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Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 3  |  Page : 313
Skin damage and quality of life among healthcare workers providing care during the COVID-19 pandemic: A multicenter survey in Banten Province, Indonesia

1 Department of Dermatology and Venereology, Faculty of Medicine, Pelita Harapan University, Banten, Indonesia
2 Department of Microbiology, Faculty of Medicine, Pelita Harapan University, Banten, Indonesia

Date of Web Publication22-Sep-2022

Correspondence Address:
Paulus M Christopher
Jenderal Sudirman Lippo Karawaci Boulevard Road, Tangerang, Banten - 15811
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_645_21

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Background: Since the occurrence of the coronavirus disease-2019 pandemic, healthcare workers (HCWs) have been strictly adhering to infection control practices within healthcare facilities. However, regular use of personal protective equipment (PPE) and hand hygiene have led to increased prevalence of skin damage, subsequently impacting the quality of life (QoL). Objective: To analyse the connection between skin damage and the QoL among HCWs in a multicenter setting in Indonesia. Methods: A cross-sectional survey was conducted among HCWs working in hospitals in Banten Province, Indonesia. The data was obtained using a reliable self-reported questionnaire (Cronbach α 0.765) and a validated Indonesian version of the Dermatology Life Quality Index. Results: A total of 113 respondents (56.5%) who experienced at least one self-perceived PPE-related skin damage and had worn PPE of any level within the last 7 days were analysed. The mean age ± SD of respondents was 26.09 ± 6.22 years old, while the mean DLQI score ± SD was 5.46 ± 4.88, with a median of 4.0 (range, 0-24). The regression model showed that the level of PPE used (P < 0.05) to be a significant risk factor. Conclusions: Skin damage due to PPE affects HCWs physically and emotionally. It is crucial to recognise its impact on life and reinforce awareness, prevention, and treatment of skin damage. Dermatologist referral and intervention should be considered for optimum management.

Keywords: DLQI, HCW, healthcare workers, QoL, quality of life, skin damage

How to cite this article:
Christopher PM, Roren RS, Tania C, Jayadi NN, Cucunawangsih C. Skin damage and quality of life among healthcare workers providing care during the COVID-19 pandemic: A multicenter survey in Banten Province, Indonesia. Indian J Dermatol 2022;67:313

How to cite this URL:
Christopher PM, Roren RS, Tania C, Jayadi NN, Cucunawangsih C. Skin damage and quality of life among healthcare workers providing care during the COVID-19 pandemic: A multicenter survey in Banten Province, Indonesia. Indian J Dermatol [serial online] 2022 [cited 2022 Oct 6];67:313. Available from:

   Introduction Top

In March 2020, the World Health Organization (WHO) declared the coronavirus disease-2019 (COVID-19) a pandemic.[1] In an effort to prevent the transmission, the WHO recommended the use of personal protective equipment (PPE) for the community, including the healthcare workers (HCWs). HCWs have been advised to wear PPE with varying levels, comprising of various components. However, PPE increases the risk of skin damage. The prevalence, characteristics, and risk factors of PPE-related skin damage have been published previously.[2],[3]

Depending on the severity and location of dermatological disease, individuals may experience significant physical discomfort and some disability.[4] A dermatological disorder may also cause disturbances in their occupation, recreation, self-perception, discrimination, embarrassment and depression.[5],[6] Additionally, the patient may experience avoidance and negative reactions (i.e., maladaptive thought processes, unfavourable self-perceptions and negative behavioural patterns) to the social environment, subsequently affecting the patient's mental state.[7]

The relationship between dermatology and mental health is often very complicated and the following impact of the dermatological disease is less known.[8] The impact of dermatological disease can vary from minor to severe impairment and may lead to a lower quality of life (QoL). QoL can be assessed with a generic questionnaire, a dermatology-specific instrument, or a disease-specific instrument used singly or in combination. The use of both a generic and a dermatology-specific instrument is generally recommended, especially where skin disease has a substantial general impact that is not evaluated by disease-specific instruments.[9],[10] However, little is known about the current issue of PPE related-skin damage related to QoL measured by the Dermatology Life Quality Index (DLQI) questionnaire. This study aimed to illustrate the connection between skin damage and QoL in HCWs in a multicenter survey in Banten province, Indonesia.

   Material and Methods Top

Study design and setting

To address this, a cross-sectional online survey from June 1 to August 31, 2020, at three hospitals of the Siloam Hospitals Group in Banten, Indonesia (Siloam Hospitals Lippo Village, Siloam Hospitals Kelapa Dua, and Siloam Teaching Hospital) was conducted. The present study received ethical approval from the Ethics Committee of the Faculty of Medicine, Pelita Harapan University (Ref: 151/K-LKJ/ETIK/VII/2020). All respondents were granted their electronic informed consent, and all data were anonymised before analysis by de-identifying respondent data. The design, setting, analyses, and reporting of this study complied with the Strengthening the Reporting of Observational studies in Epidermiology (STROBE) guidelines for cross-sectional studies in epidemiology.[11]

Study population

The sample size was calculated using the Cochran sample size formula for categorical data with a 95% confidence level (level of significance α = 0.05) and a 10% margin of error along with the proportion of cases reported from prior literature generating the minimum sample size (n) of HCWs recommended for this study was 73 respondents.[2],[12]

The study utilised a purposive sampling method and approached HCWs constituting of medical students undergoing clinical clerkship, general practitioners, specialists, nurses, midwives, laboratory personnel, radiographers, and pharmacists, caring for patients during the COVID-19 pandemic stationed in either one of the three hospitals.

Dermatology life quality index

The validated Indonesian version of DLQI, with the formal permission of Professor Andrew Finlay, was utilised for the QoL assessment.[13] The DLQI consists of 10 questions, each with four possible answers, with a score ranging from 0 to 3 regarding the past 7 days. The DLQI covers six sub-scales: 1) symptoms and feelings (Question [Q] 1 and Q2), 2) daily activities (Q3 and Q4), 3) leisure (Q5 and Q6), 4) work and school (Q7), 5) personal relationships (Q8 and Q9), and 6) treatment (Q10). A total score between 0 and 30 is calculated by summing the responses to all questions with an interpretation as follows: 0-1 = no effect at all, 2-5 = small effect, 6-10 = moderate effect, 11-20 = very large effect, 21-30 = extremely large effect. A higher score indicates a more significant impairment in the QoL.[14]

Data collection and management

The data collected for the study was obtained using a reliable self-reported questionnaire (Cronbach α 0.765) and a validated Indonesian version of the DLQI.[13] The questionnaire comprised of three sections, namely, demographic characteristics and occupational-related characteristics, skin damage, and the DLQI questionnaire. The questionnaire was designed with multiple-choice responses and space for comments on the questions. To minimise misunderstanding, concentrating on the skin damage, each skin damage choice had a definition and synonym of a more common word.

Demographic characteristics, occupation-related characteristics, and skin damage were summarised using descriptive statistics (quantitative variables were expressed as mean ± SD and qualitative variables as frequency and percentages). For analytical objectives, the occupation was categorized into three, namely, 1) doctor (medical student undergoing clinical clerkship, general practitioner, and specialist), 2) nurses and midwives, and 3) other medical personnel (laboratory personnel, radiographer, and pharmacist). The main working department was categorized into three, namely, 1) group A department (fever clinic, general ward, pharmacy, outpatient-, emergency-, and radiology department), 2) group B department (critical care unit, laboratory, testing room, operation room, COVID-19 isolation ward), and 3) both. The hand hygiene (with soap and/or alcohol-based handrub/hand sanitizer) frequency, daily and weekly wearing time of PPE, break opportunity in every shift, and daily showering frequency were categorised into two groups based on the median. A score of five was used as a cut-off for the DLQI scores categorising into two groups, i.e., low DLQI score (0-5) and high DLQI score (6-30).[14],[15]

Statistical analysis

The data collected were tabulated into Excel files (Microsoft Excel, Microsoft Corp. Redmond, WA, USA). Statistical analyses were performed using Statistical Package for Social Sciences Statistics Version 25.0 (IBM Corp., Released 2017, Armonk, NY, USA). The Kolmogorov-Smirnov test was performed for the evaluation of normality of the DLQI scores. Continuous data (recorded as range, median, mean ± SD) were analysed using Mann-Whitney U and Kruskal Wallis, as appropriate. Categorical data (presented as frequencies and proportion) were compared by univariate logistic regression analysis. Predictors were further analysed using the multivariate logistic regression model. The model goodness-of-fit was assessed by the Hosmer-Lemeshow test. A P < 0.05 has been considered significant statistically and odds ratio with a 95% confidence interval (CI) to establish the strength of associations and a measure of precision.

   Results Top

Approximately 500 surveys were distributed and 200 HCWs (doctors, nurses, midwives, and paramedical personnel caring for patients during this COVID-19 pandemic) responded (valid response rate, 40.0%).

During the study period, a total of 113 (56.5%) respondents experienced at least one self-perceived PPE-related skin damage and had worn PPE of any level within the last seven days. The mean age ± SD of the respondents was 26.09 ± 6.22 years old, with a median of 24 (range, 20-57) years old. The most reported symptoms were dryness/tightness (62.8%), itching (60.2%), and rash (50.4%), while the most reported signs were acne (68.1%), erythema (58.4%) and desquamation (44.2%). The most affected locations were the cheeks and chin (70.8%), forehead (42.5%) and nasal bridge (38.1%) [Figure 1] and [Figure 2], [Table 1].
Figure 1: Indentation due to pressure on the forehead, nasal bridge, cheeks, and chin

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Figure 2: Self-reported acute onset of erythematous papules and fissuring of the left thumb after repetitive hand hygiene practice

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Table 1: Analysis between DLQI results in relation to the characteristics (location, symptoms, and signs) of skin damage

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Within the group of HCWs with at least one self-perceived PPE-related skin damage, the mean DLQI score ± SD was 5.46 ± 4.88, with a median of 4.0 (range, 0-24), indicating that many of the respondents (65,4%) reported a mild-to-moderate effect on their QoL. A summary of the effects on the patients' life and DLQI measures obtained from the questionnaire is presented in [Figure 3]. The sub-scale with the highest score was symptoms and feelings, while the lowest score was for personal relationships. There were no significant differences in the DLQI sub-scale scores between males and females [Figure 3].
Figure 3: Summary of DLQI questionnaire results. DLQI: Dermatology Life Quality Index

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Skin damage was observed primarily in youth (61.9%) females (75.2%) working as doctors (79.6%) under group A department (54.9%) at a non-referral center for COVID-19 (62.8%) wearing level 2 PPE (46.9%) for ≥ 7 hours/day (58.4%) and ≥ 5 days/week (60.2%), with no break opportunities in every shift (55.8%). Hand hygiene frequency ≥ 20 times/day (59.3%) with double or more layers of gloves (41.0%) also contribute to these skin damages. Only a small proportion of the respondents practice using a moisturizer and a dressing material (e.g., foam, hydrocolloid, and/or perforated silicone adherent sheet) as a method of prevention (38.1% and 9.7%, respectively).

The univariate logistic regression analysis revealed seven variables from 14 significant variables (P ≤ 0.25) regarding the DLQI categorization, namely age group classification, occupation, level of PPE used, layers of gloves, and weekly duration of PPE worn, use of a moisturizer and a dressing material. The final model revealed one significant variable, the level of PPE used regarding the DLQI categorisation [Table 2].
Table 2: Univariate and multivariate analysis between DLQI results in relation to sociodemographic and occupational-related characteristics among HCWs

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   Discussion Top

Quality of life assessment is an integral part of having insight into the patient's life and the change treatment has brought into it. According to the WHO, QoL is defined as “An individual's perception of their position in the life in the context of the culture in which they live and in relation to their goals, expectations, standards and concerns.”.[16] In an attempt for precise insight, the questionnaire must be formulated to evaluate the patient's perception of the disorder on the QoL. In the field of dermatology, several specific questionnaire instruments have been developed, such as the DLQI. The DLQI, published in 1994, is the first dermatology-specific QoL questionnaire and has been used widely for many different skins conditions.[14],[17]

During the COVID-19 pandemic, PPE is one of the critical concerns for HCW's safety. According to the recommendations from WHO and guidelines from the former Indonesian COVID-19 Response Acceleration Task Force, HCWs are required to use PPE when caring for patients in healthcare facilities. The guideline categorised PPE into three levels based on the risk of transmission; level 1 PPE constituted a 3-ply surgical mask, gloves, and regular clothing, while level 2 PPE constituted level 1 PPE with an additional head cap, goggles, and gown. Lastly, level 3 PPE constituted of head cap, goggles, and face shield, N95 mask or equivalent, coverall/gown and apron, surgical gloves, and boots/rubber shoes with a protector. With varying levels of PPE standards recommended, different components of PPE are related to the different skin damage.[2],[18]

The top three most affected locations and reported symptoms were cheeks and chin, forehead, and nasal bridge together with dryness/tightness, itching, and rash, respectively. The most reported signs were acne. These findings were consistent with previous literature and may be explained due to the prolonged hours of PPE use, mechanical trauma, excessive humid internal environment, compromised skin barrier, and high stress environment.[2],[3],[19],[20],[21] Among the top three most affected locations, reported symptoms and signs, forehead and nasal bridge, rash, and erythema seemed to have a more significant impact on the patients (P < 0.05) based on the DLQI scores.

Regarding the QoL, the mean DLQI score ± SD and median (5.41 ± 4.87 and 4.0, respectively) of the present study were similar to those of previous studies on occupational dermatitis (mean: 5.5 ± 4.8) and occupational hand eczema (median: 4.5).[22],[23] When compared with the mean DLQI score ± SD of other dermatological conditions (e.g., psoriasis [7.5 ± 6.1], atopic dermatitis [9.79 ± 6.2], and hyperhidrosis [15.8 ± 6.6]), the respondents in this study appeared to have a lower mean DLQI score ± SD.[24],[25],[26] A higher DLQI score reflects a larger impact of QoL experienced in these conditions which may be attributable to more severe disease, a longer disease duration, the presence of concomitant diseases, and more progressive disease.[23]

In this study, participants carried a higher risk of getting skin damage from a higher level of PPE used. Other notable factors associated with skin damage are the long duration of PPE wear and hand hygiene practices as seen in other studies.[3],[27],[28] Similar risk factors were observed in previous studies, including higher working frequency, wearing gloves, and longer work duration appeared to be one the most common risk factors, which suggests more reasonable working hours for medical personnel should be further considered.[3],[28],[29] Additionally, an Indian study revealed that a single relationship significantly reduced the possibility of developing recent skin damage due to COVID-19-enhanced protective measures (aOR 0.4, 95% CI 0.2-0.9, P = 0.04).[30]

Although the mean DLQI scores showed a mild effect on QoL in the present, future skin problems should be anticipated. Previous studies showed that worsening hand eczema could lengthen the duration of sick leave and decrease QoL.[31] Preventive measures should be taken by educating HCWs to lower the risk of skin problems and facilitate HCWs with the proper treatment needed.[32] As previous studies showed proper management and intervention, there was a significant improvement in QoL among patients.[33] Awareness regarding skin damage among HCWs, specifically dermatologists, should be raised and advocated. Specific health and safety training must be integrated to improve the knowledge and understanding of employees regarding the prevention and control of the hazards and risks associated with skin damage, followed by the adoption of workplace safety cultures and practices.[34]


This study has several limitations. First is the cross-sectional and online nature of the study. Second, selection bias (only those with smartphones or computers could participate in the online survey) and response bias (as HCWs with skin damage are more likely to respond) might have occurred. Third, we did not study based on each component of varying levels of PPE as it can impact one site by single or multiple exposure factors. Fourth, possible associated risk factors outside the hospital, such as the use of masks and hand hygiene after work in daily life were not assessed. Lastly, skin damage and the severity of the skin damage were not confirmed by a dermatologist. Despite these limitations, the present study provides a novel insight regarding the QoL associated with skin damage among HCWs during the COVID-19 pandemic, where a varying degree of QoL impairment may be expected. Further studies are recommended to validate our findings in different populations.

   Conclusions Top

Skin damage is a common occupational-related skin problem among HCWs during this COVID-19 pandemic. The findings suggest that level of PPE used affected the QoL. Regarding skin damage characteristics, locations (forehead, eyelid, nasal bridge, temples, ears, neck, trunk, arms, ventral aspect of palms, and feet), symptoms (rash and tenderness), type of skin damage (erythema, erosion and/or ulcer, wheal, pressure indentation, lichenification, hypo-/hyperpigmentation, dry skin and maceration) also significantly impacted the QoL. Yet, our study provides the relationship between skin damage and occupational-related characteristics on the QoL, which may play a part in personal and professional scope. Recommendations to avoid and minimise skin damage have been developed, and in severe and persistent cases, dermatologic consultation is highly advised.[30]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The authors thank all the HCWs for their time and effort in participating in this study. The authors also acknowledge Siloam Hospitals Lippo Village, Siloam Hospitals Kelapa Dua, and Siloam Teaching Hospital for providing us with the opportunity to conduct the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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