key: cord-0693537-7udszec5
authors: Sarfraz, Zouina; Sarfraz, Azza; Sarfraz, Muzna; Felix, Miguel; Bernstein, Jonathan A.; Fonacier, Luz; Cherrez-Ojeda, Ivan
title: Contact dermatitis due to personal protective equipment use and hygiene practices during the COVID-19 pandemic: A systematic review of case reports
date: 2022-01-13
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2022.103254
sha: 93eece896d59e946d1a43f1c78dcbe97f034ecf3
doc_id: 693537
cord_uid: 7udszec5

BACKGROUND: Prolonged use of personal protective equipment (PPE) may lead to contact dermatitis during the coronavirus disease 19 (COVID-19) pandemic. This paper aims to identify the causative factors of contact dermatitis from PPE and hygiene practices. METHODS: The search was conducted adhering to PRISMA 2020 guidelines. A Delphi process was employed to ensure that the aims of this study were met. PubMed and Web of Science databases were systematically searched through September 12, 2021, using search terms: Contact dermatitis, case report, covid-19. The findings were tabulated as author/year, gender, age, presentation, cause, dermatological diagnosis, testing modality, provided treatment, symptom resolution (time in days), prognosis, and follow-up. RESULTS: The mean age of all individuals was 29.75 years, with 75% females. All cases presented with erythema, with 62.5% reporting pruritus and 37.5% reporting burning facial symptoms. Surgical masks and hand-hygiene products (37.5%) were the most commonly reported causative agent with 25% due to KN95/FFP type 2 use. Allergic contact dermatitis (50%) and irritant contact dermatitis (25%) were common diagnoses. Treatments included creams, emollients, and desloratadine, with restriction of irritant-causing factors. The prognosis was generally good among the cases, with 62.5% presenting complete resolution within a week and 12.5% showing moderate improvement at the fourth month after discontinuing use. CONCLUSION: This study finds pertinent links between PPE use and contact dermatitis during the COVID-19 pandemic. While many cases are bound to go underreported in literature, well-designed, large-scale studies in the future may help promote these associations in a more comprehensive manner.

Manuscript Background Personal protective equipment (PPE), including face masks and hand sanitizers, is essential for safeguarding healthcare workers (HCWs) and general population members 1 . During the coronavirus disease 19 (COVID-19) pandemic, contact dermatitis was reported among HCWs across various observational studies 23 , in addition to single-patient reports. While allergic and irritant contact dermatitis is frequent, other skins lesions may occur 4 . A systematic review identifies that prolonged PPE use may lead to an increased risk of occupational dermatitis, which comprises allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD). Another review identified that 80% of cases occurred due to ICD, with non-specific erythema and pressure contact urticaria 5 . This systematic review aims to identify the causes of contact dermatitis due to personal protective equipment use and hygiene practices by synthesizing cases reported in literature.

This systematic review was conducted adhering to the PRISMA 2020 statement guidelines 6 . A Delphi process was employed to ensure that the study objectives were met 7 Of the total 419 articles identified and post-removal of duplicates/tallying exclusion criteria, 15

full-text articles were analyzed. Seven were excluded as they were not case reports; contact dermatitis did not occur due to PPE use or hand hygiene measures. All of the eight articles that met the inclusion criteria were included in the final paper ( Figure 1 

A total of 8 case reports were included, classified by author/year, gender, age, presentation, cause, dermatological diagnosis, testing modality, provided treatment, symptom resolution (time in days), prognosis, and follow-up findings ( Table 2 ). The mean age across all cases was 29.75 years, ranging from 3-64 years. There were 6 (75%) females. The common presentation among all cases was erythema (100%), with 5 (62.5%) patients who reported itching and 3 (37.5%) patients reporting burning facial symptoms. The causative factors were KN95/FFP type 2 masks among 2 J o u r n a l P r e -p r o o f 

To the best of our knowledge, this is the first systematic review of case reports to collate evidence of dermatitis due to PPE use during the COVID-19 pandemic. The first case of mask-induced ACD due to polyurethane was reported in 2020 used in the production of PPE products, including for the sponge strip inside the mask which, may lead to the reaction of diisocyanates causing ACD or precipitate asthma attacks 9 . While polyurethanes are fully cured polymers and are not believed to be sensitizers, the residual cross-linkers are reported to lead to allergic reactions that may be responsible for a myriad of respiratory symptoms, in addition to ACD 9 . The prolonged use of facial masks and skin problems such as irritant contact dermatitis is not uncommon, with reports of various facial skin problems during the previous severe acute respiratory syndrome (SARS) epidemic 10 . Formaldehyde is a frequent contact sensitizer or irritant.

Given that patients, healthcare workers, and the general population are required to wear polypropylene surgical masks, more ACD and ICD are likely to occur in and outside the workplace 10 . Furthermore, filtering half masks of the FFP2 classification is one of the most frequently used healthcare PPE items 12 . The FFP2 masks can trigger contact dermatitis, an inflammatory, noninfectious, intolerant skin reaction induced by chemical, immunological or physical toxins 12 .

The current literature suggests that the continuous use of surgical masks among healthcare workers and general population members may cause ACD or ICD, contact urticaria, and exacerbation of acne and skin infections 13 . The causal agents in these scenarios may be flavorings, fragrances, preservatives, medications, and disinfectants 13 . During the COVID-19 pandemic, the high prevalence of occupational dermatoses has been noted in a Chinese cohort of healthcare workers where 74% of respondents reported adverse skin reactions due to hand hygiene practices and PPE use 4 . Reports of a new form of irritant rhinitis to FFP masks (FFP2/N95/KN95) during the COVID-19 pandemic may also be found 16 . Our findings highlight the broad occupational dermatosis of single patients and create awareness of the impact that common or rare skin conditions like aquagenic urticaria may have on occupational impact 4 . The risks of ICD have been increased mainly due to overzealous hand hygiene with sanitizers, leading to prolonged exposure of physical or chemical agents, as identified in our study results 14 . Such over-rigorous hand hygiene practices may lead to impairment of keratocytes, disruption of the epidermal barrier, the release of pro-inflammatory cytokines, and delayed-type hypersensitivity reactions, due to activation of the skin's immune system 14 . As opposed to hand sanitizers and gloves, wearing surgical or other masks as a cause of skin lesions and irritation has been less reported during the COVID-19 pandemic 15 . However, N95 (FF2) masks may lead to increased skin reactions due to constant friction and moisture due to the tighter fit and higher impermeability, compared to surgical masks alone 15 . Our study indicates that depigmentation, presenting as contact leukoderma or vitiligo following koebnerization due to frictional dermatitis, maybe a rare consequence of mask usage 15 .

There are certain limitations to this systematic review that must be acknowledged. First, the search was limited to two databases (PubMed and Web of Science), impacting the search process.

Published literature, including only case reports, was considered. The results of this study may not be fully generalizable but represent a noteworthy overview in the area of contact dermatitis related to PPE and COVID-19, serving as a cautionary reminder to health authorities that safety for populations must be a top priority.

This systematic review describes the links of PPE use and contact dermatitis during the COVID-19 pandemic among eight cases. Given that healthcare workers and the general public must wear J o u r n a l P r e -p r o o f face masks and practice hand hygiene more often than before, such incidences of contact dermatitis are not uncommon. Well-designed, higher-powered studies are required in this area to ensure that a better understanding of PPE and contact dermatitis is seen. More comprehension of the reasons for such dermatological reactions may be made by mitigating unawareness of irritant PPE materials using awareness-increasing platforms. With diligent hand disinfection reinforced during COVID-19, the increased prevalence of contact dermatitis is documented but our systematic review highlights the fact that the condition is readily treatable and ought not to cause any deviation from proper hand hygiene and PPE use.

Not commissioned, externally peer reviewed.

Use, and Satisfaction of Personal Protective Equipment Among Healthcare Workers: A Cross-Sectional Assessment of Low-and Middle-Income Countries

The adverse skin reactions of health care workers using personal protective equipment for COVID-19

Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions

Concomitant allergic contact dermatitis and aquagenic urticaria caused by personal protective equipment in a healthcare worker during the COVID-19 pandemic. Contact Dermatitis

Occupational dermatitis to facial personal protective equipment in health care workers: A systematic review

The PRISMA 2020 statement: An updated guideline for reporting systematic reviews

Contact Dermatitis due to Personal Protective Equipment Use and Hygiene Practices during the COVID-19 Pandemic: A Systematic Review of Case Reports

Mask-induced contact dermatitis in handling COVID-19 outbreak

Surgical mask dermatitis caused by formaldehyde (releasers) during the COVID-19 pandemic

Report: Handwashing-Induced Dermatitis During the COVID-19 Pandemic

Kontaktallergie auf FFP2-Maske in der COVID-19-Pandemie

Severe contact urticaria, mimicking allergic contact dermatitis, due to a surgical mask worn during the COVID-19 pandemic

Fluctuating Palmar Erythema in a Toddler during COVID-19 Pandemic: Do You Know the Offender?

Mask vitiligo" secondary to frictional dermatitis from surgical masks

A new form of irritant rhinitis to filtering facepiece particle (FFP) masks (FFP2/N95/KN95 respirators) during COVID-19 pandemic

Prolonged PPE use for COVID-19 makes users vulnerable to contact dermatitis 2. Irritant and contact dermatitis due to surgical masks/KN95/FFP type 2/ hygiene products was reported

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