Heather Morris – occupational health nurse – talks us through the problems caused by frequent hand hygiene procedures
Pressures placed on healthcare staff have never been greater and essential stringent infection prevention measures are in place. These include more frequent hand hygiene procedures, as well as the use of personal protective equipment (PPE) such as surgical masks, visors and gloves.
Whilst these precautions are critical in managing the current COVID-19 pandemic, they are also leading to reported dermatological problems for healthcare workers. In particular an increased frequency of irritant contact dermatitis of the hands and on the face due to the wearing of masks and visors.
It is recognised that frequent hand hygiene procedures may lead to skin problems, particularly in health care workers. [WHO, 2009] Studies show that irritant contact dermatitis is extremely common among nurses, with estimates ranging in prevalence surveys from 25% to 55%. According to the World Health Organisation (WHO) up to 85% of nurses report having had work related skin problems. [WHO, 2009]
There are two major types of skin reactions associated with hand hygiene. Irritant contact dermatitis, which includes symptoms such as dryness, irritation, itching, and even cracking and bleeding. The other type is allergic contact dermatitis, which is rarer and usually due to an allergy to one or more ingredients in a hand hygiene product. [WHO, 2009]
The majority of skin problems among healthcare workers relating to hand hygiene are due to irritant contact dermatitis. This is primarily caused by frequent and repeated use of hand hygiene products – especially soaps, detergents and sanitisers which result in skin drying. [WHO, 2009]
Healthcare workers perform hand hygiene much more frequently than workers in other fields. As a result, they have a higher exposure to potential skin irritants. A study of 4000 hospital staff showed that each person used a hand sanitiser nine times in an hour and washed their hands twice an hour. This meant that in an eight hour shift, hands were cleansed on average 88 times. Nursing staff practised hand hygiene even more frequently than other workers. [Albright, 2018] Given that this study was undertaken before COVID-19 precautions, it is likely that the number of hand hygiene procedures has increased.
Intact skin is a first line defence mechanism against infection, but repeated exposure to water and other irritants causes cumulative disruption of the skin barrier. The frequent use of hand hygiene products has been shown to disrupt the skin-barrier function by removing intercellular lipids and decreasing the skin’s outer layer – the stratum corneum’s water-binding capacity. Damage to the skin also changes skin flora, resulting in more frequent colonisation by staphylococci and Gram-negative bacilli. This can lead to infection and an increased risk of transmission to others.
Skin dermatitis is not just attributable to frequent hand cleansing but also to the use of personal protective equipment like gloves and tight fitting masks. Using gloves for extended periods of time leads to sweating that exacerbates or causes irritant contact dermatitis and putting on and removing gloves can lead to the shearing of the skin. [Badri, 2017]
Contact dermatitis due to the wearing of some surgical masks during the severe acute respiratory syndrome (SARS) pandemic has been documented in a number of studies. There are also many case studies and anecdotal reports of irritant contact dermatitis associated with the wearing of face masks. There have even been reports of dermatitis caused by the elastic on face masks leading to skin irritation. [Badri, 2017]
For health workers at risk of irritant contact dermatitis or other adverse reactions to hand hygiene products, additional skin moisturising is needed. Hand lotions and creams contain fats and oils that increase skin hydration. Some repair creams enhance hydration by the action of humectants which help restore the skin’s natural barrier.
Several controlled trials have shown that regular use of such products can help prevent and treat irritant contact dermatitis caused by hand hygiene products. In a survey of nurses in Japan, there was a 53% reported prevalence of hand dermatitis. The subsequent use of an appropriate cream was associated with a 50% reduction in dermatitis. [WHO, 2009]
In a study looking at the impact on the skin of frequent wearing of surgical gloves, there was a statistically significant improvement in skin hydration when an appropriate cream was used. [WHO, 2009]
All health staff should be encouraged to check the skin on their hands and faces (if regularly wearing a face mask or visor) to check for any signs of irritation such as redness, warmth or itching. Using a repair cream at an early stage may help prevent more severe dermatitis. For example, there is data to show that octenicare® repair creme is suitable for calming many common skin conditions, such as dermatitis, and helps to improve the skin’s hydration and elasticity. [Callaghan R, 2019]
Protection of health care workers’ hands is crucial for both their own protection and the protection of patients. Any damaged skin on the hands needs to be seriously addressed and places both staff and patients at risk because it prevents effective hand hygiene. (Royal College of Nursing, 2018) Using a barrier emollient product and a repair cream if dermatitis is suspected will help address this issue.
Factors that may contribute to hand dermatitis in health workers
Steps to minimise occupational hand dermatitis
These include:
References
Al Badri FM, Surgical mask contact dermatitis and epidemiology of contact dermatitis in healthcare workers; Current Allergy & Clinical Immunology 2017, Vol 30, No 3
Albright J, Use patterns and frequency of hand hygiene in healthcare facilities: Analysis of electronic surveillance data, American Journal of Infection Control 2018, 46, 1104-9
Callaghan R., Case study series: managing skin integrity — octenicare® repair crème, Wounds UK, Vol15, No1, 2019
Campion KM, A survey of occupational skin disease in UK health care workers; Occupational Medicine 2015; 65:29-31
RCN, 2018, Tools of the Trade Guidance for health care staff on glove use and the prevention of contact dermatitis
World Health Organisation, WHO guidelines on hand hygiene in health care, 2009
