Workplace screening for hand dermatitis: a pilot study

Abstract

Background

Health care workers (HCWs) are at increased risk for developing occupational skin disease (OSD) such as dermatitis primarily due to exposure to wet work. Identification of risk factors and workplace screening can help early detection of OSD to avoid the condition becoming chronic.

Aims

To determine risk factors and clinical findings for hand dermatitis using a workplace screening tool.

Methods

Employees at a large teaching hospital in Toronto, Canada, were invited to complete a two-part hand dermatitis screening tool. Part 1 inquired about hand hygiene practices and Part 2 comprised a visual assessment of participants’ hands by a health professional and classification as (i) normal, (ii) mild dermatitis or (iii) moderate/severe dermatitis. Risk factors were determined using chi-square and Cochran–Armitage analysis on a dichotomous variable, where Yes represented either a mild or moderate/severe disease classification.

Results

There were 183 participants out of 643 eligible employees; response rate 28%. Mild or moderate/severe dermatitis was present in 72% of participants. These employees were more likely to work directly with patients, have worked longer in a health care setting, wash hands and change gloves more frequently, wear gloves for more hours per day, have a history of eczema or dermatitis and report a current rash on the hands or rash in the past 12 months.

Conclusions

There was a high percentage of HCWs with dermatitis and risk factors for dermatitis. These findings argue for increased attention to prevention and early identification of hand dermatitis and support further testing of the workplace screening tool.

Introduction

Health care workers (HCWs) are at high risk for developing occupational skin disease (OSD) [1–5] such as dermatitis primarily due to exposure to wet work including frequent hand washing and glove use [3]. While OSD tends to become chronic, early recognition and treatment may lead to better outcomes [6,7]. While there are established tools for surveying work-related skin diseases and exposures, such as the Nordic Occupational Skin Questionnaire [8], they are not specific to assessing exposure to wet work in health care and even the shorter, abridged versions may be too long for rapid screening on an ongoing basis. The objective of this study was to pilot test a new rapid workplace screening tool for hand dermatitis in HCWs.

Methods

Employees at a large teaching hospital in Toronto, Canada, were recruited for the study while visiting the hospital’s occupational health clinic or while working on in-patient units. All available staff were approached and invited to participate. Ethics approval was obtained through the administering organization.

Participants completed a new, one-page hand dermatitis screening tool made up of two sections. The first section was completed by the participant and asked for information on demographic characteristics, hand hygiene practices and history of skin conditions. A health professional completed the second section that involved observing the participants’ hands and making a dermatitis screening classification of normal, mild or moderate/severe. The health professional made each classification based on the extent to which the participants’ hands reflected written descriptions. These descriptions were as follows: (i) normal—clear skin, no redness, dryness; (ii) mild disease—small areas of hands have slight redness, dryness or (iii) moderate/severe disease—large areas have slight redness, dryness; small areas have severe redness, dryness; scaling, fissures, crusts or scabs, vesicles and papules are present on large areas of hands. Educational material on skin health and referral for medical follow-up was provided to all participants who received a mild or moderate/severe screening result.

Results

A total of 643 staff members were deemed eligible for inclusion. Of these, 183 responded for an overall response rate of 28%. The sample was predominantly female (84%) and 69% identified nursing as their occupation. The majority of participants worked directly with patients (75%). Other demographics are presented in Table 1. The majority (68%) of participants used a combination of soap and warm water and alcohol-based hand rub for hand hygiene. A large proportion (55%) washed their hands at least 20 times per day. Glove use was also common, both in terms of the number of hours gloves were worn and the number of times gloves were changed per day.

To compare risk factors for those with dermatitis present versus those with no disease, the mild and moderate/severe screening categories were collapsed into a dichotomous dummy variable, where Yes indicated presence of dermatitis. Comparisons were made using chi-square tests for goodness of fit for unordered variables and using Cochran–Armitage test for ordinal variables. In total, 72% of the sample had a positive screening. These comparisons are shown in Table 1. Employees with a positive screening were found to be significantly more likely to: work with patients, have worked longer in a health care setting, wash their hands more frequently, change their gloves more frequently, wear gloves for a larger proportion of the day and report a past history of eczema or dermatitis as well as a current rash or a rash on their hands in the last year.

Discussion

The present study found a high rate of positives (the majority were classified as mild) using the screening tool compared to the rate of occurrence of 21–30% reported for HCWs in the literature [1,3,9]. This could be due to the large percentage of direct care providers in the sample with significant exposure to wet work or due to the screening being conducted by a trained health professional who accurately identified hands with small areas of redness and dryness as having ‘mild disease’ as opposed to being ‘normal’. In addition, prevalence studies have been conducted using a variety of methods, including surveys, examination and a combination of both. A study that compared two different surveys found a 3-fold difference between the prevalence calculated [10]. For screening purposes, a high sensitivity is important to ensure individuals with disease are not missed. The high rate of positives could also be explained by response bias where those who were more likely to have a problem were more likely to participate in the study. While 72% of participants had a positive screening result, 70% of participants reported that they did not have a current rash on their hands. Some workers may think that mild changes are normal for the job and not think about them as a ‘rash’.

The study examined a number of risk factors for a positive screen that were generally similar to those reported in the literature. The association with direct patient care, glove use (number of changes and time worn), hand washing and a history of skin conditions was similar to other studies [1,3,4]. No significant effect of age on positive screening was found in the present study. Previous research has found a relationship between age and diagnosis, with hand eczema being more common in younger HCWs, while others have failed to find such a connection [3,5]. However, this study found that participants with longer work histories were more likely to have a positive screening result. Past studies provide mixed evidence on this matter, with some studies finding a similar relationship while others did not [1,2].

In conclusion, the present study identified a high proportion of HCWs with hand dermatitis using a new workplace screening tool. This finding makes the case for increased attention to prevention and early identification of hand dermatitis. Risk factors identified for those with a positive screening result were generally consistent with the research literature that supports further testing of the tool.

Funding

Ontario Ministry of Labour grant to the Centre for Research Expertise in Occupational Disease.

Conflicts of interest

None declared.

References