Hyperpigmentation in Skin of Color From Iatrogenic COVID-19 Dermatoses

Postinflammatory hyperpigmentation (PIH) is a common dermatologic presentation in skin of color (SOC). PIH is an acquired hypermelanosis secondary to injury or inflammation. PIH can occur in all skin types, though it is more frequent and severe in SOC. Common inflammatory dermatoses leading to PIH include acne, irritant contact dermatitis, and allergic contact dermatitis. 

While it has been detailed in literature for decades, the COVID-19 pandemic has created a greater urgency in education on PIH due to personal protective equipment (PPE)-related dermatoses. A large body of research has focused on dyspigmentation from melasma and acne, though many of the precepts transferrable to current PPE effects on SOC. We have many options available for treatment, including pharmaceuticals, cosmeceuticals, and medical devices, and we should be prepared to utilize our armamentarium to treat these PPE-related dermatoses.
Relevance in 2020 

Previous public health crises have provided a look into what is to come regarding PPE-related dermatoses. In 1987, the Centers for Disease Control and Prevention implemented expanded PPE use in response to the HIV epidemic to increase protection from blood-borne pathogens. Over the next decade, use of rubber latex gloves increased 1000%; at that same time, research showed a sharp increase in cases of allergic contact dermatitis.¹

The COVID-19 pandemic has also shown to have increased the incidence of iatrogenic PPE-related dermatoses. Prior to the pandemic, it was estimated that 20% to 50% of health care workers (HCW) experienced iatrogenic dermatoses.² In contrast, two Chinese studies from March 2020 showed self-reported skin damage rates of 71% and 97% among HCWs treating COVID-19 patients.^3,4 In these studies, the most common areas affected were the nasal bridge, cheeks, forehead, and hands. Symptoms included dryness/tightness, tenderness, pruritus, and burning/pain. Presentations included desquamation, erythema, maceration, and fissuring.

Frequency in SOC
Anyone with extended PPE use is at risk for iatrogenic dermatoses. However, SOC is significantly more likely to develop pigmentary sequelae. SOC contains more melanin, which leads to an increased risk of PIH from many diseases, especially in Fitzpatrick phototypes IV through VI. Throughout the last several decades, multiple studies have shown dyschromias are common in SOC:

• A 1983 study listed nonvitiligo pigmentary changes as the third most common dermatosis in African Americans vs the seventh most common in Caucasian⁵;
• A 2002 study showed 65.3% of African Americans, 52.7% of Hispanics, and 47.4% of Indians will develop PIH secondary to acne⁶;
• And a 2007 study of diagnosis codes over 1 year listed dyschromias as the second most common diagnosis for Black patients, but it was not listed in the top 10 for White patients.⁷

These dyschromias can present an enormous burden of disease and psychological distress. One example from a 2007 survey of Arab Americans in Michigan revealed 56.4% of participants reported concerns of uneven skin tone and skin discoloration.⁸ Despite this higher burden of disease, research suggests an educational gap in preventive measures in at-risk populations. For example, multiple studies in Brazil, South Africa, and India have shown sunscreen usage is lower in SOC.⁹

Prevention of PIH is more than just a cosmetic concern; it can be an important public health issue. Untreated facial inflammatory conditions will increase facial irritation and can cause people to remove their PPE to touch their face, greatly reducing the PPE effectiveness.¹⁰ Damaged skin barriers may also lead to a poorer seal with the PPE. To address this, we must be prompt to recognize and treat, or prevent entirely, the offending inflammatory condition.  

Allergic contact dermatitis. Patients presenting with erythema, pruritus, burning or stinging sensations, and other allergic symptoms on the face should be evaluated for allergic contact dermatitis secondary to mask use.

Patch testing is considered the standard to identify offending agents from mask use. Xie et al¹¹ reported allergic contact dermatitis in an otherwise healthy 23-year-old woman previously diagnosed with acute cutaneous lupus erythematosus after performing a patch test; the patient’s facial lesions and erythema nearly disappeared after 3 days of antiallergic therapy and nonallergenic mask use. Patch testing is especially useful to non-HCWs who have numerous mask options to wear; HCWs will need to explore their other appropriate PPE options, which may include sponge-less or aluminum strip-free masks and latex-free gloves.

The following is a list of common PPE allergens, as discussed by Bhatia et al¹²: 

• Surgical masks: thiuram, methyldibromo glutaronitrile, cocospropylenediamine-guanidinium diacetate , and dibromodicyanobutane
• N95 masks: formaldehyde, ethylene urea melamine formaldehyde, quaternium-15, and aluminum
• Homemade cloth masks: formaldehyde textile resins, formaldehyde releasers such as quaternium-15 and imidazolidinyl urea, disperse dyes, p-aminobenzene, paraphenylenediamine, naphthol AS, black rubber mix, and lanolin
• Natural rubber latex gloves: rubber accelerators (thiuram, carba mix or carbamates, mercaptobenzothiazole, diphenylguanidine), antioxidants (diaminodiphenylmethane, paraphenylenediamine, black rubber mix), latex 
• Synthetic rubber, nitrile, vinyl, or neoprene gloves: rubber accelerators (carba mix, carbamates, thiuram mix, 1,3-diphenylguanidine, benzothiazoles, thioureas)

Dermatology professionals are also keenly aware of the common allergens in hygiene products, including alcohols and fragrances.¹²  

Irritant contact dermatitis. Several factors can predispose to irritant contact dermatitis, including friction, mechanical pressure, occlusion, humidity, and a dry environment. Atopic individuals are at a greater risk for the development of irritant dermatitis. Notably, there is a higher prevalence of atopic diseases (atopic dermatitis, asthma) in African Americans, which may correlate to higher irritant contact dermatitis in people with darker Fitzpatrick phototypes.¹³ 

Common irritants to keep in mind in light of the pandemic include:

• Masks: friction, mechanical pressure, humidity
• Gloves: cornstarch-based glove powder, cetylpyridinium chloride
• Hygiene products: alcohols (ethanol, isopropanolol, chlorhexidine), sodium lauryl sulphate, chloroxylenol, cetrimide, gluconolactone, sodium hydroxide

Acne and pressure injuries. The traditional factors of stress, occlusion, friction (acne mechanica), and humidity can lead to acne. Inflammatory acne is one of the most common causes of PIH in skin of color. Furthermore, the tight-fitting PPE may cause pressure injuries that can range from transient to scarring. Erosions are more likely to occur on the nasal bone, zygomatic bones, maxillary bones, and central forehead (Figure¹⁴). 

Treatment Options 
Treatment of underlying inflammatory conditions is the most urgent step in the approach of PIH. Care must be taken to work gradually to avoid further irritation and exacerbation of PIH. PPE-related dermatoses can be lessened by proper habits, though it may not always be prevented entirely. We can educate patients to limit exposure to masks whenever possible and safe to do so, in accordance with current guidelines and recommendations such as following stay-home orders. When safety and work activity allow, surgical masks may also be considered as opposed to N95 masks. Also, reusable masks should be washed daily and disposable masks replaced daily. Furthermore, only properly fitting PPE should be worn and soaps, harsh cleansers, exfoliators, and fragranced items should be avoided. Barrier creams may play a critical role in the management of each of these conditions.  

Education of broad-spectrum photoprotection is crucial. Tinted mineral sunscreens with iron oxide as an inactive ingredient are preferred. These filter blue light from screens, which may be particularly important for PIH and melasma in SOC.¹⁵ 

Treatment options depend on the level of skin involved in the PIH. For superficial or epidermal PIH, hydroquinone, azelaic acid, retinoids, topical corticosteroids, and kojic acid are commonly utilized. Cosmeceutical agents such as niacinamide, licorice, or arbutin may be added. Finally, for deeper dermal or mixed PIH, more aggressive options are considered, such as laser, light, or chemoexfoliation therapies.¹⁶ 

Mr Stevens graduated from the University of Nebraska-Medical Center in 2015. Since then, he has been in private practice on a team of two board-certified dermatologists and three dermatology PAs in Lincoln, NE.  

Disclosure: The author reports no relevant financial relationships.

References
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