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issue20253

1. ww

Volume 16, Number 3 July 2025

ISSN: 2956-7904

p. 225-344

DOI: 10.7241/ourd

Issue online since Tuesday July 01 2025

Dermatology Online

www.odermatol.cowm

Our

Issue 3.2025

- Ear contact dermatitis: Epidemiology

and main contact allergens in Dakar, Se-

negal;

- The impact of personal protective equ-

ipment on the condition of the skin in

the era of COVID-19;

- The impact of personal protective equ-

ipment on the condition of the skin in

the era of COVID-19;

- Safety profile of anti-ageing natural co-

smetic formulations with Litsea cubeba

essential oil;

- The identification of leprosy pocket

areas for contact tracing and support for

leprosy elimination in the far west hill

area of Nepal;

- Keloids in the hospital setting in nor-

thern Benin: Epidemiological, clinical

and therapeutic aspects;

- Keloids in the hospital setting in nor-

thern Benin: Epidemiological, clinical

and therapeutic aspects;

- Idiopathic pseudolymphoma cutis

upsurge of cases: Do environmental fac-

tors modify the behavior of the disease;

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Zawar Vijay, Prof (India)

Contents

Original Articles

Ear contact dermatitis: Epidemiology and main contact allergens in Dakar, Senegal..........................................225

Boubacar Ahy Diatta, Akkaoui EL Dounia, Patrice Mendy, Mamadou Sarr, Ndiague Fall, Massamba Mbengue,

Diadié Saer, Assane Diop, Ndiaye Maodo, Biram Loum, Moussa Diallo, Fatimata Ly, Suzanne Oumou Niang

The impact of personal protective equipment on the condition of the skin in the era of COVID-19.................230

Beata Zagórska, Magdalena Trzeciak

Evaluation of tele-expertise in the management of common dermatoses in peripheral health centers

in Togo from 2018 to 2023...............................................................................................................................237

Panawé Kassang, Bayaki Saka, Abas Mouhari-Touré, Sefako Akakpo, Julienne Teclessou, Emilie Lauressergues,

Christophe Przybylski, Piham Gnossike, Garba Mahamadou, Léa Matel, Raymond Barruet, Claude Akakpo,

Koussake Kombate, Béatrice Garrette, Kissem Tchangai-Walla, Palokinam Pitche

Safety profile of anti-ageing natural cosmetic formulations with Litsea cubeba essential oil................................242

Dominika Kowalczyk, Łukasz Świątek, Gokhan Zengin, Elwira Sieniawska, Katarzyna Borowska

The identification of leprosy pocket areas for contact tracing and support for leprosy elimination in

the far west hill area of Nepal............................................................................................................................249

Rebecca Martin, Dev Raj Rawol, Tara Dev Pant, Anupa Khadka,Upama Paudel, Sudip Parajuli

Keloids in the hospital setting in northern Benin: Epidemiological, clinical and therapeutic aspects....................255

Fabrice Akpadjan, Elie Ataїgba, Claire Mouasso Dipita, LauraDotsop, Nadège Agbessi, Odile Houngbo,

Christiane Koudoukpo

Brief Reports

Intralesional vitamin D3 injection in the treatment of cutaneous warts: Our experience and

literature reviews...............................................................................................................................................260

Zineb Bennouna, Hanane Baybay, Zakia Douhi, Meryem Soughi, Sara Elloudi, Fatimazahra Mernissi

Idiopathic pseudolymphoma cutis upsurge of cases: Do environmental factors modify the behavior

of the disease.....................................................................................................................................................265

Khalifa E. Sharquie, Fatema A. Al-Jaralla

Case Reports

Atypical presentations of comedones: Insights into rare associations and dermoscopic patterns.........................270

Joshi Swati, Kumar Ramesh, Shrivastava Harshita, Meena Ranjeet, Jain Suresh Kumar, Nyati Asha,

Yadav Devendra

Aspergillus onychomycoses: A report of three cases from the Yucatan Dermatology Center in Mexico..............275

Ana Isabel Macías-Macías, Lourdes Ramírez – Hobak, Edoardo Torres-Guerrero, Nixma Eljure-López,

Carlos Atoche-Diéguez

Methotrexate-induced cutaneous and hematological toxicity following a single low dose in a

hemodialysis patient: A case report....................................................................................................................279

Elkhalil El Bakali, Edgar Keby, Abir Boulhilate, Ilias Anouar, Meryem Khalidi, Jawad El Azhari,

Youssef Zemmez, Rachid Frikh, Naoufal Hjira

Acute cholecystitis complicating probable DRESS syndrome: A case report......................................................283

Nelson Venceslas Njedock Sontsa, Eric Gael Ananfack Nguefack, Cedric Gwet, Edgar Mandeng Ma Linwa,

Serge Patrick Medoua, Rudy Arnaud Nana, Albert Justin Kana

Sweet syndrome induced by an insect bite.........................................................................................................290

Sara Ait Oussous, Fatima Zahra El Alaoui El Abidi, Imane Lakhal, Mohamed Aksim, Radia Chakiri

Contents

Degos disease (malignant atrophic papulosis) with a specific location in a male patient: A diagnostic

and therapeutic challenge..................................................................................................................................294

Theodora Douvali, Andriani Tsiakou, Andriana Kavallari, Maria Kanakari, Eleftheria Tampouratzi,

Filippos Dolkiras, Christina Vourlakou, Vasiliki Chasapi

Treatment of circumscribed lymphangiomas with Er: YAG laser.......................................................................298

Sabrina Oujdi, Hanane Baybay, Sara Elloudi, Meryem Soughi, Zakia Douhi, Fatima Zahra Mernissi

Ulcerative presentation of leukemia cutis in a patient with therapy-related pre-B-cell acute

lymphoblastic leukemia.....................................................................................................................................301

Judith Monserrat Corona-Herrera, Fanny Carolina López-Jiménez, William Ardila-Castillo,

Tania Galindo-García, Linda García-Hidalgo

Urticaria in a patient with high malaria parasitemia: A rare case report..............................................................304

Nelson Venceslas Njedock Sontsa, Serge Patrick Medoua, Edgar Mandeng Ma Linwa, Rudy Arnaud Nana,

Cedric Gwet, Samuel Nkengfua, Eric-Gael Ananfack Nguefack

Clear cell acanthoma: An atypical localization...................................................................................................308

Kaoutar Mejjati, Hanane Baybay, Leila Tahiri Elousrouti, Khalil Bouayad, Zakia Douhi, Meryem Soughi,

Sara Elloudi, Fatima Zahra Mernissi

Achenbach’s syndrome: A case report of the paroxysmal blue finger in a middle-aged woman...........................311

Harisankar Anantharajan, Peter Bjerring, Luit Penninga, Theis Mariager, Carsten Sauer Mikkelsen

Opinion Articles

The role of dermatopathology in skin cancer prevention and diagnosis..............................................................313

Tessa Li Chyin Lim

Investigating the connection between insulin resistance and seborrheic dermatitis: Latest reports on

pathophysiology and clinical implications.........................................................................................................316

Franciszek Deresz, Anna Prus, Martyna Narloch

Review Article

Chimeric antigen receptor T-cell therapy in dermatological disorders: Expanding horizons...............................321

Fernando Javier Medina-Olivares

Clinical Image

Nodular hidradenoma of the vulva: a rare entity with an unusual location........................................................328

Zineb Zeggwagh, Kaoutar Znati, Sara Kerroum, Nadia Ismaili, Mariame Meziane, Laila Benzekri,

Karima Senouci

Case Letters

The Moroccan hammam, a purifying ritual: Triggered or aggravated dermatoses: A cross-sectional study..........330

Maryam Ghaleb, Ouiame Eljouari, Fatima Zohra El Ali, Kaoutar Benchakroun, Salim Gallouj

Cutaneous amyloidosis: A report of two cases....................................................................................................332

Patricia Chang, Shirley Sical, Roberto Orozco, Gylary Calderon

Dermatofibrosarcoma of the scalp mimicking a proliferating trichilemmal cyst.................................................335

Imane Kacimi Alaoui, Meryem Soughi, Zakia Douhi, Sara Elloudi, Hanane Baybay, Fatima-Zahra Mernissi

Eccrine porocarcinoma: A rare adnexal skin cancer............................................................................................337

Mamadou Diouldé 1 Kante, Khadim Diop, Abdoulaye Sadio Diallo

iii

Contents

Splinter hemorrhages a precursor sign of amlodipine-induced nail psoriasis......................................................338

Eleni Klimi

Exogenous ochronosis.......................................................................................................................................340

Patricia Chang, María Gabriela Herrera Gutiérrez, Julia Ovalle Quiñonez

Calciphylaxis: A great simulator of necrotizing vasculitis...................................................................................343

Sara El-Ammari, Zakia Douhi, Imane Kacimi Alaoui, Hanane Baybay, Sara Elloudi, Meryem Soughi,

Fatima Zahra Mernissi

2XU'HUPDWRORJ\2QOLQH

225

Ear contact dermatitis: Epidemiology and main

contact allergens in Dakar, Senegal

Boubacar Ahy Diatta1, Akkaoui EL Dounia1, Patrice Mendy1, Mamadou Sarr1,

Ndiague Fall1, Massamba Mbengue1, Diadié Saer1, Assane Diop1, Ndiaye Maodo1,

Biram Loum2, Moussa Diallo1, Fatimata Ly1, Suzanne Oumou Niang1

1Department of Dermatology, Cheikh Anta Diop University, Dakar, Senegal, 2Cervico-Facial Department, Cheikh Anta

Diop University, Dakar, Senegal

Corresponding author: Prof. Boubacar Ahy Diatta, MD, PHD, E-mail: ahydiatta@yahoo.com

INTRODUCTION

Ear eczema is a pruritic inflammatory dermatosis whose

prevalence ranges from 7% to 19% [1,2]. It accounts for

23% in Europe and 4% in the U.S. [3,4]. The causes

are multiple, dominated by allergic contact dermatitis

to metals, topical ear medications, cosmetics, and

external hearing aids [5]. Patch tests based on the

European Standard Battery are the reference tools for

investigating contact allergens. However, in Africa,

they remain limited by their availability and the

high cost in certain countries with low income. This

explains the paucity of data in the literature on contact

allergens. The aim of this study was to determine the

epidemiological characteristics of ear eczema and to

identify the main contact allergens.

PATIENTS AND METHODS

This was a descriptive, cross-sectional study with

prospective recruitment over a seven-month period

ABSTRACT

Background: Ear eczema is a frequent pruritic inflammatory dermatosis in dermato-allergology, with an estimated prevalence

of 7–19% worldwide. It has multiple causes, with a predominance of allergic contact eczema. The aim of this study was

to determine the epidemiological characteristics of ear eczema and to identify the main contact allergens responsible.

Patients and Methods: This was a descriptive, cross-sectional, multicenter study conducted over a seven-month period at

the Dermatology Departments of Aristide le Dantec Hospital, the Social Institute and the Medical Institute of Université

Cheikh Anta Diop, and the Cervico-Facial Department of Fann Hospital. We included all patients with ear eczema who

had undergone allergological tests and a nickel spot test if metal allergy was suspected. Data entry and analysis were

performed using SPSS, version 18. Results: We recorded 46 cases of ear eczema, with a hospital frequency of 0.46%. The

mean age was 22 years, with extremes of 5 months and 85 years. The sex ratio was 0.84 (25 women, 21 men). Personal

atopy was present in 80% of the cases. Ear eczema lesions were chronic in 28 cases and acute in 18 cases. The outer ear

was the site of lesions in 30 cases (65%), with both ears and symmetrical lesions. Ear involvement was isolated in 17% of

the cases, and associated with face eczema in 10%, the hands in 13%, and the scalp in 6%. Lesions of the external auditory

canal were noted in 4% of the cases. The standard European battery using the patch test was positive in all patients. The

main contact allergens were noted for nickel in 42%, cobalt in 35%, PPD in 28%, and thiuram mix in 28%. Patch tests were

relevant and concordant in 85% of the cases. The positivity of the nickel test was more relevant for six cases of contact

allergy to metals. Conclusion: Ear eczema remains a common dermatosis in dermato-allergological, with a predominance

of metal and cosmetic allergens in Dakar. Improving cosmetovigilance, especially by regulating the concentration of nickel

in cosmetic products and costume jewelry, could help to reduce the incidence of metal-allergy contact dermatitis.

Key words: Ear eczema, Contact allergens, Nickel, Dakar

Original Article

How to cite this article: Diatta BA, EL Akkaoui D, Mendy P, Sarr M, Fall N, Mbengue M, Diadié S, Diop A, Ndiaye M, Loum B, Diallo M, Ly F, Niang SO. Ear contact

dermatitis: Epidemiology and main contact allergens in Dakar, Senegal. Our Dermatol Online. 2025;16(3):225-229.

Submission: 02.11.2024; Acceptance: 15.02.2025

DOI: 10.7241/ourd.20253.1

www.odermatol.com

226

from January 15 to August 15, 2023, at the Dermatology

Departments of Aristide le Dantec Hospital, the

Institute of Social Hygiene and the Institute of Medical

and Social Welfare of Cheikh Anta Diop University,

and the Cervico-Facial Department of Fann Hospital.

All patients with ear contact dermatitis were included

in the study. The diagnosis of eczema was clinical. All

patients underwent patch testing using the European

Standard Battery. Nickel spot tests on personal products

were performed in cases of suspected nickel allergy.

A 1% alcoholic solution of dimethylglyoxime combined

with a 10% ammonium hydroxide solution (spot test)

produced a reddish-pink coloration by precipitation of

insoluble salts in the presence of nickel. This test was

sensitive from a level of 10 ppm (Fig. 1). Data entry

and analysis were performed using SPSS, version 18.

RESULTS

We recorded 46 cases of ear eczema, with a hospital

frequency of 0.46%. The patients were male in 21 cases

(45%) and female in 25 cases (54%), giving a sex ratio

of 0.84%. The mean age of patients was 22 years, with

extremes of 5 months to 85 years (Fig. 2). Personal

atopy was noted in 37 cases (80%) and familial atopy

in 28 cases (60%). The atopic equivalents were atopic

dermatitis in 22 cases, allergic rhinitis in 21, asthma

in 11, and allergic conjunctivitis in 5. Ear hygiene habits

included using cotton swabs in 14 cases, washing the

ears with fishing nets in 30, using cosmetic creams

in 5, and using topical ear medications in 3.

Other exposure factors included wearing metal earrings

in 22 cases, using earphones in 7 cases, and using hearing

aids in one case. The management was provided by a

dermatologist in 26 cases (56%), a general practitioner

in 5 cases (11%), a pediatrician in 4 cases (8%), an ENT

specialist in 2 cases (4%), and a traditional practitioner

in 6 cases (13%). It was the first episode in 16 cases

(34%) and an on-and-off eczema in 30 cases (65%).

Table 1 lists the various elementary ear lesions. Ear

eczema lesions were chronic in 28 cases (Fig. 3) and

acute in 18 cases. The outer ear was the site of lesions in

30 cases (65%), with both ear and symmetrical lesions.

Ear lesions were isolated in 17% of the cases, and

associated with face eczema in 10%, the hands in 13%,

and the scalp in 6%. External auditory canal lesions

were noted in 4% of the cases (Fig. 4). Table 2 lists

the topography of ear lesions. Epicutaneous tests were

conducted in all patients, with polysensitization in all

cases. The main contact allergens were nickel in 6 cases

(Fig. 5), cobalt in 5, and thiuram mix in 4. Table 3 lists

the different contact allergens observed. The relevance

of allergological tests was current in 64% of the cases

and longstanding in 57%. Concordance between the

standard European Battery and the personal products

reported by the patient reinforced relevance in 2 cases.

The nickel spot test reinforced relevance in 5 cases.

Patients had received topical steroids in 40 cases (86%)

and moisturizer in 32 cases (69%). Systemic treatments

were antihistamines in 36 cases (78%), antibiotics in

5 cases (10%), and oral steroids in 2 cases (4%). The

evolution was favorable in 34 cases (73%), with a relapse

in 12 cases (26%).

Figure 2: Distribution of the cases by age group.

Figure 1: Positive nickel spot test.

Table 1: Distribution of the cases according to elementary ear

lesions.

Elementary Ear Lesion

Number

Percentage

Lichenification

Dander

Erythema

Vesicle/Suintement

Hyperpigmentation

Craks

Crust

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227

DISCUSSION

We report a hospital incidence rate of 0.46% for

ear eczema in Dakar. However, ear eczema remains

frequent in allergological consultations, with a

prevalence varying between 7% and 19% in American

and European series [1,2]. In a European series

conducted over an eighteen-year period, with a study

population of 10,532 patients, 23% had ear eczema [3].

In the American series, ear eczema accounted for 4.2%,

with a study population of 4,3570 patients, conducted

over a seventeen-year period [4]. The average age

of our patients was 22, with a peak between 2 and

10 years, which corresponded to a link with the high

Figure 4: Allergic contact dermatitis of the external auditory canal.

Figure 3: Acute allergic contact dermatitis to nickel.

Figure 5: Nickel positive patch test.

Table 2: Distribution of patients by ear lesion topography.

Topography

Location

Number

Percentage

Pinna of the ear

Lobule

Helix

Gutter

Anthelix

Conch

Tragus

Ear canal

Ear canal and pinna

Table 3: Distribution of the patients according to the different

contact allergens identified.

Allergen

Number

Percentage

Metals

Potassium dichromate

7.14

Nickel

42.85

Cobalt

35.71

Plastic resins

Hydroxyethylmethacrylate

7.14

Tert‑butylphenolformaldehyde resin

(PTBP)

21.42

Epoxy resin, bisphenol A

14.28

Drug substances

Neomycin

7.14

Caine mixed 3

7.14

Colorants

PPD

28.57

Textile dye

7.14

Fragrances

Perou balsam

21.42

Fragrance mix I (FM I)

14.28

Fragrance mix II (FM II)

14.28

Colophonium

7.14

Curators

Paraben Mix

7.14

Methylisothiazolinone+methylchloroisoth

iazolinone

21.42

Methyldibromo glutaronitrile

7.14

Excipient

Lanolin Alcohol

21.42

Rubber components

Mercaptobenzothiazole

14.28

Mercapto mix

14.28

Thiuram mix

28.57

N‑Isopropyl‑N‑phenylenediaminine

(IPPD)

21.42

www.odermatol.com

228

frequency of atopic dermatitis in this age group.

According to some authors, ear dermatitis is one

of the circumstances in which atopic dermatitis is

discovered in children [6]. We noted a predominance

of female ear eczema in our study, which corresponded

to a link with data reported in the literature [7,8].

This seems to be linked to the wearing of costume

jewelry by women. Personal atopy was noted in 80%

of our patients, and it is often the sole cause of ear

eczema in infants, with a reported frequency of 16%

in adults [9]. We noted chronic eczema lesions in 60%

of our patients, often linked to delayed diagnosis. The

ignorance of our patients could explain the absence of

initial specialized care. The external ear auricle was the

most frequent site of ear eczema, in 63% of the cases,

sometimes associated with damage to the external

auditory canal, in 13%. Isolated eczema of the external

auditory canal often constitutes a differential diagnosis

with psoriasis of the external auditory canal, which

is frequent, in 18% of cases, although pruritus is less

marked in psoriasis where the scales are thicker [10].

Allergological investigations are the main tools for the

etiological search to establish allergenic avoidance

measures [11,12]. Patch tests were positive for nickel

in all patients, often with poly-sensitization to metals.

Metal contact allergens were nickel in 42% of the

cases and cobalt in 35%. Nickel is an eyelid allergen

reported in 44% of cases in Senegal [13]. In Europe,

authors report a 58% frequency of nickel allergy during

ear contact dermatitis [14]. Nickel sensitization is

frequently triggered by repeated skin contact with

objects releasing nickel in excessive quantities, such

as costume jewelry. Piercing and earrings also increase

nickel sensitization [7,14,15]. Researchers have

demonstrated that nickel sensitization is possible when

an object in contact with the skin releases more than

0.5 μg of nickel per cm2/week [15]. The nickel test

detectable with dimethylglyoxime has a specificity of

98% and a sensitivity of 59% [7,16]. In our study, the

nickel test reinforced the relevance of patch tests in 66%

of ear CAD cases in women wearing earrings. Nickel

is also found in cosmetics and handled objects such

as keys, coins, toys, and computers [17,18]. Cobalt is

the second most common metal, in 30% of the cases,

with a frequency that varies from 8% in Europe to

7.4% in the U.S. [19]. Cobalt is commonly combined

with other metals, such as nickel [20]. Cobalt alloys

are used in the manufacturing of costume jewelry,

clothing accessories, dental materials, implants, and

prostheses [20]. Allergic contact face dermatitis was

associated with allergic contact dermatitis of the ears

in 10% of the cases, with a predominance of women.

The more frequent use of cosmetic products in women

may be a contributing factor. The implementation of

cosmetovigilance measures could lower the incidence

of allergic contact dermatitis due to these allergens.

CONCLUSION

Ear eczema is a frequent complaint in dermato-

allergology. In Senegal, the causes are still dominated

by atopic dermatitis and allergic contact dermatitis to

metals and cosmetics. The availability of allergy tests

using the Standard European Battery and allergy tests

using personal hygiene products allows the monitoring

of new contact allergens in Senegal, and effective

cosmetovigilance and avoidance measures may be put

in place.

Statement of Human and Animal Rights

All the procedures followed were in accordance with the ethical

standards of the responsible committee on human experimentation

(institutional and national) and with the 2008 revision of the

Declaration of Helsinki of 1975.

Statement of Informed Consent

Informed consent for participation in this study was obtained from

all patients.

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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.

Source of Support: This article has no funding source.

Conflict of Interest: The authors have no conflict of interest to declare.

2XU'HUPDWRORJ\2QOLQH

230

The impact of personal protective equipment on the

condition of the skin in the era of COVID-19

Beata Zagórska, Magdalena Trzeciak

Department of Dermatology, Venereology and Allergology Faculty of Medicine, Medical University of Gdansk,

Gdansk, Poland

Corresponding author: Beata Zagórska, MD, E-mail: beatazagorska@gumed.edu.pl

INTRODUCTION

Linked to the COVID-19 pandemic announced by

the WHO on March 11, 2020, restrictions aimed

at breaking the epidemiological chain have become

common. One of the main methods of reducing

infections and the spread of the virus is primary

prevention, which includes hand hygiene and the use

of personal protective equipment (PPE). PPE includes

masks, gloves, hand sanitizers, gowns, face shields, shoe

covers, and goggles.

Many dermatologists from around the world

subsequently observed a positive relationship between

the COVID-19 pandemic and the appearance of new

skin lesions/diseases and the exacerbation of preexisting

dermatoses.

Skin changes observed during the COVID-19 pandemic

may be divided into those accompanying the infection

with the SARS-CoV-2 virus caused by agents used to treat

the infection, and those related to the use of PPE [1].

Healthcare workers may be at the highest risk of

dermatological problems associated with the latter

due to their greater frequency and longer duration

of use of PPE [2,3]. According to literature data, the

incidence of skin damage associated with the use of

PPE and personal hygiene measures among health-care

workers ranges from 42.8% to 98.03% [4,5]. The most

frequently described changes are pressure injuries,

pressure urticaria, contact dermatitis, itchiness,

exacerbation of pre-existing skin conditions, including

seborrheic dermatitis and acne, and new skin diseases

such as pompalox and acne [1]. Skin-related problems

ABSTRACT

Background: Due to the COVID-19 pandemic announced in Poland in 2020, a number of recommendations

were introduced, including hand disinfection and the use of personal protective equipment (PPE). The aim of

this study was to present the impact of chronic use of PPE on the condition of the skin in the era of COVID-19.

Materials and Methods: People aged 15–75, regardless of their health status and education level, living in Poland,

were invited to participate in a survey using anonymous online questionnaires. Data analysis was performed in the R

statistical environment, ver. 3.6.0, PSPP software, and Microsoft Office 2019. Results: Out of the 513 participants, 24.9%

were health-care workers, 53.8% were medical students, and 21.3% were non-medical professionals, with the majority

being women (82.3%). In each of these groups, when PPE was used, exacerbation of skin problems occurred more

often (n = 300, 60.9%) than the appearance of new ones (n = 250, 49.9%). The group in which skin lesions most often

intensified (n = 178, p = 0.013) and new ones appeared (n = 153, p = 0.02) were medical students. New dermatoses

occurred more often in people who wore masks, face shields or goggles with a mask (face, n = 110, p = 0.001) as well

as gloves and hand disinfection (hands, n = 114, p = 0.001) compared to the respondents who did not. Moreover, due

to skin changes, as many as 80 people (15.7%) declared they had stopped using PPE. Conclusion: Our survey indicated

that the use of PPE was associated with the appearance of new dermatoses and the exacerbation of existing skin diseases.

Key words: COVID-19, Health risks, Personal protective equipment

Original Article

How to cite this article: Zagórska B, Trzeciak M. The impact of personal protective equipment on the condition of the skin in the era of COVID-19. Our Dermatol

Online. 2025;16(3):230-236.

Submission: 15.02.2025; Acceptance: 12.05.2025

DOI: 10.7241/ourd.20253.2

www.odermatol.com

231

are most often observed on the face and hands [1,5].

The aim of our survey study was to present the impact

of chronic use of PPE on skin conditions during the

COVID-19 era.

MATERIALS AND METHODS

This was a cross-sectional survey conducted between

March 1, 2022, and March 1, 2023, using online Google

Forms questionnaires. In order to investigate skin

problems caused by the use of PPE, a survey was sent

by e-mail to students and medical workers and made

available on social media sites such as Facebook. The

questionnaire was addressed to people aged 15–75,

regardless of their health status and education level,

living in Poland. The questionnaire was anonymous,

required short or multiple-choice answers, and took

approx. 15 minutes to complete. The first part of the

questionnaire included questions about demographic

data such as age, sex, place of residence, education,

and professional status. It also collected information

about vaccination against SARS-CoV-2. The second

part encompassed questions about skin problems and

their location before the pandemic and during the use

of PPE, the type and duration of use of PPE, as well as

the discontinuation of PPE due to skin problems. Data

analysis was performed in the R statistical environment,

ver. 3.6.0, PSPP software, and Microsoft Office 2019.

Variables expressed at the ordinal or nominal level

were analyzed using tests based on the chi-squared

distribution. However, if the conditions for the chi-

squared test were not met, Fisher’s exact test was used.

The significance level was set at p < 0.05.

RESULTS

Characteristics of the Study Population

A total of 513 people participated in the study, of

which 24.9% were health-care workers, 53.8% medical

students, and 21.3% non-medical professionals. The

average age of the participants was 28 years, and most

of the respondents were women (82.3%). Respondents

vaccinated against the SARS-CoV-2 virus constituted

95.3%, and 98.4% of people stated that they had

used PPE during the pandemic. Table 1 presents the

sample’s demographic data.

The Effect of PPE on the Skin

Out of the 513 respondents, 60.9% declared the

deterioration of existing skin lesions, while only

49.9% reported the appearance of new lesions. Table 2

presents the actual and expected values as well as the

chi-squared test result.

Skin-Related Problems and Professional Status

Only 44.5% of the respondents in medical professions

and 48.1% in non-medical professions declared the

appearance of new skin lesions linked to the use of

PPE. Meanwhile, among medical students, as many as

57.1% reported the occurrence of skin problems. The

results regarding the exacerbation of skin lesions were

slightly different. Most respondents stated that existing

dermatological problems had worsened. Among

them, 55.5% were health-care workers, 51.9% were

representatives of non-medical professions, and 66.7%

were medical students. Table 3 presents these results.

Anatomical regions of skin-related problems

Head, neck, and face

Based on the responses to the question about the PPE

used, the study sample was divided into those using

and those not using masks, face shields, or goggles

with a mask. In turn, the locations of skin lesions were

grouped into the head and neck area (scalp, behind the

ears, forehead, neck) and the face area (cheeks, nose,

mouth area, red lips, chin). Among people wearing a

mask, face shield, or goggles with a mask, 85.8% denied

the appearance of new lesions and 88.9% denied the

exacerbation of existing lesions in the head and neck

area. In turn, 50.2% declared the occurrence of severity

of existing lesions on the facial skin. Both among people

who used the aforementioned PPE (61.9%) and among

people who did not (76.9%), most often no new changes

Table 1: Characteristic of the study population

Characteristic

Number of respondents

513

100

Age (years)

Mean

Range

15–75

Sex

Female

422

82.30

Male

17.70

Professional status

Healthcare workers

127

24.90

Medical students

275

53,80

Non‑medical professionals

109

21.30

Vaccination against SARS‑CoV‑2

Yes

488

95.30

4.70

Use of PPE

Yes

505

98.40

1.60

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232

appeared on the face. However, they were statistically

significantly (p < 0.05) more common among those

who wore a mask, face shield, or goggles with a mask

compared to those who did not (Table 4).

Hands

Among the respondents who used gloves and hand

disinfection measures (65.7%) and those who did not

(77.2%), skin lesions most often did not appear or did

not worsen. However, skin problems became more

severe or occurred statistically more often (p < 00.5)

in people wearing these types of PPE (Table 5).

Characteristics of Skin Lesions and their

Anatomical Location

The most common skin problems reported in

connection with the use of PPE were: increased

dryness, peeling of the skin and erythema (Table 6).

These changes were most often located on the skin

of the hands and face (cheeks, mouth area, and chin)

(Table 7). A similar location applied to dermatoses that

occurred in respondents before the pandemic and had

become more severe (Table 8). Among them, the most

frequently reported changes were acne, dermatitis, skin

allergies, and atopic dermatitis.

The Impact of the Duration of Mask-Wearing on

Facial Skin Problems

Among people who changed their mask every 1–3 hours,

new skin lesions appeared in 55.9%, similarly with

people who changed it every few hours (53.7%) and

once a day (57.1%). However, in those who changed

it occasionally (52.5%) or did not wear one at all

(59.6%), changes most often did not occur. However,

the differences are small and statistically insignificant

(p > 0.05) (Table 9). Nevertheless, existing skin lesions

in each group worsened, regardless of the duration of

mask-wearing. Therefore, the differences also proved

to be small and statistically insignificant.

Abandonment of PPE Due to Skin-Related

Problems

Out of the 513 respondents, as many as 80 declared

that they had stopped using PPE due to skin lesions

becoming more severe.

Table 2: Actual and expected values and the result of the χ2 test. Occurrence of new and exacerbation of existing skin lesions when using PPE

Variable

Variable level

Value

Proportion

Residuals

Results

Occurrence of new skin lesions while using PPE

Occurred

Observed

250,00

0,499

0,50

χ2=0,00

df=1

p=0,964

Expected

250,50

0,500

Did not occur

Observed

251,00

0,501

‑0,50

Expected

250,50

0,500

Exacerbation of skin lesions when using PPE

Worsened

Observed

300,00

0,609

‑53,50

χ2=23,22

df=1

p=0,001

Expected

246,50

0,500

Did not worsen

Observed

193,00

0,391

53,50

Expected

246,50

0,500

χ2 – test statistics; df – degrees of freedom; n – number; p – probability value

Table 3: The relationship between professional status and the occurrence of new and the exacerbation of existing skin lesions when using PPE

Medical status

Results

Medical

profession

Non‑medical

profession

Medical

students

Occurrence of new skin lesions while using PPE

Occurred

153

χ2=12,559

df=2

p=0,002

42,7%

39,6%

57,1%

Did not occur

115

57,3%

60,4%

42,9%

Exacerbation of skin lesions when using PPE

Worsened

178

χ2=8,718

df=2

p=0,013

55,5%

51,9%

66,7%

Did not worsen

44,5%

48,1%

33,3%

χ2 – test statistics; df – degrees of freedom; n – number; P – probability value

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DISCUSSION

The COVID-19 pandemic has forced people to use

PPE, e.g., masks, gloves, and hand disinfectants, on

a daily basis due to its ability to limit the spread of

infection and its fundamental importance in preventing

potential exposure to pathogens [6,7]. Rational and

correct use of PPE is crucial to ensuring the safety not

only of health-care workers but also of the entire society.

On the other hand, long-term use of PPE is associated

with a high rate of undesirable dermatological

reactions, including the appearance of new dermatoses

and the exacerbation of existing skin diseases [2,8,9].

The current study observed a significant impact of PPE

on skin health during the COVID-19 era.

In our study, the exacerbation of skin diseases occurred

more often than the appearance of new dermatoses

related to the use of PPE. The group most exposed to

adverse skin reactions were medical students, which

may have been due to their significant numerical

predominance compared to health-care workers or

non-medical professionals.

Skin problems related to the use of PPE affect various

parts of the body. The most frequently described

locations are the facial areas (12–87%), such as the

bridge of the nose, cheeks, chin, and forehead. Adverse

Table 4: The relationship between the use of masks, face shields,

or goggles with a mask before the occurrence of lesions and the

exacerbation of existing and the occurrence of new skin lesions in

the head, neck, and face area

Use of masks, face

shields, goggles

Results

use

no use

Exacerbation in the head and neck area

Worsened

χ2=0,244

df=1

p=0,621

11,1%

12,9%

Did not worsen

257

196

88,9%

87,1%

Exacerbation in the facial area

Worsened

145

χ2=4,438

df=1

p=0,035

50,2%

40,4%

Did not worsen

144

134

49,8%

59,6%

Occurrence in the head and neck area

Occurred

χ2=1,895

df=1

p=0,169

14,2%

9,8%

Did not occur

248

203

85,8%

90,2%

Occurrence in the facial area

Occurred

110

χ2=12,418

df=1

p=0,001

38,1%

23,1%

Did not occur

179

173

61,9%

76,9%

χ2 – test statistics; df – degrees of freedom; n – number; p – probability value

Table 5: The relationship between the use of protective gloves

and hand disinfection before the occurrence of lesions and the

exacerbation of existing skin lesions and the occurrence of new

skin lesions around the hands

Use of gloves and

hand disinfection

Results

use

no use

Exacerbation in the hand area

Worsened

χ2=7,515

df=1

p=0,006

34,3%

22,8%

Did not worsen

188

176

65,7%

77,2%

Occurrence in the hand area

Occurred

114

χ2=20,959

df=1

p=0,001

39,9%

20,6%

Did not occur

172

181

60,1%

79,4%

χ2 – test statistics; df – degrees of freedom; n – number; p – probability value

Table 6: New skin lesions related to the use of PPE

New Skin Lesion

Dryness

185

68.77

Atopic dermatitis

4.46

Peeling

32.34

Rosacea

2.97

Erythema

21.93

Seborrheic dermatitis

2.97

Acne vulgaris

18.59

Cheilitis

2.23

Contact dermatitis

18.22

Folliculitis

1.86

Itching

16.36

Psoriasis

1.12

Abrasions

15.99

Dandruff

1.12

Cheilosis

8.55

Boils

1.12

Urticaria

7.06

Tinea

0.74

Unknown changes

6.32

Contagious impetigo

0.74

Other

5.95

Rash

0.37

Herpes

4.83

Table 7: Anatomical location of new and exacerbated skin

lesions

New Skin Lesion

Exacerbation

Hands

161

61.69

Cheeks

168

56.38

Cheeks

108

41.38

Hands

150

50.34

Mouth area

107

41.00

Mouth area

142

47.65

Chin

31.80

Chin

139

46.64

Nose

25.67

Nose

29.19

Forehead

9.96

Neck

9.73

Neck

9.96

Forehead

9.06

Behind the ears

7.28

Behind the ears

4.70

Scalp

4.98

Other

3.02

Other

4.60

Scalp

1.68

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reactions also often appear on the skin of the hands

(15–85%) [1]. The results of our study were consistent

with the existing data.

One systematic review identified dry skin, pressure

erythema, and contact dermatitis of the face and hands

as the most common skin problems associated with

the use of PPE [10]. In our study, these were dryness,

scaling, and erythema also occurring in the same

locations. Similar results were discovered by Lan et al.

in their study [5]. Conversely, Foo et al. and Gheisari

et al. showed that the most common skin symptom was

acne and its exacerbation on the face [11,12].

The aforementioned skin problems may be related

to the exposure to irritants and allergens contained

in PPE, which may, in combination with occlusion,

moisture, friction, and the atopic predisposition of the

individual, cause contact dermatitis (CD) and irritant

contact dermatitis (ICD) [13]. Similarly to mechanical

damage, high facial temperature and humidity

caused by wearing a mask increases the secretion of

sebum (an increase of 10% for each increase by 1°C),

which contributes to the exacerbation/occurrence

of acne [14]. This relationship contributed to the

identification of a new nosological entity, maskne

(mask-related acne), the diagnostic criteria of which

were developed by Teo et al. They include, among

others, a typical location called the “O zone” referring

to the area covered by the mask (mouth area, nose,

and cheeks) [15]. Another study also found flares in

43.6% of acne patients, 37.5% of seborrheic dermatitis

patients, and in all rosacea patients (n = 14) [16]. We

should also not forget that other skin diseases, although

less frequently described in the literature, may also

become more severe. Examples include psoriasis and

lichen planus, which may be exacerbated by mechanical

irritation (Koebner’s symptom) [17,18]. Moreover,

damage caused by pressure or abrasion and contact

dermatitis are easily susceptible to secondary bacterial

and fungal infections.

According to existing data, one of the most important

factors related to the occurrence of adverse skin

reactions is the duration of PPE use. One study found

that wearing PPE for more than six hours a day was

associated with a higher risk of skin problems. The

same study indicated that washing hands more than

ten times a day increases the risk of dermatological

lesions 2.17 times more than wearing gloves for a long

period of time [5]. However, our study considered the

frequency of changing one’s mask without taking into

account the duration of wearing it, which may be the

reason for the discrepancies in the results.

The most disturbing from an epidemiological point

of view was the fact that as many as 15.7% of the

Table 8: Dermatoses of the respondents before the pandemic

Dermatosis

Acne vulgaris

220

55.14

Rosacea

5.26

Cheilosis

100

25.06

Other

5.26

Skin allergies

23.31

Unknown changes

4.51

Atopic dermatitis

19.55

Tinea

3.01

Herpes

19.55

Psoriasis

2.76

Dandruff

16.54

Lichen planus

2.51

Contact dermatitis

14.04

Cheilitis

2.01

Folliculitis

10.03

Boils

1.75

Seborrheic dermatitis

7.27

Contagious impetigo

0.75

Warts

7.02

Table 9: The relationship between the frequency of changing the mask and the occurrence of new and exacerbation of existing skin lesions

Frequency of changing the mask before changes occurred

Results

every

1–3 hours

every few or a

dozen or so hours

once a day

occasionally

did not use

a mask

Occurrence of new skin

lesions while using PPE

Occurred

χ2=8,857

df=4

p=0,065

55,9%

53,7%

57,1%

47,5%

40,4%

Did not occur

44,1%

46,3%

42,9%

52,5%

59,6%

Exacerbation when using PPE

Worsened

χ2=8,792

df=4

p=0,067

73,2%

63,3%

64,6%

50,6%

57,0%

Did not worsen

26,8%

36,7%

35,4%

49,4%

43,0%

χ2 – test statistics df – degrees of freedom; n – number; p – probability value

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respondents declared to have stopped using PPE due

to undesirable skin reactions, which favors the spread

of the virus.

Although the WHO announced the end of the

COVID-19 pandemic on May 5, 2023, there is still

information about new variants of the virus and many

medical professionals encounter new cases of illness

caused by the SARS-CoV-2 virus. Therefore, we should

not forget about skin injuries and dermatological

problems related to the use of PPE, even if their

use is no longer as common as it was during the

pandemic.

Our study has some limitations that should be

kept in mind. Firstly, it is impossible to verify the

reliability of the data provided by the respondents,

which is related to the superficial nature of the

qualitative research. Secondly, medical students are

overrepresented in the study compared to health-care

workers and non-medical professionals. Thirdly, there

was a disproportion in terms of sex and age among

the respondents, which may be associated with other

risk factors for adverse skin reactions (e.g., hormonal

balance, chronic diseases, skin care, use of makeup).

The limitations of this cross-sectional study may

preclude drawing reliable conclusions for the entire

Polish population.

CONCLUSION

This study showed that the use of PPE was associated

with the appearance of new dermatoses and the

exacerbation of existing ones. However, we found

that existing skin lesions were more likely to be

exacerbated than new ones were to appear. The results

of our research indicated that there was a significant

relationship between professional status and the

occurrence of skin-related problems. Our results and

literature data suggest that medical students and

health-care workers may be at the highest risk of adverse

skin reactions. In these groups, existing skin lesions

become more severe and new ones appear. The most

vulnerable parts of the body are the face and hands.

Skin problems related to the use of PPE may prevent

its proper use, thus increasing the risk of infection

with the virus. Therefore, there is a need for education

around the use of PPE and consideration of creating

special rules/guidelines for people struggling with skin

diseases.

Statement of Human and Animal Rights

All the procedures followed were in accordance with the ethical

standards of the responsible committee on human experimentation

(institutional and national) and with the 2008 revision of the

Declaration of Helsinki of 1975.

Statement of Informed Consent

Informed consent for participation in this study was obtained from

all patients.

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distributed under the terms of the Creative Commons Attribution License,

which permits unrestricted use, distribution, and reproduction in any

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237

Evaluation of tele-expertise in the management of

common dermatoses in peripheral health centers in

Togo from 2018 to 2023

Panawé Kassang1,2, Bayaki Saka1,2, Abas Mouhari-Touré1,2, Sefako Akakpo1,2,

Julienne Teclessou1,2, Emilie Lauressergues3, Christophe Przybylski3,

Piham Gnossike1,2, Garba Mahamadou1, Léa Matel3, Raymond Barruet1, Claude Akakpo1,

Koussake Kombate1,2, Béatrice Garrette3, Kissem Tchangai-Walla1,

Palokinam Pitche1,2

1Togolese Society of Dermatology and Sexually Transmitted Infections (SOTODERM), Lomé, Togo, 2Skin and Environment

Research Laboratory, University of Lomé, Lomé, Togo, 3Pierre Fabre Foundation, Lavaur, France

Corresponding author: Panawé Kassang, MD, E-mail: panawekassang@gmail.com

INTRODUCTION

Telemedicine is a medical practice that uses information

and communication technologies (ICT) to provide

distance medical services [1]. This innovative

approach to providing distance healthcare services

has developed around the world generally because

of a shortage of healthcare personnel and in the

face of specific challenges, which vary according to

geographical area [2]. The COVID-19 pandemic has

generally forced healthcare systems around the world

to adopt this approach as an effective solution for

ensuring continuity of care [3,4]. Depending on the

geographical area of the world, telemedicine is adopted

as a solution to difficulties in providing quality care

to populations difficult to access for reasons such as

geographical isolation, natural disasters, wars, and

sociopolitical and security crises [5-7]. In developing

ABSTRACT

Background: Tele-expertise in dermatology represents an avenue for modifying medical practice in response to the

needs of health economics. The aim of this study was to evaluate the medical activities of the tele-expertise project

implemented over a five-year period by the Togolese Society of Dermatology (SOTODERM). Material and methods: This

was a single-pass, cross-sectional evaluation conducted between July and August 2023 on project sites during field

visits by SOTODERM’s expert dermatologists. The main targets of this evaluation were site agents and their activities

on the tele-expertise platform. Results: In the course of this survey, 70 of the 100 health agents, including 82.9%

paramedics, were evaluated on 47 sites. On these 47 sites, dermatoses represented 2% of all reasons for consultation.

Of the dermatoses received in consultations, 2231 cases were sent to the remote expertise platform (Bogou). The

profile of the dermatoses received in consultation was similar to that of cases sent to Bogou. For the 1854 of the

2231 cases where a single diagnosis was evoked, there was diagnostic concordance in 837 cases (45.1%) between the

health worker and the expert dermatologist. The main challenge was the poor availability of dermatological drugs on

the sites. Conclusion: Togo’s dermatology tele-expertise project has had a positive impact on the accessibility and

quality of dermatological care provided by non-dermatologist health workers. However, there are still challenges in

terms of access to dermatological drugs within the framework of universal access to care.

Key words: teledermatology; tele-expertise; dermatology; SOTODERM, Togo

Original Article

How to cite this article: Kassang P, Saka B, Mouhari-Touré A, Akakpo S, Teclessou J, Lauressergues E, Przybylski C, Gnossike P, Mahamadou G, Matel L,

Barruet R, Akakpo C, Kombate K, Garrette B, Tchangai-Walla K, Pitche P. Evaluation of tele-expertise in the management of common dermatoses in peripheral

health centers in Togo from 2018 to 2023. Our Dermatol Online. 2025;16(3):237-241.

Submission: 11.03.2025; Acceptance: 24.05.2025

DOI: 10.7241/ourd.20253.3

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