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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!

 

  1. Agarwal, U. S., Besarwal, R. K., Gupta, R., Agarwal, P., & Napalia, S. (2014). Hand eczema. Indian journal of dermatology59(3), 213
  2. Lakshmi, C., & Srinivas, C. (2012). Hand eczema: An update. Indian journal of dermatology, venereology and leprology78(5), 569.
  3. Haslund, P., Bangsgaard, N., Jarløv, J. O., Skov, L., Skov, R., & Agner, T. (2009). Staphylococcus aureus and hand eczema severity. British Journal of Dermatology161(4), 772-777.
  4. Diepgen, T. L., Scheidt, R., Weisshaar, E., John, S. M., & Hieke, K. (2013). Cost of illness from occupational hand eczema in Germany. Contact Dermatitis69(2), 99-106.
  5. 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 dermatitis54(2), 106-111.
  6. Apfelbacher, C. J., Ofenloch, R. F., Weisshaar, E., Molin, S., Bauer, A., Mahler, V., ... & Diepgen, T. L. (2019). Chronic hand eczema in Germany: 5year followup data from the CARPE registry. Contact Dermatitis80(1), 45-53.
  7. World Health Organization. (2009). WHO guidelines on hand hygiene in health care. In WHO guidelines on hand hygiene in health care (pp. 270-270).
  8. 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 dermatitis67(4), 200-207.
  9. 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 SARSCoV2 pandemic: comparing a single surgical site with a COVID19 intensive care unit. Contact Dermatitis83(2), 108-114.
  10. Coondoo, A., Phiske, M., Verma, S., & Lahiri, K. (2014). Side-effects of topical steroids: A long overdue revisit. Indian dermatology online journal5(4), 416.
  11. 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, doubleblind, vehiclecontrolled phase II a study. British Journal of Dermatology182(5), 1103-1110.
  12. Oosterhaven, J. A., Voorberg, A. N., Romeijn, G. L., de BruinWeller, M. S., & Schuttelaar, M. L. (2019). Effect of dupilumab on hand eczema in patients with atopic dermatitis: an observational study. The Journal of dermatology46(8), 680-685.
  13. Oosterhaven, J. A., Romeijn, G. L., & Schuttelaar, M. L. (2018). Dupilumab treatment of very severe refractory atopic hand eczema. JAMA dermatology154(8), 969-970.
  14. Jindal, R., & Pandhi, D. (2020). Hand hygiene practices and risk and prevention of hand eczema during the COVID-19 pandemic. Indian Dermatology Online Journal11(4), 540.
  15. American Academy of Dermatology shares hand-washing tips amid COVID-19. American Academy of Dermatology website. 2020
  16. 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 COVID19 pandemic–a nationwide questionnaire study. The British Journal of Dermatology.

 

Comments

Name
Sophia

Mon, 01/17/2022 - 11:45

Thanks for a lovely blog post, Bethany. This MGR hit close to home, as I too have hand eczema!

Can you please elaborate on the CARPE registry that Dr. Molin created? If any papers exist from this work, please circulate those also.

Sophia

Name
Sophia

Name
Bethany Wilken

Mon, 01/17/2022 - 14:59

In reply to by tmedweb

Hi Sophia,
Thank you for your comment! I would love to elaborate on Dr. Molin’s involvement with the CARPE registry. Although not a focus of her presentation, I feel it is very important work that should be highlighted. The CARPE registry was set up in Germany in 2009 to prospectively investigate the management of patients with chronic hand eczema (CHE). Patients in the registry are repeatedly assessed on skin status, severity, treatment, atopy criteria as well as socio-economic factors and diagnostics. The registry has allowed dermatologist to understand characteristics of patients with CHE who are receiving dermatological care and study the long-term effectiveness and safety of different therapies in CHE patients (1). The registry has greatly contributed to the relatively small body of literature pertaining to CHE.

A recent 5-year follow-up data summary of the CARPE was the first study to evaluate a cohort of CHE patients for a long period of time. Some of the main findings included (2):
- A decrease in disease severity overtime.
- Improved quality of life scores overtime, but remained stable after the second year of follow-up.
- The percentage of patients who reported side-effects or regarded treatment as time-consuming decreased over time, while treatment satisfaction increased.
- The percentage of patients not being able to put treatment recommendations into practice increased over time.

Evidently, the summary showed CHE has improved substantially overtime. The registry has also helped to identify gaps in patient care for future research endeavours. Dr. Molin’s involvement in the CARPE registry has directly benefited patients. For example, patients in the registry require regular visits which means there is room to optimize treatment and prevention of disease progression. Please see the citations below for more information on the CARPE registry and its translational triumphs.

1. Cazzaniga, S., Apfelbacher, C., Diepgen, T., Ofenloch, R. F., Weisshaar, E., Molin, S., ... & CARPE study groups of Germany and Switzerland. (2018). Patterns of chronic hand eczema: a semantic map analysis of the CARPE registry data. British journal of dermatology, 178(1), 229-237.

2. 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.

Apfelbacher, C., Weiß, M., Molin, S., Bauer, A., Mahler, V., Schmitt, J., ... & Weisshaar, E. (2016). Which factors are associated with the use of systemic antihistamines in patients with chronic hand eczema? Results from the CARPE registry. Journal of the European Academy of Dermatology and Venereology, 30(1), 50-56.

Ruppert, L., Apfelbacher, C., Molin, S., Bauer, A., Mahler, V., Schmitt, J., ... & Weisshaar, E. (2014). Itching in patients with chronic hand eczema: data from the CARPE registry. Dermatology, 229(2), 146-153.

Name
Bethany Wilken

Name
Kiera Liblik

Mon, 01/17/2022 - 12:36

Hello Bethany - what a wonderful summary of the MGR this week!
One of the interventions for preventing dry skin that I have seen in a lot of local businesses is the use of hand sanitizer that has included aloe/moisturizer. I know that these combo-sanitizer/moisturizers often seem to be slow to dry/absorb and I do wonder if they are actually effective. Have you seen any literature on whether these lotion/sanitizers are as effective at both disinfecting and moisturizing skin as taking an extra moment to just apply sanitizer and moisturizer separately? In which case, do you think that the burden/cost of eczema would be offset enough by hospitals paying for moisturizer stations next to all sanitizer stations, or do you think that individuals should all be expected to just purchase and have available their own moisturizers (i.e. cost not justifiable)?
Thank you,
Kiera

Name
Kiera Liblik

Hi Kiera,
You have raised some great points! To address the first point of a combo- sanitizer/moisturizer, the literature on this topic is very limited. When sanitizing hands, The American Contact Dermatitis Society does recommend alcohol-based hand sanitizer with added moisturizers (1) however, I was unable to find studies comparing this practice to moisturizing after sanitizing. From a practical standpoint, I do not think traditional hand moisturizers can be replaced by a hybrid approach. Although it may be less likely to develop dryness and irritation with a combo moisturizer/hand sanitizer, I believe traditional moisturizers will provide the most protection for the skin’s barrier. Using a moisturizing sanitizer, followed by a moisturizing hand/cream lotion would likely be the best practice (no such thing as too much moisturizer) !

To touch on your second point, moisturizer stations next to all sanitizer stations would likely be a dermatologist’s dream! Even wall-mounted moisturizing stations throughout the hospital or beside sinks would definitely be a successful preventative strategy. As Dr. Molin mentioned, the burden/cost of eczema can include weeks off of work for proper recovery. In light of the pandemic, this is not something the healthcare sector can handle right now. It also cannot handle a lapse in hand hygiene and the risk of spreading COVID-19 throughout hospitals. As a result, I do think hospitals should pay for moisturizing stations and ultimately, that hand moisturizing should be included in proper hand hygiene guidelines.

Best,
Bethany

1. Rundle, C. W., Presley, C. L., Militello, M., Barber, C., Powell, D. L., Jacob, S. E., ... & Dunnick, C. A. (2020). Hand hygiene during COVID-19: recommendations from the American Contact Dermatitis Society. Journal of the American Academy of Dermatology.

Name
Bethany Wilken

Hello Bethany,
Thank you so much for your response! I wonder what the rationale is for the recommendation by the American Contact Dermatitis Society? Perhaps we will see more information emerge from research done during COVID-19. Hopefully, emerging research also underscores the importance of moisturizer becoming as available as hand-sanitizer is at workplaces at the moment!
Cheers,
Kiera

Name
Kiera Liblik

Name
Trinity Vey

Mon, 01/17/2022 - 14:49

Hi Bethany,

Great summary of last week’s MGR! Your post emphasized the alarming increase in hand eczema in healthcare workers as well as school-aged children during the pandemic. I'm wondering if you think this increase in hand eczema may increase household or community transmission of bacteria and viruses that can colonize the hands? For example, studies suggest that Staphylococcus aureus (S. aureus) hand and nasal colonization are highly prevalent in patients with hand eczema (1). While S. aureus is responsible for a significant burden of nosocomial infections, particularly surgical site infections, it is also associated with community transmission (2).

Best,

Trinity

1. Nørreslet, L. B., Edslev, S. M., Andersen, P. S., Plum, F., Holt, J., Kjerulf, A., ... & Agner, T. (2020). Colonization with Staphylococcus aureus in patients with hand eczema: Prevalence and association with severity, atopic dermatitis, subtype and nasal colonization. Contact Dermatitis, 83(6), 442-449.
2. Noskin, G. A., Rubin, R. J., Schentag, J. J., Kluytmans, J., Hedblom, E. C., Smulders, M., ... & Gemmen, E. (2005). The burden of Staphylococcus aureus infections on hospitals in the United States: an analysis of the 2000 and 2001 Nationwide Inpatient Sample Database. Archives of internal medicine, 165(15), 1756-1761.

Name
Trinity Vey

Hi Bethany,
I wanted to start off by saying great post and summary of last week’s MGR. During this talk I was very concerned with the impacts of COVID-19 on hand eczema as well. I have been thinking for a while now that the implications for hand sanitizers is beyond “dry hands”. I think you brought up a great point, Trinity, in that having hand eczema may increase your risk of bacterial infections within the household. I wonder if having a good hand care regiment would be enough to avoid this, while treating and preventing itching. I look forward to hearing your thoughts on this.
Great job Bethany,

Kyla

Name
Kyla Tozer

Hi Bethany and Trinity,

Bethany, you did a wonderful job facilitating the discussion and with this summary. I wanted to chime in on this comment Trinity made with a related topic, the severity of hand eczema and its relation to Staphylococcus aureus infection. Haslund et al., found S. aureus present on the hands of nearly half of all patients with hand eczema that were tested (1). Furthermore, there was a significant increase in hand eczema severity in patients with S. aureus on their hands (1). The authors suggested that S. aureus may relate to the continued harm the disease causes patients. Mernelius et al., also found S. aureus presence on the hands to be significantly higher in patients with severe hand eczema compared to mild hand eczema (2). These authors emphasize the importance of having effective eczema treatments, as severity of eczema may contribute to the spread of infection, particularly in the healthcare setting. Thus, hospitals should take the necessary actions to protect healthcare workers and patients.

1. Haslund et al., 2009. Staphylococcus aureus and hand eczema severity. Brit J Dermatol.
2. Mernelius et al., 2016. Staphylococcus aureus colonization related to severity of hand eczema. Eur J Clin Microbiol Infect Dis.

Name
James King

Name
Alyssa Burrows

Mon, 01/17/2022 - 16:49

Hi Bethany,

Thank you for the excellent post and the friendly reminder to moisturize our hands!

Outside of the direct HE scope of this lecture but within the realm of dermatology is how the COVID-19 pandemic has impacted the diagnosis of dermatological cancers, among other cancers. The incidence of melanoma is rising faster than all other preventable cancers in the US. It is crucial to have early diagnosis and treatment of skin cancer to reduce morbidity and mortality [1]. The COVID-19 pandemic has severely limited people’s access to healthcare and in-person visits which are vital to making these diagnosis. A study in Greece found a 30.1% mean reduction in skin cancer (compared to the last 4 years). The reduction was 36.4%, 22.3%, and 44.8% for melanoma, basal cell carcinoma, and squamous cell carcinoma, respectively [2].

Closer to home is a story from London ON where a family doctor with dermatology training recognized a lesion and diagnosed him with skin cancer and encouraged them to see someone as soon as possible. His dermatologist confirmed the diagnosis, thanking the doctor who made the initial identification [3].

I think it is interesting how broad the scope of dermatology is from HE to cancers and how the pandemic is impacting the practice.

Kind regards,

Alyssa

1. Gomolin T, Cline A, Handler MZ (2020) The danger of neglecting melanoma during the COVID-19 pandemic. Journal of Dermatological Treatment 31:444–445
2. Lallas A, Kyrgidis A, Manoli S-M, Papageorgiou C, Lallas K, Sotiriou E, Vakirlis E, Sidiropoulos T, Ioannides D, Apalla Z (2021) Delayed skin cancer diagnosis in 2020 because of the COVID-19–related restrictions: Data from an institutional registry. Journal of the American Academy of Dermatology 85:721–723
3. London, Ont. doctor makes cancer diagnosis while administering COVID-19 vaccines - London | Globalnews.ca. In: Global News. https://globalnews.ca/news/8495655/london-doctor-cancer-diagnosis-covid…. Accessed 17 Jan 2022

Name
Alyssa Burrows

Hi Alyssa,

Thank you for another interesting discussion prompt and sharing a practical example! Indeed, COVID-19 has severely limited access to healthcare and we are seeing many physicians and patients opting for virtual methods of communication. Dermatologic diagnoses are almost always based on the visible presentation of the condition. Thus, as you mentioned, in-person visits are vital. Additionally, elderly patients or those who are at a higher risk of skin cancers often routinely visit dermatologist to have skin spots examined. The fear of contracting COVID-19 from hospitals and doctor’s offices may prevent these patients from getting their routine check-ups. This may be contributing to the observed mean reduction in skin cancer diagnosis.

From Dr. Molin’s presentation and our current discussion, I think we can all agree that the pandemic has immensely impacted the field of dermatology by increasing the incidence of numerous skin diseases. With that being said, could anyone think of possible positive influences COVID-19 has had on dermatology?

Best,
Bethany

Name
Bethany Wilken

Hi Bethany and Alyssa,
Thank you so much for the wonderful summary and for leading our discussion. On the topic of COVID 19 and dermatology, another way that the pandemic has affected those with skin conditions and dermatology is with the use of immunosuppressant/immunomodulators. In the early stages of the pandemic, there were important considerations to be made regarding those already receiving systemic immunosuppressive therapy for skin diseases. For example, at the time it was unknown whether these patients have increased susceptibility to COVID19 and whether the outcomes would be different in this population. More recently, with the development of vaccines, the assessment of safety and efficacy in patients with immune mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is paramount. I was wondering based on our discussion in class, do you think there needs to be or are there specific guidelines for this population?

Name
Dilakshan Srikanthan

Hi all,
Bethany, thank you for the fantastic summary of the compelling MGR last week, and Alyssa and Dilakshan for the insightful discussion. The risks of immunosuppressive therapies for HE and other conditions have been highlighted in new ways during the COVID-19 pandemic, with physicians and patients being forced to evaluate the fine balance between protection from the severe disease that's impacting them and an impending viral infection of SARS-CoV-2. As Dr. Molin mentioned in the discussion, it's important to continue to treat HE despite novel risks from COVID-19, as supported by current literature (1). To further challenge these patients, she mentioned that the COVID-19 vaccines may not be as effective considering the potentially reduced capacity for immune response, and therefore many of these patients qualify for additional vaccine doses in the hopes that they will mount a protective immune response to the virus. In light of this challenging situation as Bethany highlighted, Dr. Molin mentioned that non-immunosuppressive therapy development is a major priority in HE research.

I also found the discussion about necessary considerations for treating HE with immunosuppressants in terms of risk to other local hand infection risks quite compelling, and I would be curious to know what the team thinks about risk calculation and mitigation in these situations.

(1) Seirafianpour F, Sodagar S, Pour Mohammad A, et al. Cutaneous manifestations and considerations in COVID-19 pandemic: A systematic review. Dermatol Ther. 2020;33(6):e13986. doi:10.1111/dth.13986

Name
Katie Lindale

Name
Alyssa Burrows

Mon, 01/17/2022 - 17:29

Hi Bethany,

Given Dr. Molin’s cross-training with Allergy, I thought it was important to discuss the idea of the atopic march, which is a theory that proposes that allergic diseases occur in a time-based order: from atopic dermatitis (eczema) and food allergy in infancy to the gradual development of allergic asthma and allergic rhinitis in childhood [1]. There is some discussion that someone may become sensitized to an antigen through a broken or damaged skin barrier. In this inflamed environment and route of exposure, the individual may become sensitized to this antigen, resulting in the immune system recognizing it as an allergen in the future. Allergic diseases are burdensome to the individual and society. Allergic diseases are multifactorial, relying on genetic and environmental interactions that are not fully understood. One leading hypothesis in allergy development is the hygiene hypothesis, which outlines that early home exposures to microbial products and other allergen-nonspecific immunostimulants modify allergic risk [2]. Given the extreme use of disinfectants, increased hand hygiene and decreased exposure to large group settings (playgroups, childcare centres), it will be interesting to see if there are changes in atopic disease prevalence in children over the coming years.

I am interested in hearing our peers' thoughts on this!

-Alyssa

1. Yang L, Fu J, Zhou Y (2020) Research Progress in Atopic March. Frontiers in Immunology 11:
2. Tse K, Horner AA (2008) Allergen tolerance versus the allergic march: The hygiene hypothesis revisited. Curr Allergy Asthma Rep 8:475–483

Name
Alyssa Burrows

Hi Alyssa and Bethany,

This is an interesting discussion point to a fantastic blog post (well done Bethany!).

I think in terms of the hygiene hypothesis, there is certainly an argument to be made that the use of sanitizers and disinfectants may result in increased risk of allergies, especially with more prenatal exposures, in addition to ones in early life/childhood.

With reports of increased prevalence of atopic dermatitis (AD) during the pandemic, which is the first step of the atopic march, it brings to light the question of whether we may see an increase in general allergic sensitization (1). AD is often caused by skin barrier dysfunction and there are two main hypotheses about how this may arise: 1) the "outside-in" hypothesis proposes that allergen exposure and IgE sensitization weakens the skin barrier, making it more susceptible to irritation and inflammation, and 2) the "inside out" hypothesis suggests that skin barrier dysfunction, such as through mutations of proteins responsible for maintaining the integrity of the skin barrier, lead to immune dysregulation. There is also a strong influence of genetics on the development of allergic diseases, with the heritability estimated to be between 60 to 75%. I wonder if for those with a genetic predisposition for allergic disease, whether environmental factors due to the pandemic (such as increased handwashing) may accelerate the occurrence (maybe starting HE?) and progression of their allergic conditions.

Only time (and longitudinal studies) will tell!

I'd love to hear any thoughts anyone may have on this topic.

Lubnaa

(1) https://doi.org/10.1016/j.ebiom.2021.103268

Name
Lubnaa Hossenbaccus

Hi Sophia,
Thank you for sharing the Maskne article!

I found an article on Healthline titled Eczema and Hand Sanitziers. I am wondering if anyone could comment on the accuracy of the information presented in this article. Does it align with Dr. Molin's presentation or are there contradictions between the two?

Best,
Bethany

Name
Bethany Wilken

Hello Bethany and Sophia,
Unfortunately I have hit a paywall on the NYT article but it is interesting to see how quickly topics in healthcare become mainstream when discussed in popular media. A 2021 article from BMJ (1) has pointed out that some other facial dermatoses may also be misidentified as 'maskne'. For example, irritant contact dermatitis is the most common dermatological problem associated with mask use. Several other facial dermatological consequences of mask use are discussed in the article, including seborrhoeic eczema, rosacea, and folliculitis (1). Perhaps it is important that we also encourage individuals with 'maskne' to consider alternatives and see their family physicians and/or dermatologists!
Warm regards,
Kiera
1) Rudd, E., & Walsh, S. (2021). Mask related acne (“maskne”) and other facial dermatoses. bmj, 373.

Name
Kiera Liblik

Name
Emmanuel Fagbola

Tue, 01/18/2022 - 11:31

Hey Bethany! Thank you for taking the time to summarize this week's MGR. I enjoyed reading a recap of the relevant conversation our class had the privilege of engaging Dr. Molin in. We talked about HE presenting as red, itchy, and scaly skin in our discussion. However, we also talked about different signs and symptoms that present in darker skin. I was wondering what symptoms are clinically relevant when diagnosing HE in darker skin? Also, have standard HE treatments been tested and deemed effective on various skin types?

Name
Emmanuel Fagbola

Name
Bethany Wilken

Tue, 01/18/2022 - 15:29

In reply to by Emmanuel (not verified)

Hi Emmanuel,
Thank you for bringing up this important EDI topic! I wish I had more space to write about this in my summary! As Dr. Molin shared with us, illnesses can manifest differently depending on the colour of the skin. For example, she said redness is often unnoticeable in dark skin. For diagnosing HE in darker skin, it is important to look for darker brown, purple or ashen grey patches of skin on the hands. Traditional signs and symptoms such as skin swelling, warmth, dryness and itching can help physicians confirm diagnosis. Most commonly, patients with darker skin suffer from a papulonodular form of eczema with post-inflammatory hyperpigmentation (1). This presents as visible, small bumps on the skin. In terms of treatment, topical, oral and injectable medications for HE are considered effective and safe for use in all skin types (2). Interestingly, eczema seems to be more prevalent in Black and mixed-race populations compared to Whites (3). People of colour are also likely to have more severe disease. This makes the overwhelmingly White education in dermatology even more devastating in my opinion.

I wanted to share with you, and our classmates the impactful story of Malone Mukwende. As a second-year medical student, he developed a handbook for diagnosing clinical signs in black or brown skin. The hand book is currently used in 102 countries. Check out the recent CBC article below.

https://www.cbc.ca/radio/asithappens/as-it-happens-tuesday-edition-1.56…

Best,
Bethany

1. Deleuran, M., & Vestergaard, C. (2014). Clinical heterogeneity and differential diagnosis of atopic dermatitis. British Journal of Dermatology, 170, 2-6.
2. Salvador, J. S., Mendaza, F. H., Garcés, M. H., Palacios-Martínez, D., Camacho, R. S., Sanz, R. S., ... & Giménez-Arnau, A. M. (2020). Guidelines for the diagnosis, treatment, and prevention of hand eczema. Actas Dermo-Sifiliográficas (English Edition), 111(1), 26-40.
3. Torrelo, A. (2014). Atopic dermatitis in different skin types. What is to know?. Journal of the European Academy of Dermatology and Venereology, 28, 2-4.

Name
Bethany Wilken

Name
Georgia Kersche

Tue, 01/18/2022 - 16:33

Hi Bethany! Thank you for the excellent discussion summary, and great job leading the discussion last week in the new online format! My hands are as moisturized as they have ever been.

I was struck by the lack of public awareness of hand eczema and the degree to which it can debilitate its sufferers. The importance of awareness cannot be overstated. As Dr. Molin mentioned, despite the huge prevalence there is a severe lack of public knowledge about hand eczema, its warning signs, and the treatment options available to people. This results in stigma and shame about hand eczema, leading to delayed treatment and psychosocial tolls. In a large study, 89% of respondents with hand eczema reported embarrassment, 79% reported affected mood, and 27% had affected physical relationships with their partners (1). This study describes a severe emotional and social toll of what some think of only as "dry skin", when it is clearly so much more. The interpersonal toll due to COVID-19 is already significant due to everyone's limitations in who they may have physical contact with. Already, people feel more isolated; to have those remaining connections inhibited by pain and shame is detrimental to our wellbeing. Early diagnosis and immediate protective measures is the best strategy to prevent severe hand eczema and the corresponding shame and toll on workplaces (2). I think the lack of awareness about the realities and prevalence of HE is one factor that could be improved with public health campaigns, screening, and the power of social media. One pilot healthcare workplace screening tool in Ontario found that though 70% of participants reported no current hand rashes, 72% of participants did have a positive result when analyzed (3). The authors acknowledged that healthcare workers may view mild changes in their skin as normal for the job and not perceive it as a rash requiring treatment and ongoing observation (3). Given the lack of awareness and importance of early detection, do you have any ideas for continuing to shine light on this shadow pandemic? Even regular screening could remind people of its existence and reduce stigma. I feel that educational campaigns in high-risk jobs like the healthcare settings could impose more knowledge of early symptoms, good lotions and other preventative strategies, and options available to them if it does get so severe that their work is impacted.

1. An ethnographic insight into the psychological impact of hand eczema. (2013). Journal Of The American Academy Of Dermatology, 68(4), AB74. doi: 10.1016/j.jaad.2012.12.306
2. Salvador, J., Mendaza, F., Garcés, M., Palacios-Martínez, D., Camacho, R., & Sanz, R. et al. (2020). Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema. Actas Dermo-Sifiliográficas (English Edition), 111(1), 26-40. doi: 10.1016/j.adengl.2019.12.007
3. Nichol, K., Copes, R., Spielmann, S., Kersey, K., Eriksson, J., & Holness, D. (2015). Workplace screening for hand dermatitis: a pilot study: Table 1. Occupational Medicine, 66(1), 46-49. doi: 10.1093/occmed/kqv126

Name
Georgia Kersche

Hi Bethany and Georgia,
Thank you for your stellar job managing the discussion last week, Bethany!
I agree that educational campaigns, screening, and other strategies could be implemented to help healthcare workers prevent and manage hand eczema. A recent study examined facilitators and barriers for putting prevention recommendations into place in the healthcare setting.1 Some of these barriers were easy to mitigate, such as that some healthcare workers were unaware that using disinfectant is better for preventing hand eczema than washing hands with soap and water. Other strategies were also easy to improve, such as ensuring that when moisturizer is provided in the workplace, it’s located in a visible, accessible, fixed location. Participants suggested posters and education sessions helped make them aware of hand eczema and reminded them to use moisturizer. Institutional support also helped with the implementation of hand eczema prevention strategies, such as supervisors supporting glove use during wet work and including a short introduction to hand eczema prevention for new employees during training.1 Overall, this study provides useful recommendations to best implement strategies to prevent hand eczema and shows that improving healthcare workers’ hand care in the workplace is feasible.

1. van der Meer, E. W., van der Gulden, J. W., van Dongen, D., Boot, C. R., & Anema, J. R. (2015). Barriers and facilitators in the implementation of recommendations for hand eczema prevention among healthcare workers. Contact dermatitis, 72(5), 325–336. https://doi.org/10.1111/cod.12331

Name
Samantha Ables

Hi Georgia and Bethany,

Thank you for the great summary and comment! I too was surprised by the lack of awareness on hand eczema and agree that this needs to change to improve countless lives. Especially during the colder months, many people get dry hands, and with the lack of common public knowledge on HE, many may not seek help due to not knowing that they might actually have a medical condition that requires intervention. A systematic review found that educational programs and materials like posters were effective in increasing awareness and prevention of hand eczema in occupational settings (1, 2). In public settings, and as individuals, I am wondering what can be done to increase awareness and help others identify signs that their dry hands could actually be HE. Following a similar model of what was found to be effective in occupational settings, could government funded billboards, bus ads and TV advertisements be a good place to start to increase education of the general public? Hopefully by increasing awareness of HE will help reduce the stigma surrounding it and even make individuals feel more comfortable requesting time off of work to recover.

(1) Public Health Ontario. (2019). Recommendations for the Prevention, Detection and Management of Occupational Contact Dermatitis in Health Care Settings. https://www.publichealthontario.ca/-/media/documents/G/2019/guide-occup…
(2) Nicholson PJ, Llewellyn D, English JS; Guidelines Development Group. Evidence-based guidelines for
the prevention, identification and management of occupational contact dermatitis and urticaria. Contact
Dermatitis. 2010;63(4):177-86

Name
Cassie Brand

Hi Georgia,

I wanted to hop in here because I think the concepts of awareness pertaining to non life-threatening conditions, the changing prevalence of such conditions during the pandemic, and how many determinants of health are taking a backseat to the COVID-19 response are under-discussed at large. Prior to MGR, I had no idea that hand eczema was already so common and is becoming even more prevalent with the increased societal emphasis on sanitation. With these themes being especially true for healthcare workers and how they can result in time away from their posts, thereby placing additional strain on those who remain, it's striking that moisturizers aren't provided alongside hand sanitizers.

I also can't help but speculate that this shadow pandemic of hand eczema is mirrored in a plethora of other conditions. It's no secret that surgeries not addressing immediately life-threatening ailments have been significantly postponed, allowing low- to medium-risk conditions to deteriorate (1, 2). Social distancing measures and the closure of public spaces like gyms and restaurants, while absolutely necessary, have also left many materially more anxious and depressed (3), and very recent research into the impacts of lockdowns and understimulation on the social and motor development of young children suggests potential long-term effects (4).

This is to say, that while the societal spotlight is shone on COVID itself (case #s, deaths, etc) and COVID-adjacent issues (school and business closures differentially impacting across socioeconomic status), these core disturbances reverberate across society in a multitude of unexplored ways and I think the rising prevalence of hand eczema is one such interesting consequence.

References
1. Byrnes, M. E., Brown, C. S., de Roo, A. C., Corriere, M. A., Romano, M. A., Fukuhara, S., Kim, K. M., & Osborne, N. H. (2021). Elective Surgical Delays Due to COVID-19. Medical Care (4), 288–294. https://doi.org/10.1097/MLR.0000000000001503
2. https://www.ctvnews.ca/health/coronavirus/with-more-than-500-000-fewer-…
3. Shevlin, M., McBride, O., Murphy, J., Miller, J. G., Hartman, T. K., Levita, L., Mason, L., Martinez, A. P., McKay, R., Stocks, T. V. A., Bennett, K. M., Hyland, P., Karatzias, T., & Bentall, R. P. (2020). Anxiety, depression, traumatic stress and COVID-19-related anxiety in the UK general population during the COVID-19 pandemic. BJPsych Open, 6(6), e125. https://doi.org/10.1192/bjo.2020.109
4. Shuffrey, L. C., Firestein, M. R., Kyle, M. H., Fields, A., Alcántara, C., Amso, D., Austin, J., Bain, J. M., Barbosa, J., Bence, M., Bianco, C., Fernández, C. R., Goldman, S., Gyamfi-Bannerman, C., Hott, V., Hu, Y., Hussain, M., Factor-Litvak, P., Lucchini, M., … Dumitriu, D. (2022). Association of Birth During the COVID-19 Pandemic With Neurodevelopmental Status at 6 Months in Infants With and Without In Utero Exposure to Maternal SARS-CoV-2 Infection. JAMA Pediatrics, e215563. https://doi.org/10.1001/jamapediatrics.2021.5563

Name
Nolan Breault

Name
Impacts of AD

Wed, 01/19/2022 - 14:19

Hi Bethany,

Thank you so much for your insightful blog post into Dr. Molin’s research! I think you did a great job of highlighting the key points of her presentation as well as adding some interesting facts surrounding hygiene as well as the implications of hand washing.

Individuals affected by AD usually have a genetically determined risk factor which affects the skin barrier function or the immune system, and as such AD has been described as an allergic skin disease (1). I read a study which talks about the global epidemiology and risk factors of atopic dermatitis, and it states, controversially, that these mutations alone are not enough to cause the clinical manifestations of the disease (2). They proposed rather that allergy is a consequence of AD in subjects with a concomitant underlying atopic constitution. They have found in this study that genetically determined alterations in the epidermis or the composition of lipids contributes to skin barrier function and inflammation, which, in turn allows easier and enhanced environmental allergen penetration of the skin, which facilitates the allergens interaction with the body’s immune system causing allergy (2). This only adds to the importance of what Dr. Morin presented to us as to the shadow impact of eczema and now after this talk and I would be interested to see data on if allergies increase in time as well with the increased prevalence of AD due to the COVID-19 pandemic. Throughout my research and Dr. Morin’s presentation it surprised me that AD had so many downstream effects and it got me thinking about how else it may affect the body. My question is if you think that there are other possible complications which could arise from AD other than what was presented to us? Psychological due to missing work/embarrassment of visible symptoms, etc.? And lastly, I am interested to know how much of a “pandemic” you believe this to be based upon what you know about eczema, do you agree with Dr. Morin?

Best,
Pierce C.

1) Fonacier, L. S., S. C. Dreskin and D. Y. Leung (2010). "Allergic skin diseases." J Allergy Clin Immunol 125(2 Suppl 2): S138-149.
2) Nutten, S. (2015). "Atopic dermatitis: global epidemiology and risk factors." Ann Nutr Metab 66 Suppl 1: 8-16.

Name
Impacts of AD

Hi Pierce,

Thank you for your comment! I also want to commend Georgia and Samantha for highlighting the importance of raising awareness for HE. As they said, the visible nature of HE and other types of eczema often result in profound psychological impacts. Some which may stem from embarrassment and self-consciousness. Perhaps, if HE was more well known people with the disease would feel less alone and the general public would support those suffering. Not only could improved education help to diminish psychological burdens, but it could also help in the self-management of the disease. Treatment of HE is multifaceted and even with adherence of treatment, rebound flares are likely to occur. The lack of control patients feel towards their disease could also amount to poor mental health. Thus, along with awareness efforts such as public media campaigns, I believe more support groups should be available for HE and all dermatology patients.

To address your questions, the complications presented to us were mostly skin infections (bacterial, viral and fungal) and mental health effects. Another complication that can result from severe eczema is scarring. This can be very burdensome for patients as they have succeeded in treating the disease yet, they have permanent reminders of their struggles. Additionally, many patients with eczema experience sleeping problems due to persistent itch. Many medications for eczema come with their own complications. Most notably, steroid use can cause acne, atrophy of the skin, delayed wound healing and skin discolouration. That being said, when used correctly, steroid creams are a safe and effective method of treatment.

To answer your second question, I agree with Dr. Molin that HE is very much a pandemic. Although not contagious like COVID-19, the incidence of HE has increased around the world and we are seeing it in populations that we haven't before (i.e. children). HE is affecting a significant proportion of the population, as proven by the statistics. The alarming 80% increase of HE in healthcare workers and an almost 50% rise in children definitely showcases HE as a pandemic. Of course, that is just my opinion (and I may be a little bias as my research is in eczema) but I would love to hear other peoples thoughts on this.

Best,
Bethany

Name
Bethany Wilken

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