The current Center for Disease Control and Prevention and the World Health Organization guidance states that in order to decrease the rate of transmission of the virus, it is imperative to social distance, practice self-imposed isolation, protect mucous membranes with masks and glasses, and to wash hands properly before touching the face. Worldwide, millions of people are adhering to these recommendations to prevent exposure and infection by voluntary self isolation, a prerogative that frontline health care providers cannot have. As the pandemic accelerates, there is an increasing concern for health care providers who take care of infected individuals in hospitals to contract the infection themselves or infect family members at home. In order to protect themselves and their loved ones, health care providers must use protective devices such as eye protection goggles, full face visors, and fluid repellent surgical masks.5 A tight seal must be created between the mask in use and the skin in order for it to be effective. However, the prolonged use of these masks, the material of the masks, facial perspiration, and the pressure utilized to achieve the seal is causing moderate to severe skin damage in health care providers on the frontlines.5 In this document, some simple and easy-to-follow guidelines are discussed and recommended to help prevent or treat personal protective equipment (PPE) induced skin damage and lesions.
Overview of Cutaneous Complications
During the COVID-19 world-wide health crisis, health care workers are obligated to use protection devices to prevent infection. Devices like fluid repellent surgical masks, eye protection goggles, full face shields, or visors are part of the PPE arsenal. Long working hours in healthcare facilities and a high risk of contamination forces frontline workers to use protective equipment for long periods of time. Here, we discuss the skin injuries caused by the prolonged or repetitive use of surgical face masks and how those injuries can be prevented and treated.
In the healthcare setting, The World Health Organization recommends the use of a particulate respirator such as the USA health-certified N95 mask, European Union standard FFP2, or equivalent to prevent droplet exposure to COVID-19.6 These masks should be worn over the nose and mouth as a physical barrier to prevent droplets and splashes from reaching facial mucosa.7 The pressure that the mask exerts on the skin is key to achieving its protective purpose, but when the masks are worn repetitively and for a long time, this external force can cause a variety of skin injuries.
Prolonged use of the masks generates pressure, friction, and shearing, which, in turn, causes tissue deformation, inflammatory edema, and in severe cases, tissue ischemia. These factors can lead to pressure ulcers especially on bony anatomical sites such as the nose and frontal bone. All of these lesions cause pain, visible pigmentary changes, and scars. Additionally, there is a change in the skin´s microclimate and microbiota that can lead to infections, including folliculitis and acne.
Skin Injuries Due to Protective Mask Pressure
The skin-seal required by protective masks is the principal location of the facial injury. Additional to the increase of temperature and humidity inside the mask, prolonged pressure, and shear forces in the sealing area generates a direct deformation of the tissue, vascular occlusion, edema, and inflammatory reaction leading to the production of a device-related pressure ulcer.8 The protective mask may act as an irritant or allergenic agent that can lead to contact or allergic dermatitis.
I. Mask-related pressure ulcer
The skin-mask interface generates three important changes in the skin homeostasis that lead to a reduction of the epidermal barrier function and dermis biomechanical and biochemical tolerance. (1) There is an increase in transepidermal water loss (TEWL) associated with blood and lymph vessel occlusion because of the deformation of the extracellular matrix (ECM) where they are located. (2) Relative temperature and humidity increase, generating a change in the skin´s microbiome. As a consequence, there is an inflammatory response and risk of infection. (3) The production of inflammatory mediators, infiltration of neutrophils and monocytes and the increment of reactive oxygen species (ROS).8
The evolution and magnitude of the lesions depends on the repetitive use, time and the amount of pressure on the same skin. For healthcare workers working in health facilities with COVID-19 patients, removing the mask is not an option. Limited access to personal protective equipment (PPE) further exacerbates the situation through its uninterrupted use.
We can classify cutaneous lesions according to their clinical presentation into 4 stages:
Stage 0: Normal skin
Stage 1: a. Erythema in the nose bridge that disappears in the first 24 hours. Skin and tissue misshaping in the malar area with or without erythema that resolves in 24 hours or less. This is related to the use of face masks for less than 6–8 hours and not consecutive days. There can be some burning sensation in the affected area but there is no pain.
b. Persistent nonblanchable erythema on the nasal bridge