Skin Damage Induced by Enhanced Protective Measures in Frontline Doctors During Covid-19 Pandemic: A Web-Based Descriptive Study.

BACKGROUND: Frontline doctors engaged in COVID-19 duties have to adopt enhanced protective measures to minimize their risk of exposure. However, these measures may lead to several skin problems, thereby affecting their performance.
OBJECTIVES: To analyze skin changes induced by enhanced protective measures and explore possible risk factors.
MATERIALS AND METHODS: A web-based descriptive study was conducted among 212 frontline COVID-19 doctors. Data were collected regarding their demography, duty, use of enhanced protective measures including prophylactic hydroxychloroquine, recent skin changes with affected sites, and possible risk factors.
RESULTS: Skin changes were reported by 41.5% of respondents (mean age 34.8 ± 5.6 years) across 210 sites. Hands were involved most commonly in 77.3% of doctors, followed by nasal bridge, cheeks, and retroauricular area. Dryness (84.1%) and skin peeling (79.5%) were the commonest clinical features. Regression model showed prolonged PPE wear (>6 h) adjusted odd's ratio (AOR) 2.9, P = 0.005], heavy sweating [AOR 12.8, P = 0.001] and frequent hand hygiene (>10 times/day) [AOR 3.1, P = 0.0006] to be significant risk factors. Hydroxychloroquine prophylaxis was deemed safe as treatment-emergent adverse events were uncommon (17.4%).
CONCLUSION: Frontline doctors have an increased risk of developing skin damage due to enhanced protective measures. Appropriate steps should be taken to address the risk factors and minimize skin damage. Persistent cases mandate dermatology referral for optimum management. Copyright:

Introduction

Since the outbreak of coronavirus disease 2019 (COVID-19) pandemic in Wuhan, in December 2019,[12] millions of healthcare workers (HCW) are serving people beyond their call of duty. In the absence of a vaccine till date, the role of enhanced infection prevention measures using personal protective equipment (PPE, i.e., cap, goggles, face shield, mask, gown, and gloves), hand sanitizers, and prophylactic drugs like hydroxychloroquine (HCQ)[3] cannot be overemphasized. The use of protective measures while dealing with suspected and confirmed cases of COVID-19 has led to an upsurge of cutaneous manifestations, often requiring medical attention.[4] We conducted this study to evaluate the type and extent of skin damage associated with the use of personal protective equipment measures (including cutaneous and systemic adverse effects associated with intake of prophylactic HCQ). Moreover, we tried to find out the possible risk factors associated with the development of skin damage.

Materials and Methods

We conducted a web-based descriptive, questionnaire survey among doctors of Eastern India and surrounding areas engaged in frontline COVID-19 duties, during 15–30 June, 2020. Our inclusion criteria included care of COVID-19 infected or suspected patients or screening duties, use of enhanced protective measures (N95 masks, visors, gloves, and/or PPE), age ≥18 years regardless of gender and voluntary participation, while doctors not coming in contact with suspected/confirmed cases were excluded. An online semi-structured questionnaire was prepared on Google-forms and circulated among eligible doctors, through emails, WhatsApp messenger, Facebook messenger, Telegram, and other social media using the snowball sampling technique. Voluntary participation implied their consent for the possible use of obtained data for scientific publication. Anonymity and confidentiality of their responses were ensured.

The questionnaire comprised three sections. The first section consisted of demographic details (age, gender, relationship status, place of work, and educational qualification). The second section consisted of details related to the type of duty (regular OPD, fever clinic, isolation ward, and critical care units), duty hours, and other factors like pre-existing skin disorder. The third section comprised questions related to the use of PPEs and other protective measures (nature of protective devices used, duration of PPE wear, number of gloves, heavy sweating after work and frequency of hand washing) and the development of recent skin changes like dryness, itching, burning/pain (symptoms) and signs like peeling of skin, redness, erosion, ulceration, maceration, fissuring, boil, furuncle, and skin lump along with affected sites. Moreover, specific questions related to the use of prophylactic HCQ were also included in the questionnaire.

We observed that it took approximately 3–4 min to complete each form, those with incomplete responses were discarded. Confidentiality and anonymity were strictly maintained. All data were tested for normality using Kolmogorov–Smirnov test. Continuous data (recorded as range, mean ± SD) were analyzed using t-test while categorical data (presented as proportion and frequencies) were compared by Fisher's exact test/Chi-square test. Predictors were further analyzed using multivariate logistic regression model. Statistical software Medcalc® v 9.6.4.0 was used for analysis. A P value <0.05 has been considered significant.

Results

We received complete responses from 212 frontline physicians (out of 251 responses, 39 were discarded due to incomplete data) engaged in COVID-19 duties and included them in our analysis. Almost half (104, 49.1%) of all respondents belonged to the age-group of 31–40 years, their mean (SD) age being 34.8 ± 5.6 years and males outnumbering females (M:F 140:72). In all, 120 (56.6%) respondents were married and 73.6% [156/212] had completed their post-graduation. The majority of our subjects (174, 82.1%) worked at government hospitals, with 58.5% (124/212) currently posted at regular out-patient departments followed by 16% (34/212), 13.2% (28/212) and 12.3% (26/212) engaged in isolation wards, COVID-19 critical care units and fever clinics respectively. Only 46 (21.7%) subjects reported at least one systemic co-morbidity like diabetes mellitus, hypertension or thyroid disorder (P = 0.9, Chi-square test). Table 1 highlights the demographic details.

Table 1

Demographic details of study participants (n=212)

Parameters	Patient’s recent-onset skin damage due to enhanced protective measures for COVID-19 duties (n=88)ǂ	Patients without any skin damage/problem (n=124)ǂ	P*
Age-group (years)
21-30	36 (40.9)	42 (33.9)	0.6
31-40	40 (45.5)	64 (51.6)
41-50	8 (9.1)	8 (6.5)
51-60	2 (2.3)	6 (4.8)
≥60	2 (2.3)	4 (3.2)
Gender
Male	44 (50)	96 (77.4)	0.000
Female	44 (50)	28 (22.6)	1
Relationship status
Married	42 (47.7)	78 (62.9)	0.04
Single	46 (52.3)	46 (37.1)
Educational qualification
Graduate	28 (31.8)	28 (22.6)	0.2
Post-graduate and above	60 (68.2)	96 (77.4)
Place of work
Government set-up	74 (84.1)	100 (80.6)	0.6
Private set-up	14 (15.9)	24 (19.4)
Type of COVID-19 duty
Regular OPD	58 (65.9)	66 (53.2)	0.08
Fever clinic	12 (13.6)	14 (11.3)
Isolation ward	12 (13.6)	22 (17.7)
Critical care unit for COVID-19 patients	6 (6.8)	22 (17.7)
Co-morbidities
Present	22 (25)	24 (19.4)	0.4
Absent	66 (75)	100 (80.6)

ǂAll values expressed in n (%), *all P values obtained by Chi-square test, COVID-19 coronavirus disease 2019, OPD Out-patient department

In the present study, 88 (41.5%) respondents reported the development of at least one recent dermatological problem due to enhanced protective measures for COVID-19 duties. Gender and relationship status showed a statistically significant association with the development of new skin lesions due to COVID-19 duties (for both, P < 0.05, Chi-square test) [Table 1]. Interestingly, no significant association was obtained between type of duty (OPD/fever clinic/isolation ward and critical care unit) and the emergence of recent skin lesions (P = 0.08, Chi-square test), thus implying that all frontline physicians are prone to develop skin damage due to enhanced protective measures during this pandemic, irrespective of their place of posting [Table 1]. Logistic regression model showed a single relationship status that 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), while no other factor contributed significantly.

Overall 210 body sites were affected by recent skin changes in 88 patients, as most patients reported involvement of >1 sites. Among them, hands were involved most frequently in 77.3% (68/88) subjects, followed by nasal bridge, cheeks/malar area, and retroauricular area in 63.6%, 34.1%, and 31.8% cases, respectively. Dryness and desquamation/skin peeling were the commonest symptom and sign reported in 84.1% and 79.5% subjects, respectively (n = 88) [Table 2]. Heavy sweating (soaked in sweat) was reported by 86.8% of respondents (184/212) due to PPE wear.

Table 2

Clinical features and sites affected in those respondents developing skin damage (n=88)

Parameters*	Patients with skin damage (n=88), n (%)
Symptoms
Dryness	74 (84.1)
Itching	52 (59.1)
Burning/pain	38 (43.2)
Signs
Desquamation/peeling of skin	70 (79.5)
Erythema/redness	36 (40.9)
Erosion/ulceration/maceration/fissuring	26 (29.5)
Boil/furuncle/skin lump	18 (20.4)
Sites affected
Hands	68 (77.3)
Nasal bridge	56 (63.6)
Cheeks/malar area	30 (34.1)
Retroauricular area	28 (31.8)
Feet	12 (13.6)
Forehead	8 (9.1)
Periocular area	6 (6.8)
Perioral area	5 (5.7)
Trunk/neck	2 (2.3)

*With overlaps between patients

Regarding use of enhanced protection measures, 30 (14.2%) subjects [n = 212], used only gloves, while 13.2% [n = 28] used goggles in addition, 26.4% [n = 56] used face shield in addition and majority (98, 46.2%) used all three together: gloves, goggles, and face shield.

Regression model showed prolonged PPE wear (>6 h) [AOR 2.9, 95% CI 1.4–6.4, P = 0.005] and heavy sweating [AOR 12.8, 95% CI 2.7–59.8, P = 0.001] to be a significant risk factors for recent onset skin damage. However, none of the components (N95 mask, gloves, goggles, or face shield) significantly contributed to the development of skin damage individually (for all, P > 0.05). Interestingly, frequent hand hygiene (>10 times/day) significantly increased the risk of hand skin damage (AOR 3.1, 95% CI 1.6–5.8, P = 0.0006), rather than wearing increased number of gloves (two or more layers) [P = 0.08, 95% CI 0.3–1.1].

Thirty two (15.1%) respondents provided a history of pre-existing skin disorder (atopic dermatitis > contact dermatitis > urticaria > psoriasis), among them 43.8% (14/32) reported recent skin damage (P = 0.9, Chi-square test), whereas 31.3% (10/32) reported aggravation of their skin disorder due to enhanced protective measures in the current situation.

In the present study, 92 (43.4%) subjects (n = 212) used prophylactic HCQ, and only 17.4% (16/92) developed a drug emergent adverse effect (12: gastrointestinal ADR, 4: cutaneous ADR-all maculopapular skin rash), but none resulted in discontinuation of medication. Thus, prophylactic HCQ is extremely unlikely to cause any drug emergent adverse effect (P < 0.001).

Discussion

In our study (n = 212), the mean age of respondents was 34.8 ± 5.6 years, and males outnumbered females (140:72). The mean age is comparable with Lin et al.[5] (32 ± 6.5 years) and Jiang et al.[6] (32.5 ± 7.1 years), however, females predominated in both studies. In the present study, 29.2% (62/212) and 12.3% (26/212) respondents were posted at inpatient wards and fever clinics, respectively, compared to 72.9% (inpatient wards) and 24.2% (fever clinics) in a study conducted in China.[5] This difference may be attributed to the exclusive inclusion of doctors in our survey compared to all HCWs (nursing and paramedical) in the Chinese study.

Recent adverse skin damage due to enhanced protective measures was reported by 88 respondents (41.5%), much lower than similar studies conducted in China (74.5%–97%),[57] but comparable to another Chinese study (42.8%),[6] which focused exclusively on skin injuries and skin tears. Our low rate may be attributed to exclusive inclusion of doctors compared to all HCWs (nurses and paramedical staff) in other studies. However, our rate is higher than the rate of occupational contact dermatitis in HCWs under normal circumstances (31.5%)[5] and that during the SARS outbreak (21.4%–35.5%).[8]

Hands, nasal bridge, and cheeks/malar area were the most commonly affected areas in 77.3% (68/88), 63.6% (56/88), and 34.1% (30/88) of respondents, respectively. These data are consistent with previous authors who have recorded the hands to be the most commonly affected in HCWs during COVID-19 pandemic[5] or under normal working conditions,[910] and the risk factors included frequent hand hygiene and wearing gloves for a longer duration.[5910] We observed similar risk factors: prolonged wearing of gloves/PPE (>6 h) [AOR 2.9, P = 0.005] and frequent hand hygiene (>10 times/day) [AOR 3.1, P = 0.0006]. Interestingly, the increased number of gloves (>2 layers) [P = 0.08] was not a significant risk factor, consistent with Lin et al.[5] Another Indian study also noted 16 patients with hand eczema, within a short span of 10 days, due to excessive use of hand sanitizers/hand washing. Teledermatology consultations have also increased in India and Italy for hand dermatitis, during this period.[11] In the present study, the nasal bridge was the second most common site to be affected in 63.6% of doctors, consistent with another Indian study (63%),[12] but less than studies conducted in China (71.8%–83.1%).[57] However, our rate is double of that as reported by Jiang et al. (30.1%),[6] possibly due to their exclusive inclusion of skin injuries and skin tears. Mechanical pressure exerted by N95 masks/respirators and goggles is responsible for the nasal bridge involvement, as reported by the previous authors.[512] Several Chinese authors have reported cheeks to be frequently involved in 75%–79% HCWs,[57] in contrast, our respondents showed a much lesser involvement of cheeks/malar area in 34.1% cases, consistent with an Indian study.[12] The increased involvement of hands may be attributed to the practice of frequent hand washing in Indians, more so during the current pandemic. Overzealous use of alcohol-based hand sanitizers may lead to further irritation and skin breach, which may act as a portal for entry of novel SARS-CoV-2 due to abundance of angiotensin-converting enzyme 2, the viral receptor, in cutaneous blood vessels basal layer of the epidermis.[12] Excessive iatrogenic hand dermatitis during COVID-19 has also been reported by Bhatia et al.,[13] and they have called it a ‘pandemic within a pandemic’. In the present study, dryness (84.1%) and pruritus (59.1%) were the commonest symptoms, while the most common signs were desquamation/skin peeling and erythema/redness in 79.5% and 40.9% of respondents, respectively. These data are consistent with Lan et al.,[7] who reported desquamation, pruritus, and erythema in 60.2%, 52.5%, and 49.4% of the study participants, respectively, while dryness was reported in fewer subjects (70.3%). Singh et al.[12] noted pruritus (67.44%) and erythema (53.49%) to be the commonest clinical features in an Indian cohort of HCWs, comparable to our observations. Heavy sweating during duty was reported by 86.8% of our respondents, comparable to Lin et al.(80.2%).[5]

Owing to the high risk of exposure among HCWs, HCQ has received unprecedented attention, as a prophylactic drug.[1415] A recent Indian study reported HCQ related adverse effects in 31% HCWs (headache > nausea > abdominal pain and diarrhea)[16]; however, only of 17.4% of our respondents reported a treatment-emergent adverse event (TEAE) with HCQ (GI disturbance > skin rash). The low rate possibly occurred due to the exclusive inclusion of doctors in our study, who are more aware of the adverse reactions and adopted corrective measures. Fortunately, no ADR was severe enough to discontinue the drug; thus, we believe that prophylactic doses of HCQ are not associated with any serious adverse effect, and may be recommended in frontline HCWs.

In our study, logistic regression showed prolonged PPE wear (>6 h) and frequent hand hygiene (>10 times/day) significantly increased the risk of skin damage, consistent with previous studies.[57] None of the components (N95 mask, gloves, goggles, or face shield) contributed significantly to the development of skin damage individually, while Lan et al.[7] reported N95 masks and goggles to be significant contributory factors, but not face shields. Wearing >2 layers of gloves was not a significant risk factor, corroborating the findings of Lin et al.[5] We noted heavy sweating during duty to be a significant risk factor for skin damage (AOR 12.8, P = 0.001), in contrast to Lin et al.[5] A Chinese study[5] reported female gender and inpatient ward duties significantly increased the risk of skin damage in HCWs, however, we observed so such predilection.

Limitations

Our study was limited by selection bias (only those with smart phones or computers could participate in the online survey), response bias (as doctors with skin damage are more likely to respond), small sample size, use of snowball sampling technique (non-randomized sample) and inability to screen multiple responses from a single participant. Another important limitation was our exclusive inclusion of frontline doctors, as we had to depend on subjective responses and thus included only medical personnel who were capable of identifying their skin problems. These skin damages could not be validated by dermatologists, and thus, we were unable to perform patch tests to rule out ACD, as it was a web-based study without any physical interaction.

Conclusion

Risk of skin damage due to enhanced protective measures is relatively high among doctors engaged in frontline COVID-19 duties, irrespective of place of posting or pre-existing skin disorder. Involvement of hands is particularly worrisome as it may act as a portal for the entry of novel SARS-CoV-2,[14] thus increasing their risk of infection; while other clinical features like dryness, desquamation, itching, and sweating may hamper with their discharge of duties. Prolonged PPE wear (>6 h/day), rigorous hand washing (>10 times/day), and heavy sweating are notable risk factors. Thus, the administration should ensure reasonable working hours restricting PPE wear to less than 6 h/day, provide better quality PPEs to minimize sweating, and impart proper education regarding their correct use. On an individual level, frontline doctors should be apprised about the possible skin changes and encouraged to follow recommendations to avoid or minimize them [Table 3]. In severe and persistent cases, a prompt dermatologic consultation is strongly warranted. Further, large-scale studies are recommended to validate our findings.

Table 3

Most common skin changes in respect of sites involved with possible reasons with recommendation to avoid or minimize it.[413171819]

Skin changes	Possible reasons	Authors recommendations to minimize or avoid
Hands and Feet
Desquamation/peeling of Skin	Frequent use of Hand sanitizer/soaps usually >10 times/day	Frequent use of emollients. Use of glycerin/aloe vera containing hand sanitizer.
Maceration	Prolonged use of gloves usually >6 h	Choose proper size of gloves Frequent changing of gloves and application of stoma or baby powder before donning of gloves. After doffing, wash, and use emollients Use of astringents like zinc oxide cream or paste topically. Wearing of cotton glove liners, nitrile gloves must be advocated to minimize hand eczema.[19]
Erythema/redness (allergic reactions)	Use of latex-containing gloves for prolonged duration.	Use of non-latex/nitrile gloves.[19] Use of gloves for shorter duration. Use of low to medium potency topical steroids or calcineurin inhibitor with emollients in severe cases. After the hand wash, hands should be patted dry softly rather than rubbing vigorously with a towel[19]
Nasal bridge, Cheek/malar, Retroauricular areas, etc.
Pressure injury	Prolonged use of mask, goggles, face shield, usually >6 h	Shorter duration of use. Use of proper size for suitable tightness Application of silicone foam or hydrocolloid dressing before donning. Use of mucopolysaccharide polysulfate or heparin cream.
Erosion/ulceration/fissuring	Prolonged use of mask, goggles, face shield, usually >6 h	Shorter duration of use. Topical mupirocin/fusidic acid with emollients Oral antibiotics in severe cases with daily dressing
Face and trunk
Boil/furuncle/skin lump	Prolonged use of mask, goggles, or face shield leading to occlusion of pilosebaceous ducts or sweat gland	Shorter duration of use. Washing of face with lukewarm water after doffing. Avoidance of facial cosmetics Use of topical antibiotics/retinoids whenever necessary. Oral antibiotics or retinoids in severe cases.
Heavy sweating	Prolonged use of PPE or its components in a closed environment.	Shorter duration of duty. Use of good quality PPE. Use of proper size of PPE or its components to achieve suitable tightness. Air-conditioning may alleviate it but it is not recommended as infection can spread through it.[16]

PPE - Personal protective equipment

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.