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Unmasking the complications of personal protective equipment

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By Christen Mowad, MD
August 5, 2020
Vol. 2, No. 31

DermWorld contributor Chris Mowad, MD
Allergic contact dermatitis and irritant contact dermatitis have long been identified as potential adverse reactions to personal protective equipment (PPE) most commonly due to gloves. The global pandemic caused by COVID-19 has heightened the need to use PPE as a safety precaution, highlighting the problems associated with infection-prevention measures, most notably masks and gloves. With increased usage and prolonged wearing of masks and gloves, the incidence of cutaneous problems related to PPE has been increasing. (1,2) Two studies done via questionnaire in China have shown that the prevalence of skin damage to frontline health care workers during the COVID crisis was 74-97%. (1,2) Lin et al reported that hands were the most common site affected. This was followed by the cheeks, nasal bridge and auricular areas. (1) In the Lan et al study, the nasal bridge was most commonly affected but problems affecting the hands, cheeks, and forehead were also reported. The most frequent symptom was dryness/tightness. Pruritus and burning/pain were also reported; increased duration of usage produced more problems. (1,2) More frequent hand hygiene with soap and water and waterless hand sanitizers were among the more common causes of hand dermatitis. (2) Given that pressure injuries are common from masks (standard and N95) and goggles, some authors have suggested using barrier films to protect and manage the wounds. (3) Although the use of adhesive barrier films may protect the face from ulceration or irritation, their impact on the effectiveness of the mask is not well studied.

Illustration for DWII on PPE
Irritant contact dermatitis. Image courtesy of DermNetNZ; provided by Prof. Raimo Suhonen.

Contact dermatitis can be either irritant or allergic in nature. Several contact allergens have been reported with masks and gloves when used as safety equipment. The most common allergens in a study by the North American Contact Dermatitis Group were rubber allergens (73%), followed by metals (14%). (4) The most common sites were the hands and the face. The final diagnosis was allergic contact dermatitis followed by irritant dermatitis. (4) Irritant contact dermatitis results from inflammation of the skin upon contact with various chemicals. It is often higher in patients with atopic dermatitis. (5) As Kantor states; “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.” (6)

The need for effective PPE is paramount amidst the current pandemic. Avoiding adverse reactions and helping mitigate and treat resulting skin problems in a timely fashion is essential for frontline health care workers and the public. This may include shorter shifts to reduce exposure time. It should also include education regarding good hand care; completely rinsing and drying the hands helps to decrease irritant contact dermatitis. Adequate emollient creams on the hands and face will help improve dermatitis in these areas. Patch testing for allergen identification should also be considered if the clinical picture is concerning for allergic contact dermatitis.

Point to Remember: Until the pandemic is behind us, issues related to PPE will be front and center in our battle against COVID-19. Dermatologists can help our colleagues and patients overcome PPE-related dermatoses with education and vigilance.

Our expert's viewpoint

Danielle M. DeHoratius, MD

I never thought there would be a time in my career when practicing that I could either be seeing patients or double as an extra on Star Trek episode. COVID-19 has caused so many changes in the way we practice as well as the diagnoses we are seeing — from an increased incidence of both contact and irritant dermatitis to “maskne.” Complicating matters is that one of the best management strategies would be to take a break from wearing PPE but that is not possible in the current climate. There is a silver lining: No sunscreen is needed under masks. Dr. Mowad crafted a very thoughtful review of the dermatoses created by the increased PPE that needs to be worn by health care workers. We must keep in mind that there are specific individuals of the general population who may also need to wear such protection including those who are immunocompromised. Thank goodness our pets don’t have to wear PPE, yet!

  1. Lin P, Zhu S, Huang Y et al. Adverse skin reactions among healthcare workers during the Coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions. Br J Dermatol. April 2020. Doi:10.1111/bjd.19089.

  2. Lan J, Song Z, Miao X et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol82(5): 1215-2016: 2020.

  3. Oranges T, Janowska A, Dini V. Reply to: Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol 2020, doi:Https://doi.org/10.1016/j.jaad.2020.04.003.5

  4. Warshaw EM, Schlarbaum JP, Silverberg, JI et al. Safety equipment: when protection becomes a problem. Contact Dermatitis 81(2):130-132, 2019.

  5. Visser M, Landeck L, Campbell L et al. Impact of atopic dermatitis and loss-of-function mutations in the filaggrin gene on the development of occupational irritant contact dermatitis. Br J Dermatol 168(2), 2013.

  6. Kantor J. Behavioral considerations and impact on personal protective equipment use: Early

All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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