How to Treat Eczema During the COVID-19 Pandemic

As the number of total cases of coronavirus disease (COVID-19) creeps higher and higher in the United States, dermatologists are fielding an increased number of calls from patients with eczema. While the medical specialty is not necessarily on the frontlines of the battle against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there are several considerations dermatology should keep in mind and suggest to colleagues as the pandemic progresses. In particular, eczema is a serious concern secondary to COVID-19 prevention methods and insights from the field could be integral to helping providers and patients now and in the future.

Mitigating Triggers
Eczema is susceptible to flare due to a number of triggers, including use of products containing irritants (eg, fragrances, formaldehyde, and isothiazolinones), dry skin, and stress.¹ The current climate surrounding the pandemic creates a perfect cascade for these triggers:

• Stress regarding COVID-19 prompts the patient to follow Centers for Disease Control and Prevention (CDC)/World Health Organization (WHO) recommendations to wash hands frequently with common skin sanitation products;
• These products contain known irritants that can cause dermatitis;
• The frequent washing/drying cycle causes the skin to dry out or become inflamed; 
• Frequent irritant exposure coupled with now dry skin develops into eczema, leading to stress about the condition; and 
• Eczema-related stress is compounded by the mental burdens associated with COVID-19—which leads to the patient washing their hands by CDC/WHO recommendations and repeating the cycle again.

Dermatologists are keenly equipped to assist patients now facing these triggers and hand eczema. Most importantly, dermatology should increase awareness of proper handwashing technique as determined by the CDC² and additional American Academy of Dermatology recommendations³:

1. Wet hands with clean, running, lukewarm water;
2. Apply a gentle cleanser, and turn off the faucet;
3. Scrub/lather hands for at least 20 seconds, covering all surfaces (palms, back of hands, between fingers, under nails, wrists);
4. Turn the faucet back on to rinse sudsy hands under clean, running, water before the final shut-off;
5. Pat hands dry until slightly damp using a clean towel; and
6. Apply a moisturizing cream or ointment to all surfaces of the hand.

Facial Considerations
During a time where directives focus on not touching the face to help prevent the spread of infection, facial eczema can pose a significant problem for patients. In these cases, dermatologists should advise patients to avoid touching the face as much as possible. However, if the face does need to be touched, patients are cautioned to wash their hands first, avoid any openings (eyes, nose, mouth), and use a clean tissue or cloth to make contact.⁴

Peers in infectious disease, pulmonology, and emergency medicine may also reach out with similar complaints of facial eczema. A descriptive study conducted during the severe acute respiratory syndrome outbreak in Singapore in 2006 found that of 103 surveyed health care professionals (HCPs), 51.4% reported itch and 35.8% reported rash with the regular use of N95 masks.⁵ Further, a recent survey of 542 HCPs in a tertiary hospital in the Hubei province of China found 97% (n=526) HCPs reported skin damage of sites such as the nasal bridge, hands, cheek, and forehead.⁶ It is essential that dermatologists suggest the use of emollients, barrier creams, and moisturizers to their peers to prevent skin complications from personal protective equipment (PPE).⁷ Aside from maintaining a healthy skin barrier, dermatologists should also recommend a conscious control of time spent wearing PPE as well as using a mask made of other materials if possible. If another material type is unavailable, two layers of gauze may be used inside the current mask.⁸

References
1. Eczema causes and triggers. National Eczema Association. Accessed March 24, 2020. https://nationaleczema.org/eczema/causes-and-triggers-of-eczema/

2. Centers for Disease Control and Prevention. Handwashing: clean hands save lives: how to wash your hands. Updated March 4, 2020. Accessed March 24, 2020. https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html

3. American Academy of Dermatology shares hand washing tips amid COVID-19. News release. American Academy of Dermatology. March 19, 2020. Accessed March 24, 2020. https://www.aad.org/news/2020-03-10-hand-washing-covid

4. National Eczema Association. Ask the ecz-perts: coronavirus (COVID-19). March 2020. Accessed March 24, 2020. https://nationaleczema.org/ate-covid-19/

5. Foo CCI, Goon ATJ, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome—a descriptive study in Singapore. Contact Dermatitis. 2006;55(5):291-294. doi:10.1111/j.1600-0536.2006.00953.x

6. Lan J, Song Z, Miao X, et al. Skin damage among healthcare workers managing coronavirus disease-2019. J Am Acad Dermatol. Published online March 11, 2020. doi:10.1016/j.jaad.2020.03.014

7. Darlenski R, Tsankov N. Covid-19 pandemic and the sin – what should dermatologists know? Clin Dermatol. Published online March 24, 2020. doi:10.1016/j.clindermatol.2020.03.012

8. Yan Y, Chen H, Chen L, et al. Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019. Dermatol Ther. Published online March 13, 2020. doi:10.1111/dth.13310