A long-term follow-up study of the Hand Eczema Trial (HET): a randomized clinical trial of a secondary preventive programme introduced to Danish healthcare workers

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

Prevalence, risk factors, and prevention of occupational contact dermatitis among professional cleaners: a systematic review

OBJECTIVE

The aim of this study was to investigate the prevalence, risk factors, and prevention of occupational contact dermatitis (OCD), as well as risk factors and consequences of OCD among professional cleaners.

METHODS

A systematic review following PRISMA guidelines was performed using Medline, EMBASE, and Cochrane Library.

RESULTS

Thirty-nine studies containing over 109.000 participants were included in the review. The prevalence of OCD varied between 2.2% and 30.1%. Main occupational risk factors for developing OCD among cleaners included wet work and irritants in cleaning products (bleach, chlorine, ammonia, multi-use-cleaning) and skin contact to metal. The most common contact allergies included rubber, biocides, nickel/cobalt, and perfumes. Other risk factors were inconsistent use of protective gloves and low educational level. Consequences associated with OCD included significant impairment in quality of life, tendency to have unscheduled absence from work, sick leave, increased rate of disability, and recognized degree of injury. Only one prevention study has been published investigating the effect of an educative course in skin-protective behavior in cleaners. The study reported a higher degree of knowledge of skin protection, a decrease in the severity of hand eczema, and a shift toward fewer daily hand washings at follow-up after 3 months.

CONCLUSION

Our study proves that OCD is common in cleaners, and the main risk factors included wet work, irritants, and contact allergies, as well as inconsistent use of protective gloves and low educational level. More focus and a greater number of studies are needed on skin protection in this population.

Occupational Hand Dermatitis

PURPOSE OF REVIEW

Occupational hand dermatitis is a common work-related disorder of the skin. Prevention and management of this disease is critical to improving workers' quality of life and for occupation-specific retention.

RECENT FINDINGS

This is a critical review of the current literature on occupational hand dermatitis. Occupational dermatitis continues to have a high prevalence among workers although the overall incidence may be slowly decreasing. Irritant contact dermatitis due to wet work exposure is the most common cause of occupational hand dermatitis. Healthcare workers, hairdressers, and metal workers are at particularly high risk for this disease. While some prevention programs have been ineffective in mitigating occupational hand dermatitis, other more resource-intensive initiatives may have benefit. Continued research is needed on ways to manage wet work exposures and on scalable, effective prevention programs for occupational hand dermatitis. The spectrum of culprit contact allergens continues to evolve, and vigilance for potential occupation-specific allergens remains important.

Impact on quality of life of an intervention providing additional information to patients with allergic contact dermatitis; a randomized clinical trial

BACKGROUND

Allergic contact dermatitis can negatively impact an individual's daily life in terms of work and interpersonal relationships. Patch-tested individuals show an improved quality of life (QoL).

OBJECTIVES

We aimed to assess the impact on QoL after patch testing and what value an intervention would have on QoL.

METHODS

Dermatology Quality of Life Index (DLQI) were assessed in participants with positive patch test reaction. The participants were randomized, in parallel design, into two groups that received either standard information (controls, n = 70) or a reminder letter in addition to standard information (intervention group, n = 66), ClinicalTrials.gov NCT01953380.

RESULTS

The response rate was 74% (n = 136). The DLQI score was significantly lower 1 year after patch testing in comparison with baseline in the entire group (mean DLQI 6.3 and 4.5 respectively, 95% CI 0.93-2.72, P < 0.001). However, linear regression analyses showed no significant differences in DLQI score at follow-up between the intervention and control groups. Neither age nor gender had impact on DLQI score.

CONCLUSION

There was an improvement of QoL at follow-up in the entire group. However, the intervention performed did not show any significantly greater improvement concerning QoL. Further research is needed to understand what factors apart from patch testing and medical care may affect QoL in patients with contact dermatitis, and what interventions are needed to improve QoL.

Prevention of occupational hand eczema in healthcare workers during the COVID-19 pandemic: a controlled intervention study

BACKGROUND

Occupational hand eczema (HE) is common among healthcare workers (HCWs) and has - in some regions of the world - increased during the COVID-19 pandemic due to related hygiene measures.

OBJECTIVES

To evaluate the efficacy of an intervention for HE prevention in HCWs during the pandemic.

METHODS

A prospective, controlled, unblinded interventional trial was conducted in 302 HCWs. The intervention group (IG) (n = 135) received online-based health education and free access to hand cleansing and hand care products. The control group (CG) (n = 167) did not receive any intervention within the study. At baseline (T0), after three (T1) and six (T2) months, participants completed standardised questionnaires. The Osnabrueck Hand Eczema Severity Index (OHSI) was assessed at T0 and T2.

RESULTS

During the observation period, there were no new HE cases in the IG (n = 115) and 12 cases (8.8%) in the CG (n = 136). OHSI values at T2 were lower in the IG (b = -1.44, P < 0.001). Daily use of emollients was higher at work (b = 1.73, P < 0.001) and at home (b = 1.62, P < 0.001) in the IG at T2.

CONCLUSIONS

The intervention was effective in HE prevention and improving skin care behaviour during the COVID-19 pandemic. This article is protected by copyright. All rights reserved.

Occupational Dermatitis and Urticaria

Occupational contact dermatitis is the most common occupational skin disease (OSD), and most of them are irritant in nature. There is less information available about contact urticaria than contact dermatitis. There are several strategies to prevent OSD, although workplace studies suggest there are gaps in their use in the workplace. Because early detection leads to improved outcomes, screening for dermatitis in industries such as health care would be useful. Both diagnosis and management involve 2 components: the actual disease diagnosis and medical treatment and the work-relatedness and management of the workplace to reduce exposures.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

Occupational Skin Disease in Physicians: A Review of the Literature

OBJECTIVES

Occupational skin disease (OSD) arises from work-related activity. However, there is a paucity of literature on OSD in physicians. The aim of the this review was therefore to examine and summarize what types of symptomatic OSD physicians experience.

METHODS

We conducted a systematic literature search on Cochrane Library, Embase, and Pubmed.

RESULTS

Contact dermatitis from formaldehyde and glutaraldehyde were found in 11.5 and 13.5% of cases, respectively. In total 2.4-14.9% had latex allergy. The reported standardized incidence ratio of squamous cell carcinoma and melanoma was up to 2.15 [95% confidence interval (CI) 1.57-1.95] and 3.2 (95% CI 1.38-6.31). Transmission of human papilloma virus (HPV) particles during carbon dioxide laser wart ablation were found in 70% of samples collected from protective gloves and in 52% of samples from vapors.

CONCLUSIONS

The most frequently reported OSD in physicians is contact dermatitis from allergens in disinfectants and rubber gloves. There is also a risk of cutaneous reactions to latex. The incidence of skin cancer was higher in physicians than in the general population, and the reason for this remains unexplained and potentially biased. There are no reports of transmission of patient HPV to surgeons during wart ablation, possibly because of proper use of protective equipment.

New evidence on the minimal important change (MIC) for the Hand Eczema Severity Index (HECSI)

BACKGROUND

How changes in hand eczema (HE) severity correlate with the single scores on the Hand Eczema Severity Index (HECSI) is sparsely investigated and particularly needed in clinical trials.

OBJECTIVES

To find the minimal important change (MIC) for HECSI based on patient's and physician's assessments using different methods.

METHODS

In this prospective follow-up study, three different anchors were used: two anchor questions for patients and physician, respectively, and the Physician Global Assessment (PGA) with a photographic guide. MIC was estimated by mean change in patients with a one-step increase to anchor-questions, receiver-operating characteristic (ROC) plot, and smallest detectable change (SDC).

RESULTS

One hundred fifty-two patients with HE (63.8% female) were included at baseline (89% completed follow-up). The mean change, ROC cutoff, and SDC values were 7.1, 4.5, 21.4 (patient-rating), 8.2, 4.5, 8.3 (physician-rating), and 16.6, 6.5, 27.1 points (PGA), respectively. SDC stratified by baseline severity was 2.9 and 11 points for mild and moderate-severe HE (physician-rating), respectively.

CONCLUSION

Identification of the MIC for the HECSI is important in relation to evaluation of treatment, intervention, and sample-size calculations. An improvement of 8.3 points on the HECSI is recommended as the MIC. MIC values may differ according to baseline severity, and this variation should be clarified in future studies.

Hand eczema among healthcare workers in Guangzhou City: a cross-sectional study

Background

Healthcare workers are at high risk of developing hand eczema. This study aimed to investigate the association between occupational hygiene and self-reported hand eczema among nurses and doctors in Guangzhou.

Methods

A cross-sectional study using a self-administrated questionnaire sent to 740 health care workers in two tertiary hospitals between 1^st April and 1^st July 2019 was conducted.

Results

In total, 521 healthcare workers responded (70.4%). The prevalence of self-reported hand eczema was 9.6% [95% confidence interval (CI): 7.1-12.1%], with 10.8% in nurses and 6.9% in doctors. According to multivariable logistic regression analysis, the prevalence was higher in those who were excessively exposed to hair dye (OR: 3.871, 95% CI: 1.106-13.549) and those having a history of food allergy were at 3.013 (95% CI: 1.314-6.907) times greater risk of having hand eczema than those who did not. The odds of having hand eczema were 4.863 (95% CI: 1.037-22.803) times greater in those who hand washed more than 50 times daily in comparison to those who washed hands less than 10 times per day. The symptoms of hand eczema were mild during the investigation period.

Conclusions

Hand eczema is common among healthcare workers in Guangzhou. The prevention of hand eczema by educational programs is needed for Chinese healthcare workers.

Degree of employment, sick leave, and costs following notification of occupational contact dermatitis-A register-based study

BACKGROUND

Occupational contact dermatitis (OCD) is the most commonly recognized occupational disease in Denmark.

OBJECTIVES

To examine the impact of recognized OCD on degree of employment, sick leave, unemployment, and job change.

METHODS

Data on all recognized individuals with OCD notified in Denmark between 2010 and 2015 (n = 8940) were linked to information on social transfer payments in the years before and after notification. The number of weeks on unemployment benefits or sick leave and the degree of employment during the 2 years prior to notification was compared with the 2 years following notification.

RESULTS

The degree of employment decreased on average 8.9 work-hours/month, corresponding to an average annual loss of income per worker of approximately €1570. The average number of weeks that workers were receiving unemployment benefits and paid long-term sick leave rose by 2.5 and 3.4 weeks, respectively, corresponding to an average additional annual cost per worker of approximately €420 and €770, respectively. Longer case-processing time was significantly associated with lower degree of employment and higher levels of unemployment and sick leave.

CONCLUSIONS

OCD has a significant negative impact on employment and economics, thus highlighting the need for a national, strategic action plan for effective prevention of OCD.

Quality of life measurement in occupational skin diseases. Position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Occupational Skin Disease

The European Academy of Dermatology and Venereology (EADV) has started the 'Healthy Skin @ Work' campaign aimed to raise awareness among the public and EU authorities on the frequency and impact of occupational skin diseases (OSDs). The EADV Task Forces (TFs) on Quality of Life and Patient Oriented Outcomes (QoL/PO) and on OSD present their mutual position statement on QoL assessment in OSDs. The EADV TFs recommend the use of the DLQI as a dermatology-specific instrument and SF-36 as a generic instrument in health-related (HR) QoL studies on OSDs. The OSD-specific questionnaire, LIOD, is not recommended for general use in its present form because of its three months recall period. The EADV TFs discourage the use of non-validated and of non-validated modifications of previously validated HRQoL instruments. The EADV TFs wish to encourage research into: the HRQoL impact of OSDs other than occupational contact dermatitis and hand eczema; comparisons between the effects of different treatments and other interventions on HRQoL in OSDs; and into the HRQoL impairment of patients with OSDs from different countries, and with different provoking factors, to predict if the results of successful therapeutic and educational interventions may be generalized across countries and between occupations.

Intervention study to evaluate the importance of information given to patients with contact allergy: a randomized, investigator-blinded clinical trial

BACKGROUND

In contact dermatitis, it is crucial to understand and remember the outcome of patch testing. Unfortunately, many patients do not remember the results of their patch tests.

OBJECTIVES

Our aim was to evaluate the effects of an intervention programme in which extensive information on specific contact allergy was provided, in individuals with positive patch test reactions.

METHODS

The study was designed as a randomized, investigator-blinded clinical trial. Participants with positive test reactions were randomized into two groups that received either standard information according to clinical routine or standard information and a reminder letter. Knowledge of contact allergies was evaluated using questionnaires 12 months after inclusion.

RESULTS

There were 184 adults included in the trial and the response rate at 1-year follow-up was 78% (143 of 184). Sixty-five per cent (45 of 69) in the intervention group and 54% (40 of 74) in the control group reported the correct name of the allergen (P = 0·23). Participants with several - as opposed to few - positive patch test reactions had difficulty in remembering the correct names of the allergens (P = 0·001). Moreover, the type of allergy had an influence on their ability to remember the name of the allergen correctly and their ability to make changes in lifestyle.

CONCLUSIONS

The intervention performed did not significantly affect the participants' ability to remember their contact allergy. To achieve better knowledge and changes in lifestyle, efforts to inform should concentrate on individuals with several positive patch test reactions, those with particular allergens, individuals over 60 years of age, and - concerning changes in lifestyle - males.