Biophysical and biochemical changes in skin health of healthcare professionals using respirators during COVID-19 pandemic.

BACKGROUND: Personal protective equipment, including respirator devices, has been used to protect healthcare workers (HCWs) during the COVID-19 pandemic. These are fitted to skin sites on the face to prevent airborne transmission but have resulted in reports of discomfort and adverse skin reactions from their continued usage. The present study addresses the objective changes in both the structural integrity and biological response of the skin following prolonged and consecutive use of respirators. MATERIALS AND METHODS: A longitudinal cohort study, involving 17 HCWs who wear respirators daily, was designed. Changes in the barrier properties and biological response of the skin were assessed at three facial anatomical sites, namely, the nasal bridge, left cheek and at a location outside the perimeter of respirator. Assessments were made on three different sessions corresponding to the first, second and third consecutive days of mask usage. Skin parameters included transepidermal water loss (TEWL), stratum corneum (SC) hydration and erythema, as well as cytokine biomarkers sampled from sebum using a commercial tape. RESULTS: The cheek and the site outside the perimeter covered by the respirator presented minimal changes in skin parameters. By contrast, significant increases in both the TEWL (up to 4.8 fold) and SC hydration (up to 2.7 fold) were detected at the nasal bridge on the second consecutive day of respirator-wearing. There was a high degree of variation in the individual expression of pro-and anti-inflammatory cytokines. Increasing trends in nasal bridge TEWL values were associated with the body mass index (p < 0.05). CONCLUSIONS: The most sensitive objective parameter in detecting changes in the skin barrier proved to be the increase in TEWL at the nasal bridge, particularly on the second day of consecutive respirator usage. By contrast, other measures of skin were less able to detect remarkable variations in the barrier integrity. Consideration for protecting skin health is required for frontline workers, who continue to wear respirators for prolonged periods over consecutive days during the pandemic.

Characterisation of superficial corneocytes in skin areas of the face exposed to prolonged usage of respirators by healthcare professionals during COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic healthcare workers (HCWs) have used respiratory protective equipment for prolonged periods, which has been associated with detrimental effects on the underlying skin. The present study aims to evaluate changes in the main cells (corneocytes) of the stratum corneum (SC) following prolonged and consecutive use of respirators. METHODS: 17 HCWs who wore respirators daily during routine hospital practice were recruited to a longitudinal cohort study. Corneocytes were collected via tape stripping from a negative control site (area outside the respirator) and from the cheek which was in contact with the device. Corneocytes were sampled on three occasions and analysed for the level of positive-involucrin cornified envelopes (CEs) and the amount of desmoglein-1 (Dsg1), as indirect measurements of immature CEs and corneodesmosomes (CDs), respectively. These were compared to biophysical measurements (Transepidermal water loss, TEWL, and SC hydration) at the same investigation sites. RESULTS: A large degree of inter-subject variability was observed, with maximum coefficients of variation of 43% and 30% for the level of immature CEs and Dsg1, respectively. Although it was observed that there was not an effect of prolonged respirator usage on the properties of corneocytes, the level of CDs was greater at the cheek than the negative control site (p < 0.05). Furthermore, low levels of immature CEs correlated with greater TEWL values after prolonged respirator application (p < 0.01). It was also noted that a smaller proportion of immature CEs and CDs was associated with a reduced incidence of self-reported skin adverse reactions (p < 0.001). CONCLUSIONS: This is the first study that investigated changes in corneocyte properties in the context of prolonged mechanical loading following respirator application. Although differences were not recorded over time, the levels of CDs and immature CEs were consistently higher in the loaded cheek compared to the negative control site and were positively correlated with a greater number of self-reported skin adverse reactions. Further studies are required to evaluate the role of corneocyte characteristics in the evaluation of both healthy and damaged skin sites.

The influence of gender and ethnicity on facemasks and respiratory protective equipment fit: a systematic review and meta-analysis.

INTRODUCTION: Black, Asian and minority ethnic (BAME) people are disproportionately affected by COVID-19. Respiratory protective equipment (RPE) has conventionally been developed for a predominantly white male population that does not represent the healthcare workforce. The literature was reviewed to determine the protection offered to female and BAME users. METHODS: Five databases were searched. Eligible studies related to respirator fit in the context of anthropometrics, gender and ethnicity. Meta-analysis was performed for gender-based anthropometric differences. A priori protocol registration was not performed. RESULTS: 32 studies were included and anthropometric data was extracted from 15 studies. Meta-analysis revealed 14 anthropometric measurements were significantly smaller for females. Mean differences ranged from 0.37 mm to 22.05 mm. Gender-based anthropometric differences did not always translate to lower fit factor scores, with 12 studies reporting worse performance and fit for females and 10 reporting no gender effect. No studies provided disaggregate anthropometric data by ethnic group. Pass rates (PR) were low or moderate in 12 BAME or mixed-ethnicity cohorts. 14 studies reported associations between facial dimensions (FD) and respirator fit. Three comparative studies showed lower PR among selective BAME people. 18 studies reported RPE performance differed with model and design. Most studies did not prespecify inclusion/exclusion criteria. Small sample size and lack of justification or power calculations was a concern. Significant heterogeneity in study designs limited comparisons, particularly relating to respirator selection or availability and defining study outcomes relating to RPE performance. CONCLUSION: The literature reports on largely Caucasian or single ethnic populations, and BAME people remain under-represented, limiting comparisons between ethnic groups. Facial anthropometrics vary between gender and likely between ethnicity, which may contribute to lower PR among females and ethnic minorities, particularly Asians. There is a need for studies including a broader spectrum of ethnicities and for consideration of female and BAME users during RPE development.

Personal protective equipment related skin reactions in healthcare professionals during COVID-19.

Since the outbreak of COVID-19 pandemic, clinicians have had to use personal protective equipment (PPE) for prolonged periods. This has been associated with detrimental effects, especially in relation to the skin health. The present study describes a comprehensive survey of healthcare workers (HCWs) to describe their experiences using PPE in managing COVID-19 patients, with a particular focus on adverse skin reactions. A 24-hour prevalence study and multi-centre prospective survey were designed to capture the impact of PPE on skin health of hospital staff. Questionnaires incorporated demographics of participants, PPE type, usage time, and removal frequency. Participants reported the nature and location of any corresponding adverse skin reactions. The prevalence study included all staff in intensive care from a single centre, while the prospective study used a convenience sample of staff from three acute care providers in the United Kingdom. A total of 108 staff were recruited into the prevalence study, while 307 HCWs from a variety of professional backgrounds and demographics participated in the prospective study. Various skin adverse reactions were reported for the prevalence study, with the bridge of the nose (69%) and ears (30%) being the most affected. Of the six adverse skin reactions recorded for the prospective study, the most common were redness blanching (33%), itchiness (22%), and pressure damage (12%). These occurred predominantly at the bridge of the nose and the ears. There were significant associations (P < .05) between the adverse skin reactions with both the average daily time of PPE usage and the frequency of PPE relief. The comprehensive study revealed that the use of PPE leads to an array of skin reactions at various facial locations of HCWs. Improvements in guidelines are required for PPE usage to protect skin health. In addition, modifications to PPE designs are required to accommodate a range of face shapes and appropriate materials to improve device safety.