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Skin deep: The effects of prolonged hand hygiene and PPE measures

A look at the impact of PPE and hand disinfection on the skin health of healthcare professionals during the Covid-19 pandemic

Repeated and frequent exposure to water, soap, and alcohol hand gel and prolonged contact with personal protective equipment (PPE) can cause dry skin and irritant contact dermatitis. The skin may start to itch, become sore and red, and develop small blisters, painful fissures and erosions. Increased use of PPE and frequent hand cleansing has led to a spike of skin irritation among healthcare workers around the world, particularly those on the frontline of the pandemic.

A total of 97 per cent of 542 surveyed front-line doctors and nurses in Hubei Province, China, were reported to have developed problems of the skin of the face and/or hands. These were related to preventive measures such as PPE (mask, goggles, face shield and double-layer gloves), frequent hand-washing and use of alcohol gel.

The most frequent symptoms were dryness, tightness, and itching or pain. Signs included desquamation, erythema, maceration, papules, fissuring and erosion.

The face, nasal bridge, cheeks and forehead were the most common sites affected. Prolonged duration of wearing N95 masks and goggles, particularly for more than six hours, was a risk factor for occupational skin disease, but this was not the case for face shields.

Frequent hand-washing, ie, more than 10 times daily, increased the risk of hand dermatitis. Reports of similar problems have also emanated from Italy.



Members of the British Society of Cutaneous Allergy recently conducted an audit of 200 hospital-based healthcare workers attending occupational skin disease clinics in the UK and Ireland set up during the Covid-19 pandemic to describe the features of occupational skin disease during this time.

Fifty-nine per cent of healthcare workers seen in these clinics for occupational skin disease were found to be affected by irritant contact dermatitis, according to research presented at the 2020 Virtual Annual Meeting of the British Association of Dermatologists, which took place earlier this month.

On average, the healthcare workers washed their hands with soap 22.8 times per day and used alcohol hand gel 22.7 times per day. Almost one-in-five (18 per cent) of these healthcare workers required time off work as a result of occupational skin problems, representing a significant burden on the health service during an extremely difficult time.

The duration for which PPE was worn, frequency of hand-washing and use of alcohol hand gel were found to have an impact on the time off work required. Longer duration of PPE wear during a shift, and more frequent hand-washing, tended to increase the amount of time off and using alcohol gel did not.

Almost all the skin problems affected the face and hands. The second-most common diagnosis seen in the audit was acne, caused by the occlusive effects of prolonged mask-wearing, which was seen in 15 per cent of healthcare workers. Pressure injuries related to mask wear were seen in 5 per cent of subjects.

Dr Isha Narang, lead researcher of the study and registrar at University Hospitals of Derby and Burton NHS Foundation, UK, said: “Wearing PPE for long periods can cause pressure and irritant effects on the skin and frequent hand-washing with soap is drying; sometimes the effects can be bad enough to require time off work. As PPE and hand-washing are essential methods of reducing the spread of Covid-19, it is important to provide healthcare workers with advice and support in managing their skin.”

Dr Harriet O’Neill, another lead researcher of the study and registrar at University Hospitals of Derby and Burton NHS Foundation, said: “For the face, protecting the skin with medical-grade silicon tape before donning tight-fitting masks, then rechecking the fit of the mask, may be helpful. Facial skin should be regularly moisturised when not at work.

“Where possible, regular breaks should be taken during shifts in which the PPE, such as masks, goggles and gloves, is removed to reduce the amount of contact time with the skin. We would also recommend that people dry their hands fully after washing by patting them dry, not rubbing them.

Moisturisers (emollients) are an essential part of treating dermatitis and should be applied generously after hand-washing and whenever the skin feels dry. In severe cases, or if an infection is suspected, further treatment from a GP or an occupational health doctor may be required.”

An update on occupational skin disease, written by the British Society of Cutaneous Allergy, is available here: www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6688

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