Prevalence of cheilitis in health care workers treating patients with COVID-19
Authors: Mehak Singh, Atul Bothra, Manoj Pawar, Anshu Maheswari, Apoorv Tiwari, Pankaj Adhicari
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: The COVID-19 pandemic heralded the use of personal protective equipment (PPE) by front-line health care workers (HCWs) working tirelessly for long hours. The extended use of PPE has led to various kinds of occupational dermatoses, including facial dermatitis, pressure injury, acne, and frictional injury, in up to 97% of HCWs.1Singh M. Pawar M. Bothra A. et al.Personal protective equipment induced facial dermatoses in healthcare workers managing COVID-19 cases.J Eur Acad Dermatol Venereol. 2020; 34: e378-e380Crossref PubMed Scopus (91) Google Scholar,2Lan J. Song Z. Miao X. et al.Skin damage among healthcare workers managing coronavirus disease–2019.J Am Acad Dermatol. 2020; 82: 1215-1216Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar In this study, we report preliminary data of HCWs experiencing various types of cheilitis due to the use of face masks. From April 15 through May 15, 2020, we came across 33 HCWs, engaged in COVID-19 duties, who complained of dryness, itching, smarting, and/or tightness of the lips after the use of face masks. The history, occupation, and clinical features including onset, duration, pattern of cheilitis, exacerbating factors, and duration of PPE worn were recorded, and final clinical diagnosis was made. Patch testing could not be performed. In the 33 HCWs, the most common presenting symptoms were tightness (63.64%) and chapping (57.57%), followed by burning sensation, smarting, and itching. The most common signs were flaking 24 (72.73%), scaling 15 (45.46%), and swelling 13 (39.39%). Generalized lip dryness, that is, cheilitis simplex (n = 21, 63.64%), was the most frequent pattern of cheilitis. Angular cheilitis was seen in 12 patients (36.36%), whereas progression to perioral involvement was seen in 5 patients (15.15%). Cheilitis venenata was observed in 10 (30.30%) patients, attributed here to N95 mask contact. Associated lip edema was present in 7 patients (21.21%). Secondary infections (27.27%) and hyperpigmentation (18.18%) were the most common sequelae (Supplemental Fig 1; available via Mendeley at https://doi.org/10.17632/655bpmbggv.1). Spicy food and hot beverages (n = 26, 78.79%) were the most common aggravating factors, followed by habitual picking/peeling (51.52%) and associated contact dermatitis to N95 masks (30.30%). Most of the HCWs admitted to extended work hours, with a mean of 8.92 ± 2.15 hours of face mask worn per day and 5.01 ± 1.11 hours of rotation per day (Table I). The patients were treated with liberal use of bland emollients and counseling to eliminate inciting factor(s) and break the wet-dry cycle by repeated application of saliva. Topical corticosteroids, topical calcineurin inhibitors, oral antihistamines, antibiotics, and vitamin B supplements were used as and when justified. Our study denotes generalized lip dryness to be the most common presentation of lip cheilitis, which might progress to perioral involvement. PPE forms the major armamentarium for HCWs' protection in the fight against COVID-19. PPE-induced dermatoses lead to frequent irritation and subsequent touching of the face, which might increase disease transmission.3Kantor J. Behavioral considerations and impact on personal protective equipment use: early lessons from the coronavirus (COVID-19) pandemic.J Am Acad Dermatol. 2020; 82: 1087-1088Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar The inadequate workforce, coupled with a relative shortage of PPE kits, results in the long duty hours of the HCWs and leads to constant chapping of the lips. An unconscious repeated contact with saliva follows, which macerates the skin and removes the protective oils, leading to a constant wet-dry cycle and resulting in disruption of skin barrier function and inflammation, which further perpetuates the cycle. Dehydration, air-conditioned rooms, and the humid environment created by the PPE also contribute (Supplemental Fig 2; available via Mendeley at https://doi.org/10.17632/phwh6mj87y.1). The authors would like to suggest that HCWs liberally use a bland emollient such as petrolatum jelly to moisturize the lips, avoid repeated lip licking, and increase hydration to prevent such occupational dermatoses.Table ISummary of demographic and clinical features, causative agents, and treatmentsParametersValue%Number of patients33—Age, y, mean ± SD32.28 ± 16.67—Sex, male:female14:19—Occupation Doctors1133.33 Nurses1236.36 Allied services (ward assistants, cleaners, transport teams, etc)412.12Symptoms Burning sensation1339.39 Smarting824.24 Itching927.27 Tightness2163.64 Chapping1957.57Signs Flaking2472.73 Scaling1545.46 Fissures1339.39 Perioral accentuations515.15 Swelling1236.36Pattern of cheilitis observed Cheilitis simplex2163.64 Angular cheilitis1236.36 Perioral involvement515.15 Cheilitis venenata1030.30Type of cheilitis Irritant contact dermatitis2472.73 Allergic contact dermatitis309.09 Friction dermatitis∗Friction dermatitis may be caused by the constant rubbing by mask or by sweat wiping.618.18Associated sequelae Hyperpigmentation618.18 Secondary infection927.27 Photosensitivity824.24Exacerbating factors Habitual peeling/picking: exfoliative cheilitis1751.52 Aggravation due to spicy food/hot beverages2678.79Duration of PPE worn/d, h, mean ± SD8.92 ± 2.15—Duration of rotation/d, h, mean ± SD5.01 ± 1.11—History of dermatitis/allergic predisposition Atopy206.06 Asthma618.18 Food allergies412.12 Lipstick/lip products allergy515.15Contact dermatitis to components of PPE Gloves515.15 Gown412.12 Face shield103.03 Face mask (including straps, nose piece, and the body)1236.36N95 masks866.67Surgical masks216.67Homemade fabric masks (dye dermatitis)216.67Medications prescribed Barrier emollient3193.94 Topical corticosteroid309.09 Topical calcineurin inhibitor927.27 Topical antibiotic927.27 Oral antihistamine1133.33 Vitamin B complex supplements1442.42PPE, Personal protective equipment; SD, standard deviation.∗ Friction dermatitis may be caused by the constant rubbing by mask or by sweat wiping. Open table in a new tab PPE, Personal protective equipment; SD, standard deviation.