Hand Dermatitis and Hygiene in the Workplace

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Chronic hand dermatitis may cause some health care workers to break from hygiene protocols.
Chronic hand dermatitis may cause some health care workers to break from hygiene protocols.

Dermatitis of the hands is an occupational consequence for many healthcare workers who have a lot of patient contact, particularly nurses. The prevalence of dermatitis in hospital nurses is reported to be as high as 85%, but the incidence is most likely underestimated, as many try to manage the condition on their own, often by modifying their adherence to required handwashing hygiene protocols.1

An observational study conducted at Nantes University Hospital in Nantes, France, found that 787 (68%) of 1159 healthcare workers who responded to a survey reported some form of dermatitis in the past 12 months.2 More than half of them worked in conventional hospital wards. The most common symptoms were dryness, redness, itching, and pain.

Nurses reported open fissures more commonly than other healthcare workers, with a frequency of 76%.2 Most importantly, 52% of those surveyed stopped using hydroalcohol, contrary to current recommendations.3

Guidelines for hygienic handwashing in healthcare settings were published by the Centers for Disease Control and Prevention (CDC) in 2002 to prevent transmission of various pathogens leading to nosocomial infections.3,4 Evidence culled from multiple studies showed that adherence with handwashing protocols by healthcare workers both before and after patient contact was the most significant method of preventing transmission and colonization of gram-negative and gram-positive bacteria responsible for most nosocomial infections.4

Hand Hygiene Efficacy

Handwashing hygiene relies on the use of 3 types of products, including nonmedicated soap, medicated products such as antiseptic and surgical handwashes, and alcohol-based rubs. The use of nonmedicated soaps was not recommended by the CDC, as they have little to no antimicrobial activity.1,3,4 A variety of medicated soaps and washes are in use that contain a range of ingredients with antimicrobial activity, such as chlorhexidine and triclosan. Hexachlorophene, once used for handwashing, has been banned from hospital use by the CDC and is not considered safe by the Food and Drug Administration.1

Most alcohol-based handrubs contain isopropanol, ethanol, or n-propanol, either alone or in combination, which all have excellent levels of activity against microbial pathogens.1 Alcohol handrubs are deemed the most effective products for antimicrobial handwashing hygiene. They are not effective for removal of obvious dirt and contamination, and so detergent-based handwashing should be done first, followed by an alcohol-based wash.4

Problems With Perception

Although application of alcohol to irritated skin causes a burning sensation, it is actually less damaging to skin than detergents, which desaturate natural skin proteins and cause changes to intercellular lipids and skin flora, leaving skin more vulnerable to colonization by bacteria.4 A study by Stutz et al5 found that perception among nurses, however, was that alcohol-based products were more damaging, resulting in the nurses increasing their use of the more harmful detergent-based products. At the same time, skin irritation has been found to be significantly reduced with the use of alcohol products compared with detergents.6 Hydroalcohol products are formulated with emollients for protection of the skin, and irritation caused by detergents is reduced by washing off residual detergent-based soaps using water or a foam-roller application of hydroalcohol.6

A high, unreported prevalence of hand dermatitis could also be measured by the use of hand cream, which was found in a 2013 study by Visser et al7 to be significantly greater among nurses who had active symptoms of fissures and itching compared with those who did not report symptoms (84% vs 66%). The frequency of hand lotion application increased from 1 to 10 times daily among those without symptoms to 1 to 14 times daily when symptoms were present.7  

Overall, 46% of nurses who had symptoms of dermatitis reported that they had taken action on their own to ameliorate their symptoms without other medical interventions, which included reduction of the frequency of handwashing, changing the type of product used for handwashing, and increasing the use of gloves. In the Visser study, 8 participants increased their use of alcohol rubs in response to dermatitis (in keeping with CDC recommendations) and 11 decreased their use of alcohol rubs and switched to plain soap and water, in direct contradiction to recommendations.7


What We Can Learn

Adherence with CDC handwashing recommendations reduces the risk for transmission of pathogens significantly, but at the cost of generating frequent dermatitis of the hand among nurses and other healthcare workers who have regular patient contact. Daily, chronic exposure to the irritants in handwashing products used in healthcare settings, coupled with a misperception among nurses about which products are most irritating to the skin, contributes to the exacerbation of the skin condition. Concerns over lost work days often motivate nurses to cover open sores with gloves, which can also contribute to worsening of the condition, and they often choose to reduce their use of more effective products, putting themselves and patients at greater risk for spreading infectious pathogens.

The causes and consequences of hand dermatitis are inadequately addressed in the current literature, suggesting the need for better education of healthcare providers about the management of hand dermatitis when it occurs. Additionally, this points to the unmet need for investigation into less damaging hygienic products for handwashing and better treatments for chronic irritation of the skin associated with those products.

References

  1. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004:17:863-893.
  2. Longuenesse C, Lepelletier D, Dessomme B, Le Hir F, Bernier C. Hand dermatitis: hand hygiene consequences among healthcare workers. Contact Dermatitis. 2017;77:330-331.
  3. Centers for Disease Control and Prevention: Hand Hygiene in Healthcare Settings. Available at: https://www.cdc.gov/handhygiene/providers/guideline.html. Updated March 26, 2016. Accessed January 2, 2018.
  4. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45.
  5. Stutz N, Becker D, Jappe U, et al. Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hands rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009:160:565-572.
  6. Löffer H, Kampf G. Hand disinfection: how irritant are alcohols? J Hosp Infect. 2008:70:44-48.
  7. Visser MJ, Verberk MM, van Dijk FJ, Bakker JG, Bos JD. Kezic S. Wet work and hand eczema in apprentice nurses; part I of a prospective cohort study.  Contact Dermatitis. 2014;70:44-55.  
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