Handwashing Until It Hurts! By Chad Schmidgal, M.D.
As healthcare providers, many of us have experienced dry, itchy, and cracking skin due to frequent handwashing and sanitizing. Hand eczema or irritant contact dermatitis (ICD) are common in occupations that involve repeated handwashing or repeated exposure of the skin to water, food materials, soaps, and other irritants. High-risk occupations include cleaning, healthcare, food preparation, as well as hairdressing and nail salon employees. In healthcare settings requiring frequent handwashing, such as ICUs, the incidence of ICD may be as high as 55.6 percent. ICD has a significant impact on an individual’s ability to work; one study of 62 workers with hand eczema reported that a third of had a greater than a 10% drop in productivity, 35% had missed time at work, and 28% had to change jobs or were not working due to hand eczema.
The typical presentation of irritant contact dermatitis is skin with macular erythema, scaling, lichenification, or fissuring. The skin may have a glazed or scalded appearance. Irritant contact dermatitis is caused by skin injury, direct cytotoxic effects, or cutaneous inflammation from contact with an irritant. Symptoms can include severe itching, pain from open fissures, and may be functionally limiting or require time away from work. ICD symptoms can occur immediately and may persist if the irritant is unrecognized. The effects of ICD are typically more pronounced in colder, less humid environments (“winter itch”).
Complete avoidance or greatly reducing the number of exposures to cutaneous irritants is the best method for treating and preventing irritant contact dermatitis. Decreasing the number of wet-to-dry cycles by reducing the number of times one washes their hands will also reduce the likelihood of developing ICD. Wash hands with warm, not hot water and use mild soaps like Dove® Sensitive or Cetaphil® and avoiding harsh soaps like Ivory® or soaps with added fragrances.
Utilizing waterless hand sanitizers is also key to preventing ICD. Ethanol-based hand sanitizers are the most practical for healthcare workers to use daily. They are cost-effective and have a low incidence of developing resistance to bacteria. One study at a French hospital comparing 16 different sanitizers concluded that Purell was the most favorable among the study participants. Whatever brand you choose, it’s important to be aware of the drying effects of ethanol on skin which can also lead to hand eczema. Avoid allergens whenever possible; the most common hand allergens in the North American Contact Dermatitis Group included preservatives, metals, fragrances, topical antibiotics, and rubber additives. This is why rubber or latex gloves can be irritating to some individuals; vinyl or nitrile gloves are better alternates.
Hand Eczema – Fast Facts:
- Wash hands with warm, not hot, water and use gentle soaps
- Utilize hand sanitizers to decrease hand washing frequency
- Avoid allergens, especially fragrance, preservatives, rubber products, and topical antibiotics
- Treat damaged skin with emollients (Vaseline® or Aquafor®)
- Visit your dermatologist if hand eczema persists
To treat ICD, frequent application of a bland emollient like Vaseline® or Aquaphor® to already irritated skin is imperative for restoring the epidermal barrier in workers with irritant contact dermatitis. For more severe cases, a dermatologist can prescribe moderate-strength topical steroids. Severe cases may need a course of oral steroids given in a tapered dose. Identifying the irritant and preventing the repeated exposure, however, remains the penultimate treatment.
Scratching the already irritated skin can further damage the skin barrier and predispose to staphylococcal infection. The skin may show signs of infection such as crusting, weeping or purulent material, and foul odor. Antibiotic treatment may be indicated for this although crusting and weeping may be related to the underlying inflammation itself. Other opportunistic infectious agents such as HSV or fungi can occur when the first line of defense is broken down in hand eczema; herpetic whitlow and tinea manus must also be included in the differential diagnosis.
Allergic contact dermatitis (ACD) may present similarly to irritant contact dermatitis. ACD is a delayed-type hypersensitivity requiring previous exposure to the allergen. ACD also tends to have a more vesicular appearance, and may spread beyond the exposed skin area, whereas ICD is more likely to remain localized. A dermatologist can perform patch testing of the skin to help delineate between the diagnoses.
1 Forrester BG, Roth VS. Hand dermatitis in intensive care units. J Occup Environ Med. Oct 1998;40(10):881-5
2 Holness, DL, Beaton, D, Harniman E. Hand and Upper extremity Function in Workers with Hand Dermatitis. Dermatitis, 2013 May-Jun;24(3):131-6.
3 Draelos, ZD. Which hand sanitizers are most practical and effective? Dermatology times, May 1, 2013.
4 Girard, R et al. Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs. Journal of Hospital Infection (2006) 63, 281e288.
5 NACDAG DATA*
The information provided is for general interest only and should not be misconstrued as a diagnosis, prognosis or treatment recommendation. This information does not in any way constitute the practice of medicine, or any other health care profession. Readers are directed to consult their health care provider regarding their specific health situation. Marque Medical is not liable for any action taken by a reader based upon this information.