Sir,
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has enforced substantial lifestyle modifications with significant emphasis placed on hand hygiene measures. This has resulted in a rise in dermatology consultation for hand eczema (HE). Health care workers (HCW) bear the brunt as they are expected to meticulously follow these practices. This study is being undertaken to assess the effect of hand hygiene practices followed by HCW on the development of HE during the COVID-19 pandemic, with an attempt to find potential predictors such as age, gender, frequency of hand hygiene, daily hours of wearing gloves, and application of moisturizers.
This was a cross-sectional online survey executed after institutional review board approval, and written informed consent was obtained from study participants. The study was conducted using Google forms (link: https://forms.gle/b8yJJFxPfsmYBv9A7) questionnaire composed of 26 questions in the English language related to the demographic profile of the participants, specialty, current posting (COVID-19 area or not), hand hygiene practices followed, changes observed over the skin of hands, and the use of moisturizers. The link to the Google form was sent to HCW (doctors and nurses) working in designated COVID-19 hospitals all over India using social media (Whatsapp). The data were collected for 2 months (August 2020–September 2020). Statistical analysis was done using SPSS software version 23. Those having signs and symptoms of HE were compared with those not having HE using the Chi-square test for categorical variables and student t-test for continuous variables. The P value of less than 0.05 was considered significant.
A total of 160 valid responses were analyzed. Seventy-five (46.9%) respondents were men and 85 (53.1%) were women, with a mean age of 30.35 ± 6.32 years. Doctors constituted 83.1% of the HCW and 16.9% were nurses. A total of 26.9% of the respondents were posted in the COVID-19 area including the intensive care unit. Pre-existing hand eczema and other allergies including allergic rhinitis, asthma, atopic dermatitis, or dry/sensitive skin were observed in 12.5% and 35% subjects, respectively. There was a statistically significant increase in the frequency of handwashing and hand sanitization with alcohol-based hand rub during the current pandemic as compared to before the pandemic (P < 0.001) [Table 1]. Frequency of moisturization though increased, was still sub-optimal with only 25% of the respondents moisturizing their hands more than thrice a day. Less than half (49.5%) of the participants considered moisturizers to be effective in preventing hand eczema and 81.9% responded that moisturizers were not available at their workplace. Self-reported signs and symptoms of hand eczema were noted in 65.6% of the study participants [Table 2]. The most common symptom reported by 55% of the subjects was dryness/tightness of the skin. There appeared no effect of age on the development of skin changes (P = 0.191), however, the female gender had a higher risk (P = 0.016). A statistically significant association was also evident with pre-existing allergies (P < 0.001) and pre-existing hand eczema (P < 0.001). The daily duration of wearing gloves was associated with higher chances of hand eczema (P = 0.014). No statistically significant association could be observed between hand eczema and frequency of hand washing, hand sanitization, and moisturization. Furthermore, the area of current posting (COVID-19 versus non-COVID-19) and occupation (doctors versus nurses) did not result in a preferential predisposition [Table 3].
Table 1.
Comparison of frequency of hand washing before and after COVID-19 pandemic
| Frequency | Before COVID-19 pandemic (%) | After COVID-19 pandemic (%) | P |
|---|---|---|---|
| Hand washing (times/day) | |||
| <5 | 41 (25.6) | 7 (4.3) | <0.001 |
| 5-10 | 72 (45.0) | 51 (31.9) | |
| 11-20 | 28 (17.5) | 63 (39.3) | |
| 21-30 | 14 (8.7) | 31 (18.6) | |
| >30 | 5 (3.1) | 8 (5.0) | |
| Hand sanitization (times/day) | |||
| <5 | 74 (46.2) | 10 (6.2) | <0.001 |
| 5-10 | 38 (23.7) | 38 (23.7) | |
| 11-20 | 22 (13.6) | 52 (32.5) | |
| 21-30 | 17 (10.6) | 33 (20.6) | |
| >30 | 9 (5.6) | 27 (16.9) | |
| Frequency of moisturization (times/day) | |||
| <3 | 53 (33.1) | 37 (23.1) | <0.001 |
| 3-5 | 80 (50.0) | 67 (41.8) | |
| 6-10 | 26 (16.2) | 52 (32.5) | |
| >10 | 1 (0.6) | 4 (2.5) | |
| Hours of wearing gloves/day | |||
| <2 | 24 (15.0) | 67 (41.8) | <0.001 |
| 2-6 | 85 (53.1) | 57 (35.6) | |
| 7-10 | 41 (25.6) | 33 (20.7) | |
| >10 | 10 (6.2) | 3 (1.9) |
Table 2.
Predominant signs/symptoms observed in subjects reporting hand eczema (n=105)
| Clinical signs/symptoms | Number (%) |
|---|---|
| Dryness/tightness | 88 (83.8) |
| Exfoliation of skin | 42 (40.0) |
| Itching | 35 (33.3) |
| Redness | 14 (13.3) |
| Fissures/erosions | 12 (11.4) |
| Nail fold redness/swelling | 10 (9.5) |
Table 3.
Comparison of selected characteristics in study participants with or without hand eczema
| Parameter | Hand eczema present (%) | Hand eczema absent (%) | P |
|---|---|---|---|
| Age in years (mean±SD) | 27.87±4.99 | 31.25±8.26 | 0.191 |
| Gender | 0.016 | ||
| Male | 56.0 | 44.0 | |
| Female | 74.1 | 25.9 | |
| Pre-existing allergies | 0.001 | ||
| Yes | 82.1 | 17.9 | |
| No | 56.7 | 43.3 | |
| Pre-existing hand eczema | 0.001 | ||
| Yes | 100.0 | 0.0 | |
| No | 60.7 | 39.3 | |
| Specialty | 0.289 | ||
| Medical | 68.6 | 31.4 | |
| Surgical | 60.3 | 39.7 | |
| Occupation | 0.311 | ||
| Doctor | 63.9 | 36.1 | |
| Nurse | 74.1 | 25.9 | |
| Area of posting | |||
| COVID-19 | 55.8 | 44.2 | |
| Non-COVID-19 | 69.2 | 30.8 | |
| Frequency of hand washing (times/day) | 0.160 | ||
| <10 | 58.6 | 41.4 | |
| 10 | 69.6 | 30.4 | |
| Frequency of hand sanitization (times/day) | 0.364 | ||
| <10 | 60.4 | 39.6 | |
| 10 | 67.9 | 32.1 | |
| Frequency of moisturization (times/day) | 0.086 | ||
| <3 | 61.0 | 39.0 | |
| 3 | 74.5 | 25.5 | |
| Daily hours of wearing gloves | 0.001 | ||
| <2 | 50.7 | 49.3 | |
| 2 | 76.3 | 23.7 |
Hand hygiene practices have emerged as the utmost precautionary measure during the current times. This, however, is not without the drawback of triggering hand eczema evident from the emergence of such reports in HCW and the general public alike. Wuhan (China), where the disease originated reported HE in 74.5% HCW involved in COVID-19 patients' care.[1] A similar high incidence of HE in HCW has been reported from Germany and Turkey (90.4% and 50.5%, respectively).[2,3] In the current study, 65.5% of the participants reported one or more features suggestive of HE. A feeling of dryness and tightness was felt by the majority with 57.1% reporting additional symptoms notably exfoliation of the skin, itching, and redness. Erdem et al. elucidated significant risk factors in their cohort of 107 HCW engaged in COVID-19 patient care. Female gender, higher age, past history of hand eczema, >20 times frequency of handwashing, and infrequent use of moisturizers were the most relevant risk factors.[3] Female gender, past history of HE, and history of preexisting allergies were statistically significant risk factors in the reported study. The preferential affliction of females could represent their frequent involvement in household chores thereby increasing allergen exposure. The frequency of hand hygiene including washing with soap or sanitizing with alcohol-based hand rub has been reported as critical risk factor in recent studies.[2,3] In the present study, although a higher proportion of participants with hand washing or sanitizing frequency of >10 times had HE (69.6% versus 58.6% for hand washing and 67.9% versus 60.4% for hand sanitization), this difference failed to reach statistical significance. Infrequent moisturization is another distinguished risk factor stated by some researchers; we conversely were not able to establish such association. Studies have reported improvement in HE severity scores in HCW regularly using hand creams.[4] Hours of wearing gloves appeared a significant risk factor, with HCW wearing gloves for more than 2 hours per day having a higher risk of developing HE (P = 0.001). It was also reported by Metin et al. in their questionnaire-based survey of 526 HCW including nurses and doctors.[5] A comparison of risk factors reported in different studies from diverse countries is depicted in Table 4.
Table 4.
Comparison of studies reporting risk factors of hand eczema in health care workers from various countries
| Study | Country | Number of subjects (HCW) | Prevalence of HE and related symptoms | Risk factors |
|---|---|---|---|---|
| Lan et al.[1] | China | 700 | 74.5% | > 10 times hand hygiene |
| Erdem et al.[3] | Turkey | 107 | 50.5% | Female gender |
| >20 times/day hand washing | ||||
| Low frequency of moisturizer use | ||||
| Past history of HE | ||||
| Metin et al.[5] | Turkey | 526 | 72.5% | Female gender |
| >10 times/day hand washing | ||||
| Wearing gloves >1 h/day | ||||
| Celik et al.[6] | Turkey | 564 | 79.3% | Female gender |
| Frequent hand washing | ||||
| Frequent use of moisturizers | ||||
| History of atopic disease | ||||
| Guertler et al.[2] | Germany | 114 | 90.4% | Increased frequency of hand washing and sanitization |
| Present study | India | 160 | 65.6% | Female gender |
| Wearing gloves >2 h/day | ||||
| Past history of HE |
The noteworthy risk factors requiring appropriate monitoring appear to be the frequency of handwashing/sanitization, hours of wearing gloves, pre-existing hand eczema, and history of atopy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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