Protecting healthcare heroes

Protecting healthcare heroes

Healthcare workers (HCWs) have an increased risk of developing occupational contact dermatitis (OCD) due to frequent hand washing with soaps and disinfectants, as well as the use of personal protective equipment (PPE), such as gloves, masks, goggles, and other protective equipment. OCD is described as a skin inflammation caused by exposure to external irritants or allergens. It can present as allergic contact dermatitis (ACD) or irritant contact dermatitis (ICD). OCD has a significantly impact on quality of life, and work productivity.1,2,3

ACD involves an adaptive immune response to chemicals penetrating the skin, triggering a non-specific immune response, while ICD is a non-specific skin reaction to irritants and is more common (44%) in the healthcare setting.1,2

Skin reactions in the healthcare setting

ICD results from repeated exposure to hand hygiene products, leading to symptoms like dryness, irritation, itching, and even cracking and bleeding. The pathophysiology involves damage to the skin’s protective barrier, particularly lipid depletion, which increases susceptibility to irritation. While alcohol-based hand rubs are generally well-tolerated, they can still cause dryness and irritation, albeit to a lesser extent than detergents.4

In ACD, fragrances, preservatives, and emulsifiers are common culprits, and symptoms can range from mild localised reactions to severe generalised ones, including anaphylaxis in extreme cases. While allergic reactions to alcohol-based hand rubs are rare, they can occur, usually due to compounds present as inactive ingredients rather than the alcohol itself.4

How do HCWs view hand hygiene?

Observational studies reveal wide variations in hand hygiene frequency, ranging from five to 42 times per shift and 1.7 to 15.2 times per hour. Opportunities for hand hygiene also vary by hospital ward, with nurses in paediatric wards having fewer opportunities compared to those in intensive care units (ICUs).4

In some acute settings, as many as 82 hand hygiene opportunities per patient per hour have been observed. However, despite high opportunities, adherence to hand hygiene practices remain variable.4

Observed adherence rates to recommended hand hygiene procedures range from 5% to 89%, with an average of 38.7%. Improvements in adherence have been reported following interventions, but sustained improvements are rare.4

Factors influencing adherence include professional category, hospital ward, time of day/week, and type and intensity of patient care. Nurses generally exhibit higher adherence compared to doctors or nursing assistants, with adherence being lowest during weekends and in ICUs where hand hygiene opportunities are more frequent.4

Perceived barriers to adherence include skin irritation, inaccessible hand hygiene supplies, interference with HCW-patient relationships, patient needs perceived as a priority over hand hygiene, glove usage, forgetfulness, lack of knowledge of guidelines, high workload, and understaffing. Some HCWs believe they only have to wash their hands, when necessary, despite evidence suggesting otherwise. 4

Preventing irritant contact dermatitis in the healthcare setting

A study showed that frequent use of hand hygiene products (100%) was the number one cause of ICD in HCWs followed by infrequent hand moisturising (>50%).5

The study also showed that all participants had an improvement rate of 70%-90% from their baseline signs and symptoms, with a mean improvement of 80% following procurement of a gentler hand hygiene product (consisting of 70% ethanol, emollients, and moisturiser) by the healthcare facility, regular use of a topical steroid cream or moisturiser, and adjustment to their clinical duties, which resulted in a temporary reduction in hand hygiene activities.5

Selecting effective, yet gentle hand hygiene products

Alcohol-based rubs with humectants tend to be better tolerated than plain or antimicrobial soaps. Furthermore, certain practices, such as washing hands with soap and water immediately before or after using alcohol-based rubs, should be avoided to prevent skin irritation.4

Selecting hand hygiene products involves assessing multiple factors to ensure efficacy, acceptability, and costeffectiveness. Pilot testing, considering local factors and HCWs’ preferences, is essential, with a focus on product efficacy, dermal tolerance, aesthetic preferences, practical considerations, and cost.4

When selecting hand hygiene products, several factors need consideration to ensure their efficacy, acceptability, and cost-effectiveness. Pilot testing is recommended to assess the acceptability of products among healthcare workers (HCWs), involving them in the selection process to increase hand hygiene adherence.4

Characteristics such as fragrance, consistency, and colour can influence HCWs’ adherence, and structured questionnaires should be used to evaluate their preferences. Pilot testing should be conducted considering local factors like climate and sociocultural backgrounds, and products should be compared with those already in use.4

Factors influencing product selection include relative efficacy, dermal tolerance, cost, aesthetic preferences, and practical considerations. Efficacy of antiseptic agents, dermal tolerance, and skin reactions should be evaluated using standardised methods, with products tested by several users over a period of weeks. Products should be at least as good as existing ones to prevent a decrease in hand hygiene adherence.4

Aesthetic preferences, such as fragrance and consistency, are important considerations. Fragrance should be mild or absent to avoid discomfort or allergic reactions among HCWs and patients. Consistency, whether gel, solution, or foam, affects user experience, but it does not significantly impact efficacy or tolerance.4

Practical considerations include product accessibility and risk of contamination. Accessibility of hand hygiene facilities influences frequency of use, and a reliable supplier is essential for continuous product availability. Products should have a low risk of contamination, especially for soap, to maintain hygiene standards.4

Cost is another crucial factor, although the level of HCWs’ acceptance is prioritised over price. While hand hygiene promotion is cost-effective, inexpensive products with undesirable characteristics may discourage adherence.4

Using moisturising skin care products regularly

Basic therapy for the prevention of ICD involves basic therapy with skin care products aimed at restoring the skin barrier, reducing inflammation and itching, and sparing the use of glucocorticoids.6

Experimental studies have shown that basic skin care therapy can promote healing of both ICD and ACD without requiring additional specific treatments. The choice of skin care product should be tailored to the stage of the condition, with hydrophilic preparations like gels, lotions, or creams suitable for acute dermatitis, while water-in-oil-based preparations like ointments are more appropriate for chronic stages.6

It is crucial to select skin care products with appropriate water and lipid content and without allergenic ingredients to avoid delaying healing.6

References are available on request.