Preventing Occupational Contact Dermatitis

Among work-related illnesses, occupational skin diseases are the second most commonly reported. Estimated total annual costs associated with these diseases, including lost workdays and loss of productivity, reaches $1 billion annually.¹

The U.S. Bureau of Labor Statistics reports that contact dermatitis caused registered nurses to miss an average of two days of work in 2000.² Irritant contact dermatitis, caused by direct skin irritation from agents such as soaps, detergents and alcohol, is the most prevalent form among nurses. "It's not a specific reaction to something that's being applied to the skin, but it is a non-specific thing that might irritate just about anybody," says William James, MD, professor at the University of Pennsylvania in Philadelphia and on the board of directors of American Contact Dermatitis Society (ACDS).

"One of the major problems that nurses have with their hands is they do a lot of hand washing. Repetitive wetting and drying will dry out anybody's hand, but with nurses there's a lot of that. We see a fair amount of just plain dryness with fissures or cuts in the skin and they can get secondary infections," he says.

Toby Mathias, MD, staff dermatologist at Group Health Associates in Cincinnati adds that "Occasionally, there are allergies to additives in rubber or latex gloves, which [nurses] are required to wear. Especially among endoscopy populations, nurses and NAs who have to handle sterilizing solutions contract allergic contact dermatitis from the antimicrobial agents in these sterilizing solutions." Allergic contact dermatitis, a delayed hypersensitivity reaction to specific substances, can appear days, months or even years after the first exposure.

Although it is the most common of all occupational skin diseases, contact dermatitis is often the most easily preventable.

The Importance of Personal Protective Equipment

The findings of one Australian study suggested that glutaraldehyde-related skin problems experienced by endoscopy nurses were related to procedural factors such as placing instruments into the chemical solution with ungloved hands.³ Sixty-four percent of the 135 participants reported accidents involving splashes to the skin. More than two thirds of the accidents occurred while moving containers or placing instruments in them. Twenty nine nurses experienced splashes to the eye.

Wearing gloves, gowns and protective eyewear is recommended when exposed to glutaraldehyde, 0.2 percent peracetic acid, 7.5 percent hydrogen peroxide, 0.08 percent peracetic acid and 1 percent hydrogen peroxide, or 0.55 percent ortho- phthalaldehyde, reports the Society of Gastroenterology Nurses and Associates. Gloves should be long enough to extend up the arm to protect the forearm or clothing from splashes or seepage.⁴ Gowns should be impervious to fluid, have long sleeves that fit snugly around the wrist, and wrap to cover as much of the body as possible.⁵

Another point to consider about personal protective equipment (PPE) is that it may have excellent barrier properties for some applications, but not with others. For example, "when (nurses) use gloves (during the cleaning of instruments) they should not be latex gloves because glutaraldehyde can actually penetrate through latex and still cause problems," Mathias says. Heavy-duty gloves made from nitrile or butyl provide better protection, yet gloves made from neoprene or polyvinyl chloride absorb and retain the sterilizing agent.

Jean Randolph, RN, COHN-S/CM, MPA, manager of employee health at Children's Healthcare of Atlanta and on the board of directors of American Association of Occupational Health Nurses, southeast region, adds that whenever endoscopy nurses are working with chemicals "look for a label on it, find out about it -- don't let yourself be exposed to things."

Randolph suggests further that nurses shouldn't work in a vacuum if contact dermatitis is present. "I would (first) go to employee health," she says. "Employee health, on the other side, should involve safety and infection control for some help because those are issues that are going to affect more than one person. Generally speaking, you almost always have two or three people with the same kind of (problem)."

Good Skin Care

Contact dermatitis usually occurs on the hands, but can also appear on the face and forearms, wherever there is exposure. A secondary aspect of the skin disease is "if people's hands have open sores they will tend to carry around Staph. aureus," James says. "Of course, that is an infective threat to patients."

The following suggestions are regularly recommended to treat as well as prevent irritant contact dermatitis:

• Use mild soaps.
• Rinse hands thoroughly, removing any chemical residue.
• Dry hands completely, focusing on web sites and areas under rings where moisture is often trapped.
• Apply lots of moisturizing creams rather than lotions to hands, especially during winter months.
• Wear protective equipment to avoid contact with known irritants such as glutaraldehyde and formaldehyde.

Allergic contact dermatitis, on the other hand, is usually treated with prescription-strength topical creams and steroids. "The way to really prevent and treat that is to identify the allergen, avoid the allergen and the rash should go away," says Christen Mowad, MD, director of patch testing at Geisenger Medical Center in Danville, Pa., and on board of directors of ACDS.

Patch testing is performed in patients with suspected allergic contact dermatitis, screening as few as 24 to 70 allergens. Mowad mentions further that "(Doctors) who have a special interest in contact dermatitis tend to patch test to a more expanded series of allergens because it has been shown that increases your ability to diagnose the actual culprit." However, patch testing is not used to identify latex allergies, Mathias adds. "It is usually a blood test and occasionally a skin test, which is only done in specialized centers since the antigen for doing the testing is not really available in the United States," he says.

Although it is the most common of all occupational skin diseases, contact dermatitis is often the most easily preventable.

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