Editor
As a novel coronavirus pathogen, COVID‐19 and the current associated pandemic have rapidly transformed daily life since its first detection in December 2019 in Wuhan, China. Not only are strict social distancing measures now the status quo, but within the occupational setting of healthcare provision, healthcare workers (HCWs) have had to quickly adapt to an entirely different way of working. Part of this new routine encompasses the now habitual donning of personal protective equipment (PPE), not least the filtering face piece respirator (FFP), particularly for aerosol generating procedures (AGPs). In this regard, front‐line workers face the largest risk not only from COVID‐19 exposure, but also from the consequences of wearing PPE for extended periods.
Whilst specific cutaneous sequelae due to COVID‐19 itself have not yet been described, skin problems related to PPE worn during the pandemic are emerging, and have recently been recognized in the document published in April 2020 by NHS England which provides advice on how to prevent facial skin damage beneath PPE. 1 , 2 This document advocates use of a skin protectant if wearing PPE for extended periods, and promotes regular breaks (ideally every 2 h) from wearing a FFP mask to relieve tissue pressure and reduce humidity. The chosen barrier cream or tape should not compromise the integrity or fit of the mask.
We postulate that the cutaneous complications reported during the COVID‐19 pandemic stem from the hyperhidrotic effect of PPE, friction, epidermal breakdown, pressure urticaria and contact dermatoses, all of which may be exacerbated in the context of pre‐existing skin disease. 1 , 3 Experience from previous pandemics has shown skin inflammation and erythema, papules, maceration and scaling to be the most frequently reported adverse cutaneous outcomes of extended PPE use, with the most commonly affected sites being the nasal bridge, cheeks, forehead and hands. 4
Here, we report individual cases of two female theatre nurses working within the same surgical unit within the United Kingdom during the current COVID‐19 pandemic, neither with pre‐existing skin disease. Each sustained a morphologically similar cutaneous eruption following single use of a FFP3 respirator mask (make: 3M, model: 8835+, batch number 1c20058026), having assisted during an uninterrupted 4.5‐h theatre list on the same day. Immediate symptoms upon removal of the mask consisted of mild erythema and pain which progressed overnight. The following morning, crops of 1–2 mm pustules with background erythema were evident over the nasal bridge, sidewall and ala, clinically in keeping with localized miliaria (Fig. 1), with the differential being an occlusive (infective) folliculitis. Whilst tender on palpation, the area was not overtly cellulitic. Given that the epidermis was intact, and wanting to avoid further compromise to the skin barrier, bacterial swabs were not performed. Dermol® 500 (Dermal Laboratories Ltd, Hertfordshire, UK) lotion was prescribed as an antiseptic soap substitute and emollient. Two weeks later, post‐inflammatory hyperpigmentation was apparent in each case, with some residual scaling and dryness.
Figure 1.
Crops of 1–2 mm pustules with background erythema over the nasal bridge, sidewall and ala, clinically in keeping with localized miliaria.
Miliaria, otherwise known as heat rash, is a disorder of eccrine glands due to obstruction and retention of sweat. It is usually associated with immobility, hot/humid environments and improper clothing or bedding which traps heat and perspiration. Within the clinical setting, it is most often seen in febrile inpatients who have been supine for extended periods. There are three subtypes – miliaria crystallina (typically face and trunk), miliaria rubra/pustulosa (most common; typically on the back) and miliaria profunda (rare; trunk and extremities). 5
To our knowledge, this is the first report of a localized facial miliaria secondary to FFP use. It is recognized that epidermal barrier interruption could enhance COVID‐19 acquisition 6 and as such, it is fundamental that steps are taken to minimize tissue trauma from PPE use, and to report such cases.
Acknowledgement
Informed written consent was gained for publication of clinical history and photographs.
Funding source
none.
References
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