key: cord-0778638-rkyu0gva
authors: Keng, Bryan M.H.; Gan, W. H.; Tam, Y. C.; Oh, C. C.
title: Personal protective equipment-related occupational dermatoses during COVID-19 among healthcare workers – a worldwide systematic review
date: 2021-09-01
journal: JAAD Int
DOI: 10.1016/j.jdin.2021.08.004
sha: b59293fe9e0f14a4a7cd4afc14cdff5c49769e61
doc_id: 778638
cord_uid: rkyu0gva

Background Occupational dermatoses caused by personal protective equipment (PPE) in the current COVID-19 pandemic are emerging occupational health challenges which must be promptly and effectively addressed to ease the burden on our healthcare workers (HCWs). Objective A systematic review was conducted to determine common PPE-related dermatoses, affected body sites, and implicated occupational contactants. We further proposed solutions to mitigate this problem. Methods Online databases were searched for articles on PPE-related dermatoses in HCWs during COVID-19, written in English and published from January 1, 2020 to January 30, 2021. Results 16 studies, involving a total of 3958 participants, were included. The most common dermatoses were xerosis, pressure-related erythema, and contact dermatitis, mainly affecting the face and hands. The most widely implicated contactants were increased frequency of hand hygiene, gloves, N95 masks, and goggles. Proposed solutions were categorized into individual self-care, protection of the workforce, and long-term preventative measures. Conclusion Through measures such as regular basic skincare education, early access to specialty clinics via telemedicine, and the design of better-fit PPE, the challenges posed by PPE-related occupational dermatoses can be significantly reduced.

Introduction 71 72 COVID-19 has taken the world by storm and drastically affected the practice of virtually all 73 healthcare workers (HCWs) across the globe. It was first declared a Public Health Emergency of 74

International Concern by the World Health Organisation on 30 Jan 2020, and has since resulted in 75 over 180 million reported cases and almost 4 million deaths worldwide (1). In many different 76 countries, HCWs have had to adapt to constantly changing policies, including strict regulations on 77 the use of personal protective equipment (PPE). The usage of PPE -measures such as wearing of 78 gloves, N95 respirators, protective suits, and increased frequency of hand hygiene -institutes 79 precautions to minimize the risk of viral transmission via respiratory droplets, aerosols, and 80 excessive contact between individuals (2-4). 81 82 It is well known that PPE usage, especially over prolonged periods, may result in occupational skin 83 diseases (5-8). Studies have shown that high incidences of PPE-related dermatoses, such as facial 84 pressure injuries and hand dermatitis, occur during the current COVID-19 pandemic (9-12). These 85 skin lesions can be of severe detriment to HCWs' morale, workability, and quality of life, with an 86 increased risk of subsequent psychological burden (13). Seeking relief from such symptoms may 87 cause inadvertent breaches of PPE, thereby increasing the risk of 15) . 88 89 There is thus a pressing need to find ways to facilitate the prevention and effective management of 90 these skin conditions. However, to the best of our knowledge, few systematic reviews have been 91 conducted to date, to critically examine the pooled data from the abovementioned studies, 92 especially in the Asian population. 93 94 J o u r n a l P r e -p r o o f and burden of PPE-related dermatoses on HCWs worldwide. We report the incidences of various 96 skin lesions concerning increased PPE usage, and propose solutions to minimize the adverse skin 97 reactions our HCWs face during this ongoing pandemic. 98 99

A study protocol was registered with the PROSPERO register of systematic reviews. 101

Databases PubMed, OVID, EMBASE, MEDLINE, and Google Scholar were searched for relevant 102 articles written in English and published from January 1, 2020 to January 30, 2021. The keywords 103 "healthcare workers", "rash", "skin" and "occupational", in conjunction with "COVID-19" and "SARS-104

CoV-2" were used. This initial search brought up 174 articles on the aforementioned databases. The 105 number of articles included in our final analysis was scoped by removing duplicates, those without 106 original data, or which lacked direct relevance to HCWs, PPE, or cutaneous diseases (Figure 1 ). 107 108

The selection of articles for inclusion and data extraction was performed independently by two 109 authors. The following information was extracted from the included studies (where available): 110 authors, region, age, site and type of skin conditions, occupational contactants, and proposed 111 solutions. Selection of articles for inclusion and data extraction was performed independently by 112 KMHB and OCC. Any disagreements were resolved with a third independent author (TYC). A risk-of-113 bias assessment of all included studies was performed (Appendix A). This systematic review was 114 performed following PRISMA guidelines. 115

Results 117 118 J o u r n a l P r e -p r o o f Sixteen articles were found suitable for inclusion in our review (9) (10) (11) (12) (13) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) . These are largely cross-119 sectional studies with cohort sizes ranging from 7 to 542. A total of 3958 participants were described 120 in these studies. The relevant findings are detailed in Tables 1-4.  121 122 Table 1 is a summary of the 16 studies included in our review. 123 124 Notably, one of the main findings across multiple papers (9, 11, 20, 25) was that longer exposure 125 duration to PPE showed a statistically significant positive association with adverse cutaneous 126 reactions. Guertler et al. (18) conducted a subgroup analysis between HCWs working directly with 127 COVID-19 patients in an ICU setting and those who did not, finding that hand hygiene practices and 128 rates of hand dermatitis were largely comparable across the 2 groups. Chernyshov et al. (21) divided 129 participants into 3 groups, 2 of which received different handcare products (gels and emollients) 130 while the remaining group did not. Their findings were that participants in the intervention groups 131 reported significantly enhanced Dermatology Life Quality Index (DLQI) scores and subjective 132 improvement in symptoms after 1 month as compared to the controls. 133 134 When analyzing the entire cohort as a whole, the most commonly affected body sites included the 135 face and hands (Table 2a) . The trunk and legs were the least affected. Xerosis (27.6%), pressure-136 related erythema (22.1%), and irritant contact dermatitis (14.8%) were the most common 137 dermatological manifestations (Table 2b) . Of note, a few studies (10, 12) did not specifically describe 138 the site or type of dermatosis encountered; 14.5% of the total study population did not report the 139 affected body site. 140 141 Pressure-related skin injuries are a frequent complication of wearing goggles and N95 masks, 160 especially for long periods. These may initially manifest as erythema and skin indentation. If proper 161 measures are not taken to protect affected areas, they may then progress to fissures, erosions, 162 blisters, or ulcers (12, 27) . Sites that are particularly susceptible to pressure include the nasal bridge 163 and cheeks (9, 28). Skin maceration and abrasions at these sites may additionally compromise the 164 protective barrier and result in a secondary infection (29). 165 166 Another commonly seen cutaneous manifestation is mask-related acne. The usage of masks and 167 goggles tends to cause excessive accumulation of sweat and sebum on the face due to increased 168 heat and humidity. This effect may be even more pronounced in countries with tropical climates 169 J o u r n a l P r e -p r o o f (30). Furthermore, friction and pressure from repetitive mask-wearing can also result in mechanical 170 trauma leading to rupture of micro-comedones and occlusion of sebaceous ducts (9, 31). Overall, 171 this may exacerbate pre-existing acne vulgaris, and may also cause the development of mechanical 172 acneiform eruptions in those without a prior history. 173 174 It is widely known that hand hygiene is a critical measure in minimizing bacterial and viral spread. 175

However, frequent hand hygiene also exposes the skin to friction and chemicals which may cause 176 loss of moisture and skin barrier damage (32), manifesting as xerotic changes in a large proportion of 177 HCWs (9, 12, 25) . This is true in both handwashing with soap and water, as well as alcohol-based 178 hand rubs (33). 179 180 Occupational contact dermatitis afflicts not only HCWs but also other professionals who perform 181 wet work, such as cleaners, dhobis, and plumbers. It can largely be divided into irritant and allergic 182 contact dermatitis (ICD and ACD) and may be caused by glove materials (commonly rubber), hand 183 cleansers, or inadequate hand drying before donning gloves (5, 34-37). ICD accounts for nearly 80% 184 of cases, featuring predominant symptoms of burning, stinging, and soreness, while ACD is more 185 uncommon and usually presents as pruritus. Management of ICD involves selecting less irritating 186 hand hygiene products and consistent use of emollients, while the cornerstone of ACD treatment is 187 identification and avoidance of the contact allergen (38). The incidence of contact dermatitis is 188 significantly associated with the duration and intensity of contact with the agent in question (39). Consistent application of emollients is an oft-cited and easily attainable way of minimizing skin 201 damage due to xerosis caused by frequent hand hygiene (12, 13, 18, 19) , but is still severely lacking 202 in practice. Kiely et al. reported that over 99% of HCWs in their study increased their hand hygiene 203 frequency in response to COVID-19, but 45% did not use any moisturizers (16). Indeed, it has been 204 shown that emollients are critical in repairing skin barrier damage, and do not compromise the 205 efficacy of handwashing or alcohol-based hand rubs (40, 41). In severe or refractory cases, there may 206 even be a role for topical and sometimes, oral glucocorticoid agents in reducing inflammation, and 207 ample time should be given for damaged skin to recover before the resumption of clinical duties. 208 Furthermore, the study by Chernyshov et al. (21) indicates that direct provision of emollients to 209

HCWs, as opposed to simply advising on skincare education, maybe far better in encouraging the 210 diligent use of such products. We, therefore, recommend that healthcare institutions consider 211 providing emollients to HCWs, especially those who face prolonged working hours in PPE. 212 213 Proper mask and PPE fitting is another key way of minimizing skin damage, in particular pressure 214 injuries, while maintaining adequate protection against viral transmission. Many studies have cited 215 facial pressure injuries concerning overly tight-fitting N95 masks or goggles (12, 13, 17) . Gowns 216 should also not be too restrictive to cause friction-related injuries during movement, while practices 217 such as double-gowning or double-gloving may further trap moisture and hence increase skin 218 exposure to heat and sweat, causing epidermal injury and worsening dermatitis (42, 43). 219 220 J o u r n a l P r e -p r o o f Related to the aforementioned pressure injuries, the application of gauze or hydrocolloid dressings 221 over pressure areas before donning N95 masks may also help to relieve symptoms (12, 22) . Ongoing 222 research is being carried out to develop better methods of incorporating these protective measures 223 into the N95 mask design (44, 45). We suggest that proper PPE fitting be accorded priority to protect 224 the occupational health of the healthcare workforce. HCWs also have the option of applying 225 hydrocolloid dressings as necessary to minimize pressure injuries, but the use of this may require 226 another N95 mask fitment test to ensure the continued efficacy of PPE protection. HCWs wearing N95 masks and goggles for more than 6 hours had significantly increased prevalence 243 of skin damage on the cheeks and nasal bridge (p<0.01), as compared to their counterparts who 244 donned this equipment for less than 6 hours. Prolonged exposure to irritant substances, sweat, and 245 humidity exacerbates many forms of skin disease, including acne, folliculitis, and contact dermatitis 246 J o u r n a l P r e -p r o o f (30, 42, 46) . We suggest that shift work in full PPE is kept to 6 hours or fewer wherever possible and 247 that HCWs be allowed breaks in well-distanced and well-ventilated areas where they can remove 248 their PPE and rest. 249 250 Another important aspect of protecting our workforce would be educating HCWs on identifying 251 cutaneous symptoms, basic skincare, and how to seek further treatment if indicated (13, 20, 24) . 252

Due to busy schedules and heavy workloads, many HCWs tend to ignore early warning signs such as 253 mild erythema, or neglect daily skin care practices. This is further exacerbated by the current climate 254 of stress and anxiety due to COVID-19, which may even cause feelings of depression or burnout (47, 255 48). We must remind our workforce to care for their well-being even while serving others. Such 256 information can be disseminated on virtual platforms such as webinars, and subsequently reinforced 257 via physical cues; for example, placing bottles of moisturizers at areas of donning/doffing PPE. 258 259 Consultation with a dermatologist or occupational health specialist should be readily available for 260 severe or recalcitrant cases (12, 24). These specialists may be able to diagnose and prescribe 261 individualized treatments for certain dermatoses -for instance, topical retinoids and benzoyl 262 peroxide for mild cases of acne vulgaris, as well as systemic therapy for severe acne vulgaris (49) or 263 antihistamines for pressure urticaria (50). Patch testing may also be a consideration, especially to 264 exclude cases of allergic contact dermatitis -in glove-related cases, contact allergy to rubber 265 additives is most common (51). Patch testing allows the identification of the culprit allergen in a 266 structured manner (52). 267 

Consensus of Chinese experts on 341 protection of skin and mucous membrane barrier for health-care workers fighting against 342 coronavirus disease 2019

Evaluation of skin problems and dermatology life quality 344 index in health care workers who use personal protection measures during COVID-19 pandemic. 345 Dermatologic therapy

Real-world assessment, relevance, and problems in use of 347 personal protective equipment in clinical dermatology practice in a COVID referral tertiary hospital

Behavioral considerations and impact on personal protective equipment use: Early 350 lessons from the coronavirus (COVID-19) pandemic

Irritant contact 353 dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study. 354 Clinical and experimental dermatology

Germany Cross-sectional study, n = 103/114, mean age = 35, 39 physicians and 75 nurses Hand eczema (90.4%)

Handwashing >10/day (71.7%)

Turkey Cross-sectional study, n = 54/107, mean age = 29.6, 47 physicians and 48 nurses Hand eczema characteristics (54/107): irritant contact dermatitis (96.3%), morphology erythema-squamatous (75.9%)

Handwashing >10/shift (81.2%), glove use >10/shift (73.6%)

* India Cross-sectional study, n = 101/101, mean age = 36.7, 46 HCWs Symptoms: pruritus (45.5%), burning (46.5%), stinging (6.9%). Morphology: erythema (79.2%), papules (60.4%), vesicles (17.8%), xerosis (15.8%)

Ukraine Cohort study, n = 77/96, mean age 34, 31 physicians and 65 nurses Hand-related symptoms: redness (80.2%)

*refers to the total number of HCWs using PPE, not limited to those with dermatoses 500

**inclusive of soap and water, as well as alcohol-based hand rubs of emollients

Proper mask and PPE fitting (12, 13, 17) Application of gauze at pressure areas before donning N95 mask (12, 22) Protection of the HCW workforce Revision of working hours to allow skin rest