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Letters Protection against the virus

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

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1743 (Published 04 May 2020) Cite this as: BMJ 2020;369:m1743

Rapid Response:

Occupational facial dermatitis in the Covid-19 pandemic

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)

Competing interests: No competing interests

14 May 2020
Felicity J Ferguson
Consultant Dermatologist
Louise Cunningham, Ian R White, John P McFadden
St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust