Dermatitis rates vastly under-counted

Real rate some 100 times higher

Health care workers may be suffering in silence from work-related dermatitis. Cases of work-related dermatitis are about 100 times greater than the rate reflected in federal data, and health care workers are at greater risk than most other occupations, according to an analysis of the National Health Interview Survey.1

Almost one in 10 (9.2%) health care workers with dermatitis reported that they had been told by a health provider that the skin disorder was work-related — about double the rate of other occupations. Overall, the prevalence of work-related dermatitis was about 100-fold higher than the count reported by the U.S. Bureau of Labor Statistics, researchers at the National Institute for Occupational Safety and Health (NIOSH) found.

Yet even that is an understatement of the problem of work-related dermatitis, says Kenneth Rosenman, MD, chief of the Division of Occupational and Environmental Medicine at Michigan State University in East Lansing and a national expert on surveillance of occupational injuries and illnesses.

Many people don’t talk to their doctors about the work-relatedness of their skin conditions, Rosenman says. In 2011, Michigan conducted a Behavioral Risk Factor Surveillance System survey and asked a question: “Do you think your skin condition was probably work related?”

Adding that question boosted the prevalence of work-related dermatitis by 76%. That means about 16% of health care workers who have dermatitis have a condition that is likely work-related, he says.

This is not just a numbers game, Rosenman emphasizes. By failing to detect cases of occupational dermatitis, employee health professionals lose the opportunity to make corrective changes, he says. “We could better address the work practices or substitute a different cleaning agent,” he says.

Better surveillance data also reveals the burden and risks of various industries and occupations. Rosenman has criticized using an employer survey as the sole method of determining federal injury and illness data.

“[The dermatitis research] is just another example that the BLS employer based survey is totally inadequate,” he says.

Frequent hand washing damages skin

Healthy People 2020 sets a goal of reducing occupational skin dermatitis by 10%. But that may be a particular challenge in health care because of frequent hand washing and donning and doffing of gloves, says Marty Visscher, PhD, director of the skin sciences program at the Cincinnati Children’s Hospital.

“If people comply with the hand hygiene guidelines, they’re going to have skin damage,” she says.

In 2011, the Bureau of Labor Statistics reported that 6.3 out of 10,000 hospital workers have work-related skin disorders, about twice the rate of 3.3 for all workers.

Some parts of the hospital and some occupations have a much higher risk. In the neonatal ICU, for example, Visscher sees employees with erythema on their knuckles, small fissures and cracks on the knuckles and even around the cuticles, and flaking on the palms. “They’ll say, ‘You should have been here last night. My hands were bleeding into the chart,’” she says.

A 2007 study found that 55% of inpatient nurses and 65% of ICU nurses had observable dermatitis.2

The problem often begins with frequent hand-washing. Depending on the patient load, a nurse on a 12-hour shift may perform hand hygiene 70 to 200 times, says Visscher. If that includes frequent hand-washing, the outer barrier of the skin is compromised, she says.

“Soap wears away some of the structural materials in the top layer of the skin,” she says. “That opens up channels for irritation ... The number one reason people will give you for not doing hand hygiene is the irritation. It is a factor.”

Frequent use of creams can help

Hand sanitizers are designed to enable repetitive hand hygiene without damaging the skin. But if the skin is already damaged, the alcohol-based rubs can cause additional irritation, says Visscher.

“When the skin is damaged enough, it has tiny cracks. When people use alcohol hand rubs, they get stinging and burning,” she says. “We can’t ignore health care workers when they’re saying this hand sanitizer stings.”

Intensive treatment with hand creams can reduce irritation and erythema, Visscher found in a study of workers in the NICU at Cincinnati Children’s Hospital. The study group used a cream called Remedy, which is free of petroleum and mineral oil, and applied it at least 10 times a day on off days and five times on work days. Workers using the test cream had less erythema than a group using their usual products and a control group.3

Visscher advises health care workers to have “proactive use of skin repair” — to put moisturizing cream on their hands frequently throughout the day. Lotion can be provided in break rooms and bathrooms, she says. “If they can carry a hand sanitizer in their pocket, they can carry a small tube of lotion in their pocket,” she says.

Lotions or creams should be free of petroleum-based products, such as petrolatum, or petroleum jelly, and mineral oil, because they can compromise the integrity of the gloves, Visscher says. In her study, about 80% of the personal lotions or creams used by health care workers contained petrolatum or mineral oil.

In fact, glove use itself is irritating because of the friction of pulling them on and off and the potential for moisture to build up on the skin beneath the glove, she says.

Nurses and other health professionals may treat their own skin problems with over-the-counter products. Hospitals should encourage health care workers to report skin conditions, says Rosenman.

“There has to be a culture at the health care facility that ‘We want to know when you think you’re having a work-related problem,’” he says. “Even if you’re self-treating, or you’re seeing your personal health care provider, we still want to know because we want to see if there’s a pattern in the hospital.”

References

1. Luckhaupt SE, Dahlhamer JM, Ward BW, et al. Prevalence of dermatitis in the working population, United States, 2010 National Health Interview Survey. Am J Ind Med 2012; epublication DOI: 10.1002/ajim.22080.

2. Lampel HP, Patel N, Boyse K, et al. Prevalence of hand dermatitis in inpatient nurses at a United States hospital. Dermatitis 2007; 18:140-142.

3. Visscher M, Davis J and Wickett R. Effect of topical treatments on irritant hand dermatitis in health care workers. Am J Infect Control 2009; 37:842.e1-842.e11.