A Step-by-Step Guide to Preventing PPE-Related Skin Damage

What your doctor is reading on Medscape.com:

APRIL 28, 2020 — Personal protective equipment (PPE) has been essential to protecting healthcare workers from the novel coronavirus, but it presents its own set of challenges to their health, notably skin damage associated with prolonged use of PPE. Medscape spoke with Kimberly LeBlanc PhD, RN, chair of the Association of Nurses Specialized in Wound Ostomy Continence (NSWOC) of Canada, and coauthor of best practice recommendations for preventing and managing PPE-related skin damage.

What’s driving the increase in reports of PPE-related skin damage?

Kimberly LeBlanc, PhD, RN:  Not only are we using more PPE than we have in living memory, but we are using it in ways that were never intended. Nearly all PPE on the market today is designed for single use. You are supposed to use it and throw it away. Masks were never designed to be worn for more than 4 hours, and certainly not to be worn from patient to patient without being changed.

But we experienced a massive global shortage of PPE so early in the pandemic that people were afraid to dispose of their PPE in case it couldn’t be replaced. Nurses were wearing the same PPE for their entire shift, and their skin really suffered as a consequence.

We started getting daily calls from nurses asking for help with these new skin issues. Our evidence summary is based on available research and expert opinion.

How does prolonged PPE use affect the skin of nurses and other HCPs caring for patients with COVID-19?

Almost every type of PPE — face masks, goggles, face shields, gloves — can cause skin problems. Even gowns can cause overheating and profuse sweating, and when combined with friction, that can lead to intertriginous dermatitis.  

Hand irritation is especially common when gloves are used with high frequency, as they are now. Not only do the hands become irritated from frequent sanitizing and handwashing, but gloves trap moisture and heat, and the reported effects include contact dermatitis, maceration, and erosion of the epidermis.  

We learned about some of these PPE-related skin problems from the 2002-2003 SARS outbreak. A 2006 study from Singapore looked at PPE-related adverse skin reactions in 307 staff members, mostly female nurses. Among those wearing N95 masks, 60% reported an increase in acne, 36% reported a rash, and 51% reported itch or dermatitis.  

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These effects increase the wearer’s risk for infection. If you have any kind of uncomfortable lesion on your face — a new blemish, an itchy rash, an abrasion, or a wound — you are more likely to inadvertently reach up and touch your face or adjust your mask. Every time you do that, you break the PPE protocol and risk contaminating your face. 

In the beginning, we were told that SARS-CoV-2 was transmitted by contact with droplets, and that surgical masks were sufficient protection unless you were performing an aerosol-generating procedure, such as intubation or extubation. Very quickly, however, the debate turned to whether the virus was also airborne. People were scared and many started wearing N95 masks all the time.

Unlike a disposable surgical mask, the N95 and N99 masks are designed to fit closely against the skin, forming a seal around the mouth and nose. In healthcare settings, these masks (also known as “respirators,” which come in different sizes and models) are fit tested on each staff member to make sure they are airtight before they are considered safe and protective. This is important when it comes to options for relieving the pressure of the N95 mask on the wearer’s face. Tighter isn’t better. When worn for many hours, nurses often have reddened indentations on their faces corresponding to the outline of the mask.

Anecdotally, we’ve heard from nurses who are even having problems with the non-airtight surgical masks.

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