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Proper skin care can drastically reduce contact dermatitis cases

Experts recommending hand care before, during and after work
By Amanda Silliker
| Canadian Occupational Safety

A worker at Bell Camp Manufacturing in Ingersoll, Ont., had developed a severe rash on his hands that became infected. He went to the hospital and was prescribed a medicated cream, but after one week, there was no improvement. The company decided to implement a comprehensive hand care program that included a pre-work skin cream, industry-specific hand cleaners and after-work conditioning cream. After this process was in place for about one week, the employee’s infected rash was completely gone.

Hand creams, cleansers, soaps and lotions should not be overlooked in industrial workplaces. Sure, they are at the bottom of the pyramid when it comes to the hierarchy of controls, but any skin irritation on the hands can pose significant problems for workers and consequently, employers.

Skin disease is the most common occupational disease in many jurisdictions. In Canada, the incidence rate across all sectors for occupational skin disease is on average 4.63 cases per 10,000 full-time employees. But experts agree many cases go unreported and untreated. According to the Centers for Disease Control and Prevention in Atlanta, up to 40 per cent of industrial workers will suffer a skin issue at some point in their working life.

Occupational contact dermatitis accounts for up for 95 per cent of all workplace skin disease, according to a 2017 study published in the Journal of the European Academy of Dermatology and Venereology.

Contact dermatitis is a skin condition caused by coming into contact with something that either irritates the skin or that causes an allergic reaction. Individuals may experience redness, scaling, blistering, cracking, crusting or swelling of the skin, as well as itching and pain. The condition is often long-lasting and chronically relapsing.

“When you have skin break downs, if your hands become dry and cracked, there is a risk you could have foreign substances enter into your body,” says Cheryl Croutch, manager of occupational health and safety services at St. Joseph’s Health Centre in Toronto.

Irritant contact dermatitis is the most common form (seen in about 80 per cent of cases). Upon contact with the substance, the skin may be immediately damaged or become damaged after repetitive exposure. This type of contact dermatitis can be caused by wet work (work that involves repeated contact with water), cleansers, detergents, alkalis and acids, oils and greases, cutting fluids and solvents, plants and animals and fibreglass, according to Ontario’s Public Services Health and Safety Association (PSHSA).

Contact dermatitis can also be caused by wearing gloves for long periods of time and not letting the skin breathe. The disease is especially prevalent in the winter.

“In the wintertime, you can have more cracks in your skin, your skin is just dryer, there’s less moisture in the air and you can get cracks along the cuticles and it’s lifting up the skin,” says Croutch.

Allergic contact dermatitis is seen in about 20 per cent of cases. Workers may be exposed to a substance for years before the allergy develops, and symptoms can spread to other parts of the body.

At Sunnybrook Health Sciences Centre’s dermatology clinic in Toronto, the dermatologists see many cases of work-related contact dermatitis every day, says Sylvia Aide Martinez Cabriales, a dermatology fellow who works at the clinic under certified dermatologist Joel Dekoven. The patients range from construction workers, mechanics and plumbers to dentists, surgeons, bakers and hair dressers.

“Anyone who spends a lot of time working with their hands, is in contact with a lot of chemicals or substances, lots of people that need to clean their hands a lot, they are usually the people that will be at risk to develop contact dermatitis,” says Martinez Cabriales.

Contact dermatitis can severely negatively affect an individual. It can restrict hand mobility and make it difficult to carry out every day workplace activities, such as gripping a tool or operating machinery. It also affects the worker’s home life because simple tasks, such as making a cup of coffee, opening jars and turning taps, can become an impossible or stressful challenge, according to the white paper Preventing Occupational Skin Disorders: Skin Care Best Practice, released by Deb Group.

Workers’ mental well-being may also be affected as they can suffer from anxiety, depression, social isolation, low self-esteem and embarrassment due to their contact dermatitis.

“It makes them feel sad and frustrated because the hands are a very important thing from a social point of view and shaking hands, for instance, they might be embarrassed and don’t want to do that,” says Martinez Cabriales. “We have seen in our clinic most patients will have damage in their self-confidence because of that.”

Contact dermatitis affects a worker’s ability to perform her job, so she may need to take time off work to recover or be assigned modified duties, depending on the severity of the disease.

“Sometimes it’s really painful and patients have blisters and they cannot do anything,” says Martinez Cabriales.

The Occupational Safety and Health Administration (OSHA) in Washington, D.C., has an online calculator for determining the cost of occupational injuries and illnesses, and the estimated impact on an organization.

The calculator shows that for one case of contact dermatitis, an employer will need to make US$792,000 in additional sales to overcome both the direct and indirect costs associated with the disease, such as health care, lost work time, workers’ compensation and training a replacement worker, says Armand Coppotelli, senior manager, business development and technical training at Deb Group in Charlotte, N.C.

Typically, it equates to about 24 lost work days for one case of contact dermatitis, he adds.

If left untreated, contact dermatitis can result in a career change for the worker.

3 MOMENTS

In order to ensure workers are taking good care of their hands, there is a best practice they should follow called the 3 Moments of Skin Care. Inspired by the World Health Organisation’s My 5 Moments of Hand Hygiene for the health-care sector, the 3 Moments model was developed by an expert panel of eight international dermatologists who drew upon personal clinical experience as well as an analysis of 75 occupational skin care studies. Essentially, it requires skin care before work, during work and after work.

“While the statistics demonstrating the current extent of the problem give cause for concern, adoption of the 3 Moments standard makes it possible to reverse the trend of occupational skin disorders,” says John English, a dermatologist at Circle Nottingham Hospital in the United Kingdom and a developer of the 3 Moments model.

Before starting work where there is a risk of exposure to irritants, workers should apply a pre-work cream, often referred to as a barrier cream. These creams act as a supporting layer for the skin’s defense mechanism and help the skin retain natural lipids and moisture. The creams also make hands easier to clean. There are even certain creams that help protect the skin in cold working conditions, strengthen the skin under gloves and help prevent excess sweat build-up inside gloves.

According to the study in the European journal, pre-work creams have been proven effective in preventing the onset of contact dermatitis and even improving skin condition in healthy subjects. They also reduce irritant access to the skin and help with the removal of oils, greases and resins.

Barrier creams should not be used in replacement of work gloves. However, in some instances, gloves are problematic, says Coppotelli, such as for anyone doing wet work or mechanics who need a certain amount of dexterity that gloves cannot provide — and a glove could get caught in machinery. Barrier creams might make sense in these situations, but they need to come with a lot of worker education around using a sufficient amount, applying it properly and re-applying often (every two to three hours).

The study in the European journal suggests that the naming convention may be problematic, as the term “barrier” might give workers a false sense of security. The study suggests that changing the terminology from barrier cream to pre-work cream might change workers’ perceptions.

“What happens when they are using a barrier cream is most of the patients think their skin will be very safe and they will do most of their work without being afraid to touch chemicals and substances,” says Martinez Cabriales. “It sends the wrong message.”

Coppotelli recommends choosing pre-work creams that are industry specific, rather than a generic barrier cream. There are creams on the market that are best suited for exposure to solvents, wet work and multi-component resins (sticky materials), for example.

“It depends on the type of facility, the type of manufacturing and what hazards employees are exposed to,” he says. “It would be like if you were going to put in a glove program, you just wouldn’t pick one universal glove, you would base it on the type of exposures so that it’s the best glove for that environment.”

It’s important to choose a pre-work cream that does not affect an industrial process, cautions Coppotelli. For example, some of the consumer products that can be purchased at the drug store contain silicone, also known as dimethicone, which can interfere with the curing of rubber parts and the bonding of paint to metal (causing “fisheyes” in the final paint job), says Coppotelli.

“A worker may bring something from home and unbeknownst to them or the employer, that could become a contaminant in the work process... And production may need to be shut down to allow for cleaning,” he says. “You want to have a good way of standardizing what is used in the workplace, so we know exactly what workers are putting on their hands so it doesn’t affect the work process.”

During work, workers wash their hands regularly. Soap and water dries out the skin and depletes it of its natural oils. Plus, many workers use alcohol-based hand sanitizers that also dry out the skin, says Croutch.

When selecting a cleanser, it’s important to avoid those that have harsh ingredients that can cause damage to the skin’s natural barrier, such as pumice and petroleum-based solvents, says Coppotelli. The mildest hand cleanser possible should be used to remove a specific contaminant. Bar soap is not recommended due to the risk of cross-contamination.

The second moment in the 3 Moments model is to apply a conditioning cream to the hands after washing and drying.

“It helps to moisturize the skin and repair any damage in the skin,” says Croutch. “It prevents it from drying and cracking and splitting and it keeps the skin soft and supple.”

But if workers are returning to their previous tasks, their “second moment” would be re-applying the pre-work barrier cream.

The third moment in the model is to apply a conditioning cream after work. This helps restore skin health for the following day by adding moisture back into the skin, replenishing the skin’s oils and improving its strength.

“During the work day, all the hand washing and friction and contact with industrial surfaces has removed the moisture from the skin… We want to add these ingredients back so that the natural barrier can start to regenerate and repair itself,” says Coppotelli. “Even men use skin moisturizers these days.”

But before any cream is applied, workers should first check to make sure they did not develop any rashes or blisters when they remove their gloves, cautions Martinez Cabriales. If they did, the moisturizer may further irritate the skin.

With any creams at any stage of the 3 Moments model, it’s important that they are applied thoroughly with special attention to the spaces in between the fingers, the nail beds and the backs of hands. The cream should be fully absorbed and feel dry before engaging in any activities.

It’s also very important for the soaps and creams to be fragrance-free and ideally, they should be preservative-free too, says Martinez Cabriales. Also, lotions with a low pH are the best option, she adds.

Employers might need to have some specialty products on hand for workers with underlying skin conditions like psoriasis or eczema, says Croutch.

When it comes to selecting the right cleansers and creams for your workforce, treat it the same as you would when selecting any other personal protective equipment. Croutch says it’s a collaborative process that includes purchasing, front-line workers, support services and occupational health and safety.

“(Skin care) products need to be compatible with existing products, such as gloves, accepted by staff and meet any applicable industry recommendations,” she says.

Coppotelli suggests starting with a plant survey to determine the potential skin hazards and irritants that could lead to contact dermatitis, speaking to workers and looking at their hands. It’s important to determine a baseline of skin health and worker education.

“They might think their hands are normal; but normal to them is not normal to us. Normal to us is a QVC model on TV — that’s actually really healthy,” Coppotelli says. “Normal hands on a work site might look a lot different, but that isn’t healthy.”

The study in the European journal found that worker compliance with hand care programs is low. One way to improve this is to ensure the product dispensers are located in convenient areas. In health care, the hand sanitizer is placed in front of a patient’s room, so the worker applies it when he is entering and leaving the room, says Croutch. This concept can be applied to industrial environments as well, such as having creams at the entrance of work areas.

“If they have, for instance, to get cream that’s only available in tubes at a tool crib, they’re not going to walk to that tool crib; it’s just out of the way,” says Coppotelli. “It has to be a good workflow for them to use the product.”

Change rooms, rest areas, washrooms, lunchrooms or cafeterias are other good locations. The Deb Group white paper recommends involving workers when deciding where to place the dispensers. The product also has to be well-stocked and clearly labelled.

Workers need to be educated on the importance of the hand care program. They should learn about what contact dermatitis is, how it can negatively affect their work and personal lives, how to properly use the skin care products and what to do if they are experiencing symptoms of skin disease. They should also be shown what healthy hands should look like.

Many organizations have seen benefits from implementing hand care programs. A 2006 pilot program in Austria’s oil industry was able to decrease the rate of irritant contact dermatitis from 55.4 per cent to 19.7 per cent by introducing workplace-adapted skin products, strategically placed and labelled dispensers and a series of standardized educational courses.

According to the European journal study, the success of a hand care program can be evaluated by drawing on an established model of hand-hygiene compliance monitoring, which includes the following components:

• establishing a denominator for the total number of hand cream application events that are possible in a given period

• developing a sustainable method for measuring the number of events fulfilled in a given period (the numerator)

• calculating a baseline from which to gauge improvements over time.

Smart soap dispensers are connecting to digital platforms to make this monitoring process even easier. They digitally track how much soap or cream is being used and when, and they provide a report and statistics on this usage. 

The authors of the European study recommend reporting data back to employees as it becomes available. This not only shows that the organization is taking hand health seriously, but it holds individuals accountable and reinforces expectations.

Employees should be surveyed again after the program has been in place for about six months, and the results should be compared to the original employee survey.

Safety managers should also evaluate the number of missed work days due to contact dermatitis, as well as how many workers are on modified duties due to the disease, says Martinez Cabriales.

Fortunately, if caught early, the impact of contact dermatitis can be minimal for both the employee and employer. If the worker is showing any symptoms, a hand assessment should be performed and she should be seen by a physician, says Croutch.

“It all depends on the severity of the issue but for regular contact dermatitis, it’s usually resolved fairly quickly once you figure out what the root cause is and why it’s happening.”

This article originally appeared in the October/November 2018 issue of COS.


Skin-health audit checklist

Regular skin health checks can help with early detection of dermatitis, which can prevent more serious disease development. Checks can also help identify any gaps in preventive measures and the need to reassess skin protection as appropriate.

• Have you conducted an audit of the contaminants in your workplace that get onto employees’ skin?

• Do you analyze skin issues to ensure your skin care program is effective?

• Have you confirmed that the hand cleansers provided are suitable for the specific contaminants in your workplace?

• Do any employees use their own products from home?

• Are employees using the correct amount of hand cleanser?

• Have all employees received training on why they need to use the skin care products provided?

• Have all employees received training on how checking their skin regularly can help reduce the risk of serious skin disease?

• Is point-of-use signage used to reinforce the skin care training messages?

• Are creams available alongside hand cleansers for use after hand washing?

Source: “The Three Moments of Skin Cream Application: An Evidence- Based Proposal for Use of Skin Creams in the Prevention of Irritant Contact Dermatitis in the Workplace,” Journal of the European Academy of Dermatology and Venereology

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Comments (1)

  • Isothiazolinones are causing major reactions - Dana Todd
    0
    10/29/2018 5:51:33 PM
    This is an excellent article, and I don't disagree with its basic content and direction. However, there is not enough being done to prevent exposure to chemicals in the workplace, specifically "sensitizers" like the isothiazolinone group of chemicals. Benzisothiazolinone, methylisothiazolinone, methylchloroisothiazolinone and octylisothiazolinone are the main version of a preservative that is growing in use in the USA, found in everything from hand soaps to office printer toner and wall paint. People who are exposed both at home and work may be getting exposure up to an average of 17 times per day, which is causing an epidemic of lifetime allergic reactions that include cracked, bleeding and painful skin rashes as well as systemic contact dermatitis that affects pulmonary and nervous systems. In cosmetic formulas outside the US, MI and MCI are partially banned, but almost nothing is being done yet in the US about cosmetic or industrial use. It would be really great if OSHA could take a look at the contact dermatitis data and compare it to patch test data to understand the correlations and rising populations.
    (Why do I care about this? Because I'm not only a victim of sensitization to isothiazolinones but I also run an online support group that numbers 10,000+ and I've watched this chem growing in usage and impact worldwide.)