Department of Dermatology

S.O.P. OF SPLIT SKIN THICKNESS GRAFTING

• Written informed consent should be taken.

• Procedure explained to patient.

• Universal precautions.

• Proper sterilization of instruments.

• Shaving of the donor and recipient area.

• Donor site is marked and cleaned.

• Topical anesthesia (EMLA) or field block with 1% lignocaine at the edges to be given.

• Split thickness graft of uniform thickness is harvested using humby’s knife by holding cutting blade at an angle of 10-15˚ and employing sliding to and fro motion.

• The harvested graft is then transferred to a sterile petri dish containing normal saline.

• The donor site is dressed with non-adherent dressing

• Recipient site is marked and cleaned.

• Topical anesthesia with occlusion or 1% lignocaine is infiltrated into four quadrants.

• The area is then abraded with mechanical dermabrader including 2-3 mm of perilesional skin.

• The graft is punctured with 2-3 holes with 24g needle, and the slide is everted on the recipient area with dermal side facing down.

• The edge of the graft is evened out with spatula.

• The graft is then immobilized with surgical adhesive followed by pressure dressing.

• Dressing is changed after 24 hour and subsequently after 1 week.

S.O.P. OF PRP THERAPY

Pre procedure workup

• Explain - risk, complications, limitations and potential alternative procedures

• Take history—Bleeding diasthesis, keloidal tendency, isotretinoin use, immunosuppressive agents, HIV, hepatitis B, herpes simplex infection, drug history (aspirin, etc.)

• Investigations—CBC, BT, CT, PT, blood sugar, hepatitis B and HIV serology.

• Informed consent and photography

PRP Preparation:

•       Method- Double spin centrifugation using a centrifuge machine.

•       Twenty millilitre blood is taken from each patient under sterile condition and put into conical tubes (15 ml) that contains 4 drops of EDTA.

•       1st spin - Centrifuge at 1500 rotations for 10 minutes 

•       Precipitation of RBCs occurs at the bottom of the tube and the plasma-containing platelets at the rest of the tube.

•       Plasma - transferred to an empty tube

•       2nd spin - centrifuge again at 3000 rotations for 10 minutes.

•       2 parts - the PRP (the lower one-third) and the platelet-poor plasma (PPP), the remaining upper portion).

•       Then PRP is taken for therapy.

•       Face of the patient - washed with soap and water.

•       The area to be treated - anesthetized with topical EMLA cream(2.5% lignocaine+2.5% prilocaine), under occlusion for 30 minutes.

Techniques of PRP delivery

• Intradermal injections by insulin syringes :The area to be injected is divided into grids and 0.1 mL is injected in each area, preferably 0.1 mL/cm² (as used in intralesional triamcinolone injection) at a distance of 1 cm each.

• Along with microneedling/dermaroller- PRP is sprinkled over the areas where dermaroller or microneedling has been done.

• Combination treatments with fractional lasers, fillers and autologous fat.

• Topical application of PRP gel on ulcers.

S.O.P. OF ND:YAG LASER THERAPY

• Informed consent obtained.

• Digital photographs of the lesion/tattoo - prior to every session, with adequate lighting and proper position.

• Assess skin type and do lesional examination again.

• Anesthesia: topical anesthesia (EMLA cream) applied for about 40 min under occlusion.

• For fewer lesions - can be done without anesthesia.

• For nevus of Ota, larger tattoo and Becker's nevus - local anesthesia or nerve blocks are preferred.

Patient preparation:

• Remove make up and jewellery.

• Position the patient comfortably.

• Shave, if hairs are more in the area.

• The treatment area should be cleansed with normal saline/betadine.

• Cover the area - not intended for treatment.

• Use protective goggles

• Mark the treatment area into grids while treating large lesions.

•    Laser safety measures to be followed.

Test patch:

• It is to be done in patients with darker skin

• A small (2 × 2 cm) area should be subjected to laser before lasing the complete lesion

• Test spots - evaluated for 5 minutes in lighter skin and 10 min in darker skin for the desired clinical end point of pigmented lesion.

• The test spot fluence is selected as the treatment fluence.

• The lasing tip is placed in direct contact with the skin and perpendicular.

• Each spot should have an overlap of 10% to 20% with the previously treated spot.

• Depending on the thickness of the lesion and clinical endpoint, number of passes is to be determined.

• If clinical end points not reached, second pass done with same or lesser fluence.

• If any adverse reaction signs are noticed, then stop the procedure and reset the parameters.

End point:

• Mild whitening (frosting) and erythema in case of freckles, nevus spilus and cafe au lait macules

• frosting and mild pinpoint bleeding in case of tattoos, nevus of Ota and postinflammatory hyperpigmentation

Post procedure Care

• Immediately after the laser cold compresses are given for 15 to 20 minutes to decrease inflammation and a thin layer of antibiotic/re-epithelization cream is applied.

• Thrice daily application of moderate potent steroid and antibiotic combination cream for 3 to 5 days.

• Twice daily intake of anti-inflammatory drug for 3 to 5 days.

• Strict Sun protection with repeated application of sunscreen and physical protection.

• Not to pick the lesion or scab and allow the scab to fall on its own

• Wash with water or mild cleanser.

• Avoid using cosmetics containing retinol/AHA/alcohol for at least 5 to 7 days.

S.O.P. OF MICRODERMABASION

Patient counselling

• Explain - risk, complications, limitations and potential alternative procedures

• Priming (at least 2 to 6 weeks prior)

Preoperative work up

• History—Bleeding diasthesis, keloidal tendency, isotretinoin use, immunosuppressive agents, HIV, hepatitis B, herpes simplex infection, drug history (aspirin, etc.)

• Investigations—CBC, BT, CT, PT, blood sugar, hepatitis B and HIV serology, fitness for GA, if required

• Informed consent and photography

Procedure

• Anesthesia: can be done under local anesthesia, regional block cryoanesthesia or general anesthesia.

• When done under local anesthesia, adrenaline avoided as the level of dermabrasion cannot be assessed because of adrenaline-induced vasoconstriction

S.O.P. OF HAND AND FEET PHOTOTHERAPY

• Written informed consent should be taken & procedure explained to patient.

• Avoid all topicals for 4 hours before procedure except mineral oil.

• All patients to wear UV opaque goggles.

• Parts not to be treated are covered.

• Patient sits with hands and feet extended, in phototherapy Hand and feet unit. 

• Initial irradiation dose: Determine MED (minimal erythema dose)

• Initial irradiation dose: 70% of MED

• It is given three times weekly for most cases, with 2 days between treatments.

• Usual course: 18-24 treatments.

• Maximum number of treatments per course: 30, Maximum dose/treatment: 4.3 J/cm².

• If develop small areas of erythema: repeat previous dose, apply high factor sunscreen to affected area for one treatment.

• If develop facial erythema or unacceptable facial pigmentation, a face shield or sunscreen should be used for each treatment.

• If develop pruritus: encourage use of emollients and antihistamines.

• If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids immediately after treatment. Postpone treatment if troublesome and reduce to 10 % increments.

• Subsequent visits:

o   Minimal erythema lasting <24 h following treatment - Increase dose by 20%

o   Erythema persistent for >24 h but <48 h -Dose held at previous level until erythema lasting < 24 h

o   Erythema lasting >48 h -No treatment on that day followed by return of dose to the last lower dose that did not cause persistent erythema.

• Missed visits:

  • 1 week – hold the previous dose constant

  • 1-2 week – decrease previous dose by 25%

  • 2-4 week – decrease previous dose by 50%

  • >4 week – return to starting dose

• Maintenance therapy- taper treatment twice weekly for 4 week and then once weekly for 4 weeks (dose held constant).

S.O.P. OF FIRE HAZARD

• Rescue/Remove - Rescue or remove any persons from the immediate scene.
• Perform - thorough assessment for burn injuries, including the entire posterior as well as anterior body surface areas.
• Apply a dry sterile dressing to injured areas.
• Assess the airway if an airway fire or a fire around the patient's face or neck has occurred.
• Assess the patient and all personnel for smoke inhalation.
• Transfer patients who meet the American Burn Association's (ABA) criteria for major burns to a burn center.
• Alert/Activate - Pull the nearest alarm and call 101.
• Confine - Close all doors to the hazard or fire area
• Stop flow of all airway gases.
• Remove all drapes and burning material.
• Extinguish small fires by patting with moist towels or sponges.
• Pour water or saline on any hot spots immediately.
• Remove drapes even if fire is immediately extinguished to assess for smoldering elements and flames.
• Extinguish/Evacuate - Extinguish using the closest fire extinguisher if the fire impedes your evacuation.
• When evacuating, be sure to feel doors for heat before opening them to be sure there is no fire danger on the other side.
• If there is smoke in the air, stay low to the ground, especially your head, to reduce inhalation exposure.
• Keep hand on the wall to prevent disorientation and crawl to the nearest exit.
• Go to your refuge area and await further instructions from emergency personnel.

S.O.P. OF SALICYLIC ACID PEEL

• Procedure should be explained to the patient & written informed consent taken.
• Pre peeling priming done and clinical photographs before the procedure taken.
• Universal precautions taken.
• Wash the face with soap and water.
• Placed in the sitting position or supine with the head elevated at an angle of 45 degree.
• Eyes are closed and the ears are plugged with cotton.
• A surgical cap is used to pull back and cover the hair.
• Face is cleaned with spirit and then degreased with acetone using a gauze piece.
• Salicylic acid peel is taken in a petri dish.
• Sensitive areas like the inner canthus of the eye, nasal–alar junction and lips are sealed with petrolatum.
• Peeling agent is then applied with a cotton tipped applicator over entire face on cosmetic units beginning from the forehead, right cheek, nose, left cheek & chin.
• The peri-oral area, and upper and lower eyelids are treated last.
• Feathering strokes are applied at the edges.
• Kept for at least 3 to 5 mins after burning subsides or until the end point of frosting obtained after 1-3 coats.
• The skin is gently dried with gauze and patient is asked to wash with cold water.
• The face is patted dry.
• Sunscreen is applied before the patient leaves the clinic.
• Emollients are used if there is excessive dryness.

S.O.P OF DARK FIELD MICROSCOPY

• Written informed consent should be taken.

• Procedure should be explained to the patient.

• Clean the lesion with sterile gauze soaked in saline.

• Moist lesion: Gently abrade with dry gauze.

• Dry lesion: Break the surface (near the edge) and squeeze the base of lesion to encourage flow of serum

• In inaccessible areas (cervix, anal canal) collect serum into capillary tube.

• Cover slip held in cornet forceps is applied to the surface of lesion.

• Place it over thin glass slide and press down firmly.

• Examine immediately under microscope.

S.O.P. FOR SLIT SKIN SMEAR

• Explain the procedure to patient and take consent for the same.

• Follow all the universal precautions.

• Select the site and clean it with ether.

• Grip a portion between thumb and forefinger of left hand (till blanching is achieved)

• Make an incision 5mm long and 3mm deep with No.15 blade.

• Turn the blade at right angle to the cut and scrape the wound several times in the same direction.

• Make the smear of collected fluid and fix it over flame.

• Perform ZN staining:

• Cover the slide with carbol fuschin and apply heat intermittently, leave for 15min and wash.

• Pour acid alcohol (1% HCL in 70% alcohol) and leave for 3sec. Wash it away with running water.

• Cover the slide with 1% methylene blue for 10sec and wash in running water

• Examine the slide under microscope.

S.O.P. OF RADIOFREQUENCY ABLATION

• Procedure explained to the patient.

• Written informed consent of patient taken.

• Correct documentation and clinical photographs taken.

• Universal precautions followed.

• Proper sterilization of instruments performed.

• Clean with betadine. Avoid spirit.

• The machine is put on minimum power setting for fulgration and medium power for ablation.

• Desired electrode is fixed to the hand piece.

• The electrode is placed on the saline soaked gauze and RF machine is activated and deactivated.

• Tissue is wetted with saline before passing radio waves to reduce tissue resistance.

• The hand piece is held in a pen like fashion and the tip of the electrode is swiftly moved through the tissue. The contact time of the tip with the electrode should be very brief.

• After each use the tip of the electrode is wiped on the rough surface of the saline soaked gauze thus removing all debris and dirt.

• The tissue is removed in parts for better cosmetic results.

• After removing the lesion, finishing touches of flushing the area with surrounding skin is done using different electrodes.

• Holding the pedunculated lesion with forceps helps to minimize the tissue damage.

• After removing the lesion, the area is cleaned and dressed with antiseptic dressing.

• Most of the time, prophylactic antibiotics are not needed except in cases of infected lesions.

• Analgesics may be given if needed.

S.O.P. OF PUNCH SKIN BIOPSY

• Procedure explained to the patient.

• Written informed consent of patient taken.

• Correct documentation and clinical photographs taken.

• Universal precautions followed.

• Proper sterilization of instruments.

• Cleaning with betadine and spirit.

• Marking the area before infiltration.

• Infiltration with local anaesthesia: 1% xylocaine with or without adrenaline, depending upon the site. While infiltrating, elevate the lesion by raising a wheal which allows the lesion to prop up.

• According to the size of sample required size of punch (1-10 mm) is selected. Routinely a 4 mm punch is used.

• Traction is given in a direction perpendicular to long axis of resting skin tension lines.

• For scalp biopsy, rim of the ring of an artery forceps is pressed against the scalp surface.

• Punch is held vertically, and a steady pressure is applied.

• Punch is rotated in a clockwise manner till tissue cast is completely separated from collagen fibres of reticular dermis and the punch reaches the subcutis (feeling of giveaway).

• Punch is withdrawn.

• Tissue cast is lifted with fine forceps or a needle to avoid crushing and damage.

• It is cut at base with scissors.

• Wound is sutured with interrupted sutures.

• Post procedure dressing, topical and oral antibiotics given.

• Suture removal after 7-10 days.

• Careful labelling of specimen including patient’s and physician’s name, date, and location of the lesion done.

S.O.P. OF PUNCH GRAFTING

• A detailed consent form describing the procedure and possible complications should be signed by the patient.

• The recipient site is locally anesthetized by infiltration of 2% xylocaine or by application of EMLA cream applied under occlusion for 1-2 hours.

• Punches of Size 1 mm–1.5 mm diameter is taken from donor areas.

• The same size of punch is used at the recipient site.

• Sockets are created in the recipient area at a distance of 5-10 mm.

• The harvested grafts are placed in the sockets.

• Thinner grafts are used so that the upper surface of the grafts remains at the level of the recipient skin.

• In case of thicker grafts, the under surface of the graft is trimmed.

• Sharp cutting instruments and non-toothed forceps are used to prevent damage to the graft cells.

• A nonadherent dressing is applied and bandaged using adhesive tape.

• The dressing over the donor site is removed after 24 hours and cleaned daily.

• The dressing over the recipient site is left on for 7 days.

• The patient is advised to keep the area immobile. 

S.O.P. OF PODOPHYLLIN APPLICATION

• Written informed consent explaining the procedure is taken.

• Patient lies down in supine position exposing the area involving the lesions.

• Vaseline is applied on the surrounding skin.

• Podophyllin is applied using a cotton stick applicator or a swab on the lesions.

• In case of large lesions, application should not exceed more than 10 cm² per sitting or more than 0.5 ml.

• Podophyllin is allowed to dry.

• Patient is asked to wash with water after 2-4 hours.

S.O.P. OF WOOD’s LAMP

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• The lamp should ideally be allowed to warm up for about 1 minute.

• The examination room should be perfectly dark, preferably a windowless room or a room with black occlusive shades.

• The examiner should get dark adapted in order to see the contrast clearly.

• The examiner should not wear an apron.

• The light source should be 4 to 5 inches from the lesion.

• Do not wash the area before procedure .

• Topical medicaments, lint and soap residues should be wiped off from the site to be examined.

S.O.P. OF MANAGEMENT OF VASOVAGAL SYNCOPE

• Recognition of unconsciousness

• Call for help.

• Check for protective reflexes.

• Place patient in Trendelenburg position, i.e., head and chest slightly below a line parallel to the floor and feet slightly elevated.

• Assess & open airway – head tilt, chin lift

• Airway patency, breathing, circulation – look, listen & feel.

• Artificial ventilation and cardiac massage – Cardiopulmonary resuscitation if required.

• Shift the patient to specialized unit for further management.

S.O.P. OF TRICHOSCOPY

• Procedure is explained and consent is taken.

• Correct documentation and clinical photographs.

• Dermoscope is attached to mobile phone with appropriate focus.

• The dermoscope is placed at the lesional site on scalp with non polarised mode.

• Multiple images are captured in different fields and magnification.

• The dermoscope is switched to polarised mode to record more pictures.

• Immersion fluid is poured over the lesional site and the images are taken in polarised mode.

• The recorded images are evaluated for follicular, interfollicular and hair shaft changes.

• Changes in scalp surface recorded.

S.O.P OF SCAR SUBCISION

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• Mark the boundaries of the scar

• Clean the area with spirit swab.

• Infiltrate with1% lignocaine mixed with adrenaline at the marked boundaries of the scar.

• Insert a 18G or 20G needle adjacent to the scar with the bevel upwards parallel to the skin surface into the deep dermis.

• Move back and forth in a fan-like motion under the scar to release fibrous bands at dermal and deep dermal subcutaneous plane.

• A snapping sound is heard as the fibrous bands are broken.

• Hemostasis is maintained with pressure.

S.O.P. OF PARING

• Informed consent will be taken

• Procedure explained to the patient

• Clean the affected site with betadine swab

• Take aseptic precautions and wear gloves

• Take a 24 number blade

• Remove hyperkeratotic skin till pinpoint bleeding occurs

• Clean with betadine

• Dressing will be done

S.O.P OF MILIA EXTRACTION

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• Clean the site with normal saline.

• Stretch the skin around milia.

• Deroof the milia with an insulin syringe.

• With the help of a milia extractor, extract the keratinous material gently by applying tangential pressure.

• Follow similar steps for other milia.

S.O.P. OF SKIN/NAIL SCRAPING

SKIN

• Informed consent from the patient will be taken

• Procedure explained to the patient

• Expose the site of lesion

• Swab the site with spirit

• Scrap the lesion at active border with a 15 number blade and put on a clean glass slide

• Add 1 to 2 drops of 10% KOH and put cover slip

• Wait for 10 to 15 minutes for the keratin to digest

• Examine under microscope

NAIL

• Written informed consent from the patient is taken

• Procedure explained to the patient

• Scrap the affected site of a nail with a considerable depth

• Scoop out the deeper kerationous matrix

• Put in 10% KOH containing container and leave for 24 hours to digest

• Examine under microscope