Annoying Skin Reaction Among The Medical Staff Using Personal Protective Equipment During COVID-19

Backgrounds: the medical staff remains liable to COVID-19. Healthcare institutions must give offer to the supply of "personal protective equipment" to them, with the prolonged contact with this equipment that may cause a variety of skin diseases. Purpose: To shed light on the cutaneous abnormal reactions to the "personal protective equipment" among the medical staff and offers solutions. Methods: This cross-sectional study conducted for the medical staff that involved doctors, dentists, pharmacists, and nurses in the high-risk Ramadi General Teaching Hospital and low-risk Private Clinics, between 4-10 July 2020, at the time after the rise in COVID-19 patients in Anbar governorate, Iraq. A thorough quantitative descriptive research included age, gender, the duration and type of used masks, gloves, Goggles/face shield, and/or gown. About 23 questions described the adverse skin reactions chiey that involve the skin. Results: A total of 196 participants were recruited for the online questionnaire, including (49.5%) doctor, (15.3%) dentist, (16.8%) pharmacist, and (18.4%) nurse, with a signicant involvement between 20-29 years old age. The use of the mask and glove were associated signicantly with an adverse skin reaction, like a wound, dry lips, Acne and/or folliculitis, hand dryness, erythema, itching, wrinkle, nail fracture. While workers who regularly used gowns had a negative correlation with adverse skin reactions including erythema with pruritus of trunk and shoulders, miliaria, and pityriasis versicolor. Goggles/face shield did not report adverse skin problems, Conclusions: The medical staff uses personal protective equipment that may develop mild dermatological adverse effects. It needs early diagnosis and treatment. There is dermatological advice that may be helpful to avoid these unwanted effects.


Introduction
COVID-19 infection has become major worldwide distress due to the extensive spread and emergence of acute symptoms in a relatively high number of infected people. The clinical cases ranging from mild symptomatic disease to "acute respiratory distress syndrome". The multiple organ systems can be affected by the disease. 1 A self-administered online survey written in English and Arabic completed by all participants. The online survey was carried out. The web-based questioner designed as Google form, containing questions and options were reviewed by a biostatistics expert and two dermatologists, therefore possible misinterpretation, grammar, mistakes were corrected as far as possible.
This study was approved by the Ethics Approval Committee, College of Medicine, University of Anbar (Ref. No: 37 , Date: 9August 2020 ), and a written consent form was obtained from each individual before the enrollment into the study, and digital photographs were sent through Gmail.
A thorough quantitative descriptive research included age (that divided in to 5 age groups, each one consists of 10 years), gender, and job were documented. All the persons who participated in the study should answer questions contained previous dermatological problems or its clinical features that they had complained before using of "personal protective equipment"(PPE) (thirty-two questions), and the type of skin, whether it is oily, dry or normal ( mixed). Also asked about oral drug intake within the last month that which included (general tonics, zinc, vitamin D3, vitamin C, hydroquinone, and antibiotics), besides the use of topical emollient cream or topical sunscreen.
The second dimension of the questionnaire for the personal protective equipment (PPE) included the type of masks (N95, surgical, clothe), gloves (latex or vinyl), Goggles/face shield, and/or protective clothing (gown). Also reported the duration of using each protective tool in separation per day, besides the duration of days per week during the previous 30 days period. Questions described the adverse skin reactions chie y that involve the skin of the face, hands, and the trunk, there were twenty-three questions.

Statistical Analyses
Descriptive analyses were used to study baseline characteristics. The data were analyzed using Microsoft Excel 2010 and SPSS version 22. The hypothesis was tested using Chi-square tests. A p-value < 0.05 was considered to represent a signi cant difference.
In general, the skin texture of participants was 94(48%) oily, 44(22.4%) dry, and 58(29.6%) normal (mixed). The reported dermatological diseases within the 3 months before the use of the PPE were seen in 81(39.3%) members, while 115(60.7%) had not skin diseases, and these are illustrated in (Table 2). The workers used protective emollient cream and sunscreen in 76(38.8%) for the face with a signi cant negative correlation and development of skin disease (Table 3) and 58(29.6%) of participants for hands with no signi cant effect on skin disease. Protect mouth and nose by face masks Commonly, there are different types of one-use masks, in this study, all the medical staff used a mask, which was one of the following types: N95, Surgical mask, Clothe mask, or N95 +surgical mask in (28.1%, 43.4%, 4.6%, and 24.0% respectively) of workers. The duration of using the mask had signi cant proportion at 3-8 hours/day, and 3-5 days/week in (67.9%, 46.9% respectively) of staff ( Table 4).
The use of the mask was associated signi cantly with an adverse skin reaction of the face. However, the proportion of the type of masks and the appearance of the adverse skin reaction was not signi cant, Pvalue = 0.625 ( Table 5). Besides that, the proportion of skin reaction of the face in men was 58.7% and was a signi cantly higher than that of women's medical staff (41.3%). Regarding the relation between the occupation of the participants, this study reported that the skin disease of the face affected 42.1% of the doctors and this was signi cantly higher than the other participated occupations (Table 6). Among the 126(64.3%) worker who reported adverse reactions of the face, including wound at the attached site of the mask or mask bond (26%), dry lips (24.5%), Acne and/or folliculitis (12.2%), herpes simplex (11.2%), pressure hair loss of occipital area (7.1%), (Figure 4), etc. (Table 7).

Keep clean hands by gloves
Medical care activities require using of a single couple of non-sterile gloves made of either latex or latexfree, Among 183(93.4%) who often used gloves, 152(81.2%) of staff used the latex-free glove, and the proportion was signi cantly more than that who used latex glove that used in 53(28.2%) of staff ( Table  8). The duration of using of the gloves had signi cant proportion at 3-8 hours/day, and 3-5 days/week in (61.5%, 48.1% respectively) of staff (Table 4).
Using the latex glove was associated signi cantly with an adverse skin reaction of the hand in (61.8%) of workers in comparison with that who using the latex free glove (47%). However, There were 46.4% of individuals developed adverse skin reaction after using the glove, and 46.9% of them were not complained of hands skin problems. There was no signi cant proportion of skin reaction of the hands in both sexes (Table 1). Also, this study reported that the skin disease of the hand affected 40.7% of the doctors and this was signi cantly higher than the other participated occupations ( Table 6).

Keep clean skin and cloth gowns
A high-risk medical staff need a sterile protective clothes as part of the typical protections against transmission of COVID-19. Of the 138(70.4%) of medical staff wore disposable protective clothing, and the duration of using of the gown had signi cant proportion at 3-8 hours/day, and 3-5 days/week in (61.1%, 43.2% respectively) of staff (Table 4).
Among 138(70.4%) of workers who regularly used gowns, 23.9% developed adverse skin reactions of the body and this was statically a signi cant with negative correlation. The skin reaction of the body in men was 63.8% and was a signi cantly higher than that of women's participants (36.2%) ( Table 1). Also, the skin disease of the body involved 31.9% of the doctors and this was signi cantly higher than the other medical occupations (Table 6). Regarding the dermatological diseases of the body after using the gowns, including erythema with pruritus of trunk and shoulders (23.2%), miliaria (10.8%), and pityriasis versicolor (4.3%) ( Table 7).
Goggles/face shield Of the 74(37.8%) of medical staff used goggles/face shield without any reported adverse skin problems, and the duration of using it ranged between (1->8) hours/day, and (1-7) days/week, with a signi cant proportion at 3-8 hours/day in (60.1%) of staff, and signi cant proportion at 3-5 days/week in (43.2%) ( Table 4). Fortunately, all of them did not report suspected adverse skin reaction.

Discussion
COVID-19 infection is extremely contagious, thus the medical staff must realize the purpose of PPE, such as "masks, gloves, face-shield and protective clothing", and its role as part of a system to reduce disease spread from patients to staff. The overall PPE t factor and the level of comfort should be taken into account mainly when used for a long time. 3,5,16 At this time, when the summer began, the outbreak of COVID 19 attacks Iraq, Anbar. The medical staff who are ghting were obligated by using the PPE, and about (68.4%) of them were used, prophylactic oral agents. Therefore, the workers were developed many adverse skin reactions, and they seek for dermatological advice. For this situation, the author considered to study the dermatological drawbacks that may be caused by the use of PPE to offer solutions, and this will reduce the tension, stress of medical staff, and they will be more active and helpful for their patients.
The skin complications among medical staff in the COVID-19 outbreak were primarily due to the over hydration effect of "personal protective equipment" (PPE), friction, epidermal barrier impairment, contact reactions, aggravation of existing skin disease. 8 Signi cant involvement of the young age group between 20-29 years (42.8%), because they consider as the rst defense medical line against COVID-19, and this is younger than that reported in other study. 12 The use of emollient cream and sunscreen for the face led to the development of skin disease with a signi cant negative correlation in (38.8%) of a worker, the exogenous causes like detergents, use of cosmetic products with occlusive dressings may in uence the skin pH. Changes in the pH are reported to play a role in the pathogenesis of skin diseases. 17 people have an oily skin texture, and use of bad quality emollient, in addition to that, they are wearing a mask can aggravate the facial skin disease.
The present research shows a signi cant correlation among workers using the mask and adverse skin reaction of the face. This is in agreement with the previous report. 8 However, the effect of the masks' types on skin reaction was not signi cant, while a series of researchers have found the related adverse responses of health care workers wearing an N95 mask. 18 The skin reaction of the face in men was signi cantly higher than that of women, and the doctors were more committed and meticulous to wear PPE and affected more than other medical staff. This results unlike that reported in other study. 12 In general, the man has an oily skin texture, hairy skin, careless for their skin, and more distressing in work than the woman.
The reported facial skin changes caused by the mask or mask bond in (64.3%) of a worker, including wound at the attached site, dry lips, acne, and/or folliculitis. The occlusion had been reported to induce acne because of the rupture of micro comedones that are not visible to the naked eye. 19 And this is the rst work that mentioned the herpes simplex and pressure hair loss of the occipital area is caused by the mask.
The pruritus occurred due to wearing a mask for a very long time, an extremely humid environment, irritating contact dermatitis to the mask material, or due to the acne or folliculitis.
To decrease adverse skin reactions successfully, the staff should use the salicylic acid soaps for oily skin, topical lubricant for dry texture skin, 20 reduce the tightness of the bond of the mask, and add a surgical mask to mark the inside of the N95 mask.
Because of COVID-19 can be extent through contact, thus hand preservation is one of the most important ways to avoid it. 3 Generally, there was no signi cant correlation between the adverse skin reaction and using the glove. Among (81.2%) of the medical staff prefer the latex-free glove, while (28.2%) used latex glove. However, the adverse skin reaction of the hand was associated signi cantly with using the latex glove in (61.8%) of workers, and (47%) of individuals using the latex-free glove.
A previous study reported that (88.5%) of workers who frequently used latex gloves complained of adverse skin reactions. 12 The most common adverse responses of using gloves in this study were dryness and ssure, hand erythema+ itching, wrinkle, nail fracture, pigmentation, paronychia. It was nearly similar to the skin abnormal responses of wearing gloves in previous studies. 12,18 Of course, some reasons led to the emergence of the hands' skin adverse reactions, including hypersensitivity to latex, 21 impair Skin barrier function, 22 , and irritant contact dermatitis. 23 So the solution is the use of hypoallergic non-latex glove, and the author prefers with cotton glove wore under the occlusive glove, Dry hands after the wash before wearing gloves. If there is no improvement in the condition, they can add a good quality hands emollients and moisturizers. 24 The adverse skin reactions of the body in (23.9%) workers who regularly used gowns. Males were 63.8% of workers who that signi cantly higher than females (36.2%). The doctors suffered from body reaction in (31.9%) of medical staff, and usually, they do not seek dermatological advice during the COVID-19 pandemic.
These data-less common than that reported in a previous study which found (60.7%) of workers had adverse skin reactions of the body due to wearing a gown, and that the female affected more than male. 12 The dermatological diseases of the body after using the gowns, including erythema with pruritus of trunk and shoulders, miliaria, and pityriasis versicolor.
The logical explanations for the emergence of these cases among medical staff, including skin barrier impairment 22 , a mild complaint, or they unworried for their skin, men differ from women, they have profuse sweating, hairy and oily skin texture.
To overcome these dermatological problems, the author gave advice, including the regular change of gown, reduce its tightness on the body during employment, use thin cotton clothes with hypo-allergic powder under the gown, and bath with shampoo contains mild antiseptic and anti-fungal for the body a twice/ week. The second-generation non sedative antihistamines can give some bene t, because of the cutaneous adverse responses using PPE were mainly in itching and rash.
There are many limitations to be recognized. The small impending medical staff employed in the highhazard areas. Emotional stress and sleep disturbances that could have contributed to the development skin diseases associated with use PPE. Assessment of the temperature of the room and humidity may have predisposed to the skin disease with the use of PPE. The recall bias could affect the selfadministered questionnaire. The skin disease was present but un notice by the participant, and may be aggravated by PPE. Lastly, the body mass index, facemask contours, facial hair thickness, and the body muscle were not assessed.

Conclusion
During the COVID-19 outbreak, the younger medical worker ( between 20-29 years) uses facial mask, latex gloves (as part of personal protective equipment) may develop mild dermatological adverse effects, it needs early diagnosis and treatment, while the latex-free, gown, and face shield have no signi cant skin abnormal response. There is medical advice that may be helpful to avoid these unwanted effects. Tables Table 1 The relation between gender and adverse skin reaction after using PPE   Table 6 The relation between the occupation and adverse skin reaction due to using of PPE  Table 7 The frequency of dermatological diseases after using the mask, gloves, gown, and goggle/ face shield   The frequency of the occupations Figure 3