Amit Gefen PhD Professor of Biomedical Engineering The Herbert J. Berman Chair in Vascular Bioengineering Department of Biomedical Engineering, Faculty of Engineering Tel Aviv University, Tel Aviv, Israel

Coronavirus Outbreak: Prevention of Device-Related Pressure Ulcers and Injuries Interview with:

Amit Gefen PhD Professor of Biomedical Engineering The Herbert J. Berman Chair in Vascular Bioengineering Department of Biomedical Engineering, Faculty of Engineering Tel Aviv University, Tel Aviv, Israel

Dr. Gefen

Amit Gefen PhD
Professor of Biomedical Engineering
The Herbert J. Berman Chair in Vascular Bioengineering
Department of Biomedical Engineering, Faculty of Engineering
Tel Aviv University, Tel Aviv, Israel What is the background for this study?

Response: Although we are witnessing continuous progress in medical technologies, the design of many of the most commonly used medical devices e.g. oxygen masks or cervical collars has changed very little over a period of decades. Not surprisingly, these devices are also the ones which are frequently associated with device-related pressure ulcers (DRPUs). These DRPUs are frequently a hospital-acquired injury which involves risk of infections (including e.g. sepsis and antibiotic-resistant bacteria), scarring with serious psychological consequences, additional and significant healthcare costs and a basis for liability suits and litigation. The problem is massive in Europe and the US and is most frequently encountered in clinical environments where devices are used intensively, such as in operation theatres, intensive care units and emergency care settings (in both adult and pediatric medicine), but also, in elderly care facilities where patients often have fragile skin. With the current pandemic spread of the coronavirus, facilities worldwide are experiencing a considerable rise in usage of emergency and intensive care equipment, which will very likely considerably escalate the incidence of DRPUs.

Early in 2019, a committee of global experts which I have chaired, has met for two days of intensive deliberation in London UK, to start developing the first-ever international consensus document on device-related pressure ulcers . After a rigorous review process by an international review committee of other experts, this consensus report has been published as a Special Edition of the Journal of Wound Care in February 2019 (, under the name “Device-related pressure ulcers: SECURE prevention“. The publisher has kindly made this publication freely downloadable and thereby accessible and available to anyone, including all professionals who may need guidance in this regard, including clinicians, industry, regulators and academic researches. What are the main findings? How likely is the widespread use of face masks/ personal protective equipment likely to result in skin breakdown?

Response: As said above, this extensive work, which has been published just days before the outbreak of the coronavirus in the western hemisphere, became very relevant to this pandemic event. Specifically, the DRPUs international consensus document discussed the role of frictional forces applied by devices in the etiology of injury, in much detail. Generally, frictional forces caused by devices distort soft tissues, resulting in sustained shear deformations which leads to skin and subdermal tissue damage. The damage cascade at the cell and tissue scales is described in the consensus document, particularly in the context of ventilation (e.g. continuous positive airway pressure, CPAP) masks. In this regard, there are similarities to tissue damage caused due to prolonged use of medical face masks, which often manifests in the form of skin tears, or friction lesions.

A skin tear is a form of avulsion that occurs as a result of static or dynamic frictional forces acting on the skin. The clinical teams engaged in all types of the coronavirus care settings are consistently reporting facial skin tears and lesions caused by prolonged use of their protective face masks, often at the bridge of the nose and on the chicks. The mask materials mechanically indent and damage facial skin, an effect that is further compromised by sweat due to the mental stress and work load that these teams are experiencing. Loss of facial skin integrity creates a portal for penetration of pathogens, including the coronavirus itself but also other hospital-acquired bacterial, viral or fungal infections. Importantly, facial (or other) skin damage can facilitate penetration of coronavirus and other pathogens into the blood circulation directly. What should readers take away from your report?

 Response: The cause for the widely-reported skin tears is that the materials of the mask, which already have a substantial coefficient of friction with skin, do not effectively release the sweat that is captured at the mask-skin contact sites, which increases the coefficient of friction further, thereby causing high frictional forces that eventually tear the skin. The accumulated moisture also compromises the mechanical strength of skin, and so, the increased frictional forces and the reduced skin tissue strength synergistically contribute to the skin tears, which are hence termed friction lesions. Since personal protective equipment (PPE) such as masks and goggles are now being used throughout the day, and under extreme workload conditions, and that sweating is intensified due to the mental and physical stress, a practical solution for clinicians is to use occlusive skin barriers on dry skin under the contact sites of the mask.

I recently reviewed the topic and suggested simple and practical means of protection in an Editorial in Wound Management & Prevention ( What recommendations do you have for future research as a result of this work? 

Response: It is already clear at this stage of the coronavirus outbreak that loss of facial skin integrity caused by PPE is putting medical teams at risk, by exposing them to the viral infection directly through the open skin. In the near future, we are planning to test different possible barriers and protective ‘smart’ materials and structures for skin protection under face masks and goggles, which will increase the tolerance of skin tissues to the sustained mechanical loads applied by PPE for intensive and extreme use scenarios. The chosen solutions should protect the structural integrity of skin and reduce its susceptibility to the mechanical damage caused by PPE.

This is a critical issue in minimizing further spread of the coronavirus (or future viral threats) among care givers and hospital teams, their families and also, clearly, reduce the likelihood of infection of other (non-coronavirus) patients.


Gefen A, Alves P, Ciprandi G, et al. Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020;29(Sup2a):S1–S52. doi:10.12968/jowc.2020.29.Sup2a.S1


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May 12, 2020 @ 1:57 am 

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