CC BY
7NAUKI MEDYCZNE | МЕДИЦИНСКИЕ НАУКИ
OCCUPATIONAL SKIN SYMPTOMS AMONG HEALTHCARE PROFESSIONALS IN LATVIA
Eliza Salijuma
Sixth year student Riga Stradins University, Latvia Maija Eglite Dr. habil. med., professor Riga Stradins University, Latvia
ABSTRACT
Introduction. Exposure to chemical, physical, biological risk factors can lead to different skin diseases. In many developed countries occupational skin diseases are second in the ranking of occupational diseases, following musculoskeletal disorders. At the European level skin diseases represent between 10 % and 40 % of recognized occupational diseases. The most frequent lesions are irritant contact dermatitis followed by allergic contact dermatitis. [1]
Aim. The aim was to study the prevalence of self-reported skin symptoms on hands and forearms among health care professionals and to find out the main risk factors for development of occupational skin disease. Gathered information will be used to develop preventive measures and raise awareness about this issue.
Materials and methods. A questionnaire, partly based on the Nordic Occupational Skin Questionnaire NOSQ-2002, was used to collect self-reported data from health care professionals from different medical institution in Latvia. 361 respondents took a part in this study: 110 physicians (30.5%), 149 nurses (41.3%) and 102 nursing assistants (28.3%).
Results. The information in the questionnaire showed that in the healthcare sectore most of the respondents (59.8%) have had 1 to 3 different skin symptoms in previous 12 moths. Statistically significant (p=0.001) nurses (34.9%) more often had multiple skin symptoms than physicians (25.76%). Only 52 (14.4%) respondents reported that they have not had any of skin symptoms. Dryness (72,3%), tenderness (34,9%) and redness (34,6 %) were main reported skin symptoms. In the time of survey 161 (44.6%) respondents had at least one active skin symptom. 270 respondents (74.8%) admitted that they have noticed reduction of symptoms during vacation. 44 respondents (12.2%) even have visited doctor because of these symptoms. 102 (28.3%) respondents have had other allergic symptoms during working hours, 46.8% of them have had rhinitis and 19.8% conjunctivitis. 36.8 % of respondents wash hands and 21.6% of respondents use hand disinfectant more than 20 times per working day. 125 (34.6%) respondents have noticed skin symptoms after using latex gloves but did not have necessity to stop using them. 61 (16.9%) had necessity to use gloves from different material because of the symptoms. There was a weak correlation between more years spent working in healthcare sector and more skin symptoms (r=0,142, p=0,014). The use of hand disinfectant (48.2%) and frequent hand washing (26.7%) were the possible irritant agents most often reported. 285 respondents (78.9%) use moisturizing hand cream daily.
Conclusion. According to the survey occupational hand diseases in healthcare field is significant topic and it is important to prevent occurrence of symptoms by educating employees about hand care and substitution of substances with skin-damaging properties. Further research should be done to exclude factors that may have had effect on the result and specify in more detail the risk factors.
Keywords: Occupational skin diseases, contact dermatitis, irritant contact dermatitis, allergic contact dermatitis, healthcare professionals
INTRADUCTION
Occupational skin diseases are a major public health problem because they are common, are often chronic, and have significant economic impact on society and on workers [2]. Although human skin can withstand many of the assaults of a hostile environment, skin is the most commonly injured organ in industry. In many developed countries occupational skin diseases are second in the ranking of occupational diseases, following musculoskeletal disorders [1]. Skin disorders comprise more than 35% of all occupationally related diseases, affecting annually approximately one worker per thousand [3]. Epidemiology data does not represent the real extent of the issue, because most of cases are not reported and the registration criteria vary from country to country too [4].
According to the study by Eurogip in 2001, there are many
reasons for this under-reporting. First employees do not always provide enough information. In some countries employees are not sufficiently aware of their exposure to the risk and are unfamiliar with the provisions of insurance systems (Belgium, Germany, Greece, France, Spain). One of the problems is lack of knowledge and training on the part of general practitioners that prevents them from recognizing or seeking occupational causes for ill health. A generalist physician might not be informed about the patient's working situation and conditions, or about the effect of specific working conditions on the skin of their patient. Another possible reason is shortage of occupational physicians. Last but not least is that employees' fear of losing their job. The Eurostat [16] has identified several factors that determine whether or not a case is notified as an occupational disease. They are: the motivation of the patient, the physician
and the employer to report the case and the motivation of social security authorities and other relevant agencies to handle such cases under the normal social security coverage or to classify them as occupational [1].
The most common occupational skin disease, covering around 50-80% of cases, is irritant contact dermatitis, which is around five times more frequent than allergic contact dermatitis. Irritant contactdermatitis is the inflammation of the skin at the place of contact with the chemical substance. Irritant contact dermatitis and allergic contact dermatitis are undistinguishable from each other by clinical or histological examinations [4]. Meding and Swanbeck for example, provided revelant epidemiologic data by investigation over 1,300 patients with hand dermatitis. 35% of these patients had irritant hand dermatitis, 22% atopic dermatitis and only 19% allergic dermatitis [15]. Furthermore, mixed form (allergic plus irritant) contact dermatitis is also very frequent. On one hand, a substance may have both irritant and sensitizing properties. In addition, the worker may be exposed to multiple substances. On the other hand, irritant exposure harms the barrier function of the skin, which promotes sensitization by enabling increased absorption of allergens [4].
Clinical signs and symptoms of hand dermatitis are polymorphic. An acute dermatitis is characterized by the presence of erythema, vesicles, exudation and papules, whereas the chronic stage especially displays lichenificiation, xerosis, infiltration, erosion and fissures, as well as crusts and hyperkeratosis. Irritant contact dermatitis can mostly be found in the interdigital spaces and on the back of the hands. Symptoms of hand dermatitis include itching, burning, tickling, pain, tightening [13]. Healing can take weeks or months. The hands may appear to have healed but for up to 3 months, may still react abnormally when exposed to contact with irritants [19].
Previous or present atopic dermatitis is a strong risk factor for developing occupational contact dermatitis. Atopic dermatitis is a common skin disorder that is based on genetic disposition of decreased barrier function and impaired repair, and features itching and dryness [4].
Hand dermatitis is a classic occupational health problem for healthcare workers in many countries [5-7]. Prevalence of hand dermatitis (for example 17 - 30%) is much higher for healthcare workers when compared to general population. Nurses are one of the occupational groups most frequently attending the Occupational Dermatology Clinic at the Skin & Cancer Foundation in Melbourne. Data from this clinic indicates that 73% of nurses seen at the clinic are diagnosed with irritant contact dermatitis and 44% with allergic contact dermatitis and 12 % having latex allergy, highlighting the existence of multiple diagnoses. Internationally the findings are similar, with healthcare workers commonly rating in the top five high-risk occupations for occupational skin diseases [19]. The consequences are serious because many employees are forced to change their jobs or quit working entirely due to hand dermatitis (occupational skin disease). The main cause of hand dermatitis is long-term and frequent ex-posure of the skin to irritating substances [8]. In healthcare professions this irritations is caused by frequent hand washing with water and soap, aggressive disinfectants, antiseptic skin cleansers and by
wearing gloves for long time, glove powder [9, 13, 19]. Even water on its own, is a known irritant [14], especially with repetitive contact. [17] Water and wet work is the main factor. That means that the hands are in water longer than 2 hours a shift, in occlusive gloves for longer than 2 hours a shift (heat, sweeting), washed more than 20 times a shift. Frequent drying of the skin using paper towel is possible cause of irritant contact dermatitis [18, 19]. Frequent hand washing is a mandatory requirement in health care settings to prevent the spread of infection from organisms on the hands. The continual use of water and soap can potentially result in hand dermatitis [17]. Alcohol - based hand rubs have only a marginal irritation potential, although they may cause a burning sensation on pre-irritated skin. A burning sensation when using alcohols therefore, suggests that the skin barrier is already damaged [13].
Researchers from the University's Institute of Population Health studied reports voluntarily submitted by dermatologists to a national database, which is run by the University (THOR), between 1996 and 2012. They found that out of 7,138 cases of irritant contact dermatitis reported 1,796 were in healthcare workers. When the numbers were broken down by year, health workers were 4.5 times more likely to suffer from irritant contact dermatitis in 2012 as in 1996. In other sectors, cases declined or did not change. The implications of increasing levels of irritant dermatitis are potentially counter-productive to the aims of infection (MRSA) reducing campaigns [15].
Allergic contact dermatitis is a delayed hypersensitivity reaction caused by a sensitizing substance touching the skin and individual developing allergy to it. Allergy can develop hours or even 1-2 days after contact with the allergen, but does not occur the first time an individual is exposed to the substance [19]. Causes of allergy affecting health care workers can include: preservatives, fragrances and other ingredients in hospital hand cleansers and moisturizers [18]. Allergic contact dermatitis can develop at anytime in a person's career and often happens after irritant contact dermatitis has already damaged the skin. It is possible to develop an allergy to chemicals in products even if they have been used for many years [19].
Allergy to the latex in many is a common problem among healthcare workers [11]. It is caused by the proteins in the sap from rubber tree, Hevea Brasiliensis. Latex allergy can develop as a result of exposure to natural rubber latex gloves, trough skin or mucous membranes, or via the respiratory system [20]. Other medical products such as catheters, masks, endotracheal and nasogastric tubes, elastic bandages and ultrasound probe covers may contain natural rubber latex [20]. It is type 1 reaction, which is immediate and potentially severe reaction which may even progress to anaphylaxis [19]. It is referred to as "contact utricaria". Individuals may use latex for many years without problems before "Contact Utricaria Syndrome" develops. This syndrome may also include conjunctivitis, rhinitis, asthma and gastro-intestinal side effects such as nausea [20].
It is important to control contact dermatitis for healthcare workers because damaged skin is associated with increase in the number and composition of bacterial flora of skin. This increase can contribute cross-infection. Significant occupational health risk to staff is that abrasions provide a route
to entry to parenterally spread viruses such as HIV, hepatitis B and C, which are associated with considerable morbidity and mortality [12].
An efficient approach of hand dermatitis in "wet work" professions requires both curative and preventive actions [10]. To prevent hand dermatitis it is important to wash hands with warm, not hot water and use the least harsh soap or lowest concentration of antibacterial soaps, use alcohol sanitizing emulsion gels if feasible, use water-based moisturizers liberally, avoid using latex gloves and protect and treat the hands when away from the work environment [17].
AIM. The aim was to study the prevalence of self-reported skin symptoms on hands and forearms among health care professionals and to find out the main risk factors for development of occupational skin disease. Gathered information will be used to develop preventive measures and raise awareness about this issue.
MATERIAL AND METHODS
A questionnaire, partly based on the Nordic Occupational Skin Questionnaire NOSQ-2002, was used to collect self-
The main reported symptoms were: dryness 261 (72,3%), tenderness 126 (34,9%) and redness 125 cases (34,6%). More severe symptoms like scaling/flacking have had 68 (18,8%) and fissures/cracks have had 97 (26,9%) of respondents. 45 (12,5%) of respondents have had burning sensation and 18 (5%) have felt pain in last 12 months.
In the time of survey 161 (44.6%) respondents had at least one active skin symptom. 270 respondents (74.8%) admitted
reported data from health care professionals from different medical institution in Latvia. The questionnaire contained 19 different questions. A total of 450 employees were approached with request to complete the questionnaires. Of the total 80,22% (361 questionnaires) were returned. 110 physicians (30,5%), 149 nurses (41,3%) and 102 nursing assistants (28,3%) took a part in this study. 134 (37,1%) of respondents worked in surgical department, 84 (23,3%) in department of internal diseases and 69 (19,1%) in the department of anesthesiology and reanimation. 20,5 % of respondents did not specify their department. Study included 329 (91,1%) women and 32 (8,9 %) men. The age of respondents was from 20 to 72 years and the mean age was 40,25.
RESULTS OF STUDY AND THEIR DISUSSION
The information in the questionnaire showed that in the healthcare sector most of the respondents 216 (59,8%) have had 1 to 3 different skin symptoms in previous 12 months. 4 to 6 symptoms have had 75 of respondents (20,7 %) and 7 to 9 only 14 (3,8%). Age did not affect the quantity of skin symptoms. 50 (13,9 %) respondents reported that they have not had any of skin symptoms.
. It was multiple ployees in
that they have noticed reduction of symptoms during vacation. 44 respondents (12.2%) even have visited doctor because of these symptoms. 102 (28.3%) respondents have had other allergic symptoms when using latex gloves or disinfectants during working hours, 46.8% of them have had rhinitis and 19.8% conjunctivitis. 23 (18,3 %) of respondents reported shortness of breath. 18 (5%) of respondents had 2 to 4 different allergic symptoms.
12345G789
Quantity
Statistically significant (p=0.001) nurses (34.9%) more often had multiple skin symptoms than physicians (25.76%^ statistically significant (p=0,014) that employees in department of anesthesiology and reanimation had more often skin symptoms than employees of departments of surgery and internal diseases. There was not difference between en
department of surgery and department of internal diseases.
26 (7,2%) of respondents have diagnosed bronchial asthma, 35 (9,7%) - atopic dermatitis, 50 (13,9%) allergic rhinitis. Respondents who had diagnosed atopic dermatitis had more skin symptoms than others (r=0,287, p=0,01). Diagnose bronchial asthma and allergic rhinitis did not have correlation with more skin symptoms.
Most of respondents 133 (36,8 %) wash their hands more than 20 times per working day. 120 (33,2%) does it 11 to 20 times per shift and 87 (24,1 %) - 6 to 10 times. Only 18 of respondents wash hands 0 to 5 times per shift. . The frequency of hand washing for surgeons and doctors from anesthesiology and reanimation department was equal - 11 to 20 times per working day. For physicians of department of internal diseases it was 6 to 10 times. The most common frequency of hand disinfecting was 6 to 10 times per working
day. Nurses in department of anesthesiology and reanimation wash their hands more than 20 times per working day but nurses of departments of surgery and internal diseases 11 to 20 times. Nursing assistants in department of anesthesiology and reanimation - more than 20 times per working day, but in departments of surgery and internal diseases 11 to 20 times .There was not statistically significant correlation between more frequent hand washing and more skin symptoms.
Majority of respondents 113 (31,3 %) use hand disinfectant 6 to 10 times per working day. 0 to 5 times per day - 82 (22,7%) and 11 to 20 times - 83 (23,0 %) of respondents. 78 (21,6 %) respondents disinfect their hands more than 20 times per shift.
There was not difference in frequency of hand disinfecting among physicians of different departments. The most common frequency of hand disinfecting was 6 to 10 times per working
day. Nurses in department of anesthesiology and reanimation use disinfectant hand rub 11 to 20 times per working day but nurses of departments of surgery and internal diseases 6 to
10 times. Nursing assistants in department of anesthesiology and reanimation use it more than 20 times per working day, but in departments of surgery and internal diseases - 10 times. There was not statistically significant correlation between more frequent use of hand disinfectant and more skin symp-toms.
The average time of using protection gloves was 5,75 h. Cik videji ir simptomi tiem kas neesa <2 h , cik tiem kas 2-6 un cik tiem, kas vairak par 6
324 respondents have used latex containing gloves. 138 (38,2%) have not noticed any skin symptoms after use. 125 (34.6%) respondents have noticed skin symptoms after using latex gloves but did not have necessity to stop using them. 61 (16.9%) needed to stop using latex gloves and chose to wear gloves from different material because of the symptoms.
The duration of working day in hours did not influence quantity of skin symptoms. There was a weak correlation between more years spent working in healthcare sector and more skin symptoms (r=0,142, p=0,014).
If respondent answered that they have had any of skin or allergic symptom, they were asked to answer what is the possible cause of it. It was possible to give multiple answers. The answer frequent hand washing as cause of skin symptoms had been chosen by 191 (52,9 %) respondent. 197 (54,6%) of respondents answered that usage of disinfectant could be possible cause of skin or allergic symptom development. 28 (7,8%) thinks that contact with drugs can cause symptoms. Usage of latex gloves as possible risk factor was reported by 57 (15,8 %) of respondents.
285 respondents (78.9%) use moisturising hand cream daily, 48 (13,3 %) several times per week and 18 (5%) several times per month.
DISCUSION
BIBLIOGRAPHY
1. European Agency for Safety and Health at Work; Occupational skin diseases and dermal exposure in European Union (EU-25): policy and practice overview
https://osha.europa.eu/el/node/6875
2. Honari G, Taylor JS, Sood A. Chapter 211. Occupational Skin Diseases Due to Irritants and Allergens. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. eds. Fitzpatrick's Dermatology in General Medicine, 8e.New York, NY: McGraw-Hill; 2012.http://accessmedicine. mhmedical.com.db.rsu.lv/content.aspx?bookid=392&Section id=41138944.
3. Salako KB, Chowdhury MU. Occupational Skin Disorders. In: LaDou J, Harrison RJ. eds. CURRENT Diagnosis
& Treatment: Occupational & Environmental Medicine, 5e. New York, NY: McGraw-Hill; 2013.http://accessmedicine. mhmedical.com.db.rsu.lv/content.aspx?bookid=1186&Section id=66481203.
4. https://oshwiki.eu/wiki/Work-related_skin_ diseases#Definition_of_occupational_skin_disease
5. Smit HA, Coenraads PJ (1993) A retrospective cohort study on the incidence of hand dermatitis in nurses. Int Arch Occup Environ Health 64, 541-4.
6. Dickel H, Kuss O, Schmidt A, Kretz J, Diepgen TL (2002) Importance of irritant contact dermatitis in occupational skin disease. Am J Clin Dermatol 3, 283-9.
7. Stingeni L, Lapomarda V, Lisi P (1995) Occupational hand dermatiti
8. Smit HA, Burdorf A, Coenraads PJ (1993) Prevalence of hand dermatitis in different occupations. Int J Epidemiol 22, 288-93
9. Nettis E, Colanardi MC, Soccio AL, Ferrannini A, Tursi A. A Occupational irritant and allergic contact dermatitis among healthcare workers. Contact Dermatitis 2002; 46:101-107
10. Koch P. Occupational contact dermatitis. Recognition and management. Am J Clin Dermatol 2001; 2:353-365
11. E Held and L L Jorgensen, American Journal of Contact Dermatitis, 10 (1999), pp 299-301
12. E Larson, et al., "Changes in Bacterial Flora Associated with Skin Damage on Hands of Health Care Personnel", American Journal of Infection Control, 26 (1998), pp. 513-521.
13. Prevention of Irritant Contact Dermatitis among Health Care Workers by Using Evidence-Based Hand Hygiene Practices: A Review Günter KAMPF, Harald LÖFFLER, Industrial Health 2007, 45, 645-652
14. Tsai TF, Maibach HI (1999) How irritant is water? An overview. Contact Dermatitis 41, 311-4.
15. Manchester University. «Hand washing focus in hospitals has led to rise in worker dermatitis.» ScienceDaily. ScienceDaily, 12 February 2015. www.sciencedaily.com/ releases/2015/02/150212065137.htm
16. Eurostat, Work and health in the EU: a statistical portrait, ed. OPOCE, Office for Official Publications of the European Communities, Luxembourg, 2004. http://www. eurostat.ec.europa.eu
17. http://www.lni.wa.gov/safety/research/dermatitis/files/ derm_hcw.pdf
18. http://occderm.asn.au/wp-content/uploads/2014/10/ healthcare-worker-pdf-scf.pdf
19. occderm.asn.au par mäsäm
20. no tä pasa par latexa cimdiem
