key: cord-0736455-98e02f3b authors: Yan, Yicen; Chen, Hui; Chen, Liuqing; Cheng, Bo; Diao, Ping; Dong, Liyun; Gao, Xinghua; Gu, Heng; He, Li; Ji, Chao; Jin, Hongzhong; Lai, Wei; Lei, Tiechi; Li, Li; Li, Liuyi; Li, Ruoyu; Liu, Dongxian; Liu, Wei; Lu, Qianjin; Shi, Ying; Song, Jiquan; Tao, Juan; Wang, Baoxi; Wang, Gang; Wu, Yan; Xiang, Leihong; Xie, Jun; Xu, Jinhua; Yao, Zhirong; Zhang, Furen; Zhang, Jianzhong; Zhong, Shaomin; Li, Hengjin; Li, Hang title: Consensus of Chinese experts on protection of skin and mucous membrane barrier for health‐care workers fighting against coronavirus disease 2019 date: 2020-03-29 journal: Dermatol Ther DOI: 10.1111/dth.13310 sha: a93fe5b061cec19263bfe6c04366a4989706d879 doc_id: 736455 cord_uid: 98e02f3b Health professions preventing and controlling Coronavirus Disease 2019 are prone to skin and mucous membrane injury, which may cause acute and chronic dermatitis, secondary infection and aggravation of underlying skin diseases. This is a consensus of Chinese experts on protective measures and advice on hand‐cleaning‐ and medical‐glove‐related hand protection, mask‐ and goggles‐related face protection, UV‐related protection, eye protection, nasal and oral mucosa protection, outer ear, and hair protection. It is necessary to strictly follow standards of wearing protective equipment and specification of sterilizing and cleaning. Insufficient and excessive protection will have adverse effects on the skin and mucous membrane barrier. At the same time, using moisturizing products is highly recommended to achieve better protection. To assess the potential skin damage, a recent cross-sectional study surveyed 330 HCWs working at fever clinics and inpatients ward of COVID-19 cases. The results showed that 71% of respondents reported self-perceived skin barrier damage. The main symptoms were burning, itch, and stinging. The most commonly reported types of eruptions were dryness or scales, papules or erythema, and maceration. Since frontline HCWs frequently encounter skin and mucous barrier damage, the consensus for protecting skin and mucosa The survey showed that 66.1% of HCWs washed hands over 10 times per day, but only 22.1% took protective skincare measures after washing. A large epidemiological study in Sweden reported that prolonged water exposure induces skin irritation. 1 Therefore, standardizing moments and disinfectants for hand hygiene and emphasizing skincare after hand washing are essential for hand care. According to Specification of Hand Hygiene for Healthcare Workers (WS/T313•2019), 2 hand hygiene should adhere to "two before and three after." It includes before touching a patient, before any aseptic procedure (including invasive procedure) is performed, after potential exposure to patient's body fluid, after touching a patient, and after touching a patient's surroundings or items that might be contaminated. If PPE is regularly used by HCWs, the above-mentioned moments for hand hygiene can be replaced by glove decontamination. However, some extra moments 3 need to be addressed: (a) before donning PPE, (b) before, during and after doffing PPE, (c) before leaving affected area, (d) before eating or drinking, (e) before and after defecation, and (f) after reaching the residence. In addition, sufficient quantities of alcohol-based hand rub are essential for cleaning. Washing hands need both hand detergents and running water. Wearing gloves is not a substitute for hand hygiene. The survey showed that 12.4% of HCWs wear three layers of gloves at the same time during daily work. Long-term use of gloves may lead to overhydration of stratum corneum, which may cause maceration and erosion. Chemical materials in latex gloves are likely to cause contact dermatitis in macerated or erosive skin. To make it worse, damaged skin is vulnerable to secondary infection. Hence, several points should be emphasized when wearing gloves. One layer of qualified latex gloves is adequate for skin protection. Additional layer is recommended for HCWs with existing skin barrier damage or underlying risk of gloves broke. Theoretically, the increased layers of gloves cannot add to protective effect proportionally, however, gloves-related adverse skin reactions may increase. The adverse skin reactions caused by prolonged wearing of masks and goggles include pressure injury, urticaria, contact dermatitis, skin dryness, and aggravation of existing skin diseases. According to a report from Singapore during the SARS outbreak in 2003, 35.5% HCWs reported acne (59.6%), facial itch (51.4%), and rash (35.8%) from N95 mask use. 7, 8 1. Protective measures for pressure injury • The choice of masks: Wear a properly fitted mask. 9 Use masks in different ways alternately to avoid sustained friction and pressure on the same site. • Application of moisturizers or gel: Apply moisturizers or gel before wearing facial protective equipment to lubricate and reduce friction between skin and masks or goggles. • Correct use of goggles: The main purpose of using goggles is to avoid being infected by transmissible splash. Over-tight using cannot enhance the protective effect but damage the skin and generate fogs instead. Patients reporting severe pruritus can take antihistamines orally. Closed and humid environments caused by water in exhaled air may cause skin barrier dysfunction and lead to subsequent skin dryness and scales. Applying high-potent moisturizers before and after wearing PPE is paramount to prevent such discomfort. Short-term close exposure to UV irradiation without eye protection can damage the cornea and conjunctival epithelium, resulting in keratitis presenting with eyelid redness, conjunctival congestion and chemosis, foreign body sensation, pain, photophobia, and blurred vision. Cutaneous reaction to UV irradiation includes erythema, swelling, exudation, pain, and tenderness. In addition, over-inhalation of ozone produced by some UV disinfection lamps (UDLs) may cause dizziness, nausea, and other adverse reactions. 17 Therefore, HCWs should avoid direct exposure to UV irradiation, especially close and long-term exposure. According to the survey, 56.7% of HCWs wore PPE for over 6 hours per day. Getting all wet after shift was reported in 64.5% of HCWs. Overhydration tends to cause cutaneous dysbacteriosis and skin barrier damage. Besides, the performance of PPE will also decline simultaneously with hydrosis. 3 Preventive measures include (a) control working hours with PPE. Nasal vestibule mucosa is a vulnerable area for virus or bacteria to colonize for its abundant blood vessels, mucinous glands and serous glands which create a humid environment. Angiotensin converting enzyme-2 (ACE2) expression was found in the basal layer of the nonkeratinizing squamous epithelium in nasal mucosa, indicating that coronavirus may infect nasal mucosa cells if basal layer is exposed due to nasal mucosa barrier breakdown. 21 Accordingly, HCWs should clean nasal cavity once leaving isolated wards and pay attention to the protection of upper respiratory tract and mucosa. 22 1 Adhere to the standards: Adhere to the standards on wearing PPE. 22 2 Nasal vestibule cleansing: Strictly follow the Standard of Nasal Vestibule Hygiene for Healthcare Workers (DB12/T551•2014). 23 • Moments for cleansing: Before leaving clean zone or getting off work. • Moments of sterilizing: masks or nasal cavity is contaminated with patient's blood, body fluid, or secretion. Oral bacteria tend to colonize on teeth and gingiva due to long-term wearing of masks and insufficient water intake, which may consequently cause oral diseases including halitosis, gingival bleeding, aggravation of periodontitis and oral ulcers. 28, 29 Protective oral care includes brushing teeth every morning and night, using mouthwash or brushing teeth after meals and ensuring timely water intake. Rinse mouth with water or normal saline when getting off work 30 Water exposure on the hands in adolescents: a report from the BAMSE cohort National Health Commission of the People's Republic of China. Specification of Hand Hygiene for Healthcare Workers Confusion on prevention and control of healthcareassociated infection of novel coronavirus General Office of the National Health Commission of the People's Repubulic of China, & National Administration of Traditional Chinese Medicine. 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PLA Health Mouthwash and oral hygiene Improving oral health care for the frail elderly: a review of widespread problems and best practices China Clinical Dermatology Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019 All authors have no conflict of interest.