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E-IJD® - ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 478
A clinico epidemiological study of adverse cutaneous manifestations on using personal protective equipment among health care workers during Covid pandemic in a tertiary care centre


From the Department of Dermatology, Madras Medical College and RGGGH, Chennai, Tamil Nadu, India

Date of Web Publication2-Nov-2022

Correspondence Address:
B Yuva Priya
Department of Dermatology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu - 600 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_1157_20

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   Abstract 


Background: COVID-19 (Coronavirus Disease 2019) pandemic was caused by a novel coronavirus. The frontline health care workers (HCW), wearing personal protective equipment (PPE) for a longer duration can result in a spectrum of adverse skin reactions. Recognizing occupationally induced adverse skin manifestations from PPE is necessary to avoid skin damage and risk of infections and to maintain compliance. Aim: This study aimed to determine the prevalence, clinical characteristics of adverse cutaneous manifestations due to PPE, and also the contributing epidemiological factors among HCW in a tertiary care institute. Materials and Methods: This cross-sectional study was conducted for a period of one month. Four hundred fifteen health care workers who used PPE continuously for >4 hours voluntarily participated in this study. By using a self-administered online questionnaire, the information and clinical photographs were collected. Results: The prevalence of adverse skin manifestations was 62.1% (258). The prevalence was more common in females. Mask-related facial skin problems were most commonly reported. Of 74 participants with pre-existing acne lesions, 35 (8.4%) reported acne flare-ups after using PPE. Increased sweating (22.6%) and itching (11%) were the most commonly noted symptoms. Conclusion: This study provides an insight into the prevalence of adverse skin reactions due to prolonged PPE usages, such as N95 masks and latex gloves in particular. Hence dermatological screening of HCW at regular intervals is inevitable to facilitate early management and prevent inadvertent protocol breaches. Further, it proposes the importance of raising proper safety measures to effectively reduce the COVID positivity rate among HCW by minimizing and preventing occupationally induced dermatosis.


Keywords: Adverse skin reactions, COVID-19, health care workers, occupational injury, personal protective equipment


How to cite this article:
Malathy PA, Daniel SJ, Venkatesan S, Priya B Y. A clinico epidemiological study of adverse cutaneous manifestations on using personal protective equipment among health care workers during Covid pandemic in a tertiary care centre. Indian J Dermatol 2022;67:478

How to cite this URL:
Malathy PA, Daniel SJ, Venkatesan S, Priya B Y. A clinico epidemiological study of adverse cutaneous manifestations on using personal protective equipment among health care workers during Covid pandemic in a tertiary care centre. Indian J Dermatol [serial online] 2022 [cited 2022 Nov 26];67:478. Available from: https://www.e-ijd.org/text.asp?2022/67/4/478/360304





   Introduction Top


The coronavirus disease (COVID-19) is the disease caused by a novel coronavirus, and the first case in India was reported on January 30, 2020. The Indian Ministry of Health and Family Welfare had reported 26,848 confirmed cases from 33 states on November 15, 2020.[1] Health care workers (HCWs) are involved in treating the patients and protecting themselves and the community. Personal protective equipment (PPE) consists of protective clothing, mask, face shield, goggles, and gloves, which are worn by HCWs for a longer duration in the current pandemic.[2],[3] This can cause many skin reactions, which may discourage HCWs from using it.[4],[5]

The most commonly reported findings were skin maceration, dryness, itching, and acne flare-up.[6],[7] The adherence to strict PPE protocol is important, and the presence of mild abrasion or itching might induce inadvertent protocol breaches like adjustment of goggles and mask.[8] If the skin gets damaged, contamination and transmission of the pathogens will happen.[9]

The aim of this study was to determine the prevalence of adverse skin reactions to PPE among HCWs. Recognizing occupationally induced skin conditions due to PPE helps to determine the true extent that can be prevented or minimized with proper safety measures.[10]


   Materials and Methods Top


Study center: Rajiv Gandhi Government General Hospital, Chennai, Tamilnadu

Study design: A hospital-based cross-sectional study

Study population and sample size: The sample size was calculated based on the reference study of Jiang et al.,[19] who reported a 42.8% prevalence of skin injuries to PPE. The allowable error was 5%, 10% non-respondents and the final sample size was 415. A total of 500 HCWs were approached until the sample size was reached. Of these, 418 responses were collected from various clinical, nonclinical postgraduates, nurses, and laboratory technicians who used PPE. Three responses were excluded due to incomplete responses. The overall response rate was 83.6%. The study was approved by the Institutional Ethical Committee.

Inclusion criteria

HCWs who used PPE such as N95 masks, latex gloves, goggles, and protective clothing for >4 hours continuously and those who were willing to give consent to participate were included.

Exclusion criteria

  1. HCWs using PPE such as N95 masks, latex gloves, goggles, and protective clothing for <4 hours.
  2. HCWs using improper medical devices like disposable masks.
  3. Those who were not willing to participate in the study.


Data collection tool

By using Google sheets, a self-administered online questionnaire based on relevant guidelines was designed and reviewed by statisticians and expert dermatologists.[11],[12] We sent the questionnaire in Google sheet link form to the frontline HCWs via the Telegram social platform from October 1 to October 26, 2020. Participants voluntarily answered and submitted the questionnaire using their mobile. The questionnaire consisted of details about the demographic profile, adverse skin manifestations (onset, types, and anatomical site), clinical photographs, and adoptive preventive measures.

Research quality control

The classification of device-related pressure injury (DRPI) depended on the staging system in the 2019 International Guide for Prevention and Treatment of Pressure Injury.[13] According to the 2017 Centers for Medicare and Medicaid Services, sweat and moisture-associated skin disease (MASD) is caused by sustained exposure to moisture which can be caused by incontinence, wound exudate, and perspiration.[14]

Statistical analysis

The collected data was entered in the Microsoft Excel sheets and analysed using SPSS software version 21.0. The mean (standard deviation) was used to describe the participant's characteristics for continuous variables. Categorical variables were described as frequencies (percentages). Univariate and multivariate analyses were performed for identifying significant factors for skin injuries.


   Results Top


General characteristics of study population

The overall prevalence of adverse skin manifestations was 62.1% (258). Out of 415 participants, 353 were doctors, 60 were nurses, and two were lab technicians. The mean age group of the participants was 27.7 years. The most commonly affected age group was 20–30 years. Out of 415 participants, 156 (37.5%) were males, and 259 (62.4%) were females. The prevalence of adverse skin manifestations was more common in females than in males, with a male to female ratio of 1:2 (85:173).

Prevalence of adverse skin manifestations, based on the etiological factors: Four kinds of skin injuries were noted in this study with the following prevalence [Table 1].
Table 1: Reported skin manifestations

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  1. Sebaceous activity related skin manifestations like acne and acne flare-up: 28.7%(119) [Figure 1]
  2. PPE per se induced skin lesions like rash, urticarial, and contact dermatitis: 15.1%(63) [Figure 2]
  3. Device-related pressure injuries (DRPI) like nose, ear, and skin damage, skin maceration, and pigmentary changes: 12.8%(53) [Figure 3]
  4. Sweat and moisture-related skin manifestations (MASD) like itching, increased sweating, and seborrheic dermatitis: 5.5%(23) [Figure 4]
Figure 1: Acne flare-up of face over mask-using area

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Figure 2: PPE material induced urticarial wheals and rashes over upper and lower limbs

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Figure 3: Device-related pressure injury of (a) hyperpigmentation on retroauricular area due to mask and (b) pressure erythema on forearm due to gown

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Figure 4: Sweat retention syndrome over the back

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Even though injuries were categorized, most of the skin problems had multifactorial contributions like poor air permeability, increased humidity, pressure, and sweating.

Characteristics of skin manifestations

21. 4% (89) had a history of pre-existing skin conditions like atopic dermatitis, acne, and contact dermatitis. Of 74 participants with pre-existing acne lesions, 35 reported exacerbation of acne (acne flare-up) after using PPE. Around 4.3% (18) of the study population had associated comorbid conditions like hypothyroidism, diabetes, and epilepsy. Among the 63 (15.1%) participants who used skincare products like moisturizers regularly, reported a lesser prevalence (5.5%) of skin manifestations. 35.1% (146) had developed skin reactions immediately after using PPE for one day. The mean duration of skin manifestations was seven days. Out of 258, 190 (45%) participants had resolution of the skin lesions in between the PPE usage. 48.9% (203) had a recurrence of the same symptoms and signs while using the PPE again. This indicates that the above-mentioned occupational skin manifestations of HCWs could be directly related to PPE use. Mask-related skin problems were most commonly reported in 41.2% (171), followed by gloves in 29.6% (123), head caps in 11% (46), and gowns in 5.3% (22). Increased sweating (22.6%) and itching (11%) were the most commonly noted complaints. Most of them (n = 302) reported a bathing frequency of more than once a day. The mean frequency of handwashing was four times a day.

Based on the site: Of 415 participants, 258 HCWs reported diverse site skin injuries (multiple anatomical sites) of 564 injuries in total, with an average of 2.1 injuries per person, and the manifestations were categorized based on four different sites [Table 2]. Forty-seven (11.3%) participants had mixed-type injuries (> two types of injuries). Among the total 564 skin injuries, 350 injuries were primary skin manifestations due to PPE, and 214 injuries were secondary skin manifestations like infections and exacerbation of pre-existing skin diseases [Table 3].
Table 2: Site-based distribution of skin injury types in HCWs (Total=564)

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Table 3: Site-based skin manifestations

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  1. Face: Among 415, 196 (47.2%) participants reported facial adverse skin reactions, including primary lesions like acneform eruption (84), pressure injuries (43), pigmentary changes (3), and secondary skin manifestations like infections (14) and exacerbation of pre-existing skin diseases (35).
  2. Hands and feet: Out of 258, 123 (29.3%) participants developed hands and feet skin reactions, mainly contact dermatitis (47), and the prevalence was higher in persons with a handwashing frequency of > four times per day [Figure 5]. Nineteen people reported increased sweating of palms, and 15 had developed chapped skin. Two individuals had developed dissemination of tinea mannum to onychomycosis, and two persons had dissemination of wart [Figure 6]. It could be due to skin maceration and itching induced pseudo koebnerisation, respectively.
  3. Scalp: One hundred fifteen (27.7%) participants reported scalp problems, including primary manifestations like seborrheic dermatitis in 46 and secondary skin manifestations like folliculitis in 13, sebopsoriasis in five, and hair loss in 51 individuals after using PPE for a longer time.
  4. Other sites: In other areas, 130 participants (31.3%) reported primary skin reactions, including acneform eruption of trunk (26), postauricular skin damage (12), acute urticaria (20), and sweat retention syndrome (21). Secondary skin manifestations were infections like pityriasis versicolor (15) [Figure 7] and tinea corporis (13).
Figure 5: Contact dermatitis to (a) elastic straps in retroauricular area and to (b) hand gloves

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Figure 6: Dissemination of wart

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Figure 7: Pityriasis versicolor infection on arms

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The prevalence of skin injuries was higher in females than in males (66.7% vs. 54.4%, P = 0.299), in nurses than in doctors (96.7% vs. 56%, P = 0.06), in those with daily wearing time ≥6 hours than in those wearing 4–6 hours (93.6% vs. 27%, P = 0.000), in those older than 35 years than in those younger than 35 years (95.1% vs. 58.5%, P = 0.748), and in those with increased sweating than in those without increased sweating (67% vs. 47.7%)[Table 4].
Table 4: Characteristics and univariate analysis of skin manifestations in HCW

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COVID positivity rate: The positivity rate among HCWs in this study population was 6% (25). They reported as COVID positive after seven days of their last duty. Among 25 participants, 18 HCWs (4.3%) reported adverse skin manifestations of PPE with an average of 2.2 injuries per person. The mean age group of affected persons was 28.5 years. The prevalence was higher in males (16) than in females (9). Eight participants had pre-existing skin diseases. Out of 18, 17 worked in the COVID isolation ward and one person in the fever screening centre. They mainly reported facial skin reactions (42.5%) followed by hands and feet contact dermatitis (20%). It would lead to inadvertent protocol breaches like the adjustment of devices. If the skin or mucous membrane gets damaged, it can lead to an increased risk of transmission of the coronavirus to HCWs.


   Discussion Top


During this COVID-19 pandemic, adverse skin manifestations among HCWs wearing PPE can impair their health and increase the chances of infection.[15] 1.8% of the HCWs tested positive for COVID in India.[16] Prolonged wearing of PPE has increased occupational adverse skin reactions.[17],[18] The overall prevalence of adverse skin manifestations was 62.1% (258 participants). It is higher than the study by Jiang et al. (42.8%)[19] and Saha et al.(41.5%).[20] The prevalence of skin manifestations was higher in females, which was similar to the study by Marraha et al.[21] The dress attire of south India and the need for looking after household work, in addition, may have a further contribution to female preponderance. From the review article of 16 studies by Keng et al.,[22] the most commonly affected body sites were face followed by hands, which was similar to our study results (face-45%), but hands were most commonly involved in the study by Saha et al.[20]

The study by Foo et al.[10] and Gheisari et al.[4] revealed that most of the HCWs who used N95 masks regularly experienced acne and facial dermatosis. In this study, acne and acne flare-up of the face were the most prevalent skin manifestations. It could be due to the hot and humid microenvironment and occlusion of pilosebaceous orifices due to local pressure on the face from the tight-fitting mask, which can lead to a flare-up of acne.[23] Pressure effect on the nasal bridge might occur due to goggles and mask-induced mechanical injury. The elastic strap can compress the ear skin and lead to postauricular skin damage. It was mostly due to pressure effect or contact dermatitis to elastic straps. Hence, a patch test may be necessary to confirm the true incidence of such cases. Several factors, including sweating, friction, occlusion, and high humidity, could explain the occurrence of primary skin manifestations and exacerbation of the above-mentioned secondary skin conditions. In Xiuquan Yuan et al.[24] study, the level of moisture attributed to protective clothing, goggles, and masks, was assessed and stated that increased moisture was associated with adverse skin reactions.

Prolonged duration of contact with latex may lead to sensitization in this study, but a more likely explanation might be the increased frequency of using sanitizer and handwashing, resulting in irritant contact dermatitis. Farah et al. from Northen Morroco had stated that bleaching immersion was highly associated with hand reaction (45%). Application of 0.1% solution is sufficient to eliminate coronavirus, but inappropriate manipulation leads to an increased incidence of hand reactions. Measures to combat hand dermatitis include using non-latex/nitrile/cotton gloves in case of latex allergy, drying the hands by soft wiping after handwash, and applying emollients immediately. Glycerin/Aloe vera-based hand sanitizers can be used. In severe hand dermatitis, a short course of topical corticosteroids can be prescribed.[25]

The prolonged duration of wearing straps of the mask, face shield, and head cap can lead to traction of hair and increased sweating. Most of the participants reported a hair washing frequency of more than three times per week, which can lead to a frizzy hair appearance.

Two persons reported the development of acute generalized eczema after using PPE within a day. Four patients reported exacerbation of pre-existing autoimmune skin conditions of psoriasis and vitiligo after using PPE for a longer time [Figure 8]. It might be due to stress by the hot-humid microenvironment and itching-induced koebnerisation.
Figure 8: Exacerbation of pre-existing autoimmune disease – oral mucosal vitiligo

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The logistic regression analysis showed that daily PPE wearing time of >6 hours and individuals with other pre-existing skin dermatosis like acne and atopic dermatitis had shown statistically significant association (< P = 0.05) to develop adverse skin manifestations to PPE at various sites [Table 5].
Table 5: Multivariate analysis of factors significantly associated with skin manifestations

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   Recommendations Top


In this study, only 15.1% of participants took preventive measures like applying moisturizers to minimize further episodes. This high prevalence of skin manifestations (62.1%) indicated that prevention and treatment were insufficient. It can be due to insufficient attention of HCWs to take routine skincare measures at an early stage. Second, they had less awareness about the management of skin injuries which has to be enlightened by training programs. Improving the PPE quality will assure further protection. Prophylactic dressings and moisturizers should be provided with every PPE kit, which have to be applied over injury-prone areas before wearing PPE. In the occurrence of skin injuries, a post-PPE wear kit can be recommende, d which includes hydrocolloid dressing, moisturizing cream, and topical antibiotics in case of any infection.


   Conclusion Top


This study provides an insight into the prevalence of adverse skin reactions due to prolonged use of PPE, such as N95 masks and latex gloves in particular. These adverse skin manifestations increase the vulnerability among HCWs to acquire viral infections and further pose a serious risk that can threaten the functioning of the health care system in this current pandemic era. Hence, dermatological screening of HCWs at regular intervals is inevitable to facilitate early management. This study is being presented to emphasize the importance of raising proper measures to improve the quality and guidelines regarding proper usage of PPE, thereby increasing the compliance and effectiveness to minimize and prevent occupationally-induced dermatosis among HCWs who are the frontline warriors in this COVID-19 pandemic. This study will provide a basis for prophylactic and post-PPE wear kit recommendations for securing HCWs and improving PPE standards around the world.

Limitation: Because of the emergency pandemic, it was difficult to determine the mental health status, severity, and prognosis of skin reactions through questionnaires, and it would be agreeable to conclude that most of the skin manifestations were mild to moderate in severity as most of the HCWs continued to use the equipment.

Key findings

  • This study demonstrated that the prevalence of skin manifestations among HCWs caused by PPE was higher. It was characterized by mixed-type injuries and diverse site injuries, affecting their health and occupational safety, even becoming a potential risk to acquiring the corona viral spread.
  • We found two statistically significant factors (longer daily wearing time and persons with pre-existing skin dermatosis), which might increase the risk of adverse skin manifestations.
  • Raising awareness about the prevention and treatment of skin manifestations is inevitable.
  • Comprehensive preventive measures such as improving PPE, shortening wear time, and taking prophylactic measures should be taken.


Ethical approval

Obtained.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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