Skin-related injuries among nurses have increased throughout the pandemic as they seek protection from SARS-CoV-2.1 Unfortunately, some nurses may not know how to protect their skin against damage from prolonged use of personal protective equipment (PPE). This article identifies dermatologic issues of extended PPE use, explores the risks of injury, and offers prevention strategies.
Extended use is defined as using equipment such as goggles and N95 masks for 2 or more hours continuously.2 Recent research revealed that nurses are at increased risk of sustaining multiple skin injuries from PPE use beyond 2 hours.1,3 Jiang et al.3 found that 43% of clinicians using PPE experienced a skin injury during the COVID-19 pandemic in China. The survey sample included physicians and nurses (12% and 88%). The most frequent skin injuries included medical device-related pressure injuries (MDRPIs), moisture-associated skin damage, and skin tears. Among those with MDRPIs, researchers noted that participants had Stage 1 pressure injuries, Stage 2 pressure injuries, and deep tissue pressure injuries (n = 49, n = 236, and n = 8, respectively). The medical staff were wearing PPE for an average of 7 hours per day.
Identifying the equipment that causes the most damage and the areas of the body most affected can help prevent skin injury. Two research teams have found that goggles account for most injuries, followed by N95 masks.4,5 The areas on the face most susceptible to injury are the nose, cheeks, and chin, and the back of the ears where PPE is secured.1,4-6
Risks of extended use
Any break in the skin presents a potential portal of entry for pathogens and subsequent infection. Discomfort from a skin injury on the nose, cheeks, or chin may make it difficult for the wearer to maintain their N95 mask's seal.2 Movement of the face or hands against the mask to relieve pressure may cause the wearer to expose themselves to SARS-CoV-2 aerosolized particles.
Outcomes of PPE-related skin injuries may include poor job performance and reduced staffing. Limited by the discomfort, nurses find it challenging to work efficiently.4 Those with skin injuries might also call in sick more often. A recent study found that 21% of its participants were absent from work because of a PPE-related skin injury.5 If left unaddressed, hospitals could see significant reductions in the effective workforce and the ability to provide quality care to patients.4 Nurses are especially prone to these injuries because of long working hours and frequent exposure to bedside care.
Healthcare workers make up the majority of those injured by PPE.3 Nurses are among those at high risk for injury. About 40% of surveyed nurses across 161 hospitals in China experienced PPE-related skin injury, suggesting that nursing and other hospital staff might not be aware of the education, training, or supplies needed to better protect themselves.3 Healthcare staff may not know how to properly wear PPE over extended periods since PPE was not originally designed for extended use.7
In the 2019 International Guideline on Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, the European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance discussed the increased need to understand pressure injuries, including the prevention and treatment of device-related injuries.8 Based on the 2016 guidelines that were developed before the current pandemic, Delmore and Ayello9 published an educational enabler that acknowledged the risk of pressure-related injury when wearing medical devices like PPE; they recommended regular inspections of the skin for signs of pressure-related injury, removing devices as soon as safely possible, and forming an interprofessional team and prevention program.
Until recently, there was little guidance on preventing PPE injuries during extended use, but now evidence-based recommendations exist.8-10
Goggles and N95 masks
Nurses must return to the basics when attempting to find methods for preventing PPE-related skin injuries. Nurses generally understand the importance of frequent turning and pressure relief of bony prominences when caring for patients; however, they appear to neglect using pressure-relieving strategies when they wear PPE. Taking a break from PPE is a nurse's way of “turning” or relieving the pressure on the bony structures of the nose, cheeks, chin, and forehead. Frequency of these adjustments should vary. Not only should goggles and masks be properly fitted, but they should ideally be removed at least every 2 hours for a minimum of 5 to 15 minutes when outside of patient contact areas.7,10 Furthermore, if there is discomfort, the PPE should be removed as soon as it is safe to do so.7
Removing PPE during COVID-related care is typically difficult to do.2 To help address these challenges, some researchers have developed stringent PPE processes involving the use of strategically placed atraumatic silicone dressings on the face.2 In a recent study, Smart et al.2 observed that using atraumatic silicone dressings with an N95 mask allowed participants to be more comfortable wearing PPE for up to 4 hours compared with those who did not use the dressing. Additionally, they demonstrated that the mask seal was maintained with the use of the silicone dressing. Extending wear time to 4 hours with the use of dressings may be helpful for nurses who cannot practically or feasibly step away from COVID-19-related care every 2 hours. However, nurses should know that altering mask fit must be done with careful consideration and caution. Altering the fit of an N95 may place the wearer at greater risk for infection. Although there is some preliminary evidence of safe use, there is not enough evidence to recommend this practice.10
Emphasis should be placed on skin hygiene and hydration. Nurses are in the habit of performing hand hygiene, but extended PPE use requires greater attention to the face and body's overall skin care. Sweat and moisture buildup on the skin produces a favorable environment for bacteria and fungi and increases the risk of skin damage.5,6 Emollients and moisturizers can prevent skin injury when applied to clean and intact skin.1,4,6 The NPIAP recommends the use of balanced pH facial cleansers combined with liquid skin protectants.10 It is not recommended to use petroleum jelly or mineral oil for skin care.10 Nurses should allow the skin to dry and apply moisturizers 30-60 minutes prior to donning PPE to avoid damaging the N95 mask.4,5,7,10 If an abrasion is present, NPIAP guidelines recommend treating it with a cyanoacrylate, moisturizer, skin sealant, or a thin dressing.10 Take caution not to apply cyanoacrylate near the eyes or mouth.10 Deep tissue pressure injuries, Stage 3 pressure injuries, Stage 4 pressure injuries, and unstageable pressure injuries require the help of a wound care professional. Nurses should also stay well hydrated and consider the recommended daily fluid intake.11 Maintaining sufficient hydration and diet will help make skin more resistant to breakdown and lower the risk of pressure injury.2 Do not drink or eat while in PPE.2
Atraumatic dressings and N95 masks
Nurses should be aware that placing something between the N95 and the skin can change the fit and seal.2 At the time of publication, there are small studies and preliminary reports that support the use of dressings with N95 mask.2,10 Despite the success of smaller studies, the NPIAP has not found enough evidence to support the use of dressings and currently has no recommendations for altering the fit of an N95.10 However, the NPIAP recognizes that some may still choose to alter the fit for increased comfort or protection. For those who have weighed the risks and benefits of using dressings, the NPIAP has provided a list of precautions and implementation considerations that are based on preliminary research findings.10
In the list of considerations, the NPIAP makes several suggestions for the application of dressings. First, preliminary reports show that strips of nonpermeable foam or thin prophylactic dressings can be used to cover bony prominences of the face and head in a single layer fashion.10 Avoid stacking multiple layers and avoid dressings that are porous. Instead try to ensure that the outer layer of the dressing is nonpermeable to avoid transfer of fluids or pathogens to the skin. If possible, nurses should have their N95 refitted and tested while using a prophylactic dressing to ensure OSHA standards are met. Additionally, the wearer needs to follow facility infection prevention protocols and recheck the seal of the mask each time it is altered.2,10 A seal check can be performed by blowing out of the mouth and checking for leaks. This check should be done after applying dressings and before patient care. The last suggestion involves removal of the dressing. After COVID-related care, and while in a safe area, the wearer should close their eyes and hold their breath to avoid aerosolized transmission of COVID-19 while removing the dressings.10
More evidence is needed to determine the best products, methods for applying dressings, and the level of safety when altering the fit of N95 masks. If nurses choose to use this prevention method based on the preliminary research findings, they need to make sure the seal is still intact with either a fit test or seal check to help ensure safety. The best recommendation is to remove PPE as soon as possible, and to avoid wearing PPE for more than 2 hours without a 5- to 15-minute break.10
Interprofessional teams should be formed to develop prevention programs.9 For example, a team could include a nurse clinician, a wound care nurse, a dermatologist, and a pharmacist. They would research and implement the skincare products, rest protocols, and atraumatic dressings to use. While such a committee may be facility-wide, unit-based champions or experts can also implement recommended protocols or products.
Not only do PPE-related skin injuries cause discomfort, but they also introduce a portal of entry for pathogens and subsequent infection. Thus, nurses who care for patients with COVID-19 need to remember skincare management basics and apply injury prevention techniques.
There is an urgent need for research and testing to improve and validate the use of atraumatic dressings or wound care products with N95 masks and other PPE. Likewise, more education is necessary to improve nurses' understanding of the barriers to proper skin maintenance.
1. Desai SR, Kovarik C, Brod B, 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
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8. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. Haesler E, ed. The International Guideline
. EPUAP/NPIAP/PPPIA; 2019.
9. Delmore BA, Ayello EA. Pressure injuries caused by medical devices and other objects: a clinical update. Am J Nurs
10. The National Pressure Injury Advisory Panel. NPIAP position statements on preventing injury with N95 masks. 2020;1–5.