Moisturizers and Cleansers in the Management of Skin Conditions Caused by Personal Protective Equipment and Frequent Handwashing

Sara Mirali, PhD; Patrick Fleming, MD, MSc, FRCPC, FCDA; Charles W. Lynde, MD, FRCPC, DABD

Skin Therapy Letter. 2021;26(4):9-13.

Abstract and Introduction

Abstract

During the COVID-19 pandemic, prolonged usage of personal protective equipment (PPE) and frequent handwashing has exacerbated or caused skin diseases, particularly amongst frontline workers. Skin conditions, such as atopic dermatitis, irritant contact dermatitis, and hand eczema, affect patients' quality of life and their ability to work. These conditions can be managed by frequent moisturization and washing with gentle cleansers. In this review, we discuss the properties of effective moisturizers and cleansers for patients with skin diseases related to enhanced infection control procedures.

Introduction

During the COVID-19 pandemic caused by the novel coronavirus SARS-CoV2, health authorities advised frontline workers and the public to take infection control precautions. Current evidence suggests that COVID-19 is transmitted through respiratory droplets and contact with contaminated surfaces.^[1] To prevent transmission, frequent handwashing and prolonged usage of personal protective equipment (PPE), such as goggles, masks, face shields, and gloves, are recommended. These enhanced precautions can cause or exacerbate inflammatory skin conditions, which impact patients' quality of life and, in some cases, their ability to work.^[2] Moreover, associated symptoms, such as pruritis affecting the face, increase the risk of transmission.

Recent studies have shown that 75–97% of healthcare workers (HCWs) treating COVID-19 patients suffered from adverse skin reactions, including contact and pressure urticaria, rosacea, perioral dermatitis, contact dermatitis, or aggravation of preexisting skin disorders. The most commonly affected areas were the hands, cheeks, and nasal bridge.^[2,3] These adverse effects are not restricted to HCWs4 and are mainly caused by the hyperhydration effects of PPE, friction, epidermal barrier breakdown, and contact reactions. All of these can aggravate preexisting skin diseases or cause new skin diseases, many of which can be controlled with proper moisturization. In this review, we discuss the role of moisturizers and cleansers in the management of skin conditions caused by frequent handwashing and PPE.

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Table 1. Basic properties of an effective moisturizer
Property	Purpose	Side Effects	Examples
Occlusive barrier	Creates a protective barrier and reduces TEWL	Cosmetically unappealing, occlusive folliculitis (petrolatum, mineral oil), contact dermatitis (lanolin)	• Fatty acids • Fatty alcohols • Lanolin • Oil-based oils and waxes • Petrolatum • Phospholipids • Silicone derivatives • Sterols • Vegetable waxes Wax esters
Humectants	Attracts water from external environment and dermis	Irritation (lactic acid, PCA, urea)	• Gelatin • Glycerin • Honey • Hyaluronic acid • Lactic acid • • Panthenol • Propylene glycol • Sodium PCA • Sorbitol • Urea
Emollients	Smooths skin, restores stratum corneum's lipid-rich matrix	Sometimes ineffective	• Ceramides • Cholesterol • Fatty acids

PCA = pyrrolidine carboxylic acid; TEWL = transepidermal water loss

Table 2. Side effects of moisturizers and potential causes
Adverse Side Effect	Potential Causes
Acne vulgaris	petrolatum
Allergic contact dermatitis	lanolin, fragrances, preservatives (benzoic acid, sorbic acid), MCI/MI, vitamin E, chamomile oil, aloe vera, olive oil, tea tree oil
Contact urticaria	preservatives, fragrances
Irritation	humectants (lactic acid, PCA, urea), preservatives, propylene glycol, solvents, retinoids, benzoyl peroxide
Occlusive folliculitis	petrolatum, mineral oils
Photosensitivity or photomelanosis	fragrances, alpha hydroxy acids, sunscreens

Adapted from Lynde et al.²³
PCA = pyrrolidine carboxylic acid
MCI/MI = methylchloroisothiazolinone/methylisothiazolinone

Table 3. Cleanser categories
Cleanser	Description	pH Range	Surfactants
Soap	• Derived from lye and natural fats • Removal of intercellular lipids and stratum corneum swelling	9.0–10.0	• Sodium lauryl sulfate • Sodium laureth sulfate
Combars	• Combination of soap and synthetic detergents • Intermediate between soap and syndet • Mild removal of intercellular lipids	7.0	Combination of soap and syndet detergents
Synthetic detergents (syndet)	• Derived from petrolatum and surfactants, contain <10% soap • A subset are lipid-free with no fats or oils • Low removal of intercellular lipids	5.5–7.0	• Sodium cocoyl isethionate • Sulfosuccinates

Table 4. Allergens in cleansers
Allergen	Examples
Fragrance	Any fragrance or fragrance-related components
Surfactants	• Cocamidopropyl betaine • Cocamide diethanolamine • Decyl glucoside • Dimethylaminopro pylamine • Oleamidopropyl dimethylamine
Preservatives	• Dimethyloldimethyl (DMDM) hydantoin • Diazolidinyl • Formaldehyde • Iodopropynyl butylcarbamate • Imidazolidinyl urea • Isothiazolinones • Quaternium-15

Adapted from Rundle et al.⁴⁰

Table 5. Ideal characteristics of moisturizers/cleansers and summary of recommendations
Characteristic	Recommendation	Clinical Evidence
Non-irritating	• Use moisturizers with glycerin as a humectant for sensitive skin • Avoid fragrances • Avoid changes in skincare routine	In a double-blind, randomized study of 197 AD patients, 20% cream caused less adverse effects compared to a cream containing 4% urea and 4% sodium chloride.¹⁶ In a multi-centre, randomized trial of 3119 individuals, the prevalence of fragrance contact allergies was found to be 0.7–2.6%.⁴⁵
Hydrating	Use moisturizers with FLG breakdown products or other humectants	In a single-centre intra-individual comparison trial of 20 AD patients, a moisturizer containing FLG breakdown products and ceramide precursors reduced TEWL and improved clinical symptoms.²⁶
Cosmetically appealing	Avoid moisturizers that contain petrolatum	Petrolatum is cosmetically unappealing to some patients.^43,46
pH balanced	Moisturizers and cleansers with a pH of 4.0–6.0 should be used	Subjects using low pH soaps reported less irritation compared to those using high pH soaps.⁴⁴
Contains ceramides	Moisturizers that contain ceramides improve symptoms of eczema and xerosis	In a cohort study of 151 pediatric and adult AD patients, twice-daily use of CeraVe® improved quality of life and skin condition after 6 weeks.¹³ Compared to a standard hydrophilic cream, CeraVe® improved barrier function and decreased TEWL and skin pH in 24 senior xerosis patients.¹⁴ In a single-centre, randomized study of 60 patients with mild to moderate eczema, use of CeraVe® moisturizer and cleanser twice daily with fluocinonide cream 0.05% significantly improved outcomes after 4 weeks.¹⁰