Occupational dermatology in the time of the COVID‐19 pandemic: a report of experience from London and Manchester, UK

Dear Editor, The COVID‐19 pandemic has resulted in healthcare systems responding to rapidly rising demand. Simultaneously, increased infection prevention measures for staff, which includes additional personal protective equipment (PPE) and more rigorous hand hygiene procedures, has resulted in an increased incidence of occupational skin disease in frontline staff.¹

From April to June 2020, self‐referral occupational dermatology ‘drop‐in’ and virtual clinics were established at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) and Salford Royal NHS Foundation Trust (SRFT) to support frontline staff. We describe our patient cohorts, delineate the commonly seen diagnoses and offer practical management advice.

Questionnaires were completed for each consultation, with 167 consultations (146 staff, average age 35·7 years, range 23–69) at GSTT and 92 (85 staff; average age 39·5 years, range 24–59) at SRFT. Overwhelmingly, staff were female (85·1% at GSTT, 87% SRFT), reflecting the workforce demographic (Table 1).

Table 1.

Comparative occupation and job role location data for Guy’s and St Thomas’ (GSTT) and Salford Royal (SRFT) NHS Foundation Trusts, obtained by questionnaire at the time of consultation. The diagnoses at initial consultation were made by the consultant dermatologist in occupational clinics. Some staff were diagnosed with more than one pathology at presentation, with the most significant recorded under primary diagnosis

	GSTT		SRFT
Staff occupation
Administrative	6 (4·1)		7 (8)
Allied health professional	16 (11·0)		23 (27)
Doctor	10 (6·8)		2 (2)
Healthcare assistant	6 (4·1)		11 (13)
Nurse	105 (71·9)		38 (45)
Pharmacist	1 (0·7)		1 (1)
Support (porter/cleaner)	1 (0·7)		1 (1)
Other	1 (0·7)		2 (2)
Total	146 (100)		85 (100)
Job location
Community	1 (0·7)		1 (1)
Emergency department	1 (0·7)		6 (7)
General ward	24 (16·4)		38 (45)
Intensive care	101 (69·2)		12 (14)
Surgery	9 (6·2)		9 (11)
Other	8 (5·5)		19 (22)
Unknown	2 (1·7)		0
Total	146 (100)		85 (100)
Diagnosis	Primary	Secondary	Primary	Secondary
Facial dermatoses
Atopic eczema	1	2	3	–
Chemical ICD	10	3	–	–
Occlusive acne	16	5	5
Pressure mechanical ICD	41	13	2	–
Pressure urticaria	–	–	2	–
Rosacea	–	1	4	–
Seborrhoeic dermatitis	5	6	5	–
Suspected ACD	8	3	1	1
Other	1	5	3	–
Total	82	38 (46)	25	1 (4)
Hand dermatoses
Atopic dermatitis	4	9	14	3
ICD	56	10	37	7
Psoriasis	1	1	2	–
Suspected ACD	7	4	1	18
Not occupational	–	–	4	–
Total	68	24 (35)	58	28 (48)

The data are presented as the number of staff (%). ACD, allergic contact dermatitis; ICD, irritant contact dermatitis.

Occupational hand dermatitis is well recognized in healthcare workers. Lan et al. reported occurrence in 74·5% of 526 staff in Hubei province, China.¹ Irritant contact dermatitis (ICD) was present in 97·1% of staff with hand dermatitis at GSTT and 76% at SRFT, reinforcing the importance of preventative strategies for frontline workers. Within our trusts an information leaflet was publicized in trust briefings and on intranets. Moisturizers were made freely available to all staff. This is particularly important as soap substitutes may not offer sufficient virucidal action against COVID‐19·² Active dermatitis was treated with topical corticosteroids to gain control and prevent staff absence. With pharmacy assistance, medications were dispensed directly from clinics (GSTT) and prescription fees were waived for occupational dermatoses, facilitating prompt management.

Limited patch testing was performed at GSTT (COVID‐19 restrictions) but was carried out according to the European Society of Contact Dermatitis guidelines.³ Of 12 staff tested with hand dermatitis, five had contact allergies of possible or probable relevance and one had occupational ACD to rubber accelerators in polyisoprene gloves. The high number of clinically relevant results underlines the necessity of patch testing, as highlighted by Cronin.⁴

High rates of facial dermatitis from facial masks and/or goggles have been described.¹ This is the first time such significant and frequent issues from medical‐grade, fit‐tested face masks have been observed. Short‐lived erythema (lasting several hours after doffing of PPE) and more significant skin disease were reported (Table 1).

Pressure‐induced facial dermatitis has been rarely reported. Pilots in the Royal Air Force, required to wear rubber masks while flying, developed ICD due to pressure, occlusion, heat and friction effects.⁵ At GSTT, 66·3% of staff with facial rashes experienced pressure ICD, likely due to both the pressure required to make the FFP3 mask ‘fit’ (i.e. protect against inhalation of airborne virus) and the long periods over which the masks are worn, often in a warm environment.

NHS England published advice stating ‘it is important that you take regular breaks (we recommend every two hours) from wearing a mask to relieve the pressure and reduce moisture build‐up.’ In our experience, staff numbers were insufficient to allow this advice to be followed.

Our management method is to recommend (i) adherence to the NHS England guidelines; (ii) application of a light moisturizer before shifts and (iii) application of Siltape (Advancis, Kirkby‐in‐Ashfield, UK; soft silicone perforated tape) over the bridge of the nose and cheeks before donning FFP3 masks. If skin breakdown has occurred, Mepilex Border Lite 4 × 5‐cm dressing (Molnlycke, Gothenburg, Sweden) over the bridge of the nose is helpful. These silicone‐based dressings offer both pressure distribution and protection. Additionally, the adhesive minimizes skin damage upon removal. Fit testing should be repeated. The tapes should be removed at each doffing as they may be contaminated. Adhesive remover, such as Appeel wipes (CliniMed Ltd, High Wycombe, UK), may be useful. This methodology has been approved by Infection Control and Tissue Viability.

ACD to components of masks has been reported in this pandemic,⁶, ⁷ but no cases were found in our cohort, although six of 15 staff tested to date had potentially relevant contact allergies.

Chemical ICD was seen at GSTT following introduction of reusable masks, with advice to sanitize using Clinell wipes (GAMA Healthcare, Watford, UK) then leave to dry. Build‐up of antimicrobial agents, including benzalkonium chloride, a nonvolatile surfactant known to be an irritant,⁸ led to eczema at contact points from the masks. Rinsing with tap water (approved by Infection Control) after use of Clinell wipes resulted in resolution. Staff should wear gloves when handling such wipes.

Occupational dermatoses have been the epidemic within the COVID‐19 pandemic. Robust risk assessment and appropriate preventative strategies need to be implemented within the National Health Service. Staff occupational dermatology clinics appear effective in ensuring the wellbeing of frontline staff as we move forward in the ‘new normal’.

Author Contribution

Felicity Jane Ferguson: Conceptualization (lead); Data curation (equal); Formal analysis (lead); Writing‐original draft (lead). Gill Street: Data curation (equal). Louise Sarah Cunningham: Writing‐review & editing (equal). Ian R White: Supervision (supporting); Writing‐review & editing (equal). John McFadden: Conceptualization (supporting); Writing‐review & editing (equal). Jason Williams: Conceptualization (supporting); Writing‐review & editing (equal).