[Skin protection and skin disease prevention courses for secondary prevention in health care workers: first results after two years of implementation]

S2k-Guideline hand antisepsis and hand hygiene

The consensus-based guideline "hand antisepsis and hand hygiene" for Germany has the following sections: Prevention of nosocomial infections by hygienic hand antisepsis, prevention of surgical site infections by surgical hand antisepsis, infection prevention in the community by hand antisepsis in epidemic or pandemic situations, hand washing, selection of alcohol-based hand rubs and wash lotions, medical gloves and protective gloves, preconditions for hand hygiene, skin protection and skin care, quality assurance of the implementation of hand hygiene measures and legal aspects. The guideline was developed by the German Society for Hospital Hygiene in cooperation with 22 professional societies, 2 professional organizations, the German Care Council, the Federal Working Group for Self-Help of People with Disabilities and Chronic Illness and their Family Members, the General Accident Insurance Institution Austria and the German-speaking Interest Group of Infection Prevention Experts and Hospital Hygiene Consultants.

Effectiveness of a Skin Care Program With a Cream Containing Ceramide C and a Personalized Training for Secondary Prevention of Hand Contact Dermatitis

Background/Objectives: The aim of our study was to investigate the effectiveness of personalized training on skin protection associated with the regular use of ceramide-containing cream (CC) versus other creams (OC) for improving hand contact dermatitis. Methods: We performed a double-center randomized trial that enrolled workers with hand dermatitis. All workers received personalized training. The intervention was 3 times per day application of the study emollient. The control arm used an emollient of choice without ceramide, as needed. The primary outcome was improvement in hand dermatitis at 1 and 3 months of follow-up. Results: In total, 102 patients with hand dermatitis were enrolled in this study. Improvement in dermatitis was found in 40%, 52.5%, 50%, and 63% of OC and CC, at the first and second follow-ups, respectively. The use of CC was significantly associated with an improvement in dermatitis (odds ratios 2.6; 95% confidence intervals 1.30-5.2), analyzed using generalized equation estimation during the follow-up. Conclusion: Our study demonstrated that an educational personalized intervention could improve the signs and symptoms in patients with hand dermatitis, and the use of a CC resulted in a significantly better outcome during the 3 months of follow-up.

Interdisciplinary and multiprofessional outpatient secondary individual prevention of work-related skin diseases in the metalworking industry: 1-year follow-up of a patient cohort

Background

In Germany, work-related skin diseases are predominant within the spectrum of reported occupational diseases. Metal workers are among the high-risk professions. Offering effective prevention programs to affected patients is of utmost importance to avoid deterioration of the disease and job loss. We conducted a 1-year follow-up in patients who participated in a multidisciplinary, complex outpatient prevention program representing a standard procedure of patient care by the respective statutory accident insurance.

Methods

The multi-component prevention program consists of multiprofessional individual patient counseling, a structured skin protection seminar in a group, as well as workplace visits and on-site counseling in terms of appropriate skin protection (e.g. gloves). An observational study with a 1-year follow-up and four measurements (T1-T4, longitudinal pre/post-test design) including dermatological examinations and standardized written questionnaires was conducted between 2013 and 2016 to assess changes over time regarding job loss and disease severity.

Results

Data from 94 patients (87 male, mean age: 45.4 years) were included in the analysis. One year after the skin protection seminar (T4), 83 patients (88.3%) remained in their original professional metalworking activity and four patients (4.3%) had given up their profession because of their skin disease. At baseline (T1), irritant contact dermatitis of the hands was the most frequent diagnosis (80.7%). Methods for self-reported disease severity showed good correlation with the clinical gold standard at T1 and T2 (dermatological examination with the Osnabrück Hand Eczema Severity Index / OHSI), and a significant decrease of the self-reported disease severity was found over time from T1 to T4 (p < 0.001). Further results indicate an improved self-perceived disease control and an overall satisfaction with the prevention program.

Conclusions

The results of this observational study demonstrate that the comprehensive prevention program positively influences the course of work-related skin diseases, increases the possibility to continue working in a “high-risk” profession and improves the disease management of metal workers. In the long term, the prevention program may lead to cost savings by preventing high therapy costs or professional retraining.

Electronic supplementary material

The online version of this article (10.1186/s12895-018-0080-2) contains supplementary material, which is available to authorized users.

Statistical analysis plan for the Healthy Hands Project; single centre cluster-randomised clinical trial of a skin care program for the prevention of contact dermatitis in health care workers

BACKGROUND

The Healthy Hands Project (HHP) is a randomised clinical trial aiming to determine the effectiveness of an intervention program in the prevention of hand dermatitis in healthcare workers (HCWs). The intervention is comprised of placing dispensers with hand creams on wards combined with continuous electronic monitoring of cream consumption and regular feedback to HCWs. The clinical severity (HECSI score) was used as the primary outcome and natural moisturising factor (NMF) levels as the secondary outcome. The study protocol for the cluster-randomised controlled trial of HHP was published in Trials in 2017. This article describes the detailed statistical analysis plan for the HHP trial.

METHODS/DESIGN

The HHP is a single-centre, cluster-randomised controlled trial with two parallel groups and blinded outcome assessment. This update article presents (1) the descriptive statistics of the primary and secondary outcomes, (2) the statistical models used for the analysis of the main outcomes, (3) sensitivity analyses on the effect of observed exposure to wet work, (4) handling of missing data including sensitivity analysis and (5) an updated power calculation. This statistical analysis plan was written prior to unblinding of the study.

DISCUSSION

This paper presents a comprehensive statistical analysis plan for the data resulting from the HHP trial. It supports transparency in reporting by clarifying differences between the previously published protocol and the proposed actual statistical analyses.

TRIAL REGISTRATION

Netherlands Trial Register (NTR), identification number NTR5564 . Registered on 2 November 2015.

The effectiveness of a skin care program for the prevention of contact dermatitis in health care workers (the Healthy Hands Project): study protocol for a cluster randomized controlled trial

Background

Health care workers (HCW) are at high risk for developing occupational hand dermatitis (HD) due to frequent exposure to ‘wet work’. Amongst HCWs, nurses are at highest risk, with an estimated point prevalence of HD ranging between 12 and 30%. The burden of disease is high with chronicity, sick leave, risk of unemployment and impaired quality of life. Despite evidence from the medical literature on the risk factors and the importance of skin care in the prevention of HD, in practice, compliance to skin care protocols are below 30%. New preventive strategies are obviously needed.

Methods/design

This is a cluster randomized controlled trial, focusing on nurses performing wet work. In total, 20 wards are recruited to include 504 participating nurses in the study at baseline. The wards will be randomized to an intervention or a control group and followed up for 18 months.

The intervention consists of the facilitation of creams being available at the wards combined with the continuous electronic monitoring of their consumption with regular feedback on skin care performance in teams of HCWs. Both the intervention and the control group receive basic education on skin protection (as ‘care as usual’). Every 6 months, participants of both groups will fill in the questionnaires regarding exposure to wet work and skin protective behavior. Furthermore, skin condition will be assessed and samples of the stratum corneum collected. The effect of the intervention will be measured by comparing the change in Hand Eczema Severity Index (HECSI score) from baseline to 12 months. The Natural Moisturizing Factor (NMF) levels, measured in the stratum corneum as an early biomarker of skin barrier damage, and the total consumption of creams per ward will be assessed as a secondary outcome.

Discussion

This trial will assess the clinical effectiveness of an intervention program to prevent hand dermatitis among health care workers

Trial registration

Netherlands Trial Register (NTR), identification number NTR5564. Registered on 2 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1803-0) contains supplementary material, which is available to authorized users.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes

BACKGROUND

To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars.

OBJECTIVES

We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular.

PATIENTS/MATERIALS/METHODS

In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes.

RESULTS

After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects.

CONCLUSIONS

The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.

Skin care education and individual counselling versus treatment as usual in healthcare workers with hand eczema: randomised clinical trial

OBJECTIVE

To evaluate the effect of a secondary prevention programme with education on skin care and individual counselling versus treatment as usual in healthcare workers with hand eczema.

DESIGN

Randomised, observer blinded parallel group superiority clinical trial.

SETTING

Three hospitals in Denmark.

PARTICIPANTS

255 healthcare workers with self reported hand eczema within the past year randomised centrally and stratified by profession, severity of eczema, and hospital. 123 were allocated to the intervention group and 132 to the control group.

INTERVENTIONS

Education in skin care and individual counselling based on patch and prick testing and assessment of work and domestic related exposures. The control was treatment as usual.

MAIN OUTCOME MEASURES

The primary outcome was clinical severity of disease at five month follow-up measured by scores on the hand eczema severity index. The secondary outcomes were scores on the dermatology life quality index, self evaluated severity of hand eczema, skin protective behaviours, and knowledge of hand eczema from onset to follow-up.

RESULTS

Follow-up data were available for 247 of 255 participants (97%). At follow-up, the mean score on the hand eczema severity index was significantly lower (improved) in the intervention group than control group: difference of means, unadjusted -3.56 (95% confidence interval -4.92 to -2.14); adjusted -3.47 (-4.80 to -2.14), both P<0.001 for difference. The mean score on the dermatology life quality index was also significantly lower (improved) in the intervention group at follow-up: difference of means: unadjusted -0.78, non-parametric test P=0.003; adjusted -0.92, -1.48 to -0.37). Self evaluated severity and skin protective behaviour by hand washings and wearing of protective gloves were also statistically significantly better in the intervention group, whereas this was not the case for knowledge of hand eczema.

CONCLUSION

A secondary prevention programme for hand eczema improved severity and quality of life and had a positive effect on self evaluated severity and skin protective behaviour by hand washings and wearing of protective gloves.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01012453.

"The itching hand"- important differential diagnoses and treatment

Skin diseases affecting the hands receive particular individual attention and constitute a considerable emotional burden. Many dermatoses also present with itching of the hands. Itch is often underestimated when it occurs in a comparably limited body area such as the hands. The high occupational significance of the hands in many professions must, nevertheless, be stressed. One of the most frequent diagnoses in itching of the hands is eczema. In the differential diagnosis, less common diseases such as neurological and systemic diseases and adverse drug reactions must also be taken into consideration. Itching of the hands can also be accompanied by other sensations, such as burning, stinging and pain. A thorough history regarding sensations and dysesthesias already allows for a diagnostic classification of the disease in some cases. Itching of the hands requires a careful and thorough diagnostic approach. This forms the basis of a specific and successful therapy which may be adapted stepwise, depending on the underlying cause, and also may require, in addition to causal therapy, symptomatic antipruritic therapy. Therapy should follow the current guidelines for chronic pruritus and hand eczema. This article reviews over the differential diagnosis and therapy of "itching hands".

Practices of skin care among nurses in medical and surgical intensive care units: results of a self-administered questionnaire

Dermatitis of hands is a problem among nurses. The aim of this prospective questionnaire based survey was to analyze practice and knowledge of skin care of medical and surgical nurses. 250 questionnaires were distributed. 49% of respondent stated that they perform skin care at least 1-2 times/day. After hand-wash 15% of participants perform skin protection, after hand-disinfection only 2%. 40% give skin care products less than 3 minutes to be applied. It was shown that this knowledge is lacking in many individuals, leading to wrong behavior at work and insufficient use of skin protection and skin care products.

[Optimal care of patients with occupational hand dermatitis: considerations of German occupational health insurance]

Occupational dermatoses (OD) have been at the top of all occupational diseases in Germany for years (>25% of all occupational diseases officially reported annually to the public statutory employers' liability insurance bodies). More than 90% of OD-cases are hand eczema. Several pilot initiatives to improve prevention of occupational skin diseases have been developed and funded since 2005 by the statutory employers' liability insurance schemes. The concept underpinning these initiatives is a nationwide multi-step intervention approach recently implemented by the public statutory insurance system administration ("step- wise procedure") which aims at offering quick and specific preventive help at all levels of severity of OD. The dermatologist has a pivotal function in this concept; for early secondary prevention, the so-called dermatologist's procedure was recently updated in order to provide more rapid and concise dermatological consultations and care. Additionally, combined outpatient dermatological and educational intervention seminars ("secondary individual prevention", SIP) and interdisciplinary inpatient prevention measures have been developed ("tertiary individual prevention", [TIP]) and are currently being further evaluated in multicenter studies.

A 7-step consultation plan for health care workers and hairdressers

BACKGROUND

Skin diseases are among the most common occupational disorders in health care workers and hairdressers. Optimal prevention methods make it possible for more individuals to remain active in their profession. We devised a 7-step consultation plan which was employed in a standard fashion and then evaluated.

PATIENTS AND METHODS

264 employees were evaluated in the Education and Support Center of the German Accident Prevention and Insurance Association in the Health and Welfare Services (BGW schu.ber.z Berlin) from 2003 to 2005 in a standardized manner. Included were detailed history, physical examination, skin physiology measurements (transepidermal water loss, corneometry, sebumetry) and then making a diagnosis and therapeutic recommendations.

RESULTS

Within the study group of 264 employees the most frequent diagnosis were toxic-irritant hand eczema (28.4%), allergic contact eczema (19.7%), atopic eczema (15.5%) and irritant contact eczema with atopic diathesis (13.6%). The frequency of contact sensitivity was high in the study group (80.7%). The skin physiological parameters were not remarkably altered and did not differ between individuals with an atopic diathesis versus without an atopic diathesis.

CONCLUSION

This standardized protocol for a "7-step consultation plan"when applied in a standardized manner offers quality-controlled but also individually-adapted support considering dermatological, educational and occupational aspects. Skin physiology parameters did not provide any further information indicating the need of the development of novel techniques to measure skin barrier function.

Occupational skin diseases in cleaning and kitchen employees: Course and quality of life after measures of secondary individual prevention

BACKGROUND

Cleaning and kitchen employees have an increased risk of suffering from occupational dermatoses. Prevention including improving individual skin care and skin protection behavior, health education, optimizing diagnostics and therapy as well as avoidance of occupational skin disease (BK 5101) is important.

PATIENTS AND METHODS

Participants in the courses were patients suspected of having an occupational skin disease. Besides socio-demographic and disease-related data, health-related quality of life (QL) was measured using the SF-36 and Skindex-29. One year later all participants were interviewed by telephone about the course of their skin disease.

RESULTS

Out of 212 participants, 84.0 % were female. The mean age was 41.6 (SD = 10.8) years.168 patients (79.2 %) suffered from hand dermatitis,with irritant contact dermatitis being the predominant diagnosis (46.2 %,n = 98). One year later 65.4 % (n = 85) of the patients interviewed still suffered from hand dermatitis.9.2 % (n = 12) had meanwhile quit their job due to the skin disease. QL was impaired in all age groups being lower with increasing age of the patients.

CONCLUSIONS

The follow-up confirmed the positive impact of the skin protection courses on patients' skin disease and well-being. Occupational skin diseases impair health-related quality of life in these professions but disease severity does not seem to play a key role.

Rehabilitation von berufsbedingten Hauterkrankungen

The high incidence rates of occupational contact dermatitis, its poor prognosis, and the high social and economic impact of the disease for the affected individuals as well as for the medical insurance companies indicates a need to strive for the target of "rehabilitation instead of retirement". Here, we highlight the need and effectiveness of rehabilitation measures in individuals with work related skin diseases (mainly contact dermatitis and hand eczema). We discuss the measures for secondary individual prevention as well as tertiary prevention, which have been established in our department together with the state medical insurance companies, mainly the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BWG: Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Service). The results of the multicentre study "Optimisation and Quality Assessment of Tertiary Prevention of Occupational Dermatoses" are presented and discussed. Both, the secondary as well as tertiary prevention measures have been successful, which has resulted in a decrease in the total annual rehabilitation costs to the BGW. A reason for this success story is the fact that in Germany these organisations are, in contrast to the health insurance companies, responsible for both acute treatment and the rehabilitation.