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Personal protective equipment recommendations based on COVID-19 route of transmission

Published:April 21, 2020DOI:https://doi.org/10.1016/j.jaad.2020.04.068
      To the Editor: Cavanagh and Wambier
      • Cavanagh G.
      • Wambier C.
      Rational hand hygiene during COVID-19 pandemic.
      have written an informative article on how dermatologists may approach hand hygiene during the coronavirus disease 2019 (COVID-19) pandemic. They describe the risk of hand dermatitis in health care workers faced with a sudden increase in frequency of hand washing. They appropriately recommend measures to decrease this risk, such as applying hypoallergenic moisturizers and not rinsing with hot water.
      The authors also state that skin damage caused by hand washing provides a route of entry for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). They note that angiotensin converting enzyme 2, a receptor that SARS-CoV-2 binds to, is present in capillaries of the skin, the basal layer of the epidermis, and eccrine glands.
      Although hand dermatitis is common among health care workers caring for COVID-19 patients, we disagree that hand fissures provide SARS-CoV-2 with a route of entry. SARS-COV-2 spreads primarily by respiratory droplets, and there is no literature to suggest that it is a bloodborne pathogen capable of infecting through cuts or open wounds. It is true that the viral spike protein of SARS-COV-2 binds to angiotensin converting enzyme 2 receptors to initiate viral entry. However, the cofactor transmembrane protease serine 2 is also necessary for spike protein priming (ie, cleavage by a host cell protease).
      • Hoffmann M.
      • Kleine-Weber H.
      • Schroeder S.
      • et al.
      SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor.
      Angiotensin converting enzyme 2 and transmembrane protease serine 2 have been shown to be highly coexpressed in a type of bronchial progenitor cell, which represents a more probable target for SARS-COV-2 infection than open wounds.
      • Lukassen S.
      • Lorenz Chua R.
      • Trefzer T.
      • et al.
      SARS-CoV-2 receptor ACE2 and TMPRSS2 are primarily expressed in bronchial transient secretory cells.
      We maintain that prevention of hand dermatitis among health care workers is important for alternate reasons, namely, increasing hand hygiene compliance. A double-blind, randomized trial found prevention, hand dermatitis was associated with increased hand hygiene compliance or an appropriate amount of sanitizing/hand washing by nurses.
      • Stutz N.
      • Becker D.
      • Jappe U.
      • et al.
      Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group.
      Furthermore we would like to emphasize that alcohol-based sanitizers are a very effective antimicrobial agent, especially for lipophilic enveloped viruses (eg, SARS-Cov-2) and are less frequently associated with hand dermatitis than hand washing with soap and water. Thus alcohol-based sanitizers may promote hand hygiene adherence and should be used more frequently by health care workers, except when hands are visibly soiled.
      Additionally, it has been shown that the face, rather than hands, was the more frequent site of skin damage in Chinese health care workers managing COVID-19, related to pressure from face masks and goggles.
      • Lan J.
      • Song Z.
      • Miao X.
      • et al.
      Skin damage among health care workers managing coronavirus disease-2019.
      Health care workers may be tempted to touch their face after removal of personal protective equipment (Fig 1). Given the respiratory route of transmission, refraining from touching the face during facial personal protective equipment application and removal is another recommendation that should be impressed upon health care workers just as strongly as preventing hand dermatitis.
      Figure thumbnail gr1
      Fig 1A 28-year-old emergency department resident with facial pressure marks from prolonged wearing of an N95 mask.

      References

        • Cavanagh G.
        • Wambier C.
        Rational hand hygiene during COVID-19 pandemic.
        J Am Acad Dermatol. 2020; 82: e211
        • Hoffmann M.
        • Kleine-Weber H.
        • Schroeder S.
        • et al.
        SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor.
        Cell. 2020;
        • Lukassen S.
        • Lorenz Chua R.
        • Trefzer T.
        • et al.
        SARS-CoV-2 receptor ACE2 and TMPRSS2 are primarily expressed in bronchial transient secretory cells.
        EMBO J. 2020;
        • Stutz N.
        • Becker D.
        • Jappe U.
        • et al.
        Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group.
        Br J Dermatol. 2009; 160: 565-572
        • Lan J.
        • Song Z.
        • Miao X.
        • et al.
        Skin damage among health care workers managing coronavirus disease-2019.
        J Am Acad Dermatol. 2020; 82: 1215-1216

      Linked Article

      • Rational hand hygiene during the coronavirus 2019 (COVID-19) pandemic
        Journal of the American Academy of DermatologyVol. 82Issue 6
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          To the Editor: The enhanced preventive measures during the SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic include proper hand hygiene. Health care workers (HCWs) may perform frequent handwashing with water and soap, leading to the potential complication of skin damage. In Lan et al's survey1 of 526 front-line COVID-19 HCWs, 74.5% reported damage to hand skin from enhanced infection prevention measures. HCWs who washed their hands more than 10 times per day reported more damage to hand skin (odds ratio, 2.17).
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      • Reply to: “Personal protective equipment recommendations based on COVID-19 route of transmission”
        Journal of the American Academy of DermatologyVol. 83Issue 1
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          To the Editor: We thank Gupta and Lipner1 for the comments and for the opportunity to further clarify the risks of hand irritation from excessive handwashing among health care workers, and we agree that alcohol sanitizers are practical, safe, and possibly more effective in neutralizing the virus from hand skin.
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