Resumption of Laser / IPL skin services post COVID-19 lockdown- British Medical Laser Association (BMLA) guidance document

At the present time, the UK is seeing a high rate of COVID-19 cases, although both the total number of cases and the number of severe cases requiring hospitalisation are falling. Government advice and legal requirements vary across the country and are subject to change. Understanding of the disease continues to progress with an improved understanding of immunity, late onset symptoms and protective measures, including vaccinations.

This document specifically addresses challenges laser practitioners and clinic managers face in the current national climate to offer laser and IPL services; taking into account that the reproduction rate ‘R0 number’ for transmission of COVID-19 is 0.7-0.9 at the time of this revision.¹

Several clinics offer a complement of aesthetic treatments of which lasers and IPL form a component. As this document specifically addresses the challenges in resumption of laser/IPL skin services, the reader should refer to general guidance and publications issued by other organisations such as the Joint Council for Cosmetic Practitioners on commencing non-laser treatments and non-dermatological laser/IPL services.^2,3

At the time of writing, non-medical laser and intense light treatments must not be offered in England and Wales until at least 12th April, Northern Ireland until at least 15th April and the majority of Scotland until at least 5th April^4-7. This includes non-medical treatments carried out in hospitals, clinics or in the home. Personal care services provided for essential medical and health needs, which cannot be deferred, may continue.

The advice provided in this document is relevant to medical treatments as well as cosmetic treatments being carried out in regions where this is not restricted. The BMLA does not provide advice on whether particular treatments are services are considered medical or non-medical, or whether they are permitted under current local or national restrictions.

Pre-treatment screening

Proper pre-treatment screening should substantially reduce the risk of contact with COVID-19 positive patients. Symptomatic patients displaying the commonest signs and symptoms of COVID-19 infection such as high temperature, new and persistent cough, and loss or change to sense of smell or taste must stay at home.⁸ Testing for COVID-19 is now widely available. Lateral flow tests for non-symptomatic patients prior to attending treatment may provide a further level of protection against contact with COVID-19 positive patients. All close-contact services are required to engage with the NHS Test and Trace system in accordance with government guidance and clients should be provided with clear information on the safety measures that they are expected to adhere to.

Excluded from this document are precursory checks and screening of potential patients for signs of COVID-19, general and COVID-19 specific hygiene in clinic reception etc. which are covered in detail elsewhere.^2,3

1. RISK ASSESSMENT: LASERS, AEROSOLS AND COVID

Aerosols are particles of respirable size generated by both human and environmental sources and that can remain viable and airborne for extended periods in indoor air.⁹ The various communicable strains of SARS-CoV-2 virus which are the causative agents of COVID-19 pandemic are thought to spread mainly from person-to-person through respiratory droplets produced when an infected person breathes, coughs, sneezes or talks. Infection with SARS-CoV-2 occurs primarily by inhalation of aerosolised virus or secondarily by contact with droplets and contaminated fomites such as garments, instruments, and furniture.

SARS-CoV-2 virus has a size of 0.06-0.14 μm with mean size of 0.1 μm.¹⁰ During a sneeze or a cough or while talking, “droplet sprays” of virus laden respiratory tract fluid, typically greater than 5 μm in diameter, impact directly on a susceptible individual. Alternatively, a susceptible person can inhale microscopic aerosol particles (droplet nuclei) consisting of the residual solid components of evaporated respiratory droplets, which are tiny enough (<5 μm) to remain airborne for hours, particularly in enclosed spaces with poor or no ventilation.⁵ Researchers in Japan have discovered the coronavirus can survive on human skin for up to nine hours, offering further proof that regular hand washing can curb the spread of the virus.¹¹

Lasers and intense pulsed light (IPL) treatment of tissues generates plumes and aerosols which include both combustion and non-combustion-generated products including tissue(s), gases, particulate materials, steam and carbonised material (smoke). All ablative and non-ablative laser procedures can generate potentially hazardous plumes.

In a recent study, gas chromatography-mass spectrometry of plume during laser hair removal showed presence of 377 chemical compounds comprising of suspected carcinogens and environmental toxins.¹² Ablative laser generated plume has been shown to contain intact human papillomavirus DNA, viable bacteriophages and viable human immunodeficiency virus.¹³ Similarly, micron-sized tattoo ink particles potentially contaminated with aerosolised blood products have been detected following laser tattoo removal.¹⁴

Results of polymerase chain reaction (PCR) and viral RNA testing for SARS-CoV-2 from blood samples of most patients with COVID-19 infection have been negative and viraemia is very uncommon.¹⁵ At the time of writing, no studies looking at the effect of laser treatments on SARS-CoV-2 viral RNA have been published although other aerosol generating procedures (AGPs) have been implicated as risk factors for transmission of SARS-CoV-2.^16,17 The WHO defines an AGP as a procedure which results in the production of airborne particles (aerosols) <5 micrometres. These can remain suspended in the air, travel over a distance and may cause infection if inhaled.¹²⁾¹⁶ Although the BMLA are not aware of a body of evidence demonstrating that laser procedures are associated with a higher incidence of worker acute respiratory infection,¹⁸ it is prudent to assume that all laser treatments are potentially COVID-19 AGPs and all necessary precautions should be followed.

Based on the above, and until such time that evidence to the contrary is available one could assume that the main route of COVID-19 infection in laser/IPL procedures remains patient generated respiratory aerosol but still consider laser generated plume/aerosol as potentially infective.

A. General hygiene and enhanced infection control procedures:

SARS-CoV-2 is primarily transmitted between people through respiratory (droplet and aerosol) and contact routes. Transmission risk is highest where people are in close proximity (within 2 metres). Airborne transmission can occur in health and care settings in which procedures or support treatments that generate aerosols are performed. Airborne transmission may also occur in poorly ventilated indoor spaces, particularly if individuals are in the same room together for an extended period of time.¹⁹

In any setting, hand hygiene remains an important defence against spread of COVID-19. Practitioners should also focus on surface decontamination procedures. These form the basis of reduction of virus transmission. Guidance regarding this is freely available.^7,8

Businesses are required to make sure that their risk assessments address the risks of COVID-19 and should make this readily available to staff and clients, for example by publishing the results of the risk assessment on their website. Workers should be provided with a specific briefing on COVID-19 safety protocols. Signs should be displayed reminding people to wear face coverings.²⁰

B. PPE- Personal protection equipment comprise of face masks, gloves, gowns/aprons, face shields and caps.

Barrier precautions such as masks and respirators are regarded as the last line of defence against viral transmission secondary to hand washing and other hygiene measures. Laser or IPL protective eyewear provides a degree of protection against the spread of COVID-19 and may be used in place of a face-shield or visor where the combination of face mask, safety goggles and visor are impracticable.²⁰ In the case of laser/IPL treatments, proper eye protection is imperative and should not be ignored. Resources detailing correct methods of donning and doffing of PPE are freely available.²¹

Face masks and Respirators

Face masks protect against aerosol spread from inside out. They are tested in the direction of expiration (from inside to outside). There is growing evidence that wearing a face covering in an enclosed space helps protect individuals and those around them from COVID-19.²² Face masks can simply be classified as surgical and non-surgical. Surgical masks worn by the practitioner protect the patient and the environment (air, surfaces, equipment, surgical site). If worn by patients, they prevent contamination of the patients’ surroundings and environment. Standard surgical masks offer no protection to the practitioner undertaking laser procedures. If available, surgical masks or 3 ply cotton masks should be offered to patients undergoing non facial laser procedures. Medical masks manufactured in the UK can be checked for registration with the MHRA at https://aic.mhra.gov.uk/era/pdr.nsf/Search?openform.

Filtering facepiece respirators (FFP), which are sometimes called disposable respirators protect from aerosol inhalation. FFP are tested in the direction of inspiration (from outside to inside). The tests take into account the efficiency of the filter and leakage to the face. FFP are subject to various regulatory standards around the world. FFP2 and FFP3 conform to EU standard EN149:2001. The FFP3 standard is often considered broadly equivalent to the US N99 standard and Chinese KN99 standard. The FFP2 standard is often considered broadly equivalent to the US N95 standard and Chinese KN95 standard. FFP2 and 3 masks should have a CE mark and a four-digit number. A list of valid numbers can be found at https://ec.europa.eu/growth/tools-databases/nando/index.cfm?fuseaction=directive.notifiedbody&sort=number&dir_id=155501&pro_id=155522. It should be noted that masks marked CE 1282 are not valid under the EU regulations on PPE and numerous masks are advertised online with that marking fraudulently.

Respirators are often more comfortable for the wearer when fitted with a valve exhalation feature, but this feature has the effect of elevating wearer safety over that of patients and others in the vicinity, and therefore is generally discouraged.²³

The World Health Organisation recommends that health care workers should wear a particulate respirator at least as protective as a N95/ FFP2, or equivalent, when performing aerosol generating procedures on patients suspected or confirmed of being infected with COVID-19.²⁴

The BMLA also recommends that until proven otherwise, all patients should be considered suspected of being infected with COVID-19. Clients are required to wear a face covering unless this obscures the treatment being performed. If client face coverings are removed, then this should be for the minimal time required to deliver the treatment, assess the response to treatment and dress the area if required. At the time of writing, some areas of the UK do not allow beauty treatments to be performed if this requires face covering to be removed.²⁵ Please check the rules in your local area before booking treatments to the face.

All practitioners should wear N95 respirators as a minimum when undertaking any laser or IPL procedures. This should in addition be complemented by a reusable cleanable face shield. For all above-clavicle procedures, where risk of exposure to patient generated respiratory aerosol is higher; where available, FFP3 respirators should be used instead (for more information on FFP2 vs. FFP3 respirators, see https://www.finder.com/uk/ffp2-vs-ffp3-face-masks).

Practitioners should be fit-tested for all respirators and should receive PPE training comprising of proper hand hygiene practices, correct fit, donning and doffing to avoid cross-contamination.²⁶

Concerns about availability and costs of respirators should be taken into account. Unlike surgical masks which are single use (3-8 hours maximum); FFP can be reusable or disposable. While the BMLA does not recommend extended use or reuse of disposable FFPs; when availability is an issue and, if unavoidable, it may be possible to extend the life of single use FFPs. The use of reusable, cleanable face shields may enhance the life of single use FFPs. Thorough decontamination and safe storage of FFP is incumbent upon the user and is beyond the scope of this guidance.

C. VENTILATION

As the SARS-CoV-2 spreads mainly through aerosol and as particle aerosol (<10 microns) remain airborne for long durations in the laser treatment room and adjacent rooms; adequate ventilation is important to ensure appropriate air handling, containment and evacuation of contaminated air.²⁷

Standard in-room air cleaners alone are not effective at protecting staff and preventing the spread of COVID-19. A HEPA (high-efficiency particulate air) filter uses mechanical filtration to remove airborne particles greater than or equal to 0.3μm in diameter at a minimum 99.97% efficiency and such filters are used in vacuum cleaners and in office buildings air management systems. Used alone, they are not adequate for medical practices.

ULPA (ultra-low particulate air) filters offer up to 99.9995% efficiency on particles down to 0.12 μm. ULPA filters in air filtration systems and ductless fume hoods may help drawing in the airborne drops to capture and remove most of them from the airflow.

Where possible, air conditioning units should be serviced and set at exhaust to extract air from the room to outside the building rather than in air circulation modes. If required air filters should be replaced in line with device manufacturers’ recommendations. Negative-pressure rooms help control the spread of airborne-transmitted infections in health care facilities such as hospitals, but will not be readily available in high street clinics. If available, laser treatments should ideally be undertaken in negative pressure rooms.²³

D. SMOKE EVACUATION SYSTEMS

Smoke evacuation systems are useful to reduce aerosol & plume generated during laser procedures but should be considered as an adjunct to hand hygiene, PPE and adequate ventilation. Laser smoke evacuation systems should have sub-micron filtration capability. Several smoke evacuation systems exist in the market but all offer certain common features such as ULPA filters and minimum flow rate of 25 cfm (cubic feet per minute) with variable flow rate to accommodate various levels of smoke.

Some devices offer multistage filtration to ensure adequate removal of all contaminants. Charcoal filter comprises of activated charcoal which absorbs gas and vapour. It helps in elimination of strong-smelling gases such as those released from laser hair removal. The optimised primary HEPA filter collects over 99.9% of all vaporised tissue and secondary ULPA filter removes solid and biological particles down to 0.01 μm.^28,29

It is important that smoke capture device (e.g., smoke evacuation pencil capture port, tubing) is positioned as close to the surgical site as possible to effectively collect all traces of surgical smoke. It has been shown that when the smoke extraction tip is moved only 2cm from the treatment area, up to 50% of the particulate matter escaped into the local environment.^30,31 Used smoke evacuator filters, tubing, and wands must be handled using standard precautions and disposed of as biohazardous waste.³²

Smoke evacuation systems should be serviced as per manufacturer’s recommendations to ensure that they function at maximum efficiency.

There is growing evidence that the use of ultraviolet light to deactivate coronaviruses in the air can be an effective means of reducing transmission.³³ Adequate safety measures must be in place to protect people against any potential harmful effects of UVC irradiation if this method is employed.

E. LASER EQUIPMENT AND TREATMENTS

Prior to resuming clinical services, practitioners much endeavour to switch on the lasers to check for any faults that may be addressed in good time. Additionally, as the lockdown has lasted for well over 10 weeks, it would be prudent for practitioners to spend some time for reorientation with laser protocols.

As SARS-CoV-2 may persist on inanimate smooth surfaces such as metal, glass or plastic for up to 9-28 days,^34,35 cleaning of laser equipment, display unit, hand pieces, guiding tips, patient goggles and practitioners’ laser eyewear should be meticulously decontaminated after every treatment and as per manufacturer’s recommendation.³⁶ SARS-CoV-2 is efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. Practitioners must refer to manufacturers- issued COSHH advice to ensure safety of use of these products on laser equipment.³⁷

Although COVID-19 is not known to transmit through skin, pre-treatment skin cleansing should be meticulous as per local guidelines to reduce aerosolisation of the virus, if present on treatment site.

Additional measures can be employed to reduce the aerosol generation during laser treatments. To avoid the excessive dispersal of aerosol and plume during laser treatment, wherever possible, positive cold air flow used during laser treatments for the purpose of skin cooling should be substituted by alternative methods such as gels and disposable ice packs, which should in turn be appropriately disposed of as clinical waste and sapphire tips thoroughly cleansed post-procedure. It has been demonstrated that cold sapphire skin cooling with gel suppresses plume during laser hair removal.³⁷

Similarly, use of hydrogel packs or cling film can reduce tissue splatter and aerosolisation during laser tattoo removal.³⁸