Industry News

Supporting Our Skin During the COVID-19 Pandemic: The Importance of Prevention

We have entered a new journey through an unprecedented time. The coronavirus (COVID-19) is ravaging the world and especially my home state of New York. I am humbled to be working every day alongside my colleagues — dedicated doctors, nurse practitioners, nurses, and ancillary staff — who are fighting, as the President of the United States puts it, “an invisible enemy.” But the enemy’s effects are profoundly visible: hospitals floors are full with patients who are intubated, critical, and in respiratory distress. Supplies of respiratory equipment are critically low. Personal protective equipment and disinfecting products have become commodities. A No Visitors’ policy is in effect; social distancing is paramount. Personal hygiene and clean surfaces have become more essential today than they have ever been.

Clinicians are appropriately focusing attention on the respiratory status of our virus-affected patients, because pneumonia-induced cytokine surge and acute respiratory distress syndrome overwhelm the presentation. But what about our skin, our biggest barrier to harmful entry and our protector against microbes and outside forces? We face tremendous challenges in caring for our great protector. Respiratory equipment already is known to be the number 1 cause of pressure injuries; as more patients are infected with coronavirus, more cutaneous pressure injuries will occur. Epidermal stripping is to be expected as numerous adhesive devices are attached to patients. More irritant dermatitis will occur among hospital workers, because frequent hand washing/sanitizing is breaking down the outer stratum corneum, not to mention the wounds associated with face masks. More than ever, as barriers between skin and equipment become critical, adhesive releasers, creams and acrylate films, and emollients are needed for worker protection.

In pediatrics and especially neonatology, we have to concentrate on prevention. My patients cannot afford serious illnesses; their bodies are often too immature to be exposed to microbes without catastrophic outcomes. Examples are prolific and include Staphylococcus aureus skin colonization, central line infections, systemic infections, community-acquired S aureus via contact and surface colonization; congenital fungal and bacterial infections related to the maternal microbiome and neonatal exposure; Clostridium difficile infections in the hospitals via fomite/surface1 transmission; and, of course, viral infections, including COVID-19 via droplets. Whether we are providers, patients in the hospital, or citizens in the community, our skin defends us daily, and every surface it touches presents a risk.¹

The infection spread due to the COVID-19 pandemic is not unique. The skin microbiome, skin, and environmental surfaces are colonized with microbes; whether commensal or pathogenic, these microbes have been the subject of many studies. In hospitals, the patient environment includes patient-care equipment, environmental surfaces, visitors touching the patient, and (in the case of a neonate) the mother/baby skin interaction during labor. We know that infants are highly susceptible to microbiome changes based on the mode of delivery. Vaginal delivery will induce colonization by diverse commensal bacteria, such as Lactobacillus species,² whereas a Caesarian section will introduce maternal skin and mouth flora including Staphylococcus and Streptococcus species.2 In addition, maternal diabetes, breast infection, or poor diet will promote pathogenic skin colonization; neonatal feeding with breast milk will promote Lactobacillus species colonization of the skin and gut.² Studies involving vernix retention in newborns demonstrated superior skin condition as well acid mantle development and commensal bacterial colonization; therefore, removing the vernix by bathing is to be avoided. Early bathing is not recommended in newborns in general for variety of reasons, except after delivery associated with certain maternal viral conditions, such as hepatitis C, human immunodeficiency virus, human lymphotropic virus, and now COVID-19. Transmission to caretakers and surfaces is highly probable and represents significant risk to personnel and patients. In the neonatal world, patient colonization with methicillin-resistant S aureus is another example of surface transmission, demonstrating the need for decontamination (skin with chlorhexidine and surfaces with strong antiseptics) and skin decolonization.

As noted in a previous Children with Wounds column,³ infected patients are recognized as a source of pathogens, and the use of transmission-based precautions is central to preventing dissemination of pathogens; colonized patients and surfaces also represent a risk of pathogen dissemination. Consistent and correct use of standard and transmission-based precautions is generally relied on to protect health care workers and help control pathogen cross transmission. However, it is far from certain whether the typical compliance levels with hand hygiene, environmental surface cleaning, and use of barriers are adequate to manage this risk. Colonization is referred to as the presence of microorganisms in or on a host, with growth and multiplication but without tissue invasion or cellular injury.¹ A colonized person shows no obvious signs of disease yet can spread microorganisms into the environment through normal day-to-day activities. Although most of the microorganisms shed are nonpathogenic to the colonized host, bacteria or viruses may be pathogenic to other people, depending on the portal of entry or the immune system strength of the susceptible host. The potential for pathogen dissemination from an asymptomatic person is high as the average human body contains ~0.3 percent bacteria by weight.⁴

Three (3) common sources of microorganisms shed by people include, feces, saliva, and skin cells.¹ As much as it provides a barrier, skin is a landing ground for these microorganisms. As skin sheds, so do the microbes inhabiting the outer layer. The American Academy of Dermatology5 estimates that out of 19 million skin cells, 30 000 to 40 000 are shed daily. Meadow et al6 reported that humans shed 1x 106 particles of >0.5 micrometer/hour. Many of these particles contain bacteria (there are 1×1011 bacteria/m2 on skin), viruses, and fungal debris in addition to human debris. Viral particles are even smaller and tend to be disseminated even more.

A few months before COVID-19 came our way, I spoke with Mary Brennan, WOCN, Assistant Director for Wound and Ostomy Care at North Shore University Hospital, Northwell Health, New York state. We discussed a study on the safety of our pillows and surfaces and contamination potential even after thorough outside cleaning that she was working on with our colleagues from the Northwell Feinstein Institute Skin Research group. She shared her experiences to inform readers.

To read the full Wound Management & Prevention article by Vita Boyar and Mary Brennan, click here.