Irritation may result in PPR protocol breaches

Since the start of the Covid-19 pandemic, particularly in the U.S., the shortage of personal protective equipment (PPE) frequently makes news headlines, but there is another wrinkle in regard to PPE: Nearly 100% of healthcare workers who are wearing PPE, particularly masks and gloves, for extended periods of time are experiencing skin damage, according to a report from China.

Moreover, in dealing with the resultant irritation, with symptoms such as dryness/tightness, itching, and pain, healthcare workers may not be practicing the best hygiene to protect themselves from contracting the virus.

It is well-known that healthcare workers are prone to hand eczema from regular hand hygiene and wearing gloves. However, during the pandemic, where healthcare workers are working longer-than-usual shifts and in constant PPE, JiaJia Lan, MD, from the Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, and colleagues surveyed 542 first-line healthcare workers and found that 97% reported skin damage due to enhanced infection-prevention measures.

In their study reported in the Journal of the American Academy of Dermatology, they noted that the sites most affected were “the nasal bridge, hands, cheek, and forehead, with the nasal bridge the most commonly affected (83.1%).”

Among their other findings:

  • The most common symptoms was dryness/tightness among 70.3%; other symptoms included tenderness (56.8%), itching (52.2%), and burning/pain (38.0%).
  • The most common sign was desquamation — 62.2% — followed by:
    • Erythema 49.4%.
    • Maceration 39.9%.
    • Fissure 32.9%.
    • Papule 32.9%.
  • Erosion and ulcer, vesicle, and wheal were reported by 10% or less of those surveyed.
  • Those who wore devices longer than 6 hours had higher risks of skin damage than those in PPE for less time “(N95 masks: odds ratio [OR], 2.02; 95% confidence interval [CI], 1.35-3.01; P <.01); goggles: OR, 2.32; 95% CI, 1.41-3.83, P<.01).
  • Wearing a face shield was not found to be a significant risk factor for forehead skin damage when worn for a long time (OR, 1.52; 95% CI, 0.93-2.50; P=.66).
  • Hand hygiene 10 or more times daily increased the risk of skin damage (OR, 2.17; 95% CI, 1.38-3.43; P<.01), more than wearing gloves for a long time.

While this finding underscores the fact that wearing PPE has drawbacks for healthcare workers in regard to having to deal with ongoing skin issues, it raises other concerns, particularly viral spread to themselves and others.

“Indeed, the role of face touching and surface contact has been recognized as a driver of viral transmission for decades, and a meta-analysis demonstrated that hand washing was associated with a 24% reduction in viral transmission, suggesting that hand-to-face contact may play a substantial role in infection,” Jonathan Kantor, MD, MSCE from Department of Dermatology and Center for Global Health, University of Pennsylvania Perelman School of Medicine, and the Florida Center for Dermatology, St. Augustine, wrote in an accompanying editorial. “The presence of even mild abrasions on the central face may increase the likelihood of face touching while not using PPE or inadvertent PPE protocol breaches, such as mask touching or adjustment, in an unconscious effort to relieve a source of irritation.”

Kantor noted that it is vitally important that healthcare workers adhere to stringent PPE protocols and added that healthcare workers need to be educated to change risky behaviors such as face touching or touching a contaminated surface with an ungloved hand. He also pointed out that use of topical agents to help reduce irritations could also be problematic and “introducing topical ointment to the skin should be done with great care; for example, using a sterile cotton-tipped applicator and a single-use petroleum jelly pack before possible exposure.”

Another option, he suggested, is that those healthcare workers who have a sensitivity to N95 respirator and goggles should explore alternatives “such as a full-face respirator or using a full-face shield rather than goggles.” However, he added that increased costs and availability may be a problem.

Lan and colleagues suggested that prophylactic dressing might potentially mitigate skin irritation, but Kantor pointed out that this might also pose problems with the potential of impacting PPE efficacy.

Another editorial commenting on the study, by Dirk M. Elston, MD, from the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, noted that the researchers’ “data offer valuable insights to help modify infection control practices to avoid occupational injuries.”

Lan and colleagues noted that steps should be taken to address long exposure times, and Elston agreed that “shorter rotating shifts in high-intensity protective gear may reduce the incidence of skin ulcertaion, but goggle fit may be more important and preemptive measure have the potential to preserve the workforce and reduce the risk of infection among hospital workers.”

He added: “Atopy, winter season, low humidity, frequency of hand washing, wet work, glove use, and duration of employment are important risk factors for hand dermatitis among medical personnel, and positive irritant patch tests with a low concentration of sodium lauryl sulfate can predict those at highest risk.”

Lan and colleagues noted some limitations to their study, including the fact that they studied only one site and they did not ascertain if some healthcare workers were wearing their masks after working hours.

  1. Nearly 100% of healthcare workers who are wearing PPE, particularly masks and gloves, for extended periods of time are experiencing skin damage.

  2. Dealing with constant irritation could prompt more frequent face touching and PPE protocol breaches.

Candace Hoffmann, Managing Editor, BreakingMED™

Lan’s et al study was supported by HUST Covid-19 Rapid Response Call Program and Hubei Provincial Emergency Science and Technology Program for Covid-19.

Lan, Kantor, and Elston disclosed no relevant relationships.

Cat ID: 469

Topic ID: 79,469,254,930,287,504,728,791,932,730,933,105,469,520,926,192,927,151,928,925,934

References

Lan J, et al “Skin damage among health care workers managing coronavirus disease-2019” J Am Acad Dermatol 2020; 82(5): 1215-1216.

Kantor J “Early lessons from the coronavirus (Covid-19) pandemic” J Am Acad Dermatol 2020; 82(5): 1087-1088.

Elston DM “Occupational skin disease among health care workers during the coronavirus (Covid-19) epidemic” J Am Acad Dermatol 2020; 82(5): 1085-1086.