Untoward Effects

Some ingredients of skin protection products, though principally hardly indispensable for stability and/or acceptance reasons, such as preservatives and fragrances, can induce contact sensitization [4, 14]. Therefore, fragrance ingredients should be used with caution and be limited to substances with a proven low sensitizing potential, in particular because these products will also be used on already impaired skin in many cases. Chemical ultraviolet filters are also potentially capable of inducing allergic as well as photo-allergic contact dermatitis in rare cases. As mentioned above, protective creams should be free of penetration-enhancing ingredients such as propylene glycol, urea and particular emulsifiers [3, 4].

Gloves themselves can contribute to skin irritation when used over long periods without intermission. Therefore, protection from skin damage caused by potential noxae has always to be balanced against untoward glove effects. It has been shown that glove powder accelerates skin roughness by using skin replicas and profilometry [15]. Singular glove occlusion with a duration of 4 and 8h, respectively, was found to induce temporary increase of stratum corneum permeability as demonstrated by a nicotinate penetration test as well as significant elevation of transepidermal water loss, whereas repeated wearing of polyvinylchloride gloves on 2 days (2 X 6h) caused prolonged barrier disturbance that persisted the following day, indicating a cumulative irritant effect [16]. Repetitive experimental usage of non-latex gloves for 6h/day for 14 days on normal skin was able to induce elevated transepidermal water loss as the most sensitive bioengineering parameter of disturbed barrier integrity [11]. Apparently, glove occlusion is more likely to cause barrier impairment in the presence of co-exposure to detergents. While gloves worn on 3 successive days for 6h each did not cause significantly negative effects on the water barrier function, the combination with pre-exposure to sodium lauryl sulphate (SLS) induced a significant barrier disturbance [10]. In a recent experimental study, which compared barrier impairment caused by combined exposure to occlusion together with or without water or SLS and with or without mechanical irritation caused by skin friction, the ranking regarding irritancy was as follows: occlusion with SLS and mechanical irritation > occlusion with SLS > occlusion with water and mechanical irritation > mechanical irritation and occlusion with water > occlusion with a glove and mechanical irritation > mechanical irritation > occlusion with water [17]. The new technical rule for hazards induced by skin contact recently implemented in Germany (TRGS 401) stigmatizes the usage of gloves for more than 2h/day, equivalent to wet work of the same duration, which is classified as a 'medium skin hazard'. However, it is still under debate whether data are sufficient to equate wet work and wearing of occlusive gloves [18].

Resulting from the above-mentioned obstacles, which general requirements can be postulated for skin products to be used together and under gloves, respectively? The intended effects should include reduction of perspiration, reduction of stratum corneum swelling after occlusion and postocclusive barrier impairment. On the other hand, it has to be proven that the ingredients do not interfere with the glove material, neither in the way of degrading the material, thus making it permeable for harmful substances, nor by enhancing the potential release of rubber allergens. While some concepts for skin protection creams have already been successfully implemented, e.g. by using particular ingredients such as aluminium chlorohydrate or synthetic tanning agents in order to reduce perspiration and to diminish swelling by formation of protein complexes [19], there are also some results from the literature indicating that caution is warranted regarding uncritical enthusiasm for combined usage.

Moisturizers are in general not qualified to be used under gloves, due to potential inappropriate ingredients, causing penetration enhancement or even sensitization under occlusion. These products, which are intended to elevate the stratum corneum hydration level by their composition, should be restricted for afterwork barrier regeneration. In an experimental study, Held and Jorgensen showed beneficial effects of a moisturizer applied on SLS-impaired skin under glove occlusion. In contrast to the exclusively SLS-impaired and occluded hands in their immersion test, the moisturizer was found to diminish the negative effect on the skin barrier function [20]. However, their results must not be generalized; moreover, the concept of using moisturizers under gloves has to be seen very critically for the above-mentioned reasons. The question whether protective creams capable of preventing allergen release from gloves can be created is complex and cannot be answered generally [21-23]. Depending on the different types of glove materials (natural latex vs. synthetic elastomers vs. plastic materials) as well as the fabrication process on the one hand and the constituents of the skin product and its circumstances of application on the other, different scenarios can result, as illustrated by two studies dealing with the same objective but coming to controversial results. While Allmers [22] showed a reduced rate of contact urticaria caused by latex from natural rubber latex gloves in a glove use test when applying a special protective cream beforehand, Baur et al. [21] experienced an increased positive response rate from 30 to 41% of subjects with specific IgE against latex in a use test with another commercially available protective cream. Moreover, they were able to demonstrate that the product even elicited contact urticaria in 5% of 109 test persons, who did not respond to a glove with a low latex allergen content [21]. These findings stress that ideally, standardized efficacy and interaction testing of skin-protective products especially intended to be used under gloves should be performed, which has not been routinely implemented yet, in parallel to in vivo efficacy testing of barrier creams, which is being recommended in interdisciplinary guidelines [1].

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