Protection against Irritants

Eczema Free Forever

Eczema Free Forever by Rachel Anderson

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Wet work and irritant exposure (table 2) in the healthcare setting are frequent due to hand hygiene which is indispensable with regard to prevention of cross-infections.

Alcohol-based hand rubs may be superior to traditional hand washing and irritate the hands less often [2, 3]. Besides easy access to hand hygiene, skin protection has been introduced as a necessary prerequisite for a satisfactory hand hygiene behaviour [2].

In the healthcare setting, frequently protection gloves are used alternating with protection creams. Even when optimized, the latter never achieve the same level of protection as protection gloves do [10]. Which glove material should be used for which purpose is briefly summarized in table 3 [11].

The technical rule for hazardous substances (approved code of practice TRGS 220) describes the required contents of the safety data sheet in Germany. An essential change of the 2002 draft is the objective to facilitate the selection of suitable gloves for the users. Beyond the European directive 2001/58/EG, the TRGS includes the wearing time of gloves while working with chemicals [12].

In a recent study on the permeability of surgical gloves to 7 chemicals commonly used in hospitals, the gloves did not exhibit permeation of potassium

Table 1. Characteristics of disinfectants by chemical composition (modified from Robert-Koch-Institut [8] and Thalmann [9])

Classes

Spectrum of activity

Comments

Alcohols Aldehydes

Amines

Chlorine compounds

(hypochlorites)

Hydrogen peroxide; peroxyacetic acid

Iodine compounds

B, T, F, cV No effect following evaporation; sensitive to organic substances; synergistic effects with iodine, chlorhexidine and quaternaries B, T, F, S, cV uV Readily volatile, relatively unstable; may preserve impurities on instruments

(unsuccessful disinfection outcome); formaldehyde causes respiratory problems in low concentrations and is suspected of being carcinogenic, glutaraldehyde fumes irritate eyes and airways; poor protein load tolerance B, T, F, cV, uV No compatibility with aldehydes, and therefore no aldehyde products should be used before or after treatment

B, cV uV Good disinfectants on clean surfaces, quickly inactivated by dirt; more active in warm water than in cold water, irritating to skin, corrosive to metal

B, T, F, cV, uV Less corrosive than iodine and chlorine compounds; reaction with chlorine-cleaving substances and bisulphite, with toxic gases and fumes being formed; when diluting, transfer acid to water, not vice versa; do not use together with other cleaning agents; cleaning agents that contain hypochlorite release toxic gases that may harm the airways; exothermic reaction with lyes; risk of decomposition with impurities of any kind, particularly heavy metals B, T, F, S, cV uV Iodine compounds are available as iodophors, which are combinations of elemental iodine and a substance that makes the iodine soluble in water; insensitive to blood and organic substances; active against hepatitis B viruses; absorption and systemic toxicity possible under certain conditions; incompatible with mercury compounds, metals and quaternaries; can stain clothing and porous surfaces

Table 1. (continued)

Classes

Spectrum of activity

Comments

Phenol derivatives B, T

Quaternaries

Coal tar derivatives, turn milky in water, strong odour; toxic; stable, not very sensitive to organic substances; ineffective on hepatitis B virus; phenols must not come into contact with strong oxidizing agents such as peracetic acid; phenols modify rubber and synthetic materials

Odourless, colourless, non-irritating, deodorizing; sensitive to organic substances, soaps, hard water; inactive against certain Gram-negative bacteria; cationic substances such as quaternaries are precipitated out by anionic derivatives (soaps and other detergents) and thus lose their effectiveness

Ammonia forms on contact with ammonium compounds

B = Bactericidal; cV = coated viruses; F = fungicidal; S = sporicidal; T = tuberculocidal; uV = uncoated viruses.

Table 2. Frequent irritants in the healthcare setting

Water

Detergents/soap

Antiseptics

Alcohols

Occlusion (glove-associated) Ethylene oxide Plaster of Paris Miscellaneous medications

Table 3. Recommended glove materials in the hospital setting (according to the AWMF Working Group for Hygiene in Hospital Practice [11])

Natural Nitrile Polyvinyl Poly- 'Household rubber latex chloride ethylene glove'

Orthopaedic surgery double gloving

General surgery x

Specific patient care x

(e.g. change of dressings) General patient care Cleaning Disinfection Handling of chemotherapeutic agents latex allergy latex allergy latex allergy x x x x x x hydroxide (45%), sodium hypochlorite (13%) or hydrogen peroxide (30%), glu-taraldehyde (2%) or chlorhexidine digluconate (4%) in the commercial disinfectant solutions studied. Slight permeation of peracetic acid (0.35%) and acetic acid (4%) from a disinfectant agent was observed through single-layered natural rubber materials. Clear evidence of formaldehyde permeation was detected through single-layered natural rubber gloves (breakthrough times were 17-67min) [13]. The gloves in this study which offered most protection from chemical permeation were the chloroprene gloves and the thick double-layered natural rubber gloves. For 70% isopropyl alcohol, breakthrough times through surgical gloves when tested according to standard methods could be demonstrated from 4.8 to 38 min (ASTM F739) versus 4.6-122 min (EN 374) for different sorts of latex gloves and >240 min (EN 374) versus 103 min (ASTM) for chloroprene rubber [14].

However, the use of occlusive protection gloves itself has adversary effects on the stratum corneum barrier properties [15] so that use times have to be limited to the necessary [16].

For many years, a 3-step programme of occupational skin protection - consisting of skin protection (so-called barrier creams) before work, cleaning and skin care after work - has been introduced into practice. While protective creams are supposed to prevent skin damage due to irritant contact, skin cleansing should mildly remove aggressive substances from the skin, whereas postexposure skin care is intended to enhance epidermal barrier regeneration. This 3-step concept is strongly propagated and is one of the generally recommended measures to prevent occupational contact dermatitis [17].

In Germany, according to the approved code of practice TRGS 531 (wet work) [18], for occupations with >2h of exposure to wet work or occlusive conditions by protection gloves, employers have to provide a 3-step programme of occupational skin protection. In spite of intensive measurements for skin care and protection in Germany, the number of recorded occupational skin diseases according to BK 5101 did not decline over the past years (data of HVBG: general German employee liability insurance association) [17]. A recent study on skin protection and secondary prevention in healthcare workers revealed that prior to the reported intervention only 35% of participants had been using the provided skin care and protection products regularly [19].

Under model conditions for irritant contact dermatitis (repetitive irritation testing with sodium lauryl sulphate), it could recently be shown that the highest benefit was achieved if all 3 protective measures were combined. Thus, the efficacy of the integrated skin protection was confirmed; however, the use of a barrier cream appeared to be the most important part [20].

When critically questioned by criteria of evidence-based medicine, it was found that for an evidence-based recommendation of skin protection, further clinical studies were needed, especially under daily working conditions evaluating the contribution of each single element of skin care programmes (products, frequency of application and education programme) [17].

In a randomized double-blind study with hospital nurses [21], Excipial Protect was compared with its vehicle. Fifty hospital nurses with mild signs of compromised skin on their hands, such as roughness or slight erythema, were included. Half of the test population received the commercial product, whereas the other half received the vehicle for a month. The effects of both types of preparation were studied weekly by clinical examination and instrumental assessment of bioengineering parameters. Results showed no significant differences between barrier cream and vehicle. Even the vehicle alone was capable of positively influencing the skin status. Critical points of this study are the small study population, the lack of a control group without any cream application, the

Table 4. Evidence-based recommendations for employees in wet-work occupations according to Held et al. [23]

Wash your hands in lukewarm water; rinse and dry your hands thoroughly after washing

Use protective gloves when starting wet-work tasks

Protective gloves should be used when necessary but for as short a time as possible

Protective gloves should be intact, and clean and dry inside

When using protective gloves for more than 10 min, wear a cotton glove underneath

Do not wear finger rings at work

Do not use disinfectant agents unless they are recommended for special hygienic reasons

Apply moisturizers on your hands during the working day or after work; select a moisturizer which is lipid rich and free from fragrance and with preservatives having the lowest allergen potential

The moisturizer must be applied all over the hands inclusive webs, fingertips and dorsal aspects

Take care also when you do domestic work (use protective gloves when doing dishwashing and cleaning) and when the weather is cold with low humidity (use insulating gloves)

short observation time and inclusion of subjects with already impaired skin conditions (roughness or slight erythema). Therefore the study qualifies for evaluating the therapeutic rather than the preventive properties of skin protection [17].

In a double-blind randomized trial [22], an oil-containing lotion was compared with a novel barrier cream in 54 healthcare workers with severe hand irritation, over a 4-week period. Subjects in both groups experienced marked improvement. Due to the inclusion criteria (impaired skin condition), this trial is qualified to prove therapeutic effects of skin protection creams. However, it has to be kept in mind that barrier creams are intended for the use on intact skin as part of the primary prevention and that they cannot substitute a proper der-matological treatment in manifest hand eczema [16].

In an intervention study in student auxiliary nurses (n = 61 in the intervention group and n = 46 in the control group), as part of the intervention an evidence-based skin care programme (table 4) was introduced, using knowledge from epidemiological and clinical experimental studies about proper glove use, correct hand washing, use of hand disinfectants and moisturizers [23]. After a 10-week period of initial practical training, 48% of the intervention group versus 58% of the control group had aggravation of skin problems. Frequency of use of hand disinfectant agents was significantly associated with aggravation of skin problems.

Over the past 10 years, primary, secondary and tertiary prevention of occupational skin disorders has been shown to be successful in hairdressers, documented with appropriate statistical methods [24, 25]. Based on these promising results of educational aspects in skin care management in this high-risk profession, recently, in cooperation with the Accident Prevention and Insurance Association for Healthcare Workers (Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege, BGW), disease prevention courses have been extended for secondary prevention of occupational skin disease in the healthcare professions [19].

In a recent intervention study for secondary prevention of hand dermatitis in geriatric nurses (n = 102 in the intervention group and n = 107 in the control group), 89% of the intervention group and 90% of the control group complained of occupational skin disease upon entry. The intervention group received repeated education and training in skin protection measures over a period of 6 months including a 3-step skin care programme, whereas the participants of the control group were seeing a dermatologist on demand. Upon study completion 6 months after the first encounter, 59% of participants of the intervention group were free of occupational skin disease. Questionnaires 3 months after study completion revealed skin lesions in 53% of the intervention group and 82% of the control group (p < 0.01) demonstrating that the education programme was superior in terms of health maintenance and employment [26].

The effectiveness of a skin care programme is based on 3 factors: first, the effectiveness of the products used; second, the frequency and elaborateness of the application of skin care products, and, finally, the effectiveness of the education (reduction of exposure to skin-damaging substances) [17]. No general agreement exists on how often workers should be advised to apply moisturizers on their hands, if they should use moisturizers at the workplace or after work or whether a 3-step skin care programme (including skin protection before work, cleansing and skin care after work) is superior.

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