Evidence of increased skin irritation after wet work: impact of water exposure and occlusion

Methodological limitations and confounders in dermal toxicity evaluation of aqueous test substance by OECD technical guidelines 402, 410: our experience of testing ethanol based hand sanitizer

BACKGROUND

In view of overzealous use of Alcohol based hand sanitizer (ABHS) during COVID-19 pandemic and associated alarming rise in the cases of hand eczema and dermatitis around the world. We conducted an in vivo dermal toxicity with objective of exploring the acute and subacute effects of ethanol based hand sanitizer (EBHS) on Sprague Dawley rats.

AIMS

To evaluate acute and subacute dermal toxicity due to ethanol based hand sanitizer (EBHS) on Sprague Dawley rats.

METHODS

In first phase, following Organisation for Economic Co-operation and Development (OECD) Technical Guidelines (TG) 402, we conducted acute dermal toxicity study with two rats and EBHS containing 72.34% ethanol. In second phase, sub-acute dermal toxicity study was conducted, following OECD TG 410 with five groups of rats (10 animals of either sexes in each group) at various doses.

RESULTS

In both the studies, no erythema, oedema, and eschar was observed. Although no clinical signs of toxicity were observed in both the studies, one death was encountered in subacute study. Macroscopically skin was normal; however, microscopic changes such as hyperkeratosis, parakeratosis, erosion, and extracellular oedema in epidermis and diffuse inflammatory cell infiltration in dermis was observed, suggestive of spongiotic dermatitis and 'clinic-pathological discordance'. However, attributing this changes to ethanol is difficult due to methodological limitations and confounders.

CONCLUSION

In both the studies, ethanol based hand sanitizer (EBHS) was found to be non-irritant with LD50 of > 2000 mg/kg and classified as Class 5/Unclassified according to GHS classification. Although, spongiotic changes were observed, methodological limitation of absence of control group in TG 402 and confounding effect of water and occlusion in all the animals/groups in both studies prevented us to attribute it to ethanol.

Skin Barrier Function Assessment: Electrical Impedance Spectroscopy Is Less Influenced by Daily Routine Activities Than Transepidermal Water Loss

BACKGROUND

Skin barrier function assessment is commonly done by measuring transepidermal water loss (TEWL). An important limitation of this method is the influence of intrinsic and extrinsic factors. Electrical impedance spectroscopy (EIS) is a lesser-established method for skin barrier function assessment. Some influential factors have been described, but no guidelines exist regarding the standardization of these measurements.

OBJECTIVE

To evaluate the effect size of daily routine activities on TEWL and EIS, as well as their correlation with age and anatomical differences.

METHODS

Healthy participants (n=31) were stratified into three age groups (18-29, 30-49, and ≥50 years). In a climate-controlled room, EIS and TEWL measurements were performed on the left and right volar forearm and abdomen.

RESULTS

Body cream application decreased TEWL and EIS values after 15 and 90 minutes. Skin washing decreased TEWL for 15 minutes and EIS values for at least 90 minutes. TEWL was increased 5 minutes after moderate to intense exercise. Coffee intake increased TEWL on the abdomen after 60 minutes. TEWL and EIS values did not correlate with participants' age and no anatomical differences were observed. No correlation was observed between TEWL and EIS.

CONCLUSION

Body cream application and skin washing should be avoided at least 90 minutes prior to measurements of TEWL and EIS. Exercise and coffee intake should also be avoided prior to TEWL measurements. EIS may be a promising tool for skin barrier function assessment as it is less affected by daily routine activities than TEWL.

Evaluating the Irritant Factors of Silicone and Hydrocolloid Skin Contact Adhesives Using Trans-Epidermal Water Loss, Protein Stripping, Erythema, and Ease of Removal

A composite silicone skin adhesive material was designed to improve its water vapor permeability to offer advantages to wearer comfort compared to existing skin adhesive dressings available (including perforated silicone and hydrocolloid products). The chemical and mechanical properties of this novel dressing were analyzed to show that it has a high creep compliance, offering anisotropic elasticity that is likely to place less stress on the skin. A participant study was carried out in which 31 participants wore a novel silicone skin adhesive (Sil2) and a hydrocolloid competitor and were monitored for physiological response to the dressings. Trans-epidermal water loss (TEWL) was measured pre- and postwear to determine impairment of skin barrier function. Sil2 exhibited a higher vapor permeability than the hydrocolloid dressings during wear. Peel strength measurements and dye counter staining of the removed dressings showed that the hydrocolloid had a higher adhesion to the participants' skin, resulting in a greater removal of proteins from the stratum corneum and a higher pain rating from participants on removal. Once the dressings were removed, TEWL of the participants skin beneath the Sil2 was close to normal in comparison to the hydrocolloid dressings that showed an increase in skin TEWL, indicating that the skin had been highly occluded. Analysis of the skin immediately after removal showed a higher incidence of erythema following application of hydrocolloid dressings (>60%) compared to Sil2, (<30%). In summary, this modified silicone formulation demonstrates superior skin protection properties compared to hydrocolloid dressings and is more suitable for use as a skin adhesive.

Evaluation of Skin Barrier Condition Among Physicians and Dentists

Background: Physicians and dentists are at risk for chronic hand eczema, but their skin barrier condition has rarely been investigated before. Objective: To objectively assess the skin barrier condition among physicians and dentists. Methods: This cross-sectional epidemiological study included an occupational questionnaire, medical examination of hand skin, skin transepidermal water loss (TEWL), and pH measurements, analyzed in 5 groups (N = 37 in each): physicians-nonsurgeons, physicians-surgeons, dentists-nonsurgeons, dentists-surgeons, and control group (unexposed workers). Results: Critical skin condition (TEWL >30 g/[m2·h]) was found in 14% of control workers, 14% physicians nonsurgeons, 22% physicians surgeons, 27% dentists nonsurgeons, and 43% dentists surgeons. The latter had the worst stratum corneum condition indicated by a TEWL median of 25.80 g/(m2·h) (interquartile range [IQR] 19.24-34.31). Hand skin pH was highest among dentists with nonsurgical specializations, with a median of 5.33 (IQR 5.15-5.60), where 38% of them had pH >5.5. Male sex (P < 0.001) and glove use for >1 h/day (P = 0.009) were associated with elevated hand TEWL values, whereas female sex (P < 0.001) and glove use for >4 h/day with elevated pH values (P < 0.001). Conclusions: Prolonged glove usage and dental profession, especially surgical work, significantly affect the skin barrier condition. This study was the first to objectively determine skin barrier condition among dentists and physicians.

Influence of quarantine mask use on skin characteristics: One of the changes in our life caused by the COVID-19 pandemic

BACKGROUND

The influence of various environmental factors on skin properties is well known. However, there is a lack of research into the effect of quarantine masks on skin properties, even though the use of masks has significantly increased after the COVID-19 outbreak. Therefore, this study aimed to investigate the influence of mask use on skin properties.

MATERIALS AND METHODS

Twenty subjects were enrolled in this study. The subjects used approved quarantine masks for 6 hours a day for 2 weeks. We measured eight skin biophysical parameters: temperature, redness, pore volume, texture, elasticity, trans-epidermal water loss (TEWL), sebum content, and pH, and evaluated acne lesions before and after using quarantine masks. The evaluation was performed on the mask-wearing area of the face.

RESULTS

Skin temperature, redness, and TEWL increased significantly after a 6-hour mask use, while the sebum content increased marginally. Skin elasticity was reduced by the use of masks over 1 and 2 weeks, whereas the pore volume and the number of acne lesions increased after a 2-week mask use. The skin changes caused by mask use showed sex-based differences in the skin elasticity (after 6 hours), redness, and roughness (after 2 weeks).

CONCLUSIONS

The use of quarantine masks causes a change in the skin temperature, redness, and TEWL in the short term and in skin elasticity, pores, and acne in the long term. This study revealed that prolonged mask use could have negative effects on the skin.

COVID-19 and hand hygiene: the vital importance of hand drying

The significance of hand hygiene for preventing the transmission of microorganisms and reducing the spread of infection has been brought into sharp focus following the global coronavirus (COVID-19) pandemic. In the months since the initial outbreak, international public health campaigns and practitioner education has concentrated on hand washing and hand sanitising, with very little reference to hand drying, if any at all. However, hand drying is integral to effective hand hygiene, and is important in controlling the spread of microorganisms and maintaining healthy skin integrity. This research commentary will focus on two issues of importance with regards to hand drying: microbial transmission and skin irritation, with implications for healthcare practitioners and practice considered. It is argued that a more holistic approach to hand hygiene must be the ambition if health professional and public behaviour is to become embedded and sustained.

Skin barrier function after repeated short-term application of alcohol-based hand rub following intervention with water immersion or occlusion

BACKGROUND

Alcohol-based hand rub (ABHR) is recommended for hand hygiene, and application on dry skin is generally well tolerated. However, hydration of the skin may lead to increased susceptibility to ABHR.

OBJECTIVES

To evaluate if increased skin hydration changes skin barrier response to ABHR, as compared to application on dry skin.

METHODS

Twenty healthy volunteers participated in a 3-day experimental setup. Intervention areas on the forearms were exposed to either water immersion or occlusion followed by repeated exposures to ABHR. Skin barrier function was assessed by measurement of transepidermal water loss (TEWL), electrical conductance, pH, and erythema at baseline and day 3.

RESULTS

The area exposed to water immersion preceding ABHR showed a significant increase in TEWL from baseline to day 3 (P = .04), and for the occluded area the same trend was found (P = .11), with an additional decrease in electrical conductance (P = .03). No significant differences were found for the control area. The assessments did not differ significantly between intervention and control sites.

CONCLUSION

Our results indicate that extensive skin hydration may lead to increased susceptibility to ABHR. Further evaluation of this observation is important, since ABHRs are widely used, particularly among health care workers in whom hand eczema is a huge problem.

[Prevention of hand eczema]

Apart from endogenous factors, hand eczema is often caused by irritant or allergic contact dermatitis related to occupational or non-occupational exposure to skin hazards. This enables several complementary approaches on the level of primary, secondary and tertiary prevention. A high priority is set on identification and subsequent reduction or elimination of causative exposures. Important preventive approaches include legal regulations, technical and organizational measures as well as correct use of adequate personal protective equipment (e.g. protective gloves). Interventions based on health education are conducted to improve individual protective behaviour. Even though evidence-based proof of effectiveness is limited, preventive measures are considered of particular importance for avoidance of occupational hand eczema and its adverse sequelae. Therefore, a complex, step-wise approach to occupational skin diseases has been established in Germany. In recent years, the positive impact of secondary and tertiary preventive measures of this approach has been demonstrated.

Glove-Related Allergic Contact Dermatitis

Hand dermatitis is a common condition with a lifetime prevalence of 20%. Glove allergic contact dermatitis (ACD) is a very important dermatitis affecting health care workers, hairdressers, cleaning personnel, kitchen workers, craftsmen, construction workers, laboratory workers, and homemakers. Occupationally related cases may be severe and can result in significant disability. Glove ACD is most commonly due to exposure to rubber accelerators, which are compounds that are added to rubber during production to increase strength and durability. Given the known allergic potential of these compounds, glove manufacturing companies have reformulated gloves leading to the introduction of new rubber allergens. In this review, we will discuss risk factors for glove ACD, both common and uncommon allergens in gloves, common contact allergens that permeate gloves, and patch testing to help uncover the inciting allergen(s).

Effect of Humidified Noninvasive Ventilation on the Development of Facial Skin Breakdown

BACKGROUND

The use of noninvasive ventilation masks is known to cause damage to facial skin tissue, which affects both the efficacy of the intervention and the patient's quality of life. The use of humidification with noninvasive ventilation is a common practice, but its relative role in the development of facial pressure ulcers has not been fully studied.

METHODS

A crossover cohort design was used in this study, with 15 healthy volunteers. Each volunteer randomly received both 10 cm H2O of CPAP with and without humidification through an oronasal mask. Skin integrity was evaluated by measuring transepidermal water loss, skin hydration, and skin pH at the bridge of the nose. Device-skin interface conditions (pressure and microclimate) were recorded at the bridge of the nose and both cheeks. The pro-inflammatory cytokine interleukin-1α was collected from the nose bridge before and after CPAP application by using a skin analysis tape. Nasal symptoms were collected by using a validated 6-point score.

RESULTS

Humidified CPAP significantly increased transepidermal water loss (P < .001) and skin humidity (P = .02) compared with non-humidified CPAP. There were no significant differences in skin hydration, skin pH, skin temperature, and cytokine expression between both conditions. However, there was a trend of increased median ratios of interleukin-1α concentrations in the humidified CPAP. There was a significant increase in the interface pressure at the bridge of the nose after CPAP application (P = .02), with higher interface pressure values at the nose bridge compared with both left (P = .002) and right (P = .003) cheeks. The participants reported elevated nasal discomfort during non-humidified CPAP.

CONCLUSIONS

These findings indicated that noninvasive ventilation with humidification had a potential disrupting effect on the barrier function of facial skin, associated with changes in skin microclimate and function. Further research is required to establish the cause of mask-related skin damage and to evaluate the effects of mask design, application techniques, and air flow and humidity settings.

Tandem repeated irritation test (TRIT) studies and clinical relevance: Post 2006

Background/Aims: Single or multiple applications of irritants can lead to occupational contact dermatitis, and most commonly irritant contact dermatitis (ICD). Tandem irritation, the sequential application of two irritants to a target skin area, has been studied using the Tandem Repeated Irritation Test (TRIT) to provide a more accurate representation of skin irritation. Objective: Here we present an update to Kartono's review on tandem irritation studies since 2006. Methods: We surveyed the literature available on PubMed, Embase, Google Scholar, and the UCSF Dermatology library databases since 2006. Results and discussion: The studies included discuss the tandem effects of common chemical irritants, organic solvents, occlusion as well as clinical relevance - and enlarge our ability to discern whether multiple chemical exposures are more or less likely to enhance irritation.

Hand eczema and wet work: dose-response relationship and effect of leaving the profession

BACKGROUND

Wet work is an important risk factor for occupational hand eczema.

OBJECTIVES

To examine the effect of job change in workers with occupational hand eczema caused by wet work, and to evaluate the dose-response relationship between intensity of wet work and eczema.

METHOD

The study is based on a subgroup (n = 954) from a descriptive, registry-based study including all participants with occupational hand eczema caused by wet work recognized by the Danish Labour Market Insurance Authority in 2010 and 2011. A follow-up questionnaire was sent out 4-5 years later (response 58%).

RESULTS

Change of profession and being outside the labour market had a positive effect on healing and improvement of hand eczema. Inverse dose-response relationships were found between the amount of time spent with wet hands at work and healing (p = 0.001) and improvement (p < 0.001), and between the frequency of hand washing at work and healing (p = 0.013) and improvement (p < 0.001).

CONCLUSIONS

Leaving the profession has a positive effect on eczema; however, even minor changes in exposure to wet work were associated with healing and improvement. This information has implications with respect to advice given to patients with occupational hand eczema caused by wet work.

Protection during production: Problems due to prevention? Nail and skin condition after prolonged wearing of occlusive gloves

Wearing of occlusive gloves during the whole working shift is considered a risk factor for developing hand eczema, similar to wet work. Moreover, the increased hydration due to glove occlusion may lead to brittle nails. Two hundred and seventy clean room workers, wearing occlusive gloves for prolonged periods, and 135 administrative employees not using gloves were investigated. This included a dermatological examination of the nails and the hands, using the Hand Eczema ScoRe for Occupational Screening (HEROS), measurement of transepidermal water loss (TEWL), and a standardized interview. Of the clean room workers, 39%, mainly women, reported nail problems, mostly brittle nails with onychoschisis. Skin score values showed no significant differences between HEROS values of both groups. TEWL values of exposed subjects were similar to TEWL values of controls 40 min after taking off the occlusive gloves. In a multiple linear regression analysis, male gender and duration of employment in the clean room were associated with a significant increase in TEWL values. The effect of occlusion on TEWL seems to be predominantly transient and not be indicative of a damaged skin barrier. This study confirmed the results of a previous investigation showing no serious adverse effect of wearing of occlusive gloves on skin condition without exposure to additional hazardous substances. However, occlusion leads to softened nails prone to mechanical injury. Therefore, specific prevention instructions are required to pay attention to this side effect of occlusion.

Influence of artificial sebum on the dermal absorption of chemicals in excised human skin: A proof-of-concept study

In an initial diffusion cell study, the influence of artificial sebum on dermal penetration and intradermal reservoir of ethanol and toluene was investigated in comparison with the effects of a skin cream (o/w- and w/o-emulsion) and untreated (control) skin. Human skin was exposed to neat ethanol and toluene for 4h, respectively. During the experiments, the penetration of the compounds was assessed in the receptor fluid. The amounts of the test compounds in the skin were determined at the end of exposure. In the control experiments, 42% of the total resorbed ethanol amounts were found in the intradermal reservoir after 4h, whereas 82% of the toluene amounts were found in the skin compartments. The treatment with artificial sebum showed no significant differences in dermal absorption of both test compounds compared to control skin. In contrast, the treatment with skin cream increased the percutaneous penetration (p<0.001) and the intradermal reservoir of ethanol ~2-fold but not of toluene. In all exposure scenarios, a relevant intradermal reservoir was formed. The results indicate that sebum does not influence the percutaneous penetration and the intradermal reservoir of epidermally applied chemicals, whereas the application of skin creams may increase the dermal penetration of the compounds.

Optimal evaluation time point for patch testing to predict skin irritation of commercial topical drugs

To develop patch testing (PT) that better reflects the skin irritation resulting from repeated applications, we methodically classified PT results and examined correlations between these results with results from repeated application tests. A total of 115 commercial topical drugs were used for patch testing. In two groups of 30 healthy individuals with normal back skin, 55 or 60 commercial topical drugs were applied to the back for 24 h. Skin reactions were scored for each group at 2 and 24 h after patch removal. Based on time-dependent changes in skin reaction at each evaluation time, PT results were classified into six different types. For repeated application testing, a total of 17 products with different types of PT results were selected. A total of 104 healthy individuals divided into three groups (n = 22-52 each) received application of 6-7 test materials, differing for each group, for 3 weeks on both arms. Incidences of positive symptoms induced by repeated drug application excluding transient erythema showed a greater correlation with reaction levels at 24 h after patch removal than 2 h after patch removal. Many test materials that triggered a high incidence of positive symptoms after repeated application also exhibited erythema or greater reaction up to 24 h after patch removal. PT offers a useful test system for predicting skin irritation that develops after repeated application of topical drug. Moreover, assessment at 24 h after patch removal is suggested as the optimal evaluation time point to reflect the results of repeated application tests.

Occlusive gloves and skin conditions: is there a problem? Results of a cross-sectional study in a semiconductor company

BACKGROUND

Although there is poor scientific evidence that working with occlusive gloves is as damaging as wet work, prolonged glove occlusion is considered to be a risk factor for developing hand eczema similar to wet work.

OBJECTIVES

To assess the effects of wearing occlusive gloves during the whole working day, without exposure to any additional hazardous substances, on skin condition and skin barrier function.

METHODS

We investigated 323 employees of a semiconductor production company in Germany: 177 clean-room workers wearing occlusive gloves during the whole shift (exposed group) and 146 employees working in administration (control group). A standardized interview was performed, the skin condition of both hands was studied using the quantitative skin score HEROS, and transepidermal water loss (TEWL) and stratum corneum hydration were measured.

RESULTS

There was no significant difference in skin condition between the two subgroups. Values for TEWL and corneometry were significantly higher in exposed participants (P < 0·05). However, the TEWL values were similar to control values if participants took off the occlusive gloves at least 30 min before the measurement. Hence, the effect of occlusion on skin barrier function seems to be transient.

CONCLUSIONS

Prolonged wearing of occlusive gloves with clean hands and without exposure to additional hazardous substances does not seem to affect the skin negatively.