Introduction
Eczema is a skin condition that leads to different inflammatory skin disorders. It destroys the skin barrier function causing the skin to be susceptible and very sensitive to dryness and infections. It can be classified into Seborrhoeic eczema, atopic eczema, varicose eczema, discoid eczema, hand dermatitis, dyshidrotic eczema, among others. Eczema can result from a combination of endogenous and exogenous factors. Endogenous factors include immune system activation and genetics, while exogenous factors are external factors such as environmental triggers and chemical allergens like hand sanitizers. Hospitals place hand sanitizers throughout the facility encouraging healthcare workers to maintain clean hands for themselves and the patients. The sanitizing solution, although meant for good, is harmful to the skin and a leading cause of eczema. This research paper will focus on hand eczema among nurses and patients, its symptoms and risk factors, diagnosis, management and treatment.
Symptoms and Risk Factors
Hand eczema is a type of eczema disease that affects only the hands. It is considered to be among the most common occupational skin diseases globally. Hand dermatitis mostly affects health workers, particularly nurses, nursing subordinates, and patients (Gupta et al., 2018). This is because they mostly work with chemicals that irritate the skin and in wet work environments, specifically by frequently handwashing (Luk et al., 2011). This, in turn, makes hand sanitizers to be among the most common risk factors for hand dermatitis (Alikhan et al., 2014). The nurses and nursing auxiliaries also engage in frequent contact with allergens and irritants (Gupta et al., 2018). Wearing gloves daily and having a history of hand eczema also lead to increased risks of nurses contracting hand eczema.
Hand eczema causes increased health costs, increased carriage of hazardous microorganisms, and impaired quality of life. Increased carriage of hazardous microorganisms created a possible means of infection transmission. According to Jeong and Kim (2017), compared to nurses that are not affected by hand eczema, nurses with hand eczema also have a significantly lower quality of life. The COVID-19 pandemic also led to increased cases of hand eczema among health workers. Techasatian et al. (2021) found the prevalence of hand dermatitis to be 20.87% during the COVID-19 pandemic. This was because there was increased use of alcohol-based sanitizers and washing hands frequently, more than ten times a day, without the use of moisturizers, especially among nurses, as a preventive measure against the spread of COVID-19 (Alkhalifah, 2022). Some of the prevalent symptoms of hand eczema include itching, redness, blisters, pain, cracks, and dryness (Luk et al., 2011). Clinically, hand eczema manifests as crusting, fissures, scaling, edema, erythema, hyperkeratosis, lichenification, and vesicles (Gupta et al., 2018). The skin disease is considered to be chronic when it has hyperkeratosis as the primary manifestation and severe when it mainly consists of crusting and vesicles.
Diagnosis of Hand Eczema
Hand dermatitis diagnosis is clinical and is mostly based on an evaluation of the medical history of the patient and a physical examination. It is also based on the assessment of the everyday activities of the patient, especially hobbies and professions. Diagnostic tests such as microbial tests, skin biopsy, prick tests, and patch tests are most useful in the diagnosis of hand eczema by developing an etiologic diagnosis and eliminating other diseases (Salvador et al., 2020). The diagnostic process starts with a review of any medical history. Patch tests utilize the baseline series that is the GEIDAC series in Spain and interpret the results from the tests with regards to clinical history (Salvador et al., 2020). Prick tests, on the other hand, use particular allergens from the home or work environment. The tests diagnose protein contact eczema using fresh food (Salvador et al., 2020). Moreover, prick and patch tests can eliminate an allergic cause from the list of diseases that can be confused with hand eczema. Lastly, a skin biopsy is very helpful in differential diagnosis like contact urticaria and protein contact dermatitis (Galea, 2021). Also, it does not provide a reliable diagnostic field for distinguishing hand eczema from palmar psoriasis, making it difficult to interpret the results.
Additionally, personal and work-related factors are very crucial in the diagnostic process. The main factors addressed include personal and family history of skin diseases as well as allergies, work-related history, and contact with allergens in the work environment or home that is types, duration, and rate of contact (Salvador et al., 2020). Another factor considered is the pattern of hand eczema that is recurrent, chronic, and severe or acute with flares description as well as remissions with regards to work, lifestyle, and seasons (Salvador et al., 2020). Skincare, handwashing behaviors, use of gloves, and influence on the quality of life are also be considered. The whole skin surface is inspected while conducting the physical assessment. During the physical examination, attention is focused on the symptoms of dermatophytosis (Salvador et al., 2020). However, it may be challenging to clinically differentiate chronic hand eczema and other skin infections that affect the hand specifically, mycosis and psoriasis.
Management
Treatment of hand is customized on the grounds of various factors such as occupation, age and clinical history of the patient, the cause of the skin disease, and the location and morphology of the lesions. The first step in managing hand eczema is carrying out a structured patient assessment and a complete physical evaluation (Salvador et al., 2020). The first step will help in deciding on the initial course of treatment while guiding the differential diagnosis. The treatment options available for hand eczema patients include emollients, soap substitutes, antibiotic therapy, topical corticosteroid preparations, bath additives, bandages, compression therapy, antifungal creams, and medicated paste bandages (Salvador et al., 2020). The use of emollients and gloves are the general measures of avoiding irritants and wet work.
Occlusive therapy or tubular bandages may be beneficial in ensuring that the emollients and creams remain in place and can result in an occlusive effect, reducing loss of water as well as using a protective film to cover the surface of the skin. Additionally, the tubular bandages and occlusive garments are designed in different sizes and are recommended with respect to body size, limb size, or age (Flavell, 2022). For example, cotton gloves designed for adults and children affected with hand eczema come in different sizes. They aid in preventing contact eczema while medicated bandages soaked in substances such as zinc oxide or ichthammol are applied below a tubular bandage which can aid in soothing lichenified and excoriated dermatitis (Flavell, 2022). However, when hand eczema is heavily infected, bandages, cotton garments, and other occlusive therapies should be avoided since infected eczema cannot be covered.
Compression therapy with hosiery or bandages can help enhance venous return and inhibit future venous ulceration. This treatment approach can also aid in reducing the discomfort of itch and inflammation linked with hand eczema (Flavell, 2022). Before compression therapy is prescribed, a Doppler ultrasound evaluation is very important since it ensures that there are no contraindications like arterial disease that may inhibit safe compression use. Additionally, the use of topical steroids and daily complete emollient therapy may be needed prior to applying compression therapy (Flavell, 2022). Antibiotic therapy is beneficial when the skin shows signs of infection, including pain, inflammation, and increased exudate. Antibiotics are very useful when used together with a topical steroid and complete emollient therapy that complements how severe eczema is while considering the area of skin to be treated.
On the other hand, emollients or soap additives and bath additives are made in a way that hydrates and softens the skin. They include ointments, moisturizing creams, bath oils, shower products, and lotions and sprays (Flavell, 2022). Emollient therapy ensures that the skin is always moisturized using a combination of products that are frequently applied. Ointments are useful when eczema becomes dry as they help soften the thick scale. Emollients are applied in smoothing or stroking motion considering hair growth direction, which prevents possible hair follicles plugging and any chance of inflammation or infection (Flavell, 2022). Additionally, emollients should be applied frequently to ensure that the skin does not remain dry or itch to restore and enhance the barrier skin function. Other hand eczema treatments are combined topical preparations, and antiviral therapy.
Topical corticosteroids can also be used to treat hand eczema. This type of medication is always rich in steroids in accordance with how severe eczema is. Therefore, it should be used in accordance with the prescribing instructions (Galea, 2021). This is because they can have adverse side effects like skin thinning. It is essential to treat acute hand eczema instantaneously to ensure that it does not become chronic, which will make it more difficult to treat. Moreover, it is also important to avoid re-exposure to allergens and irritants and provide adequate time for the regeneration of the skin barrier (Flavell, 2022). It is important for every treatment approach to focus on determining exogenous causes and recommend preventive measures as well as lifestyle changes.
Prevention
Prevention is essential in reducing and mitigating the effects of hand eczema. One of the prevention measures is continuous drying of hands immediately after washing. This promotes excellent hygiene and care since wet skin can potentially enhance bacteria transmission compared to dry skin. Additionally, the application of moisturizers after using hand sanitizers or hand washing can also help prevent hand eczema (Beiu et al., 2020). The prevention measures depend on the stage of disease and fall into primary, secondary, and tertiary categories.
First, the primary prevention measures focus on reducing the occurrence of hand dermatitis among the healthy population in society. The main aim of this level is to ensure the prevention of exposure to possible causative agents known as risk factors (Salvador et al., 2020). Evaluation of occupational risks entails quantifying and determining the risks at the workplace and is very important in primary prevention. The primary intervention is categorized into technical or organizational measures, access to specialist care, personal protection measures, and education. For instance, an efficient organizational measure can include the introduction of regulatory measures to mitigate and eliminate contact with particular allergens (Salvador et al., 2020). Moreover, healthcare workers that are allergic to rubber accelerators can use accelerator–free medical gloves as an alternative.
Second, secondary prevention measures are made in a way that prevents the existing disease from advancing to chronic levels. At this level, the primary goal is to ensure that specialists are able to detect and treat hand eczema as soon as possible. At this level, it is essential to ensure that patient education programs focus on generating behavioral changes at home or work and motivate patients to utilize measures that protect the skin and mitigate allergens’ contact with irritants and allergens (Salvador et al., 2020). Moreover, job counseling can also be an effective approach for young nurses in secondary prevention that are susceptible to hand eczema.
Additionally, protective creams are essential in preventing hand eczema from progressing to being chronic. This is because the creams create a protective layer, which can only be used on healthy skin. They ensure that the skin is protected from irritants such as hand sanitizers, detergents, and oil-based materials. However, these protective creams may give an erroneous feeling of security, resulting in unnecessary exposure to irritants and allergens. In addition to repairing the skin barrier, emollients are very useful in hydrating the skin and preventing itching (Salvador et al., 2020). Patients with successfully treated hand eczema can use moisturizers to help lengthen disease-free periods. However, moisturizers should not be applied during working hours as they may lead to an increased risk of sensitization to irritants.
Tertiary prevention measures are concerned with guiding the clinical management of hand eczema patients that have already developed a skin disease. Measures at this level should only be used with patients that have already developed chronic hand eczema. The main goal is to improve the quality of work, reduce the use of corticosteroids as well as enhance return to work (Salvador et al., 2020). However, hand eczema patients should stop working temporarily to ensure the prevention of sensitization while enhancing complete skin barrier restoration (Salvador et al., 2020). Also, it is important to use a multidisciplinary approach that involves occupational health specialists and dermatologists. Long-term patient rehabilitation can also be ensured using the Osnabrück model.
Conclusion
In conclusion, eczema affects most health workers due to their daily wet work environment and constant use of hand sanitizers. The most common symptoms of hand eczema include itching, redness, blisters, pain, cracks, as well as dryness. COVID-19 also led to an increased number of hand eczema infections among health workers and patients. This is mainly because of increased handwashing and excessive use of hand sanitizers without using moisturizers. Hand eczema diagnosis is mostly based on the assessment of the patient’s medical history and a complete physical evaluation. Microbial, skin biopsy, prick and patch tests are also used in the hand eczema diagnosis. The skin disease is managed on the grounds of occupation, age, location and morphology of lesions, and clinical history of the patient.
Treatment options for hand eczema are emollients, soap substitutes, antibiotic therapy, bath additives, bandages, compression therapy, antifungal creams, topical corticosteroid preparations, antiviral therapy, and medicated paste bandages. Hand eczema can also be prevented by ensuring to keep one skin dry immediately after washing and applying moisturizers after using hand sanitizers. Prevention measures can be classified into primary, secondary, and tertiary measures and are highly dependent on the stage of the disease.
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