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      Skin damage among health care workers managing coronavirus disease-2019

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          Abstract

          To the Editor: Since the outbreak of coronavirus disease-2019 (COVID-19) in December 2019, more than 200,000 health care workers from all over China have been participating in the fight against this highly contagious disease in Hubei province, which is the center of infection in China. Skin damage caused by enhanced infection-prevention measures among health care workers, which could reduce their enthusiasm for overloaded work and make them anxious, has been reported frequently. Previous studies have revealed that hand eczema is quite common in health care workers, 1 , 2 and the risk factors include frequent hand hygiene and wearing gloves for a long time. 3 , 4 Considering the frequent hand hygiene and long-time wearing of tertiary protective devices (N95 mask, goggles, face shield, and double layers of gloves) among health care workers during the epidemic period of COVID-19, we aimed to estimate the prevalence, clinical features, and risk factors of this skin damage among them. From January to February 2020, self-administered online questionnaires were distributed to 700 individuals, consisting of physicians and nurses who worked in the designated departments of tertiary hospitals in Hubei, China. The questionnaire included questions about the condition of skin damage and the frequency or duration of several infection-prevention measures (Supplemental Material 1, available via Mendeley at https://data.mendeley.com/datasets/zknvry83v5/2). Finally, 542 individuals (Supplemental Material 2) completed the study (response rate, 77.4%), with 71.4% (387 of 542) working in isolation wards and 28.6% (155 of 542) working in fever clinics. The general prevalence rate of skin damage caused by enhanced infection-prevention measures was 97.0% (526 of 542) among first-line health care workers. The affected sites included the nasal bridge, hands, cheek, and forehead, with the nasal bridge the most commonly affected (83.1%). Among a series of symptoms and signs, dryness/tightness and desquamation were the most common symptom (70.3%) and sign (62.2%), respectively (Table I ). The health care workers who wore some medical devices more than 6 hours had higher risks of skin damage in corresponding sites than those who did for less time (N95 masks: odds ratio [OR], 2.02; 95% confidence interval [CI], 1.35-3.01; P < .01); goggles: OR, 2.32; 95% CI, 1.41-3.83, P < .01), whereas a longer time of wearing a face shield was not a significant risk factor in causing forehead skin damage (OR, 1.52; 95% CI, 0.93-2.50; P = .66). The more frequent (>10 times daily) hand hygiene could increase the risk of hand skin damage (OR, 2.17; 95% CI, 1.38-3.43; P < .01), rather than a longer time of wearing gloves (Table II ). Table I Clinical features of skin damage among first-line health care workers Clinical features∗ Participants with skin damage (N = 526), No. (%) Symptoms  Dryness/tightness 370 (70.3)  Tenderness 299 (56.8)  Itching 276 (52.5)  Burning/pain 200 (38.0) Skin lesions  Desquamation 327 (62.2)  Erythema 260 (49.4)  Maceration 210 (39.9)  Fissure 204 (38.8)  Papule 173 (32.9)  Erosion and ulcer 53 (10.1)  Vesicle 7 (1.3)  Wheal 2 (0.4) Site  Nasal bridge 437 (83.1)  Cheek 414 (78.7)  Hands 392 (74.5)  Forehead 301 (57.2) ∗ With overlaps. Table II The association between skin damage and related exposure factors Infection-preventive measures Participants, No. Variables Participants (N = 526), No. (%) Participants with skin damage in related sites, No. (%) OR 95% CI P N95 mask 542 ≤6 h/d 225 (41.5) Cheek: 155 (68.9) 1 [Ref] >6 h/d 317 (58.5) Cheek: 259 (81.7) 2.02 1.35-3.01 <.01 Goggles 451 ≤6 h/d 186 (41.2) Nasal bridge: 141 (75.8) 1 [Ref] >6 h/d 265 (58.8) Nasal bridge: 233 (87.9) 2.32 1.41-3.83 <.01 Face shield 265 ≤6 h/d 108 (40.8) Forehead: 52 (48.1) 1 [Ref] >6 h/d 157 (59.2) Forehead: 92 (58.6) 1.52 0.93-2.50 .66 Gloves 113∗ ≤6 h/d 52 (46.0) Hands: 29 (55.8) 1 [Ref] >6 h/d 61 (54.0) Hands: 39 (63.9) 1.41 0.66-3.00 .44 321† ≤6 h/d 131 (40.8) Hands: 100 (76.3) 1 [Ref] >6 h/d 190 (59.2) Hands: 146 (76.8) 1.03 0.61-1.74 >.99 Hand hygiene 434 ≤10 times/d 113 (26.0) Hands: 68 (60.2) 1 [Ref] >10 times/d 321 (74.0) Hands: 246 (76.6) 2.17 1.38-3.43 <.01 CI, Confidence interval; OR, odds ratio; Ref, reference. ∗ These participants are limited to those who wore double layers of gloves and washed hands 1-10 times/d. † These participants are limited to those who wore double layers of gloves and washed hands >10 times/d. Our study has some limitations. Firstly, we only studied 1 site with a single exposure factor, but some sites could be related to more than 1 factor. The nasal bridge, for example, could be compressed by the N95 mask and goggles simultaneously, although goggles were the main factor. Secondly, possible risk factors such as participants wearing the N95 mask after work in daily life were not included. In conclusion, our study demonstrated that the prevalence of skin damage of first-line health care workers was very high. Moreover, we found that longer exposure time was a significant risk factor, which highlights that the working time of first-line staff should be arranged reasonably. Besides, prophylactic dressings could be considered to alleviate the device-related pressure injuries, according to a prior study. 5

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          Most cited references5

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          Wet work exposure and hand eczema among healthcare workers: a cross-sectional study.

          Hand eczema is more common in healthcare workers than in the general population. Hands are subject to changing occupational exposures as a result of mandatory hygiene regulations for healthcare workers.
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            A survey of occupational hand eczema in Denmark.

            Occupational hand eczema (OHE) is the most frequently recognized work-related disease in Denmark and the annual cost to society is high. Understanding of the epidemiology of OHE is essential to be able to give appropriate recommendations for its prevention. The study comprised 758 persons, 490 females and 268 males with recognized OHE in the period October 2001 to November 2002. Data were obtained prospectively from the National Board of Industrial Industry Registry and from a self-administered questionnaire (response rate, 82%). The most frequently recognized diagnosis was irritant contact dermatitis (ICD), mainly caused by wet occupations. The proportion of occupational ICD was equal for males and females, 59.7% and 63.1%, respectively. The estimated rates of OHE were high for bakers, hairdressers and dental surgery assistants, and a high proportion of apprentices were found among hairdressers. The prevalence of atopic dermatitis was low (16.4%) compared to previous studies among hand eczema patients. The prevalence of occupational allergic contact dermatitis in the study population was substantially higher among males than females, and the most frequent causes among males were allergy to chromium (leather exposure), rubber additives (gloves) and nickel due to exposure from work tools and metalworking industry.
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              Self-reported hand eczema in a hospital population.

              Occupational skin diseases are frequent in the healthcare sector. The objective of this study was to obtain baseline data on hand eczema and risk factors for hand eczema in an unselected hospital population. A questionnaire study on hand eczema and risk factors for hand eczema was performed among hospital employees at a middle-size Danish hospital. A total of 1909 employees from all job groups and all departments were included. Response rate was 65.3%. The overall frequency of self-reported hand eczema within the past 12 months was 23%. Divided into job groups, the frequencies varied from 8% to 32% and were significantly higher among assistant nurses (32%), nurses (30%), and nursing aids (27%). For the individual departments, the hand eczema frequencies varied from 7% to 50%, with the highest frequencies reported at medical and surgical wards. Occupational risk factors for hand eczema such as use of protective gloves and hand washing were significantly more frequent among respondents with hand eczema within the past year, which suggests a potential for prevention through workplace interventions. In conclusion, high frequencies of hand eczema were observed among assistant nurses, nurses, and nursing aids. Hand eczema was more frequent among women and in the younger age groups.
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                Author and article information

                Contributors
                Journal
                J Am Acad Dermatol
                J. Am. Acad. Dermatol
                Journal of the American Academy of Dermatology
                by the American Academy of Dermatology, Inc.
                0190-9622
                1097-6787
                18 March 2020
                May 2020
                18 March 2020
                : 82
                : 5
                : 1215-1216
                Affiliations
                [a ]Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
                [b ]Hubei Engineering Research Center for Skin Repair and Theranostics, Wuhan, China
                [c ]Second Clinical Medical College, Chongqing Medical University, Chongqing, China
                [d ]Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
                [e ]Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China
                [f ]Hunan Normal University School of Medicine, Changsha, China
                [g ]Department of Dermatology, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
                [h ]Department of Dermatology, Renhe Hospital, Three Gorges University, Yichang, China
                [i ]Department of Dermatology, Xiangyang Hospital, Hubei University of Chinese Medicine, Xiangyang, China
                Author notes
                []Correspondence to: Juan Tao, MD, PhD, Department of Dermatology, Union Hospital, Tongji Medical College, No. 1277 Jiefang Ave, Wuhan, Hubei, 430022 China tjhappy@ 123456126.com
                Article
                S0190-9622(20)30392-3
                10.1016/j.jaad.2020.03.014
                7194538
                32171808
                d596f12f-9176-4bcd-904b-d78342fc31d3
                © 2020 by the American Academy of Dermatology, Inc.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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