INTRODUCTION

Healthcare workers (HCWs) are at an increased risk of developing occupational dermatoses, especially during the COVID-19 pandemic. The pandemic and other emerging infectious diseases like monkeypox have brought about several changes in the hospital infection control policy. Due to the increased need for personal protective equipment (PPE) and hand hygiene, there were many reports of occupational dermatoses from different parts of the world. Studies from China, the UK, and Ireland showed a very high prevalence of occupational dermatoses among HCWs engaged in COVID-19 patient care [1–3]. Nicole et al. reported that almost all healthcare workers involved in the study reported new-onset dermatoses after the use of PPE [4]. Pei et al. noted that the occurrence of skin lesions in HCWs was related to their working time [5]. A study conducted among frontline nursing staff in North India reported that there was an increased occurrence of skin lesions after the use of PPE [6].

During the peak of the pandemic, we observed several new-onset dermatoses among HCWs attributable to the use of PPE. Although the pandemic is on the wane now, the use of PPE for any future pandemics by the same virus or other microbes is a realistic possibility. There is a paucity of data from South India, which is having relatively high levels of humidity causing novel PPE-related issues necessitating the modification of PPE. For this reason, we conducted a cross-sectional study among HCWs to determine the prevalence of these and to identify the contributing factors. Our primary objective was to estimate the prevalence of occupational dermatoses among HCWs during the COVID-19 pandemic in a COVID-19 care hospital in central Kerala. We also aimed to determine the factors that led to the development of these dermatoses.

MATERIALS AND METHODS

After obtaining Institutional Ethical Committee approval, a descriptive, cross-sectional study was conducted at a tertiary care hospital, which is a designated COVID-19 care hospital in central Kerala. We included all healthcare workers involved in COVID-19 patient care for at least six hours daily for a minimum of seven days. The study period was six months, and the sample size calculated based on a previous study was 67 [3]. However, we collected data from 100 consecutive eligible study participants, including doctors and nursing staff.

The sociodemographic data, nature of work, pre-existing dermatoses, and recent skin changes were recorded in a proforma. All HCWs with new-onset cutaneous manifestations were examined in detail by a dermatologist. A detailed history regarding the onset and duration of the dermatoses, progression, symptoms, any history of remission or relapse, aggravating factors, sites involved, and type of lesions were recorded. Based on the history, site, and morphology of skin lesions, a clinical diagnosis was made. A diagnosis of contact dermatitis was made based on the clinical morphology, site of dermatoses, and recurrence of the lesion at the same site with repeated contact with the same substance. Patch testing in all cases was not practical because of the busy schedule of the HCWs. In doubtful cases, special investigations like skin scrapings for fungus, gram staining, and Tzanck smear were done to confirm the diagnosis.

The analysis was done using SPSS, version 25. Qualitative data was expressed in percentages, and quantitative data was expressed as mean. A chi-squared test was done to compare categorical variables. A p value ≤ 0.05 was considered statistically significant.

RESULTS

Among the 100 study participants, the majority (n = 83; 83%) were females. 44 (44%) were nurses, 30 (30%) were doctors, and 26 (26%) were nursing assistants. Fifty-four (54%) of the HCWs developed new-onset dermatoses after working in COVID-19 wards. Forty-six (46%) developed non-infective dermatoses, and eight (8%) developed infective dermatoses (Table 1). On comparing the new-onset dermatoses among doctors, nurses, and nursing assistants, there was no statistically significant difference among the groups.

Table 1: Number of newonset dermatoses among the doctors, nurses, and nursing assistants.

A personal history of atopy was present among 13 (24%) HCWs with new-onset dermatoses and 10 (21.7%) HCWs without new-onset dermatoses. There was no statistically significant difference in personal history of atopy among these two groups (p = 0.79).

The common pre-existing dermatoses were xerosis in four (4%) and contact dermatitis with gloves in four (4%). Among those with pre-existing dermatoses, one person each had worsening of atopic dermatitis and contact dermatitis to gloves after taking COVID-19 duty.

The common causes of dermatoses were gowns and scrubs (34%), gloves (10%), and N95 masks (9%). Gowns and scrub-related dermatoses included miliaria (12, 12%), pressure urticaria (10, 10%), contact dermatitis (11, 11%), and worsening of atopic dermatitis (1, 1%). N95 masks were the common culprits for maskne (4, 4%), frictional melanosis (3, 3%), and contact dermatitis (2,2%). Sanitizers caused focal peeling of the skin of the hands in two patients.

The most common infection was dermatophytosis (4%). Contact dermatitis, which affected 23% of the HCWs, was the most common non-infective dermatosis, followed by miliaria (12%) and urticaria (10%). The frequency of various dermatoses among the study population is given in Table 2, and the different body sites involved are shown in Figure 1.

Table 2: Frequency of the various dermatoses among the study population.

Figure 1: Percentage of different body sites involved in the study population.

DISCUSSION

In our study, the majority were females (83, 83%), and it was more or less representative of the sex distribution among HCWs. More than 50% of the healthcare workers developed new-onset dermatoses after getting involved in COVID-19 care. Although this is a significant number, the prevalence was lower compared to some previous studies [1,3,7]. Differences in ethnicity and racial factors could be the possible reasons for the lower incidence of dermatoses in our study. Only those dermatoses that recurred in the subsequent COVID-19 duties were included under the contact dermatitis group.

Hu et al. reported that 51.6% of nurses and 49.1% of doctors had skin manifestations [8]. The number of new-onset dermatoses in different groups of HCW was more or less comparable in our study. This is possibly due to the same material of PPE used by the study participants and similar working hours and environment in both studies.

A study from the UK reported irritant contact dermatitis among 97.1% of HCWs, with a high incidence of pressure-related facial dermatitis due to masks and goggles [3,9]. In our study, too, contact dermatitis was the most common dermatoses among HCWs, although we could not conclusively prove the exact nature of contact dermatitis by patch testing. Gloves contributed to 34.2% of dermatoses in various other studies [10]. In our study, 34% of the HCWs developed dermatoses related to scrubs and gowns. It could be due to the material of the scrub or gown used. Miliaria was observed in 12% of the subjects studied. The occlusive nature of the gown and scrub, together with our humid environment, made it worse inside COVID-19 wards without air conditioning, which might have contributed to the high prevalence of gown- and scrub-related dermatoses. The disinfection technique employed in our hospital by soaking in concentrated bleach solution before washing could also have contributed to the scrub-related dermatoses.

Superficial fungal infections were the most common among the infective dermatoses in our study. The increased prevalence could possibly be due to the humid climate. The prevalence of atopy was lower in our study compared to a study by O’Neill et al. [3]. There was no statistically significant difference in the development of PPE-related dermatoses among atopic individuals in our study. Gowns and scrubs were the common culprits among PPE in our study in contrast to studies from China, in which it was N95 masks [1,10]. Geographic and climatic variations, the methods of PPE use, and the material of PPE may explain the difference in findings from different countries. The frequency of sanitizer-related dermatoses was extremely low in our study, probably due to the practice of applying sanitizer over the inner glove among our staff [1]. The salient differences from the previous studies are tabulated in Table 3.

Table 3: Comparison of occupational dermatoses in various studies among healthcare workers involved in COVID-19 care.

We believe that the correct identification of the cause of various dermatoses can help us to take necessary measures to prevent them. This will increase the efficiency of the health workforce. We recommend greater access to more user-friendly PPE made of hypoallergenic and more breathable materials. Regular use of emollients by HCWs during off-duty hours should also be encouraged to minimize damage to their skin.

We would also recommend removing the remnants of bleach solution by thorough cleansing measures in order to prevent scrub-related dermatoses. As these dermatoses have the potential to negatively impact healthcare workers’ productivity, we believe that the results of this study will help us to take appropriate action to reduce their occurrence.

The limitations of this study were the descriptive study design and the inability to perform patch tests to confirm the exact cause of contact dermatitis owing to the busy schedule of the HCWs.

CONCLUSION

To conclude, more than half of the HCWs engaged in COVID-19 care who were studied had PPE-related dermatoses. Gowns and scrubs contributed to more than one-third of the dermatoses, necessitating a need to customize PPE according to the working environment.

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