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The adverse skin reactions of health care workers
using personal protective equipment for COVID-19
Kaihui Hu, MD
a
, Jing Fan, MD
a
, Xueqin Li, MD
a
, Xin Gou, PhD
a
, Xinyuan Li, PhD
a,b
, Xiang Zhou, MD
a,b,∗
Abstract
In December 2019, a new coronavirus was found in Wuhan, Hubei Province, China, and spread rapidly throughout the country,
attracting global attention. On February 11, the World Health Organization (WHO) officially named the disease caused by 2019-nCoV
coronavirus disease 2019 (COVID-19). With the increasing number of cases, health care workers (HCWs) from all over China
volunteered to work in Hubei Province. Because of the strong infectivity of COVID-19, HCWs need to wear personal protective
equipment (PPE), such as N95 masks, latex gloves, and protective clothing. Due to the long-term use of PPE, many adverse skin
reactions may occur. Therefore, the purpose of this study is to explore the adverse skin reactions among HCWs using PPE.
Questionnaires were used for the research; a quantitative study was carried out to determine the incidence of adverse skin
reactions among HCWs using PPE.
A total of 61 valid questionnaires were collected. The most common adverse skin reactions among HCWs wearing N95 masks
were nasal bridge scarring (68.9%) and facial itching (27.9%). The most common adverse skin reactions among HCWs wearing latex
gloves were dry skin (55.7%), itching (31.2%), and rash (23.0%). The most common adverse skin reactions among HCWs wearing
protective clothing were dry skin (36.1%) and itching (34.4%).
When most HCWs wear PPE for a long period of time, they will experience adverse skin reactions. The incidence of adverse skin
reactions to the N95 mask was 95.1%, that to latex gloves was 88.5%, and that to protective clothing was 60.7%.
Abbreviations: COVID-19 =2019-nCoV coronavirus disease 2019, HCWs =health care workers, MERS =Middle East
respiratory syndrome coronavirus, PPE =personal protective equipment, SARS =severe acute respiratory syndrome coronavirus,
WHO =The World Health Organization.
Keywords: 2019-nCoV coronavirus disease 2019, adverse skin reactions, health care workers, personal protective equipment
1. Introduction
Since the beginning of the 21st century, the outbreak of
coronavirus has brought serious losses to society, the most
serious of which are severe acute respiratory syndrome
coronavirus (SARS) and Middle East respiratory syndrome
coronavirus (MERS). In December 2019, a new coronavirus was
found in Wuhan, Hubei Province, China, and spread rapidly
across the country, attracting global attention.
[1,2]
From the existing epidemiological data, the transmission speed
of COVID-19 is significantly faster than that of SARS, but its
pathogenicity is remarkably weaker than that of MERS and
SARS. To control the epidemic, the Chinese government has
formulated a series of social alienation strategies.
[3]
Because of
the strict blockade and quarantine measures, the spread outside
Hubei Province seems to be slowing down.
[4]
A large number of
health care workers (HCWs) from all over China rushed to Hubei
Province to jointly fight against COVID-19.
Because of the strong transmission of COVID-19 and the
uncertainty of the infection status of patients, HCWs must
provide personal protective equipment (PPE).
[5]
PPE, such as N95
masks, latex gloves, and protective clothing, will often be worn
for hours at a time. There are not a few cases of adverse skin
reactions related to the use of PPE by HCWs.
[6]
However,
existing research on poor skin reactions to the use of PPE by
HCWs is limited. The study collected the results of a survey of
adverse skin reactions caused by the use of PPE by HCWs in
Hubei Province during the COVID-19 outbreak. Combined with
these results, we can determine the prevalence and characteristics
of adverse skin reactions caused by PPE among HCWs in Hubei
Province. The findings of this study will help to determine
whether long-term use of PPE poses significant occupational
health risks and suggest possible solutions.
2. Methods
2.1. Design
The purpose of this study is to explore the problem of adverse
skin reactions among HCWs who have been using PPE for a long
Editor: Oliver Schildgen.
Sources of funding: None.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
a
Department of Urology, the First Affiliated Hospital, Chongqing Medical
University,
b
Chongqing Key Laboratory of Molecular Oncology and Epigenetics,
Chongqing, China.
∗
Correspondence: Xiang Zhou, Department of Urology, The First Affiliated
Hospital of Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong
District, Chongqing, 400016, China (e-mail: 334849168@qq.com).
Copyright ©2020 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
How to cite this article: Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin
reactions of health care workers using personal protective equipment for COVID-
19. Medicine 2020;99:24(e20603).
Received: 23 March 2020 / Received in final form: 28 April 2020 / Accepted: 7
May 2020
http://dx.doi.org/10.1097/MD.0000000000020603
Quality Improvement Study Medicine®
OPEN
1
period of time in Hubei Province. This study uses the method of
quantitative descriptive research. As a descriptive research
method, quantitative descriptive research can not only analyze
the samples qualitatively but can also combine qualitative and
quantitative data obtained by statistics. Therefore, quantitative
descriptive research is considered appropriate. In light of the fact
that the purpose of this study is to explore the incidence of
adverse reactions of HCWs who have been wearing PPE for a
long period of time, a comprehensive summary is generated
through quantitative descriptive design, which clearly reflects
adverse skin reactions.
2.2. Setting and participants
This study uses a purposeful sampling method to select qualified
research objects. Purposeful sampling methods can collect useful
information needed for this study by identifying different
participants. Based on this method, we selected participants
according to the following criteria: registered doctors or nurses;
HCWs fighting COVID-19 in Hubei Province hospitals; those
often wearing PPE, such as N95 masks, latex gloves, and
protective clothing; staff who are contacted with patients directly;
and those willing to participate in the questionnaire survey.
According to this standard, we selected a total of 65 HCWs who
met the criteria. Table 1 summarizes the population statistics of
the participants.
2.3. Ethics of human research
All participants signed an informed consent form before the
study. The research scheme has been approved by the Ethics
Committee of the First Affiliated Hospital of Chongqing Medical
University and is based on the ethical principles of medical
research involving human objects in the Helsinki Declaration.
2.4. Data collection
This survey was conducted by the distribution of questionnaires
to participants who met the criteria. The questionnaire covers the
duration of the use of masks, gloves, and protective clothing, as
well as adverse skin reactions caused by their use. Participants
who agreed to participate in the study were asked to sign an
informed consent form on the date of data collection. Finally, a
total of 61 valid questionnaires were collected. To facilitate
subsequent data analysis, all questionnaires were collected and
backed up to ensure that no data were lost during transcription
and statistical analysis.
2.5. Data analysis
SPSS21.0 software (SPSS Inc, Chicago, IL) was used for statistical
analysis. Chi-square tests and two-sample ttests were used to
compare the differences between groups. A P-value of <.05 was
considered significant.
2.6. Trustworthiness
Trustworthiness is the criterion used to assess a study. The
trustworthiness of this study is maintained by 4 main criteria:
credibility, confirmability, transferability, and dependability. For
credibility, the content of the study is discussed between
researchers and authors to determine the conclusions. For
confirmability, participants were asked to verify the survey
contents to ensure that their ideas were accurately reflected in the
study. For transferability, a vivid and detailed description of the
results and the research process were recorded. The results and
conclusions can be transferred to the study of similar fields. For
the dependability, an in-depth and vivid description of the
research methods was accurately recorded to show a compre-
hensive understanding of the research methods. Therefore, future
researchers can repeat this study.
3. Results
A total of 65 HCWs were surveyed by questionnaire. Sixty-one
(93.8%) of them responded to the questionnaire. Among them,
there were 5 men (8.2%) and 56 women (91.8%), including 30
doctors and 31 nurses. These HCWs are illustrated in Table 1.
3.1. Masks
Among the 61 HCWs who regularly used the N95 mask, 58
(95.1%) reported adverse reactions, including nasal bridge
scarring (68.9%), facial itching (27.9%), skin damage (26.2%),
dry skin (24.6%), and rash (16.4%). Seven workers had
indentation and ear pain, and 1 had acne. Six of them developed
wheals on the bridge of the nose, jaw, and cheeks. All people with
skin reactions developed these reactions after using the N95 mask
for 12 hours a day over an average of 3.5 months. HCWs using
surgical masks, cloth masks, and paper masks did not report any
adverse skin reactions. Table 2 lists the adverse reactions reported
by the HCWs surveyed who were using the N95 mask. Because of
the strong transmission of COVID-19, all 58 HCWs continued to
use the N95 mask despite their symptoms. Only 5 HCWs sought
treatment from doctors. Fifteen HCWs took medicine on their
own. The others did not take any measures. There was no
significant difference in occupational adverse skin reactions.
However, the proportion of women HCWs with skin rash was
significantly higher than that of men HCWs. Most HCWs with
skin rashes were between 20 and 29 years old. Among HCWs
with skin damage, the proportion of women was significantly
Table 1
The population statistics of the participants.
Age Numbers Percentage
20–29 16 26.3%
30–39 41 67.2%
40–49 3 4.9%
50–59 1 1.6%
Table 2
Adverse skin reactions of using N95 mask.
Nasal bridge scar 42 68.9%
Facial itching 17 27.9%
Skin damage 16 26.2%
Dry skin 15 24.6%
Rash 10 16.4%
Wheals 7 11.5%
Indentation and ear pain 7 11.5%
Skin desquamation 6 9.9%
Acne 1 1.6%
Hu et al. Medicine (2020) 99:24 Medicine
2
higher than that of men. Most of the HCWs with itching were
concentrated in the age group between 20 and 29 years old.
3.2. Latex gloves
Among 61 workers who regularly used latex gloves, 54 (88.5%)
reported adverse skin reactions, including dry skin (55.7%),
itching (31.2%), rash (23.0%), and chapped skin (21.3%). Three
people had skin soaked with sweat, and 1 had symptoms of
edema. Table 3 lists the adverse reactions of using latex gloves
reported by HCWs who were surveyed. For an average of 3.5
months, latex gloves were used for an average of 10 hours. No
one reported that the use of plastic gloves and cloth gloves can
cause adverse skin reactions. Five people switched to plastic
gloves because of wheals, while most of the participants
continued to use latex gloves. Among the 5 people, 1 switched
to plastic gloves, and 4 wore plastic gloves under their latex
gloves. Of the 54 HCWs, 10 people sought treatment from
doctors, 5 people took medicine on their own, and the others did
not take any action. There were no significant sex or occupational
differences in adverse skin reactions. However, most of the
HCWs with dry skin were between 20 and 29 years old. Most of
the HCWs with itching were 20 to 29 years old. HCWs with
chapped skin were older than those without chapped skin, and
most of them were between 30 and 39 years old.
3.3. Protective clothing
Of the 61 HCWs who regularly wore protective clothing, only 37
(60.7%) reported adverse skin reactions, including dry skin
(36.1%), itching (34.4%), rash (11.5%), and wheals (3.28%).
One person reported that protective clothing was airtight and led
to the development of sweat herpes. Muggy heat was reported by
other people. One individual reported dampness. Table 4 lists the
adverse reactions reported by HCWs who used protective
clothing. The protective clothing used is disposable and is worn
for an average of 10 hours a day for an average of 3.5 months.
Given the strong transmission of COVID-19, all HCWs continue
to use protective clothing regardless of symptoms. Two of the 37
people sought treatment from a doctor because of the symptoms
of wheals, while the others did not take any measures. There was
no significant difference in adverse skin reactions caused by
occupation. Among the HCWs with itching, the proportion of
women was significantly higher than that of men, and the age of
respondents was mostly between 20 and 29 years old. The
proportion of women HCWs with itching was higher than that of
men HCWs.
In order to release itching and rash, we give some suggestions
that are shown in the flowchart (Fig. 1). These suggestions have
been proved to be effective among HCWs in Hubei.
4. Discussion
Due to the highly contagious and nationwide spread of COVID-
19, HCWs across China who volunteer in Hubei Province are
required to wear PPE, such as N95 masks, latex gloves, and
protective clothing.
[5]
The use of PPE may cause adverse skin
reactions. However, existing studies on adverse skin reactions
due to the use of PPE by HCWs are limited. In this case, it is
possible to study the adverse reactions caused by the use of PPE to
propose solutions, which can help HCWs who are still fighting
COVID-19 to effectively reduce adverse skin reactions. In the
future, this study may still be useful for HCWs. Therefore, I used
a questionnaire to conduct a quantitative study to determine the
incidence of adverse skin reactions caused by the use of PPE by
HCWs. Ultimately, a total of 61 valid questionnaires were
collected. The results of the study showed that the most common
adverse skin reactions among HCWs using PPE included nasal
bridge scarring, facial itching, skin damage, dry skin, rash,
chapped skin, and wheals.
Medical masks are a kind of PPE that are used to prevent the
spread of respiratory tract infections. The mask can cover the
Table 3
Adverse skin reactions of using latex gloves.
Dry skin 34 55.8%
Itching 19 31.2%
Rash 14 23.0%
Chapped skin 13 21.3%
Wheals 5 8.2%
Skin soaked with sweat 3 4.9%
Edema 1 1.6%
Table 4
Adverse skin reactions of using protective clothing.
Dry skin 22 36.1%
Itching 21 34.4%
Rash 7 11.5%
Wheals 2 3.3%
The adverse skin reactionssof HCWs
using PPE
Use medicine
Serious adverse skin reactions or
medicine administration was ineffective
Recover
Seek help from a dermatologist
Figure 1. The steps to follow after experiencing adverse skin reactions.
Hu et al. Medicine (2020) 99:24 www.md-journal.com
3
mouth and nose of the wearer and, if worn properly, may
effectively help prevent the spread of respiratory viruses and
bacteria.
[7]
During the SARS outbreak in 2003, the WHO and the
Centers for Disease Control and Prevention of the United States
issued preventive measures in the care of SARS patients,
suggesting that the time of exposure to air should be reduced
to decrease the probability of airborne droplet transmission.
[8]
In
particular, it is recommended to use protective masks that meet
the certification of the National Institute of Occupational Safety
and Health. “N”stands for the National Institute of Occupa-
tional Safety and Health, and “95”indicates its filtering
efficiency. As a result, the mask has a 95% filtration efficiency
in filtering particles with a size of ≥300 nm. The N95 mask can
block 95% of the air particles and fits closely with the facial skin
to prevent the inhalation of smaller infectious particles, which can
travel long distances through the air after an infected person
coughs or sneezes. Diseases that require the use of the N95 mask
include tuberculosis, chicken pox, SARS, and measles.
[9]
The
diameter of SARS-CoV-2 is between 80 and 120 nm, but when
the virus is excreted from an infected person, it will be wrapped in
saliva to form larger droplets. Because the N95 mask can
effectively filter out particles ≥300 nm in size, it can effectively
block the spread of SARS-CoV-2.
[6]
HCWs must wear masks for
a long period of time every day because of the infectivity of
COVID-19. Therefore, it is necessary to detect adverse skin
reactions using the N95 mask.
Series of researches have explored the related adverse reactions
of HCWs wearing N95 mask. Foo et al
[6]
reported the most
common adverse skin reactions were acne, facial itching, and
rash. Furthermore, headache was highlighted in Lim research.
[10]
However, there is no headache in the present study. It probably
because the participants in Lim research have been wearing N95
mask for >1 year and the long-term utilization could result in
hypoxemia and hypercapnia which led to headache. In this study,
we found that the most common adverse reaction of the N95
mask was nasal bridge scarring, followed by facial pruritus.
Because the medical staff must have adequate personal protec-
tion, they will tie the mask tightly and squeeze the metal clip hard
to ensure the tightness of the mask. Therefore, the scar on the
bridge of the nose may be caused by the excessive pressure of the
mask and the hardness of the metal clip. The cause of itching may
be discomfort due to wearing a mask for too long a period of a
time, combined with an excessively humid internal environment.
Itching may also result from irritating contact dermatitis
attributed to an allergic reaction to the mask material. Skin
damage may be due to the excessive binding of the mask, such
that the edge of the mask is in close contact with the skin, coupled
with wearing the mask for a long period of time.
[11]
In light of the above situations, when wearing a mask, HCWs
can reduce the intensity of binding to achieve moderate tightness,
gently pinch the metal clip at the bridge of the nose, and add a
surgical mask to line the inside of the N95 mask, which can
effectively reduce adverse skin reactions.
It has been reported that COVID-19 can be transmitted
through contact, so hand protection is one of the most important
ways of preventing COVID-19 infection.
[5]
Wearing latex gloves
can effectively prevent the chance of contact infection among
HCWs. The most common adverse reactions to wearing latex
gloves in this study were dry skin, itching, and rash. It was similar
to the skin adverse reactions of wearing gloves during SARS.
[6]
There may be 3 reasons why these situations occur. One is
Immunoglobulin E-mediated hypersensitivity to latex
[12,13]
; the
second is latex allergy
[14]
; and the third may be irritant contact
dermatitis,
[15]
which arises from repeated hand washing with
soap and detergent and not completely drying the hands.
Therefore, the inside of the glove will not be able to absorb air,
resulting in irritation. If it is a dry powder glove, it is likely to be
caused by the stimulation of talcum powder in the gloves. In this
case, it is necessary to rinse off the soap or detergent before
putting on gloves and dry one’s hands before wearing gloves. If
the gloves are dry, there should not be too much talcum powder
inside. Another solution is to wear a layer of plastic gloves inside
the latex gloves. These measures can prevent the occurrence of
irritant dermatitis. If the symptoms of irritant contact dermatitis
cannot be resolved, latex allergy testing is necessary, and latex
gloves should be avoided.
[16]
HCWs must wear protective clothing for a long period of time
every day to protect themselves. Therefore, adverse skin reactions
have emerged. The adverse skin reactions of HCWs who have
been using protective clothing are relatively less common. The
most common symptoms were dry skin and itching. The main
reason for these situations is probably due to the protective
clothing being muggy and the need to wear it for a long period of
time. The frequent replacement of protective clothing can
effectively reduce the occurrence of the above symptoms.
Our study investigated the long-term use of PPE in Hubei
Province and found that most HCWs have adverse skin reactions
when wearing masks, gloves, and protective clothing. These
adverse skin reactions are usually mild because most HCWs
continue to use the equipment. Therefore, the wearer will not seek
the help of a dermatologist or self-medicate. In our study, skin
adverse reactions using PPE were mainly concentrated in itching
and rash. So, we suggest that after the occurrence of adverse skin
reactions, second-generation antihistamines or glucocorticoids
were recommended for HCWs. If any serious adverse skin
reactions to PPE occurred or medicine administration was
ineffective, they should seek help from a dermatologist. To date,
there have been no reports of adverse skin reactions caused by the
use of PPE in COVID-19. The adverse skin reactions of HCWs
reported in questionnaires cannot be verified by professionals, as
they are the subjective assessment of HCWs. Nevertheless, the
study provides a perspective on the incidence of adverse skin
reactions that can be caused by the long-term use of PPE.
There is no doubt that the threat of COVID-19 worldwide
remains uncontrollable, and the possible solutions proposed in
this study can help HCWs who are still fighting COVID-19 to
effectively reduce adverse skin reactions. This study may be useful
to HCWs in the future.
Author contributions
Xiang Zhou contributed to the design, overall planning and all-
round consideration of the study. Kaihui Hu contributed to the
data verification and paper writing. Xinyuan Li was fully in
charge of the revising work including the reference updating and
the manuscript review, besides, he offered some thoughts for the
study’s design. Xin Gou contributed to the design of the study.
Jing Fan and Xueqin Li contributed to the data analysis. All
authors read and approved the final manuscript.
References
[1] Sohrabi C, AlsafiZ, O’Neill N, et al. World Health Organization declares
global emergency: a review of the 2019 novel coronavirus (COVID-19).
Int J Surg 2020;76:71–6.
Hu et al. Medicine (2020) 99:24 Medicine
4
[2] Sun P, Lu X, Xu C, et al. Understanding of COVID-19 based on current
evidence. J Med Virol 2020; doi: 10.1002/jmv.25722.
[3] Yang Y, Peng F, Wang R, et al. The deadly coronaviruses: the 2003 SARS
pandemic and the 2020 novel coronavirus epidemic in China. J
Autoimmun 2020;109:102434.
[4] Roosa K, Lee Y, Luo R, et al. Real-time forecasts of the COVID-19
epidemic in China from February 5th to February 24th, 2020. Infect Dis
Model 2020;5:256–63.
[5] Wu YC, Chen CS, Chan YJ. The outbreak of COVID-19: an overview. J
Chin Med Assoc 2020;83:217–20.
[6] Foo CC, Goon ATJ, Leow Y-H, et al. Adverse skin reactions to personal
protective equipment against severe acute respiratory syndrome–a
descriptive study in Singapore. Contact Dermatitis 2006;55:291–4.
[7] Desai AN, Mehrotra PD. Medical masks. JAMA 2020;323:1517–8.
[8] Chia S, Koh D, Fones C, et al. Appropriate use of personal protective
equipment among healthcare workers in public sector hospitals and
primary healthcare polyclinics during the SARS outbreak in Singapore.
Occup Environ Med 2005;62:473–7.
[9] Bin-Reza F, Chavarrias VL, Nicoll A, et al. The use of masks and
respirators to prevent transmission of influenza: a systematic review of
the scientific evidence. Influenza Other Respir Viruses 2012;6:257–67.
[10] Lim EC, Seet RC, Lee KH, et al. Headaches and the N95 face-mask
amongst healthcare providers. Acta Neurol Scan 2006;113:199–202.
[11] Tan KT, Greaves MW. N95 acne. Int J Dermatol 2004;43:522–3.
[12] Douglas R, Morton J, Czarny D, O’Hehir RE. Prevalence of IgE-
mediated allergy to latex in hospital nursing staff. Aust N Z J Med
1997;2:165–9.
[13] Spaner D, Dolovich J, Tario S, et al. Hypersensitivity to natural latex. J
Allerg Clin Immunol 1989;83:1135–7.
[14] Valsecchi R, Leghissa P, Cortinovis R, Cologni L, Pomesano A. Contact
urticaria from latex in healthcare workers. Dermatology 2000;201:127–31.
[15] Weido AJ, Sim TC. The burgeoning problem of latex sensitivity.
Surgical gloves are only the beginning. Postgrad Med 1995;98:173–4.
179–182, 184.
[16] Larese FF, Bosco A, Fiorito A, et al. Latex symptoms and sensitisation in
health care workers. Int Arch Occup Environ Health 2001;74:219–23.
Hu et al. Medicine (2020) 99:24 www.md-journal.com
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