==== Front Cureus Cureus 2168-8184 Cureus 2168-8184 Cureus Palo Alto (CA) 10.7759/cureus.39846 Dermatology The Prevalence and Clinical Features of Skin Irritation Caused by Infection Prevention Measures During COVID-19 in Riyadh Region, Saudi Arabia Muacevic Alexander Adler John R Alwadany Muhannd M 1 Alotaibi Manar A 2 Almousa Abdulelah S 1 Alawdah Ahmed M 1 AlDera Norah M 3 Alqahtan Ghadeer M 4 Al Ajeel Heba Y 5 1 College of Medicine, King Faisal University, Alhofuf, SAU 2 Department of Dermatology, Prince Sultan Military Medical City, Riyadh, SAU 3 College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU 4 College of Medicine, King Khalid University, Abha, SAU 5 Dermatology, King Faisal University, Alhofuf, SAU Muhannd M. Alwadany muhannad.w91@gmail.com 1 6 2023 6 2023 15 6 e398461 6 2023 Copyright © 2023, Alwadany et al. 2023 Alwadany et al. https://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from https://www.cureus.com/articles/159262-the-prevalence-and-clinical-features-of-skin-irritation-caused-by-infection-prevention-measures-during-covid-19-in-riyadh-region-saudi-arabia Introduction: Coronavirus disease 2019 (COVID-19) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused by a novel coronavirus (CoV), was reported at the end of 2019 and caused a severe public health concern. It caused high mortalities by respiratory failure among infected people and was declared a pandemic by the World Health Organization (WHO) in March 2020. This virus caused infections through air or direct contact which documented a huge number of fatalities. Aim: This study aims to examine the impact of the COVID-19 pandemic on skin eczema of the general public in the Riyadh region of Saudi Arabia. Methods: This is a descriptive, cross-sectional, survey-based study, that was conducted via an online survey distributed to the general population of Riyadh for the period between January and February 2023. Data was collected through a questionnaire which was distributed through the social media websites. Results: A total of 697 participants were involved in this study. Around one-fifth of the study participants (19.5%) reported that they suffer from some form of allergy and have family history of allergy (21.8%). Eczema was the most common type of allergy among the study participants accounting for 32.4%. A total of 116 participants (16.6%) reported that they have personal history of hand eczema or other skin disease on the hands. Cleaning and sterilization materials were reported as the most common cause of dryness and irritation of eczema (62.1%). Around 41.0% of the participants reported that they noticed a worsening of their symptoms after the pandemic, of which dryness was the most commonly reported sign noticed getting worse by 68.1% of the participants. The vast majority of the participants (89.7%) reported that new skin symptoms emerged on their hands after the beginning of the pandemic, of which dryness was reported by all the participants. Conclusion: A considerable proportion of participants, particularly those with a history of hand eczema, experienced dermatological difficulties, including skin damage, due to the usage of COVID-19 preventive strategies. Thus, we recommend increasing the use of innovative infection prevention approaches and skin protection measures, such as regular hand hydration and maybe the use of less toxic skin disinfectants. saudi arabia prevention irritation eczema skin ==== Body pmcIntroduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), or coronavirus disease 2019 (COVID-19), was identified towards the end of 2019, causing a major public health risk [1]. The World Health Organization (WHO) declared a pandemic in March 2020 because of the significant mortality rates caused by respiratory failure among afflicted individuals [1]. This virus produced infections through airborne or direct contact, resulting in a staggering number of deaths [2]. WHO recommends using hand sanitizer, face masks, and social distance in order to reduce infections and remain safe [2]. Owing to the panic scenario, individuals employed regular hand washing (with alcohol and soap), face masks, and social isolation, which may have had adverse effects on their health, such as dermatitis or an allergy. According to one study, frequent hand sanitizer usage might lead to skin diseases [3]. It has been noted that the prevalence of dermatitis-sensitive individuals has increased. The health professionals who are already in more touch with patients and COVID-19 onset have been overloaded by this condition. Inflammation of the skin, such as eczema, was more prevalent in the general population and among healthcare professionals [3-5]. The skin barrier is the primary line of protection against antigens for the human body. Continuous hand-washing with chemicals or detergents, however, causes the epidermis to become brittle or sensitive, resulting in the progression of various illnesses or skin inflammations [6-8]. During the period of COVID-19, one study in China showed a 74.5% incidence of eczema among healthcare professionals [3]. In the western area of Saudi Arabia, one study by ZahrAllayali et al. (2021) indicated that 15.7% of participants with new instances of hand eczema and 34.5% of those with a history of hand eczema had their inflammation exacerbated [9]. Thus, it is advisable to take preventative steps, such as using skin moisturizers and limiting the usage of hand wash until absolutely required, to mitigate the negative effects of these hand sanitizers. Shelleh et al. (2004) observed a higher prevalence of dermatitis (34%) than other illnesses in the Najran General Hospital, Saudi Arabia, between 2000 and 2001 [10].  This study aims to examine the impact of the COVID-19 pandemic on skin eczema of the general public in the Riyadh region of Saudi Arabia. Materials and methods This is a descriptive, cross-sectional, survey-based study, that was conducted via an online survey distributed to the general population of Riyadh for the period between January and February 2023. The study population consisted of all patients who live in Riyadh and met the inclusion criteria and were willing to participate in the study. The total number of Riyadh region is 10,500,000. The sample size calculation with a 99% confidence interval and 0.05 precision rate is 666. Inclusion criteria were adults living in Riyadh city who are 18 years old and above, and exclusion criteria were any person who is under 18 or not willing to participate in the study. Data was collected through a questionnaire which was distributed through the social media websites. Data were analysed using descriptive statistics. Categorical variables were presented as frequency and percentage. The patients' confidentiality and the privacy of their data are the priority. Nothing leading to any ethical issue will be used, such as the names of participants. Ethical clearance was given by the ethical committee of the medical college at King Faisal University. Results Table 1 below presents participants' demographic characteristics. A total of 697 participants were involved in this study. The majority of them (86.1%) were females and males were 13.9%. Almost 62.0% of them were aged 30 years and below. The majority of them (74.9%) were single and Saudi (74.3%) and non-Saudi was 25.7%. Only 5.7% of the participants reported that they are smokers. More than half of them (64.0%) were students. Around 4.2% of the participants were working in the healthcare sector, of which 62.1% were medical team members. Almost half (55.2%) of the workers in the healthcare sector were physicians. More than half (55.2%) of the healthcare workers reported that they use gloves for more than two hours on a daily basis. Almost one-third (34.5%) of the study participants reported that they wash their hands more than 20 times per day. Around 52.0% of them reported that they use hand sanitizer more than 10 times per day. Table 1 Participants' demographic characteristics. Variable Frequency Percentage Gender Females 600 86.1% Male 97 13.9% Age groups 18-20 years 223 32.0% 21-30 years 224 32.1% 31-40 years 83 11.9% 41-50 years 48 6.9% 51 years and older 119 17.1% Marital status Single 522 74.9% Married 160 23.0% Widowed or divorced 15 2.2% Nationality Saudi 518 74.3% Non saudi 179 25.7% Smoking status Smokers 40 5.7% Profession Student 446 64.0% Unemployed 85 12.2% Education sector 70 10.0% Administrative 67 9.6% Healthcare professional 29 4.2% For those who work in the healthcare sector Healthcare field (n= 29) Medical 18 62.1% Surgical 7 24.1% Laboratory 3 10.3% Anaesthesia 1 3.4% Specialty (n= 29) Physician 16 55.2% Nurse 5 17.2% Pharmacist 3 10.3% Lab technician 2 6.9% Dietitian 1 3.4% Reception supervisor 1 3.4% Radiologist 1 3.4% Daily use of gloves )hours( (n= 29) Less than two hours 13 44.8% 2-5 hours 7 24.1% More than five hours 9 31.0% Number of times to wash hands per day: (n= 29) Less than 20 times 19 65.5% More than 20 times 10 34.5% The number of times you use hand sanitizer per day: (n= 29) Less than 10 times 14 48.3% More than 10 times 15 51.7% Allergy history of the study participants Table 2 below presents the allergy history of the study participants. More than half of the study participants (54.7%) reported that they leave their house one to two times per week. Around one-fifth of the study participants (19.5%) reported that they suffer from some form of allergy and have a family history of allergy (21.8%). Allergic contact dermatitis was the most common type of allergy among the study participants accounting for 32.4%. Similarly, eczema was the common type of allergy as a family history among the study participants accounting for 57.9%. Table 2 Allergy history of the study participants Variable Frequency Percentage How often do you leave the house during the week? 1-2 times 381 54.7% 3-6 times 229 32.9% More than 6 times 87 12.5% Do you suffer from any kind of allergy? Yes 136 19.5% What type of allergy do you have? (more than one answer could be chosen) (n= 136) allergic contact dermatitis   44 32.4% Allergic rhinitis 32 30.1% Asthma 41 23.5% Others 43 31.6% Do you have a family history with any kind of allergy? Yes 152 21.8% What type of allergy do you have family history for? (more than one answer could be chosen) (n= 152) Eczema 88 57.9% Asthma 81 53.3% Allergic rhinitis 40 26.3% Others 27 17.8% Eczema history of the study participants Table 3 below presents the eczema history of the study participants. A total of 116 participants (16.6%) reported that they have personal history of hand eczema or other skin disease on the hands. The vast majority of them (84.4%) reported that they use hand moisturizer. Around 78.4% of them reported that their eczema was diagnosed by a dermatologist and 66.4% of them reported that they follow up with a dermatologist. Most of the participants (80.2%) reported that their treatment was prescribed by a dermatologist. Only half of them (48.4%) reported that they are using the treatment prescribed by their dermatologist. One-third of them (33.6%) reported that they noticed an improvement in their eczema when they are away from work. Table 3 Eczema history of the study participants. Do you have a personal history of hand eczema or any other skin disease on the hands? Yes 116 16.6% Do you use hand moisturiser? Yes 588 84.4% Was the eczema diagnosed by a dermatologist? (n= 116) Yes 91 78.4% Did you follow up with a dermatologist? (n= 116) Yes 77 66.4% Was the treatment prescribed by a dermatologist? (n= 116) Yes 93 80.2% Are you using the treatment prescribed by your dermatologist? (n= 93) Yes, 45 48.4% Have you noticed an improvement in your eczema when you are away from work? (n= 116) Yes 39 33.6% What are the causes of dryness and irritation of your eczema? (more than one answer could be chosen) (n= 116) Cleaning and sterilization materials 72 62.1% Soap 50 43.1% Water 39 33.6% Certain foods, oils or herbs 33 28.4% Animals 16 13.8% Have you noticed a worsening of your symptoms after the pandemic? (n= 116) Yes 47 40.5% If yes, what symptoms or signs did you notice getting worse? (more than one answer could be chosen) (n= 47) Dryness 32 68.1% Severe itching 31 66.0% Skin irritation and redness 29 61.7% The appearance of rough patches or scales on the skin 27 57.4% Pain or discomfort when touching the affected area 15 31.9% Burning or pain 9 19.1% Please choose the skin symptoms that match your skin damage: (n= 116) Redness 81 69.8% Scales on the skin 63 54.3% Cracked skin 61 52.6% Open sores or infections 37 31.9% Prominent bumps 34 29.3% After the beginning of the pandemic, did you notice the emergence of new skin symptoms in the hands? Yes 104 89.7% If yes, what symptoms or signs did you notice? (more than one answer could be chosen) (n= 104) Dryness 104 100.0% Skin irritation and redness 63 60.6% Severe itching 62 59.6% The appearance of rough patches or scales on the skin 57 54.8% Pain or discomfort when touching the affected area 23 22.1% Burning or pain 22 21.2% Please choose the skin symptoms that match your skin damage after the pandemic: (more than one answer could be chosen) (n= 116) Redness 87 75.0% Cracked skin 63 54.3% Scales on the skin 51 44.0% Prominent bumps 32 27.6% Open sores or infections 25 21.6% Cleaning and sterilization materials were reported as the most common cause of dryness and irritation of eczema by the study participants accounting for 62.1%. Around 41.0% of the participants reported that they noticed a worsening of their symptoms after the pandemic, of which dryness was the most commonly reported sign noticed getting worse by 68.1% of the participants. The vast majority of the participants (89.7%) reported that new skin symptoms emerged on their hands after the beginning of the pandemic, of which dryness was reported by all the participants. Redness was the most commonly reported (75.0%) skin symptom that match the damage of the participants’ skin after the pandemic.  Discussion Current recommendations from the WHO include social distancing, avoiding touching the face, wearing masks, wearing disposable gloves, and often washing hands with soap or alcohol-based disinfectants [11]. Although these treatments are suggested for preventing the spread of COVID-19, they may also have harmful effects on the skin. Following the WHO's recommendations, frequent handwashing (using soap and water for 40-60 seconds) has become the most important activity during the COVID-19 pandemic [11]; however, these measures may disturb the normal skin flora and natural protective skin barrier, leading to a variety of skin diseases, most frequently irritant and allergic contact dermatitis [3]. Globally, a prior study conducted in China found a 74.5% frequency of hand eczema among healthcare professionals during the COVID-19 pandemic, suggesting that the COVID-19 pandemic may be linked to skin problems [7]. In our study, more than half (55.2%) of the healthcare workers reported that they use gloves for more than two hours on a daily basis. Almost one-third (34.5%) of the study participants reported that they wash their hands more than 20 times per day. Around 52.0% of them reported that they use hand sanitizer more than 10 times per day. This was confirming the findings of previous studies which reported that participants tended to wash their hands more than 10-20 times per day during the pandemic [3,9]. The American Contact Dermatitis Society anticipates an increase in the incidence of both irritant and allergic contact hand dermatitis as healthcare workers and the general public concentrate on stringent hand hygiene. The Centers for Disease Control and Prevention advise routine handwashing with soap and water to prevent virus transmission [12]. In addition, long-term use of rubber gloves, especially without the application of an underlying moisturizer, worsens and/or raises the risk of allergic and irritating contact dermatitis [12]. In our study, allergic contact dermatitis was the most common type of allergy among the study participants accounting for 32.4%. The use of moisturizers has been advised to avoid hand eczema because high anxiety levels, excessive or irrational protective actions, and specific COVID-19 measures may cause or worsen the appearance of different dermatological diseases [12,13]. A prevalent condition that is considered to be of public health significance is hand eczema. Handwashing has been by far the most important risk factor for the occurrence of hand eczema. Frequent hand hygiene is another risk factor for hand eczema [13]. In our study, cleaning and sterilization materials were reported as the most common cause of dryness and irritation of eczema by the study participants accounting for 62.1%. Around 41.0% of the participants reported that they noticed a worsening of their symptoms after the pandemic, of which dryness was the most commonly reported sign noticed getting worse by 68.1% of the participants. Redness was the most commonly (69.8%) reported skin symptom that match the skin damage of the study participants. The vast majority of the participants (89.7%) reported that new skin symptoms emerged on their hands after the beginning of the pandemic, of which dryness was reported by all the participants. Redness was the most commonly reported (75.0%) skin symptom that match the damage of the participants’ skin after the pandemic. This was confirming the findings of a previous study in Saudi Arabia by ZahrAllayali et al. in 2021 [9]. In this study, the researchers observed that during the COVID-19 pandemic, 86 (13.1%) individuals had new-onset skin irritation, while 81 (31.3%) participants experienced a worsening of previously diagnosed hand allergic dermatitis. The most prevalent symptoms were dryness and a sense of constriction. Statistically, the frequency of handwashing rose after the commencement of the pandemic (p=0.001), and there was a correlation between new-onset symptoms and more frequent handwashing and the use of hand disinfectants during the pandemic (p=0.001) [9]. In previous studies, it was shown that itching, dryness, and soreness were the most typical clinical signs of skin injury among first-line healthcare providers [9,14]. This study is among the first few studies in Saudi Arabia that examined the prevalence and clinical features of skin irritation caused by infection prevention measures during COVID-19 in Saudi Arabia. At the same time, this study has limitations. A self-administered questionnaire through an online platform could be biased depending on the access to the internet among the study participants, and it may result in demographic bias by recruiting a younger, more internet-active population. Our study was cross-sectional, and participants were asked to complete an online questionnaire. As a result, a smaller percentage of people over 30 were included in the study. The two groups were not equally split by sex; more than 85% of participants were female. Consequently, the external generalizability may be impacted by both age and sex. Conclusions Our research showed how COVID-19 prevention measures affected the skin of the general population. Due to the use of COVID-19 prevention measures, a significant portion of the participants especially those who had a history of hand eczema-reported dermatological issues, including skin damage. As a result, we advise promoting the use of novel infection prevention techniques and skin protection strategies, such as frequent hand hydration and maybe the use of less harmful skin disinfectants. Human Ethics Animal Ethics Consent was obtained or waived by all participants in this study Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. The authors have declared that no competing interests exist. ==== Refs References 1 WHO Coronavirus (COVID-19) Dashboard 2 2023 2023 https://covid19.who.int/data 2 COVID-19 transmission and protective measures 2 2023 2023 https://www.who.int/westernpacific/emergencies/covid-19/information/transmission-protective-measures 3 Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: comparing a single surgical site with a COVID-19 intensive care unit Contact Dermatitis Guertler A Moellhoff N Schenck TL 108 114 83 2020 32452036 4 The risk of hand eczema in healthcare workers during the COVID-19 pandemic: do we need specific attention or prevention strategies? 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