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Irritant Contact Dermatitis on Hands: Literature Review and Clinical

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DOI: 10.1177/1062860615611228

Clinical Application ajmq.sagepub.com

Maryanne McGuckin, Dr ScEd, FSHEA1 and John Govednik, MS1

Abstract
Hand hygiene (HH) is the single most important procedure health care workers (HCWs) can follow to reduce the risk
of spreading health care–associated infections, yet compliance with this simple task remains at less than 50%. One of
the reasons often cited for noncompliance is irritant contact dermatitis (ICD) resulting from repeated exposure to HH
products and procedure. This literature review used the World Health Organization’s components of empowerment
as a guideline for the search and development of a clinical model to address HCW HH and ICD.

Keywords
hand hygiene, irritant contact dermatitis, compliance, health care worker, skin irritation

Hand hygiene (HH) is the single most important proce-
dure health care workers (HCWs) can follow to reduce
the risk of spreading health care–associated infections.
However, compliance with this simple task remains less
than 50%.1,2 One of the reasons often cited for noncom-
pliance is irritant contact dermatitis (ICD) resulting from
the deleterious effects of repeated exposure to HH prod-
ucts and procedure.3
It is difficult to conduct a clinically realistic study
without disrupting normal practice in the clinical area. As
a result, there are relatively few published accounts about
various aspects of hand skin condition among HCWs
under typical clinical conditions.4,5 Although the number
of published studies dealing with HH has increased con-
siderably in recent years, many questions regarding HH
products and strategies for improving HCW compliance
with recommended policies remain unanswered.
The incidence of ICD has been well documented.
Boyce and Pittet6 found that up to 85% of nurses described
histories of skin problems and 25% reported symptoms of
dermatitis. Lampel et al7 found that 55% of inpatient
nurses and 65% in the intensive care unit (ICU) had
observable hand dermatitis.7 Although the rate of ICD has
been reported as unchanged for the years prior to an
increase in methicillin-resistant Staphylococcus aureus
(MRSA),8 a recent study from the University of
Manchester’s Institute of Population Health (Manchester,
UK) found that out of 7138 cases of ICD reported, 1796
were in HCWs, based on reports voluntarily submitted by
dermatologists between 1996 and 2012.9 When the num-
bers were broken down by year, HCWs were 4.5 times
more likely to suffer from ICD in 2012 as in 1996. This
increase was attributed to a drive to reduce MRSA.
The objectives of this report are 4-fold: (1) provide an
overview of skin physiology and microflora, (2) review
the literature on monitoring skin integrity on hands, (3)
summarize HH policies that address ICD, and (4) provide
a model for clinical application that includes knowledge,
skill building, and practical application in a facilitative
environment for HCWs to address ICD. To the best of the
authors’ knowledge, this is the first literature review of
ICD and HCW’s hands using HCW knowledge, skills,
and a facilitating environment as the framework for the
review and clinical application.
Methods
The authors conducted a review of the scientific literature
in peer-reviewed publications in the PubMed/MEDLINE,
ScienceDirect, ProQuest, Academic OneFile, ClinicalKey,
JSTOR, and AccessMedicine databases. Search terms
were hand hygiene, skin physiology, antiseptics, physi-
cians, medical personnel, hand disinfection, alcohol-
based hand rubs, compliance, nosocomial infections,
occupational dermatitis, hand washing, skin flora, hand
rub, and integumentary. Approximately, 120 articles were
1
McGuckin Methods International, Ardmore, PA
Corresponding Author:
Maryanne McGuckin, Dr ScEd, FSHEA, McGuckin Methods
International, 115 E Athens Ave, Ardmore, PA 19003.
Email: maryanne@mcguckinmethods.com

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2 American Journal of Medical Quality
retrieved; 71 met the criteria for HCWs and ICD, and ulti-
mately 29 sources were used in this report. Preference was
given to research that focused on the HCW’s knowledge,
actions, and choices made for product or procedure. Some
articles were not included because of redundancy of infor-
mation, particularly of background knowledge such as
role of skin and microflora, which are well documented.
A subsequent online search for provider-centered HH
policies was conducted. Although many policies are
available online, very few of the policies found had pro-
cedures in place for ICD indications. Only those few
findings are discussed here rather than include any guide-
lines that are missing ICD instruction.
Results
Following the framework of the review, results are
reported in 3 sections: (1) knowledge of skin function and
ICD, (2) skills to monitor ICD on HCW’s hands, and (3)
guidelines, practices, and policies for HCWs to act on
ICD-related issues.
Knowledge of Skin Function and ICD
This component of the review was conducted with the
goal of providing an overview of skin physiology. The
skin serves multiple functions, including that of a barrier
(eg, to water loss, irritant exposure, light) and for infection
control, sensation, structural support, and thermal regula-
tion. The outermost layer, known as the stratum corneum
(SC), provides a physical, mechanical, and immunologi-
cal barrier against environmental insults. The viable epi-
dermis continuously builds and replenishes the barrier.
The living cells release their contents to create lipid layers
that assemble between the cells, which have flattened in
shape. In this process, the cells “move up” from the lower
layers and are released or shed from the skin surface via
desquamation. The sequence is carefully programmed and
orchestrated through signaling mechanisms to form an
incredibly thin and strong structure that resembles a “brick
and mortar” array. Extremely large forces are required to
destroy its integrity. Langerhans cells (antigen-presenting
cells) are located in the viable layer (epidermis). They are
part of the immune system and “defend” the organism if
the SC barrier is breached. The SC barrier shields the
Langerhans cells from direct environmental exposure,
thereby serving an essential function in infection control.
The following 3 studies support the importance of the
skin as a barrier and the importance of keeping healthy
skin intact. The maintenance of a normal, healthy intact
skin barrier is essential for maximum protection of both
patients and HCWs alike.8 Chronic hand skin compro-
mise has significant implications for infection control. A
damaged barrier is more susceptible to penetration by
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environmental insults, including microorganisms. As
skin damage increases, the total bacteria counts on the
hand are higher.10 Irritated hands can have significantly
more colony-forming units than nonirritated hands.11 The
frequency of colonization with S hominis, S aureus,
Gram-negative bacteria, enterococci, and Candida was
higher in nurses with damaged hands.12 Damaged hand
skin in HCWs was associated with higher frequencies of
S aureus, Gram-negative bacteria, and yeast.13
Skills to Monitor ICD on HCWs’ Hands
It is a challenge to monitor ICD during regular clinical
practice without disrupting the normal behaviors of
HCWs in order to gather data. However, when studying
the impact of HH products and procedure, many sources
document if or how they monitored ICD for the study.
Examples of objective reporting (independent evaluator)
and self-reporting (self-surveys and/or monitoring of
complaints to Employee Health) were found.
In one study, 52 nurses who were assigned to perform
HH by exclusively washing or exclusively using alcohol
rub were trained to grade their own hands using the
Larson’s Skin Assessment Rating Scale, which assigned
points to skin appearance, integrity, moisture, and for this
particular study, skin sensation.10 A trained dermatologist
also provided independent scores using the Larson scale
(without the skin sensation rating) as well as a different
scale, the Sauermann Score, which rated visible changes
in dryness, redness, wrinkles, and fissures. The authors
conclude that self-reported skin damage was significantly
worse with soap than sanitizer. Self-reported Larson
scores indicated worse ICD than did Larson scores
reported by the dermatologist; the authors suggest that the
onset of skin sensation (irritability as reported only by the
HCW and not the dermatologist) may be an early sign of
skin intolerability before any visible signs of ICD appear.
In a multicenter, 2-period study, Souweine et al14 stud-
ied skin tolerance, acceptability, and compliance when
comparing use of soap (first period) versus alcohol rub
(offered in addition to soap for second period only) among
350 HCWs in 7 ICUs. Compliance increased in the second
period once the alcohol rub was introduced. Via a 7-point,
self-reported questionnaire that ranked 4 criteria (ery-
thema, itching, oozing, bleeding), HCWs reported fewer
unpleasant skin problems during the period when alcohol
rub was an option, though acceptability did not differ
between the product types. During the study, it was noted
that no one consulted the dermatologist or the occupa-
tional physician for undesirable skin effects.
Pittet et al15 reported on a hospital-wide HH program
that improved HH compliance as monitored via observa-
tion, changes in health care–associated infection rates, and
changes in product consumption. HCWs were repeatedly
McGuckin and Govednik
encouraged to consult the Employee Health unit for any
concern linked to the use of HH products during the study.
Despite the increase in compliance among some HCWs
and the substantial increase in the use of alcohol-based
hand rub, no case of substantial skin damage (excessive
skin irritation and dryness with fissuring or cracking,
severe ICD, allergic or toxic reactions) was reported to the
Employee Health unit. (This is an example of monitoring
the traffic for third-party monitoring and interventions.)
Current Guidelines, Practices, and Policies
Guidelines. In addition to providing instructions on proce-
dure, the US Centers for Disease Control and Prevention’s
2002 guidelines for HH also suggest proper care for HCW
hands.16 The guidelines charge management to provide
HCWs with hand lotions and creams and also encourage
consultation with product manufacturers on the impact of
creams and lotions on their antimicrobial soaps and
sanitizers.
The World Health Organization guidelines encourage
the use of lotions and creams to treat symptoms of ICD1;
they not only encourage HCWs to consult manufacturers
on impact and compatibility with antimicrobial HH prod-
ucts, but they also encourage HCWs to consider the aller-
gic reactions some may incur when using moisturizers.
The Royal College of Physicians’ (United Kingdom)
national guideline on dermatitis in the health care work-
place discusses the roles and efficacies of prework (barrier)
creams, conditioning creams, and HH procedures that affect
ICD.17 Although their findings indicate that prework creams
have an overall positive impact on HCW skin quality and
function, the impact of conditioning creams is less proven
and may even cause further hand irritation, and they note
the need for additional research in the clinical setting.
In addition to national/governmental guidelines, many
professional groups offer their own guidelines to address
ICD. The AORN Journal offers a continuing education
component with these statements: “Another barrier to fol-
lowing hand hygiene practices is skin irritation, which
can occur with the use of hand hygiene products.
Perioperative team members should remember to let their
hands dry completely before donning gloves, and in some
cases, alternate products should be provided to personnel
who have sensitive or reactive skin.”18(p456) It does not
specifically state the source and type of alternative prod-
ucts, or if they can be stand-alone lotions, or if they must
be emollient-rich antimicrobial soaps or sanitizers.
In Dimensions of Dental Hygiene, Shah19 discusses hand
dermatitis among oral health care and medical providers,
which is 17% to 30% more common than in the general pop-
ulation. The author suggests that HCWs use appropriate
water temperature, avoid irritants, use emollients, and choose
gloves that support skin health. Without specific reference to
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3
products or their facility approvals, the author states that reg-
ular application of ointments after handwashing is recom-
mended and to avoid oil-based moisturizers because they
may impede the effectiveness of HH products.
In a monograph for continuing study for registered
nurses, Murphy20 suggests 10 different self-study tests
that a HCW can perform to determine the source of hand
irritation. Steps include observing technique for washing
and drying, checking environmental factors such as
cleansers or laundry detergents, and even considering
seasonal weather. The final step suggests that if all else
still does not yield a reasonable case history, the HCW
should be referred to his or her own doctor or occupa-
tional health for assessment.
Public Health Ontario (Canada), a public health
agency dedicated to protecting and promoting the health
of all Ontarians through the application and advancement
of science and knowledge, manages the Just Clean Your
Hands program21 to promote, evaluate, and audit HCWs’
HH practices. Included is a fact sheet and assessment
questionnaire for skin problems associated with HH. The
tool can be used to devise a strategy to avoid practices or
products that cause irritation.
Practice. There are several documented studies on the role of
alternative soaps and sanitizers as well as creams and other
emollients to prevent or repair ICD. In 1998, Larson et al12
noted, “Skin-moisturizing products are in widespread use
among patient care personnel, but hospital policies and pro-
cedures for hand care regimens are generally silent on their
use, thus nurses bring a variety of products from home,
which increases the risk of misuse, contamination, and
incompatibility. The use of moisturizing products in health
care institutions should be examined and incorporated in a
more formalized and standardized fashion into policies, pro-
cedures, and practices.”12(p519) In 2001, Larson22 noted more
specifics in a review of HH: “Effective skin emollients or
barrier creams may be used in skin-care regimens and proce-
dures for staff (and possibly patients as well). . . . Skin mois-
turizing products should be carefully assessed for
compatibility with any topical antimicrobial products being
used and for physiological effects on the skin.”22(p225)
Rocha et al13 compared microbial flora of nurses with
healthy hands (n = 30) versus nurses with hands damaged
by frequent HH or wearing gloves (n = 30). Damaged
hands had higher bacteria counts. The authors recommend
that because irritation caused on the skin by frequent
washing and/or wearing of gloves is associated with
changes in hand microbial flora, their potential risks
should be considered when institutions/users are selecting
products/formulations to ensure hand skin health and con-
sequent compliance with their own hygiene procedures.
McGuckin et al23 managed a HH product usage moni-
toring program and noted a drop in sanitizer usage at the
4 American Journal of Medical Quality
beginning of the new year/January-February time of year.
Follow-up with members in the program revealed that
HCWs were bringing their own personal sanitizers and
lotions to work. Products given to them over the holidays
were preferred over hospital-provided products for rea-
sons such as home products having a desirable scent or
because portability of the product allowed ease of use.
Detailed monitoring of product usage will reveal the hab-
its of HCWs that may need to be addressed in order to best
follow professional directives on the use of products.
Policies. Empowerment will not occur without a workplace
environment that encourages, supports, and facilitates the
use of knowledge and skills. In terms of ICD, an important
first step is to have policies in place to ensure that every
HCW knows how to access an evaluation and care plan.
Shared in the following paragraphs are some of the health
care provider policy manuals or sections that were freely
available online. They do not represent a scientific sample of
hospital policies, but they can be used as examples of includ-
ing skin integrity in a health care provider policy manual.
Mayo Clinic HH Policy: “Only institutionally provided
and approved hand lotions and creams are used by
HCWs in the clinical setting. HCWs with hand skin irri-
tation should discuss their concerns with their supervi-
sor and Employee Health Services to develop a plan for
resolving the irritation.”24
Department of Veterans Affairs (US) directive:
“Appropriate hand lotions or creams to minimize irritant
contact dermatitis must be readily available. NOTE:
Products designed for health care applications that do
not reduce the effectiveness of other hand hygiene prod-
ucts, such as antimicrobial compounds, eg, Chlorhexidine
Gluconate (CHG), need to be provided. Some lotions
are specifically advertised as ‘CHG compliant.’ Hand
lotions or creams must be compatible with gloves being
used in the facility.”25
University of Texas Medical Branch HH policy: “Bottles
and other large containers of hand lotions may become
contaminated with pathogenic organisms. Therefore,
only small disposable bottles or packets of lotions shall
be used. Allergic reactions to products applied to the
skin may present as delayed type reactions or less com-
monly as immediate reactions. If a HCW suspects aller-
gic contact dermatitis, they will be instructed to go to the
Employee Health Center and fill out a Hand Dermatitis
Documentation form (see attached). The HCW will be
assessed by the Employee Health physician. If allergic
contact dermatitis is diagnosed, the HCW will take the
form to Materials Management whereby another hand
hygiene product will be issued.”26
Oregon Health and Science University Radiologist
Manual explicitly states, “In order to prevent irritation
to the hands, hospital approved and provided lotions
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compatible with antimicrobial soaps should be used lib-
erally while at work. Personal lotions should be used
while away from work. If hands continue to remain dry,
especially if skin integrity is affected, the employee
should consult Employee Health as soon as skin break-
down is noticed.”27 Note the directive for compatibility
with other hospital-provided products as well as the
need to seek assistance.
The University of California Medical Center HH Policy:
“Occupational Health Services is responsible for respond-
ing to and evaluating staff skin irritation complaints and
alternate product recommendations. Hospitality Services
provides one hand lotion dispenser at patient care unit sta-
tions. Additional lotion dispensers can be ordered by
patient care unit managers. . . . Apply lotion to your hands
at least at the following 4 times every day, making sure to
leave it on your skin for at least 30 minutes after each
application: (1) With your waking toilette, (2) At your
meal break, (3) At the end of your work shift, (4) Upon
retiring. Use the UCSF-provided lotion. Our hand product
manufacturer develops products that are formulated to
work cooperatively on your skin.”28
Discussion
The authors found a vast amount of research on skin
function, physiology, and impact of HH product and pro-
cedure on skin integrity. The most significant finding was
the fact that HCWs were 4.5 times more likely in 2012
compared with 1996 to experience ICD attributed to the
increase in MRSA.
This review of how ICD was identified and measured, as
a practical skill to apply the knowledge, was not as in-depth
as expected. The most common methods found were (1) self-
reporting and (2) documenting the number of complaints to
Employee Health (perhaps more of a surrogate data mea-
sure). These were clinical studies in which the methodology
was implemented as part of the study, and it was not specified
that it was a normal routine for HCWs to, for example, evalu-
ate their skin irritation with any frequency. More information
on day-to-day skin condition is needed using standardized
techniques, so that models can emerge on the best methods
for identifying and addressing ICD.
The most significant finding in this search of HH poli-
cies that addressed ICD was the existence of a number of
HH policy guidelines that did not mention skin irritation
or ICD-related topics. Specific instructional steps provid-
ing appropriate products to avoid ICD or repair-compro-
mised skin should be an integral part of that policy detail.
Empowerment and Clinical Application
HH and ICD management must be a joint process if com-
pliance is to be sustained. An important factor for both
HH compliance and ICD is empowerment of the HCW.
McGuckin and Govednik 5

Figure 1. An empowerment model to address irritant contact dermatitis (ICD) on health care worker (HCW) hands.

Measurement:
x Self-Monitoring
{ Cover indications related to appearance and sensation
ƒEstablished assessment tools
ƒHospital’s own assessment tool
x Objective Monitoring
{ Easily covers appearance-related indications but difficult to assess sensation
{ Colleague, supervisor, or trained observer
ƒConsistent measurement for multiple staff members
ƒAs above, can use established assessment tool or hospital’s own tool
x Surrogate Monitoring
{ Tally the number of ICD complaints or visits to Employee Health
Facilitative Environment:
{ Provide information on ICD causes and impact to HCWs
{ Provide alternative hygiene products, as well as lotions and creams
ƒPer manufacturers soap/sanitizer compatibility requirements
ƒTest for allergic reactions on HCWs
ƒDetermine if either prework (barrier) creams or conditioning creams are best for your team’s needs
ƒ Specifically detail instructions on how to avoid ICD when HCWs perform certain tasks (eg, don gloves or expose
themselves to risk during specific treatments such as providing oral care)
ƒObserve hygiene habits and provide feedback on any practices that increase risk of ICD
ƒMonitor environmental factors (health facility-related or external such as weather)
ƒEstablish threshold for when a HCW should be referred to a professional for treatment of ICD symptoms

Figure 2. Summary of points to establish measurement skills and a facilitative environment for monitoring and improving health
care worker (HCW) irritant contact dermatitis (ICD).

As a result of this review and based on proven models of be used to introduce management to the concept of
empowerment, the authors developed a clinical applica- empowerment and how ICD monitoring can be added to
tion for ICD and HH. Figure 1 is the framework that can an HH compliance program. Figure 2 outlines suggested

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6 American Journal of Medical Quality
practices based on the literature for clinical application of
monitoring ICD.
Conclusion
This review suggests that compliance with required pro-
cedures for HH results in damaged skin and an increased
bacterial load, so it is critical that HCWs understand this
concept and be given steps (skills) to avoid damaged
skin. Although various regulatory organizations address
ICD as a barrier to HH, no consensus was found among
these groups in the form of guidelines for reporting or
monitoring ICD by HCWs. Failure to provide policies for
HCWs when ICD appears will lead to a decrease in HH
compliance. HH compliance is a multimodal process that
will change as we look at missing links to increase and
sustain compliance.
Acknowledgment
We wish to thank Jenn Carson, BA (Hon), MSLIS, College of
Computing and Informatics (Library and Information Science),
Drexel University, for her assistance in the literature review
process.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received the following financial support for the
research, authorship, and/or publication of this article: Funding
for this literature review was provided by an unrestricted grant
from Georgia-Pacific LLC.
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