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 fit 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 fighting 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
Significant involvement of the young age group between 20-29 years (42.8%), because they consider as the first 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 significant negative correlation in (38.8%) of a worker, the exogenous causes like detergents, use of cosmetic products with occlusive dressings may influence 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 significant 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 significant, 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 significantly 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 first 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 significant 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 significantly 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 fissure, 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 significantly 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 benefit, 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 high-hazard 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 self-administered 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.