skin care using ppe

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1. British Society for Cutaneous Allergy & British Association of Dermatologists COVID-19 – Occupational skin disease First published 08.04.20 (v 1) Updated 20.04.20 (v 1.1) 1 UPDATE ON OCCUPATIONAL SKIN DISEASE DURING THE CORONAVIRUS PANDEMIC Occupational skin disease relating to the measures taken to reduce transmission of COVID- 19 is frequent. Many British Association of Dermatologists (BAD) members are being asked to provide advice remotely to manage and mitigate such skin disease. A total of 97% of 542 front-line doctors and nurses in Hubei Province, China (77.4% response rate of 700 clinical staff surveyed) were reported to have developed problems of the skin of the face and/or hands.1 These were related to preventive measures such as personal protective equipment (PPE – mask, goggles, face shield, and double-layer gloves), frequent handwashing and use of alcohol gel. The most frequent symptoms were dryness, tightness, and itching or pain. Signs included desquamation, erythema, maceration, papules, fissuring and erosion. The face, nasal bridge, cheeks and forehead were the most common sites affected. Prolonged duration of wearing N95 masks and goggles, particularly for more than 6 hours, was a risk factor for occupational skin disease, but this was not the case for face shields. The nasal bridge is subject to pressure from both the tightly fitting nose piece of the mask and the goggles. The goggles are particularly implicated in causing the lesions. Frequent handwashing, i.e. more than 10 times daily, increased the risk of hand dermatitis. This echoed similar reports at the time of the Severe Acute Respiratory Syndrome (SARS) crisis. Reports of similar problems also emanated from Italy, where the rate of COVID-19 infection is high. • In the U.K., severe facial erosions were reported in healthcare professionals, for example those in London wearing the FFP-3 mask 8833 Particulate Respirator (3M); similar problems are now being reported around the UK. Such breaches in facial skin may increase the risk of touching the face (hence infection) when not wearing a mask, encourage breaches of PPE protocol in attempts to shift the site of pressure, or – if severe – lead to inability to work. Shorter rotating shifts (limited to 2 hours wearing PPE before a break) may be helpful in reducing the duration of pressure. Attempts to shift the points of pressure and abrasion may reduce the effectiveness of the mask. For example, the use of adhesive barrier films (e.g. Cavilon or Medi Derma S) or paraffin-based emollients, prior to donning protective gear, may help reduce the prevalence of skin disease and preserve the workforce; however, it might reduce the efficacy of the PPE. Emollients should be applied no less than 30 minutes before donning PPE. Barrier sprays, films and wipes should be allowed to dry for at least 30 seconds. Barrier dressings such as Duoderm Extra Thin, Silderm Tape or 1 https://www.jaad.org/article/S0190-9622(20)30392-3/pdf
2. British Society for Cutaneous Allergy & British Association of Dermatologists COVID-19 – Occupational skin disease First published 08.04.20 (v 1) Updated 20.04.20 (v 1.1) 2 Mepitac Tape may be used under the mask and goggles at sites of pressure, to mitigate the effects successfully. Convatec, the company that makes Duoderm Extra Thin, has produced instructions on how to use it under PPE. It is essential in all staff to check, when such products are used, that there is no loss of fit, so re-fitting of PPE is necessary in all cases. • If pressure from the goggles is the main problem, staff should switch to wearing a vizor. When not at work, the application of plain petroleum jelly and other emollients (e.g. Aquaphor) plus mild-to-moderate topical steroids is helpful. If wipes are used to clean PPE such as masks or goggles, they should be allowed to dry before donning. NHS England has produced guidance on helping to prevent facial skin damage under PPE. https://www.england.nhs.uk/coronavirus/publication/guidance-supply-use-of-ppe/. Contact urticaria was seen in a nurse in Wales being ‘fit-tested’ for a face mask. The chemical used for the testing is denatonium benzoate, which has been previously reported to cause urticaria and asthma. Many NHS Trusts (e.g. Derby) are providing boxes of free emollients and topical clobetasone butyrate to healthcare workers; others (such as Salford Royal and Guys and St Thomas’) are waiving prescription fees for their healthcare workers affected by occupational skin disease related to COVID-19. BAD members could consider encouraging their local Trusts to do likewise. Some dermatology departments (e.g. Manchester, Chelsea and Westminster) are offering non-face-to-face ‘drop-in’ remote consultations, using self-referral with proforma and images, for staff with occupational skin disease related to PPE. There are plans to set up similar clinics in other London hospitals, and in Cardiff, Bristol, Edinburgh, Newport, Leicester and Oxford. The BSCA committee has commenced an audit of PPE-related skin problems to allow early identification of any equipment particularly likely to cause issues. Care of the hands: • Frequent handwashing with soap and water is recommended, or the use of alcohol gel (>3 ml on each hand) on visibly clean skin. Hand sanitiser gel may be less irritating than sanitiser foam.
3. British Society for Cutaneous Allergy & British Association of Dermatologists COVID-19 – Occupational skin disease First published 08.04.20 (v 1) Updated 20.04.20 (v 1.1) 3 • Dermol 500 and Stellisept lotion as handwashes are not effective in deactivating coronavirus. • Skincare products containing benzalkonium chloride may induce an additional irritant effect with repeated and prolonged use. • Emollient hand cleansers are not protective against COVID-19 but are acceptable for social cleansing at home. • Patting the hands dry, rather than rubbing, is recommended. • Frequent application of emollient after each handwashing can help to mitigate the irritant effects of handwashing, alcohol gel and prolonged glove-wearing. • Emollient should also be applied frequently when not at work. • The ‘best’ moisturiser is the one which the patient feels is most comfortable on the skin. • Gloves should be worn when using surface wipes. • Hands should be cleaned/sanitised on arrival at work, returning home and before eating. • Wearing two pairs of gloves and only removing the outer set to handwash between patients may provide some protection from hand dermatitis. • There is no evidence that drinking lots of fluids before a shift in direct patient contact hydrates the skin.
4. Page 1 of 5 British Association of Dermatologists | www.bad.org.uk/leaflets | Registered Charity No. 258474 HAND DERMATITIS / HAND ECZEMA What are the aims of this leaflet? This leaflet has been written to help you understand more about the causes and treatment of hand dermatitis. What is hand dermatitis? Hand dermatitis is also called hand eczema. It is common and can affect about one in every 20 people. It can start in childhood as part of an in-built tendency to eczema, but is commonest in working-age adults. Hand dermatitis may be a short-lived, mild problem. However, in some people it lasts for years in a severe form that can have a great impact on daily life and restrict someone’s ability to work. Who is most likely to get hand dermatitis? People who have had eczema in childhood (atopic eczema) and those who work in jobs with frequent water contact (wet work) have a high risk of getting hand dermatitis. What causes hand dermatitis? In many people, hand dermatitis happens because of direct damage to the skin by harsh chemicals or irritants, especially soap, detergent and repeated contact with water. This is called irritant contact dermatitis. Skin contact with allergens such as perfumes, rubber or leather can also cause dermatitis in people with an allergy to these substances. This is called allergic contact dermatitis.
5. Page 2 of 5 British Association of Dermatologists | www.bad.org.uk/leaflets | Registered Charity No. 258474 In many cases, however, the cause of hand dermatitis is unknown, and there is no trigger. It is also common for someone to have more than one cause of their hand dermatitis, for example a combination of in-built and irritant contact dermatitis. Is hand dermatitis hereditary? No, it is not hereditary; however the tendency to get hand dermatitis can run in families along with childhood eczema, asthma and hay fever. What are the symptoms of hand dermatitis? Like other forms of dermatitis, the affected areas of skin feel hot, sore, rough, scaly and itchy. There may be itchy little bubbles or painful cracks. What does hand dermatitis look like? In hand dermatitis, the skin is inflamed, red and swollen, with a damaged dried out surface which makes it look flaky. There may be cracked areas that bleed and ooze. Sometimes small water blisters can be seen on the palms or sides of the fingers. Different parts of the hand can be affected such as the finger webs, fleshy finger pulps or centre of the palms. There are several different patterns of hand dermatitis, but these do not usually tell us its cause and the pattern can change over time in one person. Hand dermatitis may get infected with bacteria called Staphylococcus or Streptococcus. This causes more redness, soreness, crusting, oozing and spots or pimples. How is hand dermatitis diagnosed? Diagnosing hand dermatitis is done by carefully examining the skin. Examining the feet and other body areas will show if it is part of a more widespread skin complaint. Patch tests are important in finding out if allergic contact dermatitis has helped cause a person’s hand dermatitis. The tests are done over several days and at the end need to be read by an expert. Most adults are tested for about 50 common allergies. If someone also handles unusual chemicals at work or during hobbies they may need extra tests put on.
6. Page 3 of 5 British Association of Dermatologists | www.bad.org.uk/leaflets | Registered Charity No. 258474 Can other skin complaints look like hand dermatitis? Psoriasis of the hands can look similar to dermatitis, especially when there are thick, scaly patches on the palms. Ringworm or fungus infection also causes itchy scaly rashes. These usually start on the feet or groin, but can spread to the hands and nails. Skin samples from affected areas can be sent for fungal analysis (mycology) if this needs to be ruled out. Which occupations often cause hand dermatitis? Occupations with a high chance of hand dermatitis include cleaners, carers, people who look after young children, chefs, hairdressers, mechanics, surgeons, dentists, nurses, florists, machine operators, aromatherapists, beauticians, and construction workers. Any job which involves repeated contact with water or hand washing more than 10 times a day (‘wet work’) has an increased chance of causing hand dermatitis. Can hand dermatitis be cured? In most cases, treatment controls the condition but does not cure it. Getting effective treatment early may avoid it turning into a chronic complaint. In people with allergic contact dermatitis, avoiding the allergen(s) may help or even clear the hand dermatitis. How can hand dermatitis be treated? Moisturisers (emollients) are an essential part of treating hand dermatitis. They help repair the damaged outer skin and lock moisture inside the skin making it soft and supple again. They should be applied repeatedly throughout the day and whenever the skin feels dry. CAUTION: This leaflet mentions ‘emollients’ (moisturisers). When paraffin- containing emollient products get in contact with dressings, clothing, bed linen or hair, there is a danger that a naked flame or cigarette smoking could cause these to catch fire. To reduce the fire risk, patients using paraffin-containing skincare or haircare products are advised to avoid naked flames completely, including smoking cigarettes and being near people who are smoking or using naked flames. It is also advisable to wash clothing and bed linen regularly, preferably daily.
7. Page 4 of 5 British Association of Dermatologists | www.bad.org.uk/leaflets | Registered Charity No. 258474 Soap substitutes are very important as they clean the skin without drying and damaging it like liquid soap and bar soap can. Steroid creams and ointments are the commonest prescribed treatment for hand dermatitis. They relieve symptoms and calm inflamed skin. Stronger strength steroids are usually needed as mild steroids (1% hydrocortisone) do not work on thick skin. They are applied up to twice a day. When used as suggested by your doctor or nurse topical steroids do not cause problems. If they are over-used, there is a risk of skin thinning so they should be stopped once the dermatitis has settled. Antihistamine tablets are not always helpful in hand dermatitis. Sedating antihistamines cause drowsiness and can help you sleep. Potassium permanganate soaks can be useful in severe blistering hand dermatitis to dry the blisters and prevent bacterial infection. (See BAD leaflet) Topical Calcineurin inhibitors are prescribed as creams and ointments to treat dermatitis instead of steroids. While they may work less well than strong steroids, they do not carry any risk of skin thinning. They can often cause burning or itching after application. Ultraviolet (UV) Therapy is a hospital-based treatment for very severe hand dermatitis. It involves visiting hospital for treatment two or three times a week for about six weeks. Steroid tablets may be given for a few weeks for a severe flare of hand dermatitis. The dose is usually decreased gradually over a few weeks. Longer-term use is not advisable due to the side effects. Alitretinoin is based on vitamin A and is prescribed by specialists for severe chronic hand dermatitis. A treatment course usually lasts up to 6 months. It must never be taken during pregnancy. Systemic immunosuppressants are powerful treatments sometimes prescribed by specialists to treat severe hand dermatitis. These are usually given to people who have had an organ transplant and include azathioprine, ciclosporin and methotrexate. People taking these tablets need to be watched carefully and have regular blood tests.
8. Page 5 of 5 British Association of Dermatologists | www.bad.org.uk/leaflets | Registered Charity No. 258474 Preventing hand dermatitis – what can I do? Always use protective gloves at work and at home when in contact with irritating chemicals and water. Wear cotton gloves underneath or chose cotton-lined gloves if you have to work for longer. The best choice of glove material (rubber, PVC, nitrile etc) will depend on which chemicals or allergens are being handled. Gloves should be clean and dry inside and not broken. If gloves cannot be worn, a barrier cream should be applied before exposure to irritants. After exposure, wash the hands carefully with a soap substitute, rinse, dry thoroughly then moisturise. The BAD has a leaflet on How to care for your hands. Where can I get more information about hand dermatitis? Health and Safety Executive website: www.hse.gov.uk/food/dermatitis.htm For details of source materials please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk). This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists; individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor. This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel BRITISH ASSOCIATION OF DERMATOLOGISTS PATIENT INFORMATION LEAFLET PRODUCED SEPTEMBER 2012 UPDATED JANUARY 2016 REVIEW DATE JANUARY 2019
9. Prevention and Management of Skin Damage beneath PPE Skin damage caused by PPE, specifically masks and visors/goggles can occur for 4 reasons:  Pressure  Shear  Friction  Moisture The damage can occur under both FFP3 masks and water repellent surgical masks. Prevention of friction and shear can be optimised through accurate fit testing. It is not recommended that dressings such as Comfeel Plus Transparent be used under FFP3 masks as this may compromise mask fit. If you apply any dressings under FFP3 you should repeat the fit test 1st line prevention  Follow Trust guidance on face mask fitting. Avoid over tightening  Keep skin clean and well hydrated  If applying moisturiser this should be done at least 30 minutes before applying PPE  Apply Secura no sting 1ml barrier wipe to areas susceptible to damage from moisture, this can be applied under both FFP3 and water repellent surgical masks. N.B. this will take up to 30 seconds to dry. Do not use the spray formula as this may go in your eyes  Perform regular inspection of your skin for signs of redness, painful areas and damage  Siltape (silicone perforated tape) can be applied to at risk areas under surgical masks (nose, cheeks, ears and chin)  Stay well hydrated  If wearing FFP3 masks remove at least every 2 hours to allow skin to reperfuse  Do not apply Secura around the eye area or on the eyelids Managing damaged skin If a skin break occurs on your face or ears;  Apply Comfeel plus transparent cut to size to the affected area leaving a 1cm border from the wound edge. The maximum wear time is 7 days  Medihoney barrier cream can be applied to inflamed skin prn, allow to dry before applying FFP3 and/or the water repellent surgical masks  Consider using the respirator hood rather than the FFP3 mask  Report skin damage as a clinical incident on datix Both Secura no sting barrier film wipe and Siltape have been added to all ONPOS accounts for ease of ordering. Medihoney and Comfeel are available on all wards.