Hand dermatitis (HD) is a bodily reaction that occurs when the skin becomes inflamed, characterised by red swelling and tiny blisters that form a crust. The clinical aspect varies in accordance with the clinical phases: acute, sub-acute or chronic. Redness, swelling, weeping and blistering are characteristic of the acute phase, when early detection and proper treatment are crucial to prevent it becoming severe or prolonged. Occupational hand eczema is common in “wet work” occupations, especially in the nursing profession, and even more frequent in workplaces where workers have to wash their hands continually. The literature suggests that the prevalence of HD in nurses varies around the world, as is evident from the summary table (below, with references) showing figures for the decade 2005-2015.

The main preventative recommendations are: adequate hand hygiene and glove wearing, regular application of emollients, use of alcohol rubs where appropriate, educational programmes concern the control of skin infections and appropriate hand washing as a routine part of hand care. Regular monitoring in the occupational medical service is essential for primary, secondary and tertiary prevention.

Keywords: dermatitis, wet work, emollients, inflammation of the skin, eczema

ADI, alcoholic disinfection; CG, control group; HCW, health care worker; HD, hand dermatitis; HE, hand eczema; ICU, intensive care unit; IG, intervention group; OE, occupational exposure; OSD, occupational skin disease; TEWL, trans epithelial water loss; Y, year

Occupational skin disease is any disorder of the skin that is caused or made worse by workplace activity.¹ This term includes occupational hand dermatitis, a condition that occurs frequently in nurses. In current terminology, the term “dermatitis” is used synonymously with “eczema” and describes inflammatory reactions in the skin with a spectrum of clinical and histopathological characteristics.² As its suffix suggests, dermatitis refers to “inflammation of the skin”, a reaction that occurs when the skin becomes inflamed and it takes on a red, swollen appearance with tiny blisters that form a crust.

The clinical aspect varies depending on the clinical phases. These are: acute, sub-acute and chronic. Redness, swelling, weeping and blistering are characteristic signs of the acute phase. During the sub-acute phase, redness, dry flaky skin, cracks and crusty exudates are evident. Chronic hand dermatitis is characterized by flaking, scaling, cracking and hand thickening. In line with the clinical evolution, the earlier the condition is detected the better, so as not to allow the progression through the pathological clinical phases.

Occupational hand eczema (OHE) is common in “wet work” occupations,^3-5 the hands being the part of the body mainly affected in the majority of cases, especially in the nursing profession, and even more frequently in workplaces where employees are obliged to wash their hands continually in order to prevent infections. This occurs in workplaces such as intensive care units (ICUs),⁴ emergency care, isolation wards, transplant wards, oncology, etc.,.

The main objective of this study is to describe and compare the prevalence of HD as reported by articles published during the decade 2005-2015. The paper also sets out to emphasise the importance of prevention and hand care measurements.

The literature from 2005 to 2015 was reviewed. The main search was carried out during a research training period at the Occupational Health Department of the Education Centre, Guy’s and St Thomas’ NHS Trust and King’s College London, UK, June 2015. The literature search was carried out using PubMed and the terms were: dermatitis, dermatoses, eczema, hand and nurses.

The search formula used on PubMed was:  (hand dermatoses [MeSH Terms] and nurses [MeSH Terms]

“dermatitis” and “eczema” and “hand” and “nurses”.  The inclusion criteria were that the abstract had to be in English and published during the period of study (2005-2015). Articles that analysed care professions other than nurses were excluded.

Table 1 shows the prevalence of HD in the literature published in the period 2005-2015. The table includes the year of the publication, the main author, the title of the paper and the journal in which it was published, the study type, the country where the study was conducted, the sample size, how dermatitis was measured (self-assessment, photography, clinical diagnosis), and other comments. A total of 21 references to HD in nurses were found and included in the table. The highest rate of HD prevalence was 82%. Figure 1 is a photograph of HD in the acute phase; the subject is a nurse whose case came to light during a health monitoring inspection conducted by a hospital’s occupational health service.

Figure 1 Redness and swelling in acute phase hand dermatitis.

The main objective of this study is to describe and compare the prevalence of HD as reported by academic articles during the decade 2005-2015. Table 1 set out the results of a 10-year review of HD prevalence in nurses.

According to the literature, the prevalence of HD in nurses varies considerably around the world, with reports of 17.7% in mainland China,⁶ 20% in the United Kingdom,¹ 22.1% in Hong Kong,⁷ 30% in Denmark,⁸ 31% in the Netherlands,⁹ 31% in South Korea,¹⁰ 40% in Germany,³ 46% in Poland,¹¹ 50% in Australia,¹² 53.3% in Japan ¹³ and 55% in the United States.¹⁴ It also varies according to the way HD is detected (self-reported, appearance of symptoms or clinical observation, or formal diagnosis by a clinician). For example, Campion reports figures of 20% (diseased skin), 40% (eczema) and 60% (redness); Lee et al. ¹⁰ report a frequency of 75.6% for symptom-based OHE and 31.0% for self-reported OHE.¹⁰ The workplace is another factor to consider: the wetter hands tend to become, the greater the prevalence. Thus Dulon et al.¹⁵ report 18% of geriatric nurses suffering from OHE, whereas Lampel¹⁴ mentions an HD prevalence of 65% among ICU nurses.¹⁴

In addition there are endogenous conditions, atopic and vesicular HD being cases in point. Nurses with pre-existing atopic dermatitis are 5.3 times more likely to suffer from HD compared to nurses without this condition.⁶

For the latter group, the early detection and reporting of OHE in the initial stages of the disease is of the utmost importance for the effectiveness of secondary prevention, as Wilke et al.³ point out in their follow-up study.³ In these cases it is essential that the professionals turn to the occupational health service, so that the service can arrange a reasonable adjustment or redeployment and specific programmes in the case of severe OHE.³ The occupational health service may recommend temporary restriction from clinical work with immuno-compromised patients after a risk assessment. Visits to the occupational health service are also important in order to manage the cause of irritation or allergy as a means of controlling the exposure. The service will also make an assessment of the most suitable protective clothing, inspecting the affected skin at regular intervals as a matter of ongoing health monitoring. Furthermore, in some countries there may be a legal obligation to detect and notify HD in nurses as a “professional disease” and other issues of tertiary prevention.

Another factor to take into account in the prevalence of HD is the age and training level of nurses. Thus HD rates vary in accordance with the nursing students’ progress in their studies.¹⁶ In their prospective cohort study of 721 apprentice nurses, Visser et al.⁹ show a progressively increasing prevalence of HE among their subjects: 23% in the first year, 25% in the second year and 31% in the third year of the follow-up study. They mention frequent hand washing during the traineeships, frequent hand washing at home and having a subsidiary job involving wet work as independent risk factors for this condition. The authors recommend paying more attention to skin protection in vocational education. Proper preventative programmes and suitable education are also suggested.¹⁰

Most of the tools used to monitor the incidence of HD and skin health are based on questionnaires or clinical observations. There have also been attempts to use biomarkers such as transepidermal water loss.¹⁷ The observations of the nurses themselves remain important however. At least one article suggests that nurses perceive disinfection with alcohol as more damaging than hygienic hand washing.¹⁸

Among the risk factors reported for HD are youth, having a history of atopic dermatitis, frequent hand washing (>20 times/day) and the prolonged wearing of gloves (>5 minutes).¹⁰ On the other hand, appropriate use of moisturiser is a protective factor, with the pathology being reported less frequently among regular users (>3-4 times/day).¹⁰ Age and appropriate training are thus variables to consider when designing a preventative programme. Kromark et al.¹⁹ report that older nurses participate in advisory sessions on skin protection more and apply cream to their hands more frequently.¹⁹

A complementary objective of this review is to note the prevention and hand care measures that have been put forward by the authors concerned.  Some practical recommendations in this regard include proper and reasonable use of gloves, adequate hand hygiene and washing techniques, avoiding having wet hands (whether frequently or for long periods), avoiding coming into direct contact with chemicals that cause dermatitis, regular application of emollients, the use of alcohol rubs when appropriate, an educational programme providing advice about controlling skin infections, proper hand washing including the careful rinsing of all detergents and following a regular hand care routine . One suggested routine for using moisturising creams is to apply moisturisers (a fingernail-sized amount) from a dispenser every 2-3 hours, after hand washing with warm water, during breaks and before going to sleep. It is also important to use gloves made from suitable materials when the nurse is allergic to certain substances (latex for instance). Most of the risk factors related to HD²⁰ are preventable, and it is necessary to emphasise the importance of primary and secondary prevention.²¹ Primary prevention is especially important in the case of student nurses. In this respect, health promotion programmes geared towards preventing HD are advisable at any health centre during nursing training courses. The prevention approach needs to be multifaceted, taking into account psychosocial factors likely to achieve behavioural change. The Hands4U control trial among health workers is an example of how such multifaceted approaches can be used to enhance the implementation of recommendations for the prevention of hand eczema.^22,23 In this context, the SCIN trial study²⁴ provides a promising protocol for securing the behavioural change needed to prevent hand dermatitis in nurses.

A limitation of the present study is its failure to specify the prevalence at a particular point or over a particular period. Other concerns how the dermatitis was diagnosed. In articles where HD was diagnosed by a clinician, some authors argue that medical records underestimate the true prevalence, since many workers with hand dermatitis do not consult a doctor for their symptoms.²⁵ Most of the studies measured HD using a questionnaire. Some, such as the “Contact disease severity index”²⁶ have been validated and standardised.^27,28 One of them, the “Nordic Occupational Skin Questionnaire”,²⁸ has been translated into other languages, including Spanish.²⁹

In conclusion, it is evident that HD prevalence differs in accordance with such variables as the way it is measured, the age of the subjects, and the characteristics of the workplace. The high prevalence reported by some studies calls for more attention to be paid to this condition and for educational programmes that employ a multifaceted strategy; they also highlight the central role of occupational health services in the early detection of HD and the implementation of preventative measures, including education in a routine aimed at improving hand care in wet work occupations such as nursing.

None.

The author declared that there are no conflicts of interest.

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