What You Need to Know About Hand Hygiene and Dermatitis During the Coronavirus Pandemic

• COVID-19
• Dermatitis
• Hand Dermatitis
• Hand Hygiene
• Hand Washing

As the importance of diligent infection control grew during the Coronavirus disease 2019 (COVID-19) pandemic, an increase in the intensity of handwashing was recommended. Here, we briefly review and provide clinical pearls for frontline healthcare workers experiencing COVID-19 surges. Furthermore, we highlight dermatologic consequences of hand hygiene measures.

The Centers for Disease Control and Prevention (CDC) has recommended gloving during the pandemic for patient care “in accordance with standard and transmission-based precautions.” However, double gloving is discouraged, and institutional guidelines may vary.¹ The major benefit of gloves is barrier protection for both the patient and provider against infection when there is direct contact with possibly contaminated skin or bodily fluids. However, gloves do not prevent the need for proper hand hygiene before donning and after removing gloves and should not be reused.²

Wearing gloves can induce contact allergies to common rubber chemicals and polymerization catalysts used in production, such as thiurams, carbamates, and mercaptobenzothiazoles.³ Latex can induce immediate-type allergic reactions leading to contact urticaria and asthma attacks, but latex usually does not induce delayed-type eczematous reactions. Moreover, occlusion from examination gloves accelerates transepidermal absorption of potential allergens and irritants, and the constant humidity damages the skin barrier.³ This results in increased contact sensitization and irritant dermatitis, particularly in atopic individuals with genetically impaired skin barriers and hyperirritability at baseline.

Another cornerstone of hand hygiene is handwashing. The CDC has recommended soap and water for 20 seconds or an alcohol-based hand rub (ABHR) with >60% ethanol or >70% isopropanol.⁴ Scenarios where the CDC encourages handwashing include: immediately before/after touching patients, contact with blood/bodily fluids, visibly soiled hands, and after glove/PPE removal.² Because traditional handwashing can be time-consuming for healthcare workers, ABHRs can be used more rapidly in busy clinical settings. However, clinicians should note that increased frequency of handwashing can result in contact dermatitis of the hands.

When noticing skin change, it is important to distinguish dermatitis subtypes to guide diagnosis, identify potential allergens, and direct appropriate treatment (Table 1). Irritant contact dermatitis (ICD) develops after repeated exposure to substances, including soaps and water (Figure 1). In contrast, allergic contact dermatitis (ACD) is an immune-mediated response to allergens, such as rubber chemicals and other additives in gloves or disinfectants (Figure 2).⁵ Clinical manifestations of both include xerosis, erythema, scale, pruritus, and fissuring, while ACD can have the addition of vesicles and bullae. In the acute and subacute phase of eczema, the ICD is localized to sites of exposure and concentrated in areas of broken skin. In contrast, ACD usually spreads beyond the sites of exposure. Chronic ACD is also associated with impaired use of hands and disability if the allergen is not determined.⁶

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Figure 1.

Representative photograph of irritant contact dermatitis (ICD) in a patient resulting from frequent handwashing.

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Figure 2.

Representative photograph of allergic contact dermatitis (ACD) in a patient undergoing patch testing to allergens found in rubber chemicals and polymerization catalysts used in the production process.

Healthcare workers are uniquely predisposed for developing dermatitis given increased soap, water, and ABHR exposure. Specifically, handwashing with soap and water is more likely to cause ICD than ABHRs due to greater irritation.^7,8 Notably, health care workers are 55% more likely to develop hand dermatitis with handwashing ≥10 times daily.⁸ In the early rise of the pandemic in China, two-thirds of healthcare workers met this threshold.³ While definitive treatment for ICD and ACD is avoidance of the inciting agents, moisturizers provide symptomatic relief, prevent skin breakdown, and reduce irritation.^3,7⇓–9 As such, ABHRs should be used whenever possible, followed by the application of an emollient to minimize hand irritation.

The risk for hand-based dermatitis is likely increasing with growing hand hygiene awareness and glove use. Understanding glove use, hand hygiene, and emollient use post-handwashing are paramount for the frontline healthcare worker during the COVID-19 pandemic.