Iatrogenic dermatitis in times of COVID‐19: a pandemic within a pandemic

Editor

The pandemic of the 21st century COVID‐19 emerged in Wuhan, China, and swiftly became a global phenomenon. The frontline barriers for preventing spread are hand hygiene and personal protective equipment (PPE). The amplified hygiene practices and PPE as recommended have brought in its wake a second pandemic – a pandemic of dermatitis! ¹

We reviewed the most prevalent types of iatrogenic skin damage among healthcare workers (HCWs), notably irritant, and allergic contact dermatitis (ACD) to PPE and hand hygiene measures, as well as face mask induced pressure‐related skin damage. ² , ³ , ⁴ The prevalence of occupational skin disease among HCWs in earlier studies (pre‐COVID era) has been estimated to range from 20 to 50%. ⁵ However, in two recent studies from Hubei, China, a staggeringly higher number of HCWs (97%, n = 526/542 and 71%, n = 234/330) HCWs engaged in the care of COVID‐19 patients reported self‐perceived skin barrier damage. ² , ⁶ Majority experienced skin dryness/tightness (70.3%) and desquamation (62.2%) commonly occurring on the nasal bridge (83.1%) (Fig. 1). ² Skin damage was more prevalent among HCWs wearing N95 masks and goggles for more than 6 h a day, whereas the face shield produced no such effect on prolonged wearing. Goggles were reported as the commonest (51.92%) culprit among PPE and about a fifth of patients reported work absenteeism because of dermatitis. ³ Face mask and headgear worn tightly for prolonged hours result in ACD, ICD, pressure urticaria, friction dermatitis, abrasions and aggravation of pre‐existing dermatoses. ⁶ N95 respirators may contain formaldehyde, a known allergen. ⁷ Retro‐auricular skin is vulnerable to frictional dermatitis due to ear loops of the facemasks. ⁴ Frequent hand washing (>10 times daily) increased the risk of skin damage more than prolonged wearing of gloves.

Figure 1.

Iatrogenic dermatitis during COVID‐19 pandemic. (a) Contact dermatitis to hand cleanser in a patient, present distinctly over the dorsum of metacarpophalangeal joints and web spaces (highlighted with ‘*’). (b) Irritant contact dermatitis to chlorhexidine gluconate (savlon) over the volar aspect of forearm of a patient. (c) Contact dermatitis to latex gloves in a patient, showing sharp cut‐off at wrist. (d) Irritant contact dermatitis secondary to prolonged use of powdered gloves in a health care worker (Courtesy of Dr. Ahmed Nassar, Assistant lecturer of Dermatology, Ain Shams University, Cairo, Egypt). (e) Angioedema over hand after contact with latex gloves in a patient. (f) Pressure injury over the forehead and malar areas (highlighted with ‘*’) occurring as a result of tight fitting helmet and N95 mask in a health care worker (Courtesy of Dr. Abhigyan Mukherjee, Consulting dermatologist, Dr Mukherjee’s Skin, Hair and Laser Clinic, Pune, India).

Hand hygiene‐associated dermatitis usually manifests on the knuckles and web spaces, where these irritants and allergens accumulate. Occasionally, both ICD and ACD can coexist. ACD to gloves presents with erythematous itchy plaques on convexities of dorsal surface of hands with a clear demarcation of erythema at wrists (Fig. 1). ⁶

Contact dermatitis to various PPEs and hand hygiene measures can occur due to a variety of factors involving irritants and allergens in these agents, compounded by moisture, occlusion, friction, cold dry weather and atopic predisposition of an individual. These exposures lead to ICD and ACD through changes involving the skin barrier, cells and cytokines. Excessive hand hygiene depletes skin commensals that play an important role in Th1, Th2 and Th17 balance. ⁸

Patch test is the gold standard for diagnosis of ACD. The battery of allergens includes standard series, textile series, fragrance series, masks, gloves and hand cleansers used by the patients. Some allergens relevant to SARS‐CoV‐2 pandemic viz 1,3 diphenyl guanidine, DMDM hydantoin, propylene glycol, formaldehyde and formaldehyde releasers may not be present in a single series. ACD to glove allergens also is commonly reported (Table 1). ⁷

Table 1.

Potential allergens and irritants in the personal protective equipment and hand hygiene measures

Masks	Purpose	Allergens	Irritants
Standard surgical mask or fluid resistant surgical mask	Single use mask Loose fitting Prevents large particles (> 5 microns) expelled by the wearer from reaching the environment. Fluid resistant Protects against large droplets and splashes	Thiuram (in elastic ear strap); Methyldibromo glutaronitrile; Cocospropylenediamine‐guanidinium diacetate (preservative in disinfectant for cleaning mask); Dibromodicyanobutane (in adhesive used in mask)	Friction and humidity
N95 respirator or filtering face piece (FFP) FFP 1 FFP 2 FFP 3 (highest level of protection)	Fit tightly Fluid resistant Protects against very small air borne particles, body fluids and splashes Has a filtration efficiency of 95% against particulate aerosols of size 300 nm and above	Formaldehyde Ethylene urea melamine formaldehyde Quaternium‐15 (formaldehyde releasing preservative) Aluminium (in the nose clip)	Friction, mechanical pressure
Home‐made (cloth or paper masks)	Loose fitting Not fluid resistant Prevents large particles expelled by the wearer from reaching the environment	Formaldehyde textile resins (melamine formaldehyde, urea formaldehyde); Formaldehyde releasers (quaternium‐15, imidazolidinyl urea); Disperse dyes, p‐aminobenzene, Paraphenylenediamine, Naphthol AS, ‘Black rubber mix’ Lanolin	Friction, humidity

Gloves	Additional information	Allergens	Irritants
Natural rubber latex (NRL) gloves (powdered or unpowdered)	Users can be sensitive to either NRL or chemical additives or both. Can worsen existing hand dermatitis from occlusion and maceration	Rubber accelerators (thiuram, carba mix/ carbamates, mercaptobenzothiazole,diphenylguanidine) Antioxidants (diaminodiphenylmethane, paraphenylenediamine, black rubber mix) Immediate hypersensitivity to latex	Glove powder‐ cornstarch based Sterilization of gloves by gamma irradiation can increase bacterial endotoxin level, which is water soluble and can be absorbed onto glove powder leading to irritation
Synthetic rubber gloves‐ Nitrile gloves Vinyl gloves Neoprene gloves	Manufactured similarly to latex gloves, including use of vulcanization accelerators	Rubber accelerators (carba mix, carbamates, thiuram mix, 1,3‐diphenylguanidine, benzothiazoles, thioureas)	Cetylpyridinium chloride

Hand hygiene products	Components	Allergens	Irritants
Alcohol‐based hand rub (liquid, gel or foam)	Contain one or more types of alcohol, humectants, other active ingredients with excipients	Alcohols ‐ ethanol, isopropanol Fragrances Acrylates Preservative Benzyl alcohol Stearyl or isostearyl alcohol Quaternium ammonium chloride (QAC) Iodine or iodophors Chlorhexidine Triclosan Chloroxylenol Phenoxyethanol Myristyl alcohol Propylene glycol Parabens Benzalkonium chloride	Ethanol, n‐propranolol, isopropanolol, chlorhexidine, chloroxylenol, triclosan
Waterless/bar soaps	With or without added antiseptic agents	Fragrances, tocopherol Polyethylene glycol Ethylhexylglycerin	SLS – sodium lauryl sulphate
Water‐based/liquid soaps		Fragrances Methylchloroisothiazolinone/ methylisothiazolinone (MCI/MI) Quaternium‐15 Sodium benzoate Phenoxyethanol DMDM hydantoin Iodopropynyl butylcarbamate Alkyl glucosides Chloroxylenol Polyethylene glycol Cocamidopropyl betaine Triclosan
Antiseptic agents	Dettol (chloroxylenol B.P. 4.8%w/v)	Chloroxylenol, terpineol	Chloroxylenol, alcohol
	Savlon(cetrimide 3.0% w/v, chlorhexidine gluconate 0.3% w/v)	Chlrohexidine gluconate, benzyl benzoate, cetrimide, isopropyl alcohol, terpineol	Cetrimide, chlorhexidine, gluconolactone Sodium hydroxide
Antiseptic hand wipe	Fabric or paper pre‐wetted with an antiseptic agent. Not as effective as antiseptic agents or alcohol‐based hand rubs	Methylchloroisothiazolinone/ methylisothiazolinone (MCI/MI) Propylene glycol Fragrances Benzalkonium chloride.

Healthcare workers education about hand hygiene measures combined with liberal moisturizing for skin barrier repair, avoidance of suspected allergens, ergonomic workplace interventions and emphasizing the need for redesigning PPE is vital in tackling this iatrogenic health hazard. Alteration in the frequency of hand washing, use of correct fitting PPE and barrier creams are important. Fragrance‐free emollients avoid the risk of further sensitization. If avoidance of allergen is not possible, protective measures like clothing, cotton lining latex or vinyl gloves and two‐layered gauze‐lined masks may be helpful. ⁶ , ⁹

Further, the base of topical medicaments (corticosteroids and calcineurin inhibitors) to treat the dermatitis should be free from potential allergens. Correct use of PPEs and hand hygiene measures can protect HCWs from acquiring COVID‐19 infection. However, iatrogenic problems because of these measures may prevent their proper use, putting HCWs at risk. There is an urgent need to sensitize the larger health fraternity about these issues. ¹ , ⁴ , ⁶