The role of PPE or Personal Protective Equipment has taken a drastic change in recent times.What was once used solely in workplaces with a certain degree of safety hazards is now an undeniable necessity in ensuring our health and protection.

Personal Protective Equipment acts as a barrier between the skin and harmful contaminants or impact hazards from the environment. In this current age, it is what stands between the unprecedented transmission of the highly infectious COVID-19 and our safety.

With the virus being transmitted through direct and indirect contact, mere physical proximity amongst each other can pose as a serious threat.  While we slowly work to resume necessary social activities, we must take necessary precautions to mitigate the harms.  Everyone in the workplace should wear PPE and understand what it is for.

What is PPE?

Personal Protective Equipment is an apparatus or accessory worn over the body to protect against injury, contamination, impact, and exposure to microbes, biological secretions, splatters, chemicals, and other safety hazards.

There are different types of PPE, and each one is specifically made to protect against a particular type of safety hazard. With COVID-19, the mode of transmission is through physical contact—so the protective equipment recommended by WHO is one that acts as a barrier against the skin, face, and respiratory system.

Types of PPE for COVID-19

Face and Eye Protection

These PPE equipment protect the eyes and face from any possible infection, exposure or immediate impact from biological spatters, viral contaminants, and harmful microbes.

Face Shields cover the entire facial area including the eyes, nose, and mouth with a clear polycarbonate lens that offers unrestricted visibility. Face Shields may be repeatedly used as long as the proper disinfection process is undertaken after every use.

Medical Goggles fully enclose the entire area around the eyes to protect against becoming contaminated or infiltrated with biological spatters, infectious microbes, and impact hazards. Medical Goggles may be repeatedly used as long as the proper disinfection process is undertaken after every use.

Respiratory Protection

This apparel prevents pathogenic microorganisms, infectious contaminants, toxic gases, or any other particulate matter that may cause irritation and infection from entering the lungs through the nose and mouth.

N95 Masks have four layers of protection to effectively filter 95% of all air particulates from entering the respiratory system. N95 Masks have passed the US Regulatory standards for respiratory protection against viruses, microbes, and all toxic inhalants. N95 Masks should be worn for a maximum of eight hours only and should be replaced as often as necessary.

KN95 Masks are tight-fitting respirator masks that cover the mouth and nose against all air contaminants including pollution, pollen, dust, smoke, germs, bacteria, ash, and other nasal allergic triggers. KN95 masks pass health regulatory standards around the world. KN95 Masks should be worn for a maximum of eight hours only and should be replaced as often as necessary.

Surgical Masks prevent biological spatters, pathogenic microorganisms, and viral contaminants from getting expelled by the wearer towards the environment. Masks should be discarded and replaced as soon as they become contaminated.

Skin and Body Protection

This PPE covers the skin so that no liquid spatters, toxic chemicals, viral microbes, and biological secretions can come into contact with the body.

Medical Coveralls enclose the entire body including the head, arms, torso, and legs with a non-woven fabric that effectively repels moisture, fluids, and liquid matter. Disposable Emergency Medical Coveralls should be used for a maximum of eight hours only.

Medical Gloves provide secure, enclosed protection for the hands against contamination and exposure to liquid spatters, biological secretions, viral microbes, and other hazardous particles. Gloves should be used for a maximum of 8 hours only and discarded after every use that involves some degree of exposure to contaminants.

All PPE clothing must be sterile, CE-marked/FDA-Approved and recommended by the World Health Organization.

How To Wear PPE?

The proper donning and disposal of PPE is key to ensure that the PPE performs for optimum protection.

An important reminder in wearing PPE is that one garment must not interfere with another. The entire set of apparel worn by an individual must be comfortable enough for movement but also for utmost functionality with no leakages.

Here are the following steps to wear full PPE properly:

1.  Identify and gather the proper PPE set. Always ensure it is the correct size for the person who will be wearing it.

2. Wash hands thoroughly for thirty seconds.

3. Put on the Medical Coveralls.

4. Wear the mask (KN95 or N95 or Surgical Mask) while ensuring that the nosepiece is fitted to the nose. Place the loops around the ears. Both nose and mouth should be covered. Secure the top tie on the crown of the head and the bottom tie on the base of the neck

5. Put on either the Face Shields or Goggles. Use the most appropriate face protection that does not interfere with the seal of the mask.

6. Put on the gloves.

How To Remove PPE Gear?      

PPE gear must be removed properly or else contamination and exposure to infectious contaminants are very likely, invalidating the usage of PPE in the first place.

Here are the following steps in removing the PPE in proper order:

1.  Remove gloves properly, making sure the hands do not come into contact with the external side of the glove that has been exposed to the environment.

2. Remove the coveralls carefully in the utmost avoidance of contact to the side exposed to the environment. Assistance from another person may be required.

3. Wash hands thoroughly for 20 seconds and more, or use hand sanitizer.

4. Remove the Face Shield or Goggles by grabbing the strap or snapping the lock. Pull it upwards and away from the head.

5. Remove the mask by tugging at the loops over the ears and throw it in the proper trash bin immediately. Do not touch the front of the mask.

6. Wash hands thoroughly for 20 seconds.

Conclusion

With the number of Covid-19 cases rising, it is a necessary precaution to maintain social distancing, adhere to quarantine, and to wear PPE when in contact with another individual. PPE is very integral to our safety and survival as well as others around us.

Understanding what Personal Protective Equipment is, what it does, and how to wear and dispose of it properly is how we can ensure not only our health and safety but everyone around us.

Filler Complications

Introduction

The increased popularity of dermal fillers in enhancing facial aesthetics is due to their minimally invasive nature, short recovery time, and excellent outcomes. While collagen fillers dominated the market for over 20 years since their approval by the Food and Drug Administration (FDA) in 1981, it was the emergence of hyaluronic acid (HA) fillers that paved the way for new filler brands and technologies.

As with any medical procedure, a multitude of complications can occur after filler injection. The supposed reversibility of HA-based fillers adds their popularity; however, increased use of these fillers also puts less common but significant side effects in the spotlight. Injecting physicians must be aware of the adverse effects associated with dermal fillers because some of these complications can be devastating and irreversible. Additionally, some complications occur more frequently with specific filler materials or products; thus, the injector must know the properties of each filler at their disposal.

Patient Evaluation

As many complications are due to problems with injection technique, it is important to train extensively and gain experience, preferably with a reversible filler, in order to minimize potential problems. However, side effects are also related to the inherent properties of the filler or unappreciated patient factors.¹ Patients presenting with complications after a filler injection should be questioned about previous medical procedures, filler-related issues, number of injections and treated areas.² Immunosuppressed patients must be counseled for higher risk of infection. In patients with immunologic diseases, it is recommended to consult the rheumatologist or dermatologist before performing additional procedures.

If a patient is not satisfied with previous filler outcomes, the physician should not re-administer the same product. It is best to suggest an alternative filler material or treatment modality, or not treat at all.  In attempting to remedy a complication, the patient should be informed that the elective treatment might require multiple sessions. It is also important to inform the patient that such interventions may result to permanent scarring.

Pre-Procedure Considerations

The best way to treat complications is to prevent them from occurring. Providing excellent predictable outcomes and avoiding unsatisfactory results begins before the actual injection process. While there is no filler product available without concomitant side effects, the physician can minimize complications by choosing the appropriate filler type and injection technique. Not all hyaluronic acid fillers have the same properties and indications. Each filler differs in cohesiveness, molecular size, and cross-linking technologies. In patients who have been treated multiple times, a detailed facial surgery and filler history should be obtained to guide the decision to inject, the placement of the product, and the type of filler to use.

The patients’ expectations should be managed. Completing a proper initial evaluation prior to injection is essential. The priority of the treatment is to satisfy the patient, thus before and after photographs should be taken. During the initial assessment, identify asymmetries and discuss each skin concern to facilitate a clear and honest discussion towards achieving the patient’s desired outcome. It is also essential to discuss the financial commitment involved in pursuing the treatment plan, including the number of syringes needed and if subsequent sessions will be necessary to reach the patient’s intended goal.

Skin Testing

The reactivity profile of the chosen filler should be reviewed prior to injection. Any filling material from foreign sources can theoretically trigger immune reactions to a variable degree, from redness to anaphylaxis. Products that are highly reactive, such as those containing bovine collagen, require skin testing prior to injection.³ Anaphylaxis is extremely rare but the Food and Drug Administration (FDA) still requires allergy testing for these products. The most popular filler material, hyaluronic acid, has a low rate of hypersensitivity, ranging from 0.6% to 0.8% regardless if the formula is bacterial or viral in origin.⁴ Hypersensitivity reactions to bovine collagen may be local or systemic while reported reactions to hyaluronic acid were often immediate, localized, and typically resolved within three weeks.⁵

The use of collagen fillers has declined due to the development of new fillers with better safety profiles. New products containing hyaluronic acid and calcium hydroxyapatite have been found to be superior to collagen with a very small chance of local reactions. Popular bovine collagen and human collagen products are no longer being manufactured; the only product available with 80% purified bovine collagen, which requires skin testing, has polymethylmethacrylate as the main ingredient (Artefill).

Filler Selection

Product-related complications are influenced by the physiochemical properties of the filler and the patient’s response to the product.⁶ Currently, available fillers may be classified as temporary or permanent. Temporary fillers are biodegradable and are absorbed or metabolized by the body. The duration of effects of these fillers vary and is dependent on the type and amount of filler injected, treatment location, and injection technique utilized.⁷ Temporary fillers cleared by the FDA include hyaluronic acid, collagen, calcium hydroxylapatite (CaHA), and poly-l-lactic acid (PLLA). The only FDA-approved permanent filler contains biocompatible, non-biodegradable polymethylmethacrylate (PMMA) beads intended to reduce wrinkles around the mouth, and recently, for the treatment of acne scars.

Inappropriate Placement and Its Manifestations

It is imperative to understand the underlying body, soft tissue structures and vascular anatomy when injecting facial fillers. Accurate and safe placement of filler products depends not only on these factors but also on thorough understanding of the patient’s history and the product’s properties. Inappropriate placement of fillers, such as superficial injection, can lead to a range of complications. Injecting too superficially is a common error and may result in inflammatory nodule formation, visible product, a bluish hue under the skin, and hypertrophic scarring.^8,9 While these reactions can be somewhat prevented by the use of correct injection technique, they can, however, cause anxiety and dissatisfaction for patients.

Simple lumps and bumps associated with superficial placement can be alleviated by massaging the area, as well as through aspiration or incision and drainage.¹⁰ If the reaction is due to an hyaluronic acid product, hyaluronidase can help treat this problem. Polymethylmethacrylate plus collagen is a permanent filler that, less forgiving, can be associated with another set of complications such as long-lasting itching and redness. If the product in question contains calcium hydroxyapatite (Radiesse), superficial injection is associated with white nodule formation. This is often managed by puncturing and expressing the nodules using a No 11 blade or needle.¹¹ The same technique is used if the injecting physician overfills a particular area. Massaging the area to disperse the product is an adequate solution in some cases; however, one can puncture the skin and express excess filler if the overfill persists.

Injection Site Reactions

Despite best practices, including allergic testing and proper product selection, reactions can still occur. Local injection site reactions are the most common side effect associated with filler injection since it requires skin piercing and introduction of a foreign substance. Other foreign materials other than the filler, such as residual makeup incompletely removed from the patient’s skin, could cause a reaction; therefore, makeup in the injection area must be removed prior to application. The most commonly observed reactions are redness, swelling, bruising, tenderness or pain, and itchiness. These reactions are often mild to moderate and could last for a few days to a week.

Edema and ecchymosis are often due to injection technique, speed of injection, and filler choice. Regardless of the product injected, swelling and bruising are usually localized, mild, and self-limiting. Comparing the package inserts of some popular fillers: Juvederm Ultra (HA) has an 86% reported incidence of swelling and 59% incidence of bruising; Injections from Sculptra (PLLA) has 4-7% incidence of swelling and 6-38% incidence of bruising; and the use of Radiesse (CaHA) has a reported 69.2% incidence of swelling and 63.2% incidence of bruising.^12,13,14 Dr. John Quinn suggests using the smallest needle possible and microcannula for danger areas to reduce the risk of swelling and bruising. This is particularly important when augmenting the lip as the labial artery runs deep in the body of the lips, thus the border between wet and dry area is more likely to bruise.

Early Onset Complications

One of the most devastating complications of soft tissue augmentation with injectables is intravascular injection, which can lead to potential tissue necrosis, scarring, and even blindness. The best treatment for vascular compromise begins with sufficient prevention. Thorough knowledge of facial anatomy and awareness of danger zones reduces the risk, but actual vascular structures possess considerable variation. Early recognition of the warning signs is highly important as the injecting physician must be ready to administer appropriate treatment immediately. Hyaluronidase and other supplemental treatments, such as a warm compress, nitro paste, and sildenafil, must be immediately available.

The glabella, nasolabial fold, and nose are the most common danger zones, as these areas have rich anastomoses with the internal carotid artery.¹⁵ Nose reshaping with facial fillers has become a common procedure in the past few years. Because of the increasing incidence of nasal tip necrosis due to the compression of facial blood vessels in the area, this procedure should be performed by specialists rather than newly trained practitioners. Post-injection blindness is not a commonly reported side effect with dermal filler, but knowing proper management and prevention is paramount. Pain and pallor are common signs of arterial compromise. Embolization and compression of the glabellar arteries can occur due to the small amount of space between the skin and periosteum in this area.⁸ In the event of a vascular compromise, treatment includes massage, hyaluronidase, heat, and topical GTN.

Delayed Onset Complications

Delayed onset nodule formation and granulomatous reactions have been reported with several filler products. Biofilms may play a role in the presentation of delayed onset erythematous nodules (“angry red bumps”). These bumps are different from ordinary nodules (collections of injected fillers) and are regarded as possible foreign body reactions, hypersensitivity reactions, infections, or sterile abscesses. To help minimize the risk of infection, clean preparation of the skin using chlorhexidine is recommended prior to filler injection. A granuloma is an immune response to an implanted foreign material and develops via an accumulation of immune-related cells, such as lymphocytes, in an attempt to eliminate the foreign body.¹⁶

In contrast to granuloma, the key signs of infection are erythema, warmth, and tenderness. The usual cause of late onset infection is less common bacteria like mycobacteria.¹⁷ Successful treatment requires appropriate antibiotic therapy as well as aggressive debridement of all infected skin and subcutaneous tissue. Dr. Quinn prescribes clarithromycin 500 mg twice a day for four weeks, while other physicians advise the use of ciprofloxacin 750 mg bd for a month.

Implanted fillers can migrate up to several years after injection. Semi-permanent and permanent fillers are most likely to migrate, but infection or delayed granuloma can also trigger migration. If the injected product is HA-based, hyaluronidase is the preferred treatment, but surgical removal may be necessary for other filler materials.

Conclusion

An efficient way to enhance facial aesthetics with minimal downtime, dermal fillers are the gold standard for soft-tissue augmentation. While adverse events are rare, cautious injection and public education regarding the potentially catastrophic consequences of unregulated filler injection are essential. It is the responsibility of the physician to consider the individual characteristics of each patients and the properties of available fillers when selecting a treatment. The physician’s readiness to handle various adverse events, and careful following of treatment consensus in the occurrence of a nodule, granuloma, or vascular compromise, ensures optimal management.

References

1.  Leonhardt, J.M., Lawrence, N., & Narins, R.S. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid, Dermatol Surg, 31, 5.

2.Jin Moon, H., & Sook Yi J. (2016). Management of Facial Filler InjectionComplications in Aesthetic Plastic Surgery of the East Asian Face, Thieme, p. 406

3. Bailey, S., Cohen, J., & Kenkel, J. (2011). Etiology, Prevention, and Treatment of Dermal Filler Complications, Aesthetic Surgery Journal, 31, 1.

4. Andre, P. (2004). Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA—Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001, J Eur Acad Dermatol Venereol, 18, 4.

5. Friedman, P.M., Mafong, E.A., Kauvar, A.N., & Geronemus, R.G. (2002). Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg, 28, 6.

6. Gravier, M., Bass, L., Lorence, P., et al. (2018). Differentiating non-permanent injectable fillers: Prevention and treatment of filler complications, Aesthetic Surgery Journal, 38, 1.

7. Luebberding, S., & Alexiades-Armenakas, M. (2013). Critical appraisal of the safety of dermal fillers: a primer for clinicians, Curr Derm Rep

8. Narins, R.S.M., Jewell, M.M., Rubin, M.M., Cohen, J.M., & Strobos, J.M. (2006). Clinical conference: management of rare events following dermal fillers-focal necrosis and angry red bumps, Dermatol Surg, 32.

9. Zielke, H., Wölber, L., Wiest, L., Rzany, B. (2008). Risk profiles of different injectable fillers: results from the injectable filler safety study (IFS Study), Dermatol Surg, 35, 1.

10. Brody, H.J. (2005). Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement, Dermatol Surg, 34, 1.

11. Berlin, A., Cohen, J.L., & Goldberg, D.J. (2006). Calcium hydroxylapatite for facial rejuvenation, Semin Cutan Med Surg, 25.

12. Juvederm package insert. [Available from: http://www3.juvederm.com/professionals/pdf/juvederm_dfu.pdf ]. Accessed April 1, 2019.

13. Sculptra package insert. [Available from: http://products.sanofi -aventis.us/sculptra/sculptra.html ]. Accessed April 1, 2019.

14. Radiesse Injectable Implant Instructions For Use. [Available from: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050037c.pdf ]. Accessed April 1, 2019.

15. Brennan, C. (2014). Avoiding the “danger zones” when injecting dermal fillers and volume enhancers, Plast Surg Nurs, 34, 3.

16. Sidwell, R.U., Dhillon, A.P., Butler, P.E., & Rustin, M.H. (2004). Localized granulomatous reaction to a semi-permanent hyaluronic acid and acrylic hydrogel cosmetic filler, Clin Exp Dermatol, 29.

17. Hirsch, R.J., Narurkar, V., & Carruthers, J. (2006). Management of injected hyaluronic acid induced Tyndall effects, Lasers SurgMed, 33, 3.

18. Plaus, W.J., & Hermann, G. (1991). The surgical management of superficial infections caused by atypical mycobacteria, Surgery, 110.

The skin covers the entire body, making it our largest organ. Due to its exposure to the elements, it comes as no surprise that the skin is largely affected by the environment and its changes. Temperature and humidity changes necessitate adjusting skincare routines to maintain skin health, as many skin-related diseases and issues—such as  acne, psoriasis, eczema, and rosacea—show seasonal variability. Fortunately, there are plenty of effective skincare products that differ in terms of moisture content, thickness, and strength, which means there are plenty of products to meet the skin’s needs. It is important to consider seasonal changes when planning clinical treatments as well.

Understanding the structure and function of skin

The skin can be divided into two main layers: the epidermis and dermis. The uppermost layer is the epidermis, which is composed of tightly packed epithelial cells. It is essentially the barrier that keeps out harmful substances such as bacteria, toxins, and UV light, among a number of others. The epidermis is primarily composed of keratinocytes, which form the stratum corneum on the outermost layer of the epidermis. Melanocytes, the cells responsible for producing melanin in response to UV radiation and hormonal stimulation, are mixed in.

The dermis is composed of connective tissue and is comprised of a mixture of nerve endings, blood vessels, hair follicles, sebaceous glands, and sweat glands. It is also a thicker layer due to collagen and elastin; these substances give the skin its strength and flexibility. Finally, below the dermis is the subcutaneous layer called the hypodermis. It is a layer of loose connective tissue made up of a number of fat cells.

Skin changes with seasons

Recently, the British Journal of Dermatology published a study suggesting that the barrier function of the skin changes between the summer and winter. Looking specifically at the skin on cheeks and hands in summer and winter, the researchers assessed the changes that occur in skin at the cellular level in 80 subjects. They analysed natural moisturizing factors (NMF) and skin texture. There are seasonal effects on NMFs in hands and cheeks, and there is also an increase in the breakdown of filaggrin, which is a protein that maintains the barrier’s function. Additionally, they found changes in the texture of corneocytes.

The heat of the summer often increases sebum production in the skin, and pigmentation increases due to UV exposure. On the contrary, trans-epidermal water loss occurs at a lower rate during the summer; this means that the skin is more hydrated and that more beneficial lipids are present in the stratum corneum than during to the winter months. So, what causes such huge changes in our skin’s behaviour and how do we minimize potential damage?

Also Read: Mesotherapy for Facial Skin Hydration

Warm weather

Although being in the sun can be dangerous due to exposure to UV radiation, there is the benefit of vitamin D being produced via sun exposure. In many countries, winters are dark, and there is not enough UVB radiation to synthesize vitamin D.  This process can only occur during the warmer months. The NHS recommends safely getting vitamin D by exposing uncovered skin to the sun for short periods of time. Between the hours of 11:00 a.m. and 3:00 p.m., most people can expose their limbs to the sun for up to 30 minutes, but sunscreen should be worn on the face to protect it from premature aging. Vitamin D offers many benefits to the skin as well, as it aids in cell differentiation, proliferation, cutaneous immune function, and much more. In fact, being deficient in vitamin D has been linked to acne and skin cancers.

Pigment change can also occur due to sun exposure, and patients undergoing laser or plasma treatments and the popular chemical peels are more likely to develop post-inflammatory hyperpigmentation. Those with melasma often find that it worsens during the summer. These concerns or complications can be avoided by using SPF sunscreen, avoiding direct sunlight, and keeping out of extreme heat.

High temperatures lead to an increase in sebum production. When it mixes with sweat, the skin looks very shiny. As such, acne might get worse, but, conversely, it may get better because there is less dead and dry skin to clog pores. Eczema and psoriasis have also been found to improve during the summer months. On the other hand, heat and humidity might lead to fungal infections, such as athlete’s foot. Rosacea is worsened by UV radiation. Some medications may also increase photosensitivity, and patients may develop rashes as a result.

Treatment

In the summer, it is best to avoid aggressive treatments such as retinol, unless the patient adheres to using SPF daily and stays out of the sun. Otherwise, patients are advised to use an oil-controlling cleanser and a light antioxidant serum to take care of any free radicals created by UV exposure.  In patients with oily and acne-prone skin, chemical and physical exfoliation is recommended along with a salicylic acid product to break up the sebum. Mandelic acid is an appropriate chemical peel for the summertime, as it is a less aggressive alpha hydroxy acid and less likely to cause complications. Otherwise, any treatments that might cause PIH, such as lasers, peels, or plasma, should be limited or avoided.

Cooler months

The winter can be harsh on the skin due to the rapidly changing temperatures. When we go from inside to outside, capillaries expand and contract, causing redness and telangiectasia. When we are exposed to wet, snowy weather, our barrier function can be stripped. The cold, dry air only increases trans-epidermal water loss. Combined with central heating, skin often ends up dry and irritated. Patients with already dry skin will often experience some difficulties managing the excessive dryness.

Treatment

During the winter months, the goal should be to increase hydration and promote the natural moisture of the skin in order to support the health of the epidermis. Repairing the barrier function can be accomplished with ingredients like ceramides and hyaluronic acid, whereas colloidal oatmeal soothes dry and itchy skin.  Since temperatures and UV radiation are much lower during these months, the risk of complications from more aggressive procedures is minimized, but the skin should be appropriately prepared prior to being subjected to these sorts of procedures so as to avoid complications. This means that during the fall months, the skin can be treated with retinols to prepare it for peels and lasers. Finally, just because it is cold does not mean patients should forgo SPF protection!

Summary

Temperature, humidity, and UV radiation all change with the seasons. It is no surprise our skin is affected by these changes! Understanding the physiology of our skin can help patients prepare for all the variations caused by the changing of the seasons, which in turn can help them minimize the chances of developing skin diseases. Importantly, patients should not wait for signs of disease before seeking or beginning treatment. Preparing the skin in the spring and fall will ensure that skin is ready for the more extreme conditions of summer and winter.