Larson Et Al., 1997

Prevalence and correlates of skin damage on the hands of nurses

E. L a r s o n , PhD, RN, F A A N , CIC, a C. F r i e d m a n , M P H , CIC, b J. C o h r a n , M S N , RN, CIC, c

J. T r e s t o n - A u r a n d , M S , RN, CIC, d a n d S u s a n G r e e n , BS, e W a s h i n g t o n , D.C. , A n n A r b o r , M i c h . ,

C h e v e r l y , Md . , a n d St. Pau l , M i n n .

OBJECTIVE: To describe the prevalence and correlates of skin damage on nurses ' hands.

DESIGN: Prevalence survey using self-report questionnaire of hand care regimens, problems, and skin condition, and visual examinat ion of the hands at 30X magnification by trained investigators to evaluate degree of skin scaling.

SETTING: Four hospitals: two in the Mid-Atlantic and two in the nor thern United States.

PARTICIPANTS: Convenience sample of 410 nurses working 30 hours or more per week in acute care units.

OUTCOME M E A S U R E S : Damage to skin of the hands.

RESULTS: Approximately one fourth of subjects (n = 106) met the criteria for currently damaged hands; 85.6% (n = 351) reported ever having skin problems. Damage was not correlated with age (p = 0.43), sex (p = 0.14), or skin type (p = 0.25), type of soap used at home (p = 0.58), reported durat ion of handwashing (p = 0.12), or glove brand (p = 0.90), but was significantly correlated with the type of soap used at work (p = 0.01), number of hand washes per shift (p = 0.0003), number of times gloves were worn (p = 0.008), and study site (p = 0.009). Variables significantly predictive of skin damage in a logistic regression analysis were type of soap used at work and number of times gloves were worn (p = 0.04). Geographic location was not a factor, because both the highest and lowest prevalence of skin damage occurred in the nor thern study institutions.

CONCLUSIONS: Damage to skin of the hands is a common and potential ly serious problem among nurses, and is associated with gloving and handwashing practices rather than with geographic or demographic factors. Efforts to improve skin condition must focus on improving products and identifying any interactive effects be tween hand care products and glove materials and brands. (Heart Lung ® 1997;26:404-12)

P U R P O S E

The frequent handwashing and gloving neces~ sary in health care and food service occupations may have detrimental effects on the skin of the hands, including dryness, cracking, and sensitivity

From the aGeorgetown University School of Nursing, Washington, the bUniversity of Michigan Health System and eSt. Joseph Mercy Hospital, Ann Arbor, dprince Georges Hospital Center, Cheverly, and e3M Health Care, St. Paul. This study was funded in part by 3M Health Care, St. Paul, Minn. Reprint requests: Elaine Larson, PhD, RN, Dean, Georgetown University School of Nursing, 3700 Reservoir Road NW, Washington, DC 20007~1069. Copyright © 1997 by Mosby-Year Book, Inc. 0147-9563/97/$5.00 + 0 2/1/84319 "

to handwashing products or latex in gloves. 1,2 Lesions on damaged hands increase the risk of col- onization with larger numbers of microorganisms, gram~negative bacteria, yeast, coagulase-positive staphylococci, and other potential pathogens, as well as the risk of shedding these microorganisms. Damaged hands also become a deterrent to handwashing because washing can exacerbate skin problems.

Although there have been increasing anecdotal reports of hand damage associated with glove use and handwashing, the prevalence and magnitude of skin problems are not known. Additionally, fac~ tors associated with skin damage have not been systematically assessed. The purpose of this study

4 0 4 SEPTEMBER/OCTOBER 1997 HEART & LUNG

was to determine the prevalence and severity of damage to skin of the hands of health care professionals working in acute care settings and to iden- tify correlates to skin condition.

M E T H O D S

Study population. Four hospitals in two geographic areas were selected: two in the Mid- Atlantic region and two in Michigan. These two regions were selected to determine whether the colder northern weather during winter months would have a detectable effect on the prevalence of skin problems. In both geographic regions, one universi ty-based academic health center (UH) and one community hospital (CH) were selected. The Mid-At lant ic UH had 360 beds and employed approximately 650 nurses; Mid-At lant ic CH had 450 beds and employed approximately 550 nurses. The northern UH had 850 beds, with a staff of about 2000 nurses; the northern CH had 550 beds, with a nursing staff of approximately 1000. Nurses who worked more than 30 hours per week in an acute care setting, such as critical care or the operating room, were el ig ible to participate.

Instruments. Three instruments were used for the study. The Hand Information Form was a 3- page questionnaire designed to solicit self-report information from each participant on hand care, gloving practices, hand condit ion, and demographics. Respondents were asked to estimate the number of t imes per shift and the duration of hand washes, and list the brands of soap, lotions, and other products used on hands. They were asked to describe when gloves were worn, how often, and for what amounts of time, and the types and brands of gloves worn. Respondents were also asked to report any problems with their hands in the past, the frequency and type of such problems, the relative severity compared to their peers, and what they did to ameliorate these problems. Last, if they had skin problems, they were asked to rank order from most to least important eight factors that might contribute to skin problems: climate, handwashing, type of soap used, gloving, allergies or sensitivit ies, skin type (defined as light, susceptible to sunburn; medium, more l ikely to tan than burn; or dark, tans readily), what they did with their hands (e.g., gardening), or other. During pi lot testing, this form was evaluated by five nurses (two of whom had reported damaged hands to the occupational health clinic) for clarity, inclusiveness, ease of use, and time required to complete. Based on their input, minor changes in wording and sequencing of items were made.

The Visual Scoring of Skin Condit ion form used

a stereomicroscopic method of visual examination of the hands at 30X magnification, 3 and consisted of a scale with a range of 0-5 (Table I). To ensure high interrater reliabil ity, each data collector was trained by conducting a series of ratings of hands, with a range of damage (at least 10) simultaneous- ly with at least one other researcher or data collector, unti l a high level of agreement (~ 90%) was attained. In pi lot testing among 94 nurses, score on the Visual Scoring tool was highly correlated with their own ratings of the dryness of the skin of their hands (sign test, p ~ 0.0000), indicating good con- current validity.

The Hand Skin Assessment form (Table II) was a self-rating Likert-type scale used by participants to assess the current condit ion of their own hands. Participants gave themselves a score from 1 to 7 in four dimensions: appearance, intactness, moisture content, and sensation. Range of scores was 4 to 28, with 28 indicating that in all dimensions the skin was total ly healthy. This instrument has been used in previous studies to evaluate the effect of handwashing on skin condition, 4"6 and scores have been shown to correlate with other physiologic measures of skin damage, such as transepidermal water loss and corneocyte shedding. 7

All three of these tools were used for each par- t icipant and took a total of about 10 minutes to complete. Skin was considered "damaged" when there was a score of less than 16 on the Hand Skin Assessment form (the nurse's own rating) and 2 or more on the Visual Scoring of Skin Scaling form (the researcher's rating).

Procedure. Approval was obtained from the appropriate inst i tut ional review board of each of the four study institutions. The study was coordi- nated through one institution, but an infection control practit ioner served as a site coordinator at each of the four study hospitals. A sample size of 400 subjects was sought: 100 subjects per hospital. This number provided sufficient statistical power (beta = 0.10 and two-sided alpha -- 0.05) to test for differences of 20% or more in skin condit ion between hospitals and between the two geographic sites. Rather than using advertising to recruit subjects, which might have been more l ikely to attract only those with skin problems, el igible units were identif ied, and site coordinators met with unit administration and staff to orient them to the study. To again ensure a representative sample, nurses were recruited to participate in the study during staff meetings, change of shift report, and at other times, as convenient to the staff. Within each group that was approached, participa- t ion rates varied from 65% to 100%, averaging 89%

H E A R T & L U N G VOL. 26, NO. 5 4 0 5

Table I Visual Scoring of Skin Scale

Using a magnify ing glass, visually inspect the skin on the domi nan t hand wi th use of the following scale:

0 = N o r m a l No observable scale or irri tation of

any kind,

1 = Very s l i g h t l y sca ly Occasional scale that is not necessarily

un i fo rmly distributed.

2 = S l i g h t l y sca ly Scale in sulci and on plateaus. More

visible scale that is more un i formly distributed, but no wide-spread uplifting.

3 = Sca ly Visible scale giving the overall appearance

of the skin surface a whit ish appearance . Definite uplift ing of edges or scale- sections. Hand is rough to the touch.

4 = Sca ly t o V e r y sca ly More scale and p r o n o u n c e d separat ion of

scale edges f rom skin, a l though they m a y still be lying flat on the skin surface.

Some evidence of cracking in sulci and on plateaus. Also, skin m a y appear irritated wi th some reddening.

5 = V e r y sca ly Extensive cracking of skin surface. In

some cases, scales are very large, but some individuals neve r develop large scales. The skin m a y appear to be very irritated, wi th wide-spread reddening and /o r occasional bleeding.

Mean score (n = 410) = 1.6.

Table I I Hand Skin Assessment Form

On a scale of 1-7, rate the current condit ion of the skin of you r hands

A P P E A R A N C E

A b n o r m a l : Red, blotchy, rash

1 2 3 4

Mean score: 4.9.

INTACTNESS

M a n y abras ions or f issures

1 2 3 4

Mean score: 4.9.

MOISTURE CONTENT

E x t r e m e l y dry

1 2 3 4

M e a n score: 3.5.

S E N S A T I O N

Ext reme i tching, b u r n i n g or soreness l 2 3 4

M e a n score: 5.1.

Normal : No redness,

blotching, rash

5 6 7

C o m p l e t e l y intact: No abras ions or

f i ssures 5 6 7

N o r m a l a m o u n t of mo i s tu r e

5 6 7

No i tching, b u r n i n g or

soreness 5 6 7

Total mean score: 18.4 (range, 4-28).

for the entire study. Data were collected during a 7-month period of time, October 1995 through April 1996.

Data analysis. Initially, nonparametric, univari- ate analyses using the chbsquare statistic and KruskaPWallis analysis of variance were conducted to examine relationships between indiv idual variables. Then all variables shown to be significantly associated with skin damage were entered into a logistic regression equation to identi fy those factors associated with skin damage, controll ing for potent ia l confounding and in terdependence between variables.

R E S U L T S

Between October 1995 and April 1996, 410 nurses from four sites participated: 137 from the Mid- Atlantic UH, 107 from the Mid-Atlantic CH, 66 from the northern UH, and 100 from the northern CH (Table 11I contains description of subjects). There were significant differences in the nurse popula- tions by site. Significantly more nurses in the two northern hospitals, as compared with the Mid- Atlantic hospitals, described themselves as light~ skinned (56.7% and 40.6%, respectively; p = 0.008). Significantly more nurses in the two UH, when compared with the CH, were less than 40 years old

406 SEPTEMBER/OCTOBER 1997 HEART & LUNG

(70.4% and 47.8%, respectively; p -- 0.0000) and had been in their jobs less than 5 years (41.9% and 23.4%, respectively; p = 0.0008). There were no significant differences among the four sites in the sex of the nurses (p = 0.25), most being women (n = 387, 94.4%).

Hand care and gloving practices. Seventeen of 400 nurses responding to the question (4.2%) reported washing their hands 100 or more times per shift, and 16 of 392 (4.1%) reported taking 2 minutes or longer per wash. It appeared, in fact, that some nurses included scrubs as well as regu- lar hand washes in their reporting. These few out- liers resulted in skewing of the data (i.e., artificial- ly increasing duration and frequency numbers) and were omitted from the analysis of handwashing frequency and duration. The median and mean reported number of hand washes per shift were 25 and 29.8, respectively (range, 1 to 100; standard deviation SD _+ 18.6), for a median and mean duration of 15 seconds and 20.5 seconds, respectively (range, 1 to 100 seconds; SD + 17.3 seconds). Most nurses (75.3%) used an antimicrobial-containing soap at work, and many (47.7%) also used an antimicrobial soap at home. The majority (92.7%) used hand lotion, mostly an over-the-counter brand (90.8%). Some (21.1%) also reported using other products on their hands, including Vaseline (Chesebrough Pond's, Inc.), medicated ointments, and heavy creams.

Approximately one third of nurses reported wearing gloves with almost all patient contacts (37.9%), and twice that number (61.6%) whenever blood or body fluid contact was anticipated. The median and mean numbers of glove changes per shift were 20 and 22.3, respectively (range 0 to 150; SD + 19.6). Estimated amounts of total time that gloves were worn each shift were: less than 1 hour, 30.4%; 1 to 2 hours, 35.0%; 3 to 4 hours, 20.1%; or more than 4 hours, 14.5%. Most nurses wore latex gloves only (68.0%), some wore both latex and vinyl (28.1%), and a few wore only vinyl (3.9%). Some (14.3%) reported wearing hypoallergenic gloves. Ten brands were named; however, three brands constituted 84.8% of those worn. Practices, which differed significantly by study institution, were type of soap used at work and home, number of reported hand washes per shift, use of special lotions or skin products, and number of times gloves were worn (Table IV).

Reported profilems with hands. Mean self- assessment scores of the condition of the hands, out of a maximum score of 28 (normal), was 18.4 (SD _+ 5.4). Mean skin scaling score out of a range of

Table III Description of nurse participants (n = 410)

N u m b e r (%) Facility

Mid-Atlantic universi ty hospital 137 (33.4)

Mid-Atlantic communi ty 107 (26.1) hospital

Nor thern universi ty hospital 66 ( 16. i ) Nor thern communi ty 100 (24.4)

hospital

T y p e o f u n i t Operat ing/recovery room 69 (16.8) Adult ICU 110 (26.8) Pediatric ICU 21 (5.1) Neonatal ICU 41 (10.0) Other acute care 163 (39.8) Missing 6 (1.5)

Sex Female 387 (94.4)

Age (yr) < 25 19 (4.6) 25-40 224 (54.6) 41-55 153 (37.3) > 55 14 (3.4)

S k i n t y p e Light I92 (46.8) Medium 172 (41.8) Dark 46 (11.2)

T i m e in j o b (yr) < 1 48 (11.7) 1-4 85 (20.7) 5-10 112 (27.3) > l0 165 (40.2)

[CU, Intensive care unit.

0 to 5 was 1.6 (SD + 1.2) (Table I). Approximately one fourth of participants (106, 25.9%) met the criteria for having damaged hands at the time of assessment (self-assessment score of 16 or less and skin scaling score of 2 or more). In addition, 85.6% of nurses reported having problems with their hands at some time. These problems includ~ ed excess dryness (96.0%), cracking (80.5%), red~ ness (75.7%), itching (73.4%), and other problems (16.8%) such as bleeding, contact dermatitis, cracked nails, and infection.

Most respondents reported that the frequency of their hand problems was intermittent--several times each year (50.7%), or frequent--more often than not (24.8%), and they judged these skin problems as not too serious; within normal limits

HEART & LUNG VOL. 26, NO. 5 407

Table IV Hand care regimens and skin damage by study site (n = 410)

M i d - M i d - A t l a n t i c A t l a n t i c N o r t h e r n N o r t h e r n p Va lue

Al l UH CH U H CH b e t w e e n sub jec t s (n = 137) (n = 107) (n = 66) (n = 100) s i tes

W o r k s o a p Chlorhexidine 31.0% 68.1% 16,3% 7.7% 81.1% 0.0000 Iodophor 2.6% 1.5 % 7.1% 0 I .1% - - Other antimicrobial 43.2% 2.9% 62.2% 47.7% 0 Nonantimicrobial 23.2 % 27.4 % 14.3 % 44.6 % 17.8 % - -

H a n d w a s h e s / s h i f t Mean 29.8 34.5 25.7 30.3 27.4 0.003 Median 25 SD + 18.6 Range I - 100

S e c / w a s h Mean 20.5 18.5 20.0 23.7 i9.0 > 0.25 Median 15 SD _+ 17.3 Range 1 - 100

A n t i m i c r o b i a l 47.7% 53.5% 34.6% 42.4% 57.6% 0.009 s o a p a t h o m e ?

Use l o t i o n ? 92.7% 94.1% 92.5% 90.9% 92.0% 0.85

Use m e d i c a t e d o r 9.2% 7.9% i i . 7 % 15.3% 4 . 4 % 0.03 spec ia l p r o d u c t ?

Glove c h a n g e s / s h i f t Mean 22.3 26 17 27 19 0.0004 Median 20 SD ___ 19.6 Range 0-150

H y p o a l l e r g e n i c g l o v e s ? 14.3% I3 .3% 20.7% 9.1% 12.0% 0.19

H i s t o r y o f h a n d 85.6% 85.4% 81.3% 87.8% 89.0% 0.52 p r o b l e m s ?

S k i n d a m a g e p r e s e n t ? 25.9% 27.0% 25.2% 39.4% 16.0% 0.009

UH, University hospital; CH, community hospital.

(37.3%); sl ightly worse than most (42.7%); or serious enough to affect work or modify skin care (19.9%). Most nurses (86.5%) reported that their skin condi- t ion improved after t ime off work.

Nurses reported a number of strategies used to alleviate problems with their hands, the most common of which was addit ional use of hand lotion (74.3%). Use of lot ion or Vaseline under gloves at night and use of prescription products were reported by 9.1% and 8.2% of nurses, respectively. Other strategies such as avoiding certain products, using glove liners or powderless gloves, and missing work were each ment ioned by fewer than 2.5% of

respondents. There were no significant differences in strategies used by nurses at the four study sites (p = 0.46).

Correlates of skin damage. In a rank ordering of 1 to 7, nurses rated handwashing as the major contr ibutor to the condit ion of their skin (rank: 1.8). Other factors, in descending order of importance, were gloving (3.0), climate (3.1), and type of soap (3.2). Factors such as allergy, skin type, and what activities were done with the hands (e.g., gardening) had ranks higher than 5, and were therefore considered by respondents to be relatively unim- portant in affecting the condit ion of their hands.


None of the demographic variables was significantly associated with the presence or absence of skin damage: age (p = 0.43), sex (p = 0.14), skin type (p = 0.25), or t ime in job (p = 0.34). There was no significant correlation between skin damage and type of soap used at home (p = 0.58), reported duration of handwashing (p = 0.12), or brand of glove used (p = 0.90). There was a significant correlation between skin damage and type of soap used at work (p = 0.01), number of hand washes per shift (p = 0.0003), number of t imes gloves were worn each shift (p = 0.008), and study site (p = 0.009). Damage occurred in 20.8% of the hands of nurses who used a handwashing product containing chlorhexidine gluconate, 31.0% who used a nonant imicrobia l -conta in ing soap, and 35.9% who used other antimicrobial-containing products (p = 0.01).

A logistic regression model in which skin damage was the dependent variable and independent variables included type of soap used at home and work, number of hand washes, number c times gloves were worn each shift, and study site was sta- t istically significant (p = 0.04). However, the only variables that remained independent ly and significantly associated with skin damage when other factors were control led was type of soap used at work (p = 0.03), and the number of t imes per shift gloves were worn (p = 0.01).

D I S C U S S I O N

Measuring skin damage. Although there is anecdotal evidence that skin problems are frequent among health care professionals, a major impediment to obtaining accurate prevalence data has been the development of operational defini- tions of skin damage for hands, and assessment techniques that are not only reliable and valid but that are also portable, inexpensive, and feasible for use in a clinical setting. Image analysis, corneocyte counts, and evaporimetry have been used in laboratory settings, but are costly, t ime consuming, require highly trained personnel, and are impracti- cal as screening tools. 8"t2 Assessment by derma- tologists is also expensive, may be inconve- nient, and has not been shown to have a high degree of re l iab i l i ty for early signs of damage on hands. 13

Several invest igators have compared self- reported symptoms and objective clinical diagnosis of skin irritancy and found acceptable levels of sensit ivi ty and specificity. However, estimates of prevalence of skin problems were improved by combining self-reporting with objective measures. ~4A5 Simion et al. 16 demonstrated that sub-

jects could reproducibly identi fy subtle differences in their skin condit ion when various soaps were used, and that this self-assessment correlated well with observable signs. For this reason, the protocol for this study incorporated both subjective and objective assessment. Based on the pi lot testing, we feel confident that the skin assessment methods used were inexpensive, practical, easily administered, and had high levels of rel iabi l i ty and validity.

Prevalence of skin damage. It is diff icult to com- pare reported rates of skin problems in health care professionals because differing definit ions have been used. Regardless of what def ini t ion is used, however, the prevalence is consistently high. In a l -day prevalence survey of 367 health care workers during the winter, 42.5% had chapped hands defined as red, dry skin with flaking and small cracks, and 5.7% had dermatit is defined as the presence of open lesions with exudate. Among nurses, the rates of chapping and dermatit is were 44% and 6%, respectively. 17 Ojajarvi et al. 13 reported that 27 of 37 (72.9%) nurses who washed their hands frequently had wounds on their fingertips, redness, and excessive dryness of hands.

In a study comparing self-reported diagnosis and dermatologic evaluation for measuring the prevalence of hand damage among 109 nurses, dermatit is was ident i f ied in 18.3% and 19.4%, respectively. However, when respondents were asked specific questions about symptoms over the previous year (e.g., whether they had redness, swelling, vesicles, or scaling), the period prevalence was 47.7%. 15 The prevalence of hand dermatit is among a sample of nurses in the Netherlands was 30%, 5.7 times that of the general population. Interestingly, hand dermatit is among surgical assistants was no more common than among the general population, suggesting that the type of exposure in nurses with frequent hand washes may be more harmful to the skin than the less frequent but longer exposures in surgery. ~8

The sample of 410 nurses in our study consti- tutes the largest survey of the hands of health professionals that we found in the literature, and the fact that four different insti tut ions in two geographic areas were included provides information across settings. The definit ion used in this study was more rigorous than definit ions used in other clinical studies, because both subjective and objective measures of skin damage were included. Although there was a high correlation between self-assessment scores and observer skin scaling score in this study, both scores had to

HEART & L U N G VOL. 26, NO. 5 4 0 9

demonstrate evidence of poor skin condition before subjects were considered to have damaged skin. Thus we believe that our estimate of a prevalence Of approximately one fourth of nurses with significant skin damage is conservative but accurate, and seems to be consistent with other studies in which prevalence ranged from 18.3% to 72.9%. Additionally, the: fact that most nurses (85.6%) reported that they had problems with their hands at some time highlights the magnitude of this problem.

Correlates of Skin damage. It was surprising to note what l itt le effect demographic variables, par- ticularly age, skin type, and sex had on the condition of skin of the hands. This may be due to the fact that most subjects were women, and only 14 subjects were more than 55 years old, so the thin- ning and drying effects of aging on the skin would not be detectable in this population. Likewise, we had hypothesized that the colder winter climate in the northern region would be associated with increased prevalence of skin damage. Although there were significant differences in skin damage among the four study institutions, the highest and lowest prevalence of damage were in the university and community hospitals in the same northern city. Thus it appeared that factors other than demographics and climate were the major correlates of skin damage in this study. Others also have confirmed that there is l itt le seasonal influence on rates of dermatitis among hairdressers and nursing students. 3

Soaps and detergents are known to cause changes to the skin, which include desiccation and defatting as well as temporary removal of the skin's acid mantle. ~9'2° Drying of the skin below 10% water content results in a loss of surface integrity, 2~ and is a risk factor for hand dermatitis. 3'22'23

It is generally agreed that removal of a certain amount of contaminated surface fats and of bacteria attached to superficial epidermal cells is an essential hygienic feature. However, the lipid and cell removal through washing should be somewhat limited to avoid damage to lower layers of the epidermis.

Changes in the lipid or water content of the skin of the hands as a result of frequent washing results in changes in bacterial flora and increased shedding of organisms from the hands. In fact, nosocomial outbreaks have been linked to health care providers with hand dermatitis? 4 Damage to the skin of hands also explains the phenomenon noted by several researchers 13,25,26 that those who

must wash their hands very frequently (for exam- ple, several times per hour) actually shed more microorganisms than those who wash less frequently. Thus the dryness of hands associated with frequent handwashing among nurses increases the risk of both hand dermatitis and shedding of microorganisms.

This does not mean that health care professionals should wash their hands less frequently, because when patients or contaminated objects are touched, handwashing is necessary to remove transient contaminants to prevent their transmis- sion to other patients on personnel hands. In fact, there are minimum national standards that specify minimum duration of handwashing (10 seconds) as well as indications. 27"29 It does mean, however, that manufacturer attention to formulating products with minimal irritancy potential is indicated. It also means that nurses should make every effort to prevent hand dryness and dermatitis.

Because the skin's flexibility and pliability depend on hydration of the stratum corneum, ~ hand lotion could serve as one important compo- nent of the hand hygienic practices of individuals such as nurses, who must wash their hands frequently with agents that contribute to defatting, drying, and changing the pH of the skin. In the 1960s and 1970s, hand lotions were banned from acute care settings, and health care professionals were discouraged from using them because of nosocomial infections associated with contaminated lotion. 3°,31 However, newer forms of packaging prevent lotions from becoming contaminated, so they no longer represent a potential reservoir for gram-negative bacteria. In fact, bacterial shedding from the skin is reduced when lotion is used. 32 Antiseptic hand creams and protective lotions not only reduce skin shedding but can actually reduce microbial counts on skin. 33,34 Some newer protective lotions and foams may also reduce the risk of contact with latex allergens. 35 Thus hand lotion would seem to be an excellent adjunct, not only to the prevention and alleviation of skin problems, but also to infection control.

An unexpected finding in this study was the significant correlation between skin damage and frequency of glove wearing. Almost 100% of nurses in this study reported wearing gloves with almost all patient contacts, or whenever blood or body fluid contac~ was expected. This represents a dramatic change in practice since the eady 1980s, resulting from the increasing prevalence of infections with human immunodeficiency virus and other blood

4 1 0 SEPTEMBER/OCTOBER 1997 HEART & LUNG

borne pathogens, and the subsequent implemen- tat ion of universal precautions and body sub- stance isolation. The high frequency of glove use by health care professionals, part icular ly nurses, has been ver i f ied in other studies. 3<37 In fact, some have po in ted out that gloves are being mis- used and overused as a subst i tute for handwashing and other general precautions. 38 An important caveat, however, is that the data on hand hygiene and gloving practices were sel f-reported by nurses and may be exaggerated. Future studies of such practices should include val idat ion by observer. Nevertheless, unless certain aspects of behavior (e.g., gloving) were d i f ferent ia l ly exaggerated, the correlations between ind iv idual variables found in this study would not be affected.

Our f indings suggest that there is more than just a cost concern with regard to the increasing use of gloves; their use also results in damage to the skin. Contact dermat i t is and lgE med ia ted -a l l e rgy to latex have been recognized for decades, and their prevalence has increased in recent years. 39"44 Though allergic reactions were not reported with any frequency in this sample, mi lder forms of reac- t ion may be occurring with a higher frequency than previously recognized. We made no at tempt in this study to di f ferent iate between various forms of irritant contact dermat i t is , but the associat ion between symptoms and glove wearing indicates the need for further study of latex-associated reactions. Powder in gloves binds to latex antigens and concentrates noxious substances present, 4~'47 but very few nurse part icipants used hypoal lergenic or powder-free gloves.

Conclusions and recommendations. Skin d a m - age is a common and serious problem for nurses' hands, and is associated with handwashing and gloving practices rather than with cl imate or demographic factors, Hence, efforts to improve skin condi t ion among professionals who must practice frequent handwashing and gloving should focus on product deve lopment or modif icat ion of (1) soaps, detergents or other cleansing agents to minimize effects on normal l ip ids, moisture, and pH of skin; (2) emol l ients or skin protectants; and (3) gloves or other products that prov ide a cost-effective barr ier with minimal effects on the skin. Addi t ional work is needed to sort ou t any interact ive effects between various hand care products and glove ingredients and brands.

We gratefully acknowledge support with data col- lection from Ms. Joanne Espanol and Ms. Melissa Magante.

R E F E R E N C E S

1. Kirk JE. Handwashing: quantitative studies on skin lipid removal by soaps and detergents based on 1500 experiments. Acta Derm Venereol 1966;(suppl):l-183.

2. Hassing IH, Nater JP, Bleumink E. Irritancy of low concentra- tions of soap and synthetic detergents as measured by skin water loss. Dermatologica 1982; 164:314~21.

3. Highley DR, Savoyka VD, O'Neill Jl, Ward ]B. A stereomicroscopic method for the determination of moisturizing efficacy in humans. J Soc Cosmet Chem 1976;27:351-63.

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Documents

Larson Et Al., 1997