How Healthcare Workers Can Prevent Pressure Injuries from N95 Masks

On the front lines of the COVID-19 pandemic, healthcare workers have relied on personal protective equipment (PPE) such as N95 respirator masks to protect themselves and others from the virus.

Yet the same tight seal that makes N95 masks effective against airborne transmission can also often result in pressure injuries on the skin. Pressure injuries from N95 masks can be caused by the intensity and duration of pressure and shear forces on the parts of the face that come into direct contact with the mask, as well as friction and moisture.

For example, speaking while wearing an N95 mask causes facial skeletal muscles to contract. This can cause the straps of the mask to tighten and the mask itself to create friction against the skin as it slides along the regions of contact. The simple act of talking can cause shearing in the subdermal tissues of the face, which can be further exacerbated by excess sweating due to the stress of the intense workload thrust upon healthcare workers during the COVID-19 pandemic.

The International Wound Journal reported that as of May 2020, just a few months after the pandemic began, 97% of frontline healthcare workers have had skin damage related to PPE, with 83.1% of the damage on wearers’ nasal bridge.

To that end, the National Pressure Injury Advisory Panel (NPIAP) released a statement, writing “We are deeply concerned about the facial injuries we are seeing in fellow clinicians as a result of prolonged use of N95 respirator masks while caring for patients with COVID-19.”

In Ireland, hospital staff experienced a decrease in the incidence of mask-related pressure injuries (from 29% to 8%) after following a care bundle consisting of cleansing the face with baby wipes, applying skin balm as well as silicone tape to their nose bridge and cheekbones. Here are more tips from NPIAP:

How to Prevent Mask-Related Pressure Injuries

1. Use a skin protectant on all areas of the face that come into contact with your mask to help prevent and treat friction injuries.

This can include liquid skin sealants as well as protectants that are specially formulated to help prevent stage one pressure injuries and low-exudating stage two pressure ulcers, according to NPIAP’s evidence-based recommendations for healthcare workers on how to prevent pressure injuries from N95 mask.

They are available in many different forms including sprays, wipes, and foams. Make sure to avoid contact with eyes and allow the protectant to dry completely before putting on your mask. Keep your facial area clean and free of harsh chemicals whenever possible. According to Wound Source, you should clean and hydrate your face approximately 30 minutes before wearing your mask.

2. Reduce the pressure on your face by removing your mask for short periods of time when it is safe to do so.

Make sure to wash your hands before and after touching your mask and try to remove your mask in 15-minute increments every two hours when you are not in contact with patients, advises the NPIAP. If this is not possible, you can remove your mask in shorter increments, such as 5 minutes every 2 hours, when you are in an environment that is conducive to doing so.

3. Healthcare workers can choose to use thin prophylactic dressings to help reduce pressure on the face at their own discretion if they do not interfere with the fit of the mask.

The NPIAP is clear to not make a recommendation on the use of thin prophylactic dressings under N95 respirator masks due to critical uncertainties regarding whether this practice will increase the risk of COVID-19 infection.

If after weighing risks and benefits and consulting institutional policies, a clinician wants to a use thin prophylactic dressing to prevent mask-related pressure injury, NPIAP suggests: Dressings can be cut into thin strips and placed on the nasal bridge, cheek bones, and behind ears at the point of contact with the mask or straps to help relieve the pressure of the mask against the face. If using a foam dressing, make sure that the outer layer is non-porous as this may allow fluids or microorganisms to come in contact with the skin. Stacking multiple dressings is not recommended as this may increase pressure.

After dressings are applied, ensure that your N95 mask is sealed properly by exhaling and checking for leaks (prior to contact with patients).

4. Severe pressure injuries should be treated by wound care professionals.

If partial thickness pressure injuries do occur, treat these abrasions with topical moisturizers, liquid skin protectants/sealants or cyanoacrylates, according to the NPIAP. In the case of deep tissue pressure injuries (DTPI) as well as stage 3, stage 4, and unstageable pressure injuries, seek treatment by qualified wound care professionals.

For more recommendations on how to prevent pressure injuries from N95 masks, read the complete NPIAP statement here.