Skin protection in nursing work: promoting the use of gloves and hand alcohol

Biomonitoring of hand and forearm transepidermal water loss and skin PH among nursing apprentices

BACKGROUND

Measurements of transepidermal water loss (TEWL) and stratum corneum (SC) pH can help indicate work-related skin barrier damage, but sensitivity to confounding personal and ambient factors limits their potential as biomonitoring tools.

OBJECTIVES

To evaluate the difference between hand and forearm skin barrier conditions as a tool for early recognition of workers with occupational contact dermatitis.

PARTICIPANTS AND METHODS

The participants were nursing apprentices (N = 238, median age 19 years) from Zagreb, Croatia. They filled out a questionnaire based on the Nordic Occupational Skin Questionnaire, underwent a clinical examination of skin on the hands, and were evaluated for their TEWL and SC pH on the dorsum of the hand and volar part of the forearm.

RESULTS

We found that the difference between hand and forearm TEWL values (ΔTEWL) greater than 7 g/m2/h, or >50%, or the difference in SC ΔpH >0.50, predicted visible skin changes found on clinical examination. However, only the association with ΔpH >0.50 retained statistical significance when controlled for sex, age, ambient temperature, and relative humidity in a multiple regression model.

CONCLUSIONS

The difference between hand and forearm SC pH values is suggested as a reliable biomonitoring tool in recognition of damaged skin barrier conditions in occupational settings.

Difference between hand and forearm transepidermal water loss and skin pH as an improved method to biomonitor occupational hand eczema: our findings in healthcare workers

The aim of this cross-sectional field study was to establish the condition of hand and forearm skin barrier among dentists and physicians and how it may be associated with personal and work-related factors. The study consisted of an occupational questionnaire, clinical examination of skin on hands, and transepidermal water loss (TEWL) and pH measurements on hands and forearms. The participants were divided in the following groups (N=37 each, N=148 in total): physicians, medical surgeons, dentists, and dental surgeons. We calculated the difference between hand and forearm TEWL and pH (ΔTEWL and ΔpH, respectively) and divided it by the forearm values (ΔTEWL% and ΔpH%, respectively). There was a clear trend of increasing median ΔTEWL%, starting from physicians with non-surgical specialisation (56 %) to medical surgeons (65 %), dentists (104 %), and dental surgeons (108 %), with the latter two groups showing particularly worrisome signs of work-related skin barrier impairment, since they had double the TEWL on hands than on forearms. Although less prominent, the same worsening trend was noted for skin pH, with dental surgeons having on average a 0.3 points higher skin pH on hands than on forearms. These findings were mainly associated with prolonged glove use and male sex. Our findings also suggest that comparing TEWL and pH between hands and forearms can better establish occupational skin barrier impairment on hands.

Evaluation of Skin Barrier Condition Among Physicians and Dentists

Background: Physicians and dentists are at risk for chronic hand eczema, but their skin barrier condition has rarely been investigated before. Objective: To objectively assess the skin barrier condition among physicians and dentists. Methods: This cross-sectional epidemiological study included an occupational questionnaire, medical examination of hand skin, skin transepidermal water loss (TEWL), and pH measurements, analyzed in 5 groups (N = 37 in each): physicians-nonsurgeons, physicians-surgeons, dentists-nonsurgeons, dentists-surgeons, and control group (unexposed workers). Results: Critical skin condition (TEWL >30 g/[m2·h]) was found in 14% of control workers, 14% physicians nonsurgeons, 22% physicians surgeons, 27% dentists nonsurgeons, and 43% dentists surgeons. The latter had the worst stratum corneum condition indicated by a TEWL median of 25.80 g/(m2·h) (interquartile range [IQR] 19.24-34.31). Hand skin pH was highest among dentists with nonsurgical specializations, with a median of 5.33 (IQR 5.15-5.60), where 38% of them had pH >5.5. Male sex (P < 0.001) and glove use for >1 h/day (P = 0.009) were associated with elevated hand TEWL values, whereas female sex (P < 0.001) and glove use for >4 h/day with elevated pH values (P < 0.001). Conclusions: Prolonged glove usage and dental profession, especially surgical work, significantly affect the skin barrier condition. This study was the first to objectively determine skin barrier condition among dentists and physicians.

Effects of ultra-pure soft water on the hands of nurses in a neonatal intensive care unit: A randomized crossover study

BACKGROUND

Healthcare workers (HCWs) wash their hands with tap water (TW) and soap. However, hard TW causes dermatitis.

OBJECTIVES

The present study aimed to compare the effects of ultra-pure soft water (UPSW) with those of TW on the hands of HWCs.

METHODS

The present study was a prospective randomized trial with a crossover design. All the nurses in the neonatal intensive care unit (NICU) at the study centre were divided into Sequence 1 (UPSW to TW) or 2 (TW to UPSW) and washed their hands with TW or UPSW in alternating 4-week periods with a 4-week washout period. Trans-epidermal water loss (TEWL) and stratum corneum hydration (SCH) were evaluated. Skin condition was self-assessed.

RESULTS

Twenty-one and 22 nurses were assigned to Sequence 1 and Sequence 2, respectively. USPW increased SCH to a significantly greater degree than TW (mean: 26.3 μS ± 12.3 SD; 95% confidence interval: 1.12-51.54; p = 0.041) although it did not affect TEWL. UPSW use significantly improved the subjects' skin condition, as reflected in an overall increase in the assessment scores.

CONCLUSIONS

UPSW improved SCH and the condition of hand skin. Prolonged USPW use may increase nurses' comfort during work and hand hygiene compliance.

Investigation of the prevalence of hand eczema among healthcare professionals in Turkey: A cross-sectional study

BACKGROUND

Hand eczema is one of the common occupational dermatoses, having high prevalence among healthcare professionals (HCP). We found no epidemiological data in the literature concerning the prevalence of hand eczema among HCP in Turkey.

AIMS

The aim of the present study was to investigate the prevalence of hand eczema among HCP in Turkey and to determine the demographic characteristics and risk factors that cause eczema.

METHODS

A clinical assessment- and questionnaire-based cross-sectional study was conducted with 734 HCP working in a tertiary hospital. Demographic characteristics and personal and occupational risk factors were evaluated in terms of the development of hand eczema.

RESULTS

The survey response rate was 81.8%. The point prevalence of eczema was 27.6%, and the 12-month prevalence was 45.9%. Age, occupation, duration of work, atopic diseases, handwashing frequency, dry skin, moisturizing frequency, and presence and duration of glove use were important factors in the development of hand eczema. Powdered glove reaction was significantly higher in those with hand eczema (p = 0.0001).

CONCLUSIONS

The prevalence of hand eczema is high among HCP in Turkey. Combining self-reported questionnaires with clinical examination findings can provide a more accurate calculation of the prevalence of hand eczema. The availability of epidemiological data on hand eczema can provide guidelines for the prevention and treatment of this condition. Except for situations requiring absolute handwashing, disinfecting hands with alcohol-based lotions and applying a powder-free policy in all healthcare centers will reduce the prevalence of hand eczema among HCP.

Art of prevention: Allergic sensitization through damaged skin: Atopic, occupational, and stasis dermatitis

The prevention of allergic contact dermatitis hinges on maintaining the integrity of the skin barrier and responding appropriately when it is disturbed. Although intact skin is subject to sensitization via highly irritating allergens, such as poison ivy, acutely inflamed and chronically inflamed skin is subject to sensitization to allergens without inherent irritant potential. In the chronically inflamed state of atopic dermatitis, sensitization to proteins, such as food, also carries a risk for systemic contact dermatitis via ingestion of the allergen. Minimizing the development of irritant dermatitis is key to preventing sensitization. However, in patients with already chronically inflamed skin, reducing the use of products to the involved areas, recommending hypoallergenic products with caution, and taking measures to prevent biofilm formation are also integral to preventing sensitization to chemicals and proteins, such as food and commensal organisms.

Clinical Pattern and Patch Test Profile of Hand Eczema in Hospital Employees in a Tertiary Care Hospital of North India

Introduction:

Health care workers form an important occupational group with a high risk of hand eczema. All health care professionals are exposed to a variety of allergens and irritants which can cause hand dermatitis, resulting in significant morbidity.

Aims and Objectives:

To assess the clinical profile of hand eczema in hospital employees, to perform patch test in relevant cases and to find out the most common sensitizers in them.

Materials and Methods:

This was a cross-sectional, hospital-based study in which the staff was screened for features of hand eczema and patch testing was done in the suspected cases of allergic contact dermatitis.

Results:

Out of 340 employees screened, 46 employees (13.5%) suffered from hand eczema. The most common type was wear and tear dermatitis accounting for 17 (36.9%) cases, followed by discoid eczema, pompholyx, focal palmar peeling, finger-tip eczema, hyperkeratotic eczema, ring eczema, and unspecified types. Patch testing was positive in 15 (32.6%) cases. The most common allergen was paraphenylene diamine, followed by fragrance mix, nitrofurazone, mercaptobenzothiazole, potassium bichromate, black rubber mix, and thiuram mix. A statistically significant association (0.001) was found with an underlying history of atopy.

Conclusion:

Hand eczema is a commonly encountered dermatological complaint in many hospital employees. Proper counseling, work, up, patch testing, and treatment can mitigate the symptoms in such employees.

Effectiveness of interventions for preventing occupational irritant hand dermatitis: a quantitative systematic review

OBJECTIVE

The aim of this review was to identify, appraise and synthesize the best available evidence on the effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions (a combination of two or more of the interventions listed here) in preventing occupational irritant hand dermatitis (OIHD) in wet workers, comparing each intervention to an alternative intervention or to usual care (workers' regular skin care regimen).

INTRODUCTION

The most significant occupational skin problem potentially encountered in wet work occupations is occupational dermatitis. When the skin comes into contact with hazardous substances at work, this can cause occupational dermatitis. Substances which may cause occupational dermatitis include cleaning products, organic solvents, metalworking fluids, cement, flour, adhesives, other chemicals and even certain plants. Occupational skin disease has adverse effects on quality of life and the long term prognosis for skin health is poor unless workplace exposures are addressed. To date, no systematic review has been undertaken to determine the effectiveness of interventions for the primary prevention of OIHD in wet workers.

INCLUSION CRITERIA

The review included any workers from healthcare (e.g. nurses, doctors and allied health professionals) and also people in different wet work occupations (e.g. hairdressers, florists, catering workers, metal workers) at similar risk of OIHD. Studies that assessed the following interventions in the primary prevention of OIHD in wet workers at the workplace and at home (before and after work) were included:Types of studies considered were experimental study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, and before and after studies. Primary outcome measures were OIHD incidence, and secondary outcome measures were product evaluation and change of occupation because of OIHD versus staying in the occupation.

METHODS

Published and unpublished literature in the English language was sought between 2004 and 2017. The databases searched included: COCHRANE CENTRAL, MEDLINE, CINAHL, AMED and Embase. The search for unpublished studies included: Google Scholar, Open DOAR and Robert Gordon University's thesis database, "OPEN AIR".

RESULTS

There were no studies located that met the inclusion requirements of this review.

CONCLUSION

There is currently no evidence available to determine the effectiveness of interventions to prevent OIHD amongst wet workers that met this review's inclusion criteria.

Seeking Clearer Recommendations for Hand Hygiene in Communities Facing Ebola: A Randomized Trial Investigating the Impact of Six Handwashing Methods on Skin Irritation and Dermatitis

To prevent disease transmission, 0.05% chlorine solution is commonly recommended for handwashing in Ebola Treatment Units. In the 2014 West Africa outbreak this recommendation was widely extended to community settings, although many organizations recommend soap and hand sanitizer over chlorine. To evaluate skin irritation caused by frequent handwashing that may increase transmission risk in Ebola-affected communities, we conducted a randomized trial with 91 subjects who washed their hands 10 times a day for 28 days. Subjects used soap and water, sanitizer, or one of four chlorine solutions used by Ebola responders (calcium hypochlorite (HTH), sodium dichloroisocyanurate (NaDCC), and generated or pH-stabilized sodium hypochlorite (NaOCl)). Outcomes were self-reported hand feel, irritation as measured by the Hand Eczema Score Index (HECSI) (range 0-360), signs of transmission risk (e.g., cracking), and dermatitis diagnosis. All groups experienced statistically significant increases in HECSI score. Subjects using sanitizer had the smallest increases, followed by higher pH chlorine solutions (HTH and stabilized NaOCl), and soap and water. The greatest increases were among neutral pH chlorine solutions (NaDCC and generated NaOCl). Signs of irritation related to higher transmission risk were observed most frequently in subjects using soap and least frequently by those using sanitizer or HTH. Despite these irritation increases, all methods represented minor changes in HECSI score. Average HECSI score was only 9.10 at endline (range 1-33) and 4% (4/91) of subjects were diagnosed with dermatitis, one each in four groups. Each handwashing method has benefits and drawbacks: soap is widely available and inexpensive, but requires water and does not inactivate the virus; sanitizer is easy-to use and effective but expensive and unacceptable to many communities, and chlorine is easy-to-use but difficult to produce properly and distribute. Overall, we recommend Ebola responders and communities use whichever handwashing method(s) are most acceptable, available, and sustainable for community handwashing.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Registry ISRCTN89815514.

Occupational skin disease among Australian healthcare workers: a retrospective analysis from an occupational dermatology clinic, 1993-2014

BACKGROUND

Healthcare workers (HCWs) are at risk of developing occupational skin disease (OSD).

OBJECTIVES

To ascertain the causes of OSD in Australian HCWs in a tertiary referral clinic.

METHODS

A retrospective review was performed of patients assessed at the Occupational Dermatology Clinic in Melbourne from 1993 to 2014.

RESULTS

Of 685 HCWs assessed in the clinic over a period of 22 years, 555 (81.0%) were diagnosed with OSD. The most common diagnosis was irritant contact dermatitis (ICD) (79.1%), followed by allergic contact dermatitis (ACD) (49.7%). Natural rubber latex allergy was also relatively frequent (13.0%). The major substances causing ACD were rubber glove chemicals (thiuram mix and tetraethylthiuram disulfide), preservatives (formaldehyde, formaldehyde releasers, and isothiazolinones), excipients in hand cleansers, which are hard-to-avoid weak allergens, and antiseptics. ACD caused by commercial hand cleansers occurred more frequently than ACD caused by alcohol-based hand rubs (ABHRs). Occupational ICD was mostly caused by water/wet work and hand cleansers, and environmental irritants such as heat and sweating.

CONCLUSIONS

Understanding the causes of OSD in HCWs is important in order to develop strategies for prevention. We suggest that skin care advice should be incorporated into hand hygiene education. The use of ABHRs should be encouraged, weak allergens in skin cleansers should be substituted, and accelerator-free gloves should be recommended for HCWs with OSD.

Hand dermatitis: a review of clinical features, prevention and treatment

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Occlusive gloves and skin conditions: is there a problem? Results of a cross-sectional study in a semiconductor company

BACKGROUND

Although there is poor scientific evidence that working with occlusive gloves is as damaging as wet work, prolonged glove occlusion is considered to be a risk factor for developing hand eczema similar to wet work.

OBJECTIVES

To assess the effects of wearing occlusive gloves during the whole working day, without exposure to any additional hazardous substances, on skin condition and skin barrier function.

METHODS

We investigated 323 employees of a semiconductor production company in Germany: 177 clean-room workers wearing occlusive gloves during the whole shift (exposed group) and 146 employees working in administration (control group). A standardized interview was performed, the skin condition of both hands was studied using the quantitative skin score HEROS, and transepidermal water loss (TEWL) and stratum corneum hydration were measured.

RESULTS

There was no significant difference in skin condition between the two subgroups. Values for TEWL and corneometry were significantly higher in exposed participants (P < 0·05). However, the TEWL values were similar to control values if participants took off the occlusive gloves at least 30 min before the measurement. Hence, the effect of occlusion on skin barrier function seems to be transient.

CONCLUSIONS

Prolonged wearing of occlusive gloves with clean hands and without exposure to additional hazardous substances does not seem to affect the skin negatively.

Effect of the hand antiseptic agents benzalkonium chloride, povidone-iodine, ethanol, and chlorhexidine gluconate on atopic dermatitis in NC/Nga mice

Antiseptic agents can cause skin irritation and lead to severe problems, especially for individuals with atopic diatheses. We investigated the effect of 4 different antiseptic agents using an atopic dermatitis (AD) model mouse. NC/Nga mice were subcutaneously injected with mite allergen (Dp) to induce AD-like skin lesions (ADSLs), and an application of 0.2% (w/v) benzalkonium chloride (BZK), 10% (w/v) povidone-iodine (PVP-I), 80% (v/v) ethanol (Et-OH), or 0.5% (v/v) chlorhexidine gluconate (CHG) was applied to the ear envelope. BZK induced a significant increase in the severity of the clinical score, infiltration of inflammatory cells, local expression of inflammatory cytokines in subcutaneous tissue, and total serum immunoglobulin (Ig) E. PVP-I increased the clinical score, number of mast cells, and production of inflammatory cytokines, and total serum IgE. Et-OH increased the clinical score and number of inflammatory cells, but showed no effect on serum IgE levels. No differences in any parameters were observed between CHG and the vehicle. Collectively, the results suggest the severity of the ADSL was related in part to the strength of the immunoreaction. These findings suggest that CHG could offer the lowest risk of inducing ADSL in individuals with atopic dermatitis and that medical staff and food handlers with AD could benefit from its use.

Occupational hand eczema among nursing staffs in Korea: Self-reported hand eczema and contact sensitization of hospital nursing staffs

Occupational hand eczema is frequent in hospital workers, especially in nurses. A comprehensive understanding regarding hand eczema is essential for establishing proper prevention and treatment strategies. The purpose of this study was to identify the risk factors for hand eczema in hospital nursing staffs. A self-administered questionnaire study was performed on hospital nursing staffs at a single general hospital in Korea. In addition, 70 patients with hand eczema underwent patch testing. Five hundred and twenty-five of 700 invited nurses completed the study (response rate, 75.0%). The overall frequency of symptom-based hand eczema was 75.6%, and self-reported hand eczema was 31.0%. Risk factors for hand eczema were young age, history of atopic dermatitis, frequent hand washing (>20 times/day) and long duration of glove wearing (>5 min). Hand eczema was less frequent among frequent hand moisturizer users (>3-4 times/day). Positive patch test reactions were observed in 61.4%. Frequent allergens were nickel sulfate (35.7%), cobalt chloride (28.6%) and thiomersal (21.4%). Among various antibiotics, ciprofloxacin (11.4%), trimethoprim/sulfamethoxazole (11.4%) and gentamicin (7.1%) were revealed as common allergens, in order of frequency. Hand eczema is quite common among hospital nursing staffs. Proper preventive programs and educations are demanded.

Innovative management of severe hand dermatitis

The successful treatment of hand dermatitis (HD) depends less on the selection of the proper topical steroid or a particular systemic agent than on addressing any underlying cause or perpetuating factor. Thus, innovative treatment is based on comprehensively addressing the patient's problem. Aggressive approaches may be required for the most severe forms of HD.

Stratum corneum cytokines, structural proteins, and transepidermal water loss: effect of hand hygiene

BACKGROUND/AIMS

There are few reports on the cytokine response to high frequency hand hygiene among health care workers (HCWs) in an occupational setting. We have observed significant skin barrier compromise consistent with chronic irritant contact dermatitis in HCWs. We hypothesized that repetitive hand hygiene would activate the epidermal inflammatory cascade and lead to changes in structural proteins and cytokines.

METHODS

Keratin 6, keratin 1, 10, 11, involucrin, IL1alpha, TNFalpha, IL8, IL1RA, and IL10 were analyzed from the SC using bead-based arrays. Knuckle and dorsum samples were evaluated for HCWs (n=23) before and after repetitive hand hygiene and compared with those of age-matched non-wet workers (n=23) without hand skin irritation. Erythema, dryness, and barrier integrity were measured.

RESULTS

Transepidermal water loss (TEWL) was higher for HCWs but unchanged with exposure. IL1alpha and TNFalpha were highest in control volar forearm. IL1alpha, TNFalpha, and IL8 were significantly lower in HCWs than controls despite higher erythema, dryness, and TEWL. Decreases in keratin 1, 10, 11, increases in keratin 6, and reduction in IL1alpha, TNFalpha, and IL8 were seen after hand hygiene.

CONCLUSION

This preliminary study showed significantly lower SC biomarker levels in HCW compared with controls and regional differences between the hand and forearm. Exposure to repetitive hand hygiene results in substantial chronic skin irritation without time for barrier recovery between work periods. The impact on SC structural proteins and cytokines has many commonalities with chronic inflammation, although mechanistic questions remain.

Short- and long-term effects of single and repetitive glove occlusion on the epidermal barrier

The aim of this study was to analyse the occlusive effects of glove materials (polyvinyl chloride, natural rubber latex) on epidermal barrier function and to relate the findings to the definitions of wet work in the current German ordinance on hazardous substances (2007) and in the German technical regulations on hazardous substances (TRGS 401; 2008). Short-term effects of wearing gloves once for 4 h, as well as the long-term effects of wearing gloves for 4 h daily for 7 days were assessed in a group of 20 healthy volunteers using non-invasive methods (transepidermal water loss (TEWL), capacitance, skin colour, skin surface pH). Data were collected 30 min and 3 h after single use, as well as 1 day after a 1-week application. TEWL and capacitance data showed hyperhydration of the horny layer 30 min after a 4-h occlusion as compared to baseline (p < 0.05). Three hours later, full recovery to basal values was observed. Additionally, a significant long-term effect after daily occlusion for 4 h for 7 days could not be demonstrated. In current literature, there is controversial evidence concerning the effects of glove occlusion. This study could not verify significant damage to skin barrier after 7 days of repeated occlusion 4 h daily in healthy volunteers. These findings require further discussion regarding the definitions in the current German ordinance on hazardous substances and in the TRGS 401.

Thiuram allergy--a potential dermal allergy among health care workers

Occupational health nurses should be cognizant of the myriad exposures that can result in dermal reactions among health care workers.

Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group

BACKGROUND

Nurses have a high risk of developing hand eczema due to hand disinfection procedures.

OBJECTIVES

To investigate the perception of nurses regarding the adverse effects of hand washing (HW) and alcoholic disinfection (ADI), and to obtain data on the prevalence of hand dermatitis and sensitization to alcohols and alcohol-based hand rubs (ABHRs).

METHODS

A self-administered questionnaire survey, carried out as a pilot study (PS), followed by a modified multicentre study (MC) in five hospitals. Patch tests to ethanol (80%), 1-propanol (60%), 2-propanol (70%) and ABHRs were performed in a subsample.

RESULTS

The majority (PS 60.1%; MC 69.5%) of nurses considered ADI to be more damaging than HW. Mostly, ADI and HW were suspected to have irritant effects (ADI 79.2%/52.1%; HW 65.5%/36.2%) compared with an allergenic potential (ADI 10.4%/5.8%; HW 7.8%/3.9%). The prevalence of hand dermatitis in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions. In 50 tested individuals no sensitization and only two irritant reactions to alcohols and three single-positive reactions to ABHRs were observed, none of the latter related to alcohols.

CONCLUSIONS

Although ADI is known to cause less skin irritation than HW, nurses perceive ADI as more damaging, resulting in: (i) a low compliance with ADI and (ii) a higher prevalence of hand dermatitis because the more deleterious HW is preferred. This may result in an increase in occupational disease and nosocomial infections. Educational programmes should promote ADI as a procedure with good efficiency and skin tolerability to reduce the prevalence of hand eczema in nurses and to enhance compliance with hand hygiene standards.

Skin exposure in geriatric care ? a comparison between observation and self-assessment of exposure

The aim of this study was to compare observation and self-assessment of skin exposure to irritants during a working day in nursing in geriatric care. The study group consisted of 40 volunteers, 13 nurses, and 27 assistant nurses. Before the start of a working day, the participants completed a questionnaire regarding skin exposure to water, gloves, hand disinfection, and moisturizers. Observers subsequently used a hand-held computer to register the time and frequency of each exposure. The total mean skin exposure time was 96 min per working day, including glove use. The mean exposure time to water was 9 min per working day. A tendency to overestimate was found for all exposures. A strong correlation between self-reports and observations was found for hand disinfection and moisturizers, while a moderate correlation was found for gloves and number of water exposures and a weak correlation for total time of water exposure. Despite the differences between self-assessment and observation of the exposure, we consider the questionnaire to be useful for surveying skin exposure in nursing. Furthermore, the observations in this study suggest that nursing work in geriatric care may comprise limited exposure to water.

How irritant is alcohol?

BACKGROUND

Alcohol-based hand rubs are used worldwide to prevent transmission of nosocomial pathogens.

OBJECTIVES

To investigate skin irritation caused by alcohols alone and in combination with detergent washing.

METHODS

Single and repetitive patch testing with 60-100% alcohols [ethanol, 1-propanol, 2-propanol (synonyms: isopropyl alcohol, isopropanol)], a positive control [0.5% sodium lauryl sulphate (SLS)] and negative controls (empty chamber and water) were performed. Wash tests were performed with 80% ethanol and 0.5% SLS on the forearms with each agent alone and with both agents in a tandem design. Skin hydration, erythema and barrier disruption [measured as transepidermal water loss (TEWL)] were evaluated (always 15 volunteers).

RESULTS

We found no significant change in skin barrier or erythema induced by the alcohols in the patch tests, whereas skin hydration decreased significantly. Application of alcohols to previously irritated skin did not show a stronger skin barrier disruption than application of SLS alone. Wash tests demonstrated that alcohol application caused significantly less skin irritation than washing with a detergent (TEWL, P < 0.001; skin hydration, P < 0.05; erythema, P < 0.05). Even on previously irritated skin, ethanol did not enhance irritation. By contrast, a protective effect of ethanol used after skin washing was observed (TEWL, P < 0.05; skin hydration, P < 0.05; erythema, P < 0.05).

CONCLUSIONS

Alcohol-based hand rubs cause less skin irritation than hand washing and are therefore preferred for hand hygiene from the dermatological point of view. An alcohol-based hand rub may even decrease rather than increase skin irritation after a hand wash due to a mechanical partial elimination of the detergent.

Skin reactions related to hand hygiene and selection of hand hygiene products

BACKGROUND

In October 2004, The World Health Organization (WHO) launched the World Alliance for Patient Safety. Within the alliance, the first priority of the Global Patient Safety Challenge is to reduce health care-associated infection. A key action within the challenge is to promote hand hygiene in health care globally as well as at the country level through the campaign "Clean Care is Safer Care." As a result, the WHO is developing Guidelines on Hand Hygiene in Health Care, designed to be applicable throughout the world.

METHODS

This paper summarizes one component of the global WHO guidelines related to the impact of hand hygiene on the skin of health care personnel, including a discussion of types of skin reactions associated with hand hygiene, methods to reduce adverse reactions, and factors to consider when selecting hand hygiene products.

RESULTS

Health care professionals have a higher prevalence of skin irritation than seen in the general population because of the necessity for frequent hand hygiene during patient care.

CONCLUSION

Ways to minimize adverse effects of hand hygiene include selecting less irritating products, using skin moisturizers, and modifying certain hand hygiene practices such as unnecessary washing. Institutions need to consider several factors when selecting hand hygiene products: dermal tolerance and aesthetic preferences of users as well as practical considerations such as convenience, storage, and costs.

Dermatitis de manos

Hand dermatitis is a common skin disease that often has a chronic and relapsing course. Several subtypes of hand dermatitis have been described. In this review, we describe the clinical characteristics of each form of hand eczema, laboratory tests helpful in the diagnosis, and treatment options for this condition.

TEWL measurements as a routine method for evaluating the integrity of epidermis sheets in static Franz type diffusion cells in vitro. Limitations shown by transport data testing

The suitability of transepidermal water loss (TEWL) measurements in vitro as a barrier integrity test for human heat separated epidermis (HSE) was investigated. A model system consisting of a Teflon membrane mounted in Franz diffusion cells (FDC) filled with phosphate buffer saline (PBS) was set up. The membrane was used intact and punctured with a needle (up to five holes). After each puncturing the TEWL was measured. Only the TEWL of intact and punctured membrane differed significantly regardless of the number of holes. From three donors intact human HSE and punctured HSE were compared and no significant difference of the TEWL was found. Permeation experiments with flufenamic acid (FFA) showed a significantly higher diffusion rate through punctured HSE. TEWL and drug permeation were compared for skin stripped three, seven and 15 times prior to heat separation to an intact control group. Only the TEWL values of intact HSE and HSE stripped 15 times differed significantly. However, seven and 15 times stripping resulted in significantly higher diffusion rate. In conclusion, TEWL measurements can detect severe damage of the stratum corneum (SC) but not small changes, which nevertheless may already influence drug diffusion. Therefore, TEWL measurements appears to be of limited use as a barrier integrity test for human HSE in in vitro test systems.

Primary prevention in health care employees: a prospective intervention study with a 3-year training period

Irritant contact dermatitis is a mayor problem in health care employees. Because educational programs have shown convincing success in certain occupations (e.g. in hairdressers), this study investigates the effect of a special training program in health care trainees. 521 trainees from 14 nursing schools in Central Germany were randomly divided in 2 groups, (i) an intervention group with a regular teaching protocol regarding all aspects of primary prevention and (ii) a control group without any further teaching. Morphological changes of the hands, use of hand care creams and knowledge regarding skin care were evaluated regularly during their 3 years lasting training period (1999-2002). In the intervention group, we found at the end of the 3-year training period a significant better skin condition of the hands than in the control group: a 3-year prevalence of morphological skin changes of 66.7% versus 89.3%. The unteached trainees (control group) had an odds ratio (OR) of 4.8 [95% confidential interval (CI): 2.9-7.8] for developing any skin changes on the hands after 3 years. Besides the effect of the teaching, the history of hand dermatitis before the study start was an independent risk factor for development of further hand dermatitis [OR 1.9, 95% CI: 1.0-3.6). Age and sex showed no influence on the skin condition. Atopic constitution had an influence on the development of skin changes only at the evaluation after 18 month. The observed effect in the intervention group may best be explained by different behaviour of the trainees, e.g. the amount of hand washing was reduced, while procedure of hand disinfection remained unchanged compared with the control group. However, the amount of used skin care cream did not differ between the both groups. This study shows that primary prevention of skin disease by regularly teaching during the training period of medical employees can effectively reduce the risk of development of irritant skin changes of the hands. Therefore, teaching and continuous motivation regarding preventive individual and collective measures during the training of medical staff should be an obliged part of the curriculum.

Transepidermal water loss and incidence of hand dermatitis in a prospectively followed cohort of apprentice nurses

The purpose of the study was to evaluate the incidence of hand dermatitis, the impact of potential risk factors and the efficacy of skin bioengineering in a prospectively followed cohort of apprentice nurses. 104 participants were prospectively followed for 3 years. Before the start of training, after about 1 year and in the third year of occupational exposure, a standardized questionnaire was distributed, and a clinical examination with skin bioengineering of the dorsum of hand and forearm was performed. The 12-month period prevalence of self-reported symptoms of hand dermatitis was 36.5%[95%-confidence interval (CI) 27.3-46.6] at intermediate follow-up and 43.3% (95%-CI 33.6-53.3) at the final examination. Apprentices with self-reported symptoms at the final examination showed a significant increase of transepidermal water loss (TEWL) at the dorsal hand from 10.15 g/m2h to 13.55 g/m2h. TEWL at this site did, at the initial examination, not differ significantly between persons who later reported symptoms of hand dermatitis at the final examination and those who did not (10.50 g/m2h versus 10.15 g/m2h, respectively). Our results do not support the notion that an increased basal TEWL is a good indicator for hand dermatitis risk.