Skin problems in healthcare personnel

Introduction

Healthcare is a major employer worldwide. It has strong employment growth, as demand increases for doctors, nurses and other medical personnel. However, it is also considered to be an environment at high risk for the development of occupation-related skin dermatoses. For instance, one study surveying 706 nurses found that 47.3% of them had some form of occupational skin disease, allergic contact dermatitis and irritant contact dermatitis are the most commonly reported.

Why are medical personnel at risk for occupational skin disease?

There are many factors which increase the risk of developing an occupational skin disorder, including:

• Exposure to a variety of cleansers, medications, latex, and a variety of other potential allergens and/or irritants.
• Long work hours, which increase the duration of the exposure.
• High levels of wet work and frequent hand-washing that can lead to contact dermatitis.
• Exposure to needles, lancets and other sharp instruments, which increase the risk of mechanical injury.

Understanding occupational skin disorders

The skin has evolved as a protective barrier against invasion by pathogens and contact with irritants or sensitisers [see Skin barrier function]. However, the nature of some professions compromises this barrier, including dental and medical personnel, construction workers, cleaners, hairdressers, food handlers and farmers/agricultural workers. Healthcare workers are considered to be at high risk of developing skin problems.

Healthcare workers are at particular risk of latex allergy, contact dermatitis and mechanical injury.

Latex allergy

Latex allergy is a Type 1 hypersensitivity reaction to latex proteins (contact urticaria) and in extreme cases can be fatal. Diagnosis is based on the medical history which is typically immediate redness and swelling on exposure to latex gloves. Latex reactions can be severe, but generally resolve within an hour or so.

Contact dermatitis

Contact dermatitis can be due to either allergens (eg, rubber accelerants) or irritants (eg, water, harsh soaps, friction), with irritant dermatitis being the more common. Long work hours and prolonged exposure can also be causative factors. The most common signs and symptoms of dermatitis include redness and itching, but swelling, pain, burning sensations and scaling also occur.

Mechanical injury

Exposure to needles and other sharps means medical personnel are at high risk of needlestick injuries, cuts, or skin punctures. In the United States, the Occupational Health and Safety Administration (OSHA) estimates that 5.6 million healthcare workers annually suffer from mechanical injuries. This puts doctors and nurses at high risk for transmission of blood-borne diseases such as human immunodeficiency virus (HIV), or hepatitis C. Secondary bacterial infection can follow breaks in the skin.

Workplace risk assessment

The medical profession is highly regulated and thorough workplace risk assessments are mandated by most governing bodies. Assessment should include:

• Infection control protocols
• Procedures for the safe storage and use of sharps
• Use of devices with automatic safety features
• Provision of personal protective equipment
• Staff education on safety procedures
• Education on the nature and risks of various disinfectants and other worksite materials.

Workplace safety must be a priority for both administration and workers.

Personal protective equipment

Due to the risk for infective disease transmission between patients and medical personnel, gloves are mandated for workers performing direct personal care, handling bodily fluids, or other potentially infectious material. Gloves should also be worn when coming into contact with disinfectants, cleaners and other chemicals. However, if gloves are made of rubber, they may cause latex sensitivity or dermatitis; the increased use of non-latex gloves in the medical profession has helped to reduce this risk.

Effects of personal protective equipment on the skin during the COVID-19 pandemic

Prolonged wearing of gloves, face masks, protective goggles, and fullbody suits during the COVID-19 pandemic is resulting in healthcare personnel presenting with skin dryness and flaking, itch, irritant contact hand dermatitis, acne, folliculitis, and eczema flares, with subsequent effects on quality of life. Face mask-related skin problems particularly affect the cheek, chin, behind the ear, and nose. Goggles affect the periocular skin and bridge of nose. Excessive sweating, poorly fitted PPE, occlusion and friction are believed to be contributing factors to the development of skin symptoms and dermatoses.

Hand care advice for medical personnel

Proper hand care reduces the chances of occupational dermatoses and includes:

• Use of gloves (preferably non-latex) to reduce exposure to irritants, allergens and potentially infected materials
• Reliance on the use of alcohol-based hand gels to reduce the need for constant hand-washing — these should have an alcohol concentration of > 60% to kill pathogens such as SARS-CoV-2, the cause of COVID-19.
• Application of barrier creams, emollients or lotions to moisturise and protect the skin.
• Knowledge of the early signs and symptoms of dermatitis or other skin disorders so that these can be reported and the worker can receive prompt and early medical treatment.

[see Hand care for healthcare workers]

Diagnosis of occupational skin disorders should include:

• Assessment of a patient’s employment and job duties, the possible irritants and allergens at work, workplace safety and the presence of similar problems in fellow employees.
• Ruling out other possible causes of the condition that are non-work-related
• Patient presentation with contact urticaria, dermatitis or infection.
• Patch testing and other tests due determine the presence of patient allergies.

Treatment of occupational skin disorders can include:

• Reduction or elimination of exposure to potential allergens and irritants
• Use of gloves
• Use of alcohol-based hand rub and, when needed, gentle soaps and cleaners to wash hands. Dry hands thoroughly after cleaning
• Note that cream cleansers are not antimicrobial; soap and water or an alcohol-based hand sanitiser is needed for washing hands in order to destroy pathogens such as SARS-CoV-2 responsible for COVID-19.
• Applications of moisturisers and barrier creams
• Use of oral or topical steroids
• Antibiotics to treat secondary infections
• For persistent or severe inflammatory conditions, use of second-line treatments include phototherapy, methotrexate, ciclosporin and azathioprine.