COVID-19 Related Occupational Dermatoses

Written by Dr Lisa F Kiely, Dermatology Specialist Registrar

The COVID-19 pandemic created many challenges for frontline healthcare workers. The World Health Organisation recommended frequent hand washing and the use of personal protective equipment to counteract the risk of infection. As the pandemic progressed it became apparent that these necessary infection control practices were compromising the skin integrity of our front line staff.

Healthcare workers represent one of the highest risk professions for developing occupational skin disease. Frequent handwashing, use of occlusive gloves and masks can cause both irritation from friction and a disruption in the skin microbiome leading to the development of dermatitis.

Occupational dermatoses can result in a multitude of adverse effects including decreased compliance with adequate PPE and hand hygiene, staff absenteeism and a reduced quality of life.

At the beginning of the pandemic there was a surge in irritant contact dermatitis (ICD) predominantly affecting the hands. A cross sectional study from a large university hospital in Ireland revealed that almost 83% of staff surveyed developed irritant contact dermatitis most commonly affecting the hands followed by the nose and cheeks. 1 Although 99% of staff reported an increase in hand-washing frequency in line with international guidance, 45% denied any use of emollients. This imbalance further predisposes to the risk of ICD.

A multicentre study from the UK and Ireland emphasised the impact of COVID-19 related occupational dermatoses with 15% of staff requiring time off work due to their skin disease resulting in a total of 468.5 missed working days across all sites. 2 This, in combination with pre-existing staff shortages due to exposure and infection, creates increased strain on an already vulnerable health service.

As the pandemic progressed, in addition to ICD, an emerging theme was that of mask-related dermatoses. 3

A city wide study including three Irish University Hospitals showed that 55% of staff developed Maskne since the onset of the Pandemic. 4 Factors which contributed to the development of maskne included a previous history of acne and staff with a family history of acne.

Staff working in a “hot and sweaty” environment were significantly more likely to develop Maskne. Both temperature and humidity have previously been shown to contribute to acne pathogenesis. Previous studies have reported a 10% increase in sebum excretion for every one degree Celsius rise in temperature. This is a result of both the working environment in addition to the hot and humid micro-environment in the mask covered areas. Furthermore, humidity results in occlusion, irritation and oedema of the pilosebaceous unit, further exacerbated by local pressure from close fitting masks.

The skin microbiome is sensitive to changes in sebum composition and environmental factors such as temperature, pH, humidity and hydration. The resulting microflora dysbiosis contributes to the pathogenesis of Maskne and may promote multiplication of Cutibacterium acnes leading to more inflammatory lesions. Additionally, mechanical friction can produce increased levels of interleukin-1α contributing to the pro-inflammatory state.

Although emollients have been recommended to reduce the risk of ICD, our study found that healthcare workers who used emollients under masks were significantly more likely to develop Maskne. This is likely related to the comedogenic occlusive nature of moisturizers.

Female staff members and younger age groups were more likely to report the development of maskne. Strikingly, although the majority of staff reported some degree of maskne, only 12.5% of staff sought medical attention.

We must not underestimate the impact that these COVIDrelated dermatoses can have on both skin integrity and psychosocial functioning.

We urge healthcare providers encountering these problems to be proactive in the management of these occupational skin conditions in order to reduce the ongoing burden on our patients and staff.

RECOMMENDATIONS

Irritant contact dermatitis of the hands

• Alcohol-based (foaming if available) hand sanitizer instead of soap and water
• Emollient soap-free hand wash at home or where situations where you don’t need to disinfect hands
• Avoid washing with hot and very cold water
• Pat dry; don’t rub
• Moisturisers are a crucial measure for both prevention and treatment of hand dermatitis particularly ointment formulations for maximal benefit – apply as regularly as possible
• A trial of moderate potency topical steroids is reasonable if conventional methods fail
• Refer to dermatology in cases of recalcitrant hand dermatitis

While avoidance of handwashing is impossible, the preferential use of foaming alcohol sanitizer over soap and water is advised. Alcohol based hand sanitizers with moisturisers have the least sensitizing and irritancy potential when compared to soaps and synthetic detergents. Soaps remove beneficial intracellular lipids and can damage proteins in the stratum corneum leading to increased irritation and sensitivity.

It takes time for skin to develop and recover from dermatitis. Skin can remain vulnerable for at least 6 months after they appear to be healed as such emollient use should be an ongoing measure.

Maskne

Management of maskne is no different from management of conventional acne.

• Avoidance of greasy emollients under masks in high-risk or affected groups
• Use a gentle salicylic acid cleanser
• Use of oil-free and noncomedogenic products
• Early topical treatment with combination Benzoyl peroxide alone or in combination with topical antibiotics or topical retinoids for mild acne
• Escalation to oral tetracycline/ trimethoprim antibiotics (in combination with topical retinoid and benzoyl peroxide) for moderate to severe inflammatory acne
• Early referral to dermatology for consideration of oral isotretinoin in patients with severe nodular acne, scarring acne or acne resistant to an adequate trial of oral antibiotic therapy

Combination therapy should be used to target different aspects of acne pathogenesis.

The use of topical maintenance regimens after oral antibiotic therapy cannot be overemphasised.

References

1. Kiely LF, Moloney E, O’Sullivan G, Eustace JA, Gallagher J, Bourke JF. Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study. Clinical and Experimental Dermatology. 2021 Jan 5;46(1).
2. O’Neill H, Narang I, Buckley DA, Phillips TA, Bertram CG, Bleiker TO, et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. British Journal of Dermatology. 2021 Mar 16;184(3).
3. Rudd E, Walsh S. Mask related acne (“maskne”) and other facial dermatoses. BMJ. 2021 Jun 7;
4. Kiely LF, O’Connor C, O’Briain G, O’Briain C, Gallagher J, Bourke JF. Maskne prevalence and associated factors in Irish healthcare workers during the COVID-19 pandemic. Journal of the European Academy of Dermatology and Venereology. 2022 Mar 16

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