Skin adverse events related to personal protective equipment: a systematic review and meta-analysis

SYSTEMATIC REVIEW Skin adverse events related to personal protective equipment: a systematic review and meta-analysis T. Montero-Vilchez, 1,2 C. Cuenca-Barrales, 1,2 A. Martinez-Lopez, 1,2 A. Molina-Leyva, 1,2, * S. Arias-Santiago 1,2,3,4 1 Department of Dermatology, Virgen de las Nieves University Hospital, Granada, Spain 2 Biosanitary Institute of Granada (ibs.GRANADA), Granada, Spain 3 Cell Production and Tissue Engineering Unit, Virgen de las Nieves University Hospital, Andalusian Network of Design and Translation of Advanced Therapies, Granada, Spain 4 Department of Dermatology, Faculty of Medicine, University of Granada, Granada, Spain *Correspondence: A. Molina-Leyva. E-mail: [email protected] Abstract Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global pandemic that has spread all over the word. To avoid the virus transmission, healthcare workers must wear adequate personal protective equipment (PPE). PPE is associated with several side events, including skin reactions. The objective of this study was to summarize the prevalence, type and risk factors for cutaneous adverse events related to PPE and prevention measures to avoid them. A systematic review and meta-analysis was conducted using MEDLINE, Scopus and EMBASE databases from conception to 21 January 2021. All types of epidemiological studies regarding skin adverse events related to PPE were included. The literature search identified 1007 references, 35 of them met the eligible criteria and were included for analysis, representing 31 453 participants. The media of skin side events related to PPE was 75.13%. The rate of cutaneous adverse events related to mask was 57.71%, and those associated with gloves and hand hygiene products was 49.16%. Most common skin adverse events were contact dermatitis, acne and itching. The most damaged anatomical regions were the nasal bridge, the cheeks and the hands. The duration of PPE wearing was the most common risk factor. Frequent handwashing, gloves and masks were the agents most frequently related to skin reactions. N95 respirators were the most harmful mask type for the skin. Hydrocolloid use prevented from developing skin adverse events related to masks. In conclusion, the rate of cutaneous adverse events related to PPE use is high. A longer duration of PPE wearing was the most common risk factor. Using hydrocolloid could prevent from skin injuries related to mask use. Received: 4 March 2021; Accepted: 21 May 2021 Conflicts of interest The authors declare no conflict of interest. Funding source None. Introduction In December 2019, a novel virus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and causal agent of the novel coronavirus-2019 disease (COVID-19), emerged in Wuhan, China Popular Republic, and rapidly spread around the world. Currently, more than 90 million people have been infected, with up to 2 million of deaths worldwide. 1 To fight against the pandemic and avoid the virus transmission, healthcare workers (HCWs) must wear adequate personal protective equipment (PPE), including medical masks, goggles or face shields, plastic gowns and gloves, and perform frequent handwashing. 2 The long-term working sessions and the daily use of the PPE can lead to physical and psychological disturbances among HCWs. 3,4 Moreover, several cutaneous adverse events have been related to PPE. 5 Nevertheless, the prevalence of skin cutaneous adverse events related to PPE ranges between different studies, 6,7 it is not known the type of material most likely to cause skin damage, and there is scarce evidence regarding preventive measures to avoid adverse skin events related to PPE. 8,9 The aims of this study were to summarize the prevalence, type and risk factors for cutaneous adverse events related to PPE and to evaluate preventive measures taken to avoid cutaneous adverse events related to PPE in HCWs and the general population. ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. DOI: 10.1111/jdv.17436 JEADV Material and methods Design A systematic review and meta-analysis were conducted (Supplementary Material). Research questions: 1 What is the prevalence of skin adverse events related to PPE? 2 Which are the most common skin adverse events associated with PPE and which are the most affected regions? 3 What are the risk factors for developing skin side events related to PPE? 4 What is the prevalence and what kind of side events are related to mask use? 5 What is the prevalence and what kind of side events are related to gloves and handwashing? 6 What prevention measures could be taken to avoid skin adverse events related to PPE? Search strategy A literature search was performed using MEDLINE, Scopus and EMBASE databases from conception to 21 January 2021, following PRISMA Guidelines (Supplementary Material). The following search algorithm was used: ((PERSONAL PROTECTIVE EQUIPMENT) OR GLOVES OR MASK OR FACEMASK OR (RESPIRATORY EQUIPMENT) OR (ALCOHOL-BASED HAND RUB) OR SOAP OR ALCOHOL) AND (SKIN OR CUTANEOUS OR DERMATOLOGY OR (SKIN REACTION) OR (SKIN ADVERSE EVENTS)) AND (COVID-19 OR (CORONAVIRUS DISEASE 2019)). Inclusion and exclusion criteria The search was limited to: (i) human data, (ii) in vivo studies, (iii) skin adverse events related to PPE and (iv) articles written in English. All types of epidemiological studies (clinical trials, cohort studies, case–control studies and crosssectional studies) regarding skin adverse events related to PPE were included and analysed. Reviews, guidelines, protocols, case series, case reports and conference abstracts were excluded. Study selection Two researchers (TMV and CCB) independently reviewed the titles and abstracts of the articles obtained in the first search to assess relevant studies. The full texts of all articles meeting the inclusion criteria were reviewed, and their bibliographic references were checked for additional sources. The articles considered relevant by both researchers were included in the analysis. Disagreements about inclusion or exclusion of articles were subjected to discussion until a consensus was reached. If not reached, resolution was achieved by discussion with a third researcher (AMLo). Variables The variables assessed were study design, rate and type of skin adverse events related to PPE, risk factors for developing skin manifestations, number of participants, author, country, age, sex, assessment tools, anatomical regions damaged and kind of preventive measures. Statistical analysis The overall prevalence of skin cutaneous events related to PPE was calculated by a random effect meta-analysis weighted by the study sample size. Forest plots were constructed to summarize the prevalence estimates and their 95% CIs. These figures present measures of heterogeneity across studies (Cochrane Q statistic, noted the I2 statistic). Microsoft Excel version 2016, Redmond, WA, USA, was used to run these data. 10 Results The literature search identified 1007 references, 668 after removing duplicated papers. After reviewing the title and abstract, 136 records underwent full-text review. A total of 101 records were excluded because they did not investigate skin adverse events associated with PPE. Other reasons for exclusion along with the flow chart are shown in Fig. S1 (Supporting Information). Finally, 35 studies, representing 31 453 participants, met the eligible criteria and were included and fully reviewed. What is the prevalence of skin adverse events related to general personal protective equipment? The media of skin side events related to PPE was 75.13%, after conducting a random effect meta-analysis weighted by the study sample size (Fig. S1, Supporting Information). Thirteen studies explored cutaneous adverse events related to PPE. 5–7,11–20 Seven studies evaluated the prevalence of skin side events related to PPE. 5–7,11–14 All the reports were cross-sectional studies that evaluated the presence of skin side events with self-administered questionnaires. 1912 out of 2424 participants had skin side events, with high female:male ratio, and an age ranged from 20 to 65 years (Table 1). Which are the most common skin adverse events associated with PPE and which are the most affected regions? Contact dermatitis, acne and eczema were the most frequent disorders; 19,20 itching and burning the most common symptoms; 20 and erythema and papules the most frequent signs. 20 The prevalence and the type of specific skin conditions related to PPE and the features of skin side events were also investigated 15–18 (Table S1, Supporting Information). The most frequently damaged anatomical regions were the nasal bridge (67.22%), the cheeks (66.9%) and the hands (62.6%). 5,12,13 Soap and water (56.4%), gloves (47.5%), ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 2Montero-Vilchez et al. Table 1 Studies regarding prevalence of skin adverse events related to personal protective equipment Study and site Design Participants Age (years) Sex (female: male ratio) Assessment tools Prevalence of skin side events Most common adverse events Anatomical regions most damaged Risk factors Yuan Netal. China Cross-sectional study 129 HCWs NS NS Online selfadministered questionnaire 94.6% (122/129) Facial indentation, rash, dermatitis NS NS Swaminathan Ret al.UK Cross-sectional study 72 HCWs NS 1.7:1 Online selfadminister questionnaire 43.2% (31/72) NS NS NS Pei S et al. China Cross-sectional study 484 HCWs 20–60 3.14:1 Online selfadminister questionnaire 73.1% (354/484) Pruritus, erythema, prurigo, blisters, rhagades, papule/ oedema, exudation/ crust, lichenification Face, hand, limbs, trunk High level of protection, higher working frequency, longer duration of wearing protective suits† Lin P et al. China Cross-sectional study 376 HCWs NS 3.5:1 Questionnaire 74.5% (280/376) NS Hands, cheeks, nasal bridge Female sex, working in hospitals with a more severe epidemic, working in inpatient wards, longer PPE wearing periods (>6h)‡ Lan J et al. China Cross-sectional study 542 HCWs 20–56 3.8:1 Online selfadminister questionnaire 97.0% (526/542) Symptoms: Dryness/ tightness, tenderness, itching, burning/pain Signs: Desquamation, erythema, maceration, fissure, papule, erosion and ulcer, vesicle, wheal Nasal bridge, cheek, hands, forehead. Wearing a N95 mask or goggles, longer PPE wearing periods (>6 h), frequent hand hygiene (>10 times daily)‡ Daye M et al. Turkey Cross-sectional study 440 HCWs 33.5 (21.0–65.0) 1.5:1 Questionnaire 90.2% (397/440) Dryness, itching, flaking, tingling, spalling, peeling, lichenification NS Not using moisturizers, previous history of allergies or skin disease, using mask with metal nose bridge and located especially on the nose§ Battista RA et al. 2020. Italy Cross-sectional study 381 participants (185 HCWs, 31 people with high public contact job, 165 with low public exposure) 35.0 11.7 2:1 Email/phone questionnaires 53.02% (202/381) Itching, acne, skin rash, pressure-related symptoms NS Longer PPE wearing periods (>6 h), using a N95/FFP2 mask‡ Continuous data are expressed as media SD or median (interquartile range), and categorical data are presented as relative(absolute) frequencies. HCWs, healthcare workers; L3PPE, level 3 barrier protection personal protective equipment; NS, not specified; PPE, personal protective equipment. †Non-defining statistical test. ‡Logistic regression analyses. §Chi-square (v 2 ) test. ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 Skin and personal protective equipment 3 sanitizers (38.6%) and masks (20.8%) were the most frequent culprit agents. 20 What are the risk factors for developing skin side events related to PPE? Longer duration of PPE wearing was the risk factor most frequently associated with skin side events. 5,7,12–14,19,20 Other risk factors related to high rate of cutaneous adverse events were female sex, 12 non-use of moisturizers, 14 a previous history of dermatitis 16 or wearing a N95 mask compared with a surgical one. 7 What is the prevalence and what kind of side events are related to mask use? The media prevalence of skin side events related to mask use was 57.17% after conducting a random effect meta-analysis weighted by the study sample size (Fig. S2, Supporting Information). Eleven studies evaluated the skin effects related to mask wearing. 21–31 Four studies analysed the overall prevalence of skin side events related to mask wearing 21–24 (Table 2). All of them were cross-sectional studies assessing the prevalence by questionnaires. 5296 participants were included, 3900 non-HCWs and 1396 HCWs. 2430 participants reported cutaneous adverse events related to mask use. The prevalence of skin side events related to mask use was higher in HCWs (63.14%) than that in non-HCWs (42.38%) without statistically significant differences (Fig. S4, Supporting Information). Longer periods of mask wearing were a risk factor for skin adverse events, 21,22 while controversial results were found regarding the type of mask. Most reports observed that wearing a surgical mask was a risk factor for developing skin side events compared with other kind of mask. 21,23,24 Nevertheless, Matusiak et al. 22 showed that surgical mask was a protective factor for sweating and itch. Acne and itching were the most common adverse events reported in these studies. 21–23 Moreover, two studies analysed itching related to mask wearing 25,26 (Table 2). Itching was reported in 875 out of 4644 participants. The worst intensity of itch using a numeric rating scale was moderate in most cases. Sensitive skin, atopic predispositions, facial dermatoses (such as acne or seborrheic dermatitis) and longer periods of mask use were risk factors for developing mask-related itching. 25,26 The frequency of itching was also higher in people wearing a N95/FFP2 mask compared with other types of masks. 25 In addition, five studies evaluated skin barrier function impairment due to mask wearing 27–31 (Table 3). Temperature 27,28,30,31 and redness or erythema 28–30 were higher while stratum corneum hydration (SCH) 28–30 was lower on the maskcovered area compared with the non-covered one. Controversial results were observed in other parameters. The effect in skin barrier function between surgical mask and N95 one has been evaluated in three studies. 27,29,30 Two studies showed higher transepidermal water loss (TEWL) values on the mask-covered area compared with the non-covered, 29,30 while another two investigations did not report changes between both areas. 28,31 Comparing different types of masks, it was observed that temperature increase was higher when using a N95 mask (1.2 vs. 0.7°C). 28 Nevertheless, greater TEWL increases were found when using a surgical mask (12.54 vs. 5.28 g/h/m 2 ,P=0.026). 30 Other study did not report differences in skin homeostasis parameters between types of masks. 30 What is the prevalence and what kind of side events are related to gloves and handwashing? The media prevalence of skin side events related to gloves and handwashing was 49.16% after conducting a random effect meta-analysis weighted by the study sample size (Fig. S5, Supporting Information). Skin effects related to gloves use and handwashing were evaluated in nine studies 24,30,32–38 (Table 4). Three studies evaluated the general prevalence of skin adverse events associated with gloves use and hand hygiene in 3713 participants (3283 non-HCWs and 430 HCWs). 24,32,33 1475 participants reported skin side events. The prevalence of skin side events related to gloves and handwashing was higher in HCWs (68.16%) than in non-HCWs (36.88%; Fig. S6, Supporting Information). One report also found that hand skin manifestations increased by 8.4% compared with the prepandemic period. 33 Most common adverse event was dryness, erythema, itching and fissures. 24,32,33 Female sex, 33 working in unit with COVID-19 patients, 33 handwashing more than 10 times/day, 24 alcohol concentration >60% 24 and using gloves 24 were related to a higher rate of skin adverse event. 33 Furthermore, three studies evaluated the prevalence and risk factors of hand eczema in 7079 participants (6858 children and 221 HCWs). 34,36,37 The prevalence of hand eczema in children was 38.3% (2627/6858) during the pandemic, and it increased by 26.2% compared with the prepandemic period. The prevalence of hand eczema in HCWs was between 14.9% 36 and 50.5% 37 without differences between HCWs working in COVID-19 intensive care units and HCWs without frequently contact with COVID-19 patients. 36 People in the first group were surgeons and nurses from a single surgical centre, and participants in the second group were physicians and nurses from an intensive care unit for COVID-19 patients. The median Hanc Eczema Severity Index was 24 (range 3–84). 37 Female gender, 34 previous history of atopic dermatitis 34 or hand eczema 37 and high frequency of handwashing 34,37 were risk factors associated with hand eczema. Its most frequent morphology was erythematous squamous (75.8%, 41/54), and the most common affected area was the hand dorsum (85.2%, 46/54). 37 Contact urticaria was observed in 8.2% (32/390) HCWs and was associated with the number of working hours and previous history of dermatological diseases. 35 Irritant contact dermatitis was reported in 42.4% (4496/6273) children. Female gender and ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 4Montero-Vilchez et al. Table 2 Studies regarding the prevalence of skin adverse events related to mask wearing Study and site Design Participants Age (years) Sex (female: male ratio) Type of masks Assessment tools Prevalence of skin adverse events Main adverse events Risk factors General skin adverse events Techasatian L et al. Thailand Cross-sectional study 833 participants. 357 HCWs (42.9%) and 476 non-HCWs (57.1%) 32 (IQR 25–41) 2.75:1 -526 surgical masks (63.15%) -292 cloth masks (35.05%) -9 surgical masks covered by a piece of cloth (1.0%) -6 N95 masks (0.72%) Questionnaire 54.5% (454/833) Acne, rashes, itch, pigmentation and pressure-related skin injuries Wearing a surgical mask compared with a cloth mask, longer periods of mask wearing (>4 h), mask reuse† Matusiak, Łet al. Poland Crosssectional study 876 HCWs From 18 to 27 NS NS Online questionnaire 96.9% (849/876) Warming/ sweating, itch, skin irritation Not wearing a surgical mask compared with the other types of masks† Chaiyabutr C et al. Thailand Cross-sectional study 1231 non-HCWs NS 2.81:1 -1231 fabric masks (52.3%) -552 surgical masks (44.8%) -N95 mask (2.8%, n=35) Online selfadministered questionnaires 62.3% (767/1231) Acne, itching, greasy skin, erythematous rash, pain on mask border, dry skin, worsening of pre-existing dermatoses, abrasion Surgical mask, female sex, age <40 years, having oily skin, having acne before starting to wear masks, longer periods of mask wearing (>4h)† Alsaidan MS et al. 2020. Saudi Arabia Cross-sectional study 2356 participants. HCWs (6.91%, n=163) and nonHCWs (93.1%, n=2193) 21 (IQR 18–26) 0.78:1 -1779 surgical/face masks (75.5%) -430 others (18.3%) Online selfadminister questionnaire 15.3% (360/2356) Dryness, scaling, itchiness, redness, change in texture, change in colour, pain/ burning, ulcer Wearing a surgical mask compared with other types of mask‡ Itching Szepietowski et al. Poland Cross-sectional study 2315 Polish students 20.2 1.7 4.07:1 -755 three layers surgical mask (54.2%) -891 cloth mask (64%) -257 respirators (N95 +FFP) (18.4%) -16 half-face elastomeric respirator (1.1%) -8 full-face respirator: (0.4%) Online questionnaire 19.6% (273/1393) The WI-NRS was assessed as 4.07 2.06 points (range 0– 10 points), indicating itch of moderate severity Sensitive skin, atopic predisposition, having atopic dermatitis, acne or seborrheic dermatitis and wearing face masks for longer periods (>5h)† ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 Skin and personal protective equipment 5 high frequency of handwashing were associated with high rate of irritant contact dermatitis. 32 Only one study reported objective impairment in skin barrier function associated with nitrile gloves use. They showed higher TEWL (31.11 vs. 14.24 g/h/m 2 ,P<0.001), SCH (43.26 vs. 58.28 AU, P<0.001), temperature (33.29°C vs. 32.57°C, P<0.001) and erythema (243.97 vs. 215.55 AU, P<0.001) at the area covered by gloves compared with the non-covered area. 30 What prevention measures could be taken to avoid skin adverse events related to PPE? Hydrogel patch, small patches used in areas of pressure points of PPE, could be used to avoid skin injuries related to mask use. Four studies evaluated prevention measures for avoiding skin adverse events related to PPE 8,39–41 (Table 5). All of them were focused on preventing skin injuries related to mask use. Zhou et al. 39 observed that hydrogel use decreased pain, itching and indentation both on cheeks and on nasal bridge in 26 HCWs wearing N95 masks. Moreover, Dong et al. 41 observed that the use of hydrogel patch on one side of the face reduced overall skin reaction rate (including indentation, redness and pain) compared with the other side without hydrogel in 19 front-line HCWs using N95 masks. Dressing mask with extra-thin hydrocolloid was also compared with foam dressing in 88 HCWs without differences between groups in skin injuries. 8 Furthermore, it was also observed that the use of prophylactic dressing and nasal strip reduced skin injuries by 2.5 times. Itching, erythema, papules, pustules and discomfort in breathing were also reduced, while satisfaction scores increased. 40 Moreover, it has been reported that the use of moisturizing hand cream might prevent from developing skin adverse events related to handwashing and gloves use (Table 4). Discussion In this systematic review, we have observed that the prevalence of skin adverse events related to PPE is high. Contact dermatitis, acne, eczema and itching were the most common skin adverse events. Masks and gloves are the agent most frequently related to cutaneous side events. Longer duration of wearing PPE was the most frequent risk factor for developing cutaneous reactions. Prevention measures were focused on skin injuries related to mask use. Three out of four individuals could develop skin adverse events related to PPE. Nevertheless, this rate showed high variation between studies. 5–7,11–14 Differences in participants (nonHCWs, HCWs in frequently contact with COVID-19 patients or HCWs not working in COVID-19 units) could explain these disparities. 7 Moreover, the prevalence of skin adverse events was mainly evaluated by self-administered questionnaires. High variability rate was also observed in skin side events associated with masks, 21–24 and gloves and handwashing. 24,32,33 It was observed that the rate of skin side events related to both mask and gloves Table 2 Continued Study and site Design Participants Age (years) Sex (female: male ratio) Type of masks Assessment tools Prevalence of skin adverse events Main adverse events Risk factors Krajewski PK et al. Poland Cross-sectional study 2329 participants (1156 HCW and 1173 students) HCW: 40.5 11.8 Students: 20.9 2.9 HCW: 4.48:1 Students: 2.79:1 -1363 surgical mask (58.52%) -591 cloth mask (25.37%) -221 respirators (N95/FFP2) (9.49%) -138 half-face mask: (5.93%) Online questionnaire All participants: 25.8% (602/2329) HCWs: 31.6%, (365/1156) Students 20.2%, (237/1173) The WI-NRS was 4.6 2.0 points for the whole population, 4.6 2.0 points for HCWs and 4.7 2.1 points for students, indicating a moderate itch severity Sensitive skin, atopic predispositions, facial dermatoses, wearing face masks for longer periods (>4 h), wearing a N95/ FFP2 mask compared with other types of masks§ Continuous data are expressed as media SD or median (interquartile range), and categorical data are presented as nor n/N(%). AD, atopic dermatitis; FFP2, filtering respirator mask coded filtering facepiece 2; HCW, healthcare workers; NRS, numeric rating scale, SCH, stratum corneum hydration, TEWL, transepidermal water loss; WI-NRS, worst intensity of itch. †Logistic regression analyses. ‡Chi-square (v 2 ) test. §Kruskal–Wallis one-way analysis of variance on ranks. ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 6Montero-Vilchez et al. Table 3 Studies regarding skin barrier dysfunction related to mask use Study and site Design Participants Age (years) Sex (female: male ratio) Type of masks Assessment tools Outcomes after mask removal Outcomes comparing types of masks Scarano A et al. Italy Prospective observational crossover study 20 non-HCWs NS NS - Surgical mask - N95 maskWearing it for 1 h Skin temperature, humidity, heat, discomfort, mask touching Temperature increased at the perioral region and superior lip immediately after removal of the mask compared with baseline Higher increases in temperature were observed with N95 wearing (1.2 0.5) compared with surgical masks (0.7 0.5°C). Humidity heat, breathing difficulty, discomfort and mask touching were also higher under the N95 Park SR et al. Republic of Korea Prospective observational study 21 non-HCWs From 20 to 49 NS Korea Filter 94 mask for 6 h Temperature, redness, sebum secretion, SCH, TEWL, elasticity Temperature and redness increased while SCH decreased on the maskcovered area compared with the non-covered area. Sebum secretion, TEWL and elasticity did not change NS Montero-Vilchez et al. Spain Cross-sectional study 34 HCWs 44.97 11.97 1.6:1 - Surgical masks (52,94%, n=18) - FFP2 masks (47.06%, n=16) TEWL, SCH, temperature, erythema TEWL, temperature and erythema were higher on the area covered by masks compared with the noncovered area while SCH was lower TEWL was significantly greater at the area covered by a surgical mask than at the FFP2 one (12.54 vs. 5.28 g/h/m 2 ,P=0.026) Kim J et al. Korea Prospective observational study 20 non-HCWs 28.10 3.49 0.8:1 Korea Filter 94 mask for 6 h daily for 2 weeks Temperature, redness, pore volume, texture, elasticity, TEWL, sebum content, pH Temperature and pore volume increased after mask use. Elasticity and pH decreased. No differences in redness, roughness, TEWL and sebum were observed NS Hua W et al. China A randomized crossover study with repeated measurements 20 non-HCWs 34.3 11.5 10:1 - N95 respirators - Surgical masks TEWL, SCH, erythema, pH and sebum secretion SCH, TEWL, pH and erythema increased significantly after mask use and were higher at the area covered by the mask than at the non-covered area There was no significant difference between the physiological values between the two types of masks. More adverse reactions and a higher score of discomfort and incompliance were reported following N95 mask use that following use of medical mask Continuous data are expressed as media SD or median (interquartile range), and categorical data are presented as nor n/N(%). AD, atopic dermatitis; FFP2, filtering respirator mask coded filtering facepiece 2; HCW, healthcare workers; NRS, numeric rating scale, SCH, stratum corneum hydration, TEWL, transepidermal water loss; WI-NRS, worst intensity of itch. ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 Skin and personal protective equipment 7 Table 4 Skin adverse events related to gloves use and handwashing Study and site Design Participants Age (years) Sex (female: male ratio) Assessment tools Aim Main outcome Other outcomes Risk factors Overall prevalence of skin adverse events Dindarloo K et al. Iran Crosssectional study 1090 non-HCWs 35.22 (range from 15 to 70) 1.12:1 Self-administered questionnaire Overall prevalence of skin adverse events 41.4% (451/1090) Most common skin adverse events: dryness, itching, redness and injuries NS Altuniski Toplu Set al. Turkey Crosssectional study 267 HCWs 35.0 6.9 1.63:1 Self-administered questionnaire Overall prevalence of skin adverse events 73.6% (203/267) Most commons skin adverse events: dryness, erythema, hand fissure, itching, burning-pain, vesicle Female sex, working in units without COVID-19 patients¶ Alsaidan MS et al. 2020. Saudi Arabia Crosssectional study 2356 participants. HCWs (6.91%, n=163) and non-HCWs (93.1%, n=2193) 21.00 (IQR: 18–26) 0.78:1 Online selfadministered questionnaire Overall prevalence of skin adverse events 34.85% (821/2356) Most commons skin adverse events: dryness, change in texture, scaling, itchiness, change in colour, redness, pain/ burning, ulcer Handwashing >10 times/day, alcohol concentration >60%, using hand gloves§ Prevalence of a specific skin condition Simonsen AB et al. Denmark Crosssectional study 6858 children using day care 3.4 1.37 1:1 Parental selfadministered questionnaire Prevalence of hand eczema 38.3% (2627/6858) The prevalence of hand eczema increased by 26.2% after the pandemic Atopic dermatitis, female gender, older age, high frequency of handwashing‡ Pourani MR et al. Iran Crosssectional study 390 HCWs 34.57 9.41 2.9:1 Online selfadministered questionnaire Prevalence of hand contact urticaria 8.2% (32/390). The rate of hypersensitivity to latex gloves was 32.6% (123/390) in all HCWs and 53.1% (17/ 32) in HCWs with contact urticarial Longer work hours per week, history of dermatological diseases, allergic conjunctivitis, asthma, hypersensitivity to latex gloves† Guertler A et al. Crosssectional study 114 HCWs: 35.9% (40/ 114) HCWs involved in intensive care and 64.91% (74/114) HCWs not involved 35.23 10.78 1.59:1 Self-administered questionnaire Prevalence of hand eczema 14.9% (17/114) No differences in hand eczema between HCWs involved in intensive care of COVID-19 patients and HCWs without direct contact with COVID-19 patients were found NS ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 8Montero-Vilchez et al. Table 4 Continued Study and site Design Participants Age (years) Sex (female: male ratio) Assessment tools Aim Main outcome Other outcomes Risk factors Erdem Y et al. Turkey Crosssectional study 107 HCWs 29.6 6.3 2.06:1 Clinical evaluation Prevalence of hand eczema 50.5% (54/107) The median HECSI score was 24 (range 3 –84) The use of moisturizing hand cream in daily life, a previous history of hand eczema, handwashing frequency (>20 times/day)‡ Borch L. Denmark Crosssectional study 6273 children 6.70 3.12 1:1 Self-administered questionnaire Prevalence of irritant contact dermatitis 42.4% (4496/6273) NS Female gender, schoolchildren compared with preschool, handwashing >7 times/day†† Assessment of skin barrier function parameters MonteroVilchez T et al. Spain Crosssectional study 34 HCWs 44.97 11.97 1.62:1 Skin homeostasis parameters: TEWL, SCH, temperature, erythema To evaluate the effect of using nitrile gloves on epidermal barrier function TEWL (31.11 vs. 14.24 g/h/m 2 ,P<0.001), SCH (43.26 vs. 58.28 AU, P<0.001), temperature (33.29°C vs. 32.57°C, P<0.001) and erythema (243.97 vs. 215.55 AU, P<0.001) were higher at the area covered by gloves compared with the non-covered area NS Continuous data are expressed as media SD or median (interquartile range), and categorical data are presented as nor n/N(%). HCWs, Healthcare workers; HECSI, Hand Eczema Severity Index; SCH, stratum corneum hydration, TEWL, transepidermal water loss. †Analysis not specified. ‡Logistic regression analyses. §Chi-square (v 2 ) test. ¶McNemar test. ††Poisson regression with robust error variance. ©2021 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology JEADV 2021 Skin and personal protective equipment 9