Covid-19: skin damage with prolonged wear of FFP3 masks

Dear Editor

Might Gillian C Higgins [Rapid Reponse: 15 May 2020) have the answer?:
"In WW2 every man, woman and child was gifted a gas mask. More people in the UK have now died of COVID-19 than lives lost in the Blitz".

The past can sometimes teach us better ways. I am old enough to have been given one. Pity I donated mine to a museum.

Too young to remember them? Try googling 'WW2 gas masks'. Add 'comic' or 'cartoon' to the search text if you are also in need of a laugh.

Dear Editor,

Core Surgical Trainee Ms Anna Payne reports nasal skin damage from wearing FFP3 masks in intensive care[1]. We agree that hydrocolloid dressings can ameliorate damage caused by ill-fitting masks. We would certainly advise against using creams on the face prior to donning, as this could become a sticky surface which particles may adhere to, creating a possible mode of infection transmission to the user when they wash their face.

As stated by the Health and Safety Executive:

‘Under the law, (respiratory protective equipment) RPE is the last line of protection. Remember, RPE can protect only the wearer and if it is used incorrectly, or is poorly maintained, it is unlikely to provide the required protection. Note also that RPE can be uncomfortable to wear and may interfere with work, which can lead to incorrect use.’[2].

Healthcare staff are ill-served by poorly designed and procured products. The Clinical Human Factors Group (CHFG) published a guide for ergonomic procurement[3]. This aids those in procurement to interrogate using Human Factors in considering: the user; the task; the environment and the overall context.

Viral aerosols are produced during coughing, sneezing and by aerosol generating procedures[4]. Surgical masks, although arguably more comfortable for the user, do not prevent the wearer from inhaling viral aerosols[5,6]. FFP3 respirators provide far superior respiratory protection[7, 8]. However, FFP3 masks have been introduced to the healthcare setting under immense pressure. Trainers and users alike have not been afforded sufficient time to be familiarised with PPE prior to immersion in work. Some workers have been inappropriately guided to pull the mask tight, until they feel pain. This is harmful in that it both compresses skin capillaries and also distorts the seal, this is a recognised issue with all form of respiratory protection[6]. The tension has to be ‘just right’ and fit testing should be a daily routine with a buddy to check alignment on the face and check for leaks. The most common leak is indeed around the bridge of the nose, which causes goggles to steam up.

In addition to superior worker protection and comfort; FFP3 reusable respirators provide economic and ecological benefits, whilst reducing reliance upon precarious global supply chains. A disposable mask costs £5, whilst a reusable half mask which protects the wearer for an entire pandemic and beyond, costs £15. Simple decontamination protocol can easily be implemented[9]. The ergonomic fit on the reusable respirator is far superior owing to the seal on a half and full mask being 10mm and 20mm respectively. There are manufacturers of FFP3 reusable respirators in the UK. We advocate for the use of FFP3 reusable respirators for all healthcare workers.
In WW2 every man, woman and child was gifted a gas mask. More people in the UK have now died of COVID-19 than lives lost in the Blitz[10,11].

References:
1. Payne A. Covid-19: skin damage with prolonged wear of FFP3 masks. BMJ 2020;369:m1743 doi: 10.1136/bmj.m1743[published Online First: Epub Date]|.
2. Great Britain H, Staff SE, Health GB, et al. Respiratory Protective Equipment at Work: A Practical Guide: HSE Books, 2013.
3. CHFG CHFG. Selecting safe and easy to use products for healthcare. Secondary Selecting safe and easy to use products for healthcare 2020. https://drive.google.com/file/d/1F9rtAsj9SQOPkslZBL2qqOAkT9OHY-rp/view.
4. Bourouiba L, Turbulent Gas Cloud and Respiratory Pathogen Emissions. Potential Implications for Reducing Transmission of COVID-19. JAMA. 2020;323(18):1837-1838. doi:10.1001/jama.2020.4756
5. Gawn J, Clayton M, Makison C, et al. Evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators. Health Safety Exec 2008
6. Brosseau LM. COMMENTARY: COVID-19 transmission messages should hinge on science. Secondary COMMENTARY: COVID-19 transmission messages should hinge on science 2020. https://www.cidrap.umn.edu/news-perspective/2020/03/commentary-covid-19-....
7. Lee SA, Hwang DC, Li HY, Tsai CF, Chen CW, Chen JK.  Particle Size-Selective Assessment of Protection of European Standard FFP Respirators and Surgical Masks against Particles-Tested with Human Subjects. 2016;8572493. doi: 10.1155/2016/8572493
8. Cherrie JW, Loh Mirandah, Aitken RJ. Protecting Healthcare Workers from Inhaled SARS-CoV-2. Occupational Medicine
2020. doi:10.1093/occmed/kqaa077
9. https://multimedia.3m.com/mws/media/1793959O/cleaning-and-disinfecting-3... (accessed 15/5/20)
10. https://www.ft.com/content/40fc8904-febf-4a66-8d1c-ea3e48bbc034 (accessed 15/5/20)
11. https://www.iwm.org.uk/history/the-blitz-around-britain (accessed 15/5/20)

Dear Editor

Collaborative working is a key feature of remote team-working during this pandemic. Occupational health nurses and dermatology have worked together closely for many years in Cardiff. However, with corporate executive level support we quickly set up a COVID-19 occupational virtual skin clinic “seeing” up to 10 patients per week. This service has been advertised via CEO daily updates, staff Connect apps and COVID-19 branded posters.

Occupational health nurses screen health care workers (HCWs) to advise self care measures or refer persistent moderate to severe skin disease to dermatology for a virtual telephone consultation. A central administration email can receive clinical photographs securely reviewed by the dermatologist.

The health board is supplying free emollients on the wards for HCWs via a central ward-based ordering system. Alternatively, patient named prescriptions are being delivered by hand to HCWs on site or faxed directly to the pharmacy for dispensing. All prescriptions are free in Wales. Follow up is either direct with dermatology, occupational health or proposed future skin allergy patch tests or skin prick testing for latex allergy.

To date, we have screened over 45 HCWs and enabled the majority to self-manage their FFP3 or PPE-related skin problems with occupational health nursing or medical support. The full impact for redeployment of HCWs will be clearer in the next few months.

The majority of skin problems seen to date are pre-existing hand dermatitis exacerbations, facial rashes and nasal bridge erosions as described previously (1-4) and odd eyelid swellings related to fluid resistant surgical masks possibly due to immediate latex allergy.

This prospective data is being fed into a multicentre data collection exercise currently with the British Society for Cutaneous Allergy and highlights the benefits of virtual occupational skin health clinics during the current pandemic.

References
1. BMJ 2020; 369:m1743
2. https://www.jaad.org/article/S0190-9622(20)30392-3/pdf
3. https://www.bmj.com/content/369/bmj.m1743/rr-1
4. https://www.bmj.com/content/369/bmj.m1743/rapid-responses

Dear Editor

We would corroborate the experience of Anna Payne, Core Surgical Trainee at Bart’s Health NHS Trust. The current Covid-19 pandemic has seen unprecedented rates of occupational dermatitis amongst healthcare workers (1). High incidence rates are being seen of facial dermatitis from facial masks and/or googles worn as part of personal protective equipment (PPE). To our knowledge, this is the first time such significant and frequent issues from medical grade, fit-tested face masks have been observed.

Within our Staff Occupational Dermatology Clinic, which was established in response to the Covid-19 outbreak, we have seen multiple presentations of facial dermatoses corresponding to the pressure areas from the masks. These rashes include short lived erythema (lasting several hours post doffing of PPE), erosions and pressure ulcers to the nasal bridge, eczematous rashes, exacerbations of underlying atopic eczema, seborrheic dermatitis and occlusive acne, among others.

The most common presentations are of erosions overlying the nasal bridge and/or of mild to moderate dermatitis over nose and cheeks. For the latter, allergic contact dermatitis has been considered but in the small number of staff we have patch tested all results have been negative. Patch testing was performed as per European Guidelines (2) with an extended European baseline series of contact allergens (Chemotechnique Diagnostics™ using IQ Chambers™, occlusion for 2 days with readings on days 2 and 5), rubber chemical accelerators (mercaptos, thiurams, carbamates), other contact allergens that can commonly cause allergic contact dermatitis on the face (e.g., fragrance substances, preservatives, plants, resins, medicaments and other allergens in cosmetics) and samples of the mask. These patients are diagnosed with a pressure-mechanical irritant contact dermatitis.

Pressure from mask wearing is seen in some occupations e.g. paint spraying, pharmaceutical drug manufacturing. All these occupations are characterised by the need to prevent the worker from inhalation exposure to airborne chemicals. However, pressure-induced facial dermatitis has been rarely reported. In a review of contact dermatitis caused by physical irritants from St John’s Institute of Dermatology, London, it was noted that for some pilots in the Royal Air Force who were required to wear rubber masks whilst flying, irritant contact dermatitis (ICD) developed due the effects of pressure, occlusion, heat and friction to the face (3).

It is possible that pressure ICD is now commonly seen amongst healthcare ‘frontline’ workers due to both the amount of pressure required to make the FFP3 mask ‘fit’ (i.e. protect against inhalation of airborne virus) and the long periods of time that the masks are being worn, often in a warm environment. NHS England and NHS Improvement published an advice document on preventing facial skin damage beneath PPE on 9th April 2020, stating that “it is important that you take regular breaks (we recommend every two hours) from wearing a mask to relieve the pressure and reduce moisture build-up. Where possible, rotate in teams where FFP3 can be removed between clinical shifts. This will help allow the skin time to recover.” (4) Unfortunately, in our experience, including from dermatology ‘popup’ clinics on our Covid-ICUs, this advice may not be routinely adhered to. It should also be borne in mind that one type of mask may not be suitable for all staff.

Our management of affected members of staff is to recommend adherence to NHS England guidelines, application of a light moisturiser to the skin before the shift starts and application of SiltapeTM (Advansis) (a soft silicone perforated tape) over the bridge of the nose and cheeks (before donning their FFP3 mask). If skin breakdown has occurred, we recommend the use of Mepilex border liteTM 4x5cm (Molnlycke) dressing over the bridge of the nose. These silicone-based tapes and dressings should offer pressure distribution superior to hydrocolloid dressings. Additionally, the adhesive employed leads to less skin damage upon removal. Fit testing should be repeated when using these tapes. The tapes should be removed at each doffing as they may be contaminated. Staff may wish to use an adhesive remover, such as AppeelTM wipes. The methodology has been approved by our Infection Control and Tissue Viability Teams.

References
1. Lan J, Song Z, Miao X et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020 May; 82(5):1215-1216.
2. Johansen JD, Aalto-Korte K, Agner T et al. European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice. Contact Dermatitis. 2015 Oct; 73(4):195-221.
3. Morris-Jones R, Robertson SJ et al. Dermatitis caused by physical irritants. Br J Dermatol. 2002 Aug; 147(2):270-5.
4. NHS England and NHS improvement. Preventing facial skin damage beneath personal protective equipment. 2020 April. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/... (last accessed 5th May 2020)