Impact of COVID-19 and PPE measures on occupational skin disease in healthcare workers

Introduction: The crucial role of infection control measures has been emphasized in controlling the spread of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). More rigorous hand hygiene and face mask practices have led to increased reports of skin problems of the hand and face. A retrospective survey was conducted to investigate the incidence and severity of occupational skin disease in healthcare workers (HCWs). Method(s): An electronic survey was circulated to HCWs working in two London hospital sites between January 2021 to May 2021. Demographics, details on hand washing, alcohol gel, emollient and face mask use was recorded alongside details of skin disease. Result(s): 75 responses were recorded from doctors (57%), nurses (20%), healthcare students (12%), therapists (7%) and students (4%). 19 people (25%) washed their hands more than 30 times a day, 37 (49%) people 10-30 times, and 12 people (16%) washed between 5-10. Similar results were found for alcohol gel use. 34 (47%) did not apply emollient once during a shift. Common hand symptoms included dryness (89%, n=67) and erythema (65%, n= 49). 73 (97%) HCWs wore face masks more than 4 hours/day, with common facial symptoms being acneiform lesions (71%, n=43) and erythema (62%, n=37). 61 participants were unsure who to contact regarding occupational skin disease. Discussion and conclusion: Our results illustrate high levels of occupational skin disease in HCWs, including symptoms of xerosis and dermatitis. Campaigns to improve knowledge and adherence regarding emollient application may help to substantially minimize the prevalence of occupational skin disease among HCWsCopyright © 2023

Occupational dermatoses during the second COVID-19 pandemic wave: an audit of 401 healthcare workers

Healthcare workers (HCWs) assessed by dermatologists during the first wave of the COVID-19 pandemic had high rates of irritant hand dermatitis, facial dermatitis and acne triggered by wearing personal protective equipment (PPE) (Ferguson FJ, Street G, Cunningham L et al. Occupational dermatology in the time of the COVID-19 pandemic: a report of experience from London and Manchester, UK. Br J Dermatol 2021;184: 180-2). We report data from a tertiary National Health Service trust during the second COVID-19 wave in winter 2020-21. At its peak, the Trust had 835 COVID-positive inpatients and 263 intensive care unit (ICU) beds - one of the largest ICUs in Europe. Building on the published experience of dermatology units, we ran 30 dermatology pop-up clinics over 3 weeks in allocated rest areas across the Trust: 08.00-09.00 h and 13.00-14.00 h on weekdays, from 18 January 2021. HCWs requiring formal dermatology referral were provided with letters to their line managers. In 3 weeks, 401 HCWs were assessed: 327 females and 74 males (mean age 35 2 years). The most frequently seen occupation was nurses (n = 130;32 4%) followed by doctors (n = 74;18 4%). On average, staff spent 9 5 h in PPE per shift. Consistent with the existing literature, the most common diagnosis was irritant hand dermatitis (n = 186;46 4%). There was an increased incidence of acne (n = 171;42 6%) vs. the first wave, where the reported incidence was 17% in a multicentre study (O'Neill H, Narang I, Buckley DA et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. Br J Dermatol 2021;184: 575-7). Less common in the second wave was facial eczema (n = 50, 12 5%) and pressure injury (n = 30;7 5%). Thirty-one (16 7%) of the HCWs with hand dermatitis required the prescription of potent topical corticosteroids, suggesting at least moderate symptoms. The majority received emollient samples. It was rare for HCWs to require formal referral (n = 11;2 7%). In our cohort, at least four (1 0%) HCWs required time off work owing to their skin problems. Our data support previous reports of increased occupational dermatoses in HCWs during the COVID-19 pandemic. We highlight the sheer scale of the issue, with 401 HCWs presenting for dermatological assessment in only 3 weeks in one trust. Compared with our experience during the first wave, acne exacerbated or precipitated by masks is increasingly common, which may be due to emollient use to prevent facial eczema or injury when wearing masks.

Hand care: it's time to take the gloves off

The increased incidence of hand dermatitis (HD) is well documented in healthcare professionals (HCPs) (Flyvholm MA, Bach B, Rose M, Jepsen KF. Self-reported hand eczema in a hospital population. Contact Dermatitis 2007;57: 110-15). It is reported that HD accounts for 95% of all occupational dermatitis (Bains SN, Nash P, Fonacier L. Irritant contact dermatitis. Clinic Rev Allergy Immunol 2019;56: 99-109). We sought to better understand the prevalence of HD in HCPs in a large teaching hospital, identify any associated risk factors and assess their knowledge of hand care. Additionally, we aimed to assess the availability of ward facilities and posters for hand hygiene and hand care. The survey was conducted between November 2015 and January 2016. A review of ward facilities and posters for hand care and hand hygiene was conducted in October 2020. A total of 820 HCPs responded to the survey. Altogether, 444 respondents (54 1%) reported a previous history of HD and 226 (27 6%) reported active dermatitis. These included 153 (18 6%) doctors/ dentists, 76 (9 3%) allied health professionals (AHPs), 46 (5 6%) nurses/midwives, 27 (3 3%) administrative staff, 16 (1 9%) other, five (0 6%) technicians and 108 (13 2%) medical/ dental/nursing/midwifery/AHP students. Only 10 (1 2%) took time off work owing to their HD, with five (0 6%) requiring > 5 days off work, but 67 (8 2%) wished they had taken time off work. In total, 416 (50 7%) respondents washed their hands > 20 times daily and 229 (27 9%) used disinfectants > 20 times per day. Those with a prior history of atopic dermatitis (AD) were at higher risk of developing HD [relative risk (RR) 1 69, 95% confidence interval (CI) 1 52-1 89;P < 0 001], and within 6 months of starting their job/placement (RR 1 82, 95% CI 1 3-2 5;P < 0 002). Only 107 (13 0%) respondents were able to identify all 11 correct statements regarding hand care. Two hundred and twenty (49 5%) of the 444 HCPs with a history of HD never received hand care advice when they started their current role. The 24 adult wards surveyed had a total of 162 general-use sinks, all with hand soap and disinfectant, and 154 hand hygiene posters. In contrast, only 22 sinks had emollients available. No posters were seen regarding hand care and skin health. This survey highlights the high prevalence of HD among HCPs, especially those with AD, but many are still not aware of good hand care measures. Additionally, our survey reflects the need for early education and equal facilities for hand care and hand hygiene, as both are important when delivering good clinical care, to protect patients and staff, especially in the midst of the COVID-19 pandemic.

Fragranced hand gels: beware the risk of contact allergy

An 11-year-old boy presented to the children's Emergency Department in Autumn 2020 with acute blistering of his palms. No other parts of the body or mucosal surfaces were involved. He was systemically well, with no significant past medical history except for eczema in early childhood. He had recently started back at school and was using hand gel regularly as part of precautions to reduce SARS-CoV-2 (COVID-19) transmission during the pandemic. There had been no other contact with chemicals, plants, crafting materials, glues, paints or homemade slime. Clinical photographs showed swelling and large bullae on the thenar eminence and lateral fingers. There was no erythema, nail involvement or significant scaling. The clinical diagnosis was acute pompholyx that was either irritant or allergic in origin. Testing to the standard series showed inconclusive results to some fragrances in the standard series. The patch testing to fragrance in the standard series was repeated and the fragrance series was added. The repeat test confirmed allergic contact dermatitis to fragrance with a positive to Myroxylon pereirae, linalool, limonene, sandalwood oil and majantol. The hand gels were found to contain linalool and limonene. To curb the spread of COVID-19, regular handwashing and the use of alcohol-based hand sanitizers/gels are part of everyday hygiene guidance for the general public. Therefore, the incidence of hand dermatitis is likely to rise. The World Health Organization and the Food and Drugs Administration advise that a minimum alcohol content of 60% is required to inactivate viral particles;however, it is also important to be aware that hand sanitizers/gels may also contain other constituents, including thickeners, humectants (e.g. propylene glycol) and fragrance. Research into the ingredients of 10 widely used hand sanitizers recently investigated by an independent watchdog for their alcohol content found that six had their ingredients listed online and five contained fragrance. The patient responded to topical treatment with a superpotent topical steroid cream (Dermovate) twice daily, white soft paraffin 50 : 50, an antiseptic emollient (Dermol 500) to wash the hands and allergen avoidance. We highlight to other dermatologists that contact allergy to fragrance or other components in hand sanitizer/gels may present acutely with pompholyx and to consider testing to the standard and fragrance series if this is suspected.

Optimization of common hand cleansers for protection from viral spread and occupational hand dermatoses

Irritant contact dermatitis (ICD) affects over 20% of health care workers, who manage their condition by substituting soap with an emollient cleanser. It is not clear whether emollient cleansers have the same level of virus eliminating activity as soap. Therefore, we evaluated a range of emollient cleansers for virus eliminating activity against enveloped (coronavirus and herpes simplex virus) and nonenveloped viruses (adenovirus (Ad)). In accordance with European standards a range of cleansers were combined with viruses under different (‘clean’ and ‘dirty’ hand hygiene) conditions. Virus viability and architecture were determined by plaque /TCDI50 assays and transmission electron microscopy. Traditional soaps (natural fatty acid), synthetic soaps and emollient cleansers (e.g., ceramide-containing cleansers) exhibited significant antiviral activity in enveloped viruses. However, the antiviral activity of traditional soaps reduced drastically when combined with hard water. Moreover, nonenveloped viruses were less susceptible to both synthetic soaps and emollients cleansers. Interestingly, traditional soaps inhibited the viability of Ad at high concentrations, but only in soft water. Most emollient cleansers were effective at eliminating enveloped viruses, suggesting that they are an acceptable substitute for soap to control the spread of viruses, like SARS-CoV-2, and protect against ICD. Nonenveloped viruses showed resistance to most of the hand hygiene products tested, except for traditional soap. This suggests that hand washing alone may not be sufficient to control the spread of nonenveloped viruses. Taken together this suggests that different virus strains respond differently to soaps and cleansers, and that this should be considered in the guidance for hand hygiene.

Viral exanthems Unravelling viral rashes

Common causes of viral exanthems in Australia include herpesviruses, enteroviruses, parvovirus B19, varicella, measles and rubella viruses and mosquito-borne alphaviruses. The cause can often be diagnosed clinically from the rash distribution and morphology, confirmed only when necessary with serological or PCR tests. Most viral exanthems are self-limiting, requiring supportive care alone.

Erythema multiforme related to AstraZeneca SARS-CoV-2 vaccine

A 44-year-old man of Pakistani origin presented to emergency 6 days following his first dose of the AstraZeneca (AZ) SARSCoV- 2 vaccine. He developed flu-like symptoms followed by erythematous pruritic rash. Physical examination showed a maculopapular rash associated with purpura and targetoid lesions affecting his distal extremities, trunk and mucous membranes. He also had crusting and ulceration of his oral and genital mucosal areas. He had no other significant past medical history. A biopsy was taken from his right arm and sent for urgent histology and direct immunofluorescence. Histology revealed parakeratotic scale with interface dermatitis comprising basal layer vacuolation and lymphocyte exocytosis. The epidermis showed prominent dyskeratotic keratinocytes scattered throughout the epidermis. The papillary dermis showed a mild perivascular lymphocytic infiltrate including eosinophils and melanophages. Other investigations showed leucocytosis (12 × 109 L-1), high eosinophils (0.9 × 109 L-1), raised liver enzymes with alkaline phosphatase 159 U L-1 and alanine aminotransferase 172 U L-1. A full infection screen, including herpes simplex virus, SARS-CoV-2 and atypical viral infection, was negative. Immunology was also reported as negative. Based on the findings, a diagnosis of erythema multiforme (EM) secondary to AZ vaccine was made. He was treated with topical steroids and emollients, leading to resolution of his skin and mucosal areas in 4-6 weeks. Recently, there have been a few reported cases of EM in patients with COVID-19 (Jimenez-Cauhe J, Ortega-Quijano D, Carretero- Barrio I et al. Erythema multiforme-like eruption in patients with COVID-19 infection: clinical and histological findings. Clin Exp Dermatol 2020;45: 892-5) and two patients who have had the Pfizer-BioNTech vaccine [Kim M, Kim J, Kim M et al. Generalized erythema multiforme-like skin rash following the first dose of COVID-19 vaccine (Pfizer-BioNTech). J Eur Acad Dermatol Venereol 2021], but the information is limited. Our case emphasizes the need for further studies into the cutaneous adverse effects related to COVID-19vaccines.

Skin picking disorder

Objectives: Skin-picking disorder (SPD), also known as excoriation disorder, neurotic excoriation or dermatillomania, is characterized by repetitive and compulsive picking of skin leading to tissue damage. It is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic criteria for SPD require recurrent picking, resulting in skin lesions that cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Method:We present a case of a 12-years-old girl with one-year history of multiple pruritic papules, plaques and excoriations on the face, scalp, arms and legs. Skin changes appeared following COVID-19 infection, which patient described as extremely stressful. The patient did not admit scratching of the skin but examination showed a high level of shame and embarrassment associated with her skin appearance. Results: Laboratory findings were within normal rage. Skin biopsy was performed and histopathology results confirmed secondary skin lesions (iatrogenic excoriations). Based on clinical findings and psychological evaluation the patient was diagnosed with pathological skin picking. The skin lesions were treated with topical emollients under occlusion and the combination of topical corticosteroids and antibiotics. The patient also received Habit-reversal therapy (HRT). The evaluation on follow-up appointment showed favorable improvement in cognitive status and skin lesions and she remained under our supervision. Discussion: SPD often manifests in automatic or focused patterns. In automatic type, patients are unaware of their picking habits and have less conscious awareness than those with focused type. HRT is the core treatment and consists of awareness training (self-monitoring forms), stimulus control, competing-response training, social support and generalization of skills. A compassionate approach during the diagnostic and treatment could positively influence the treatment outcome.

Evaluation of clinical efficacy of synthetic tannin and polidocanol-based agents and modern emollients in the hand eczema treatment. Use of new hand antiseptics during the pandemic in patients with hand eczema

Background. Patients with hand eczema account for 30–40% of dermatological patients. With the pandemic of new coronavirus infection COVID-19 and the need for frequent antiseptics use, there has been a steady increase in hand eczema incidence. The dominant symptoms in exacerbating eczema are skin inflammation and itching, which requires effective and safe skincare that is effective and safe. Objective. To evaluate the efficacy of the therapy with synthetic tannin and polidocanol-based agents and modern emollients, the time of resolution and degree of severity of clinical symptoms of eczema in patients, as well as the time and duration of remission, safety and compliance with sodium hypochlorite hand antiseptic spray. Materials and methods. Thirty-four patients with exacerbation of hand eczema were examined. The study was conducted in two stages. At the stage 1, before the remission, the patients received synthetic tannin and polidocanol-based agents and modern emollients;at the stage 2, monotherapy with modern emollients was used. Patients used sodium hypochlorite spray as a hand sanitizer throughout the study period. Results. The NESCI score became zero in 33 (96%) patients after the complex treatment of hand eczema. The Dermatology Life Quality Index by the end of stage 2 decreased 6-fold compared to the beginning of the study. No exacerbation of the dermatosis was observed in any of the patients included in the study during the use of sodium hypochlorite hand spray. Conclusion. The complex therapy with synthetic tannin, polidocanol-based agents, and modern emollients in hand eczema helps to achieve stable medical remission, decreases the itching intensity, and improves the patients’ quality of life. The use of new hand sanitizers during the pandemic in patients with hand eczema did not result in dermatosis exacerbations.

Hand hygiene and skin health in times of COVID-19

COVID-19, caused by SARS-CoV-2 virus, results in serious clinical manifestations in humans. The reactions, which are mainly respiratory, can also have significant effects on other body systems, such as cardiovascular, and can progress to death. Handwashing with running water and soap, and using alcohol-based antiseptic formulations are recognized measures in controlling COVID-19 spreading. Our study presents a review on hand hygiene and its relation with skin health in times of COVID-19. Handwashing with soap and running water promotes dirt removal and can inactivate SARS-CoV-2 by disrupting the viral lipid membrane. The use of alcohol-based antiseptic preparations on hands inactivates or inhibits the development of pathogenic microorganisms, such as the COVID-19 virus. World Health Organization recommends 80% ethyl alcohol-based or 75% isopropyl alcohol-based formulations for hand antisepsis, as they have a proven virucidal effect against SARS-CoV-2. Numerous problems can occur with frequent hand sanitizing regarding skin health. Skin dryness, increased skin sensitivity, and irritant contact dermatitis are some manifestations, which are mainly noticed in healthcare workers during COVID-19 pandemic. Accidents and burn risk involving alcohol-based antiseptic products are also a concern. From the pandemic beginning until November 2020, the Brazilian Burn Society has counted 700 hospitalizations due to serious burn accidents caused by 70% alcohol use, in liquid or gel form. For minimizing or avoiding dermatological reactions on hands, it is important to use antiseptic formulations and soaps containing moisturizing agents. The presence of humectants such as glycerin and emollients such as vegetable oils in the formulations can attract water and keep it in the skin, relieving hand skin irritation. So, humectants and emollients help maintaining the skin health in a proper hand hygiene routine. Even after most of world's population has been immunized with vaccines to prevent COVID-19, our hands will still have potential to transmit SARS-CoV-2 and it should not be overlooked. Understanding the state of the art of the antiseptic formulations and the impact of these products on hand skin health are critical to develop new knowledge on antiseptic products and their application in controlling infectious diseases spread, such as COVID-19.