirus SARS-CoV-2 and the disease associated with this virus (COVID-19) constitute a serious public health problem.1
The SARS-CoV-2 pandemic has led to the suspension of most contact dermatitis units and patch testing services because of the need for hospitals to prioritize treatment of COVID-19.2,3
As the pandemic is gradually coming under control, we must now consider the requirements, limitations, and conditioning factors affecting resumption of work in contact dermatitis units in a scenario in which the virus is still circulating and occasional or seasonal exacerbation episodes are possible.
The risk of spread of SARS-CoV-2 in contact dermatitis units is unknown, although common areas in these units follow similar disinfection protocols to those of other hospital services. However, in contact dermatitis units, which generally have specific consulting rooms with constant movement of physicians and nurses, contact with patients is closer and longer over time, with several visits in a few days. This close contact entails specific problems with respect to safety and the spread of SARS-CoV-2 between health professionals and between patients and health professionals.
With the aim of balancing the risks and benefits for patients and optimizing safety for staff in charge of patient visits and diagnostic tests, the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) of the Spanish Academy of Dermatology and Venereology has drawn up the following recommendations:
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The number of patch tests should be adapted to the possibilities of the individual center based on relevant safety factors. In other words, a reasonable number of patients should be scheduled depending on their specific characteristics and on other simultaneous consultations in order to avoid crowding in the waiting room or overlapping appointments (e.g., 1 patient per hour, 5-6 patients per week). Consequently, it may be advisable to restrict the indication for patch testing to those cases where it is likely to have greater diagnostic yield, at least until the risk of infection has decreased.
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The waiting list should be reviewed in order to prioritize patients depending on disease severity and urgency. Appendix B provides a detailed list of conditions that should be prioritized, although the attending physician’s evaluation should prevail in each case.
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Alternatively, the patient should be given the option of postponing patch testing, especially in high-risk cases (elderly patients or patients with risk conditions for COVID [cardiovascular disease, diabetes, arterial hypertension, obesity, chronic respiratory disease, liver disease, cancer, and immunosuppression]). Similarly, and based on medical criteria, patch testing can be postponed in patients with mild or moderate eczema at sites not considered a priority and not active in recent months or with little impact on quality of life.
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If feasible, we can provide the patient with scanned copies of all the necessary documentation relating to the tests (information, regimens, informed consent documents) by e-mail and receive the documents signed via the same channel. The e-mail should be official and not sent as an individual message from the patch testing team.
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If available, the first visit can be virtual in the case of patch testing indicated by an external physician or physician other than the attending physician at the contact dermatitis unit. In this case, patch testing should be preceded by an online visit, with or without images and/or video. Thus, based on the individual clinical history, this approach would make it possible to prioritize patients whose diagnosis would be optimized with patch testing. Patients can provide information for the history, complete a questionnaire (e.g., history of atopy, occupational details, and contact allergens), send photographs of the lesions and of their own products (and of the ingredients in the case of personal care products) or of the summary of product characteristics in the case of occupational contact allergens.
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During the days before patch testing, patients should be contacted by telephone to ensure that they or the people they live with or the people they have been in recent contact with do not have symptoms of COVID-19. The symptoms to be asked about are shown in a questionnaire (Appendix C). Testing will be postponed in the case of patients who have tested positive for COVID-19. These patients should then be referred to their health center in order to adhere to the protocols established for each center and region. Similarly, before each face-to-face visit, patients must be asked about signs or symptoms that are suggestive of COVID-19 (questionnaire in Appendix B). When COVID-19 is suspected, patch testing should be postponed until the infection can be confirmed or ruled out. Given that some patients may not have symptoms or a detectable viral load before developing symptoms, the absence of the symptoms should not lead us to neglect general safety measures. In the case of patients who present with signs or symptoms that are suggestive of COVID-19 after performance of patch testing and before the reading, priority will be given to virtual methods of reading and interpretation. If this is not possible, and depending on the individual situation, patch testing can be postponed or the reading performed in a specific area for patients who are positive for COVID-19 and using appropriate personal protective equipment. Patients should receive specific recommendations, preferably before patch testing (Appendix D).
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The procedures followed for patch testing should be adapted to appropriate safety requirements for the SARS-CoV-2 pandemic (Appendix E).
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Visit for reading/interpretation of patch test results (48-96 h). The first reading should be taken immediately after removal of the patches. In equivocal cases, we should wait half an hour following the previously established safety recommendations. In specific cases, we can turn to teledermatology, which enables patients to send images they themselves have taken. Similarly, a video consultation will enable us to visualize the outcome of the examination, provide an interpretation, and record results in the clinical history, with recommendations for the patient. At this visit, we should calculate the time necessary to resolve doubts and send all the documentation (e.g., report, avoidance measures, treatment, and new appointments).
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These actions will make it possible to reduce the number of in-person visits, although not the time taken by and assigned to the physician for medical procedures. This may be even longer, given the need for a strict protocol and additional requirements. In other words, quality and detail should be preferred over quantity.
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These procedures should be based on circuits that guarantee the confidentiality and reliability of digitally transmitted data.
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All of these recommendations are suggestions, which can be adapted to the requirements and possibilities of the individual health center.
José Carlos Armario Hita (Cádiz), Leopoldo Borrego Hernando (Las Palmas de Gran Canaria), José Manuel Carrascosa Carrillo (Barcelona), Susana Córdoba Guijarro (Madrid), Laia Curto (Barcelona), Virginia Fernández Redondo (Santiago de Compostela), Ignasi Figueras Nart (Barcelona), Juan García Gavín (Pontevedra), María Elena Gatica Ortega (Toledo), Anna Giménez Arnau (Barcelona), Elena Giménez Arnau (Barcelona), Enrique Gómez de la Fuente (Madrid), Ricardo González Pérez (Álava), Felipe Heras Mendaza (Madrid), Marcos Hervella Garcés (Pamplona), Pilar Manrique Martínez (Vizcaya), Pedro Mercader García (Murcia), Francisco Javier Ortiz de Frutos (Madrid), Javier Miquel Miquel (Valencia), María Antonia Pastor Nieto (Guadalajara), Mercedes Rodríguez Serna (Valencia), Inmaculada Ruíz González (León), Araceli Sánchez Gilo (Madrid), Paloma Sánchez-Pedreño Guillén (Murcia), Javier Sánchez Pérez (Madrid), Tatiana Sanz Sánchez (Madrid), Esther Serra-Baldrich (Barcelona), Juan Francisco Silvestre Salvador (Alicante), Violeta Zaragoza Ninet (Valencia).
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Occupational eczema.
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Severe eczema.
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Eczema of the face or hands and widespread eczema that does not respond to appropriate treatment or protection measures.
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Acute recurrent eczema of unknown origin.
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Patients in whom dermatitis progresses with a high impact on quality-of-life.
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Patients who are to undergo a surgical or therapeutic intervention that cannot be delayed and for which the results of patch testing are essential (drugs, medical devices, glucose sensors/insulin pumps, dental intervention, orthopedic intervention, patients who are atopic before systemic therapy).
During the last 14 days, have you experienced any of the following symptoms?
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Fever.
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Cough.
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Difficulty breathing.
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Muscle pain.
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Tiredness.
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Impairment or loss of sense of taste or a bitter taste with food and water.
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Reduced sense of smell or loss of sense of smell.
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Diarrhea.
If you notice any of the symptoms, please call us and we will decide what to do. However, in principle, it would be best if you did not come to the hospital.
During the week you undergo testing, you should take your temperature every day and ensure that you do not have any of the symptoms mentioned above. Please contact us if you notice any symptoms.
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Before coming to the center, please re-read the information on tests that we gave you when you came to your first visit or that you were sent by e-mail.
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Please keep to the time of your appointment. If you arrive early, please wait in the car. You must not arrive late. We are trying to avoid crowding in the waiting rooms. We would be grateful if you would help by arriving at the allotted time.
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Do not forget to bring your own products (shower gel, creams, and products for your skin condition). Please bring these in their original container.
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Your own products will be placed in a clean bag and can be left in the hospital until testing is complete. You can also bring them and take them home again, although they must be here at each visit.
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You are recommended to bring the signed informed consent document (you can send this by e-mail as a scanned document if this option is available at your center). Alternatively, you can sign the informed consent document during your first visit.
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Please go to the toilet before leaving home so that you do not to have to do so in the hospital.
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Please try to bring as few personal objects as possible (bag, fan, umbrella). If possible, try to make sure that these are washable. Please make sure your hair is tied up and avoid wearing jewelry.
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Please try not to wear bracelets, watches, necklaces, or earrings on the day you undergo testing.
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You must be wearing a mask when you arrive, and you cannot remove it during your stay in the hospital.
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You must enter the hospital unaccompanied unless you need help. Only minors or people with special needs (elderly and dependent persons) can be accompanied. Persons accompanying patients to the hospital must remain outside or in the car.
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You must follow the recommendations of the staff at the center and maintain the recommended safe distance (1.5-2 m).
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While in the hospital do not touch anything (e.g., doors, handles) and maintain a safe distance from other people. Avoid crowding.
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In the clinic, we will try to speak as little as necessary. Where possible, every effort will be made to send notifications and information by e-mail so that you do not have to take papers from the hospital to your home. If this is not possible, you will have to disinfect the papers when you arrive home or leave them in a safe place where they will not contaminate other objects.
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Your belongings (e.g., clothing, bag) will be placed on the stretcher (clean sheets for each patient) or hung up in the consulting room. For your safety, please take care not to touch anything. You will have to strip to the waist. The required test patches and your own products will be applied to your back.
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We will give you the information about your next appointment by telephone or by e-mail. Wherever possible, we will try to keep your appointment at the same time throughout the week of patch testing.
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When you return home from hospital on the days of your tests you must take the following precautions (and in the following order):
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Leave items such as bags and papers at the entrance.
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Remove your shoes and leave them at the entrance.
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Wash your hands with soap and water for 1 minute.
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Remove your mask.
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Remove your clothes.
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Wash carefully and try to keep the test area dry (use a handheld shower, clean other areas and wash your hair separately in the sink).
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Wash clothes in the washing machine at 60°.
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Disinfect objects or materials that are likely to carry infection (e.g., phone, keys, bag) with alcohol.
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Finally, wash your hands again very carefully.
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You should follow these steps every time you return from the hospital.
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Organize the appointments list in order to avoid the accumulation of patients in the waiting room.
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Ensure that the waiting room enables patients to maintain a distance of 1.5-2 m between each other.
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Provide patients with hand sanitizer at the door and with a mask if they have not brought one from home.
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There should be a clean, well-signposted circuit, in addition to staff who can inform patients and facilitate access to the clinic in order to prevent them from walking around the highest-risk areas.
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If a patient has to partially undress, then he/she should have access, where possible, to an individual consulting room or stretcher where clothes can be left. Clothes will be kept in a disposable bag. It is important to ensure appropriate disinfection of surfaces and of other areas such as chairs and door handles between one patient and the next.
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Gloves and mask should be worn when receiving patients, during the visit, and during the patch tests. The use of safety glasses or a face shield and an impermeable gown will be evaluated in specific cases (possible risk of aerosol transport).
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Apply hand antiseptic (gel/water-alcohol solution) before and after each patient.
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Collect the informed consent document in a plastic sheath supplied by the hospital (standard).
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Apply tests using gloves that can be discarded after each patient.
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Patch tests can be marked using adhesive material (preferably surgical steri-strip), individual acetate sheets, or 1 marker per patient. Disinfect the area to be marked with water-alcohol solution.
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In the case of patients who bring their own products, these should be provided in individual bags and handled while wearing gloves
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Establish appropriate ventilation of areas between one patient and the next.
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During the removal of patches and the first reading, follow the procedures and recommendations indicated for application of the patch test.
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During the week, give patients the option to store their own products in clean bags that can remain in the hospital until the tests are complete.
Please cite this article as: Carrascosa JM, Pastor-Nieto MA, Ruiz-González I, Silvestre JF, Borrego L, Gatica-Ortega ME, et al. Recomendaciones del Grupo Español de Investigación en Dermatitis de Contacto y Alergia Cutánea (GEIDAC) de la AEDV en relación con la realización de pruebas epicutáneas durante la pandemia por SARS-CoV-2 (COVID-19). Actas Dermosifiliogr. 2020;111:650–654.
on behalf of Grupo Español de Investigación en Dermatitis de Contacto y Alergia Cutánea (GEIDAC)
www.publicationethics.org.
