Advice for patients
When a patient is going through the patch testing process, it is important that they are educated about good skin care. This can be done from the very first time they visit the dermatologist, but even at the first point of seeing their GP. Good skin care is vital for the prevention and also the treatment of occupational contact dermatitis and eczema. Undamaged skin provides an excellent natural barrier to skin irritation and the development of allergy. Understanding what substances or conditions aggravate the skin and avoiding them is also very important.
Skin care involves several different components, and it is like a package: all are equally important. It includes glove use, avoiding irritating soaps and hand cleaners, use of a soap substitute, use of moisturisers and barrier creams and use of topical corticosteroids (when necessary).
Good skin care practices should be encouraged in the home and the workplace setting and anywhere there is the potential for skin problems. It is particularly important that workplaces have a skin care plan implemented for all workers to follow. This should spell out appropriate use of hand washes, moisturisers and gloves which are appropriate for the particular work environment. This plan should encourage the set-up of skin care systems which are easy for employees to use e.g. next to all wash stations, a moisturiser +/- a barrier cream should be provided.
Moisturising creams are an essential element of good skin care. Moisturizing creams used regularly can repair and maintain moisture in the skin, and may prevent dry skin from becoming inflamed, and turning into dermatitis. They are the most important treatment measure for irritant contact dermatitis. Dryness in the web spaces between the fingers is often the place where irritant contact dermatitis first occurs. This sign should be a prompt reminder to start using moisturizer or increase its usage.
Patients should be encouraged to use moisturiser regularly, especially at the end of the day or end of a shift, as it will repair and maintain moisture in the skin. There are several different types of moisturisers, and it is important that patients are educated about these differences.
When recommending types of moisturisers to patients, there are several things to consider:
- Ensure appropriate moisturiser is available at all times.
- A greasy ointment (usually thick and clear, like Vaseline) is most effective for healing damaged skin, but is not always practical for day use. Ideally it should be used when you get home and before bed. If an ointment can’t be used, a less greasy cream purchased in a tub or tube is next best.
- Moisturizing lotions are also available. A lotion is a thin and watery substance often purchased in a pump pack. Pump packs of sorbolene lotion are convenient and useful for moisturising during the day, but are not generally as effective moisturizers as an ointment or cream.
- Some oil-based moisturisers may not be suitable for use under some gloves, as these moisturisers can damage the protective functions of the gloves. Generally, we do not recommend the use of moisturisers under occlusive (tight-fitting, waterproof type) gloves. However, at night, creams may be applied under cotton gloves. Do not use cling wrap instead of gloves, as this causes more sweating, which contributes to irritant contact dermatitis.
- A fragrance-free moisturiser is best
Hand cleaners and hand washing
Hand washing practices are an important component of the skin care routine for contact dermatitis. Patients with dermatitis should be educated about the importance of selecting appropriate hand cleansers and good hand washing technique.
There are a range of different hand washing products available, and the one used will depend on the task being performed and the type of work being performed. Washing with very hot water is damaging to the skin, warm or cold water is preferred. Excessive amounts of hand washing can also aggravate eczema and cause the development of irritant contact dermatitis.
Soaps are used for general hand washing and they don’t contain antiseptics. They can come in either a bar or liquid formula and usually more irritating and contain more allergens than soap substitutes. In the workplace, some soaps and hand cleansers can be too harsh or strong for the skin. Soap which has sand or grit in it can be additionally damaging and drying, additionally bar soaps are often quite alkaline which can be drying to the skin.
If your patient has dermatitis related to their workplace, it is important they are encouraged to talk to their employer or workplace safety supplier about a suitable type of hand cleanser for the workplace, supplied in a dispenser which is both convenient and hygienic, preventing contamination of the product, and which dispenses the correct amount required.
2. Alcohol based hand rubs (ABHR)
Alcohol based hand cleansers are routinely used in the healthcare industry but with the COVID-19 pandemic have become more popular. ABHRs reduced the need for hand washing and contact with soaps, and cater for those who do not always have access to hand washing facilities such as builders and other trades persons. As a result they reduce the likelihood of developing irritant contact dermatitis.
Occasionally, people may think they are allergic to ABHR, because it stings their hands when applied. This stinging does not mean you are allergic to it, it just means you skin is damaged and good skin care is needed. Fortunately allergy to ABHRs is extremely rate (and less common than with liquid soaps). However, transient stinging will occur if the skin is cracked or split: even a paper cut can be unpleasant! Fortunately, this does not cause any harm and the best way to manage this is to increase moisturising of the skin. Using a different brand of ABHR may be less irritating and more moisturising to the skin.
3. Soap substitutes
Soap substitutes are less irritating than normal soaps as they have a similar acidity (pH) to that of the skin, and therefore are preferred for people with dry or damaged skin, or have eczema. These should be used at home and work if appropriate (e.g. they can’t be used as substitute for antiseptic cleansers).
4.Antimicrobial skin cleansers
These are usually found in healthcare environments and play a vital role in infection control. Chlorhexidine is a common ingredient in many antimicrobial hand washes, but fortunately allergy to chlorhexidine is rare. Antimicrobial or antiseptic hand washes can sometimes be drying and damaging to the skin, and should only be used if necessary.
Hand washing is the most common cause of hand dermatitis so when educating patients with dermatitis, there are a few key things to consider and recommend:
- Avoid unnecessary hand washing where possible
- Use a wash suitable for the substances used in the workplace/ home environment. Use of harsh gritty cleanser (soap with sand in it) or solvents should be discouraged, if it is not really needed, as they too are damaging to the skin. Less irritating soap substitutes are preferred for people with dry or damaged skin. Additionally the use of an ABHR can reduce the requirement for hand washing with water.
- Use warm water and not hot water for handwashing
- It is important that hands are dried well (particularly between the fingers and under rings).
To date, some evidence about the effectiveness of barrier creams is conflicting.
Barrier creams often do not act as the protective shield which may be claimed, and other precautions such as wearing gloves, will still be required. However, applying barrier cream before work can make cleaning the skin easier at the end of the day, such as when working with grease or oil.
Just as all gloves are not suitable for every job, not all creams are right for the job. Some are made to help protect against water-based substances and other are made to protect against oil-based substances. A safety supplier will provide advice on the best type to use in the patients’ specific workplace.
In many situations, use of a specific barrier creams is not necessary, and a moisturising cream may have a similar effect. Again, there is much research available which suggests that after-work moisturising is most important.
In addition to the use of moisturisers, some hand rashes will also need prescribed treatments, such as corticosteroids either as a topical application or oral tablet form.
Topical corticosteroids (applied directly to the skin) are available in a white cream or a clear greasy ointment. Dermatologists usually prefer to prescribe ointments rather than creams, as they are more effective and they do not contain preservatives, which sometimes cause allergy.
Generally speaking, topical corticosteroids available over the counter are not strong enough to treat dermatitis on the hands and/or body. However, they may be suitable for the face. As a general rule, it is suggested that 1% hydrocortisone is the only steroid used on the face. Other prescription creams or ointments which are not corticosteroid-based can also be used.
Sometimes following skin splitting or cracking, sores can develop, which may indicate an infection has started. Oral (and less commonly, topical) antibacterial treatment is sometimes indicated. In some cases, a tar-based cream may be helpful to treat thickened scaly skin.
Important things to remember when using corticosteroid treatments are:
- They are most effective if used frequently and early during the itchy or inflammatory phase of dermatitis
- Use on affected areas and stop once the skin becomes normal
- Use them when there is no need for hand washing, such as before bed. If used this way, the corticosteroids remain in the skin and will be most effective.
- Apply the steroid cream/ointment and allow to soak in for a few minutes then apply the moisturiser
- Ensure the patient has a prescription which gives them adequate supply of cortisone for their rash i.e., have they got enough to apply to their legs for 7 days? Also consider costs for the patient and what they can afford.
In severe cases of eczema and dermatitis, oral corticosteroids may be prescribed.
Other treatments – topical, physical, systemic
We would caution against the use of other topical agents on the skin (substances applied to the skin). We have seen a number of cases of allergic contact dermatitis to neat or concentrated tea tree oil applied directly to the skin. Other essential oils if applied undiluted may cause problems.
Physical treatments may be helpful, and include ultraviolet light treatment. The Skin Health Institute, Melbourne, where the Occupational Dermatology Clinic is based, is also fortunate to have access to a specialized form of low dose radiation treatment, Grenz ray, which we find to be very helpful. For more information about this visit www.skincancer.asn.au
Finally, in severe cases, dermatologists may prescribe oral tablets, also known as ‘steroid-sparing’ agents.