Department of Dermatology

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 IPL THERAPY

• Standard precautionary measures should be observed:
• Eyes of the patient should be wrapped with white gauze pieces or covered with goggles.
• The treatment area should not be covered by metallic objects such as chains.
• Cosmetic chairs made of washable material and without any visible metallic surface, which may reflect light-Laser beams accidentally, should be used.
• Hair should be trimmed with an electrical trimmer or the patient can shave the area a day earlier.
• The area to be treated should be properly cleaned with soap/detergent and it should be free from make-up.
• A topical anesthetic such as EMLA/Prilox ^® is applied 30-90 minutes before the actual procedure
• Adequate lighting on treatment area is essential.
• Depending on the area to be treated, the patient can be in a supine or sitting position.
• The hand piece of the system should be placed perpendicularly to the skin surface.
• The larger the spot size, the better is the penetration.
• After the entire procedure is complete, cryogen spray or chilled Eau Thermal water or ice packs may be used.
• Proper sunscreen is applied.

S.O.P. OF CO2 LASER ABLATION

Informed consent

• 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.

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.

Procedure

• The laser probe is put over the lesion and the foot pad is pressed

• Laser waves are delivered in a pulsed manner until the lesion is cleared

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.

• 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 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 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. FOR WHOLE BODY PHOTOTHERAPY

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 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 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 NAIL AVULSION

• Procedure to be explained to patient

• Written informed consent of patient to be taken.

• Universal precautions.

• Proper sterilization of instruments.

• Correct documentation and clinical photographs.

• Cleaning with betadine and spirit.

• Proximal digit block is given by introducing needle at the base of digit and then pushed in ventral direction injecting large amount of 2% lignocaine.

• Waiting time of 10-15 minutes.

• Separation of nail plate from proximal nail fold by introducing freer septum elevator under proximal nail fold and moved laterally in gliding movement.

• Separation of nail plate from nail bed by introducing Freer septum elevator under the nail plate at the level of hyponychium and pushed toward lunula.

• The spatula is withdrawn and re-introduced in adjoining area till entire area is separated.

• Separated nail plate is grasped with a hemostat and avulsed by twisting the hemostat along long axis.

• Sectioning of avulsed nail with nail splitter in case of partial nail avulsion.

• Post procedure dressing, topical and oral antibiotic.

• Dressing changed after 48 hours and examined.

• Dressing for 10-30 days.

• Written informed consent is taken after explaining the procedure, the achievable results, recurrence rate and various complications of the procedure.

• History regarding general medical condition and cutaneous complaints is taken.

• Physical examination: the skin type of patient, features of lesion such as site, size, shape, margin, location, depth, approximation to superficial nerves and any previous treatment sites is undertaken.

• The area to be treated is adequately exposed and cleaned thoroughly with spirit or povidone iodine. 

• Eyes, ears, nares are protected with goggles, gauze, or padding.

• Topical anesthesia or intralesional anesthesia is given.

Timed spot freeze technique

• Cryogen is sprayed from a hand-held gun device at 1 cm from surface of the lesion.

• Spraying is continued till the formation of ice ball.

• Adequate treatment is ensured by measuring the lateral spread of freeze.

• Spraying is continued for adequate duration.

• The lesion is allowed to thaw to complete one freeze thaw cycle.

• Complete thawing is observed when the frozen white surface disappears.

Open spray technique

• Indication: Large superficial irregular shaped lesions.

• Paint brush method: Cryogen is sprayed from one side of lesion, moving up and down across the lesion.

• Spiral method: Cryogen is sprayed from center of the lesion towards outside in concentric circle.

Confined spray technique

• Indications: Small round and discrete lesions near vital structures.

• Polystyrene cones are placed on the cryogun.

POST PROCEDURE CARE

• The patient is explained about the immediate skin reactions that occur post-cryotherapy.

• The patient is asked to apply a mild to moderately potent topical steroid and antibiotic combination and a non-steroidal anti-inflammatory drug (NSAID) is concomitantly administered.

• The treated area is left open, washed gently with soap and water and patted dry.

S.O.P OF IONTOPHORESIS

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• Fill the two trays with room temperature water up to the electrodes.

• Connect the trays to the unit’s output. Make sure the machine is off.

• Make sure the patients have no jewelry on and all cuts are covered with Vaseline or a similar substance.

• Have the patient place each hand in one tray. The water should reach just above the tops of the hands.

• Turn the machine on. Begin with the intensity knob at 0 and gradually increase the amperage until it is between 15 to 18 mA. Treat at this level for 10 minutes.

• Once the 10 minutes are up slowly decrease the current flow to zero.

• When the meter reads zero and the active light shuts off, switch the direction of the flow.

• Repeat steps four through six for another 10 minutes.

S.O.P. OF DERMAROLLER

A written informed consent must be obtained prior to the procedure and before photographs.

• Photographs:

Digital photographs to be taken in standard positions from front and sides prior to the procedure. Take photographs before every session, with same patient position.

• Anaesthesia:

• Topical anaesthesia, EMLA /Lignocaine spray is to be applied 45 minutes to 1 hour before the procedure under occlusion with cellophane tape. After an hour, topical anaesthetic is removed.

• The area to be treated is painted with antiseptic povidone- iodine and isopropyl alcohol solutions.

• Normal saline is used to cleanse the area treated with antiseptic.

• Patient positioning:

The procedure is done in a semi supine position with head elevated to 45° and eyes closed.

•Preoperative care:

• Active acne should be treated prior to the procedure. Topical retinoids, should be stopped, at least a week before the procedure.

• Oral isotretinoin is to be ideally stopped 6 months before.

• Any active infection like herpes simplex should be treated. Patient with strong history of herpes labialis should receive prophylactic oral antivirals before the procedure.

Technique:

• Dermaroller is held in the hand with a pen grip.

• The skin to be treated is stretched with one hand and the other hand is used to slide the roller. The roller is moved in a direction perpendicular to the stretching force.

• Choosing the proper needle size ensures proper depth of penetration. Usually, 1.5 to 2 mm long needles are used for the treatment of acne scars.

• Bony areas like forehead and nose require lesser pressure.

• Periorbital areas being delicate must be treated with special care.

• The dermaroller should be held with a proper grip by the right hand and should be rolled over the area in different directions rolled in horizontal, vertical and oblique directions 6 to10 times.

• Uniform controllable pinpoint bleeding spots are taken as the end.

• The oozing can be wiped and minimized by keeping cold saline gauze over treated areas. This will also reduce the erythema and oedema post procedure.

• The treatment is to be repeated after 4 to 6 weeks. The patient should be thoroughly counselled regarding the outcome of procedure and need for multiple sessions.

• One roller is used per patient. The roller must be properly cleaned after every use. Avoid repeated use (more than 4–5 times) as it can make needles blunt.

Post-procedure care:

• Saline gauzes are kept for 15 to 20 minutes.

• Patient needs to be explained about changes likely to occur post procedure.

• Facial erythema and oedema appear initially which lasts for 24 to 48 hours. Crusting and scab formation is noted by the 2nd or 3rd day which falls off by itself after 4 to 5 days without any mark or pigmentation.

• Strict sun protection is advised to avoid post inflammatory hyperpigmentation.

• patient is advised to avoid use of cosmetics till a week or till the scabs fall off.

• Patient asked to avoid use of scrubs, cleansers.

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 CHEMICAL CAUTERIZATION

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• Dip the wooden stick in the chemical to be used.

• Remove excess chemical.

• Apply the chemical carefully without spilling it to the surrounding skin.

• End point is erythema and frosting.

• Instruct the patient to not wash the site for 3 hours.

• Procedure to be repeated weekly, if needed.

SOP OF TCA CROSS

• Inform the patient about procedure and take consent for the same.

• Do a patch test in the post auricular area.

• The face is cleaned with spirit and degreased with acetone.

• Scars are marked with surgical marker.

• Proper eye shield is used and patient is made to lie down with face slightly projecting upwards.

• The skin is stretched.

• 100% TCA is applied to the base of the scar using wooden toothpick till frosting appears.

• Advice strict post-procedure photo-protection

  .

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 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 COMEDONE EXTRACTION

• Informed consent will be taken from patient

• Procedure explained

• Clean the affected site with betadine swab

• Take aseptic precautions and wear gloves

• Take a sterile comedone extractor

• Press onto to the lesion such that comedone lies in the center of extractor

• Take out the keratinous material

• Repeat the procedure if several lesions present

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 INTRALESIONAL STEROID INJECTION

• Written informed consent of patient should be taken.

• Procedure should be explained to the patient.

• Clean the site with spirit swab. Allow the area to get dry.

• Lesional area is infiltrated with 1% lignocaine.

• The initial dose per injection site varies depending on the lesion.

• 0.1-0.2ml is injected per square centimetre of involved skin using insulin syringe. Total dose should not exceed 1ml per dose. The corticosteroid can be full strength or diluted with normal saline or local anaesthetic.

• Inject the needle at a 45 to 90 degree angle into the lesion to the level of mid dermis, then slowly inject the drug.

• The skin rises slightly and blanches when deposited correctly into the mid dermis.

• Clean any blood if present with a swab.

• Repeat the injections 3 weekly, if needed.

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 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 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 INCISIONAL SKIN BIOPSY

• Procedure explained to the patient & written informed consent taken.

• Correct documentation and clinical photographs taken.

• Universal precautions followed.

• Proper sterilization of instruments performed.

• Cleaning with betadine and spirit.

• An ellipse is drawn using a surgical marker, methylene blue or gentian violet at the active edge of the lesion including normal skin.

• Apex of ellipse should have 30֯ angle on each side.

• The length should be three times the width.

• Infiltration with local anaesthesia: 1% xylocaine with or without adrenaline, depending upon the site. Field block is given.

• Area is kept taut and scalpel with No. 15 blade is held like a pencil.

• As the incision progresses blade is angled to 45֯ to cut the tissue with the belly of the blade.

• At the end of the incision again the scalpel is lifted vertically to prevent the excision from extending beyond the end point.

• Same steps are repeated on the other side.

• Ellipse of tissue separated from underlying tissue with scalpel or dissecting forceps.

• Interrupted sutures are taken.

• For larger and deeper defects suturing is done in two layers.

• Dressing done after applying antibiotic cream.

• Sutures removed after 5 – 10 days depending on the area.

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

S.O.P. OF EXCISIONAL SKIN BIOPSY

SOP OF DERMOSCOPY

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

• Clinical photographs of the patient should be taken before performing dermoscopy.

• Clean the lens of 3Gen-DermLite DL4 dermoscope using wipes and alcohol solution and let it dry.

• Put attatchment on the smartphone with which photographs have to be taken.

• Clean the site to be assessed with ethanol and let it dry

• Put ultrasound gel or gel sanitizer as interface medium, visualize the affected area using polarized light and then under non polarized light by touching the skin using dermoscope through liquid interface.

• Observe the lesion under dermoscope using smartphone and take appropriate photographs.[CONTACT DERMATOSCOPY].

• Now wipe off the gel/sanitizer and observe the lesion using dermoscope without touching the skin in both polarized and non-polarised mode and take required photographs[NON-CONTACT DERMATOSCOPY].

• Clean the lens of dermoscope again after finishing the procedure.

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 TZANCK SMEAR

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

• In case of a blister: Deroof a fresh blister.

• Floor is scraped using a sterile blade.

• Material is the smeared on a clean glass slide.

• In case of genital ulcer: wipe the lesion with saline gauze, followed by dry gauze.

• Remove a small piece of tissue from the border of a well-defined ulcer using a curette/forceps/edge of a blade.

• Place this specimen on a clean grease-free microscopic glass slide and crush the specimen between two clean slides.

• In case of suspected molluscum contagiosum: compress the lesion to extrude the cheesy material or use a small curette to remove the top of a papule.

• Crush the specimen between two clean grease free microscopic slides and stain.

• Prepare a solution with 1:10 dilution with giemsa stain and water.

• Pour the prepared solution over the smeared slide, keep for 10 minutes.

• Examine under the microscope.

S.O.P. OF GRAM STAINING

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

• Clean the site with ethyl alcohol, let it dry.

• In case of crusted lesion, scrap the crust and take the exudate on a clean slide.

• In case of pus-filled lesions, take out the pus with swab on a clean slide.

• Dry and heat fix the smear.

• Slide is flooded with 2% crystal violet and allowed to stain for 2 minutes.

• Rinse off gently with water.

• Gram’s iodine is added and kept for 1 min

• Decolorize with acetone-ethanol for 10-20 seconds.

• Counterstain with safranin for 30 sec-1min and rinse with water.

• Air dry and examine under the light 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 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 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

S.O.P. OF LIGHT MICROSCOPY

Turn the revolving turret so that the lowest power objective lens (eg. 4x) is clicked into position.

• Place the microscope slide on the stage and fasten it with the stage clips.

• Look at the objective lens and the stage from the side and turn the focus knob so the stage moves upward.

• Move it up as far as it will go without letting the objective touch the coverslip.

• Look through the eyepiece and move the focus knob until the image comes into focus.

• Adjust the condenser and light intensity for the greatest amount of light.

• Move the microscope slide around until the sample is in the centre of the field of view.

• Use the focus knob to place the sample into focus and readjust the condenser and light intensity for the clearest image.

• When you have a clear image of your sample with the lowest power objective, you can change to the next objective lenses. You might need to readjust the sample into focus and/or readjust the condenser and light intensity.

• Do not let the objective touch the slide.

• When finished, lower the stage, click the low power lens into position and remove the slide.

PRECAUTIONS :

• Do not touch the glass part of the lenses with your finger

• Use only special lens paper to clean the lenses.

• Always keep your microscope covered when not in use.

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 UV STERILISATION

• Clean and dry the instruments to be sterilised.

• Make sure the power plug is plugged properly.

• Open the door of UV chamber.

• Place the instruments separately into the chamber.

• Close the door and press the start button. ( timing of sterilization varies for various objects; usually 20-25 minutes)

• See through the perspective window to confirm that all the lamps are working functionally.

• When the lamps are turned off, open the chamber door and take out the objects.

S.O.P. OF AUTOCLAVE

• Loosen the screws and open the lid of autoclave .

• All the culture media , gloves , gowns , rubber materials , dressings are to kept in the tray.

• Fill water in the tray.

• The lid is then fastened with the screw clamps.

• Connect it to the electric socket by which heating will be done.

• It is to be set at a temperature of 121 degree Celsius at a pressure of 15 pounds (lbs ) for 15 minutes.

• The steam circulate within the chamber under high pressure to sterilize all the instruments.

S.O.P. OF ACCIDENTAL CHEMICAL SPILL

• Alert people in the area. Avoid breathing vapours and try to determine what spilled.
• Wear personal protective equipment including safety goggles and gloves during clean-up.

• Confine the spill to a small area. Use a commercial kit or absorbent material to absorb spilled materials.

• Place the saturated absorbent in a plastic bag. Label the bag with a hazardous waste tag.

• Clean the spill area with water.

• In case of contact with skin, remove contaminated clothing.

• Irrigate the affected area with copious amounts of water.

• Wash for at least 20 minutes, taking care not to allow runoff to contact unaffected areas.

• Chemical burns involving elemental metals (lithium, potassium, sodium and magnesium) should not be irrigated with water. It should be soaked with mineral oil.

• People with minor chemical burns do not require hospitalisation. 

• For more severe burns, patients should receive treatment as for a typical thermal  

  • burn patient.

• In some situations, an antidote may be given to counteract the offending chemical agent. (eg. Sodium bicarbonate for Trichloroacetic acid)

• Careful monitoring of the wound should be performed.

• Keep wound clean and prevent drying out.

• Management of secondary infection.

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 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. FOR PATIENT ADMISSION

• Make diagnosis and explain the patient about the necessity of admission.

• Send RT-PCR for COVID and shift the patient to ward, once negative.

• Take high risk consent ( if necessary)

• Send relevant investigations.

• Issue of CADS number from Emergency and submit to Sister Incharge ( Ward 10)

• Start appropriate treatment.

• Maintain patient’s confidential record file.

• Maintain 12 hourly progress report of patient.

• Plan discharge on the basis of clinical and symptomatic improvement.

S.O.P. FOR OUTPATIENT DEPARTMENT

• Patient will register himself/herself in OPD 7.

• Greet the patient.

• Ask for his/her presenting complaints.

• Examine the patient. Privacy should be maintained. Female patient should be examined in the presence of a female attendant.

• Send investigations wherever necessary.

• Diagnose on the basis of history and clinical examination.

• Explain the patient about diagnosis and various treatment options available.

• Treat the patient with best option available.

• Counsel for follow up.