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Dermatology & Cosmetology

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Abstract

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

Abbrevations

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

Introduction

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.

Method

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.

Results

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.

Discussion

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.

Year

Main Author

Title and Journal

Study Type

Country/ Sample Size

How Dermatitis is Measured

Prevalence %

Other Comments

2015

Campion KM1

A survey of occupational skin disease in UK health care workers
Occupational medicine

Questionnaire-
based survey

HCWs from United Kingdom, including 232 nurses

A brief skin questionnaire modified from NOSQ) self-completion

In nurses, skin disease: 20%
Eczema: 40%
Redness: 60%

Nurses who attended vaccine clinics during October-November
2013

 

2014

 

Visser et al.9

Wet work and hand eczema in apprentice nurses; part I of a prospective cohort study.
Contact Dermatitis

A prospective cohort study

The Netherlands
721 apprentice nurses

Designed diary cards recording wet work exposure and HE symptoms

1st Y: 23%
2nd Y: 25%
3rd Y: 31%

Underlined the importance of skin protection in vocational
education

2013

Lee et al.10

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

Self-administered questionnaire

Korea (General Hospital)
Nursing staff
500/700 nurses completed the study

Questionnaire
(75% response rate)

Symptom-based HE: 75.6%

Self-reported HE: 31.0%

HE was less prevalent among frequent users of hand moisturisers (> 3-4/day)

2012

Wilke et al.3

Long-term effectiveness of secondary prevention in geriatric nurses with occupational hand eczema: the challenge of a controlled study design
Contact Dermatitis

 

Controlled study design

Germany
102 geriatric nurses with occupational HE

Standardised questionnaire and compared baseline (To), three month follow-up (T1) and six years after intervention (T2)

Morphological signs (vesicles)
CG: 40%
IG: 12.8%

Cite: “The high prevalence of occupational dermatitis”
Interdisciplinary prevention programme (IG).CG medically treated by dermatology

 

2012

 

Wilke et al.3

Sustainability of interdisciplinary secondary prevention in patients with occupational hand eczema: a 5-year follow-up survey.

Contact Dermatitis

Cohort study in a interdisciplinary secondary prevention programme

Germany
Wet work occupations
134 patients

 

Self-reported
T0 Baseline
T1 9 months
T2 5 years

Prevalence and severity of self-reported OHE were significantly reduced compared to T0

An outpatient skin protection seminar comprising dermatological and educational interventions
No measurable change in the use of skin care products

 

2011

 

Nai-Ming T & Luk et al.7

Hand eczema among Hong Kong nurses: a self-report questionnaire survey conducted in a regional hospital

Contact Dermatitis

 

Self-reported questionnaire survey

 

Hong Kong regional Hospital
1,240 nurses

Self-reported questionnaire, returned anonymously within two weeks
(59% response rate)

 

HE among respondents was 22.1%

More than 90% had moderate-severe HE
Psychosocial impact also determined
“Preventive measures should be emphasised”

 

2011

 

Cheng-CheLan et al.20

Hand dermatitis among university hospital nursing staff with or without atopic eczema: assessment of risk factors.

Contact Dermatitis

 

Observational study

Kaoghsiun Medical University Hospital
1,132 Nurses

Associations between different risk factors and HD were documented

248/1,132 with HD (21.90%)

Only 17% had atopic eczema
Try also to identify behavioural risk factors

 

2011

 

Kurpiewska et al.5

A survey of work-related skin diseases in different occupations in Poland.

Int Journ of Occup Safe and Ergonom

 

Cross-sectional study

 

Poland (different work populations)
581 healthcare workers

 

Self-reported skin symptoms on hand and forearm

 

51% of nurses reported skin disorders

 

67% of midwives and 41 % of physicians reported skin
disorders

2008

Dulon et al.15

Prevalence of skin and back diseases in geriatric care nurses
Int Arch Occup Environ Health

Cross-sectional study

Germany
1,309 nurses and nurses’ aides

Underwent clinical examinations of their hands, and answered a questionnaire

The prevalence of HE was 18.0%

Dry body skin as a risk factor. Workplace health promotion needed

 

2008

 

Kromark et al.19

Health indicators and preventive behaviour of older employees in geriatric care.

Gesundheitswesen

 

Cross-sectional study

Germany
2,149 nurses working in home care

Questioned in written form and dermatological investigation

HE was not more prevalent in older nurses

The older nurses participated more in advisory sessions on skin protection and applied cream to hands more frequently

 

2009

 

Skudlik et al.27

 

Hand eczema in geriatric nurses in Germany--prevalence and risk factors
Contact Dermatitis

 

Cross-sectional study

Germany
1,375 Geriatric Nurses from 86 nursing homes

 

Investigated by 41 occupational physicians

HE in 243 nurses
18 % prevalence

2/3 HE developed after starting their profession; Most chronic (85%)
Tendency for dry skin

 

2009

 

Stutz et al.18

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. British Journal of Dermatology

 

A pilot study (PS), followed by a modified multicentre study (MC)

 

Germany
five hospitals

 

Self-administered questionnaire survey

HD in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions

 

Concordance between the symptom-based diagnosis and the self-diagnosis was limited
Nurses perceive ADI as more damaging

 

2007

 

Flyvholm et al.8

Self-reported hand eczema in a hospital population.

Contact Dermatitis

 

Questionnaire study

Denmark1909 Hospital (middle size) employees

Frequency of self-reported HE in the previous 12 months

23% overall HE frequency. 30% in nurses

7-50% HE in surgical wards
HE more frequent in women and in younger age groups

 

2007

 

Lampel et al.14

Prevalence of hand dermatitis in inpatient nurses at a United States hospital.

Dermatitis

Cross-sectional study

United States
inpatient nurses at hospital

Visited twice by a single physician, questioned and diagnosed

 

55%
had HD

65% of ICU nurses had HD
With self-reported atopic dermatitis, the prevalence was 71%

 

2005

 

Smith et al.13

Hand dermatitis among Korean nursing students

IntJourn of Nursing Practice

 

 

Cross-sectional study

270 Korean nursing students from Seoul University.

Validated questionnaire survey (202 from 270 received)

1st Y 6.9% HD
4th Y 22.9% HD

Might be less prevalent compared to their international counterparts

2006

Smith et al.16

Hand dermatitis risk factors among clinical nurses in Japan
Clin Nurse Research

Cross-sectional study

Japan
1,162 clinical nurses

Questionnaire
(Response rate 74%)

The overall HD rate was 53.3%

The use of hand cream was associated with a 50% reduction in HD risk

2005

Szepietowski & Salomon11

Hand dermatitis: a problem commonly affecting nurses
RoczAkad Med Bialymst.

Cross-sectional study

Poland
Hospital nurses

Incidence of self-reported and self-examination HD

About 70% of respondents declared the presence of symptoms of HD within the last 12 months;46% had skin lesions at the moment of self-examination

Almost 75% of employees with hand dermatitis had observed the worsening of skin problem.
48% of hospital employees with hand eczema reported psychological distress caused by their skin lesions

2005

Jungbauer et al.22

Characteristics of wet work in nurses.
Int Arch of Occup and Environm Health

Continuous observation

Germany
45 randomly chosen nurses from different wards during a morning shift

Labour observation techniques

No prevalence results.
Wet work in ICU accounted for 24% of morning shift duration

They suggest increasing the use of gloves for patient washing in order to reduce the frequency of exposure to water and soap

 

2005

Schürer et al.21

Secondary individual prevention of hand dermatitis in geriatric nurses
Int Arch of Occup and Environm Health

Prospective controlled study
(3 months)

Germany
209 geriatric nurses

102 (IG) secondary individual prevention
107 (CG) consulting a dermatologist on demand
Questionnaire
Severity of OSD was classified upon each visit

Upon entry 89% (IG) 90% (CG)
Upon study completion
59% (IG) was free of OSD
After 3 months questionnaires revealed skin lesions in 53% (IG) and 82% (CG)

 

Incidence of OSD in geriatric nurses is increasing in Germany

Secondary individual prevention in geriatric nurses is effective in the secondary prevention of OSD.

 

2005

 

Schmid et al.17

Transepidermal water loss and incidence of hand dermatitis prospectively followed cohort of apprentice nurses. Contact Dermatitis

 

Prospective followed cohort
(12 months)

Germany
104 apprentice nurses

Before
1st Y OE
2nd Y OE
Standardised questionnaire and clinical examination with skin bioengineering to measure TEWL in dorsum of hand

The 12- month period prevalence of self-reported symptoms HD was 36.5%

Apprentices with self-reported symptoms at the final examination showed a significant increase of TEWL
Results do not support the notion that an increase basal TEWL is a good indicator for HD risk

2005

Smith et al.12

Prevalence of hand dermatitis among hospital nurses working in a tropical environment. The Australian Journal of Advanced Nursing

Cohort study
(12 months)

Australia
148 female nurses from a large tertiary hospital in Queensland

Validated self-reporting HD questionnaire

12-month prevalence ranged from 43.2% to 59.0% with an overall group mean of 50.0%

No statistically significant differences between the different hospital wards.
12-month prevalence of HD was higher than previous reports from other countries

Table 1 Hand dermatitis prevalence in literature published 2005-2015.

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

Conclusion

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.

Acknowledgements

None.

Conflict of interest

The author declared that there are no conflicts of interest.

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