COVID-19: how to avoid skin damage while wearing PPE
As nurses worldwide feel the pain of prolonged PPE use, we assess the advice on minimising the discomfort caused by masks and visors
- Nurses have reported skin damage and bruises after wearing personal protective equipment during long shifts
- PPE needs to be properly fitted and ideally worn for shorter periods of time, but when this is not possible, there are other ways nurses can reduce the risk of damage
- Experts offer advice on avoiding skin damage, emphasising a ‘clean, protect and restore’ approach
This article was updated on 12 January 2021
Wearing visors, masks, gloves – never mind the constant hand-washing and use of alcohol gel – can all leave nurses’ skin sore.
Now the added effects of cold weather mean the pandemic can be even more punishing on healthcare professionals’ ravaged skin.
Nursing experts say that some extra steps can help boost protection for the skin during the chilly months.
Combination of winter weather and working in PPE can be brutal for the skin
Personal protective equipment (PPE) is an essential part of the fight against coronavirus, protecting staff and patients, and all nurses will have been wearing more than they did before the virus outbreak. Those working in high-risk areas such as intensive care are advised by Public Health England (PHE) to wear eye protection, a filtering face-piece respirator, fluid-resistant gown, disposable apron and gloves.
This has taken a toll on clinicians’ skin, and images of nurses with faces chaffed after long shifts behind personal protective equipment (PPE) have been viewed widely in recent months.
Reddened skin, sores, chaffing and bruising caused by masks and eye protection, particularly across the bridge of the nose and the cheekbone, have been shared online.
Skin damage after wearing masks and visors for long periods
Over the course of the pandemic, nurses are wearing PPE on a daily basis for long periods in a way that could be hurting their skin.
Visors can leave marks on the forehead, as staff wear them for hours, and the loops on masks can rub painfully behind the ears. Skin on the hands can be left red, dry, flaky, cracked and sore through constant washing and use of alcohol rubs.
A study of healthcare staff in China during the outbreak found that goggles were particularly tough on the skin, especially on the bridge of the nose.
Mark Collier, independent nurse consultant and associate lecturer in tissue viability, based in Lincolnshire, says the wintry combination of cold weather and low humidity sets off a cycle that leads to the breakdown of the skin barrier function. This can increase dryness, itching and the development of urticaria, or hives.
For anyone who already has skin problems, the colder months can bring particular misery, especially when moving between extremes of temperature, from the cold outside to sudden indoor warmth.
Many buildings will be colder and draughtier as a result of people heeding advice to boost ventilation as a way to reduce virus transmission.
Mr Collier says: ‘Winter can exacerbate skin conditions, including eczema, psoriasis and rosacea. As all of these are affected by extremes in temperature, it can cause serious skin irritation, cracking and pain. Remember your hands, lips, nose, and ears are all prone to dryness and chapping [dry, rough or sore skin] during cold weather.’
What is the best way to avoid skin damage due to PPE?
Damage to the skin is painful and, if severe, can lead to cracks that leave the skin vulnerable to developing infections.
So how can it be avoided? Expert nurses were keen to stress that some simple steps and using correctly fitted equipment should help minimise any skin problems.
Mr Collier recommends nurses take a ‘cleanse, protect and restore’ approach to looking after the skin, with a few tweaks for extra protection in winter.
Increasing the frequency of application of moisturisers and emollients, and considering using a richer, thicker type can help protect dry skin, he says. ‘Switching to a product that contains a combination of a blend of humectants (agents that act to reduce moisture loss) and emollients, including fatty acids, ceramides and cholesterols, can help to put back what the skin is lacking and support the skin barrier,’ he says.
When it comes to non-medicated soaps and skin cleansers, avoiding humectants during cold months can be a good idea. ‘A humectant is an ingredient that attracts water to itself – which can be helpful when the air is humid, as the product will draw moisture into the skin. But when humidity is low, a humectant will instead draw moisture from the lower layers of your skin, making it even more dehydrated,’ he says.
Nurses should make sure they are drinking plenty of water, to hydrate their skin. This can easily be forgotten when it is not warm, or when going to the toilet means awkward and time-consuming PPE removal.
Getting plenty of sleep and a skin-friendly diet with plenty of omega-3 and omega-6 fatty acids all support a healthy skin barrier, Mr Collier says.
Being kind to your hands this winter – the extra challenge for nurses
Hands have taken a particular hammering during the pandemic, with hand-washing and the use of alcohol rub increasing exponentially.
As nurses can’t currently reduce the frequency of their hand-washing, Deirdre Harris, an independent infection control nurse who works in London, has a survival list to help staff through a the next few months. [see box]
The steps she advocates are designed to restore and protect the skin as much as possible when nurses are off duty.
They includes limiting contact to harsh chemicals, and avoiding tasks that involve immersion in water at work or at home with rubber gloves. She also advises striking a balance between hand-washing using and use of alcohol gel.
Some nurses will still need extra support for their skin as they grapple with the dual challenges of PPE use and winter weather conditions.
‘If undertaking these measures doesn’t help then seek medical advice from you GP or occupational health department,’ Ms Harris says.
10 tips to protect your hands from the ravages of winter
Infection control nurse Deirdre Harris advises:
- Wear warm gloves when outside
- Use a heavy-duty, intense handcream or ointment at bedtime
- Always carry handcream
- During the day, reapply hand cream or lotion after washing your hands
- Wear rubber gloves for washing up at home and other tasks that require hands to be immersed in water
- While at work, try to wear appropriate gloves when undertaking equipment and environmental-cleaning jobs, including when using wipes to clean surfaces and equipment
- Protect your hands from exposure to harsh chemicals, including perfumed soaps
- Alcohol gel supplied to healthcare staff usually has added emollients. However try to strike a balance between hand-washing with soap and water and using alcohol gel
- Protect your hands from high temperatures, for example use lukewarm rather than hot water when washing them
- Avoid hot-air hand dryers
Official advice on protecting skin while wearing protective equipment
Ms Harris says one of the main problems with a sore face arises because of very long use of the masks, with little opportunity for removal.
NHS England guidance recommends staff who are wearing FFP2 and FFP3 masks take regular breaks - ideally hourly - from wearing the masks to relieve pressure, reduce moisture build up and allow the skin time to recover.
It adds that good hydration helps the skin and that a simple moisturiser can be rubbed into the skin 30 minutes before PPE is donned.
‘Skin that can normally tolerate a certain amount of pressure will be predisposed to damage much earlier at the moment. A liquid barrier film is easy to apply and dries in only 30 seconds’
Mark Collier, independent nurse consultant and associate lecturer in tissue viability
Ms Harris says that surgical masks with ties appear to cause less rubbing than those with elastic loops for the ears. If there is a choice, it may be worth going for masks with ties, she says.
Getting a properly fitted, or appropriately sized, mask is also important, she says. ‘The fit of the mask may also cause rubbing and if people touch and move their mask this has a potential to cause irritation.’
Many nurses unable to have appropriate fittings for masks
A 2020 Nursing Standard survey of almost 3,500 UK nurses regarding PPE heard from many that surgical masks did not fit well, that an insufficient supply meant they had to use them for a long time, and that often appropriate fit testing for FFP3 masks was not available.
NHS England advice on preventing facial skin damage from wearing FFP2 and FFP3 masks says skin can be protected with careful doffing of a mask. ‘
Take time to fit your mask before starting a clinical consultation. Ensure all folds in your mask have been used to optimise the correct fit for you and do not over-tighten. If you feel your mask is digging in, move away from direct patient contact, remove the mask using doffing guidance and allow the skin to recover for approximately five minutes. Replace your mask with a new one ensuring a good fit.’
When it comes to protecting the skin from rubbing, the guidance recommends the use of skin barrier product that dries quickly and does not leave residue as this may ‘ball’ under the mask and cause further problems.
These products, which include Cavilon and Medi-Derma S are more often used on fragile intact skin as a skin protector or before the application of an adhesive dressing.
How to protect your skin
Before your shift
- Drink plenty of water to hydrate the skin
- If using a moisturiser, do so at least 30 minutes before donning PPE
- Apply a liquid barrier film and allow to dry
While at work
- Ensure your PPE is properly fitted and use face masks with ties, if available
- Put masks on carefully and change if uncomfortable
- If visors or goggles are being cleaned with wipes, allow them to dry before wearing
- Wash hands with soap and water and/or alcohol rub. Pat hands dry rather than rubbing
- Hydrate when possible
- Try not to wear PPE, especially FFP3 masks, for more than two hours at a time
After your shift ends
- You can wash your hands with a soap substitute at home
- Apply moisturiser/emollient to hands and face
- Drink lots of water
Liquid barrier film can minimise risk of pressure damage
Mr Collier says using these products will minimise the risk of damage to the skin.
‘Pressure damage is exacerbated by moisture, and wearing PPE for any length of time will result in the wearers’ skin getting warm and sweaty,’ says Mr Collier.
‘So even skin that can normally tolerate a certain amount of pressure will be predisposed to damage much earlier at the moment. A liquid barrier film is easy to apply and dries in only 30 seconds. It should then maintain its function for at least two days, even with normal washing.’
This can generally be applied with a single-use swab on any part of the face where the skin is at risk from pressure damage, on the cheeks, forehead and around the ears.
‘These products should be widely available in NHS trusts, care homes and the community, and I would be very disappointed if they were not,’ Mr Collier says.
Barrier dressing tapes such as DuoDERM Extra Thin, SilDerm or Mepitac can be used under masks and goggles to mitigate pressure, according to a joint statement from the British Society for Cutaneous Allergy (BSCA) and British Association of Dermatologists (BAD).
But NHS England says dressings should not be used with FFP2 and 3 masks as they can affect the fit.
What about using soap substitutes?
When it comes to handwashing, nurses are often advised to use a soap substitute, such as Dermol 500, instead of soap to protect the skin on their hands.
However, BSCA and BAD advise that Dermol 500 and Stellisept cleansers do not deactivate coronavirus, so should not be used at work, however they can be used by nurses at home to minimise damage to the skin.
NHS guidance doesn’t say whether soap substitutes are acceptable, only that hands should be washed and alcohol rub used.
The ‘cleanse, protect and restore’ approach to skin care
When skin on the face or hands is sore and when you are not at work, the application of plain petroleum jelly and other emollients, such as Aquaphor, plus mild-to-moderate topical steroids is helpful, according to the joint statement from BSCA and BAD. Some trusts are providing emollients and topical steroids free of charge to staff.
If skin damage occurs, PHE says that nurses should inform their line manager and fill in an incident form.
- NHS England and NHS Improvement: Helping prevent facial skin damage beneath tight fitting face piece respirators (FFP 2 and 3 masks)
- Public Health England: Coronavirus (COVID-19): PPE hub
- British Society for Cutaneous Allergy and British Association of Dermatologists: COVID-19 occupational skin disease