key: cord-1027421-4vl3nfgt authors: Hui-Beckman, Jessica; Leung, Donald Y.M.; Goleva, Elena title: Hand Hygiene Impact on the Skin Barrier in Healthcare Workers and Individuals with Atopic Dermatitis date: 2021-08-13 journal: Ann Allergy Asthma Immunol DOI: 10.1016/j.anai.2021.08.007 sha: 1e2cad40325dbf52b8bfc9227921364af2f892df doc_id: 1027421 cord_uid: 4vl3nfgt nan the spread of viruses and bacteria. 1 With the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic, hand hygiene measures have intensified. However, there are reports of increased dermatologic effects from increased hand washing, such as hand irritation. 2 This is especially notable in occupations such as healthcare workers (HCWs) who already have an increased risk of irritant contact dermatitis (ICD). [2] [3] [4] Also, individuals who have existing skin barrier dysfunction, such as atopic dermatitis (AD), may have magnified symptoms from increased hand hygiene. With the SARS-CoV2 pandemic, there are reports of increased hand irritation and dryness. [1] [2] [3] Prior studies on both healthy and AD subjects have shown that exposure to alcohols in hand sanitizers and detergents in soaps cause decreased natural moisturizing factor (NMF), as well as increased transepidermal water loss (TEWL). [5] [6] However, another study did not show significant changes in TEWL after repeated exposure of healthy skin to alcohol irritants. 7 Additionally, there is no data available about skin barrier response with skin tape strip (STS) provocation after the use of these agents, which is a useful tool for the evaluation of skin barrier integrity. In this study, we examined the impact of increased hand hygiene practices as a result of the SARS-CoV2 pandemic on HCWs and AD patients. This IRB approved study took place at National Jewish Health in Denver. Questionnaires were administered to inquire about allergy history, hand hygiene practices, and skin symptoms related to hand hygiene. Skin barrier assessment was performed by TEWL, as an objective way to measure skin barrier function. 8 TEWL was measured using the GPSkin Pro device (GPOWER Inc., Seoul, Korea) in an exam room with a controlled microclimate. TEWL was measured at baseline, then again after 5 STS to assess water loss in the skin. Next, subjects Thirty-six adults (18-60 years old) were enrolled. Subjects had either a history of AD (n=17) or were non-atopic with no history of allergies (n=19). The groups were also stratified according to whether they were a HCW with patient contact (n=17) or not a HCW (n=19). There were 8 subjects with AD who were HCWs (AD+HCW), 9 subjects with AD who were not HCWs (AD+non-HCW), 9 subjects who were non-atopic HCWs (NA+HCW), and 10 subjects who were non-atopic and not HCWs (NA+non-HCW). There was no significant difference in age, gender, or race among the groups. All AD subjects had mild AD skin severity. The mean eczema area and severity index (EASI) score of the AD+HCW group was 0.7; the mean EASI score of the AD+non-HCW group was 1.7 (EASI score: 0-72). A skin exam was completed by a physician, with the AD group having greater evidence of xerosis, erythema, and lichenification; abnormal skin findings were seen in 10 AD subjects compared to 4 non-AD subjects. Seven of the AD subjects reported history of contact dermatitis, but none noted sensitization to the ingredients used in this study. Subjects withheld topical medications to the area sampled for 7 days prior, moisturizers were withheld for 24 hours, and subjects did not bathe on the day of the visit. For HCW, study visits were scheduled at the start of the shift when applicable. The majority of subjects in all groups reported increased hand dryness and irritation since the pandemic onset. The HCW group had significantly increased frequency of hand sanitizer use per day compared to the non-HCW group (on average 9-18 times per day in HCW group, as compared to 2-3 times per day in non-HCW group, p=0.0085). There was no difference in the use of soap and water among the groups. Prior to treatment with hand sanitizer and soap baseline TEWL AUC was significantly higher in AD+HCW and AD+non-HCW subjects as compared to NA+non-HCW subjects ( Figure 1 ) (p<0.05). In all four groups, the TEWL AUC increased after hand sanitizer use, with even greater increase after soap and water use. Both HCW groups (AD+HCW, NA+HCW) had an increased TEWL response after hand sanitizer use as compared to NA+non-HCW group (p<0.01 and p<0.05, respectively). Within the broader AD group, there was a significantly higher increase in the TEWL AUC after hand washing with soap and water compared to the non-atopic subjects (TEWL AUC, MeanSD, 33775 g/m 2 * h vs. 28262 g/m 2 * h, respectively, p<0.05). In a four-group comparison, AD+HCW workers had a significantly greater TEWL AUC after the use of soap as compared to NA+non-HCW subjects (p<0.05) (Figure 1 ). HCWs have chronic use of hand sanitizer, and a higher incidence of ICD. 4 This may explain the significantly higher TEWL AUC after the use of hand sanitizer among HCWs, as they have an already compromised skin barrier. HCWs also reported use of skin emollients, the majority being unscented creams and lotions. Despite this, their TEWL was increased. Future studies on effects of specific emollients would be of interest, as it has been shown that emollients are not equally effective. 9 The AD subjects in our study had a significantly higher baseline TEWL AUC and had the highest TEWL AUC response after hand washing. It is known that AD individuals have less NMF in the outer skin layers which is needed for skin hydration. 10 These data support the underlying skin barrier dysfunction present in AD. Hand washing with soap and water leads to the removal of the healthy skin products, which is congruent with prior studies. 7 Regarding the limitations of this study, the AD subjects had mild disease at the time of evaluation. Future studies will be useful in assessing subjects with moderate-to-severe AD. Overall, our study objectively displays the insults that occur to the skin barrier from hand sanitizer and soap products. While frequent hand hygiene is important, this study demonstrates that clinicians should be mindful of counseling their patients of skin care after use of hand sanitizers and soaps. Horizontal lines within each box represent the median. *p<0.05, **p<0.01. attitude and self-reported performance and challenges of hand hygiene using alcohol-based hand sanitizers among healthcare workers during COVID-19 pandemic at a tertiary hospital: a crosssectional study Hand hygiene during COVID-19: recommendations from the American Contact Dermatitis Society Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: comparing a single surgical site with a COVID-19 intensive care unit Occupational dermatitis: how to identify the exposures, make the diagnosis, and treat the disease Barrier function and natural moisturizing factor levels after cumula-tive exposure to short-chain aliphatic alcohols and detergents: results of occlusion-modified tandem repeated irritation test Barrier damaging effects of n-propanol in occlusion-modified tandem repeated irritation test: modulation by exposure factors and atopic skin disease How irritant is alcohol? Research techniques made simple: transepidermal water loss measurement as a research tool Pilot study measuring transepidermal water loss (TEWL) in children suggests trilipid cream is more effective than a paraffin-based emollient Cutaneous barrier dysfunction in allergic diseases The authors acknowledge Nicole Meiklejohn for her assistance in preparing this manuscript.