Skin Cancer Management During the COVID-19 Pandemic

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Practice Points

  • Consider the rate of cases and transmission in your area during a pandemic surge when triaging surgical and nonsurgical cases.
  • If performing head and neck surgical procedures or cosmetic procedures in which the patient cannot wear a mask, consider testing them 24 to 48 hours before the procedure.
  • Follow Centers for Disease Control and Prevention (CDC) guidelines concerning screening asymptomatic patients. Also, follow CDC guidelines on testing patients who have had prior infections.
  • Ensure proper personal protective equipment for yourself and staff, including the use of properly fitting N95 respirators and face shields.



The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2), has presented a unique challenge to providing essential care to patients. Increased demand for health care workers and medical supplies, in addition to the risk for COVID-19 infection and asymptomatic transmission of SARS-CoV-2 among health care workers and patients, prompted the delay of nonessential services during the surge of cases this summer.1 Key considerations for continuing operation included current and projected COVID-19 cases in the region, ability to implement telehealth, staffing availability, personal protective equipment availability, and office capacity.2 Providing care that is deemed essential often was determined by the urgency of the treatment or service.

The Centers for Medicare & Medicaid Services outlined a strategy to stratify patients, based on level of acuity, during the COVID-19 surge3:

  • Low-acuity treatments or services: includes routine primary, specialty, or preventive care visits. They should be postponed; telehealth follow-ups should be considered.
  • Intermediate-acuity treatments or services: includes pediatric and neonatal care, follow-up visits for existing conditions, and evaluation of new symptoms (including those consistent with COVID-19). These services should initially be evaluated using telehealth, then triaged to the appropriate site and level of care.
  • High-acuity treatments or services: address symptoms consistent with COVID-19 or other severe disease, of which the lack of in-person evaluation would result in harm to the patient.

Employees in hospitals and health care clinics were classified as essential, but dermatologists were not given explicit direction regarding clinic operation. Many practices have restricted services, especially those in an area of higher COVID-19 prevalence. However, the challenge of determining day-to-day operation may have been left to the provider in most cases.4 As many states in the United States continue to relax restrictions, total cases and the rate of positivity of COVID-19 have been sharply rising again, after months of decline,5 which suggests increased transmission of SARS-CoV-2 and potential resurgence of the high case burden on our health care system. Furthermore, a lack of a widely distributed vaccine or herd immunity suggests we will need to take many of the same precautions as in the first surge.6

In general, patients with cancer have been found to be at greater risk for adverse outcomes and mortality after COVID-19.7 Therefore, resource rationing is particularly concerning for patients with skin cancer, including melanoma, Merkel cell carcinoma, mycosis fungoides, and keratinocyte carcinoma. Triaging patients based on level of acuity, type of skin cancer, disease burden, host immunosuppression, and risk for progression must be carefully considered in this population.2 Treatment and follow-up present additional challenges.

Guidelines provided by the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO) elaborated on key considerations for the treatment of melanoma, keratinocyte carcinoma, and Merkel cell carcinoma during the COVID-19 pandemic.8-10 Guidelines from the NCCN concentrated on clear divisions between disease stages to determine provider response. Guidelines for melanoma patients proposed by the ESMO assign tiers by value-based priority in various treatment settings, which offered flexibility to providers as the COVID-19 landscape continued to change. Recommendations from the NCCN and ESMO are summarized in Tables 1 to 5.

Although these guidelines initially may have been proposed to delay treatment of lower-acuity tumors, such delay might not be feasible given the unknown duration of this pandemic and future disease waves. One review of several studies, which addressed the outcomes on melanoma survival following the surgical delay recommended by the NCCN, revealed contradictory evidence.12 Further, sufficiently powered studies will be needed to better understand the impact of delaying treatment during the summer COVID-19 surge on patients with skin cancer. Therefore, physicians must triage patients accordingly to manage and treat while also preventing disease spread.


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