Skin Irritation from Prolonged Use of Tight-Fitting RespiratorsPosted on by
Filtering Facepiece Respirators (FFRs) are typically used by workers, including first responders and healthcare professionals, for short, infrequent periods of time to protect against potential airborne transmissible diseases. However, during widespread respiratory infectious disease outbreaks, there may be a need to implement respirator extended use practices due to an inadequate supply of FFRs. Skin irritation caused by disposable FFR use for extended periods of time has been documented during past outbreaks of respiratory infectious diseases.
Respiratory protection program managers, healthcare providers, and end users should understand how proper respirator fit and use can decrease skin irritation, as well as how to treat potential skin irritation caused by extended respirator use.
The Potential for Skin Irritation
Disposable FFRs are typically the most common and readily available respirator in healthcare settings. Reusable half facepiece and full facepiece tight-fitting elastomeric respirators are another option during times of FFR shortage. Both elastomeric respirators and FFRs must seal against a user’s skin, exerting pressure on the face, in order to effectively block particles from entering the breathing zone. Adverse effects of FFRs can include, but are not limited to, skin irritation, acne, skin discomfort, pressure on the nose, pressure-related skin damage, irritant dermatitis, and allergic dermatitis.1-4 Notably, the straps on NIOSH-approved N95 FFRs do not typically have latex in them so latex allergies are not a problem.
In addition to pressure applied to the skin, friction and moisture may contribute to skin and tissue damage. Friction can occur during normal working movement, including head or face movement, and when speaking or breathing. Moisture can accumulate within the respirator due to sweat, or humidity added to exhaled air by the airway and lungs with normal breathing. Persons wearing respirators for long hours, such as during a pandemic, are at increased risk for skin irritation because of the long hours of skin contact.
NIOSH-approved FFRs are designed to be biocompatible (i.e., not harmful to living tissue) and are generally constructed from polypropylene, a thermoplastic polymer or type of plastic.5 The NIOSH FFR approval process includes testing for cytotoxicity (being toxic to cells), sensitization, and irritation on a pass/fail basis.5 NIOSH also consults with the Food and Drug Administration (FDA) about any new material used in the construction of N95 FFRs to be used in healthcare.5 However, during times of widespread extended use of FFRs, skin irritation such as allergic dermatitis still occurs.
Tips to Prevent Skin Irritation
Respiratory protection is a vital part of the strategy to protect healthcare professionals from inhaling infectious particles. Therefore, preventing skin irritation from disposable FFRs and elastomeric respirators starts with fit testing and proper use. Respiratory protection program managers must ensure that staff are trained and wear a well-fitting and comfortable size for each brand and model that they have been fit tested and cleared to use. Proper size and fit will ensure that users have the needed respiratory protection and that the respirator is not causing friction or putting too much pressure on the skin. During the fit test procedure, OSHA requires that the wearer be provided adequate time to assess whether the respirator being fit tested is comfortable for them to wear. A 5-minute wear period is required before the fit test begins.
FFR strap placement can prevent excessive pressure against the skin. Headbands should be placed according to the manufacturer’s user instructions, usually on the crown of the head and behind the neck, not resting on the ears. NIOSH does not typically approve respirators that use ear loops, and non-NIOSH-approved respirators that do use ear loops create potential for skin irritation behind ears. When a respirator can be properly doffed (taken off) after use, it is ideal to have a break in pressure to ensure adequate blood flow to prevent skin damage.
Workers from a variety of industries that use respirators, including first responders and healthcare workers responding during disease outbreaks or pandemics, need to care for themselves as well as those around them. This includes overall nutrition and proper hydration to ensure skin care and health remains at an optimum level. Supervisors should remind workers and facilitate time for them to eat and stay hydrated. Facial skin care should include washing with a product intended to be used on the face to avoid irritation. Moisturizers should include those intended for use on the face and be applied well in advance of any need to use an FFR so that any residue is absorbed. Any residual lotion, cream, or ointment, including make-up residue, could interfere with the fit and seal of an FFR and potentially allow the user to be exposed to a respiratory pathogen. Guidelines from FFR manufacturers and respiratory protection program managers should be consulted. Certain FFR manufacturers may specifically suggest avoiding thick creams or ointments, such as those that contain petroleum jelly, as they can cause the FFR to slip on the skin and not allow sufficient seal.6 Available skin protectants and barrier films recommended by specific FFR manufacturers are options to prevent skin damage from friction and moisture.6
Treating Skin Irritation from Extended Use of FFRs – A Team Effort!
When skin irritation occurs from extended use of tight-fitting respirators, all parties involved in treating the skin condition need to understand the continued need for the user to wear a respirator and the importance of its fit, function, and seal. This includes, but is not limited to the end user, end user’s supervisor, primary care provider, dermatologist, and respiratory protection program manager. Ointments or dressings are typical treatments for skin irritation, however, as discussed above, these products might interfere with the fit and seal of a respirator. Any treatment option must ensure the safety and health of the user, so that they are not exposed to a respiratory pathogen while working.
If skin irritation leads to non-intact or broken skin, precaution must be taken to ensure it does not lead to an infection. If respirator use must continue, any treatment prescribed or used must not interfere with the fit, function, and seal of the respirator to ensure the safety of the user. If the open skin is due to dermatitis, another NIOSH-approved FFR could be the solution if the allergy is suspected to be from a component in the respirator. In the case of a pressure injury from the seal of an FFR, NIOSH-approved reusable elastomeric respirators and powered air purifying respirators (PAPRs) are possible alternatives. Reusable elastomeric respirators and PAPRs have different seal locations to allow the area around the nose and mouth to heal. These options may allow an irreplaceable worker to continue working during prescribed treatment until healed.
Adam Hornbeck, MSN, APRN, FNP-BC, FNP-C, is a nurse practitioner in the NIOSH National Personal Protective Technology Laboratory Research Branch.
Jaclyn Krah Cichowicz, MA, is a health communications specialist in the NIOSH National Personal Protective Technology Laboratory.
Selcen Kilinc-Balci, PhD, MBA, is a physical scientist in the NIOSH National Personal Protective Technology Laboratory.
Dana Rottach, PhD, is a physical scientist in the NIOSH National Personal Protective Technology Laboratory Research Branch.
Jonisha Pollard, MS, CPE, is a team leader and acting deputy branch chief of the Research Branch in the NIOSH National Personal Protective Technology Laboratory Research Branch.
Harold L. Boyles, RN, MSHCA, is a nurse consultant and acting branch chief of the NIOSH National Personal Protective Technology Laboratory.
Other blogs on the effects of prolonged PPE use on healthcare workers include:
1. Gheisari, M., Araghi, F., Moravvej, H., Tabary, M., Dadkhahfar, S. Skin reactions to non-glove personal protective equipment: an emerging issue in the covid-19 pandemic. Journal of the European Academy of Dermatology and Venereology : JEADV 17 April 2020 https://doi.org/10.1111/jdv.16492
2. MacIntyre C.R., Wang Q., Cauchemez S., Seale H., Dwyer D.E., Yang P., et al. A cluster randomized clinical trial comparing fit-tested and non-fit-tested N95 respirators to medical masks to prevent respiratory virus infection in health care workers. Influenza Other Respir Viruses 2011;5:170-9.
3. MacIntyre C.R., Wang Q., Seale H., Yang P., Shi W., Gao Z., et al. A randomized clinical trial of three options for N95 respirators and medical masks in health workers. Am J Respir Crit Care Med 2013;187:960-6.
4. MacIntyre C,R,, Chughtai, A.A. Facemasks for the prevention of infection in healthcare and community settings. BMJ 2015;350:h694 doi: 10.1136/bmj.h694
5. NIOSH Conformity Assessment Letters to Manufacturers. NIOSH CA 2018-1010. November 2018. Accessed on 11 May 2020. https://www.cdc.gov/niosh/npptl/resources/pressrel/letters/conformitymanuf/pdfs/CA-2018-1010-P.pdf
6. 3M. Frequently asked questions on preventing PPE-related skin injuries. Accessed on 8 May 2020. https://www.3m.com/3M/en_US/medical-us/coronavirus/ppe-information-and-guidance/#protection