Analysis

Sore hands? How nurses can prevent and treat contact dermatitis

The condition can be devastating for a nurse’s career and well-being, but it’s possible to minimise risk

The condition can be devastating for a nurse’s career and well-being, but it’s possible to minimise risk

  • The everyday tools of patient care, including gloves and certain chemicals, create a hostile environment for nurses’ skin health
  • Contact dermatitis has implications for staffing, nursing practice and infection control – as well as the individual
  • Find out what you can do to protect yourself and others in your workplace

Picture: iStock

Nurses and doctors experience contact dermatitis at more than four times the rate of workers in other sectors, according to latest estimates from the Health and Safety Executive (HSE).

However, RCN Tools of the Trade guidance on contact dermatitis says under-reporting is likely. It quotes figures indicating that each year in the UK 1,000 health workers develop work-related contact dermatitis but says this may represent the tip of the iceberg.

Skin health and its importance to a nurse’s career

While gauging the number of nursing staff with serious skin health problems appears to be difficult, assessing the potential impact of those conditions on individuals is more straightforward.

RCN professional lead for infection prevention and control Rose Gallagher is clear that contact dermatitis can be ‘absolutely devastating’ for some health workers.

‘In the most severe cases, we know that nurses have had to give up their careers,’ she says.

What exactly is contact dermatitis and why is it such a big problem for nurses?

The HSE explains that overhydration and dehydration can compromise the skin’s barrier properties. If skin is overhydrated, by wearing gloves that prevent sweat evaporation for example, production of natural moisturising factors is inhibited.

1.7 billion

Number of nitrile gloves used in the NHS each year

(Source: RCN)

Equally, dry atmospheric conditions such as an air-conditioned workplace with low humidity can also be damaging, with skin dehydrating and becoming rough and flaky.

When the skin is breached, dermatitis can result. Although some people have an inherited tendency to develop the condition, work-related cases commonly involve an external agent that causes skin irritation or an allergic reaction, or both.

Ms Gallagher says nurses are at particular risk of contact dermatitis because they are exposed to a range of irritants and allergens. So soap, for example, may not on its own cause a reaction. ‘But when it’s combined in a cocktail effect with other irritants, that can cause lots of problems for nurses’ hands,’ she says.

Contact dermatitis: signs, management and prevention


Picture: iStock

Itchy, red, dry, cracked, blistered skin, typically on the hands, indicates contact dermatitis.

In allergic contact dermatitis, sensitisation can occur at first contact or after months or years of contact. ‘Healthcare workers may not realise that harm is occurring,’ says RCN guidance.

Steps to take to minimise harm

A three-step approach, ‘avoid-protect-check’, can help prevent contact dermatitis. Avoid direct contact between unprotected skin and hazardous and/or wet work, ‘where this is sensible and practical’, advises the RCN. Protect the skin if contact cannot be avoided. And check hands regularly for skin damage.

32˚C 

Optimum water temperature for rinsing washed hands

(Source: RCN Tools of Trade guidance)

Practise appropriate hand hygiene and glove use, following local policies and procedures. Read the RCN’s Tools of the Trade guidance and consult your safety representative, if you belong to a union. If problems occur, tell your manager and/or occupational health.

Avoiding contact with the irritant or allergen is the main way of managing contact dermatitis, says the British Association of Dermatologists. Gloves, emollient creams and avoiding contact with soaps and detergents are also recommended.

Pharmacological interventions

The association advises that it can take several months for contact dermatitis to settle. Steroid creams can help reduce skin inflammation and in severe cases oral steroids and antibiotics may be required.

Before consulting a health professional about your contact dermatitis, the RCN recommends you compile relevant information such as the type of any gloves you use, substances and chemicals with which you have contact at work and home, and whether your skin improves during breaks from work. 

 

Materials that are skin irritants

Latex gloves are a common ingredient in that cocktail. Many organisations are now moving more towards nitrile or synthetic gloves. But, says Ms Gallagher, glove use still poses a risk.

‘There are other chemicals called accelerators that are used as part of the glove-manufacturing process, which we know can also provoke a reaction in some staff.’

‘Cutting down on glove overuse has supported staff to have healthier hands so they can complete their responsibilities’

Helen Dunn, lead nurse for infection prevention and control, Great Ormond Street Hospital

She adds: ‘That’s where using gloves appropriately will help staff to reduce the risk and support good skin health.’

Sarah Wilkes is senior infection prevention and control nurse at University Hospitals Birmingham NHS Foundation Trust, where staff are offered regular skin health checks. She says some nurses put on gloves automatically, even in situations where they are not required, which could be damaging their skin.


Activities that do not require gloves
to be worn include preparation of
IV medication  Picture: iStock

Weaning nursing staff off unnecessary glove use

Taking her lead from the RCN’s glove awareness work and a successful skin health campaign at Great Ormond Street Hospital (see case study), Ms Wilkes has been trialling an initiative to cut glove use during the preparation and administration of intravenous medication.

‘It was received well, although nurses typically said they found it odd at first, not wearing gloves.’

Raising awareness of contact dermatitis was a strong selling point of the initiative, which will be adopted trust-wide to mark RCN Glove Awareness Week 2020, starting on 27 April.

But Ms Wilkes says it had other important effects too, including reduced waste. It also focused attention on the patient experience. ‘Lots of patients prefer human contact and having gloves on disrupts that.’

How Great Ormond Street Hospital tackled overuse of gloves

Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) ran a campaign to improve skin health among staff through more appropriate glove use. Lead nurse for infection prevention and control Helen Dunn outlines the initiative’s aims and outcomes:


Helen Dunn, centre, with colleagues from the Gloves are off campaign, practice educators
Nicola Wilson and Amy Leonard  Picture: GOSH

We launched our Gloves are off – safer in our hands campaign in April 2018 to improve hand hygiene and staff well-being.

We were concerned staff were frequently reporting skin issues such as contact dermatitis, which we suspected was caused by overuse of non-sterile gloves.

At that point, GOSH was ordering around 200,000 pairs of gloves per week and we were aware that we also needed to do more to reduce waste.

I worked with lead practice educators Amy Leonard and Nicola Wilson to put together a campaign based on the RCN’s glove awareness week.

Aims of the campaign

Gloves are off focused on educating staff about when gloves should be worn for their own protection, as well as empowering colleagues to undertake risk assessments when deciding whether or not to wear gloves.


An illustration from the campaign pushes the message that over-reliance on use of gloves 
should be consigned to the past

One of our key messages was that non-sterile gloves should only be used by health professionals when they were likely to touch blood, bodily fluids or mucous membranes.

We developed a ‘train the trainer’ package so that our educators could take the messaging across the trust. The messaging was also supported on internal communication channels.

To ensure the programme was successful, it was important we didn’t focus on nursing staff alone. We worked hard to reach a wide range of staff across the trust, talking to porters, occupational therapists, physios, pharmacists and GOSH school employees.

Positive feedback and outcomes

We’ve been really pleased with the impact the campaign’s had on reducing contact dermatitis and improving well-being at the trust.

Before the Gloves are off campaign, we knew a small number our staff were finding it difficult to carry out clinical work because of skin-related issues. We’ve had feedback from our colleagues that these issues improved in many areas of the trust. Cutting down on glove overuse has supported staff to have healthier hands so they can complete their responsibilities.

Sustained benefits for people and the environment

We’ve also had anecdotal evidence from staff that the improvement in their hand health has been sustained since the campaign’s launch. We haven’t seen a rise in infections as a result of the way we use gloves since beginning the campaign, which is really positive.

The wider benefits of gloves are off have been significant. In the year following the launch, GOSH ordered 3.7 million fewer gloves than in the previous 12 months. This saved more than £90,000 and meant 18 tonnes less plastic was used.

 

Much more than just a bit of skin redness 

So there are good reasons to attend to skin health, particularly through appropriate glove use. But ultimately does it matter much if a nurse contracts contact dermatitis. Is it not, after all, ‘just a bit of red skin’?


Dermatitis can make it more difficult to use alcohol-based hand cleansers, or indeed
soap and water Picture: iStock

The RCN’s guidance addresses that question by considering the far-reaching consequences of contact dermatitis.

If you do develop sore, red hands, it is likely you will be unable to use alcohol hand sanitisers. Because of the soreness, you may even be unable to wash your hands with soap and water. You may also be more susceptible to infection.

‘We can’t afford to lose any nurses, least of all to conditions which are potentially preventable’

Rose Gallagher, professional lead for infection prevention and control, RCN

‘That means we need to remove staff from clinical duties until their hands are healed and until they are able to perform hand hygiene again,’ Ms Gallagher says. In the worst cases, the condition may not resolve even when exposure to the substance responsible is removed.


Rose Gallagher, RCN professional
lead for infection prevention and control
Picture: David Gee 

Advice for line managers

  • Ensure compliance with specific legal requirements, such as the Health and Safety at Work Act and COSHH (control of substances hazardous to health) regulations, to ensure the risks of developing contact dermatitis are minimised
  • Implement regular skin health checks to identify contact dermatitis at an early stage
  • Consider how to prevent exposure to harmful substances and, where possible, eliminate this exposure. For example, replace powdered latex gloves with powder-free alternatives, the RCN advises 
  • Employers and employees have a responsibility to work together to reduce the prevalence of dermatitis,’ says the RCN’s Rose Gallagher. ‘Every employer should have policies and procedures in place, and I see skin health as an integral part of hand hygiene policies'
  • Make sure staff know where to go to get help with contact dermatitis and that they attend appropriate health and safety training
  • Encourage regular use of hand creams and conditioning creams after hand washing 

 

Implications for nurse staffing

Having to take time off work to let your hands recover, or being moved to non-clinical duties, affects staffing levels, which as every nurse knows are far from adequate.

But there is also a risk of psychological distress, a known issue for people with dermatitis. The RCN says if it is evident to others, dermatitis can make the person affected ‘miserable and withdrawn’, particularly if the condition becomes chronic.

So that ‘little bit of red skin’ does matter – to the individual, to the wider health service and, ultimately, to patients.

‘We can’t afford to lose any nurses, least of all to conditions which are potentially preventable if they are recognised early,’ says Ms Gallagher. ‘That’s why skin health checks are so important.’


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