COVID-19 and dermatological personal protective equipment considerations

Abstract

Cutaneous injury and irritation among health care workers has substantially risen during the COVID-19 pandemic. In a field already laden with skin-induced injury and irritation due to high levels of handwashing and glove wearing, increases have been reported in handwashing-induced xerosis, irritant dermatitis, and contact dermatitis from N95 respirators and other surgical masks. Masks, goggles, face shields, and gloves all potentially create abrasions from long hours of use, leading to itching, pain, and aggravation of underlying skin conditions. Personal protective equipment (PPE)–related skin injury can be serious, and the American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic. These are reviewed and discussed in conjunction with overarching guidelines for mitigating the spread of the virus.

Current personal protective equipment (PPE) guidelines from the World Health Organization (WHO) include droplet and contact precautions for health care workers (HCWs) who are caring for COVID-19 patients and airborne precautions during aerosolizing procedures.¹ PPE in the setting of droplet precautions includes surgical masks and goggles, while contact precautions add fluid-resistant gowns and gloves. During an aerosolizing procedure, HCWs are advised to wear N95 respirators or filtering facepieces, goggles, gown, and gloves. Aerosolizing procedures include tracheostomy, endotracheal intubation, bronchoscopy, cardiopulmonary resuscitation, manual ventilation, airway suctioning, sputum induction, and nebulizer therapy.² The Centers for Disease Control and Prevention (CDC) outlines recommendations for the duration of PPE use, stating that “extended use,” where the N95 respirator is kept on throughout the shift and multiple patient encounters, is favored over “reuse,” where the N95 respirator is removed between each encounter.³ In this literature review, we discuss specific PPE design and use, the dermatologic consequences of PPE items, brief pathophysiology and risk factors of associated skin conditions, and current recommendations to prevent and address PPE-induced dermatologic conditions.

Source acquisition and aims

Primary literature resources were obtained via PubMed, SCOPUS, EMBASE, and Google Scholar. Sources were filtered based on three primary aims: the source focuses on our primary topic of interest, COVID-19 dermatological PPE considerations, or a related subtopic; the source and related discussions are within the scope of recommendations made by the American Academy of Dermatology (AAD) for guiding prevention and treatment of occupationally induced dermatologic conditions during the COVID-19 pandemic; and source discussions are within the overarching guidelines of the WHO, CDC, and other reputable organizations recommending best practices to mitigate the spread of the COVID-19 virus.

Ppe-induced dermatologic conditions

Surgical masks are loose-fitting devices designed to protect the wearer from exposure to large respiratory droplets or sprays of bodily fluids.⁴ Unlike surgical masks, N95 respirators have the ability to filter small airborne particles.² Due to their polypropylene fabric processed by a nonwoven technology, N95 respirators can filter particles >300 nm in size.⁵ While the coronavirus is approximately 100 nm in size, the National Institute of Occupational Safety deemed N95 respirators safe due to viral transmission via salivary droplets, which add substantial volume during person-to-person transmission.

While masks serve a vital role in protecting HCWs from exposure to COVID-19, there have been many studies exploring the dermatologic consequences of increased PPE use. In a study of 542 HCWs in Hubei, China, 97% of HCWs suffered from adverse skin reactions due to PPE use during the pandemic.⁶ In a similar study in Jinnah Hospital in Pakistan, 97% of HCWs wearing masks for >4 hours a day reported PPE-induced cutaneous reactions.⁷ The participants were then examined by a dermatologist for accurate diagnosis and documentation. The most reported symptom was acne (56.8%), followed by ear fissuring (54.9%), pressure bruises on the nose bridge (32.3%), and contact dermatitis (22.5%). Contact dermatitis can manifest in various ways including xerosis, burning, pruritus, urticaria, fluid-filled bullae, erosions, and ulcers.⁸

The irritation to the skin caused by surgical masks can be attributed to adhesives on the nasal bridge as well as simple friction during extended use. Additionally, trace impurities of formaldehyde and bronopol can be released from the nonwoven polypropylene in surgical masks and N95 respirators, causing allergic contact dermatitis.⁹ Tightly sealed N95 respirators create a humid climate and with local pressures can occlude pilosebaceous ducts, leading to an environment favorable to acne-causing microbes.¹⁰

Goggles shield the eyes from infectious pathogens. The CDC recommends indirectly vented goggles for infection control purposes.¹¹ Adverse skin reactions from goggles are common, with 83.1% of HCWs in Hubei, China, reporting either nasal bridge desquamation or pressure bruising.⁶ The mechanical trauma of goggles disrupts the skin integrity, resulting in xerosis and aggravation of underlying dermatosis.¹² Less common were reports of acne, irritant contact dermatitis, and allergic contact dermatitis due to goggle use >6 hours. The proposed mechanism for the association of goggles and acne includes occlusion and friction due to tight-fitting equipment. Microscopically, the skin undergoes rupture of microcomedones and subsequent acneiform eruption.¹³

Gown use is recommended in direct patient care of COVID-19 patients as well as during aerosol-generating procedures.¹ Disposable gowns are made of natural and synthetic nonwoven fabrics, rarely associated with adverse skin reactions. Still, there have been reports of irritant and allergic contact dermatitis due to additive chemicals such as melamine formaldehyde, which provides wet strength to the paper gown.¹⁴ Pruritic rashes can occur on the neck, flexures, trunk, and legs in those who have sensitivities to chemicals in the gown. In larger surveys of HCWs and skin reactions, gowns have been less problematic than masks, goggles, and gloves. In a study by Foo et al only 1.6% of staff reported adverse skin reactions attributed to gown use, such as pruritus and rash localized to the wrist.¹⁰

Many HCWs wear gloves >4 hours a day due to WHO recommendations that gloves should be used during all encounters with COVID-19 patients. Long-term use of gloves can cause an excessively moist environment that overhydrates the stratum corneum, leading to maceration and possible erosion. Other glove-induced adverse skin reactions include contact dermatitis, with 33.3% of HCWs affected.¹⁵ This is likely due to a type I immunoglobulin E–mediated hypersensitivity reaction to latex.¹⁵ Additionally, rubber accelerators like nitrile and vinyl are used in the manufacturing of gloves and can also cause erythema, pruritus, and scale.¹⁶ In those who use gloves for prolonged periods, hyperpigmentation and lichenification can occur over the metacarpophalangeal joint.

Closely associated is the relationship between handwashing/disinfecting and hand eczema. Even before COVID-19, this relationship was studied and established, but it is now more prevalent among HCWs due to higher rates of handwashing and sanitization.¹⁶ In a study of >12,000 HCWs, 21% reported hand eczema; 30% were washing their hands with soap >20 times per day and 45% were using alcohol disinfectants >50 times per day.¹⁷ The mechanism of increased hand eczema in HCWs involves the interplay between water and surfactants. Consistent exposure to water and humidity causes swelling of the stratum corneum and increased permeability of the skin, thereby increasing skin’s sensitivity to irritants.¹⁸ Repeated use of soaps and surfactants, which normally have only a weak irritant effect, can have a cumulative effect leading to irritant contact dermatitis. Specifically, surfactants have the ability to disrupt our natural cutaneous barrier by removing skin surface lipids, denaturing epidermal keratin, and altering the cell membrane of keratinocytes.

Mitigating cutaneous PPE effects

Contact dermatitis is a prominent side effect of both masks and goggles. For surgical masks and N95 respirators, using an alcohol-free barrier film to wipe behind ears and areas with direct contact with the masks can reduce moisture and friction injury. These areas include the cheeks, nose, chin, and behind the ears. Before HCWs don a mask, they should allow the barrier film wipe to dry. Another option would be wearing a headband with buttons that attach to the straps of a surgical mask. To avoid behind-the ear-irritation, N95 respirator straps should be worn around the crown of the head, having no contact with the ear. For those using N95 respirators for extended periods during a shift, the AAD recommends cleaning and moisturizing the face with noncomedogenic emollients 1 hour before N95 respirator use.¹⁵ Moisturizers containing petrolatum are not advised before N95 respirator use, as they can compromise the sealing of the mask. For those experiencing allergic contact dermatitis reactions to certain components in the N95 respirators, the AAD recommends switching to another type of N95 respirator.

Pressure-related injury can also be a consequence of masks and goggles. Similar to protection against contact dermatitis, the AAD recommends using an alcohol-free barrier film as a skin sealant before donning an N95 respirator or goggles. Other methods to relieve pressure at high-impact points, such as adding cushions to the bridge of the nose, have been studied. In one study, six topical products worn under N95 respirators were compared and tested for pathogen contamination using fluorescent lotion as a simulation.¹⁹ An important result of this study was that the thin hydrocolloid dressing, when applied under the N95 respirator, improved skin irritation from pressure and did not result in contamination or disrupt the mask seal. These methods require further testing, as the AAD still does not recommend any material or cushioning for N95 respirator use at this time due to possible disruption of the seal. Another factor in pressure-related injury is excessive tightness of either mask or goggles. It is important to note that increased tightness of the straps or mask itself does not improve the efficacy of the PPE but rather increases the risk of skin damage and subsequent mask manipulation.¹² Masks should be fit tested according to standards of the Occupational Safety and Health Administration to ensure proper seal and protection.²⁰

Acne exacerbation due to PPE use is caused by the environment created by the mask. Increased local pressure and humidity are the main factors, which can be decreased by taking a break and removing the mask for 15 minutes every 2 to 3 hours of use.¹⁴ If goggles are the causative agent for acne flares, a face shield may be considered for these HCWs if appropriate. Glove-related protective measures include limiting use to one pair of gloves, as multiple layers can cause overhydration of the stratum corneum and possible maceration or erosion.¹² Only those with an existing hand skin injury should be advised to wear two pairs of gloves.

Basic handwashing recommendations include washing with warm water, not hot, and using fragrance-free soap followed by patting the skin dry. Between handwashing, HCWs are advised to use alcohol-based hand solutions. The various components of these solutions and their effects on the skin have been a point of discussion, as more and more HCWs complain of dry skin and hand eczema. A study conducted with 40 Brazilian HCWs compared alcohol-based hand solutions containing varying concentrations of glycerin, functioning as a humectant agent. They found that alcohol solutions containing 0.5% glycerin led to increased skin tolerance among the HCWs.²¹ Importantly, glycerin content should not exceed 0.5% due to decreased antimicrobial efficacy of the alcohols. In addition to these considerations regarding soap and alcohol-based sanitizers, frequent moisturizing of hands, whether intermittently during a shift or at night, can decrease dryness.²² Most moisturizing products, such as ointments, creams, and lotions, include a varying combination of humectants and occlusive emollients. Humectants, such as topical urea or propylene glycol, protect the stratum corneum by pulling water from the deeper layers of the skin. Additionally, occlusive emollients, such as beeswax, olive and soybean oils, dimethicone, lanolin, and white petrolatum, are used to prevent water loss. Together, these two moisturizing agents form a sealed barrier of hydration and can help prevent xerosis in the general population as well as irritant contact dermatitis in those with a history of atopic dermatitis.²¹ The AAD specifically recommends moisturizers with petrolatum due to its ability to reduce transepidermal water loss by 98%.

Extended PPE use is a unique factor during the current pandemic. Specifically, Lan et al found that those who were wearing PPE for >6 hours had an increased risk of skin damage on the cheeks, nasal bridge, forehead, and hands.⁶ This finding supports the need for workplace guidelines requiring 15-minute breaks from PPE every 2 to 3 hours to reduce the risk of cumulative adverse skin reactions. Making small adjustments like this in the workplace prioritizes HCWs’ comfort and safety during times of increased PPE use and helps to ensure PPE compliance.

In conclusion, the widespread increased PPE use and handwashing during the COVID-19 pandemic has heightened the risk of a variety of cutaneous injuries or aggravation of previous skin conditions. These can have measurable effects on HCWs and their compliance with proper CDC- and WHO-recommended PPE use. Injuries are commonly described in the literature. Even inadvertent, unconscious mask manipulation and adjustment could lead to heightened exposure risk. Transmission may also be elevated if protective cutaneous layers are compromised. Knowledge of specific skin injury based on PPE type, relevant dermatologic conditions, and subsequent treatment and recommendations is critical to minimize further cutaneous injury and elevate overall compliance.