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

The prevalence of hand dermatitis among intensive care unit nurses

BACKGROUND

Healthcare workers are at high risk of developing occupational hand dermatitis (HD) due to their frequent exposure to wet-work and use of gloves. Complaints of HD may interfere with work and cause loss of work productivity, or sick leave, and may have impact on job pleasure and performing daily activities. The prevalence of HD among intensive care unit (ICU) nurses is unknown.

OBJECTIVES

To investigate the point prevalence and the 1-year prevalence of HD among ICU nurses, and to determine the impact of HD on work and daily activities.

METHOD

A questionnaire-based cross-sectional study was performed among ICU nurses. Participants were recruited in the Amsterdam University Medical Centre. A symptom-based questionnaire was used to determine HD and atopic predisposition, and an additional questionnaire was used concerning the influence of HD. ICU nurses with an atopic predisposition or symptoms suiting HD were invited for the hand dermatitis consultation hour (HDCH). Data were analysed with logistic regression.

RESULTS

A total of 184 ICU nurses were included. The point prevalence of HD was 9.8% (95% CI: 5.9-15.0) and the 1-year prevalence was 26.6% (95% CI: 20.4-33.6). Sick leave was reported by 0.5%. HD seemed to have more impact on job pleasure than on work productivity.

CONCLUSION

The high prevalence rate of HD resulting from our study highlights the need for the prevention of occupational HD among healthcare workers.

Psychological burden, anxiety, depression and quality of life in patients with hand eczema: A systematic review and meta-analysis

BACKGROUND

Living with hand eczema (HE) has been associated with impaired quality of life (QoL), having anxiety and depression but the magnitude of association is not clear.

OBJECTIVES

The aim of this systematic review and meta-analysis was to determine the psychological burden in terms of anxiety, depression and quality of life in patients with HE.

METHODS

Several databases were systematically searched. Weighted means with standard deviation (SD) were calculated for disease severity, QoL, depression and/or anxiety scores among patients with HE. For studies presenting QoL, depression and/or anxiety scores in patients with HE and in controls the weighted means were compared with an unpaired t-test. In studies reporting Hand Eczema Severity Index (HECSI) and Dermatology Life Quality Index (DLQI), the correlation between HECSI and DLQI was estimated using Spearman's rank correlation (rs).

RESULTS

In total, 81 studies encompassing 17,835 patients with HE and 31,541 controls were included. The weighted mean DLQI was 10.66 (SD 8.93) corresponding to a moderate-to-large effect on QoL and a strong correlation (rs: 0.76, 95% CI:0.56-0.87) between DLQI and HECSI was observed. The mean EQ-5D-VAS was significantly lower in patients with HE compared with controls (68.03 (SD 10.52) vs. 80.63 (SD 1.17), p < 0.00001). Patients with HE had higher mean HADS (Hospital Anxiety and Depression Scale) anxiety score (7.4 vs. 5.8, p = 0.0008) than controls but not higher HADS depression score (6.5 vs. 5.7, p = 0.32). Only one study assessed risk of anxiety, depression and suicidal ideation showing an increased odds of all diseases among patients with HE compared with controls.

CONCLUSION

Hand eczema has a moderate-to-severe impact on quality of life with a strong correlation between disease severity and impact on quality of life. Patients with hand eczema have an impact on QoL comparable to other chronic diseases when measured with generic QoL scoring systems.

Assessing the efficacy of a German-inspired intervention on occupational contact dermatitis in Denmark: A randomised controlled trial with 3-month follow-up

BACKGROUND

Occupational contact dermatitis (OCD) is a prevalent, often chronic disease that poses a risk for job loss and decreased quality of life. In Germany, a multi-step prevention programme emphasising early detection and highly specialised multidisciplinary treatment has been implemented with great success.

OBJECTIVES

To examine the effectiveness of a Danish-adapted version of the German prevention effort on OCD severity, quality of life and occupational consequences at 3-month follow-up.

METHODS

Randomised, controlled trial. Participants were recruited after the first referral from General Practitioner to Dermatologist with suspected OCD. The intervention group (IG) received a Danish-adapted, multidisciplinary intervention, while the control group (CG) navigated the Danish healthcare system without interference from the study. OCD severity, occupational consequences and quality of life were assessed at 3-month follow-up using self-reported questionnaires.

RESULTS

A statistically significant decrease in the severity of eczema was found at 3-month follow-up in the IG compared to the CG. The IG were statistically significantly more likely to have seen a dermatologist at 3-month follow-up. Higher treatment level in the IG was indicated by the results but was not statistically significant. No significant difference was found in quality of life or occupational consequences.

CONCLUSIONS

These initial findings suggest that early and specialised treatment of OCD improves OCD prognosis.

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

A prospective randomized controlled trial of Psychodermatology on the efficacy of Rilastil Difesa Sterile® cream in the hand eczema of healthcare workers during the COVID-19 pandemic

Hand eczema is one of the most frequent dermatological diseases, with an incidence increased during the COVID-19 pandemic. The impact on life quality is considerable, giving rise to the need for a psycho-dermatological approach. This is a Randomized Control Trial (RCT) evaluating, either by the dermatological or psychological point of view, the effectiveness of an emollient and rehydrating topical product (Rilastil Difesa Sterile® cream) versus a standard treatment (i.e. moisturizing basic cream) in a group of 51 healthcare workers suffering from hand eczema during the COVID-19 pandemic. The enrolled subjects were randomized into a treatment or a control arm, treated for 8 weeks, and monitored through a clinical score (HECSI) and questionnaires evaluating the impact of the pathology and treatment on quality of life (DLQI and QOLHEQ). A psychometric evaluation was performed using the SCL-90 R, OCI-R, and CPDI scales. Our data, despite not reaching the statistical significance, demonstrated that both the clinical and psychological scores decreased mostly in patients treated with Rilastil Difesa Sterile® cream when compared to those treated with simple topical emollients. Moreover, we observed a high level of psychic suffering in dermatological patients and a parallel change in dermatological and psychological indicators, thus confirming their connection.

Promoting public skin health through a national continuing medical education project on cosmetic and dermatologic sciences: a 15-year experience

Background

The developments in cosmetic sciences and technologies have generated a gap between the cosmetics and their users. Users including regular customers, clinicians, industry personnel, researchers, testing agencies, beauty salon workers, and mass media hardly possess the ability to distinguish truth from falsehood. The gap remained as one major reason for inappropriate cosmetics usage, insufficient efficacy, and even cosmetics adverse reactions (CARs).

Methods

Aiming at enhancing the relevant practitioners' cosmetic and dermatologic sciences, we launched a cosmetic and dermatologic sciences continuing medical education (CME) since 2008. The objective of the current study was to evaluate the effectiveness of the CME. We summarized and analyzed the project for the last 15 years. Meanwhile, an online survey consisted of three parts was performed to evaluate the CME and to collect the trainees' comments.

Results

A total of 3,923 trainees have participated in the CME project from 2008 to 2022. The trainees included clinicians, industry staffs, biomedical researchers, third-party cosmetics testing staffs, beauty salon staffs, students, and media staffs. The trainees had theory courses on cosmetic and dermatologic sciences, cosmetics DIY practice & video watching, and an optional guided tour during the 4.5-day CME. Eight hundred and twenty-three trainees and 586 control subjects responded to the online survey. The comprehensive test in the second part of the survey demonstrated that compared with the control group, the CME project significantly enhanced the trainees' perception and knowledge regarding the cosmetics formula sciences, basic dermatologic sciences, cosmetics usage, noninvasive measurements, new advances, CARs, and laws (p = 0.000). Trainees of all occupations ranked "basic dermatologic sciences and skin diseases" as the most significant sections. Trainees of all occupations believed the CME has contributed most in "understand the function & efficacy of cosmetics." We noticed the occupational variances. Over 97% of trainees were willing to recommend the CME to the others.

Conclusion

The CME project significantly enhanced the trainees' cosmetic and dermatologic sciences, which bridged the gap between cosmetics and public skin health. This multidisciplinary CME also contributed to establishing an interdisciplinary interaction and cooperation platform for the multiple occupations involved in the public skin health maintenance and promotion.

The prevalence of contact dermatitis among surgical assistants, anaesthesia assistants and anaesthesiologists working at the Amsterdam University Medical Centre

BACKGROUND

Professions requiring frequent and/or long lasting wet-work are at high risk for contact dermatitis (CD). CD may lead to loss of work productivity, sick leave and reduced quality of work. The 1-year prevalence of healthcare workers varies between 12% and 65%. However, the prevalence of CD among surgical assistants, anaesthesia assistants and anaesthesiologists is unknown.

OBJECTIVES

(1) To establish the point-prevalence and 1-year prevalence among surgical assistants, anaesthesia assistants and anaesthesiologists and (2) to determine the impact of CD on work and daily activities.

METHOD

A single-centre cross-sectional prevalence study was conducted among surgical assistants, anaesthesia assistants and anaesthesiologists. Data were obtained from the Amsterdam University Medical Centre between the 1 June 2022 and 20 July 2022. For data collection, a questionnaire was used, derived from the Dutch Association for Occupational Medicine (NVAB). Participants with an atopic predisposition or symptoms of CD were invited to the contact dermatitis consultation hour (CDCH).

RESULTS

A total of 269 employees were included. The total point prevalence of CD was 7.8%; 95% CI: 4.9-11.7, the total 1-year prevalence was 28.3%; 95% CI: 23.0-34.0. The point-prevalence among surgical assistants, anaesthesia assistants and anaesthesiologists was 14%, 4% and 2%, respectively. The 1-year prevalence was 49%, 19% and 3%, respectively. Two employees reported changed work-tasks because of symptoms, no sick days were reported. The majority of the visitors of the CDCH indicated an impact on work productivity and daily activities because of CD; however, the extent to which varied widely.

CONCLUSION

This study established that CD is a relevant occupational health disease among surgical assistants, anaesthesia assistants and anaesthesiologists.

Prevalence, risk factors, and prevention of occupational contact dermatitis among professional cleaners: a systematic review

OBJECTIVE

The aim of this study was to investigate the prevalence, risk factors, and prevention of occupational contact dermatitis (OCD), as well as risk factors and consequences of OCD among professional cleaners.

METHODS

A systematic review following PRISMA guidelines was performed using Medline, EMBASE, and Cochrane Library.

RESULTS

Thirty-nine studies containing over 109.000 participants were included in the review. The prevalence of OCD varied between 2.2% and 30.1%. Main occupational risk factors for developing OCD among cleaners included wet work and irritants in cleaning products (bleach, chlorine, ammonia, multi-use-cleaning) and skin contact to metal. The most common contact allergies included rubber, biocides, nickel/cobalt, and perfumes. Other risk factors were inconsistent use of protective gloves and low educational level. Consequences associated with OCD included significant impairment in quality of life, tendency to have unscheduled absence from work, sick leave, increased rate of disability, and recognized degree of injury. Only one prevention study has been published investigating the effect of an educative course in skin-protective behavior in cleaners. The study reported a higher degree of knowledge of skin protection, a decrease in the severity of hand eczema, and a shift toward fewer daily hand washings at follow-up after 3 months.

CONCLUSION

Our study proves that OCD is common in cleaners, and the main risk factors included wet work, irritants, and contact allergies, as well as inconsistent use of protective gloves and low educational level. More focus and a greater number of studies are needed on skin protection in this population.

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.

Occupational Hand Dermatitis

PURPOSE OF REVIEW

Occupational hand dermatitis is a common work-related disorder of the skin. Prevention and management of this disease is critical to improving workers' quality of life and for occupation-specific retention.

RECENT FINDINGS

This is a critical review of the current literature on occupational hand dermatitis. Occupational dermatitis continues to have a high prevalence among workers although the overall incidence may be slowly decreasing. Irritant contact dermatitis due to wet work exposure is the most common cause of occupational hand dermatitis. Healthcare workers, hairdressers, and metal workers are at particularly high risk for this disease. While some prevention programs have been ineffective in mitigating occupational hand dermatitis, other more resource-intensive initiatives may have benefit. Continued research is needed on ways to manage wet work exposures and on scalable, effective prevention programs for occupational hand dermatitis. The spectrum of culprit contact allergens continues to evolve, and vigilance for potential occupation-specific allergens remains important.

Illness perceptions of occupational hand eczema in German patients based on the common-sense model of self-regulation: A qualitative study

BACKGROUND

Occupational skin diseases (OSD) in the form of hand eczema (HE) are a common work-related disease. Illness perceptions as presented in Leventhal's Common-Sense Model (CSM) are important for patients' self-management of diseases. Understanding these illness perceptions is essential for patient communicating. No quantitative or qualitative studies which investigated subjective illness perceptions in patients with occupational HE utilized the CSM as theoretical framework. The Objective of this study is to investigate illness perceptions of patients with occupational hand eczema (HE) using the CSM.

METHODS

We applied an exploratory qualitative approach and conducted purposive sampling. Thirty-six patients with occupational HE were interviewed using an interview guide based on the dimensions of the CSM, including coherence and emotional representation. All participants participated in a three-week inpatient program at a clinic specialized on occupational dermatology. One interview had to be excluded before analysis, since one participant's diagnosis was retrospectively changed from ICD to tinea and hence did not match the inclusion criteria. Thirty-five interviews were transcribed verbatim and analyzed. Data was analyzed deductively and inductively using qualitative text analysis. MAXQDA 2018 (Verbi, Berlin, Germany), a software for qualitative data analysis, was applied for coding and summarizing of results. All dimensions of the CSM were explored for occupational HE.

RESULTS

Several sub-categories could be identified. Participants named a variety of causes in different areas (e. g. external irritants and other hazardous factors, psycho-social factors, allergies, having a 'bad immune system' or lifestyle). The great impact of the disease on the participants' life is shown by the wide range of consequences reported, affecting all areas of life (i. e. psychological, physical, occupational, private). Considering coherence, an ambivalence between comprehensibility and non-comprehensibility of the disease is apparent.

DISCUSSION

The complexity of illness perceptions presented in this paper is relevant for those involved in HE patient education and counseling, e. g, health educators, dermatologists, and, occupational physicians. Future research might further investigate specific aspects of illness perceptions in patients with occupational HE, especially considering the complexity of coherence and overlapping dimensions (i. e. emotional representation and psychological consequences).

Prevention of occupational hand eczema in healthcare workers during the COVID-19 pandemic: a controlled intervention study

BACKGROUND

Occupational hand eczema (HE) is common among healthcare workers (HCWs) and has - in some regions of the world - increased during the COVID-19 pandemic due to related hygiene measures.

OBJECTIVES

To evaluate the efficacy of an intervention for HE prevention in HCWs during the pandemic.

METHODS

A prospective, controlled, unblinded interventional trial was conducted in 302 HCWs. The intervention group (IG) (n = 135) received online-based health education and free access to hand cleansing and hand care products. The control group (CG) (n = 167) did not receive any intervention within the study. At baseline (T0), after three (T1) and six (T2) months, participants completed standardised questionnaires. The Osnabrueck Hand Eczema Severity Index (OHSI) was assessed at T0 and T2.

RESULTS

During the observation period, there were no new HE cases in the IG (n = 115) and 12 cases (8.8%) in the CG (n = 136). OHSI values at T2 were lower in the IG (b = -1.44, P < 0.001). Daily use of emollients was higher at work (b = 1.73, P < 0.001) and at home (b = 1.62, P < 0.001) in the IG at T2.

CONCLUSIONS

The intervention was effective in HE prevention and improving skin care behaviour during the COVID-19 pandemic. This article is protected by copyright. All rights reserved.

Patients' perspectives on quality of care for chronic hand eczema: a qualitative study

Background

Hand eczema (HE) has a significant impact on patients’ quality of life and work‐related activities. However, little is known about the patients' perspectives on quality of care for HE.

Objectives

To evaluate the patient perspective of the HE care process in a tertiary referral center.

Methods

Qualitative, semi‐structured focus groups were carried out, recorded, transcribed, and analysed using an inductive‐deductive thematic approach.

Results

Fifteen patients participated in four focus groups. Time and attention, together with being listened to and understood by the health care professional, were the most important aspects of care for HE mentioned by participants. Other aspects of care that were regarded as important were that diagnoses, causes and follow‐up of HE were not always clear to the participant; more psychosocial support was needed, and that participants experienced frequent changes in doctors. Information provided by nurses was valuable, but more individualized advice was needed.

Conclusions

To better meet the needs of patients, more explanation should be given about the causes of HE and the final diagnosis. Besides focusing on the treatment, it is also important to focus on its impact on the patient and options for psychosocial and peer support should be discussed. Furthermore, the beneficial role of the specialized nurse as part of integrated care was emphasized.

An update on the prevalence and risk exposures associated with hand eczema in Danish hospital employees: A cross-sectional questionnaire-based study

BACKGROUND

Hand eczema (HE) is common in health care workers (HCWs). During the last decade, new recommendations have supported increased use of alcohol-based hand rub (ABHR) to partially replace hand washings to lower the prevalence of HE. However, newer data on this recommendation is lacking.

OBJECTIVES

To assess current 1-year prevalence of HE in HCWs, to investigate exposure, and the extent of subjective discomfort to hand washings and ABHR.

METHODS

A digital questionnaire was sent to 4876 HCWs from April to May 2020.

RESULTS

Of 2125 respondents (1779 women, 346 men), 14.7% reported HE within the last year. In total, 9.1% reported >20 hand washings per shift and 76.0% reported ABHR use >20 times per shift. HE was significantly associated with hand washings (adjusted odds ratio [OR] 1.73 [95% confidence interval [CI] 1.26-2.36]) and glove use on wet skin (adjusted OR 1.99 [95% CI 1.27-3.12]). Subjective discomfort to ABHR was reported significantly more often than to hand washings (P < .001) and significantly more often in HCWs with HE than in those without HE (P < .001).

CONCLUSIONS

The current 1-year HE prevalence in HCWs of 14.7% was lower than in previously reported Scandinavian data. HE was related to frequent hand washings, as previously reported, and to glove use on wet skin, which is a possible risk factor for HE that should be further explored.

Shoe Dermatitis

Shoe dermatitis is a type of contact dermatitis precipitated by allergens or irritants found in shoes. Potassium dichromate, commonly used in leather processing, is one of the most prevalent agents responsible for shoe dermatitis; however, it is not the only one. Shoe dermatitis caused by an allergen or an irritant may affect a person of any age, sex, or ethnicity. Numerous treatments exist for shoe dermatitis, the most simple yet important being avoidance of causative agents. Pharmaceutical agents commonly used are emollients, humectants, and topical corticosteroids. In more severe cases, topical calcineurin inhibitors and phototherapy may be used.

Secondary and Tertiary Prevention: Medical Rehabilitation

Allergies are a major public health burden, and targeted measures are required in terms of prevention and treatment. The most common allergic conditions encompass atopic dermatitis (AD), food allergy (FA), allergic asthma (AA), and allergic rhino-conjunctivitis (AR). Primary prevention aims at preventing the onset of allergic disease, before the disease process begins. Secondary prevention aims at preventing progression and exacerbation of allergic disease whereas tertiary prevention aims at reducing disease burden in patients with established disease, by allergen immunotherapy (AIT) or medical rehabilitation. Rehabilitation programs are used for treatment of AA and AD and usually consist of extensive patient assessment, optimization of treatment management, patient education, and behavioral interventions, ideally involving a multidisciplinary treatment team and sometimes provided in a specific climate, usually alpine or maritime. Similarly, prevention of occupational skin diseases requires interdisciplinary approaches on the level of secondary and tertiary preventive intervention; if this is provided, then prevention programs have proven highly (cost-) effective. Unfortunately, the recently published Minimal Standards of Prevention of these dermatoses, underlining especially the importance of meticulous allergological diagnosis and subsequent multidisciplinary patient education, are so far being adhered to only in very few European countries.

Occupational Dermatitis and Urticaria

Occupational contact dermatitis is the most common occupational skin disease (OSD), and most of them are irritant in nature. There is less information available about contact urticaria than contact dermatitis. There are several strategies to prevent OSD, although workplace studies suggest there are gaps in their use in the workplace. Because early detection leads to improved outcomes, screening for dermatitis in industries such as health care would be useful. Both diagnosis and management involve 2 components: the actual disease diagnosis and medical treatment and the work-relatedness and management of the workplace to reduce exposures.

Hand Dermatitis in the Time of COVID-19: A Review of Occupational Irritant Contact Dermatitis

Occupational contact dermatitis accounts for 95% of all cases of occupational skin disease with irritant contact dermatitis (ICD) constituting 80% to 90% of these cases. Health care workers, hairdressers, and food service workers are typically most affected by occupational ICD of the hands as these occupations require frequent hand hygiene and/or prolonged exposure to water, also known as "wet work." In the context of the current COVID-19 pandemic, frequent hand hygiene has become a global recommendation for all individuals, and new workplace guidelines for hand sanitization and surface sterilization are affecting occupations not previously considered at risk of excessive wet work including grocery or retail workers, postal workers, sanitization workers, and others. In this review, we discuss the etiology and pathogenesis of occupational ICD with additional focus on treatment and interventions that can be made at an institutional and even national level for education and prevention of ICD resulting from frequent hand hygiene.

Structured diagnostic assessment of hand eczema in cleaning workers

Hand dermatitis is a widespread problem among cleaners. In most cases, it is caused by a combination of wet work and contact with irritants, which can result in irritant (toxic) contact dermatitis. In some cases, the irritant contact eczema then evolves into allergic contact dermatitis, although not all cases of allergic contact dermatitis are preceded by irritant contact dermatitis. This mini-review proposes a two-step diagnostic algorithm based on patch testing, which can be used if allergic contact dermatitis is suspected in cleaning workers. As a first step, we recommend performing the DKG standard series (German Contact allergy research group, DKG), the DKG rubber series, both DKG "further fragrances" series as well as the DKG preservative and disinfectant series. If there are clear hints of an occupational contact dermatitis, the first step can also involve testing patients' own products alongside the standardized tests. In a second step (at the latest), if standardized tests do not suffice to identify the culprit allergen and there is well-founded suspicion, we recommend testing the patients' own products. If necessary, the second step can also include testing the individual contact allergens contained in the screening mixes that are part of the standard series.

Occupational Skin Disease in Physicians: A Review of the Literature

OBJECTIVES

Occupational skin disease (OSD) arises from work-related activity. However, there is a paucity of literature on OSD in physicians. The aim of the this review was therefore to examine and summarize what types of symptomatic OSD physicians experience.

METHODS

We conducted a systematic literature search on Cochrane Library, Embase, and Pubmed.

RESULTS

Contact dermatitis from formaldehyde and glutaraldehyde were found in 11.5 and 13.5% of cases, respectively. In total 2.4-14.9% had latex allergy. The reported standardized incidence ratio of squamous cell carcinoma and melanoma was up to 2.15 [95% confidence interval (CI) 1.57-1.95] and 3.2 (95% CI 1.38-6.31). Transmission of human papilloma virus (HPV) particles during carbon dioxide laser wart ablation were found in 70% of samples collected from protective gloves and in 52% of samples from vapors.

CONCLUSIONS

The most frequently reported OSD in physicians is contact dermatitis from allergens in disinfectants and rubber gloves. There is also a risk of cutaneous reactions to latex. The incidence of skin cancer was higher in physicians than in the general population, and the reason for this remains unexplained and potentially biased. There are no reports of transmission of patient HPV to surgeons during wart ablation, possibly because of proper use of protective equipment.

New evidence on the minimal important change (MIC) for the Hand Eczema Severity Index (HECSI)

BACKGROUND

How changes in hand eczema (HE) severity correlate with the single scores on the Hand Eczema Severity Index (HECSI) is sparsely investigated and particularly needed in clinical trials.

OBJECTIVES

To find the minimal important change (MIC) for HECSI based on patient's and physician's assessments using different methods.

METHODS

In this prospective follow-up study, three different anchors were used: two anchor questions for patients and physician, respectively, and the Physician Global Assessment (PGA) with a photographic guide. MIC was estimated by mean change in patients with a one-step increase to anchor-questions, receiver-operating characteristic (ROC) plot, and smallest detectable change (SDC).

RESULTS

One hundred fifty-two patients with HE (63.8% female) were included at baseline (89% completed follow-up). The mean change, ROC cutoff, and SDC values were 7.1, 4.5, 21.4 (patient-rating), 8.2, 4.5, 8.3 (physician-rating), and 16.6, 6.5, 27.1 points (PGA), respectively. SDC stratified by baseline severity was 2.9 and 11 points for mild and moderate-severe HE (physician-rating), respectively.

CONCLUSION

Identification of the MIC for the HECSI is important in relation to evaluation of treatment, intervention, and sample-size calculations. An improvement of 8.3 points on the HECSI is recommended as the MIC. MIC values may differ according to baseline severity, and this variation should be clarified in future studies.

Hand eczema among healthcare workers in Guangzhou City: a cross-sectional study

Background

Healthcare workers are at high risk of developing hand eczema. This study aimed to investigate the association between occupational hygiene and self-reported hand eczema among nurses and doctors in Guangzhou.

Methods

A cross-sectional study using a self-administrated questionnaire sent to 740 health care workers in two tertiary hospitals between 1^st April and 1^st July 2019 was conducted.

Results

In total, 521 healthcare workers responded (70.4%). The prevalence of self-reported hand eczema was 9.6% [95% confidence interval (CI): 7.1-12.1%], with 10.8% in nurses and 6.9% in doctors. According to multivariable logistic regression analysis, the prevalence was higher in those who were excessively exposed to hair dye (OR: 3.871, 95% CI: 1.106-13.549) and those having a history of food allergy were at 3.013 (95% CI: 1.314-6.907) times greater risk of having hand eczema than those who did not. The odds of having hand eczema were 4.863 (95% CI: 1.037-22.803) times greater in those who hand washed more than 50 times daily in comparison to those who washed hands less than 10 times per day. The symptoms of hand eczema were mild during the investigation period.

Conclusions

Hand eczema is common among healthcare workers in Guangzhou. The prevention of hand eczema by educational programs is needed for Chinese healthcare workers.

Methods to improve quality of life, beyond medicines. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes

The pharmaceutical approach to skin disease has been hugely successful, but despite effective drugs being available and used, there are still vast numbers of people who continue to have some level of persisting skin disease and continue to experience quality of life (QoL) impairment. So the question that needs to be answered, while we await further advances in our drug-based armamentarium, is how can we improve patients' QoL, beyond drugs? A working group was formed from members of the EADV Task Force on QoL and Patient Oriented Outcomes. Participants were asked to suggest all the ways in which they considered patients' QoL may be improved beyond medicines. Four groups of management approaches that may improve QoL in dermatology were identified: interventions within the dermatology service (hospitalization, multidisciplinary teams, patch testing and establishing relevant allergens and education), external services (corrective make-up, climatotherapy and balneotherapy), psychological (psychological intervention, cognitive therapy, hypnosis), lifestyle (lifestyle behavioural changes, religion and spirituality and music). The ultimate aim of therapy is to eradicate a disease in an individual and return the person's life to normal. But until the day comes when this has been achieved for every skin disease and for every patient there will be a need to support and assist many patients in additional non-pharmaceutical ways. These 'adjuvant' approaches receive too little attention while dermatologists and researchers strive for better pharmacological therapy. The different ways in which patients may benefit have been reviewed in our paper, but the reality is that most have a very poor evidence base. The research challenges that we have to meet are to identify those approaches that might be of value and to provide evidence for their optimal use. In the meantime, clinicians should consider the use of these approaches where QoL remains impaired despite optimal use of standard therapy.

A behaviour change package to prevent hand dermatitis in nurses working in health care: the SCIN cluster RCT

BACKGROUND

Although strategies have been developed to minimise the risk of occupational hand dermatitis in nurses, their clinical effectiveness and cost-effectiveness remain unclear.

OBJECTIVES

The Skin Care Intervention in Nurses trial tested the hypothesis that a behaviour change package intervention, coupled with provision of hand moisturisers, could reduce the point prevalence of hand dermatitis when compared with standard care among nurses working in the NHS. The secondary aim was to assess the impact of the intervention on participants' beliefs and behaviour regarding hand care, and the cost-effectiveness of the intervention in comparison with normal care.

DESIGN

Cluster randomised controlled trial.

SETTING

Thirty-five NHS hospital trusts/health boards/universities.

PARTICIPANTS

First-year student nurses with a history of atopic tendency, and full-time intensive care unit nurses.

INTERVENTION

Sites were randomly allocated to be 'intervention plus' or 'intervention light'. Participants at 'intervention plus' sites received access to a bespoke online behaviour change package intervention, coupled with personal supplies of moisturising cream (student nurses) and optimal availability of moisturising cream (intensive care unit nurses). Nurses at 'intervention light' sites received usual care, including a dermatitis prevention leaflet.

MAIN OUTCOME MEASURE

The difference between intervention plus and intervention light sites in the change of point prevalence of visible hand dermatitis was measured from images taken at baseline and at follow-up.

RANDOMISATION

Fourteen sites were randomised to the intervention plus arm, and 21 sites were randomised to the intervention light arm.

BLINDING

The participants, trial statistician, methodologist and the dermatologists interpreting the hand photographs were blinded to intervention assignment.

NUMBERS ANALYSED

An intention-to-treat analysis was conducted on data from 845 student nurses and 1111 intensive care unit nurses.

RESULTS

The intention-to-treat analysis showed no evidence that the risk of developing dermatitis was greater in the intervention light group than in the intervention plus group (student nurses: odds ratio 1.25, 95% confidence interval 0.59 to 2.69; intensive care unit nurses: odds ratio 1.41, 95% confidence interval 0.81 to 2.44). Both groups had high levels of baseline beliefs about the benefits of using hand moisturisers before, during and after work. The frequency of use of hand moisturisers before, during and after shifts was significantly higher in the intensive care unit nurses in the intervention plus arm at follow-up than in the comparator group nurses. For student nurses, the intervention plus group mean costs were £2 lower than those for the comparator and 0.00002 more quality-adjusted life-years were gained. For intensive care unit nurses, costs were £4 higher and 0.0016 fewer quality-adjusted life-years were gained.

HARMS

No adverse events were reported.

LIMITATIONS

Only 44.5% of participants in the intervention plus arm accessed the behaviour change package.

CONCLUSION

The intervention did not result in a statistically significant decrease in the prevalence of hand dermatitis in the intervention plus group.

FUTURE WORK

Participants had a high level of baseline beliefs about the importance of using hand moisturisers before, during and after work. Future research should focus on how workplace culture can be changed in order for that knowledge to be actioned.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53303171.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 58. See the NIHR Journals Library website for further project information.

Quality of life measurement in occupational skin diseases. Position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Occupational Skin Disease

The European Academy of Dermatology and Venereology (EADV) has started the 'Healthy Skin @ Work' campaign aimed to raise awareness among the public and EU authorities on the frequency and impact of occupational skin diseases (OSDs). The EADV Task Forces (TFs) on Quality of Life and Patient Oriented Outcomes (QoL/PO) and on OSD present their mutual position statement on QoL assessment in OSDs. The EADV TFs recommend the use of the DLQI as a dermatology-specific instrument and SF-36 as a generic instrument in health-related (HR) QoL studies on OSDs. The OSD-specific questionnaire, LIOD, is not recommended for general use in its present form because of its three months recall period. The EADV TFs discourage the use of non-validated and of non-validated modifications of previously validated HRQoL instruments. The EADV TFs wish to encourage research into: the HRQoL impact of OSDs other than occupational contact dermatitis and hand eczema; comparisons between the effects of different treatments and other interventions on HRQoL in OSDs; and into the HRQoL impairment of patients with OSDs from different countries, and with different provoking factors, to predict if the results of successful therapeutic and educational interventions may be generalized across countries and between occupations.

A behaviour change package to prevent hand dermatitis in nurses working in the National Health Service: results of a cluster randomized controlled trial

BACKGROUND

Occupational hand dermatitis poses a serious risk for nurses.

OBJECTIVES

To evaluate the clinical and cost-effectiveness of a complex intervention in reducing the prevalence of hand dermatitis in nurses METHODS: This was a cluster randomized controlled trial conducted at 35 hospital trusts, health boards or universities in the UK. Participants were (i) first-year student nurses with a history of atopic conditions or (ii) intensive care unit (ICU) nurses. Participants at intervention sites received access to a behavioural change programme plus moisturizing creams. Participants at control sites received usual care. The primary outcome was the change of prevalent dermatitis at follow-up (adjusted for baseline dermatitis) in the intervention vs. the control group. Randomization was blinded to everyone bar the trials unit to ensure allocation concealment. The trial was registered on the ISRCTN registry: ISRCTN53303171.

RESULTS

Fourteen sites were allocated to the intervention arm and 21 to the control arm. In total 2040 (69·5%) nurses consented to participate and were included in the intention-to-treat analysis. The baseline questionnaire was completed by 1727 (84·7%) participants. Overall, 789 (91·6%) ICU nurses and 938 (84·0%) student nurses returned completed questionnaires. Of these, 994 (57·6%) had photographs taken at baseline and follow-up (12-15 months). When adjusted for baseline prevalence of dermatitis and follow-up interval, the odds ratios (95% confidence intervals) for hand dermatitis at follow-up in the intervention group relative to the controls were 0·72 (0·33-1·55) and 0·62 (0·35-1·10) for student and ICU nurses, respectively. No harms were reported.

CONCLUSIONS

There was insufficient evidence to conclude whether our intervention was effective in reducing hand dermatitis in our populations. Linked Comment: Brans. Br J Dermatol 2020; 183:411-412.

Does Adherence to World Health Organization Hand Hygiene Protocols in the Operating Room Have the Potential to Produce Irritant Contact Dermatitis in Anesthesia Providers?

Anesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.

[Prevention of hand eczema]

Apart from endogenous factors, hand eczema is often caused by irritant or allergic contact dermatitis related to occupational or non-occupational exposure to skin hazards. This enables several complementary approaches on the level of primary, secondary and tertiary prevention. A high priority is set on identification and subsequent reduction or elimination of causative exposures. Important preventive approaches include legal regulations, technical and organizational measures as well as correct use of adequate personal protective equipment (e.g. protective gloves). Interventions based on health education are conducted to improve individual protective behaviour. Even though evidence-based proof of effectiveness is limited, preventive measures are considered of particular importance for avoidance of occupational hand eczema and its adverse sequelae. Therefore, a complex, step-wise approach to occupational skin diseases has been established in Germany. In recent years, the positive impact of secondary and tertiary preventive measures of this approach has been demonstrated.

Positive change in hand care habits using therapeutic patient education in chronic hand eczema

BACKGROUND

Chronic hand eczema (CHE) is a major burden for patients. Maintenance treatment involves prevention measures limiting detrimental behaviour and aggravating factors.

OBJECTIVE

To evaluate the effect of a standardised care program including therapeutic patient education (TPE) on hand care behaviours, clinical severity, quality of life, and work productivity.

METHODS

A single-centre study was conducted prospectively. Together with the prescription of a topical steroid, patients participated in individual TPE sessions. Evaluations were performed initially and repeated three months after the therapeutic intervention. They included a structured analysis of hand care behaviours, the assessment of the mTLSS (modified Total Lesion Symptom Score), DLQI (Dermatology Life Quality Index), and WPAI (Work Productivity and Activity Impairment).

RESULTS

Seventy-one patients were included (30 men, 42.3%). Three months after completion of the standardised care program, hand care behaviours such as hand washing and rinsing, hand drying, wearing protective gloves, using moisturizing creams, and following specific treatments and recommendations for CHE improved significantly in the 58 patients who completed the study and were associated with a significant improvement in the mTLSS, DLQI, and WPAI scores.

CONCLUSIONS

TPE helps patients change their hand care behaviours and adopt skin protection measures, and may improve CHE severity, quality of life, and work productivity.

Assessment of Occupational Safety and Hygiene Perception among Afro-Caribbean Hair Salon Operators in Manchester, United Kingdom

Because of exposure to a number of potential health hazards within the work environment, hairstylists experience occupational diseases that include occupational asthma, skin conditions and musculoskeletal diseases. The paucity of studies assessing occupational safety and hygiene management among Afro-Caribbean hair salon operators in the UK promoted the study. Qualtrics^TM was used to assess the participants' perception of exposure to hair products and their personal safety and hygiene knowledge, attitudes, awareness, and risk perceptions at work. In five salons, indoor air quality was monitored over one working week for selected environmental pollutants: temperature, humidity, CO, CO₂ and Total Volatile Organic Compounds (TVOCs) using a GrayWolf Direct Sense Indoor Air Quality-IAQ (IQ-610). The use of unflued gas heating to raise the indoor temperature was common among the salons' operators which explains the high carbon monoxide readings recorded. Itchy eyes and nose (44.4%) shoulder, neck and back pain (39.2%) were frequently reported. Age-stratified analysis of reported occupational ailments showed participants within an age bracket of 31-35 reported allergies (24%) and itchy eyes and nose (19.1%) as the most common of occupational ailments. Respiratory, skin and musculoskeletal symptoms ranked as major occupational ill-health experiences among the study population. The study outcome demonstrated that the type of activity and the hair products used play an important role in the level of pollutants in the working environment. The substitution of the more harmful hair products with safer alternatives is needed, as is the encouragement of health surveillance.

Effectiveness of a skin care programme for the prevention of contact dermatitis in healthcare workers (the Healthy Hands Project): A single-centre, cluster randomized controlled trial

BACKGROUND

Healthcare workers (HCWs) are at risk of developing hand dermatitis (HD). Guidelines recommend moisturizers to prevent HD, but in practice their effectiveness has been poorly investigated.

OBJECTIVES

To assess whether an intervention aimed at improving skin care leads to a reduction in HD severity.

METHODS

In this 1-year randomized controlled trial, 9 wards (285 HCWs) were allocated to an intervention group (IG), and 10 wards (216 HCWs) were allocated to the control group (CG). The intervention included provision of cream dispensers with electronic monitoring of use, regularly communicated to the HCWs. The primary and secondary outcomes were change from baseline in Hand Eczema Severity Index (HECSI) score (ΔHECSI) and change in natural moisturizing factor (NMF) level (ΔNMF).

RESULTS

At 12 months, the rates of loss to follow-up were 41% and 39% in the IG and the CG, respectively. The HECSI score was reduced in the IG by -6.2 points (95%CI: -7.7 to -4.7) and in the CG by -4.2 points (95%CI: -6.0 to -2.4). There was no significant difference in ΔHECSI or ΔNMF between the groups. Relative improvement in the HECSI score was significantly higher in the IG than in the CG (56% vs 44%). In a subgroup of HCWs with mild HD, the IG showed a larger HECSI score decrease than the CG (P < 0.001).

CONCLUSION

Although there was no significant effect on the primary outcomes, the intervention showed overall positive effects on the HECSI score.

Skin Protection Seminars to Prevent Occupational Skin Diseases: Results of a Prospective Longitudinal Study in Apprentices of High-risk Professions

BACKGROUND

Occupational skin diseases (OSDs) are frequent in professions with exposure to skin hazards. Thus, a health educational intervention for apprentices of high-risk professions was conducted. It was the aim of this study to gain insight into possible effects of this intervention.

METHODS

A one-time skin protection seminar was conducted in 140 apprentices of health-related and non-health-related professions [trained cohort (TC)]. In addition, 134 apprentices of the same occupations were monitored [untrained cohort (UTC)]. The OSD-specific knowledge and the skin condition of the hands were assessed at baseline (T0), after the seminar (T1), and after 6 (T2) and 12 months (T3).

RESULTS

The OSD-specific knowledge increased in all cohorts from T0 to T3, but we found a significantly higher knowledge in the TC at T2 (p < 0.001, t = 3.6, df = 196, 95% confidence interval = 0.9, 3.3) and T3 (p < 0.001, t = 3.8, df = 196, 95% confidence interval = 1.0, 3.2) compared to the UTC. Our results indicated a better skin condition of the hands in the TC of the health-related professions but not in the non-health-related professions.

CONCLUSION

The study indicates that an educational intervention may positively influence the disease-specific knowledge and the prevalence of OSD in apprentices. However, definite conclusions cannot be drawn because of the heterogeneous study cohorts and the study design. Future research should aim at tailoring primary prevention to specific target groups, e.g., in view of the duration and frequency of skin protection education, different professions, and gender-specific prevention approaches.

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.

Hand eczema in nurses, nursing auxiliaries and cleaners-A cross-sectional study from a tertiary hospital in western India

BACKGROUND

Healthcare workers have a high risk of developing hand eczema.

OBJECTIVES

To determine the prevalence and severity of dermatologist-determined hand eczema among healthcare workers, carry out patch testing, and correlate the findings with impairment in quality of life (QoL) and demographic and vocational factors.

METHODS

Seven hundred and ten healthcare workers (279 nurses, 246 cleaners, and 185 nursing auxiliaries) were screened for the presence of hand eczema. Severity of eczema was calculated with the Hand Eczema Severity Index (HECSI), and QoL was measured with the Dermatology Life Quality Index (DLQI). Individuals with hand eczema were also patch tested.

RESULTS

The point and 1-year prevalences of hand eczema were 7.2% and 18.9%, respectively. Hand eczema was significantly associated with atopic dermatitis. The mean HECSI score was 9.39; it was significantly higher in patients with atopic dermatitis and those with recurrent hand eczema. The mean DLQI score was 5.37. Cleaning staff had significantly greater impairment in QoL. HECSI and DLQI scores were positively correlated. Patch testing showed that thiuram mix, antibiotics and cleansers as sensitizers were over-represented in healthcare workers as compared with controls.

CONCLUSIONS

Hand eczema was particularly common in hospital cleaners and staff with atopic dermatitis. Further studies are needed to address the burden of occupational hand eczema and develop guidelines for its management at a national level.

Analysis of Dental Professionals' and Dental Students' Care for their Skin

Objectives

To determine prevalence of undesirable, work-related skin lesions and their localizations in dental professionals and students, and to collect data about diagnostic procedures they undergo and skin care they take when these lesions occur.

Subjects and methods

Our research included 444 respondents (dentists, dental assistants, dental technicians, dental students) who filled out a questionnaire. They were asked to specify if they had observed any lesions on their skin and where; if they had undergone any treatments and in what way; if they had undergone any allergy tests; and if they had taken any protective measures.

Results

Of all the respondents that took part in the survey, 249 (56.1%) reported undesirable skin reactions commonly on their hands and fingers (96%). Before our survey, only 15% of them had seen a dermatologist, while 33% had undergone allergy tests (without a dermatologists’ clinical examination). Also, 45% of them sometimes used soaps for sensitive skin and the majority (61%) of them used protective hand creams 1-2 times per day.

Conclusion

Although a large number of dental professionals and students have noticed work-related skin lesions, only some of them sought dermatologists’ professional help and most of them did not take care of their skin adequately when those lesions occurred. According to the results of this study, it is necessary to take additional preventive measures to increase dental professionals’ and students’ awareness of occupational dermatoses and adequate skin care.