Abstract

Objective

to identify the diverse scientific evidence on the types of skin lesions caused due to the use of Personal Protective Equipment in health professionals during the COVID-19 pandemic and to verify the recommended prevention measures.

Method

this is an integrative review carried out in the MEDLINE, CINAHL, LILACS, SCOPUS, Science Direct, Web of Science and SciELO databases. The search was conducted in a paired manner, constituting a sample of 17 studies categorized according to the types of skin lesions and preventive measures.

Results

the main types of skin lesions related to mask use were stage 1 pressure ulcers, acne and cutaneous depression. Regarding the use of glasses and face shields, the most frequent were stage 1 and 2 pressure ulcers. Xerosis and irritant contact dermatitis occurred due to using gloves and protective clothing, respectively. The main preventive measures recommended were using hydrocolloid or foam dressing in the pressure regions, moisturizers and emollients.

Conclusion

a considerable number of skin lesions associated with using the equipment were noticed, and the data obtained can guide the professionals in identifying risks and promoting preventive measures to avoid their occurrence.

Descriptors:
Personal Protective Equipment; Skin; Health Personnel; Skin Diseases; Disease Prevention; COVID-19

Resumo

Objetivo

identificar as evidências científicas sobre os tipos de lesões de pele ocasionadas pelo uso de Equipamento de Proteção Individual em profissionais de saúde durante a pandemia da COVID-19 e verificar as medidas de prevenção recomendadas.

Método

trata-se de uma revisão integrativa realizada nas bases de dados MEDLINE, CINAHL, LILACS, SCOPUS, Science Direct, Web of Science e no banco de dados SciELO. A busca foi realizada de forma pareada, constituindo uma amostra de 17 estudos categorizados quanto aos tipos de lesões de pele e às medidas preventivas.

Resultados

os principais tipos de lesões de pele relacionados ao uso de máscara foram lesão por pressão estágio 1, acne e depressão cutânea. Quanto ao uso de óculos e protetor facial, as mais frequentes foram lesão por pressão estágios 1 e 2. Xerose e dermatites de contato irritante ocorreram devido ao uso de luvas e roupas de proteção, respectivamente. As principais medidas preventivas recomendadas foram o uso de curativo de hidrocoloide ou espuma nas regiões de pressão, hidratantes e emolientes.

Conclusão

observou-se um número considerável de lesões de pele associadas ao uso dos equipamentos e os dados obtidos podem direcionar os profissionais na identificação de riscos e promoção de medidas preventivas para evitar sua ocorrência.

Descritores:
Equipamento de Proteção Individual; Pele; Profissionais da Saúde; Dermatopatias; Prevenção de Doenças; COVID-19

Resumen

Objetivo

identificar que evidencia científica hay sobre los tipos de lesiones cutáneas provocadas por el uso de Equipos de Protección Individual en los profesionales sanitarios durante la pandemia del COVID-19 y verificar las medidas de prevención recomendadas.

Método

se trata de una revisión integradora realizada en las bases de datos MEDLINE, CINAHL, LILACS, SCOPUS, Science Direct, Web of Science y la biblioteca electrónica SciELO. La búsqueda se realizó de forma pareada, la muestra estuvo conformada por 17 estudios categorizados según los tipos de lesiones cutáneas y medidas preventivas.

Resultados

los principales tipos de lesiones cutáneas relacionadas con el uso de mascarillas fueron las lesiones por presión estadio 1, el acné y la depresión cutánea. En cuanto al uso de gafas y pantalla facial, las más frecuentes fueron las lesiones por presión estadios 1 y 2. Se detectó xerosis y dermatitis irritante de contacto por el uso de guantes y ropa de protección, respectivamente. Las principales medidas preventivas recomendadas fueron el uso de apósitos de hidrocoloide o espuma en las regiones de presión, humectantes y emolientes.

Conclusión

hubo un número considerable de lesiones cutáneas asociadas al uso de equipos y los datos obtenidos pueden orientar a los profesionales para que identifiquen los riesgos y promuevan medidas preventivas para evitar su aparición.

Descriptores:
Equipo de Protección Personal; Piel; Personal de Salud; Enfermedades de la Piel; Prevención de Enfermedades; COVID-19

Introduction

In January 2020, COVID-19, a disease caused by the new Coronavirus (SARS-CoV-2), was considered an international public health emergency and, in March 2020, the World Health Organization (WHO) declared it as a pandemic¹1. Organização Pan-Americana de Saúde. Folha informativa sobre COVID-19 [Internet]. 2020 [cited 2021 Aug 6]. Available from: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875
https://www.paho.org/bra/index.php?optio... . Since then, health professionals have been dealing with many challenges, such as: prolonged exposure; work overload; lack of training; inadequate staffing; precariousness of the work environment; and Personal Protective Equipment (PPE) in insufficient quality and numbers, among other factors that jeopardize these professionals’ biosafety²2. Quadros A, Fernandes TCM, Araujo BR, Caregnato RCA. Desafios da Enfermagem Brasileira no Combate da COVID-19: uma reflexão. Enferm Foco [Internet]. 2020 [cited 2021 Aug 6];11(1):78-83. Available from: http://revista.cofen.gov.br/index.php/enfermagem/article/view/3748/807
http://revista.cofen.gov.br/index.php/en... .

COVID-19 has stood out for its high transmissibility and clinical severity, and also for having a higher incidence among health professionals³3. Freitas ARR, Napimoga M, Donalisio MR. Assessing the severity of COVID-19. Epidemiol Serv Saúde. 2020;29(2):e2020119. doi: https://doi.org/10.5123/s1679-49742020000200008
https://doi.org/10.5123/s1679-4974202000... . To reduce the risk of exposure in the professionals who are on the front lines in the fight against COVID-19, in its Technical Note No. 04/2020, the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, ANVISA) recommends wearing PPE according to the standard precautionary type for droplets, aerosols and/or contact. Thus, to care for suspected or confirmed COVID-19 cases, goggles or face shield, cap, surgical or N95/PFF2 mask or equivalent (depending on the type of precaution), apron and sterile-procedure gloves for non-invasive procedures must be used⁴4. Agência Nacional de Vigilância Sanitária (BR). Nota Técnica nº 04/2020 GVIMS/GGTES/ANVISA. Orientações para Serviços de Saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2) [Internet]. Brasília: ANVISA; 2021 [cited 2021 Aug 6]. 118p. Available from: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/nota-tecnica-gvims_ggtes_anvisa-04_2020-25-02-para-o-site.pdf
https://www.gov.br/anvisa/pt-br/centrais... .

Although PPE use is intended for protection, the professionals are also prone to the occurrence of skin lesions caused by their prolonged use and frequent hand hygiene, which can progress to pressure ulcers, acute and chronic dermatitis and worsening of preexisting dermatosis, as well as being a gateway to secondary infections⁵5. Yan Y, Chen H, Chen L, Cheng B, Diao P, Dong L, et al. Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019. Derm Therapy. 2020;33(4):e13310. doi: https://doi.org/10.1111/dth.13310
https://doi.org/10.1111/dth.13310... ^-66. Darlenski R, Tsankov N. Covid-19 pandemic and the skin-What should dermatologists know? Clin Dermat. 2020;38(6):785-7. doi: https://doi.org/10.1016/j.clindermatol.2020.03.012
https://doi.org/10.1016/j.clindermatol.2... .

Prolonged contact with PPE affects the integrity of the skin barrier due to the force of continuous or sliding friction and the skin’s own structural condition, causing tissue deformation, which leads to the process of cell death and triggers tissue damage. It is also noteworthy that factors such as excessive sweating generated by mental stress and exhausting workdays and non-optimization of the PPE in the face of tissue deformation, in addition to the adaptation made by the professionals to improve sealing of the facial region, in search of overprotection, effectively contribute to tissue damage⁷7. Gefen A, Ousey K. Update to device-related pressure ulcers: SECURE prevention. COVID-19, face masks and skin damage. J. Wound Care. 2020;29(5):245-59. doi: https://doi.org/10.12968/jowc.2020.29.5.245
https://doi.org/10.12968/jowc.2020.29.5.... .

In this regard, it is important to highlight that tissue damage is a limiting factor for care, as health professionals, subjected to extensive working hours with physical and emotional exhaustion, have become a population at risk for the development of injuries and faced with the lack of adequate protective equipment, worsened signs and symptoms of skin lesions and/or pre-existing diseases and, in most cases, without access to prevention measures due to lack of knowledge and guidance as a result of scarcity of studies, the costs of such materials or even the lack of resources from hospital institutions⁸8. Chowdhury MM, Bevan N, Ryan K. Covid-19: virtual occupational skin health clinics for healthcare workers. BMJ. 2020;369:m2281. doi: http://dx.doi.org/10.1136/bmj.m2281
https://doi.org/http://dx.doi.org/10.113... .

Considering that the protective equipment used in health care is indispensable, it becomes necessary to implement measures that help to preserve skin integrity in the area exposed to risk, measures that will directly contribute to protecting the skin and, consequently, to ensure care quality and patient safety. Therefore, the justification for this review is based on the contribution to the health professionals’ practice, especially nurses, for providing information about skin lesions associated with using PPE and the measures that can be adopted to prevent their occurrence because, in addition to favoring safe professional practice and promoting effective care for the assisted population, it will guide the professionals in similar situations that may occur, allowing for the development of risk anticipation strategies for the maintenance of skin integrity.

Therefore, the objective is to identify the diverse available scientific evidence on the types of skin lesions caused by PPE use in health professionals during the COVID-19 pandemic and to verify the recommended prevention measures.

Method

Type of study

This study consists of an integrative review filed on the FigShare platform⁹9. Silva LFM, Almeida AGA; Pascoal LM, Santos M Neto, Lima FET, Santos FS. Lesões de pele por equipamentos de proteção individual e medidas preventivas no contexto da COVID-19: revisão integrativa. FigShare. 2021 Oct 25. Preprint. doi: https://doi.org/10.6084/m9.figshare.16869497
https://doi.org/10.6084/m9.figshare.1686... . The study was conducted in six stages: 1) definition of the research question; 2) definition of the databases and criteria for inclusion and exclusion of studies; 3) definition of the information to be extracted from the studies selected; 4) assessment of the studies included in the review; 5) interpretation of the results; and 6) presentation of the review/knowledge synthesis¹⁰10. Whittemore R. Combining evidence in nursing research: methods and implications. Nursing Res. 2005;54(1):56-62. doi: https://doi.org/10.1097/00006199-200501000-00008
https://doi.org/10.1097/00006199-2005010... .

To guide the search, the research question was elaborated using the PICo (Population, Interest and Context) strategy: P - Health professionals; I - Types of injuries related to PPE use and Preventive measures; and Co - The COVID-19 Pandemic. This acronym allows reaching an effective search from the elaboration of an enlightening research question to direct the study according to the objectives proposed¹¹11. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative evidence [Internet]. 2020 [cited 2021 Aug 06]. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/3283910681/Chapter+2%3A+Systematic+reviews+of+qualitative+evidence
https://jbi-global-wiki.refined.site/spa... . This strategy allowed formulating the following guiding question: “What types of skin lesions are caused by PPE use in health professionals during the COVID-19 pandemic and which are the recommended prevention measures?”.

An initial search was carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE) database, via the National Library of Medicine (PubMed), to verify the main descriptors or keywords used in the studies on the theme of the guiding question. Controlled vocabularies were selected from the Descriptors in Health Sciences (Descritores em Ciências da Saúde, DeCS), the Medical Subject Headings (MeSH) and MH Exact Subject Headings (CINAHL vocabulary), namely: COVID-19; occupational injury; facial injuries; personal protective equipment; protective devices and skin. As this is an incipient theme, it was decided to also use keywords (uncontrolled vocabularies) to obtain a targeted search strategy, namely: device related pressure injuries, skin injury and skin damage, used in the Spanish language for the LILACS and SciELO databases. To perform crossings among these words, the operators used were the Boolean operators AND and OR (Figure 1).

Data collection

The search was carried out in January 2021 through the CAPES Journal Portal, through access to the Federated Academic Community (Comunidade Acadêmica Federada, CAFe), with selection of Universidade Federal do Maranhão(UFMA) higher education institution, searching the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via the National Library of Medicine (PubMed); Cumulative Index to Nursing and Allied Health (CINAHL); Literatura Latino-Americana e do Caribe em Ciências da Saúde(LILACS); SCOPUS; Science Direct and Web of Science and Scientific Electronic Library Online (SciELO).

To improve the quality of data collection, the Rayyan app was used, developed by the Qatar Computing Research Institute (QCRI)¹²12. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. doi: http://doi.org/10.1186/s13643-016- 0384-4
https://doi.org/http://doi.org/10.1186/s... , to assist in the process of organizing and selecting the studies, as well as removing duplicates. In addition to that, the search was performed by two researchers, independently and simultaneously, following a search protocol directed to the guiding question and eligibility criteria. The inclusion criteria established for the selection of studies were original articles that answered the guiding question, covering injuries and/or preventive measures, published in English, Spanish or Portuguese.

Instrument used to collect the information

For data collection, categorization and interpretation, an adapted instrument was used¹³13. Marziale MH. Instrumento para recolección de datos: revisión integrativa [Internet]. 2015 [cited 2021 Aug 6]. Available from: http://gruposdepesquisa.eerp.usp.br/sites/redenso/wp-content/uploads/sites/9/2019/09/Instrumiento_revision_litetarura_RedENSO_2015.pdf
http://gruposdepesquisa.eerp.usp.br/site... with the following items: title of the publication; author(s); year of publication; journal; objective; type of study; level of evidence; types of injuries and preventive measures.

Data analysis

The level of evidence of the articles included was classified as follows:

In addition to that, an analysis of the methodological quality was carried out using the instruments proposed by the JBI¹⁵15. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative evidence. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [Internet]. Adelaide: Joanna Briggs Institute; 2020 [cited 2021 Aug 6]. Available from https://synthesismanual.jbi.global. https://doi.org/10.46658 /JBIMES-20-03 that contain a checklist with questions for each type of study with the following answer options: Yes; No; Not applicable or Not clear. After categorization of the studies, the data were synthesized for the descriptive analysis according to year of publication, language, study locus, objective, type of study, level of evidence, types of skin lesions and preventive measures related to PPE use in health professionals.

Results

A total of 851 articles were identified and, after analyzing the titles and abstracts and applying the inclusion and exclusion criteria, 50 articles were pre-selected for full reading. Among the 50 articles analyzed, 17 were included in the final sample of this review. The path followed to search and select the studies observed the PRISMA group recommendations¹⁵15. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative evidence. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [Internet]. Adelaide: Joanna Briggs Institute; 2020 [cited 2021 Aug 6]. Available from https://synthesismanual.jbi.global. https://doi.org/10.46658 /JBIMES-20-03 and can be seen in the flowchart below (Figure 2).

The 17 articles that comprised the final sample were published in 2020 and 2021, in English and Spanish. The studies were carried out in the following countries: Bahrain, Brazil, China, India, Iraq, Mexico, Paris (France), Thailand, Turkey and the United States, with China (35.5%) being the country with the highest number of publications. The types of study were as follows: prospective cohort¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... ^-1818. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... (11.8%), randomized clinical trial¹⁹19. Hua W, Zuo Y, Wan R, Xiong L, Tang J, Zou L, et al. Short-term skin reactions following use of N95 respirators and medical masks. Contact Dermatitis. 2020;83(2):115-21. doi: https://doi.org/10.1111/cod.13601
https://doi.org/10.1111/cod.13601... ^-2020. Gasparino RC, Lima MHM, Souza Oliveira-Kumakura AR, Silva VA, Jesus Meszaros M, Antunes IR. Prophylactic dressings in the prevention of pressure ulcer related to the use of personal protective equipment by health professionals facing the COVID-19 pandemic: A randomized clinical trial. Wound Repair Regen. 2021;29(1):183-8. doi: https://doi.org/10.1111/wrr.12877
https://doi.org/10.1111/wrr.12877... (11.8%) and descriptive cross-sectional²¹21. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391...

22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020...

23. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2...

24. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00...

25. Pacis M, Azor-Ocampo A, Burnett E, Tanasapphaisal C, Coleman B. Prophylactic Dressings for Maintaining Skin Integrity of Healthcare Workers When Using N95 Respirators While Preventing Contamination Due to the Novel Coronavirus: A Quality Improvement Project. J Wound Ostomy Continence Nurs. 2020;47(6):551-7. doi: https://doi.org/10.1097/WON.0000000000000713
https://doi.org/10.1097/WON.000000000000...

26. Agarwal A, Agarwal S, Motiani P. Difficulties Encountered While Using PPE Kits and How to Overcome Them: An Indian Perspective. Cureus. 2020;12(11):e11652. doi: https://doi.org/10.7759/cureus.11652
https://doi.org/10.7759/cureus.11652...

27. Yuan N, Yang WX, Lu JL, Lv ZH. Investigation of adverse reactions in healthcare personnel working in Level 3 barrier protection PPE to treat COVID-19. Postgrad Med J. 2020;(1148):351-4. doi: https://doi.org/10.1136/postgradmedj-2020-137854
https://doi.org/10.1136/postgradmedj-202...

28. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212...

29. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic. Dermatol Ther. 2020;33(6):e14346. doi: https://doi.org/10.1111/dth.14346
https://doi.org/10.1111/dth.14346...

30. Atay S, Cura SÜ. Problems Encountered by Nurses Due to the Use of Personal Protective Equipment During the Coronavirus Pandemic: Results of a Survey. Wound Manag Prev. 2020;66(10):12-6. doi: https://doi.org/10.25270/wmp.2020.10.1216
https://doi.org/10.25270/wmp.2020.10.121...

31. Techasatian L, Lebsing S, Uppala R, Thaowandee W, Chaiyarit J, Supakunpinyo C, et al. The effects of the face mask on the skin underneath: A prospective survey during the COVID-19 Pandemic. J Prim Care Community Health. 2020;11:2150132720966167. doi: https://doi.org/10.1177/2150132720966167
https://doi.org/10.1177/2150132720966167...

32. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... ^-3333. Erize-Herrera JA, García-Mireles V, Uh-Sánchez I, Felix-Téllez F, Encarnación-Martínez M, Estrada-Aguilar L. Dermatological manifestations in healthcare workers associated with the use of personal protective equipment when attending patients with COVID-19 infection in hospitals in the metropolitan area of Mexico city. Piel. 2020. doi: https://doi.org/10.1016/j.piel.2020.10.004
https://doi.org/10.1016/j.piel.2020.10.0... (76.4%). When evaluating the level of evidence, 76.4% of the publications were classified as level 4b.

Figure 3 presents the characterization of the studies that were included in the final sample, considering objective, country where the study was carried out, language, level of evidence and methodological quality of the study.

Table 1 shows the types of injuries related to PPE use. The main PPE items associated with the occurrence of skin injuries were as follows: surgical or N95 mask, goggles, face shield, gloves and protective clothing. The most frequent injuries caused by mask use were the following pressure ulcer (stage 1)¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... ^-1818. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... ^,2121. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^-2424. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... (35.2%); acne²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2929. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic. Dermatol Ther. 2020;33(6):e14346. doi: https://doi.org/10.1111/dth.14346
https://doi.org/10.1111/dth.14346... ^-3030. Atay S, Cura SÜ. Problems Encountered by Nurses Due to the Use of Personal Protective Equipment During the Coronavirus Pandemic: Results of a Survey. Wound Manag Prev. 2020;66(10):12-6. doi: https://doi.org/10.25270/wmp.2020.10.1216
https://doi.org/10.25270/wmp.2020.10.121... ^,3232. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... (23.5%); skin depression¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... ^,1919. Hua W, Zuo Y, Wan R, Xiong L, Tang J, Zou L, et al. Short-term skin reactions following use of N95 respirators and medical masks. Contact Dermatitis. 2020;83(2):115-21. doi: https://doi.org/10.1111/cod.13601
https://doi.org/10.1111/cod.13601... ^,2222. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2727. Yuan N, Yang WX, Lu JL, Lv ZH. Investigation of adverse reactions in healthcare personnel working in Level 3 barrier protection PPE to treat COVID-19. Postgrad Med J. 2020;(1148):351-4. doi: https://doi.org/10.1136/postgradmedj-2020-137854
https://doi.org/10.1136/postgradmedj-202... (23.5%); irritant contact dermatitis²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2929. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic. Dermatol Ther. 2020;33(6):e14346. doi: https://doi.org/10.1111/dth.14346
https://doi.org/10.1111/dth.14346... ^,3232. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... (17.6%); rash²³23. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^,2626. Agarwal A, Agarwal S, Motiani P. Difficulties Encountered While Using PPE Kits and How to Overcome Them: An Indian Perspective. Cureus. 2020;12(11):e11652. doi: https://doi.org/10.7759/cureus.11652
https://doi.org/10.7759/cureus.11652... ^,3030. Atay S, Cura SÜ. Problems Encountered by Nurses Due to the Use of Personal Protective Equipment During the Coronavirus Pandemic: Results of a Survey. Wound Manag Prev. 2020;66(10):12-6. doi: https://doi.org/10.25270/wmp.2020.10.1216
https://doi.org/10.25270/wmp.2020.10.121... (17.6%); pressure ulcer (stage 2)²¹21. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... (11.7%) and injuries associated with moisture¹⁸18. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... ^,2424. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00... (11.7%).

Regarding the injuries associated with using protective eyewear, stage 1 pressure ulcers stood out¹⁸18. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^-2424. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... (23.5%), followed by stage 2²¹21. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... (17.6%). The injuries related to face shield use that showed higher frequency were stage 1 pressure ulcers²¹21. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^-2424. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... (23.5%). Regarding the use of gloves, xerosis²¹21. Jiang Q, Liu Y, Wei W, Zhu D, Chen A, Liu H, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: A multicentre cross-sectional survey. Int Wound J. 2020;17:1300-9. doi: https://doi.org/10.1111/iwj.13391
https://doi.org/10.1111/iwj.13391... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^-2424. Xia W, Fu L, Liao H, Yang C, Guo H, Bian Z. The physical and psychological effects of personal protective equipment on health care workers in Wuhan, China: A Cross-Sectional Survey Study. J Emergency Nurs. 2020;46(6):791-801. doi: https://doi.org/10.1016/j.jen.2020.08.004
https://doi.org/10.1016/j.jen.2020.08.00... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... ^-2929. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic. Dermatol Ther. 2020;33(6):e14346. doi: https://doi.org/10.1111/dth.14346
https://doi.org/10.1111/dth.14346... (23.5%) and fissures²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2929. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic. Dermatol Ther. 2020;33(6):e14346. doi: https://doi.org/10.1111/dth.14346
https://doi.org/10.1111/dth.14346... ^-3030. Atay S, Cura SÜ. Problems Encountered by Nurses Due to the Use of Personal Protective Equipment During the Coronavirus Pandemic: Results of a Survey. Wound Manag Prev. 2020;66(10):12-6. doi: https://doi.org/10.25270/wmp.2020.10.1216
https://doi.org/10.25270/wmp.2020.10.121... (17.6%) stood out. As for the injuries associated with using protective clothing, irritant contact dermatitis stood out²³23. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^,2626. Agarwal A, Agarwal S, Motiani P. Difficulties Encountered While Using PPE Kits and How to Overcome Them: An Indian Perspective. Cureus. 2020;12(11):e11652. doi: https://doi.org/10.7759/cureus.11652
https://doi.org/10.7759/cureus.11652... (11.7%).

The main preventive measures related to injuries caused by PPE use were grouped according to the type of PPE. For injuries resulting from using a mask, goggles and face shield, most of the articles¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... ^-1818. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... ^,2020. Gasparino RC, Lima MHM, Souza Oliveira-Kumakura AR, Silva VA, Jesus Meszaros M, Antunes IR. Prophylactic dressings in the prevention of pressure ulcer related to the use of personal protective equipment by health professionals facing the COVID-19 pandemic: A randomized clinical trial. Wound Repair Regen. 2021;29(1):183-8. doi: https://doi.org/10.1111/wrr.12877
https://doi.org/10.1111/wrr.12877... ^,2323. Shanshal M, Ahmed HS, Asfoor H, Salih RI, Ali SA, Aldabouni YK. Impact of COVID-19 on medical practice: A nationwide survey of dermatologists and health care providers in Iraq. Clin Dermatol. 2020. doi: https://doi.org/10.1016/j.clindermatol.2020.11.010
https://doi.org/10.1016/j.clindermatol.2... ^,2828. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... (27.7%) recommended using a hydrocolloid or foam dressing in the pressure regions, but other recommendations were also mentioned, such as using moisturizers and emollients for protection, especially when the professionals are not treating patients, in addition to correct adjustment of the mask and to using a protective ear strap.

As recommendations for the use of gloves, the studies cited the following: washing and drying the hands and feet well; applying a barrier cream before and after using the PPE; avoiding wearing gloves for a long time; and using cotton gloves or a layer of plastic gloves inside the latex gloves. Regarding the use of protective clothing to avoid injuries, the recommendation is to apply a barrier cream before and after using PPE items to avoid skin peeling and drying (Figure 4).

In addition to the recommendations directed to each PPE category, some studies listed recommendations for general care measures in the prevention of injuries. They were as follows: PPE removal²⁶26. Agarwal A, Agarwal S, Motiani P. Difficulties Encountered While Using PPE Kits and How to Overcome Them: An Indian Perspective. Cureus. 2020;12(11):e11652. doi: https://doi.org/10.7759/cureus.11652
https://doi.org/10.7759/cureus.11652... and not using emollients or moisturizing creams when the PPE is used for a period longer than four hours, as they can result in excessive shear forces on the skin and, in such cases, they must be replaced by talc, lanolin containing vaseline or a mixture of coconut oil, cocoa butter and beeswax, as they provide excellent long-lasting lubrication³²32. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... .

Discussion

The COVID-19 pandemic required prolonged PPE use not only by the team of health professionals, but also by the entire hospital staff. Therefore, the number of professional service providers who needed to use PPE increased considerably, as did the skin lesions associated with the intensive use of these materials. Given the lack of studies with in-depth and updated information on the occurrence of skin lesions associated with PPE use and prevention strategies, there was a growing concern in researchers to produce knowledge on the theme to assist the multiprofessional team⁷7. Gefen A, Ousey K. Update to device-related pressure ulcers: SECURE prevention. COVID-19, face masks and skin damage. J. Wound Care. 2020;29(5):245-59. doi: https://doi.org/10.12968/jowc.2020.29.5.245
https://doi.org/10.12968/jowc.2020.29.5.... .

In the studies identified in this review, surgical or N95 masks, goggles, face shields and gloves were the main factors responsible for the onset of injuries. A survey carried out in China identified that 95.1% of the health professionals who regularly used N95 masks more than 12 hours a day for a mean of 3.5 months complained of some type of skin involvement²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... . Another study observed that 47.3% of the interviewees, who used PPE items for more than four hours, also presented some type of impairment²⁸28. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... . These data indicate that, in addition to the type of PPE, use time is also a risk factor for the onset of injuries.

The WHO indicates that N95, PFF2 or equivalent masks should not be used for a period longer than four hours due to the risk of discomfort and pain. However, in times of a public health emergency and when there is shortage of equipment, they can be used, without removing them and without losing their protective effectiveness, for a long period, when caring for several patients who have the same diagnosis³⁴34. World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19): Interim guidance [Internet]. Geneva: WHO; 2020 [cited 2021 Aug 6]. 7p. Available from: https://apps.who.int/iris/handle/10665/331498
https://apps.who.int/iris/handle/10665/3... .

Persistent PPE use over the recommended time requires measures to avoid or minimize the occurrence of injuries. However, this recommendation was not observed in a study carried out in China, as only 17.7% of the interviewees used prophylactic dressings or lotions on the skin during the assistance provided. The authors believe that the fact that 42.8% of the evaluated professionals had skin lesions is related to the lack of training or to the fear of using dressings for protection, which prevented correct fixation of the PPE²⁸28. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... .

Among the types of skin injuries, stage 1 pressure ulcers were among the most frequent in those who used PPE items. In China, a study identified pressure ulcers in 30% of the professionals interviewed and, of these, 81.1% were in stage 1 and 18.3% were in stage 2²⁸28. Jiang Q, Song S, Zhou J, Liu Y, Chen A, et al. The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study Advances in Wound Care. 2020;9(7):357-64. doi: https://doi.org/10.1089/wound.2020.1212
https://doi.org/10.1089/wound.2020.1212... . Another study identified that 25.58% of the health professionals presented pressure ulcers on the face³⁵35. Singh M, Bothra A, Pawar M, Maheswari A, Tiwari A, Adhicari P. Prevalence of cheilitis in health care workers treating patients with COVID-19. J Am Acad Dermatol. 2020;83(5):e373-e374. doi: https://doi.org/10.1016/j.jaad.2020.06.1025
https://doi.org/10.1016/j.jaad.2020.06.1... , while another study evidenced that 68.9% had pressure ulcers on the nasal bridge associated with prolonged PPE use²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... .

Such lesions are formed from a sustained mechanical load that is applied to soft tissues near a bony prominence. It is noted that magnitude of the load depends on the time it is used to cause harms; therefore, a low load applied for a prolonged period causes as much tissue damage as a high load for a short period³⁶36. Haesler E, National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park: Cambridge Media; 2014. In the case of health professionals working on the front lines against COVID-19 and in an attempt to avoid respiratory infection by the Coronavirus, it was common for them to adjust their N95 masks so that the edge was in excessively close contact with the skin and the metal clip fitted firmly over the nose to ensure a complete seal²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... . This fact may have contributed to the formation of lesions on the face and nasal bridge of these professionals.

A study that evaluated the protective measures for skin lesions found that mild emollients, silicone cream and film dressing applied in the region of greater mechanical pressure between the mask and the skin were more accepted to the detriment of using foam dressings, as these require greater skill to apply and adhere them correctly. However, the authors highlighted that using creams and emollients in large amounts can facilitate adhesion of dirt, making it difficult to reuse the mask in a context of scarcity, while the film dressing needs to be removed carefully to avoid pain³⁷37. Lansang P, Orrell KA, Tran J, Chen T. Skin Damage Prevention Strategies During COVID-19: Assessing Their Effect on N95 Mask Seal Integrity. J Cutan Med Surg. 2020;24(6):646-7. doi: https://doi.org/10.1177/1203475420943861
https://doi.org/10.1177/1203475420943861... .

Foam dressings with a silicone edge are beneficial when used correctly, as shown in a study developed by nurses in Bahrain. The professionals who used the dressing presented fewer skin reactions after one hour of continuous use when compared to those who did not use any protection. Before using the face mask, it is recommended to properly prepare and cut the foam dressing and place it on the nose, on the side of the face, below the chin, central region of the forehead and close to the ears, as well as use moisturizers after removal¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... . A number of research studies have shown that the dressing does not interfere with sealing of the masks¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... ^,3737. Lansang P, Orrell KA, Tran J, Chen T. Skin Damage Prevention Strategies During COVID-19: Assessing Their Effect on N95 Mask Seal Integrity. J Cutan Med Surg. 2020;24(6):646-7. doi: https://doi.org/10.1177/1203475420943861
https://doi.org/10.1177/1203475420943861... .

Facial acne was also among the most frequent types of lesions in the studies analyzed. A survey carried out in Singapore with professionals who were assisting in the fight against the Severe Acute Respiratory Syndrome (SARS) infection in 2003 identified acne as the main skin reaction (65%) associated with prolonged use of N95 masks³⁸38. Foo CCI, Goon ATJ, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome - a descriptive study in Singapore. Contact Dermatitis. 2006;55(5):291-4. doi: https://doi.org/10.1111/j.1600-0536.2006.00953.x
https://doi.org/10.1111/j.1600-0536.2006... . Another research study carried out in India pointed to acne as the fifth most common dermatosis among health professionals who used PPE items for more than eight hours a day, behind irritant contact dermatitis, allergic dermatitis, pressure and friction marks and sweat dermatitis³⁵35. Singh M, Bothra A, Pawar M, Maheswari A, Tiwari A, Adhicari P. Prevalence of cheilitis in health care workers treating patients with COVID-19. J Am Acad Dermatol. 2020;83(5):e373-e374. doi: https://doi.org/10.1016/j.jaad.2020.06.1025
https://doi.org/10.1016/j.jaad.2020.06.1... .

The onset of acne can be explained by the obstruction of the pilosebaceous ducts caused by prolonged occlusion and local pressure on the skin due to using the mask which, together with mental stress, extremely heavy workload and sleep deprivation, contributes to the emergence of acne or to aggravation of the existing problem. For acne control, in addition to general skin care, it is recommended to wash the face twice a day, choose suitable facial cleansers, use light cosmetics or avoid them and, in mild to severe cases, use an appropriate drug treatment with topical antibiotics and/or retinoid ointment to systemic treatment, with monocycline or isotretinoin, as directed by a physician³⁹29. Long H, Zhao H, Chen A, Yao Z, Cheng B, Lu Q. Protecting medical staff from skin injury/disease caused by personal protective equipment during epidemic period of COVID-19: experience from China. J Eur Acad Dermatol Venereol. 2020;34(5):919-21. doi: https://doi.org/10.1111/jdv.16388
https://doi.org/10.1111/jdv.16388... .

Another type of skin lesion that stood out in the studies included in this review was skin depression, which can occur due to prolonged use of masks, glasses and face shields¹⁹19. Hua W, Zuo Y, Wan R, Xiong L, Tang J, Zou L, et al. Short-term skin reactions following use of N95 respirators and medical masks. Contact Dermatitis. 2020;83(2):115-21. doi: https://doi.org/10.1111/cod.13601
https://doi.org/10.1111/cod.13601... ^,2222. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2727. Yuan N, Yang WX, Lu JL, Lv ZH. Investigation of adverse reactions in healthcare personnel working in Level 3 barrier protection PPE to treat COVID-19. Postgrad Med J. 2020;(1148):351-4. doi: https://doi.org/10.1136/postgradmedj-2020-137854
https://doi.org/10.1136/postgradmedj-202... . This type of lesion usually regresses spontaneously²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,2727. Yuan N, Yang WX, Lu JL, Lv ZH. Investigation of adverse reactions in healthcare personnel working in Level 3 barrier protection PPE to treat COVID-19. Postgrad Med J. 2020;(1148):351-4. doi: https://doi.org/10.1136/postgradmedj-2020-137854
https://doi.org/10.1136/postgradmedj-202... ; however, a recommended treatment for redness and swelling consists of using a hydropathic compress with three to four layers of gauze soaked in cold water or saline every two hours, followed by the application of moisturizers²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... . Prevention of this type of injury, in addition to those already mentioned, is about the correct use of facial PPE, with the proper size, well-fitted and not tight¹⁸18. Yildiz A, Karadag A, Yildiz A, Çakar V. Determination of the effect of prophylactic dressing on the prevention of skin injuries associated with personal protective equipments in health care workers during COVID-19 pandemic. J Tissue Viability. 2021;30(1):21-7. doi: https://doi.org/10.1016/j.jtv.2020.10.005
https://doi.org/10.1016/j.jtv.2020.10.00... ^,4040. Masood S, Tabassum S, Naveed S, Jalil P. COVID-19 Pandemic & Skin Care Guidelines for Health Care Professionals. Pak J Med Sci. 2020;36(COVID19-S4):S115-S117. doi: https://doi.org/10.12669/pjms.36.COVID19-S4.2748
https://doi.org/10.12669/pjms.36.COVID19... ^-4141. Desai SR, Kovarik C, Brod B, James W, Fitzgerald ME, Preston A, et al. COVID-19 and personal protective equipment: Treatment and prevention of skin conditions related to the occupational use of personal protective equipment. J Am Acad Dermatol. 2020;83(2):675-7. doi: https://doi.org/10.1016/j.jaad.2020.05.073
https://doi.org/10.1016/j.jaad.2020.05.0... and using N95 mask straps over the head⁴¹41. Desai SR, Kovarik C, Brod B, James W, Fitzgerald ME, Preston A, et al. COVID-19 and personal protective equipment: Treatment and prevention of skin conditions related to the occupational use of personal protective equipment. J Am Acad Dermatol. 2020;83(2):675-7. doi: https://doi.org/10.1016/j.jaad.2020.05.073
https://doi.org/10.1016/j.jaad.2020.05.0... , in addition to using cotton disks fixed with hypoallergenic surgical tape in the nasal and zygomatic region to avoid friction⁴²42. Cabbarzade C. A Practical Way to Prevent Nose and Cheek Damage Due to the Use of N95 Masks in the COVID-19 Pandemic. Aesthet Surg J. 2020;40(10):608-10. doi: https://doi.org/10.1093/asj/sjaa167
https://doi.org/10.1093/asj/sjaa167... .

The presence of dermatitis was identified in health professionals who used PPE items, mainly due to using masks and alcohol gel²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... ^,4343. Long H, Zhao H, Chen A, Yao Z, Cheng B, Lu Q. Protecting medical staff from skin injury/disease caused by personal protective equipment during epidemic period of COVID-19: experience from China. J Eur Acad Dermatol Venereol. 2020;34(5):919-21. doi: https://doi.org/10.1111/jdv.16388
https://doi.org/10.1111/jdv.16388... ^-4444. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... . Such dermatitis cases can be divided into two types: allergic contact dermatitis and irritant contact dermatitis. The latter comprises a non-immunological response that commonly affects the hands and face and occurs as a result of direct damage to the skin by chemical or physical agents in a way that the skin cannot repair itself quickly. Allergic contact dermatitis is a delayed type IV hypersensitivity reaction to an external allergen that occurs only in an individual who has been previously sensitized. This re-exposure to the allergen results in circulating memory T cells that travel to the skin and trigger an immune reaction that causes skin inflammation, typically within 48 hours⁴⁵45. Rashid RS, Shim TN. Contact dermatitis. BMJ. 2016 Jun 30;353:3299. doi: https://doi.org/10.1136/bmj.i3299
https://doi.org/10.1136/bmj.i3299... .

Generally, the exposure time to allergen content and/or moisture has been identified as the main risk factor for contact dermatitis; therefore, wearing a mask and glasses for more than six hours or washing the hands more than ten times a day can increase the risk of local dermatitis. It is also important to consider additional exposure to the mask’s material, as well as repeated hand washing outside the work environment as a way to prevent SARS-CoV-2 infection⁴⁴44. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... .

Preventive measures for contact dermatitis include the application of emollients before using masks and not using them with the material responsible for burning and itching. However, if this is not possible, it is recommended to use preventive covers and/or dressings that prevent the mask from coming into direct contact with the skin, in addition to extra care such as avoiding using 75% ethanol for skin cleaning and using too hot water. Mild cutaneous rashes may spontaneously improve after three to five days without further treatment⁴³43. Long H, Zhao H, Chen A, Yao Z, Cheng B, Lu Q. Protecting medical staff from skin injury/disease caused by personal protective equipment during epidemic period of COVID-19: experience from China. J Eur Acad Dermatol Venereol. 2020;34(5):919-21. doi: https://doi.org/10.1111/jdv.16388
https://doi.org/10.1111/jdv.16388... . In turn, aggravation of pre-existing conditions such as psoriasis, atopic dermatitis and allergic reactions may require more complex management, including temporary distancing of these health professionals from work⁴⁴44. Masen MA, Chung A, Dawczyk JU, Dunning Z, Edwards L, Guyott C, et al. Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury. PLoS One. 2020;15(9):e0239363. doi: https://doi.org/10.1371/journal.pone.0239363
https://doi.org/10.1371/journal.pone.023... .

Regarding the use of gloves and protective clothing, injuries such as dry skin, itching and cutaneous rashes were present in professionals who used these PPE items for more than ten hours a day for a mean of 3.5 months²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... . Xerosis was identified in a Mexican survey as one of the main lesions found in health professionals (90.35%), followed by desquamation, erythema, fissures, vesicles and maceration, whose main affected area was the hands. The data obtained showed a significant association between lesions and using alcohol gel, with a 1.81-fold increase in the risk of xerosis³³33. Erize-Herrera JA, García-Mireles V, Uh-Sánchez I, Felix-Téllez F, Encarnación-Martínez M, Estrada-Aguilar L. Dermatological manifestations in healthcare workers associated with the use of personal protective equipment when attending patients with COVID-19 infection in hospitals in the metropolitan area of Mexico city. Piel. 2020. doi: https://doi.org/10.1016/j.piel.2020.10.004
https://doi.org/10.1016/j.piel.2020.10.0... . This lesion is characterized by a reduction in the amount and/or quality of lipids and hydrophilic substances on the skin. Management of xerosis is based on the regular use of a combination of topical substances that are intended to improve hydration, compensate for the lack of lipids and improve the skin barrier function⁴⁶46. Augustin M, Wilsmann-Theis D, Körber A, Kerscher M, Itschert G, Dippel M, et al. Diagnosis and treatment of xerosis cutis - a position paper. J Dtsch Dermatol Ges. 2019;17(7):3-33. doi: https://doi.org/10.1111/ddg.13906
https://doi.org/10.1111/ddg.13906... .

A research study, which evaluated the main skin lesions and their risk factors in the COVID-19 pandemic context in the health team, found that maceration was present in 52.9% of the sample⁴⁷47. Lin P, Zhu S, Huang Y, Li L, Tao J, Lei T, et al. Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions. Br J Dermatol. 2020;183:190-2. doi: https://doi.org/10.1111/bjd.19089
https://doi.org/10.1111/bjd.19089... . This type of injury results from prolonged exposure to moisture, which causes the skin to soften and break down so that the conjunctival fiber pulls away and the skin often appears white. Generally, this injury can be prevented by using semipermeable materials, which allow water vapor to escape, and the indicated treatment consists of using superabsorbent dressings to reduce excess moisture⁴⁸48. Whitehead F, Giampieri S, Graham T, Grocott P. Identifying, managing and preventing skin maceration: a rapid review of the clinical evidence. J Wound Care. 2017;26(4):159-65. doi: https://doi.org/10.12968/jowc.2017.26.4.159
https://doi.org/10.12968/jowc.2017.26.4.... .

With regard, specifically, to PPE use by health professionals, other preventive measures are recommended, such as choosing the appropriate size of gloves and rubber boots, applying ostomy powder on hands and feet, waiting, after hand washing and/or using alcohol gel on the skin, that it dries completely before using PPE items, as well as frequently exchanging these materials. These measures help protect the skin against friction and excessive hydration. In the case of persistent maceration, using an astringent cream, such as zinc oxide, helps to treat this type of lesion⁴³43. Long H, Zhao H, Chen A, Yao Z, Cheng B, Lu Q. Protecting medical staff from skin injury/disease caused by personal protective equipment during epidemic period of COVID-19: experience from China. J Eur Acad Dermatol Venereol. 2020;34(5):919-21. doi: https://doi.org/10.1111/jdv.16388
https://doi.org/10.1111/jdv.16388... .

Adverse skin reactions due to using coats and protective clothing are less common; however, their occurrence can be associated with the moisture generated by heavy fabrics and with the need to use them for long periods of time. Strategies such as removing the clothes for a few minutes or changing them frequently can help reduce those reactions²²22. Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore). 2020 Jun 12;99(24):e20603. doi: https://doi.org/10.1097/MD.0000000000020603
https://doi.org/10.1097/MD.0000000000020... .

A paper developed by nurses in Bahrain used a mnemonic with the word HELP to help health professionals incorporate skin care before, during and after using PPE items. In general, it was recommended to drink water regularly, keep the skin clean and hydrated (especially hands and face), observe the PPE use time, maintain a balanced diet of calories and proteins, use barrier creams ten minutes before using PPE items and protective coverings in the areas of greatest skin contact with them¹⁷17. Smart H, Opinion FB, Darwich I, Elnawasany MA, Kodange C. Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements. Adv Skin Wound Care. 2020;33(8):418-27. doi: https://doi.org/10.1097/01.ASW.0000669920.94084.c1
https://doi.org/10.1097/01.ASW.000066992... .

Despite the growing number of publications on the prevalence of injuries, prevention and treatment guidelines, studies that used a methodological approach that provided high levels of scientific evidence are still incipient. As this is an emerging topic from a new disease, the lack of a common term, descriptors or specific keywords for this, which may have left some study out the research result, stands out as a limitation of this study. In addition to that, the low number of randomized clinical trials precludes generalization of the results.

The results obtained can help health professionals, especially nurses, to know the types of skin lesions frequently associated with PPE use and which measures can be taken to prevent their occurrence. And also to support managers in carrying out training sessions for the prevention of possible injuries and incorporation of recommendations into the institution’s routine.

Conclusion

Skin lesions caused by PPE use in health professionals were more notorious during the COVID-19 pandemic, when it was possible to observe the consequences of their prolonged use on a larger scale. Most of the professionals who worked in direct care for patients infected with the new Coronavirus presented some type of skin impairment, especially those who used PPE items for a daily period of more than six hours. Masks, especially those of the N95 type, were the main factor responsible for the occurrence of skin injuries, followed by goggles, face shields and gloves. As for the injury types, acne, pressure ulcers (stages 1 and 2), skin depression and xerosis were more frequently observed in the professionals.

The main measures to prevent skin damage involve routine care, such as keeping the skin hydrated, consumption of liquids and using moisturizers and emollients, instituting the habit of skin hygiene and avoiding using excessive makeup, in addition to using protective pads on bony prominences of the face, preferably with foam and silicone edges to facilitate removal, use properly adjusted PPE items and, if possible, avoid continuous use of PPE items for prolonged periods of time.

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