Technology & Services

Occupational Irritant Contact Dermatitis in Healthcare Workers

Meeting the Challenge of revention
a report by
Dinah Gould
Professor of Nursing, Faculty of Health, South Bank University,
on behalf of SSL International plc
Introduction !hich the skin is e"amine# $y me#ical personnel are
more likely to yiel# vali# fin#ings% atch&testing is '
Irritant contact #ermatitis (ICD) is the term use# to re*uire# to i#entify the irritant% +
#escri$e re#, sore, itchy skin resulting from
mechanical or chemical in-ury% It may #evelop very Which Occupational Groups are .
*uickly or up to /0 hours later% ICD is usually a mil#, Most at Risk?
self&limiting con#ition $ut recurs !ith repeate#
e"posure an# may $ecome chronic% It is #istinguishe# eople !ho !ork in heavy in#ustry, those !hose /
from atopic #ermatitis, a con#ition that results from !ork involves contact !ith harsh chemicals that have
e"posure to an allergen in suscepti$le in#ivi#uals% the potential to #amage skin an# those !ho are
Ho!ever, those !ith a history of atopy are more at re*uire# to un#ertake !et !ork routinely are most at
risk% ICD occurs most often in people !hose !ork risk% They inclu#e1 young, other!ise fit, men
e"poses them to prolonge# contact !ith !ater (2!et employe# as metal!orkers, ru$$er!orkers, $eauty / .3
!ork4) an# the han#s are fre*uently affecte#% therapists an# $akers% Hair#ressers have $een the .. ./
su$-ect of numerous research stu#ies $ecause of the
Occupational ICD is #efine# as a pathological many hours they engage in !et !ork !ith e"posure
con#ition of the skin for !hich occupational to harsh chemicals such as #yes an# styling flui#s% 5
e"posure can $e sho!n to $e the main causal or ma-or inci#ence stu#y among /,/6/ trainee
contri$utory factor% It is a ma-or pro$lem that hair#ressers in 7ermany reveale# that '/. (89:) 8
employers cannot affor# to overlook, accounting for #evelope# skin changes #uring the three years of
more #ays lost from !ork than any other their apprenticeship% 5##itional factors . 8
occupational #isor#er apart from musculo&skeletal contri$uting to risk inclu#e#1 lo! am$ient
con#itions% ;or e"ample, in the <=, the Health an# temperature (causing skin to #ry)> youth (-uniors #o 0
Safety ?"ecutive (HS? .++@) has estimate# that over most !et !ork) an# a history of atopy% .0
'0,333 people #evelop occupational ICD !ith four
million !orking #ays lost each year% ICD Affecting Healthcare Workers 0
Much has $een !ritten a$out occupational ICD an# Specialists in occupational health me#icine recognise
the literature is international, although more research that nurses an# other healthcare !orkers are
appears to have $een con#ucte# in ?urope than the particularly at risk of ICD in vie! of their e"posure
<= or the <S% to !et !ork an# chemicals (#etergents, antiseptics)
that can #amage skin% It has $een estimate# that
How Many eople are Affected? nurses in Denmark un#ertake an average 8%@ hours
(range 3%@ to + hours) #aily an# are e"pose# to 5 *uestionnaire stu#y among /3,333 ran#omly #isinfecting pro#ucts on an average of /. (range 3 to selecte# citiAens in S!e#en reporte# that /@: ha# 63) occasions% Self&report *uestionnaire stu#ies
/
#evelope# symptoms #uring the previous year% confirm this high risk of e"posure%
@ . @ ,. 9
Women are more likely to $e affecte# an# to perceive their symptoms as severe% Bisks in the In these stu#ies, *ualifie# nurses ten#e# to report
9
general population also appear to $e associate# !ith fe!er episo#es an# less severe #amage than heavy #omestic commitments, especially chil# care un*ualifie# healthcare assistants an# cleaners% This is an# lack of access to mo#ern #omestic appliances% pro$a$ly $ecause nurses must un#ergo a
6
comprehensive occupational health assessment $efore Disa#vantages of the self&report approach employe# they commence training% 5pplicants !ith a history of in these stu#ies are1 lo! response rate, $iase# fin#ings severe atopy are not consi#ere# suita$le on (those !ith pro$lems !ill respon#) an# reliance on occupational health groun#s, thus removing one of ! self&report (!hich may $e inaccurate)% Stu#ies in the ma-or risk factors% ;or nurses, ICD is a nuisance
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Technology & Services
rather than a reason for leaving their profession% intrinsically resistant to anti$iotics rises, !ith
Devertheless, it is an occupational health pro$lem concomitant increase in the total num$er of $acteria,
that shoul# not $e #ismisse# $y managers% so that more are present to contri$ute to cross&
infection% There is also significant occupational
Besearch stu#ies have repeate#ly #emonstrate# that health risk to staff% 5$rasions provi#e a route of entry
sore, #ry han#s are a ma-or #isincentive to practising to parenterally sprea# viruses such as HIG, hepatitis C
han# hygiene% ;ailure to comply !ith han# hygiene an# C, !hich are associate# !ith consi#era$le . 6
protocols is highly un#esira$le $ecause han# hygiene mor$i#ity an# mortality% These risks are / 8
is accepte# $y infection control e"perts !orl#!i#e as compoun#e# $ecause nurses are reluctant to take sick
the single most effective an# cost&effective metho# of leave, continuing to !ork #espite marke# #iscomfort
preventing infection in healthcare settings% Most from ICD% .' . @, . 9
healthcare&relate# infections are #isseminate# via the
han#s an# #econtamination after patient contact has5nother compelling reason for controlling any
$een #emonstrate# to re#uce cross&infection% occupational health haAar# among healthcare . +
Tra#itionally, !ashing !ith soap an# !ater removes professionals, especially nurses, is that recruitment
transient $acteria on the skin that are easily an# retention is no! recognise# to $e a pro$lem
transferre#, resulting in cross&infection% Durses internationally% Dursing is no longer a popular / 3 /0
report that soaps #ry the skin an# make han#s sore, a option among school&leavers $ecause the hours are
pro$lem that is !orse !ith antiseptics% Ho!ever, long an# unsocia$le, !ith poor pay, particularly as
antiseptics are recommen#e# !hen risks of infectionthe career options open to young !omen the
are particularly high $ecause they #estroy $acteriatra#itional recruits to nursing have no! much
an# are thus more effective than soap% improve#% The e"istence of occupational health / 3
haAar#s !ill contri$ute to the poor image of the
Han# hygiene has $ecome so esta$lishe# in stan#ar# profession to ne! recruits an# !ill not encourage
infection control policies internationally that there is those alrea#y employe# to stay% Wise managers !ill
no possi$ility that nurses or other healthcare !orkers $e a!are of this pro$lem an# !ill !ish to tackle it $y
!oul# ever $e a#vise# not to un#ertake it% ;or #oing all they can to re#uce occupational health risks
e"ample, !earing gloves #oes not eliminate the nee# such as ICD%
to #econtaminate han#s% If the gloves are $eing use#
to prevent the transfer of infection to a suscepti$le How ICD can "e A#oided
patient !hen performing an aseptic techni*ue (e%g%
#ressing a !oun#, catheterisation) the han#s must 5ll employees at risk of ICD shoul# $e traine# to
first $e #econtaminate# $ecause gloves can perforate% recognise early signs of irritation an# take
preventative action promptly, reporting symptoms
Decontamination is necessary !hen gloves have $een that #o not resolve% 9
remove# $ecause the han#s may $ecome
contaminate# through acci#ental contact !ith their Healthcare !orkers are a#vise# to a#opt a rigorous
outer surfaces% 7loves themselves may increase the regime of han# care to re#uce suscepti$ility% / @
risk of #eveloping sore, #amage# skin% 5llergy to the urchasers shoul# seek the a#vice of pharmacists an#
late" in many $ran#s can $e e"acer$ate# $y the infection control teams so that han# hygiene pro#ucts
po!#er they contain is a common pro$lem amongare chosen carefully, in line !ith evi#ence&$ase#
healthcare !orkers% 5lthough the inci#ence of recommen#ations% Throughout ?urope, the <= an# /.
allergy can $e re#uce# $y provi#ing alternatives tothe <S, alcoholic preparations are increasingly
late" an# po!#er&free pro#ucts, the han#s $ecome recommen#e#% 5n alcohol gel or solution is applie# / 9
macerate# #uring occlusion, friction causes irritation #irectly to the han#s, then massage# to contact all han#
an# there is increase# likelihoo# of #eveloping ICD surfaces% 5lcohols are $ecoming popular $ecause they in response to soaps an# antiseptics as a result%are highly effective !hen fre*uently applie# #uring
/.
patient care, convenient to use (canisters of pro#uct can ICD is $ecoming such an issue among healthcare $e place# at the $e#si#e, so there is no nee# to !aste !orkers that, in some countries, it is attracting the time !alking to a sink) an# are ine"pensive% attention of tra#e union officials%
/ /
?mollients are incorporate# into the pro#uct so that Why Controlling ICD is Crucial for the alcohol content #oes not cause #e&fatting an# #ry Healthcare Workers the skin% Ho!ever, some staff are reluctant to use alcohol $ecause their han#s are alrea#y chappe# Damage# skin is associate# !ith an increase in the through fre*uent tra#itional #econtamination an# it num$er an# composition of the $acterial flora of causes stinging% The ans!er is to persevere !ith the skin% The prevalence of clinically significant species alcoholic preparation so that the skin heals% The
/ 8
$ such as Staphylococcus aureusan# 7ram&negative ro#s initial #iscomfort !ill then resolve%
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Occupational Irritant Contact Dermatitis in Healthcare Workers
The emollients incorporate# into alcohol pro#ucts from home% Self&selection an# supply may not $e the
eventually $uil# up so that tra#itional !ashing is $est policy, ho!ever, as staff may have limite#
re*uire# to remove them% When this is necessary, the information concerning pro#uct ingre#ients or
con#ition of the skin can $e maintaine# $y applying effectiveness an# may ina#vertently increase the risks
#econtaminant to han#s that have alrea#y $een of cross&infection $y re&using open tu$es that have
moistene#, rinsing thoroughly an# careful #rying $ecome contaminate# through repeate# han#ling%
!ith goo# *uality, a$sor$ent #isposa$le paper to!els%
5nec#otal reports from hospitals in !hich alcoholic In a later stu#y, the same authors foun# preliminary
pro#ucts have $een intro#uce# in#icate that there are evi#ence that supplying staff !ith emollients at !ork
no! fe!er reports of sore, #ry han#s $ut the pro$lem helpe# to counteract the effects of repeate# #econtam&
is $y no means era#icate#% 5t times !hen staff are ination% The pro#uct !as #ispense# in single&use 8 .
o$lige# to #econtaminate fre*uently, for instance sachets an# !as !ell&tolerate#% Devertheless, there are
#uring an out$reak or long shifts (at night shifts), many unans!ere# *uestions relating to protocols for
there !ill al!ays $e some risk of ICD% application% Optimal fre*uency remains to $e
esta$lishe# an# pro$a$ly #epen#s on the con#ition of
Managers shoul# ensure that gloves are purchase# in the in#ivi#ual4s skin, the num$er an# types of
a choice of #ifferent materials an# that staff have $een #econtamination performe# (soap, a*ueous antiseptic
a#vise# not to !ear the same ones over long perio#s or alcohol)% Techni*ue of application also #eserves
of time% If prolonge# use is necessary, they shoul# $e attention% 5#e*uate cover of the han#s !ith emollient
remove#, han#s shoul# $e !ashe# an# #rie# is essential to ensure protection areas of the skin that
thoroughly an# ne! gloves put on% The fre*uency escape contact !ill not $e protecte#% Trials have / .
!ith !hich gloves shoul# $e replace# is not state# in #emonstrate# that application is poor in all occupa&
the literature% ;rom clinical e"perience, 83 minutes tional groups so far e"amine#, inclu#ing hospital
seems a reasona$le length of time $ut it may vary cleaners% ?mployees !ere aske# to coat the han#s 8 /
$et!een in#ivi#uals% !ith la$elle# emollient, ultraviolet (<G) light !as
then use# to #emonstrate !hich areas escape# contact%
T!o types of han#&cream have $een #evelope# to Most (H.@3, 96:) #i# not a#e*uately protect han#s
help re#uce the risk of #ermatitis1 $arrier an# although they recognise# the importance of skincare
emollient creams% Carrier creams effectively protect an# purchase# their o!n pro#ucts% 5ll registere#
the skin against harsh chemicals $ut have no surprise at the num$er of han# surfaces (#orsum,
moisturising effect% Ia$oratory stu#ies !ith animal fingers, inter#igital spaces) left !ithout protection% / 6
mo#els an# human volunteers have #emonstrate#
that emollients have a $eneficial effect on the 5 later intervention stu#y $y the same authors
con#ition of the stratum corneum, increasing the #emonstrate# that employees can $e taught ho! to
!ater content an# preventing the #rying effect of ensure even cover of han#s !ith emollient using the
e"perimentally&in#uce# irritation% Moreover, <G light techni*ue% Continue# application $y this / ' 8 8
regular application of emollients can prevent metho# over si" !eeks significantly improve# the
#etergent&in#uce# ICD in healthy volunteers $y con#ition of skin, compare# !ith a group instructe#
re#ucing transepi#ermal !ater loss an# encourages $y vi#eotape #emonstration only%
esta$lishe# lesions to heal% ?mollient han#&creams / +
appear to $e the most suita$le for controlling Conclusion
occupational ICD in healthcare settings !here the
main risks are e"posure to repeate# !et !ork an# ICD is a significant occupational health pro$lem
lo!&gra#e irritants such as #etergents% Compliance throughout ?urope, the <= an# the <S% 5lthough it
has $een goo# !hen emollient creams have $een affects many occupational groups more severely than
teste# un#er 2in use4 con#itions !ith hospital staff% healthcare !orkers, healthcare staff re*uire special
/
consi#eration $ecause ICD resulting in $roken skin %he Role of &kin Care in increases the possi$ility of cross&infection, especially if re#enting and %reating ICD the associate# soreness operates as a #isincentive to compliance !ith han#&hygiene protocols% In a##ition, The use of emollient creams to prevent an# treat !ork in healthcare settings is likely to involve han#ling esta$lishe# ICD has $een recommen#e# $y $loo# an# $o#y flui#s, placing staff at risk of #eveloping occupational health e"perts !ith application $efore serious, potentially fatal parenteral infections% ICD can
8 3
prolonge# glove use to re#uce maceration, occlusion, $e re#uce# $y careful choice of han# #econtaminants an# friction% 5 preliminary stu#y !ith .86 nurses in an# gloves, provi#ing emollient creams an#
/ .
the <S confirme# the increase# rate of $acterial encouraging staff to use them as part of the overall carriage on #amage# skin% Most of the nurses applie# infection control an# occupational health strategy% han#&cream t!o to three times per shift to re#uce the urchasers, managers an# pharmacists play a key role in ' associate# soreness an# #ryness, $ringing supplies #eveloping an# implementing these policies%
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Technology & Services
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Occupational Irritant Contact Dermatitis in Healthcare Workers
60! % " -a&sing an$ : *gner, #Preventative an$ ?6! " "igger'*lberti, et al!, #Self'application of a
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6186! SSL International plc
?/ Ne( Bri$ge Street
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Hygiene -egi&ens to I&prove Skin Health *&ong :el+ 35 1/9/ 96/777
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64 367775, pp! 1?9816!
)
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