Medical Grand Rounds: Bringing the Shadow Pandemic of Hand Eczema to Light
Bethany Wilken, MSc Candidate, (Translational Medicine)
During Medical Grand Rounds last week we had the pleasure of hearing from Dr. Sonja Molin. Dr. Molin is a practicing dermatologist at Hotel Dieu hospital. She shared with us the concerning rise in hand eczema (HE) during the COVID-19 pandemic, defining the disease as a shadow pandemic.
HE is an inflammatory, non-contagious skin disease of the hands1. Characterized by dry, scaly, cracking and itchy skin, HE is painful. Dr. Molin explained that a history of atopic dermatitis in childhood is a risk factor, but irritant exposure and contact allergens may also lead to skin barrier defects2. Once the skin barrier is impaired, it becomes an “open door.” Partially due to an increase in the skin’s pH, bacteria and viruses can penetrate the skin barrier and exacerbate skin inflammation3.
Certain occupations such as hairdressers, are at a higher risk for irritant and allergen exposure. The resultant causation or aggravation of HE is known as occupational HE. Mean, annual total costs of occupational HE per patient are estimated at $12,000 CAD4. Furthermore, the visible nature of HE can have profound psychological impacts on individuals. Patients with occupational HE are shown to have lower quality of life scores than patients with full-body dermatologic diseases5. Dr. Molin’s development of the CARPE registry has translated into a decreased severity of HE over-time and improved psychological outcomes6. By raising awareness for occupational dermatology, she promotes social security reform that will make all the difference for her patients.
Healthcare workers are working selflessly to care for an unprecedented influx of patients, while preventing the spread of COVID-19. Proper hand hygiene, including an overzealous of sanitizing and hand washing, can compromise the integrity of the skin barrier resulting in HE7. The use of gloves also contributes to irritant contact and allergic contact HE. Pre-pandemic HE was estimated as low as 12% in healthcare workers8. Fast forward to the pandemic, a German study reported a 90.4% incidence rate that correlated with two times an increase in the frequency of handwashing9. Considering the psychological impacts of HE and its damage to functionality, we must protect our healthcare workers.
Dr. Molin has proposed solutions to protect the healthcare workforce including adjustment of work hours to give time for recovery, and education on HE. Future translational research should focus on effective ways of informing workers on the early detection of symptoms and skin protection to avert more severe disease. When severe disease occurs, topical steroids are currently the gold standard for treatment. However, constantly rising instances of their abuse and misuse is leading to serious local and systemic side effects10. New topical and systemic medications targeting the cytokine-mediated signaling cascade (delgocitinib)11and interleukins (dupilumab)12,13 is promising. The discovery of non-immunosuppressant therapeutics for HE should be a priority.
The loss of doctors and nurses would devastate the current pandemic; preventative measures are vital. The number one preventative measure is moisturizing! The ingredients in hand lotions/creams replace depleted skin lipids and improve the barrier function of the skin14. The hands should be moisturized while the skin is still damp with a fragrance- and preservative- free lotion/cream. Additionally, the American Association of Dermatology recommends sanitization with alcohol-based sanitizer over hand washing with soap15. Practical tips include avoiding washing hands in hot water or washing with soap after applying sanitizer. To address glove-related irritation, Dr. Molin suggested trying cotton gloves as liners, using accelerator-free gloves and applying a water-based moisturizer before use.
These preventative measures are not limited to healthcare workers and occupational HE. We have all increased our hand hygiene practices during the pandemic, which heightens our risk of HE. For example, prior to school closures due to COVID-19, 6.5% of children had HE in Denmark. Upon returning to school and implementing a strict hand hygiene regimen, the prevalence rose to 50.5%16.
Following her presentation, Dr. Molin generously engaged in a discussion with our TMED class. We were fascinated by her insights on the long-term consequences of HE, EDI initiatives in dermatology and her international medical experience. Most notably, was the mention of “maskne” and how this pandemic-induced dermatologic condition was well represented in the lay press, while an article about HE has yet to be seen.
Dr. Molin should be applauded for her determination in bringing this HE pandemic out of the shadows. On behalf of TMED students we thank Dr. Molin for her work in promoting awareness of HE and validating indirect health burdens of the COVID-19 pandemic… and on behalf of Dr. Molin, a friendly reminder to moisturize your hands!
- Agarwal, U. S., Besarwal, R. K., Gupta, R., Agarwal, P., & Napalia, S. (2014). Hand eczema. Indian journal of dermatology, 59(3), 213
- Lakshmi, C., & Srinivas, C. (2012). Hand eczema: An update. Indian journal of dermatology, venereology and leprology, 78(5), 569.
- Haslund, P., Bangsgaard, N., Jarløv, J. O., Skov, L., Skov, R., & Agner, T. (2009). Staphylococcus aureus and hand eczema severity. British Journal of Dermatology, 161(4), 772-777.
- Diepgen, T. L., Scheidt, R., Weisshaar, E., John, S. M., & Hieke, K. (2013). Cost of illness from occupational hand eczema in Germany. Contact Dermatitis, 69(2), 99-106.
- Cvetkovski, R. S., Zachariae, R., Jensen, H., Olsen, J., Johansen, J. D., & Agner, T. (2006). Quality of life and depression in a population of occupational hand eczema patients. Contact dermatitis, 54(2), 106-111.
- Apfelbacher, C. J., Ofenloch, R. F., Weisshaar, E., Molin, S., Bauer, A., Mahler, V., ... & Diepgen, T. L. (2019). Chronic hand eczema in Germany: 5‐year follow‐up data from the CARPE registry. Contact Dermatitis, 80(1), 45-53.
- World Health Organization. (2009). WHO guidelines on hand hygiene in health care. In WHO guidelines on hand hygiene in health care (pp. 270-270).
- Ibler, K. S., Jemec, G. B., Flyvholm, M. A., Diepgen, T. L., Jensen, A., & Agner, T. (2012). Hand eczema: prevalence and risk factors of hand eczema in a population of 2274 healthcare workers. Contact dermatitis, 67(4), 200-207.
- Guertler, A., Moellhoff, N., Schenck, T. L., Hagen, C. S., Kendziora, B., Giunta, R. E., ... & Reinholz, M. (2020). 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. Contact Dermatitis, 83(2), 108-114.
- Coondoo, A., Phiske, M., Verma, S., & Lahiri, K. (2014). Side-effects of topical steroids: A long overdue revisit. Indian dermatology online journal, 5(4), 416.
- Worm, M., Bauer, A., Elsner, P., Mahler, V., Molin, S., & Nielsen, T. S. S. (2020). Efficacy and safety of topical delgocitinib in patients with chronic hand eczema: data from a randomized, double‐blind, vehicle‐controlled phase II a study. British Journal of Dermatology, 182(5), 1103-1110.
- Oosterhaven, J. A., Voorberg, A. N., Romeijn, G. L., de Bruin‐Weller, M. S., & Schuttelaar, M. L. (2019). Effect of dupilumab on hand eczema in patients with atopic dermatitis: an observational study. The Journal of dermatology, 46(8), 680-685.
- Oosterhaven, J. A., Romeijn, G. L., & Schuttelaar, M. L. (2018). Dupilumab treatment of very severe refractory atopic hand eczema. JAMA dermatology, 154(8), 969-970.
- Jindal, R., & Pandhi, D. (2020). Hand hygiene practices and risk and prevention of hand eczema during the COVID-19 pandemic. Indian Dermatology Online Journal, 11(4), 540.
- American Academy of Dermatology shares hand-washing tips amid COVID-19. American Academy of Dermatology website. 2020
- Simonsen, A. B., Ruge, I. F., Quaade, A. S., Johansen, J. D., Thyssen, J. P., & Zachariae, C. (2020). High incidence of hand eczema in Danish school children following intensive hand hygiene during the COVID‐19 pandemic–a nationwide questionnaire study. The British Journal of Dermatology.