key: cord-0994025-1egfc99y
authors: Bhatia, Riti; Sindhuja, Tekumalla; Bhatia, Saurabh; Dev, Tanvi; Gupta, Atula; Bajpai, Meenu; Gupta, Somesh
title: Iatrogenic dermatitis in times of COVID‐19: A pandemic within a pandemic
date: 2020-06-04
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16710
sha: 5f755349a4535a95766758f0e7d3a80d30c54ac0
doc_id: 994025
cord_uid: 1egfc99y

The pandemic of the 21st century, COVID‐19 emerged in Wuhan, China and swiftly became a global phenomenon. The frontline barriers for preventing spread are hand hygiene and personal protective equipment (PPE). The amplified hygiene practices and PPE as recommended have brought in its wake a second pandemic‐ a pandemic of dermatitis!. We reviewed the most prevalent types of iatrogenic skin damage among health‐care workers (HCWs), notably irritant, and allergic contact dermatitis (ACD) to PPE and hand‐hygiene measures, as well as face mask induced pressure‐related skin damage.

This article is protected by copyright. All rights reserved

The pandemic of the 21st century, COVID-19 emerged in Wuhan, China and swiftly became a global phenomenon. The frontline barriers for preventing spread are hand hygiene and personal protective equipment (PPE). The amplified hygiene practices and PPE as recommended have brought in its wake a second pandemic-a pandemic of dermatitis! 1 We reviewed the most prevalent types of iatrogenic skin damage among health-care workers (HCWs), notably irritant, and allergic contact dermatitis (ACD) to PPE and hand-hygiene measures, as well as face mask induced pressure-related skin damage. [2] [3] [4] The prevalence of occupational skin disease among HCWs in earlier studies (pre-COVID era) has been estimated to range from 20-50%. 5 However, in two recent studies from Hubei, China, a staggeringly higher number of HCWs (97%, n=526/542 and 71%, n=234/330) HCWs engaged in the care of COVID-19 patients reported self-perceived skin barrier damage. 2, 6 Majority experienced skin dryness/tightness (70.3%) and desquamation (62.2%) commonly occurring on the nasal bridge (83.1%) (Fig. 1 ). 2 Skin damage was more prevalent among HCWs wearing N95 masks and goggles for more than 6 hours a day, whereas the face shield produced no such effect on prolonged wearing. Goggles were reported as the commonest (51.92%) culprit among PPE and about a fifth of patients reported work absenteeism because of dermatitis. 3 Face mask and headgear worn tightly for prolonged hours result in ACD, ICD, pressure urticaria, friction dermatitis, abrasions, and aggravation of pre-existing dermatoses. 6 N95 respirators may contain formaldehyde, a known allergen. 7 Retro-auricular skin is vulnerable to frictional dermatitis due to ear loops of the facemasks. 4 Frequent hand-washing (>10 times daily) increased the risk of skin damage more than prolonged wearing of gloves.

Hand hygiene-associated dermatitis usually manifests on the knuckles and web spaces, where these irritants and allergens accumulate. Occasionally, both ICD and ACD can coexist. ACD to gloves presents with erythematous itchy plaques on convexities of dorsal surface of hands with a clear demarcation of erythema at wrists (Figure 1 ). 6 Contact dermatitis to various PPEs and hand hygiene measures can occur due to a variety of factors involving irritants and allergens in these agents, compounded by moisture, occlusion, friction, cold dry weather and atopic predisposition of an individual. These exposures lead to ICD and ACD

This article is protected by copyright. All rights reserved through changes involving the skin barrier, cells and cytokines. Excessive hand hygiene depletes skin commensals that play an important role in Th1, Th2 and Th17 balance. 8 Patch test is the gold standard for diagnosis of ACD. The battery of allergens includes standard series, textile series, fragrance series, masks, gloves, and hand cleansers used by the patients. Some allergens relevant to SARS-Cov-2 pandemic viz 1,3 diphenyl guanidine, DMDM hydantoin, propylene glycol, formaldehyde and formaldehyde releasers, may not be present in a single series. ACD to glove allergens also is commonly reported (Table 1) . 7 HCW education about hand hygiene measures combined with liberal moisturizing for skin barrier repair, avoidance of suspected allergens, ergonomic workplace interventions and emphasizing the need for redesigning PPE is vital in tackling this iatrogenic health hazard. Alteration in the frequency of handwashing, use of correct fitting PPE, and barrier creams are important. Fragrance-free emollients avoid the risk of further sensitization. If avoidance of allergen is not possible, protective measures like clothing, cotton lining latex or vinyl gloves, and two-layered gauze-lined masks may be helpful. 6, 9 Further, the base of topical medicaments (corticosteroids and calcineurin-inhibitors) to treat the dermatitis should be free from potential allergens. Correct use of PPEs and hand-hygiene measures can protect HCWs from acquiring COVID-19 infection. However, iatrogenic problems because of these measures may prevent their proper use, putting HCWs at risk. There is an urgent need to sensitize the larger health fraternity about these issues. 1, 4, 6 Legend for Illustration 

COVID-19 and contact dermatitis: alerts and warnings. Recommendations from the EADV Contact Dermatitis Task Force

Accepted Article This article is protected by copyright. All rights reserved

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Accepted Article

The patients in this manuscript have given written informed consent to the publication of their case details