Hand dermatitis in nurses: is promotion of protective behaviour ineffective?
Authors: R. Brans
Journal: British Journal of Dermatology (2020)

Linked Article: Madan et al. Br J Dermatol 2020; 183:462–470. Hand dermatitis (HD) caused by occupational exposure to skin hazards is the most common work-related skin disease. Its often chronic course is associated with substantial consequences for the affected individuals and society, specifically regarding impaired quality of life, work absenteeism, job loss or retraining.1 Work-related HD occurs frequently in nurses owing to a high degree of wet work and exposure to irritants and allergens.2 Guidelines recommend promotion of protective measures and skincare to prevent HD.3 However, a recent Cochrane review revealed that there is not enough evidence for the effectiveness of interventions used in the prevention of work-related irritant HD. It was argued that this does not necessarily mean that the current measures are ineffective, but rather that more high-quality standardized studies are needed to increase the level of evidence.4 In this issue of the BJD, Madan et al.5 present the results of such a high-quality cluster randomized controlled trial involving 2040 nurses across the UK. This study included only nurses at increased risk of HD, i.e. (i) intensive care unit nurses with a high level of hazardous exposures and (ii) student nurses with a history of atopic conditions and thus increased endogenous susceptibility for HD. The intervention group received access to a behavioural change programme (BCP), offered online or as a hard copy, in addition to receiving hand moisturizers, while nurses at control sites received usual care. The participants had a high level of positive beliefs about good handcare. However, the intervention did not have a significant effect on reducing the prevalence of HD. Other randomized trials in healthcare workers also failed to show a clear benefit.6, 7 Does this mean that such approaches are ineffective for reducing HD in nurses? There is no doubt that using protective gloves whenever necessary, replacing handwashing using soap with disinfecting hands whenever possible, and applying emollients are important strategies to prevent or reduce HD in nurses.3 However, it is challenging to find an adequate approach that improves adherence to protective behaviour, while also maintaining a balance between the efforts required and the efficacy of the intervention. Madan et al. used a very pragmatic approach, which may have led to the low uptake of the BCP and low overall efficacy observed. We have learned from previous research that face-to-face education is effective in secondary prevention of HD in healthcare workers.8 However, this is time-consuming and less cost-effective, but might still be a good option when focusing on those who are already affected by HD. In Germany, for example, participation in a skin protection seminar aiming to improve health-related behaviour has been an effective standard procedure in the management of individuals with work-related HD, including healthcare workers, for many years.9 Madan et al. selected nurses at high risk for HD. It might be necessary to develop more elaborate and targeted interventions for such high-risk groups, while less complex measures may already benefit individuals at lower risk. Therefore, efforts to promote protective behaviour in order to prevent HD in nurses should be continued, while further well-designed studies are required to shed more light on this issue. The author thanks Swen Malte John (University of Osnabrück) for his review of this commentary.