Editorials

Avoiding hand eczema in healthcare workers

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8370 (Published 12 December 2012) Cite this as: BMJ 2012;345:e8370
  1. Kim Thomas, associate professor 1,
  2. John English, consultant dermatologist2
  1. 1Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK
  2. 2Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
  1. kim.thomas{at}nottingham.ac.uk

Good evidence that individualised education can lead to secondary prevention

Occupational hand eczema in healthcare workers is common worldwide and an important public health concern.1 In our institution, and probably across the whole of the healthcare sector, the rise in incidence and prevalence has mirrored the campaigns to reduce hospital acquired infections.2 It is perhaps not surprising that irritant contact dermatitis occurs in people who wash their hands as often as 50-60 times a shift, and because damaged skin often carries a higher bacterial load,3 this also has implications for infection control. Fortunately, this problem is potentially amenable to prevention strategies.

In a linked research paper (doi:10.1136/bmj.e7822), Ibler and colleagues evaluate the usefulness of a structured skin care intervention to prevent hand eczema among healthcare workers in Denmark.4 Primary prevention generally involves the introduction of a skin protection programme,5 which includes reducing exposure to irritants, regularly using fragrance-free and lipid-rich moisturisers, and wearing occlusive gloves for the shortest time possible. Educational based programmes have been recommended as a way to get this message across to healthcare workers.6

The linked randomised controlled trial evaluated a secondary prevention programme: it compared an individualised education programme with standard care in 255 healthcare workers with self reported hand eczema. The trial was well designed, thoroughly executed, and clearly reported. It provides compelling evidence to support the effectiveness of such an approach in the secondary prevention of hand eczema in healthcare workers over a five month period.

To date, research has generally focused on the primary prevention of occupational hand eczema (reducing the incidence of the disease), rather than on secondary prevention (minimising progression of the disease in people who already have some degree of hand eczema). A Cochrane review on interventions for the primary prevention of occupational irritant hand dermatitis found four relevant clinical trials, including 895 participants from a variety of work settings (print and dye workers, metal workers, cleaners, kitchen workers, and hairdressers).7 These trials showed no clear evidence to support the use of barrier creams or after work cream for primary prevention.

A more recent systematic review of the management of occupational dermatitis specifically in healthcare workers found two studies by the same group that explored the value of educational interventions for the primary prevention of hand eczema in workers at old people’s homes and student auxiliary nurses.6 8 9 These studies were excluded from the Cochrane review because workers who already had hand eczema were included alongside those who were healthy at the start of the study, making an assessment of the efficacy of the intervention for primary prevention difficult to ascertain. These two trials suggested potential benefits of education based programmes, but the results were inconclusive owing to limitations in trial design and reporting.

The current study nicely fills the gap in our knowledge of preventive interventions. After patch and skin prick testing for common allergens, people with skin problems received counselling on the interpretation of their test results and instructions on how to care for their skin. This included avoidance of relevant allergens, both at home and at work; how to wash and dry hands; use of disinfectants instead of washing if hands were not visibly dirty; and use of emollients three times a day.

Delivery of the intervention took 20-30 minutes per participant. The content of the education package is in line with current understanding of best preventive skin care for occupational dermatitis.6 Such an approach is probably generalisable to most healthcare delivery systems; indeed, the authors report that a similar programme has already been implemented in Germany.

Although the current trial provides the best evidence so far to support the benefit of an educational intervention for the secondary prevention of hand dermatitis in healthcare workers, it does not evaluate the economic impact of the intervention. The cost effectiveness of an individualised educational programme such as this is still unknown. Future research could also look at longer term outcomes to see whether the effects are sustained beyond five months. It could also investigate whether such approaches are useful in primary prevention of hand eczema in healthcare workers—a topic recently highlighted as important by the UK National Institute for Health Research Health Technology Assessment Programme.10 Whether the observed improvements in skin health could reduce cross infection and hospital acquired infections also remains to be seen.

Notes

Cite this as: BMJ 2012;345:e8370

Footnotes

  • Research, doi:10.1136/bmj.e7822
  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; JE has received speaker’s fees from Baisilea Pharma, which no longer markest a hand eczema drug.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References