Overzealous hand hygiene during the COVID 19 pandemic causing an increased incidence of hand eczema among general population
Authors: Mehak Singh, Manoj Pawar, Atul Bothra, Nishant Choudhary
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Proper hand hygiene is one of the enhanced preventive measure to halt the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) COVID-19.1Lan J. Song Z. Miao X. et al.Skin damage among healthcare workers managing coronavirus disease-2019.J Am Acad Dermatol. 2020; 82: 1215-1216Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar However, an overzealous use of sanitizers and frequent hand washing may cause hand eczema (HE) owing to a disrupted skin barrier.2WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization, Geneva, Switzerland2009Google Scholar We aim to report a rise in the incidence of new-onset HE among the general population due to overzealous hand hygiene. We have been using telemedicine for consultations with new patients since the lockdown was initiated in our country, India. During the period from March 24, 2020, through April 5, 2020, we diagnosed 16 patients (9 male, 7 female) with new-onset HE who were not involved in any health care–associated occupations. The diagnoses were based on history and clinical photos/video. Ten patients were diagnosed with irritant contact dermatitis, 5 patients had allergic contact dermatitis, and 1 patient exhibited mixed patterns. Almost all patients admitted excess use of hand sanitizers and/or hygiene. Almost all sanitizers contained alcohol as a main ingredient. The most common symptoms reported were itching, burning sensation, and dryness, and the most common signs observed were erythema, scaling, and vesiculation (Table I). We observed a peculiar pattern of HE: erythema and fine scaling initially started in the web spaces of fingers (ie, interdigital eczema) and on the palms, which is quite pathognomic for dermatitis induced by sanitizers. This may be due to trapping of the sanitizer in these spaces and because a dollop is taken in the palms first.Table IPatient demographic and clinical profiles and contents of sanitizersNo.Age, years/sexHistory of allergiesType of dermatitisSymptomsSignsApproximate frequency of application per dayAlcohol content of sanitizerCHG or triclosanpercentageAdded emollients and moisturizer/other additives161/FNoneICDItching, dryness, skin tightness, and slight burningFine scaling all over the hands (more in palms), with erythematous foci in the interdigital space5-6 times70% v/v ethanol2.5% v/v solutionequivalent to CHG 0.5% w/vPresent (not specified)230/MAlcohol flushing and urticariaACDItching and skin tightnessErythema, taut skin, and papulesImmediate with 1 application70% v/v ethanol2.5% v/v solutionequivalent to CHG 0.5% w/vNone314/FNoneICDItching followed by burning and smartingInterdigital fissuring and bleeding, crusting and papules, and lichenified patches over the dorsum of the hands and wrists8-9 times69.4% w/w denatured alcoholNonePEG, PEG/PPG-17/6, tetrahydroxypropyl ethylene diamine433/MNoneACDItching with bumpsExudation, erosions, and crusting with papular eruptions at the base of the fingers and wrists20-24 times68% isopropyl alcoholNoneHoney extract, palm extract, olive extract, coconut fruit extract, wheat amino acids, retinyl palmitate, tocopheryl acetate, glycerin, carbomer, cellulose, hydroxyethyl urea556/MNot knownICDItching and burningVesiculations, excoriations, and bleeding5-6 times91% w/v (alcohol)NoneNone624/FAsthma, penicillin sensitiveACDItching and drynessFine scaling and erythema with unclear borders2-3 times62.25% (ethyl alcohol 95% v/v, IP 55% w/w; isopropyl alcohol IP 10% w/w)NoneVitamin E773/FNoneICDBurning, pain, and tightnessCrusting and pustules on a background of erythema, concentrated around web spaces—clearly demarcated areas of erythema12-14 times60% isopropyl alcoholNoneHrivera (Coleus vettiveroides), coriander, lime, ushira (Vetiveria zizanioides)842/MNoneICDItching and oozingVesicles with exudation and erythemaImmediate with 3 applications70% w/v (alcohol)NoneNone933/MHistory of chronic urticaria treated by albendazoleICDItching and redness all over the handsVesiculation, crustingImmediate70% v/vethanolTriclosan 0.5% w/vNone1017/FNoneICDItching and skin peelingErythema with mild scaling17-19times1- Propanol and 2- propanol: total alcohol concentration of 75% (disinfectant)NoneMecetronium ethyl sulfate 2%1166/MNoneICDItching, burning after application of sanitizer, skin tightnessErythema, infiltration, and rhagades (interdigital eczema)6-9 times69.4% w/w denatured alcoholNonePEG, PEG/PPG-17/6, tetrahydroxypropyl ethylenediamine1272/MAsthmaICDIntense itching with increases on sun exposure and burning with reapplicationPalmar surface fine scaling, some evidence of photoexacerbation—dorsum of hand showing hyperkeratosis, hyperpigmentation, and papules (maybe due to plant extracts)3-4 times60% isopropyl alcoholNoneHrivera (Coleus vettiveroides), coriander, lime, ushira (Vetiveria zizanioides), neem extracts1327/MNoneICDItching followed by burning and stingingClearly delineated patches of erythema and flakingImmediate with 2-3 applications70% w/v isopropyl alcohol0.5% w/vVitamin E1446/MNoneICD + ACDItching and redness with face burning and smartingInterdigital erythema, fissures, and bleeding; itching and flaking; redness around eyes and nasal ala7-8 times70% v/v ethanol2.5% v/v solutionEq equivalent to CHG 0.5% w/vPresent (not specified)1538/FGI upset with kiwi and eggACDItching and hand swellingContact urticariaImmediate reactionNoneNone0.125% benzalkonium chloride1620/FNoneICDItching, redness, and"skin wrinkling"Scaling, clustered papulovesicles, hyperkeratosis, or fissuring on a background of hyperkeratosis9-10 times62.25% (ethyl alcohol 95% v/v, IP 55% w/w; isopropyl alcohol IP 10% w/w)NoneVitamin EACD, Allergic contact dermatitis; CHG, chlorhexidine gluconate; F, female; GI, gastrointestinal; ICD, irritant contact dermatitis; IP, isoparaffin; M, male; PEG, polyethylene glycol; PPG, polypropylene glycol; v/v, volume/volume; w/w, weight/weight. Open table in a new tab ACD, Allergic contact dermatitis; CHG, chlorhexidine gluconate; F, female; GI, gastrointestinal; ICD, irritant contact dermatitis; IP, isoparaffin; M, male; PEG, polyethylene glycol; PPG, polypropylene glycol; v/v, volume/volume; w/w, weight/weight. A recent study from China showed high prevalence of HE (74.5%) among health care workers managing COVID-19, and the risk factors included frequent hand hygiene.1Lan J. Song Z. Miao X. et al.Skin damage among healthcare workers managing coronavirus disease-2019.J Am Acad Dermatol. 2020; 82: 1215-1216Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar Frequent hand hygiene leads to gradual depletion of surface lipids, resulting in deeper action of detergents into the superficial skin layers.2WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization, Geneva, Switzerland2009Google Scholar Irritant contact dermatitis is more commonly reported with iodophors, chlorhexidine, chloroxylenol, triclosan, and alcohol-based products, whereas allergic contact dermatitis has been reported with quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol, and alcohols.2WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization, Geneva, Switzerland2009Google Scholar In our patients, we could not perform patch testing, and follow-up was not done. The overzealous hand hygiene amidst the COVID-19 pandemic may lead to increased cases of HE, but what is feared is that the disrupted skin barrier may create a route of entry for COVID-19, as the cell receptor for SARS-CoV-2 entry (ie, angiotensin-converting enzyme 2) is present in large quantities in the blood vessels of the skin, basal layer of the epidermis, and hair follicles.3Hamming I. Timens W. Bulthuis M.L. Lely A.T. Navis G. van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis.J Pathol. 2004; 203: 631-637Crossref PubMed Scopus (4244) Google Scholar Rational hand washing for 20 seconds with sanitizers containing ethanol is warranted.5Yan Y. Chen H. Chen L. et al.Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019.Dermatol Ther. 2020; ([Epub ahead of print]) (Accessed April 8, 2020): e13310https://doi.org/10.1111/dth.13310Crossref PubMed Scopus (215) Google Scholar Sanitizers should be allowed to dry first, and then hypoallergenic hand cream/emollients should be applied to prevent the trapping of sanitizers in web spaces.4Cavanagh G. Wambier C. Rational hand hygiene during COVID-19 pandemic.J Am Acad Dermatol. 2020; 82: e211Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar,5Yan Y. Chen H. Chen L. et al.Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019.Dermatol Ther. 2020; ([Epub ahead of print]) (Accessed April 8, 2020): e13310https://doi.org/10.1111/dth.13310Crossref PubMed Scopus (215) Google Scholar Also, most people have a habit of washing hands before or just after sanitizer application, which should be avoided because damp hands increase the permeability of sanitizers/detergent, leading to an increased chances of HE.2WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization, Geneva, Switzerland2009Google Scholar Although hand hygiene is of the utmost importance in our fight against COVID-19, the general public should be made aware of proper and rational hand hygiene and warned against excess hand hygiene.