Contact irritant dermatitis is ranked as one of the top concerns of healthcare practitioners, with skin diseases ranked as the number one cause of occupational illness across all professions. According to a study by the National Institute for Occupational Safety and Health, combined irritant and type IV or chemical-induced dermatitis account for 15 to 20 percent of all occupational diseases and incur costs of more than $1 billion annually.1 Fully 75 percent of these contact dermatitis cases can be classified as irritations. A study by Elaine Larson, et al in Heart and Lung Journal shows that of 410 nurses, almost 86 percent reported that they had problems with their hands at some time, and the clinical assessment revealed that many of those had "significant skin damage." 2

Contact dermatitis is an inflammation of the skin evidenced by itching, redness and various skin lesions, due to contact with an irritating substance. The frequent hand washing and gloving required in healthcare occupations can have detrimental effects on skin, including dryness, cracking and increased sensitivity to hand washing products. Clinicians’ frequent occupational exposure to various soaps, detergents, disinfectants and other caustic chemicals are known to cause changes to the skin, which can be aggravated further by seasonal low humidity.

Because of these issues and their link with healthcare-associated infections, there has been a great deal of interest in new gloves and other products that contain additives known to moisturize or otherwise benefit the skin. However, quantitative measures detailing whether these additives actually have a beneficial effect on skin have been lacking.

A key element when assessing gloves and other products designed to improve skin health is to examine the available test data that specifically demonstrates the benefit of the product in actual or simulated clinical use, using recognized tests developed by dermatologists.

Hand dermatitis: a significant healthcare issue

Irritation or contact dermatitis is a non-allergic reaction. Though clinicians frequently describe their reactions as allergic in nature, irritations are not an immunological response, but simply an irritant response to any number of substances or factors.

There are two types of irritations, acute and chronic. Acute irritations have a rapid onset, may be severe in nature and manifest for only a short period of time. Symptoms typically reported are: redness, itching, and possibly a burning sensation. Chronic irritations have symptoms that persist for a longer duration and include cracks, fissures, hard bumps and sores. Symptoms appear in a localized area, in the skin area directly in contact with the irritating substance.

Sources and causes of irritations

Non-antimicrobial soaps may be associated with considerable skin irritation and dryness, although adding emollients to soap preparations may reduce their propensity to cause irritation. Alcohol-based products in various forms such as gels, rinses, rubs and foams, have gained in popularity of late. Frequent use of alcohol-based formulations can cause drying of the skin unless emollients, humectants or other skin-conditioning agents are added. Even well-tolerated alcohol hand rubs containing emollients may cause a transient stinging sensation at the site of any broken skin. Though they are recognized as increasing compliance and adherence in routine hand hygiene, there are also reports of clinicians experiencing irritant dermatitis to these products as well. The Centers for Disease Control and Prevention stated it anticipates an increase in reports of irritant and even allergic contact dermatitis as more of these products are made available.3

All surgical scrub solutions have been known to cause irritant dermatitis. The frequency of skin irritation is concentration-dependant. Products containing 4 percent chlorhexidine gluconate are most likely to cause dermatitis when used frequently for antiseptic hand washing.

Gloves may also be the source of an irritant reaction. Glove powder is a common cause of irritant reactions, especially in exam glove wearers. The simple practice of donning and removing gloves, especially if gloves are not properly sized, may cause friction across the dorsum of the hand (knuckles) and develop into a reddened irritant reaction.

It is common practice for clinicians to use over-the-counter hand lotions and moisturizers in the clinical environment. From an infection-prevention standpoint, this is an unacceptable practice since these products may harbor and grow infectious microorganisms and they are not approved for use in the healthcare setting. Most of these products are highly fragranced, are not compatible with other hand hygiene products and can be the source of either an acute or chronic irritation.

A more delicate issue to address with clinicians is that related to age. It is well documented and has been profoundly recognized that the nursing population is aging. The majority of practicing nurses today are over 40 years of age and the average age of an operating room nurse is 48.7. This population is at greater risk for dry skin. Another recently recognized phenomena is that the younger population, the 20- to 30-year-olds, are experiencing an increase in dermal reactions as well. The research and causality behind this is still evolving.

How skin health
can affect hand hygiene

Damaged hands become a deterrent to hand washing because washing can worsen skin problems. Studies published in the American Journal of Infection Control report that skin breakdown is "a major occupational health problem among healthcare workers, not only nurses and others with direct patient contact, but also laboratory personnel and persons working in housekeeping and building maintenance." 4

These and other studies published in the American Journal of Infection Control have demonstrated that, with skin trauma, there is increased shedding of damaged skin cells. Also, chronic dermatitis has been associated with heavier colonization of bacteria, yeast, staphylococci and other potential pathogens and outbreaks of healthcare acquired infection.5 Clearly, improvement in the hand condition of clinicians is greatly needed.

CDC guideline for hand hygiene

The recently published Centers for Disease Control document "Guideline for Hand Hygiene in the Healthcare Setting," 6 which addresses the issues that can result in higher incidence of nosocomial infections among patients, points to skin irritation as a key reason clinicians do not adhere to recommended hygiene guidelines. The guidelines specifically recommend that healthcare workers select products that contain emollients in order to reduce the potential for contact irritant dermatitis.

Patient outcomes

The Institute of Medicine recently reported that as many as 98,000 patients a year acquire a preventable hospital-related infection. It is also believed that many of these infectious agent transmissions could be prevented through simple hand hygiene. In clinicians with compromised skin, (a skin barrier that is breached by open lesions or cracks), their hands may harbor an increased amount of infectious organisms compared to individuals with healthy, intact skin. Dry skin may shed or flake more than healthy skin. Since organisms can be shed along with skin flakes, this may increase the likelihood that organisms can be transmitted to patients. Patients may acquire a nosocomial infection by simple contact with a gloved or non-gloved hand as well.

Employee outcomes

Employees with compromised skin are at an increased risk of occupational exposure to a potentially infectious organism such as hepatitis B, C or even HIV. The broken skin provides a more direct route for an organism to enter the individual’s blood stream. They are also at increased risk for exposure to contact organisms such as staphylococcus aureus and e.coli. Dermatic hands may also result in lost productivity, impact job satisfaction and employee morale.

Impact on clinical practice

Products that promote and maintain healthy skin will result in increased compliance and frequency of hand washing and hand hygiene in healthcare providers. It is specifically stated in the CDC guidelines that employers should "provide personnel with efficacious hand hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift." 7

In light of these new guidelines, clinicians, especially infection control professionals, have taken a renewed interest in products that promote and maintain healthy skin. They are using these guidelines to support their rationale and justification to purchase products. Products that reduce trans-epidermal water loss, increase skin hydration (moisturize), have low irritancy potential and improve skin tolerance can increase adherence to hand washing and hand hygiene, and will be integral to an overall hand care and skin wellness program.

Nosocomial infections,
skin health linked

Healthcare workers are not fully adhering to recommended hand-washing procedures. While lack of time and poor technique play some role in this issue, infection control professionals are recognizing the direct link between skin health and nosocomial infections.

Repeated use of hand scrubs and hand-washing products has been cited as one of the contributing factors for dermatitis. Commonly-reported irritants include iodophors, chlorhexidine, PCMX, triclosan and alcohol-based products. Numerous articles note that failure to use supplemental hand lotions or creams is one of the factors contributing to dermatitis associated with frequent hand washing activity.8 Several controlled trials have demonstrated that regular use of hand lotions or creams helps prevent and treat irritant contact dermatitis.9

Measuring skin health and damage

Various physical properties of the skin are important in the development of an irritant skin response. The following noninvasive measuring methods have been used to investigate these properties and assess the health or degree of damage to the skin:

Dermatological test results
aid glove selection

A clinician’s intact skin is his or her first line of defense against microorganisms, chemicals and other fluids. As a result, there has been a great deal of interest in new glove products and other products that contain additives known to moisturize or otherwise benefit the skin. However, quantitative measures detailing whether these additives actually have a beneficial effect on skin have been absent. Other key questions for consideration include: how were these products tested and on what population? Does the testing simulate actual use? Did actual users of the product give input into its development?

Gloves as well as skin care products containing various additives designed to improve skin health will provide vastly different skin benefits, depending on the ingredient selected, the amount of the ingredient present and the formulation of the product. A key consideration when assessing these products is to examine the available test data that specifically demonstrates the benefit of the product in actual or simulated clinical use conditions using "gold standard" tests developed by dermatologists. By understanding these issues and test methods, clinicians can more effectively evaluate the efficacy of gloves or other products containing additives designed to improve skin health and integrity.

1 "NIOSH and Project Nora", Latex Allergy News 11(5): 1084-1121, 1996.
2 Prevalence and Correlates of Skin Damage on the Hands of Nurses." Heart & Lung, September/October 1997, Vol. 26, No. 5, pp. 404-412.
3 Boyce, J.M., Pittet, D., "Guideline for hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force," Vol. 23, No. 12 Suppl., Infection Control and Hospital Epidemiolgy, 2002.
iv Larson,E., et al. "Changes in bacterial flora associated with skin damage on hands of health care personnel." Am J Infection Control, 1998; 26: 513-521.
v Ibid.
4 Boyce, J.M., Pittet, D., "Guideline for hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force," Vol. 23, No. 12 Suppl., Infection Control and Hospital Epidemiolgy, 2002.
5 Ibid.
6 Ibid.
7 Grove, G.L., et al, "Methods for Evaluating Changes in Skin Condition Due to the Effects of Antimicrobial Hand Cleansers: Two Studies Comparing a New Waterless Chlorhexidine Gluconate/Ethanol Emollient Antiseptic Preparation with a Conventional Water-Applied Product," Am J Inf Con, 2001, Vol.29, No. 6, 361-369.
8 Menne, T. and Maibach, H., "Hand Eczema," 2nd edition. CRC Press, Boca Raton, FL. 2002.
9 Ibid.