COVID-19 and personal protective equipment: Treatment and prevention of skin conditions related to the occupational use of personal protective equipment
Authors: Seemal R. Desai, Carrie Kovarik, Bruce Brod, William James, Matthew E. Fitzgerald, Ave Preston, George J. Hruza
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: There have been an increasing number of reports of occupationally induced skin conditions in health care workers related to the use of personal protective equipment (PPE) during the coronavirus disease 2019 (COVID-19) pandemic.1Gheisari M, Araghi F, Moravvej H, et al. Skin reactions to non-glove personal protective equipment: an emerging issue in the COVID-19 pandemic [e-pub ahead of print]. J Eur Acad Dermatol Venereol. https://doi.org/10.1111/jdv.16492. Accessed May 7, 2020.Google Scholar,2Lan J. Song Z. Miao X. et al.Skin damage among health care workers managing coronavirus disease-2019.J Am Acad Dermatol. 2020; 82: 1215-1216Abstract Full Text Full Text PDF PubMed Scopus (379) Google Scholar The breadth and variety of different types of PPE, such as facemasks, gloves, and respiratory equipment, as well as the extended use beyond previous standards, have led to a spectrum of common dermatologic conditions, including contact/irritant dermatitis, pressure-related skin injury, acneiform eruptions, and moisture-associated skin irritation (Table I).Table ISkin condition related to masks—treatment and prevention strategiesSkin conditionSurgical maskN95 maskContact/irritant dermatitisUse alcohol-free barrier film wipe behind the ears before wearing, orApply thin foam dressing behind the ear beneath ear loop of surgical mask.N95 mask straps should be worn on the crown of the head, so should not be sitting on top of the ears.Pressure-related skin injuryApply thin foam dressing behind the ears beneath ear loop of surgical mask.Prophylactic dressings can be used under surgical masks for treatment/prevention. Proposed materials include a thin hydrocolloid dressing or thin foam dressing. Cut/adjust material to application site and apply dressing to skin without tension. Once PPE is removed at end of shift, wash hands, don clean gloves, gently remove dressings, and wash hands again. When removing prophylactic dressings, close eyes and avoid inhaling any aerosolized virus or particles.Apply alcohol-free barrier film wipe (not spray) on areas of direct PPE contact (eg, nose, cheeks, forehead, behind the ears) to protect skin from moisture and friction. Before applying, ensure the area is free of make-up, etc. Do not apply to eyes or eyelids. Allow to dry for 90 seconds before donning PPE.Wear facial PPE correctly and make sure size is correct.If skin damage is present, consider applying petrolatum to open areas 3-4 times a day when away from work. If an open area of skin is present, a hydrocolloid dressing may be used to help it heal; however, using these dressings under N95 masks requires refit testing to ensure adequate seal.AcneWash your face with gentle, mild fragrance free, noncomedogenic cleanser in the morning and at the end of the day. Take appropriate breaks from the mask: 15 minutes off every 2 hours.Wash your face with gentle, mild fragrance-free, noncomedogenic cleanser in the morning and at the end of the day.Take appropriate breaks from the mask: 15 minutes off every 2 hours.Moisture- associated skin irritationWash your face with gentle, mild fragrance-free, noncomedogenic cleanser in the morning and at the end of the day. Take appropriate breaks from the mask: 15 minutes off every 2 hours.Wash your face with gentle, mild fragrance-free, noncomedogenic cleanser in the morning and at the end of the day.Take appropriate breaks from the mask: 15 minutes off every 2 hours—if safe and practical to do so.PPE, Personal protective equipment. Open table in a new tab PPE, Personal protective equipment. Surgical and N95 masks, as well as goggles and face shields, have been reported to cause contact dermatitis, typically behind the ears (from elastic straps), on the bridge of the nose, or rarely on the entire face. Mask-induced contact dermatitis and contact urticaria can occur due to adhesives, rubber in straps, free formaldehyde released from the nonwoven polypropylene, and from metals in clips.3Foo C. Goon A.T. Leow Y.H. et al.Adverse skin reactions to personal protective equipment against severe acute severe acute respiratory syndrome-a descriptive study in Singapore.Contact Dermatitis. 2006; 55: 291-294Crossref PubMed Scopus (227) Google Scholar,4Donovan J. Kudla I. Holness L. et al.Skin reactions following use of N95 facial masks.Dermatitis. 2007; 18: 104Crossref Google Scholar The tighter and more secure N95 masks can cause significant skin damage due to pressure on anatomic points such as the bridge of the nose and across the zygoma. Moisture can accumulate under either type of facemask and predispose to skin breakdown and, potentially, superinfection. Facial PPE should be adjusted to fit correctly and should not lead to excess pressure or discomfort on any one particular area of the face. Skin should be routinely cleaned and moisturized using noncomedogenic emollients at least 1 hour before using facial PPE. Petrolatum-based products are not recommended as a skin sealing or repair agent because they may interfere with the integrity of the mask itself, in particular, the N95.5National Pressure Injury Advisory Panel (NPIAP)NPIAP position statements on preventing injury with N95 masks.https://cdn.ymaws.com/npiap.com/resource/resmgr/position_statements/Mask_Position_Paper_FINAL_fo.pdfDate: 2020Date accessed: May 7, 2020Google Scholar According to the Centers for Diseases Control and Prevention, contact dermatitis accounts for 10% to 15% of all health care occupational illnesses. Glove-related allergic contact dermatitis is relatively common in health care workers. The most common causes are rubber accelerators used in the manufacturing of gloves. Skin manifestations include pruritus, erythema, scale, vesicles, and in prolonged cases, hyperpigmentation and lichenification. Health care workers should be encouraged to use moisturizers frequently, especially when not in direct patient care, and ensure hands are clean and dry before the use of gloves and other PPE during patient contact time. For more severe cases of contact dermatitis, topical corticosteroids and other prescription therapies may be warranted. In addition to masks, gloves, and respirators, the repetitive and prolonged use of sterilizing agents, including hand soaps, detergents, and repeated exposure to water, can lead to irritated skin and an increased risk for contact sensitization. To reduce this risk, especially after handwashing, emollients with ceramides or petrolatum, or both, may be beneficial.6Beiu C. Mihai M. Popa L. et al.Frequent hand washing for COVID-19 prevention can cause hand dermatitis: management tips.Cureus. 2020; 12: e7506PubMed Google Scholar As health care workers, we are ultimately responsible for protecting our patients, ourselves, and the broader community. Wearing PPE for extended periods, as has occurred in the era of COVID-19, can have potentially serious consequences for health care workers. Recognizing occupationally induced skin conditions from PPE, and which of these can be prevented or minimized with proper measures, is critical to help mitigate long-term skin sequelae and maintain compliance. We would like to thank staff at the American Academy of Dermatology for their logistical and administrative support. We would also like to thank, in particular, Theresa Carbone, BSN, RN, CWOCN, William Falone, MSN, RN, CWON, and Shawn Parsons, MSN, CRNP, CWON, along with the Penn Medicine Wound Care Nursing Collaborative, for their ongoing efforts to educate health care workers and the public on the occupational risks in the era of COVID-19.