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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 42-46

Dermatological manifestations among doctors using personal protective equipment in coronavirus disease 19 pandemic: a study based on self-reported questionnaire and telephonic consultation


Department of Dermatology, Venerology and Leprosy, Dr. D. Y. Patil Medical College and Hospital and Research Centre, Pune, Maharashtra, India

Date of Submission30-Sep-2021
Date of Decision07-Dec-2021
Date of Acceptance08-Dec-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Shreya Deoghare
Department of Dermatology, Venerology and Leprosy, Dr. D. Y. Patil Medical College and Hospital and Research Centre, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_87_21

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  Abstract 


Background: Coronavirus disease 19 (COVID-19) pandemic is a recent outbreak of a viral infection caused by severe acute respiratory syndrome coronavirus 2. Increase in the use of personal protective equipment (PPE) among doctors has resulted in increase in adverse effects such as contact dermatitis, urticaria, acne, and infections. Objectives: To identify the prevalence of common dermatosis developing in doctors using PPE. To compare if dermatosis is more common in doctors working in COVID-19 dedicated setup. To assess if the development of dermatosis use was related to the duration of PPE use. Materials and Methods: A cross-sectional type of observational study was conducted. A questionnaire was circulated on social media to the doctors. The response was collected in Microsoft Excel and analyzed. Results: Two hundred and sixty-nine (71.35%) doctors reported the development of dermatosis due to personal protective equipment (PPE) use. Eczema of the face (30%) and acne (26.25%) were the commonly reported dermatosis in our study. The development of dermatosis was significantly related to the duration of PPE use. Our study revealed a high prevalence of dermatosis among doctors using PPE, which was related to the duration of work. Conclusion: Hence, there is a need to make the doctors aware about such dermatosis, suggest prevention measures, provide them with effective dermatological treatment, and establish guidelines for prevention for occupational skin disorders at a national level.

Keywords: Adverse skin reactions, coronavirus disease 19 pandemic, eczema, occupational acne, personal protective equipment


How to cite this article:
Deoghare S, Pol D, Kothari R, Kumar A, Deora MS. Dermatological manifestations among doctors using personal protective equipment in coronavirus disease 19 pandemic: a study based on self-reported questionnaire and telephonic consultation. Clin Dermatol Rev 2022;6:42-6

How to cite this URL:
Deoghare S, Pol D, Kothari R, Kumar A, Deora MS. Dermatological manifestations among doctors using personal protective equipment in coronavirus disease 19 pandemic: a study based on self-reported questionnaire and telephonic consultation. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 25];6:42-6. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/1/42/338596




  Introduction Top


Coronavirus disease 19 (COVID-19) pandemic is a recent outbreak of a viral infection caused by severe acute respiratory syndrome coronavirus 2.[1] The first case emerged in Wuhan, China in December.[1] COVID-19 outbreak was declared as a Global Health Emergency by the WHO on January 30, 2020.[2],[3] Later, the WHO declared it a pandemic on March 11, 2020.[4] The first case of COVID-19 was reported in India on January 30, 2020.[5]

Personal protective equipment (PPE) are equipment designed to protect the wearer from the spread of infection or illness.[6],[7] The Ministry of Health and Family Welfare gave guidelines on the rational use of PPE.[7] It recommends the use of goggles and face shields, the frame of which should provide a good seal to cover the eyes, nose, and mouth. Masks that are used should be either triple-layer medical mask or an N-95 Respirator mask. If available, nitrile gloves are preferred over latex gloves to prevent contact allergic dermatitis caused by latex. Nonpowdered gloves are preferred to powdered gloves. Overalls or gowns, shoe covers, and headcovers are used to protect the torso, feet, and head.[7]

Increase in the use of personal protective equipment (PPE) among doctors has resulted in increase in adverse effects due to the use of PPE. The reasons could be – increase in frequency and duration of use, wearing of ill-fitting equipment (very tight or very loose), or allergy to the material of PPE. A study conducted by Li[8] found that N95 and surgical facemasks induce local increase in temperatures and humidity.

Badri[9] reported that health-care workers are affected by occupational skin diseases, commonly reported ones being occupational contact dermatitis (OCD), occupational contact urticaria, occupational acne, and infections. OCD on hands can present with symptoms of sweating, itch, and pain; and signs of erythema, vesicles, papules, scaling, fissures, hyperkeratosis.[10] This is due to the use of gloves and hand sanitizers. Similar manifestations on the trunk, hands, and legs may represent OCD due to the use of overalls or gowns.[11] OCD due to the use of masks has similar symptoms and signs limited to the area in contact. Occupational acne presents new onset or exacerbation of comedones, papular or pustular lesions of acne on the area covered by the mask.[12]

Dermatologists all over the world are focussing to find out the dermatological manifestation in COVID-19 positive patients, and thus side-lining the fact that the doctors are also suffering from adverse effects due to prolonged use of personal protective equipment (PPE). These are limited case reports of occupational skin diseases developing due to the use of PPE among doctors[8],[9],[10],[11],[12] from the earlier pandemics and very few large-scale studies have been documented about the same.[13],[14],[15],[16] Hence, by this study, we aim to identify dermatosis due to PPE use in doctors.

The objectives of our study were to identify common skin symptoms developing due to the use of PPE in doctors, to compare if dermatosis is more common in doctors working in COVID-19 dedicated setup and to assess if the development of dermatosis (PPE) use was related to the duration of work.


  Materials and Methods Top


This is a cross-sectional type of observational study conducted in April 2020 after approval of the Institutional Ethics Committee. A specific questionnaire was prepared and made accessible online through the link created using Google Forms. Link was circulated among doctors all over India using social media platforms like WhatsApp and Facebook. Participants voluntarily answered questions referring to: Demographic data, work environment, and any dermatological symptoms and signs. The responses were recorded in Google Sheets and transferred to Microsoft Excel. The statistical analysis was performed using primer of biostatics software.

The study included all doctors, who have received their basic medical graduation degree (MBBS) and are working in a hospital or institution setup, which may or maybe not be a COVID-19 dedicated setup. All doctors irrespective of the fact that they developed any skin manifestations, were requested to participate in the study. Doctors who were unwilling to participate were excluded from the study.


  Results Top


A total of 377 doctors participated in the study. The mean age of the doctors was 27.32 ± 6.23 years. There were 205 (54.37%) males and 172 (45.09%) females in the study. Out of the total, 179 (47.48%) doctors were working in COVID-19 dedicated setups and 198 (52.51%) were working in non-COVID-19 setup.

Our study revealed that a large number of doctors 269 (71.35%) developed skin problems during the COVID-19 pandemic. However, only 22 (5.83%) doctors consulted a dermatologist for their skin problems.

[Table 1] shows the components of personal protective equipment (PPE) used by doctors during the COVID-19 pandemic. [Table 2] shows the skin-related symptoms reported by doctors. [Table 3] shows the morphology of skin lesions. [Table 4] shows the common sites of involvement. The provisional diagnosis was made after analyzing photographs of lesions through teleconsultation and simultaneously comparing it with the symptoms and signs that were stated in the questionnaire [Table 5]. We then calculated the percentage of doctors developing dermatosis in the COVID-19 dedicated setup and non-COVID-19 setup [Table 6].
Table 1: Components of personal protective equipment used by doctors during COVID-19 pandemic

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Table 2: Skin-related symptoms reported by doctors

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Table 3: Morphology of skin lesions

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Table 4: Site of involvement

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Table 5: Dermatosis developing in the doctors using personal protective equipment

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Table 6: Dermatosis developing in doctors using personal protective equipment in relation to the type of setupd

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  Discussion Top


There were many important findings in our study. Our study revealed that 71.35% of doctors developed skin problems during the COVID-19 pandemic due to the use of personal protective equipment (PPE). The most common symptom reported was increased sweating, while the most common morphology of skin lesion reported was erythema. Face (nose, cheeks, above and behind ear) was the most common affected site of dermatosis due to use of PPE. Our study found out that eczema was the most prevalent dermatosis in doctors using PPE in the COVID-19 pandemic followed by occupational acne. The development of dermatosis in doctors using PPE was unrelated to their place of work, whether it was a COVID-19 dedicated setup or not. The development of dermatosis in doctors using PPE was related to the duration of work.

The mean age of the 377 doctors who participated in our study was 27.32 ± 6.23 years. While Foo[14] reported 32.4 years as the mean age of the 340 participants in his study. It reflected the fact that a large number of young adult doctors working as residents are engaged in COVID-19 duties. Our study had 54.37% males and 45.09% female doctors. This was in contrast to the study conducted by Lin[13] in Wuhan, where the maximum of 77.7% of respondents were women and Foo[14] in Singapore where the maximum of 85.7% of respondents were women. Our study has nearly equal representation of doctors from both sexes.

Our study revealed that 71.35% of doctors developed skin problems during the COVID-19 pandemic due to the use of PPE. This percentage was similar to the study of Lin,[13] where 74.5% of respondents developed adverse skin reactions. However, the study conducted by Foo[14] revealed that 35.5% of the staff using masks, 21.4% of staff using gloves, and 1.6% of the staff wearing gowns developed adverse skin reactions. The study conducted by Zuo[16] revealed mask-related adverse skin reactions in 49% of participants. Lan[15] reported adverse effects in 97% of first-line health-care workers.

In this study, only 5.83% of doctors consulted a dermatologist for their skin problems. This was similar to the study of Foo,[14] where only 15 out of 109 staff consulted the doctor for their skin condition. Hence, there is a need to create awareness among doctors about the adverse skin reactions that they can develop due to the use of PPE and measures to prevent it.

The common symptom reported in our study were increased sweating in 54.64% of doctors, followed by redness of skin in 50.13%, itching in 35.54%, dryness of skin in 24.93%, and others [Table 3]. While the common morphological features reported were erythema in 38.19% of doctors, acne in 26.25%, erosion in 11.14%, urticaria in 10.61%, and others [Table 4]. The common skin eruptions reported by Lin[13] were dryness or scales (68.6%), papules or erythema (60.4%), and maceration (52.9%). Foo[14] reported acne (59.6%), facial itch (51.4%), and rash (35.8%) as the common adverse effects in the staff wearing masks; dry skin (73.4%), itch (56.3%), rash (37.5%), and wheals (6.3%) as the common adverse skin effects in the staff wearing gloves. In the study of Lan,[15] the common symptoms seen were dryness/tightness in 70.3%, tenderness in 56.8%, itching in 52.5%, and burning/pain in 38.0%. The skin lesions reported in this study were desquamation in 62.2%, erythema in 49.4%, maceration in 39.9%, and fissure in 38.8%. Zuo,[16] in this study reported exacerbation of acne in 43.6% of patients and seborrheic dermatitis in 37.5%.

Our study revealed that the face and hands were the common sites of adverse skin reactions. The nose was involved in 28.64% of doctors, followed by cheeks in 26%, above and behind the ear in 75 19.89%, palms in 19.36%, and others [Table 5]. Other studies reported similar findings. Hands (84.6%), cheeks (75.4%), and nasal bridge (71.8%) were the commonly affected areas in the study of Lin.[13] In the study of Lan,[15] the commonly affected areas were nasal bridge in 83.1%, cheek in 78.7%, hands in 74.5%, and forehead in 57.2%.

Our study revealed that masks and gloves were the most commonly used PPE, used by 100% and 88.85% of doctors, respectively. Hence, the face and hands tend to be the most common involved sites in dermatosis due to PPE use in all the studies. Eczema of the face (30%), acne (26.25%), and hyperhidrosis (18.83%) were the most common dermatosis reported in our study. The reason for this can be that face masks cause local increase in temperatures and humidity, as said by Li[8] in this study. Eczema of hands (15.11%) was also commonly reported dermatosis in our study. This could be due to allergy to the materials of gloves.

In this study, 47.48% of the doctors were working in COVID-19 dedicated setups and 52.51% were working in non-COVID-19 setup. There was no significant difference in the development of dermatosis due to PPE use among these two groups [Table 6]. However, Lin[13] in this study reported a higher prevalence of adverse skin reactions among those working in hospitals with more severe epidemic and inpatient wards.

Lin[13] and Lan[15] reported that adverse skin reactions were more when PPE was worn for more than 6 h in a day. This finding was similar to our study [Table 7]. Considering the duration, dermatosis due to PPE use was more in doctors who worked for more than 6 h in the day. Hence, we can conclude that the chances of developing dermatosis are more in those who use PPE for a prolonged duration. Moreover, hence, there is a need to regulate working hours of doctors.[15]
Table 7: Correlation of dermatosis in doctors due to personal protective equipment with working hours

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Our study had several limitations. Since the questionnaire was circulated via social media, it is most likely to reach the young adult doctors and they are the ones most likely to respond compared to senior doctors. The total number of participants was less to represent the entire population of doctors. Furthermore, not everyone responded to the survey and those with skin problems were more likely to respond. These two factors are likely to lead to a selection bias in our study. Despite these limitations, our study revealed a high prevalence of dermatosis among doctors using PPE, which was related to the duration of work.

[TAG:2]Conclusion [/TAG:2]

There is a need to provide the affected doctors with effective dermatological treatment and establish guidelines for prevention for occupational skin disorders at a national level.[16]

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 initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowlegments

I would like to thank Dr, Hetal Waghela, Professor and Dr. Biswajit Chaklader, 2nd-year resident, Department of Community Medicine, for helping us with the statistics in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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1.
Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91-8.  Back to cited text no. 1
    
2.
Gallegos A. WHO Declares Public Health Emergency for Novel Coronavirus. Medscape Medical News; January 30, 2020. Available from: https://www.medscape.com/viewarticle/924596. [Last accessed on 2020 Jun 18].  Back to cited text no. 2
    
3.
Ramzy A, McNeil DG. W.H.O. Declares Global Emergency as Wuhan Coronavirus Spreads. The New York Times; January 30,2020. Available from: https://nyti.ms/2RER70M. [Last accessed on 2020 Jun 18; Last updated on 2020 Apr 16].  Back to cited text no. 3
    
4.
World Health Organization. WHO Director-General's Opening Remarks at the Media Briefing on COVID-19 – 11 March 2020. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-COVID-19---11-march-2020. [Last accessed on 2020 Jun 18].  Back to cited text no. 4
    
5.
Ministry of Health and Family Welfare. Government of India. COVID-19 INDIA. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Jun 18; Last updated on 2020 Jun 18].  Back to cited text no. 5
    
6.
U. S. Food and Drug Administration. Personal Protective Equipment for Infection Control. Available from: https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control. [Last accessed on 2020 Jun 18; Last updated on 2020 Feb 02].  Back to cited text no. 6
    
7.
Ministry of Health and Family Welfare Directorate General of Health Services. Novel Coronavirus Disease 2019 (COVID-19): Guidelines on Rational Use of Personal Protective Equipment. Available from: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf. [Last accessed on 2020 Jun 18].  Back to cited text no. 7
    
8.
Li Y, Tokura H, Guo YP, Wong AS, Wong T, Chung J, et al. Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int Arch Occup Environ Health 2005;78:501-9.  Back to cited text no. 8
    
9.
Badri FA. Surgical mask contact dermatitis and epidemiology of contact dermatitis in healthcare workers. Curr Allergy Clin Immunol 2017;30:183-8.  Back to cited text no. 9
    
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Agarwal US, Besarwal RK, Gupta R, Agarwal P, Napalia S. Hand eczema. Indian J Dermatol 2014;59:213-24.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Donovan J, Skotnicki-Grant S. Allergic contact dermatitis from formaldehyde textile resins in surgical uniforms and nonwoven textile masks. Dermatitis 2007;18:40-4.  Back to cited text no. 11
    
12.
Tan KT, Greaves MW. N95 acne. Int J Dermatol 2004;43:522-3.  Back to cited text no. 12
    
13.
Lin P, Zhu S, Huang Y, Li L, Tao J, Lei T, et al. Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: A survey in Wuhan and its surrounding regions. Br J Dermatol 2020;183:190-2.  Back to cited text no. 13
    
14.
Foo CC, Goon AT, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome – A descriptive study in Singapore. Contact Dermatitis 2006;55:291-4.  Back to cited text no. 14
    
15.
Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol 2020;82:1215-6.  Back to cited text no. 15
    
16.
Zuo Y, Hua W, Luo Y, Li L. Skin reactions of N95 masks and medial masks among health-care personnel: A self-report questionnaire survey in China. Contact Dermatitis 2020;83:145-7.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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