INTRODUCTION

Linked to the COVID-19 pandemic announced by the WHO on March 11, 2020, restrictions aimed at breaking the epidemiological chain have become common. One of the main methods of reducing infections and the spread of the virus is primary prevention, which includes hand hygiene and the use of personal protective equipment (PPE). PPE includes masks, gloves, hand sanitizers, gowns, face shields, shoe covers, and goggles.

Many dermatologists from around the world subsequently observed a positive relationship between the COVID-19 pandemic and the appearance of new skin lesions/diseases and the exacerbation of preexisting dermatoses.

Skin changes observed during the COVID-19 pandemic may be divided into those accompanying the infection with the SARS-CoV-2 virus caused by agents used to treat the infection, and those related to the use of PPE [1].

Healthcare workers may be at the highest risk of dermatological problems associated with the latter due to their greater frequency and longer duration of use of PPE [2,3]. According to literature data, the incidence of skin damage associated with the use of PPE and personal hygiene measures among health-care workers ranges from 42.8% to 98.03% [4,5]. The most frequently described changes are pressure injuries, pressure urticaria, contact dermatitis, itchiness, exacerbation of pre-existing skin conditions, including seborrheic dermatitis and acne, and new skin diseases such as pompalox and acne [1]. Skin-related problems are most often observed on the face and hands [1,5]. The aim of our survey study was to present the impact of chronic use of PPE on skin conditions during the COVID-19 era.

MATERIALS AND METHODS

This was a cross-sectional survey conducted between March 1, 2022, and March 1, 2023, using online Google Forms questionnaires. In order to investigate skin problems caused by the use of PPE, a survey was sent by e-mail to students and medical workers and made available on social media sites such as Facebook. The questionnaire was addressed to people aged 15–75, regardless of their health status and education level, living in Poland. The questionnaire was anonymous, required short or multiple-choice answers, and took approx. 15 minutes to complete. The first part of the questionnaire included questions about demographic data such as age, sex, place of residence, education, and professional status. It also collected information about vaccination against SARS-CoV-2. The second part encompassed questions about skin problems and their location before the pandemic and during the use of PPE, the type and duration of use of PPE, as well as the discontinuation of PPE due to skin problems. Data analysis was performed in the R statistical environment, ver. 3.6.0, PSPP software, and Microsoft Office 2019. Variables expressed at the ordinal or nominal level were analyzed using tests based on the chi-squared distribution. However, if the conditions for the chi-squared test were not met, Fisher’s exact test was used. The significance level was set at p < 0.05.

RESULTS

Characteristics of the Study Population

A total of 513 people participated in the study, of which 24.9% were health-care workers, 53.8% medical students, and 21.3% non-medical professionals. The average age of the participants was 28 years, and most of the respondents were women (82.3%). Respondents vaccinated against the SARS-CoV-2 virus constituted 95.3%, and 98.4% of people stated that they had used PPE during the pandemic. Table 1 presents the sample’s demographic data.

Table 1: Characteristic of the study population.

The Effect of PPE on the Skin

Out of the 513 respondents, 60.9% declared the deterioration of existing skin lesions, while only 49.9% reported the appearance of new lesions. Table 2 presents the actual and expected values as well as the chi-squared test result.

Table 2: Actual and expected values and the result of the χ2 test. Occurrence of new and exacerbation of existing skin lesions when using PPE.

Skin-Related Problems and Professional Status

Only 44.5% of the respondents in medical professions and 48.1% in non-medical professions declared the appearance of new skin lesions linked to the use of PPE. Meanwhile, among medical students, as many as 57.1% reported the occurrence of skin problems. The results regarding the exacerbation of skin lesions were slightly different. Most respondents stated that existing dermatological problems had worsened. Among them, 55.5% were health-care workers, 51.9% were representatives of non-medical professions, and 66.7% were medical students. Table 3 presents these results.

Table 3: The relationship between professional status and the occurrence of new and the exacerbation of existing skin lesions when using PPE.

Anatomical regions of skin-related problems

Head, neck, and face

Based on the responses to the question about the PPE used, the study sample was divided into those using and those not using masks, face shields, or goggles with a mask. In turn, the locations of skin lesions were grouped into the head and neck area (scalp, behind the ears, forehead, neck) and the face area (cheeks, nose, mouth area, red lips, chin). Among people wearing a mask, face shield, or goggles with a mask, 85.8% denied the appearance of new lesions and 88.9% denied the exacerbation of existing lesions in the head and neck area. In turn, 50.2% declared the occurrence of severity of existing lesions on the facial skin. Both among people who used the aforementioned PPE (61.9%) and among people who did not (76.9%), most often no new changes appeared on the face. However, they were statistically significantly (p < 0.05) more common among those who wore a mask, face shield, or goggles with a mask compared to those who did not (Table 4).

Table 4: The relationship between the use of masks, face shields, or goggles with a mask before the occurrence of lesions and the exacerbation of existing and the occurrence of new skin lesions in the head, neck, and face area.

Hands

Among the respondents who used gloves and hand disinfection measures (65.7%) and those who did not (77.2%), skin lesions most often did not appear or did not worsen. However, skin problems became more severe or occurred statistically more often (p < 00.5) in people wearing these types of PPE (Table 5).

Table 5: The relationship between the use of protective gloves and hand disinfection before the occurrence of lesions and the exacerbation of existing skin lesions and the occurrence of new skin lesions around the hands.

Characteristics of Skin Lesions and their Anatomical Location

The most common skin problems reported in connection with the use of PPE were: increased dryness, peeling of the skin and erythema (Table 6). These changes were most often located on the skin of the hands and face (cheeks, mouth area, and chin) (Table 7). A similar location applied to dermatoses that occurred in respondents before the pandemic and had become more severe (Table 8). Among them, the most frequently reported changes were acne, dermatitis, skin allergies, and atopic dermatitis.

	Table 6: New skin lesions related to the use of PPE.
	Table 7: Anatomical location of new and exacerbated skin lesions.
	Table 8: Dermatoses of the respondents before the pandemic.

The Impact of the Duration of Mask-Wearing on Facial Skin Problems

Among people who changed their mask every 1–3 hours, new skin lesions appeared in 55.9%, similarly with people who changed it every few hours (53.7%) and once a day (57.1%). However, in those who changed it occasionally (52.5%) or did not wear one at all (59.6%), changes most often did not occur. However, the differences are small and statistically insignificant (p > 0.05) (Table 9). Nevertheless, existing skin lesions in each group worsened, regardless of the duration of mask-wearing. Therefore, the differences also proved to be small and statistically insignificant.

Table 9: The relationship between the frequency of changing the mask and the occurrence of new and exacerbation of existing skin lesions.

DISCUSSION

The COVID-19 pandemic has forced people to use PPE, e.g., masks, gloves, and hand disinfectants, on a daily basis due to its ability to limit the spread of infection and its fundamental importance in preventing potential exposure to pathogens [6,7]. Rational and correct use of PPE is crucial to ensuring the safety not only of health-care workers but also of the entire society. On the other hand, long-term use of PPE is associated with a high rate of undesirable dermatological reactions, including the appearance of new dermatoses and the exacerbation of existing skin diseases [2,8,9]. The current study observed a significant impact of PPE on skin health during the COVID-19 era.

In our study, the exacerbation of skin diseases occurred more often than the appearance of new dermatoses related to the use of PPE. The group most exposed to adverse skin reactions were medical students, which may have been due to their significant numerical predominance compared to health-care workers or non-medical professionals.

Skin problems related to the use of PPE affect various parts of the body. The most frequently described locations are the facial areas (12–87%), such as the bridge of the nose, cheeks, chin, and forehead. Adverse reactions also often appear on the skin of the hands (15–85%) [1]. The results of our study were consistent with the existing data.

One systematic review identified dry skin, pressure erythema, and contact dermatitis of the face and hands as the most common skin problems associated with the use of PPE [10]. In our study, these were dryness, scaling, and erythema also occurring in the same locations. Similar results were discovered by Lan et al. in their study [5]. Conversely, Foo et al. and Gheisari et al. showed that the most common skin symptom was acne and its exacerbation on the face [11,12].

The aforementioned skin problems may be related to the exposure to irritants and allergens contained in PPE, which may, in combination with occlusion, moisture, friction, and the atopic predisposition of the individual, cause contact dermatitis (CD) and irritant contact dermatitis (ICD) [13]. Similarly to mechanical damage, high facial temperature and humidity caused by wearing a mask increases the secretion of sebum (an increase of 10% for each increase by 1°C), which contributes to the exacerbation/occurrence of acne [14]. This relationship contributed to the identification of a new nosological entity, maskne (mask-related acne), the diagnostic criteria of which were developed by Teo et al. They include, among others, a typical location called the “O zone” referring to the area covered by the mask (mouth area, nose, and cheeks) [15]. Another study also found flares in 43.6% of acne patients, 37.5% of seborrheic dermatitis patients, and in all rosacea patients (n = 14) [16]. We should also not forget that other skin diseases, although less frequently described in the literature, may also become more severe. Examples include psoriasis and lichen planus, which may be exacerbated by mechanical irritation (Koebner’s symptom) [17,18]. Moreover, damage caused by pressure or abrasion and contact dermatitis are easily susceptible to secondary bacterial and fungal infections.

According to existing data, one of the most important factors related to the occurrence of adverse skin reactions is the duration of PPE use. One study found that wearing PPE for more than six hours a day was associated with a higher risk of skin problems. The same study indicated that washing hands more than ten times a day increases the risk of dermatological lesions 2.17 times more than wearing gloves for a long period of time [5]. However, our study considered the frequency of changing one’s mask without taking into account the duration of wearing it, which may be the reason for the discrepancies in the results.

The most disturbing from an epidemiological point of view was the fact that as many as 15.7% of the respondents declared to have stopped using PPE due to undesirable skin reactions, which favors the spread of the virus.

Although the WHO announced the end of the COVID-19 pandemic on May 5, 2023, there is still information about new variants of the virus and many medical professionals encounter new cases of illness caused by the SARS-CoV-2 virus. Therefore, we should not forget about skin injuries and dermatological problems related to the use of PPE, even if their use is no longer as common as it was during the pandemic.

Our study has some limitations that should be kept in mind. Firstly, it is impossible to verify the reliability of the data provided by the respondents, which is related to the superficial nature of the qualitative research. Secondly, medical students are overrepresented in the study compared to health-care workers and non-medical professionals. Thirdly, there was a disproportion in terms of sex and age among the respondents, which may be associated with other risk factors for adverse skin reactions (e.g., hormonal balance, chronic diseases, skin care, use of makeup). The limitations of this cross-sectional study may preclude drawing reliable conclusions for the entire Polish population.

CONCLUSION

This study showed that the use of PPE was associated with the appearance of new dermatoses and the exacerbation of existing ones. However, we found that existing skin lesions were more likely to be exacerbated than new ones were to appear. The results of our research indicated that there was a significant relationship between professional status and the occurrence of skin-related problems. Our results and literature data suggest that medical students and health-care workers may be at the highest risk of adverse skin reactions. In these groups, existing skin lesions become more severe and new ones appear. The most vulnerable parts of the body are the face and hands. Skin problems related to the use of PPE may prevent its proper use, thus increasing the risk of infection with the virus. Therefore, there is a need for education around the use of PPE and consideration of creating special rules/guidelines for people struggling with skin diseases.

REFERENCES

1.Gül Ü. COVID-19 and dermatology. Turk J Med Sci. 2020;50:1751-9.

2.Montero-Vilchez T, Cuenca-Barrales C, Martinez-Lopez A, Molina-Leyva A, Arias-Santiago S. Skin adverse events related to personal protective equipment:A systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2021;35:1994-2006.

3.Gürlek Kısacık Ö, Özyürek P. Skin-related problems associated with the use of personal protective equipment among health care workers during the COVID-19 pandemic:A online survey study. J Tissue Viability. 2022;31:112-8.

4.Jiang Q, Song S, Zhou J, Liu Y, Chen A, Bai Y, et al. The Prevalence, characteristics, and prevention status of skin injury caused by personal protective equipment among medical staff in fighting covid-19:A multicenter, cross-sectional study. Adv Wound Care (New Rochelle). 2020;9:357-64.

5.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.

6.Schittek GA, Köstenberger M, Allerberger F, Schaden E;FASIM-COVID-Taskforce Collaborators. Web-based survey of the importance and effectiveness of personal protective equipment during the COVID-19 pandemic. Intensive Crit Care Nurs. 2021;63:102996.

7.Brown L, Munro J, Rogers S. Use of personal protective equipment in nursing practice. Nurs Stand. 2019;34:59-66.

8.Zhou NY, Yang L, Dong LY, Li Y, An XJ, Yang J, et al. Prevention and treatment of skin damage caused by personal protective equipment:Experience of the first-line clinicians treating SARS-CoV-2 infection. Int J Dermatol Venereol. 2020;3:70-5.

9.Worsley PR, Spratt F, Bader DL. COVID19:Challenging tissue viability in both patients and clinicians. J Tissue Viability. 2020;29:153-4.

10.Keng BMH, Gan WH, Tam YC, Oh CC. Personal protective equipment-related occupational dermatoses during COVID-19 among health care workers:A worldwide systematic review. JAAD Int. 2021;5:85-95.

11.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.

12.Gheisari M, Araghi F, Moravvej H, Tabary M, Dadkhahfar S. Skin reactions to non-glove personal protective equipment:An emerging issue in the COVID-19 pandemic. J Eur Acad Dermatol Venereol. 2020;34:297-8.

13.Navarro-Triviño FJ, Merida-Fernández C, Ródenas-Herranz T, Ruiz-Villaverde R. Allergic contact dermatitis caused by elastic bands from FFP2 mask. Contact Dermatitis. 2020;83:168-9.

14.Han C, Shi J, Chen Y, Zhang Z. Increased flare of acne caused by long-time mask wearing during COVID-19 pandemic among general population. Dermatol Ther. 2020;33:13704.

15.Teo W-L. Diagnostic and management considerations for “maskne“in the era of COVID-19. J Am Acad Dermatol. 2021;84:520-21.

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.

17.Van Joost T, Tjiam KH. Psoriasis in Köbner’s sign. Nederlands Tijdschrift voor Geneeskunde. 1987;131:929.

18.Cowden A, Van Voorhees AS. Introduction:History of psoriasis and psoriasis therapy. In:Weinberg, J.M. (eds) Treatment of Psoriasis. Milestones in Drug Therapy. 2008. Birkhäuser Basel.