key: cord-0831982-5pk9pskt authors: Babić, Željka; Šakić, Franka; Franić, Zrinka; Macan, Jelena title: Skin barrier function in nursing apprentices during the coronavirus disease 2019 (COVID‐19) pandemic date: 2022-02-28 journal: Contact Dermatitis DOI: 10.1111/cod.14069 sha: 72b7a4ef01a64f79113935148317b518bfb2e849 doc_id: 831982 cord_uid: 5pk9pskt BACKGROUND: Studies investigating simultaneous influence of personal and work‐related factors on skin health during the coronavirus disease 2019 (COVID‐19) pandemic are missing. OBJECTIVES: To investigate the associations of skin hazards relevant for nursing apprentices with parameters of skin barrier function. METHODS: A total of 238 nursing apprentices attending the final year of education (median age 19 years) from vocational schools in Zagreb, Croatia, were enrolled in this study. We administered a questionnaire based on the Nordic Occupational Skin Questionnaire to the nursing apprentices, performed clinical examination of skin on the hands, and evaluated transepidermal water loss (TEWL) and stratum corneum (SC) pH on the dorsum of the hand. RESULTS: Around half of nursing apprentices had compromised hand skin barrier function, as indicated by TEWL values >25 g/m(2)/h (48%) and SC pH >5.5 (57%). Skin barrier was compromised in around 40% of nursing apprentices without clinically observed skin symptoms. Elevated SC pH was independent of ambient conditions associated with skin symptoms and female sex. CONCLUSIONS: Measurement of SC pH was shown to be less sensitive to field conditions than TEWL, and should be employed more in the field studies. Strengthening of skin health promotion in healthcare workers and apprentices is needed in pandemic conditions. Measurement of transepidermal water loss (TEWL) and stratum corneum (SC) pH provides objective information on the skin. Increased TEWL and pH above physiological levels indicate compromised SC integrity or function. Significantly higher hand TEWL values were found among nurses in comparison to workers not exposed to skin hazards. 1, 2 Furthermore, a significant increase in hand TEWL among nursing apprentices was seen after just 10 weeks of regular practical training. 3 Despite this, there are studies questioning the use of TEWL measurement among nursing apprentices as a predictor of development of skin symptoms. 4 Because of the coronavirus disease 2019 (COVID-19) pandemic, there is increased strain on the skin, particularly among healthcare workers, due to the intense hand hygiene requirement (eg, longer hand washing durations, washing the hands more often, prolonged glove use). Frequent hand washing and skin occlusion under prolonged glove use seem to have a profound negative impact on skin barrier function noted by increases in TEWL values. 4, 5 In addition, occlusion significantly enhances the skin barrier damage caused by soaps in a dose-response manner. 6 By contrast, hand sanitizers on their own do not seem to disturb TEWL, 4 but they alter the SC pH. 7 However, hand sanitizers can worsen existing skin irritation because a significant increase in TEWL values was noted when n-propanol was applied in concentrations commonly used in sanitizers on skin previously irritated by detergents. 8 When investigating associations of work-related exposure, personal factors should also be included in an analysis, because studies have shown significant associations of age, sex, and atopic status with parameters of skin barrier function. 9, 10 Overall, there is a need for more studies investigating the simultaneous influence of several personal and work-related factors in a real-life setting of increased hand hygiene regimen, especially during the COVID-19 pandemic, because the recent prevalence of hand dermatitis among healthcare workers was reported to be around 75% 11 and around 50% among nursing apprentices. 12 To address this need, the aim of our study was to investigate the associations of skin hazards relevant for healthcare workers including frequent hand washing, hand sanitizing, and prolonged glove use with parameters of skin barrier function among nursing apprentices attending the final year of their education during the COVID-19 pandemic. This study is a part of the project investigating hand eczema among nursing apprentices in Croatia with a previously described protocol. 12 In brief, all 264 nursing apprentices from three vocational schools in the Croatian capital city, Zagreb, attending their final (fifth) year of education were invited to participate. All participants were aged 18 years or older, and gave their written informed consent to be included in the study. Ethical approval was granted by the Ethical Committee of the Hand TEWL values were significantly positively associated with participants' age: for each increasing year of participants' age, hand TEWL values were higher by 4.08 g/m 2 /h (P = .001). The same trend of association was noted when it was investigated using Spearman correlation (rho = 0.209, P = .001), and when TEWL values were dichotomized as elevated vs normal values (Table 1 ; Mann-Whitney test, P < .001). SC pH was significantly positively associated with female sex: median (IQR, total range) was 5.61 (5.31-5.91, 4.58-6.86) among women, in comparison with 5.39 (5.00-5.60, 4.48-6.32) among men (Mann-Whitney test, P = .001). The same trend was noted when pH values were dichotomized as elevated vs normal (Table 1 ; χ 2 test, P = .016). Self-reported history of atopic dermatitis judged on the basis of the report of itchy rash in skin folds, behind ears, around eyes (NOSQ-2002) was not significantly associated with hand TEWL or pH, studied either as a continuous or as a dichotomized variable. Parameters of skin barrier function were significantly associated with hand skin symptoms. Overall, in 115 participants (48%) one or more type of skin changes on hands were found on the clinical examination (erythema, infiltration, desquamation, papules, vesicles, or fissures). Around 30% higher median TEWL value was found in those with one or more skin changes than in those with heathy skin; specifically, median (IQR, total range) hand TEWL values on unaffected skin were 26 .54 g/m 2 /h (18.82-36.21, 5.56-70.90) among those with skin symptoms, in comparison to 20.57 g/m 2 /h (15.11-34.12, 3.02-60.76) among those without any symptoms (Mann-Whitney test, P = .14). In addition, significantly higher proportion of participants with hand skin symptoms had elevated hand TEWL values: 65 of 115 (57%) participants with skin symptoms and 49 of 123 (40%) without symptoms had TEWL over 25 g/m 2 /h (χ 2 test, P = .010). Table 1 shows proportions of hand skin symptoms among participants with elevated or normal hand TEWL values. We further investigated associations of specific types of skin symptoms with individual skin integrity as indicated by TEWL ( Figure 1 ). Only infiltration was significantly associated with elevated TEWL values ( Figure 1 , χ 2 test, P = .001). Regarding hand SC pH, the same trend of associations with having one or more skin symptom was noted; specifically, median ( .202 110 (81) 70 (68) .016 History of atopic dermatitis, n (%) 50 (21) 26 (22) 24 (19) .514 28 (21) 22 (21) .908 One or more skin changes on clinical examination, n (%) 65 (57) 50 (40) .010 78 (57) 37 (36) .001 OHSI score on clinical examination, median .022 Note: Bold indicate variables significantly associated with the outcomes (P < .05 Besides personal factors and skin symptoms, we investigated associations of skin barrier function with work-related factors. Overall, T A B L E 2 Characteristics of the nursing apprentices and differences between those with elevated hand TEWL value and with normal TEWL The possibility that ambient factors that we could not control distorted found associations was investigated by multiple logistic and linear regression models adjusted for room air temperature and relative humidity, and hand washing prior to skin-bioengineering measurement. Only the associations with SC pH remained significant when controlling for these confounding factors (Table 3) : women and those with skin symptoms had over two times higher odds of having elevated pH (Table 3 ; P = .004 and .001, respectively; P model <.001). The same significant trend was noted when pH was investigated as a continuous variable (coefficient for having one or more skin changes on clinical examination = 0.17, 95% confidence interval 0.05-0.28, P = .006, coefficient for female sex = 0.27, 95% confidence interval 0.14-0.40, P < .001; P model <.001, pseudo R 2 = 0.140). The main finding of our cross-sectional study on final-year nursing apprentices is that around half of them have compromised hand skin barrier function as indicated with elevated TEWL values (>25 g/m 2 /h) and pH values above physiological levels (>5.5). Elevated SC pH was robustly and independently of ambient conditions associated with skin symptoms on hands determined by clinical examination, but hand TEWL values on unaffected skin were predominantly susceptible to ambient air humidity and consequently were not reliably associated with skin symptoms in this field study. A period of education chosen for this study seems to have a great influence on the found associations of TEWL with skin symptoms. Basal TEWL values measured before the beginning of practical training do not seem to predict later hand skin symptoms, 3 were the separate work-related risk factors. The only significant association, which was that elevated hand TEWL values were associated with less hand washing, is of unexpected trend and probably a statistical artefact due to the small number of participants in the subcategories. To the best of our knowledge, SC pH in European nursing apprentices has not been investigated before, although pH was investigated among French healthcare workers (predominately nurses) in the context of hand sanitizing. 21 One study on South African nursing apprentices investigated pH values only with respect to their race. 22 Our participants were White and their age was of a narrow range and not associated with hand SC pH. Women in our study had significantly higher SC pH than men. Overall, the association with sex is still inconclusive in the literature and greatly dependent on the test site. 20, 23, 24 Specifically, a German study on healthy adults found higher SC pH on the dorsum of women's hands in comparison to men, 25 which is in line with our results. Varying results have been reported regarding other test sites. For example, a Danish study found lower pH on the forearms of women compared with men, 26 but a German study found the opposite trend. 27 Results of our multiple logistic regression model, by which we investigated associations of relevant predictors simultaneously, confirmed both female sex and hand skin symptoms were independently associated with elevated SC pH on the unaffected skin. Regarding work-related habits, as with TEWL, we found no significant association of frequencies of washing and sanitizing hands and duration of glove use with hand SC pH values, likely due to the reasons discussed above. Finally, because increased pH was found in children with atopic dermatitis even on the unaffected skin, 28 we wanted to investigate the association of a history of atopic dermatitis with elevated SC pH; however, in our study sample there was no significant association. Besides the aforesaid limitations, the main limitation of our study was that skin-bioengineering measurements were performed in vocational schools where ambient air temperature and humidity could not be controlled due to the lack of air conditioning in the appointed classrooms. The aforementioned previous studies on nursing apprentices were also performed in field conditions. 3, 17, 18 Notwithstanding the usefulness of TEWL measurement as a screening tool for detecting early, subclinical skin damage, authors of these studies generally share a concern that the utility of single measurement in field conditions is questionable because obtaining optimal circumstances for TEWL analysis in the field is difficult. This problem has been further addressed in a recent review by Jansen van Rensburg et al 29 who investigated reports from a wide variety of occupational settings, including hairdressing, metal, food, and printing industries. They noted that temperature and humidity reported were highly variable between the studies, and their overall conclusion was that studies that aimed at using bioengineering methods to measure acute changes in skin barrier function showed much more conclusive results than those wanting to utilize these measurements as skin disease predictors. Steps can be taken to ensure higher reliability. Ideal conditions would have been to measure TEWL in controlled laboratory conditions with room temperature of 21 ± 1 C, relative air humidity of 50 % ± 5% relative humidity, and with participants' acclimatization to the standardized room air conditioning. This should be recommended for future studies employing TEWL measurement to exclude the possibility of measuring skin surface water loss instead of transepidermal water loss, in nonstandardized ambient conditions. However, since these conditions were out of our control during the field measurement, in statistical analysis we adjusted for ambient air temperature and humidity recorded during measurements, and prior hand washing reported by participants. Associations of SC pH with skin symptoms was not affected when adjusting for measurement circumstances, and could therefore be considered a reliable finding, but TEWL was greatly affected by ambient air humidity. In summary, pH measurement was shown to be a bioengineering method suitable for field conditions, and with a general advantage of quick measurement, it should be employed more in future field studies. In conclusion, our results support findings about the increased skin barrier damage in healthcare workers and apprentices due to the intense hand hygiene regimen implemented during the COVID-19 pandemic, even in those without clinical skin changes. Therefore, there is clearly a need for increasing health promotion in terms of hand eczema. Existing recommendations for skin care should be more promoted in healthcare workers and even apprentices. Our data on proportions of participants with impaired skin barrier function and skin changes could be used as real-life examples giving more impact to preventive messages. Data about the significant association of hand skin symptoms with barrier function parameters measured on unaffected skin justify promoting skin-bioengineering measurements as methods for early detection of acute skin changes, which could aid clinical skin assessments and timely prevention of work-related hand dermatitis. Measurement of SC pH was shown to be less sensitive to field conditions than measurement of TEWL, and should be employed more in future field studies. 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