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Prevention in Health-Care Professionals

  • Lilla LandeckEmail author
  • Britta Wulfhorst
  • Swen-Malte John
Living reference work entry

Abstract

Job-related hazards for the development of skin diseases in health care professionals are prolonged wet work, contact to potential allergens as well as infectious agents, and the exposure to ionizing radiation. Most common skin diseases resulting comprise irritant/allergic contact dermatitis, infections, and skin cancer/radiodermatitis.

To avoid irritant contact dermatitis, use protective (barrier) creams and moisturizers.

Infections can be prevented by hand hygiene, including hand washing and/or disinfection, and the use of medical gloves.

Hand disinfection is eudermic and should be the preferred method of hand hygiene.

Medical gloves should protect against microorganisms and chemicals. Gloves used in the medical sector have to achieve at least an acceptance quality level (AQL) of 1.5.

For prevention of skin cancer due to ionizing radiation, a continual dose monitoring, annual medical examinations, and rigorous approach to radiation protection and dose reduction are necessary.

Keywords

Prevention Health-care-professionals Contact dermatitis Infectious diseases Skin cancer 

1 Core Messages

  • Occupational skin diseases among health-care professionals comprise infections, irritant and allergic contact dermatitis, contact urticaria, and skin cancer due to ionizing radiation. The hands are thereby the most common affected body site.

  • Infections can be prevented by hand hygiene, including hand washing and/or disinfection and the use of medical gloves.

  • Hand disinfection is eudermic and should be the preferred method of hand hygiene.

  • Medical gloves should protect against microorganisms and chemicals. Gloves used in the medical sector have to achieve at least an acceptance quality level (AQL) of 1.5.

  • For prevention of skin cancer due to ionizing radiation, a continual dose monitoring, annual medical examinations, and rigorous approach to radiation protection and dose reduction are necessary.

2 Introduction

Health-care professions include different key fields that are licensed to provide some kind of health care, including:
  • Medical (physicians)

  • Nursing (nurses, physician assistants, nurse practitioners, operating department practitioners)

  • Dentistry (dentists, dental assistants)

  • Physical therapy (masseur, physicotherapists)

  • Allied Health (pharmacists, audiologists, dieticians, occupational therapists, psychologists, chiropractors, optometrists, radiographers, social workers, emergency medical technicians, pre- and posthospital care staff)

Job-related hazards for the development of skin diseases in health-care professionals are prolonged wet work, contact to potential allergens as well as infectious agents, and the exposure to ionizing radiation. Possible diseases resulting comprise irritant/allergic contact dermatitis, infections, and skin cancer/radiodermatitis. Infectious protection necessitates the regular use of gloves, which – paradoxically – may increase the risk of irritant skin reactions.

Certain health-care professional subgroups may show additional job-related risk factors for the development of skin diseases. Please see chapters “Occupational Contact Dermatitis in Dental Personnel”, “Laboratory Technicians”, “Operating Room Staff”, and “Veterinarians” for detailed information.

3 Top Ranking Skin Diseases Among Health-Care Professionals

3.1 Irritant Contact Dermatitis

Contact to irritants such as chemicals and aggressive disinfectants, prolonged wet work periods, frequent hand washes, and the occlusive high humidity milieu under medical gloves frequently result in irritant contact dermatitis of the hands (Suneja and Belsito 2008). The point prevalence of irritant contact dermatitis among health-care professionals is around 30% and therefore approximately threefold higher compared to non-health-care professionals (Smit et al. 1993; Thyssen et al. 2010). Most frequently affected health-care professional subgroups comprise registered nurses and nursing aides/attendants (Smit et al. 1993; Warshaw et al. 2008; Suneja and Belsito 2008). Physicians suffer less often from contact dermatitis, those wearing gloves for a prolonged time and are exposed to scrubs (e.g., surgeons) are at risk.

Clinically, irritant contact dermatitis often begins in the interdigital spaces on the back of the hands. As the border between normal and pathologic skin changes of the hands is indistinct and the initial skin changes are often misinterpreted, many individuals affected do not seek medical attention. Particularly, since irritant contact dermatitis represents a curable disease when eliciting irritants are avoided and appropriate preventive measures are taken, early stage identification is important.

3.2 Allergic Contact Dermatitis

Health-care professionals are exposed to many chemicals capable of causing allergic contact dermatitis. While allergic contact dermatitis is compared to irritant contact dermatitis in general, less frequent among health-care professionals, it may even be easier to treat, if the offending allergen can be identified and the individual is provided with the means to avoid it. Most common contact allergens vary by investigation but are reported to include (Suneja and Belsito 2008; Schnuch et al. 1998; Warshaw et al. 2008):
  • Glove ingredients (e.g., Carba mix, thiuram mix)

  • Preservatives (e.g., Quaternium 15, benzalkonium chloride)

  • Fragrances

  • Biocides (e.g., Glutaraldehyde, formaldehyde)

Glove ingredients represent a major cause of possible sensitization sources. Because of their widespread use in the medical sector, they are discussed separately in this chapter.

Preservatives may be contained in disinfectants, sterilizing solutions, soaps, and other personal care, but also in pharmaceutical products. Due to their ubiquitous use, in Europe, preservatives must always be declared by name (INCI) on the ingredient product labels according to the Cosmetics Directive and the Detergents Regulation of the EU (Yazar et al. 2011; Council Directive 76/768/EEC). Commonly incorporated preservatives in cosmetic and pharmaceutical products are formaldehyde and the formaldehyde-releasing preservatives (quaternium 15, diazolidinyl urea, imidazolidinyl urea, bronopol, DMDM hydantoin), and benzalkonium chloride. Sensitization may occur due to increased number of personal hand washes/disinfections, surface or instrument disinfections, or because of handling of patient care products (Suneja and Belsito 2008; Schnuch et al. 1998; Warshaw et al. 2008). Specific sensitization to formaldehyde in the health-care sector may also be a result of direct exposure to formaldehyde such as seen in pathologists. Benzalkonium chloride (0.5–2.0%) which is a common preservative in ophthalmic products may be used in dilute solutions of 1:1,000 to 1:2,000 for disinfection of skin and mucous membranes and for cleansing polyethylene, nylon tubing, and catheters.

Fragrances are also common allergens in health-care professionals. Sensitization derives from cosmetics, cosmoceuticals (cosmetics with biologically active ingredients claiming a medical benefit), or pharmaceutical products. It has been suggested that fragrance ingredients account for 30–45% of the allergic reactions to cosmetics (European Commission 1999). As a consequence of an increasing number of sensitized individuals, there was a need to protect consumers. For this reason, the European Union has changed legislative, and manufacturers are obliged to label 26 key fragrances in detergent and cosmetic products according to the INCI nomenclature for the European market since 2005. This applies to fragrances when a threshold concentration is exceeded, (10 ppm [0.001%]) for leave-on products and 100 ppm [0.01%] for rinse-off products (Council Directive 76/768/EEC). Commonly used fragrances are limonene, linalool, butylphenyl methylpropional, hexyl cinnamal, citronella, and geraniol (Magnano et al. 2009; Yazar et al. 2011).

Biocides Glutaraldehyde is frequently causing allergic contact dermatitis but only in subgroups of health-care professionals. Dental personnel are thereby at risk for allergies to glutaraldehyde from disinfectants but also from acrylates (e.g., methyl- and ethyl methacrylates (MMA, EMA), ethyl acrylates (EA) (Schnuch et al. 1998)).

3.3 Infectious Diseases

Please see chapter “Biologic Causes of Occupational Dermatoses” for detailed information.

A summary of top ranking skin diseases in health-care professionals, possible culprits, and prevention strategies are tabulated in Table 1.
Table 1

Top ranking skin diseases in health care professionals, possible culprits, and prevention strategies

Disease

Culprits

Possible prevention strategies

Irritant contact dermatitis

Irritants

 Chemicals (e.g., cleaning, laboratory, radiology)

 Prolonged wet work

 Frequent hand washes/disinfections

 Occlusive milieu under gloves

Minimizing the exposure time to irritants to a lowest possible level

Utilization of protection strategies: wearing of appropriate gloves, application of protective barrier creams and emollients

Wearing cotton gloves under occlusive gloves

Allergic contact dermatitis

Allergens

 Components of natural and synthetic rubber gloves (most common cause)

 Acrylates

 Preservatives, germicidal agents (e.g., glutaraldehyde)

 Medications (e.g., tetrazepam)

Avoidance of offending allergen

Replacement of allergic components

Use of preservative free products

Utilization of protection strategies: wearing of appropriate gloves, application of protective barrier creams and emollients

Wearing cotton gloves under occlusive gloves

Infectious diseases

Culprits

 Bacterial (streptococcal, staphylococcal, cutaneous tuberculosis, erysipeloid)

 Fungal (dermatophytes)

 Yeast ( candida)

 Virus (herpes simplex virus, varicella zoster virus)

 Scabies, pediculosis

Hand washes and disinfections, wearing of protective gloves, protective clothing and surgical masks

Appropriate non-touch-techniques (e.g., careful handling of needles)

Contact urticaria

Culprits

 Gloves (latex proteins)

 Medications:

  Antibiotics (e.g., penicillin, bacitracin, cephalosporin)

  Aspirin, salicylate

  Chloramine, chlorpromazine

 Alcohol

Use of powder-free (latex) gloves

Minimal exposure techniques to medications due to complete avoidance or replacement of offending allergens

Wearing of protective gloves and protective clothing

Skin cancer due to ionizing radiation

Ionizing radiation

Application of radiation protection measures

Adequate staff positioning/increase distance from patient to decrease exposure to scattered dose rates

Use of protective screens, wearing of lead aprons,dosimetry

3.4 Prevention Strategies

3.4.1 Prevention of Contact Dermatitis

Barrier Creams and Emollients

The basic preventive measure to avoid the development of irritant contact dermatitis is the limitation of exposure to irritants, particularly of wet work, to a lowest possible level. In addition, the use of protective barrier creams may help to build up a diffusion barrier on the skin surface protecting from penetration of irritants. Although sometimes marketed as “invisible gloves,” protective barrier creams cannot offer a protection level that would be comparable with protective gloves. Preparations marketed as “invisible gloves” may feign a seeming protection that causes health-care professionals at risk to be careless of contact to irritants (Wulfhorst et al. 2011). Application of barrier creams is recommended before contact to irritants and on a regularly basis, for example, every 2 h. When (re)applied, the skin has to be cleaned and dried to avoid increased penetration of remaining irritants from the skin surface (Kresken and Klotz 2003). Application should incorporate all areas of the hands, particularly the dorsum of the hands and the interdigital spaces. In contrast to barrier creams, emollients for skin care should be used after work. This is particularly important for those products containing urea as an active ingredient. Urea may support the penetration of allergens and irritants into the skin when used during the work shift.

Gloves

Gloves testes for the US market have to meet criteria defined by the American Society for Testing and Materials (ASTM 2009ac). Gloves represent another prevention mainstay for health-care professionals. They provide a barrier to potentially infectious materials and other contaminants such as irritants and allergens. However, paradoxically, the act of prevention by wearing gloves may lead to an increase of contact dermatitis.

Medical Gloves: Medical gloves are used to protect patients and users from cross-contamination of microorganisms and therefore to protect human health. Especially surgical teams are at risk, for example, having three times higher incidence rates of Hepatitis B compared to the general public (Rabussay and Korniewicz 1997).

Medical gloves are legally covered by the European Council Directive 93/42/EEC (Wulfhorst et al. 2011) and the European Standard (EN) 455 (CEN – EN 455 I-III 2002). The EN 455 defines the minimum properties; it specifies requirements for shelf life, labeling, and disclosure of information relevant to the test method used. In contrast to the high demand of medical gloves, regulations for quality testing of those are designed rather to test physical properties (e.g., dimension, strengths) and macroscopic material defects due to the water leak test than to investigate the safety with regard to permeation of microorganisms or chemicals. European standards for medical gloves according to EN 455 do not require permeability tests for microorganisms or for chemicals.

When choosing medical gloves, it is recommendable to select gloves that fulfill, in addition to EN 455, the European Standard EN 374 – which summarizes standards for chemical protective gloves. The EN 374 defines performance characteristics of gloves with regard to protection against chemicals and/or microorganisms (“chemical protection gloves”). Thus, it can be assumed that the individual protection level of gloves is higher, when they were certified according to both, EN 455 and 374.

Gloves tested for the US market have to meet criteria defined by the American Society for Testing and Materials (ASTM).

Standard test methods for protective glove barrier and resultant glove characteristics: Standard test methods of the protective glove barrier include the investigation of: (1) the glove penetration and (2) the permeation. Standard tests for penetration and permeation are specified in EN 374 (European manufacturers) and similarly in ASTM F739, F 1383, ASTM F903 (US manufacturers) (EN 374; ASTM F903; ASTM F739; ASTM F1383).

Penetration: Penetration refers to the passage of chemicals through macroscopic holes or pores and is tested by an air or water leakage test. This test determines acceptance quality level (AQL) values. The AQL value names the maximum share of faulty units which can be considered as satisfactory quality for purposes of a sampling inspection. For medical gloves, an AQL of 1.5 is required, which means that of 100 tested gloves, less than two have a defect. Further performance classes are as follows:

Class 1

AQL <4.0

Class 2

AQL <1.5

Class 3

AQL <0.65

Permeation and chemical resistance: In contrast, permeation refers to the migration of chemicals through the protective glove material on a molecular level (sorption, diffusion, desorption) to the skin. Key parameter for permeation measurement is the breakthrough time in minutes. The breakthrough time is defined as the time between the application of a test chemical and the point of time at which a permeation rate (PR) of 1 μg/min/cm2 (EN Standard) respectively 0.1 μg/min/cm2 (ASTM standard) is detected. There are six performance indicators classified:

Breakthrough time

>10 min

Performance class 1

>30 min

Performance class 2

>60 min

Performance class 3

>120 min

Performance class 4

>240 min

Performance class 5

>480 min

Performance class 6

Generally, permeation of different chemicals is dependent on their polarity: Polar chemicals such as acetone will dissolve polar glove materials such as nitrile rubber gloves. Vice versa, nonpolar chemicals such as hexane or benzene will dissolve nonpolar glove materials such as latex.

The presented tests implicate different problems: (1) The standard only determines permeation under conditions of total contact but without stretching, flexing, or other factors that will occur in a real working environment. (2) Tests are conducted at a specific temperature of 23 ± 1 °C, whereas temperature of gloved hands may easily reach >30 °C. (3) Permeation breakthrough time is measured only for individual chemicals, whereas real working environments are characterized by a mixture of different chemicals.

As the tests are conducted according to laboratory standards rather than to real working conditions, quality results may not be applicable for several work settings.

Chemical Resistance: Gloves are regarded to be chemically resistant and correspondingly labeled on glove packages (Table 2), if gloves protect against at least 1 out of 18 defined chemicals (methanol [A], acetone [B], acetonitrile [C], dichloromethane [D], carbon disulfide [E], toluene [F], diethylamine [G], tetrahydrofuran [H], ethylacetate [I], n-heptane [J], sodium hydroxide 40% [K], sulfuric acid 96% [L], nitric acid 65% [M], acetic acid 99% [N], liquid ammonia 25% [O], hydrogen peroxide 30% [P], hydrofluoric acid 40% [Q], formaldehyde 37% [R]) (EN 374). Only the EN 374 requires testing of chemical resistance, while EN 455 which applies specifically to medical gloves does not.
Table 2

Pictograms of gloves according to EN 374

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374-1 Type A*

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374-1 Type B*

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374-1 Type C*

A: Resistant for at least 30 min against at least 6 chemicals (specific chemicals are indicated by upper case letter) upon penetration test according to EN 374-2

B: Resistant for at least 30 min against at least 3 chemicals (specific chemicals are indicated by upper case letter) upon penetration test according to EN 374-2

C: Resistant for at least 10 min against at least 1 chemical (specific chemical is indicated by upper case letter) upon penetration test according to EN 374-2

Possible Side Effects to the Skin Due to Gloves
Contact Dermatitis Irritant Contact Dermatitis Due to Occlusion Effects

It has been reported that long-term glove wearing may increase the irritability of the skin, leading to irritant contact dermatitis (Zhai and Maibach 2001), also called hydration dermatitis (Schäfer et al. 2002). However, there are recent reports that there is only marginal influence of occlusion on healthy individuals (Wetzky et al. 2009). To avoid the development of irritant dermatitis, health-care professionals should avoid occlusion effects due to intermissions in glove wearing, the use of cotton glove liners, and reduction of transpiration due to application of anti-transpirant agents.

Allergic contact dermatitis: Vulcanization accelerators from natural and synthetic rubber gloves frequently result in allergic contact sensitizations (type IV allergy). Among those, thiurams, dithiocarbamates, and mercaptobenzothiazoles are leading sensitizers (Bhargava et al. 2009; Knudsen et al. 2006; Geier et al. 2003). They may serve as sulfur donor during vulcanization (during which polymer chains are cross-linked) of natural or synthetic rubber products. In addition, they act as accelerators in this process, as they increase the rate of cure (Warshaw et al. 2008). Although vinyl gloves typically do not contain rubber additives (Hamann et al. 2005) and could theoretically serve as an alternative, they have been discussed being inferior in view of durability and therefore less protective to microorganisms compared to other glove types (e.g., latex, nitrile) (Kerr et al. 2004; Rego and Roley 1999).

Allergic reactions to unexpected ingredients of polyvinylchloride (PVC) gloves such as bisphenol A, formaldehyde, or benzisothiazolinone have been reported too (Aalto-Korte et al. 2007; Pontén 2006). In rare cases, type IV reactions to natural rubber latex have been described in the literature (Sommer et al. 2002; Wilkinson and Beck 1996).

Regional contact dermatitis societies and manufacturers of gloves offer on their webpages databases of gloves free of rubber accelerators for sterile and nonsterile use (http://www.contactderm.org, http://www.2mains.ch, http://www.ehs.okstate.edu/hazmat/Gloves.htm OSU Environmental Health and Safety Dept.). However, information given in these databases is based upon manufacturers’ declarations and standards.

Table 3 demonstrates recent (unpublished) data of 505 patch-tested registered nurses with suspected occupational contact dermatitis. Sensitization to vulcanization accelerators, disinfectants, and preservatives is still striking among nurses.
Table 3

Most common allergens in 505 nurses with suspected allergic contact dermatitis compared to 20,473 controls (all others tested, excluding thereby nurses), 2005–2009, data from the Information Network of Departments of Dermatology (IVDK) (unpublished data; Geier, 2011, personal communication)

Allergens

Percentage positive in %

Nursesa

N = 505

Controlsb

N = 20,473

Nickel (II)-sulfate 6*H 2O

25.9

24

Fragrance mix

8.9

6.5

Thiuram mix

8.3

2

Polyvinylpyrrolidone-iodine

7.7

1.5

Fragrance mix II

7.7

4.6

Tetraethylthiuram disulfide (disulfiram)

7.3

0.8

Cobalt (II)-chloride, 6*H 2O

6.9

7.9

Myroxylon pereirae (Balsam of Peru)

5.5

6.0

(Chloro)-methylisothiazolinone (MCI/MI)

5.3

2.0

Methyldibromo glutaronitrile

5

3.1

Potassium dichromate

5

4.5

Lyral

4.6

2.7

Glutaraldehyde

4.4

0.3

Tetramethylthiuram disulfide

3.4

0.5

Tetramethylthiuram monosulfide

3.4

0.7

Glyoxal

3.4

0.2

Bold possible glove allergens, italic other allergens from the health care sector allergens

aNurses patch tested with an established occupational background

bAge- and sex-matched individuals tested, excluding nurses

Further, Less Common Side Effects

Type I allergies: Immediate hypersensitivity to latex, particularly latex contact urticaria, was a common problem in the late 1980s and 1990s in medical professions. Previous studies based on skin prick tests indicated that 2–17% of exposed health-care professionals were sensitized to natural rubber latex (Liss et al. 1997; Liss and Sussman 1999), compared to less than 1% in the general population (Liss and Sussman 1999). To confirm the diagnosis of latex allergy, skin prick tests and/or in vitro assays for latex specific IgE may be performed. Thirteen different natural rubber latex allergens have been characterized at the molecular level with Hev b 6.01, Hev b 5, Hev b 3, and Hev b 1 as principal in vivo rubber latex allergens (Reunala et al. 2004). Work-up for patients with a history of urticaria from gloves should include a CAP test to the latex protein, Hevea braziliensis, and testing of pieces of the glove. Hev b 5 and 6 are more common allergens among health-care workers, suggesting therefore an occupational background of the sensitization (Toraason et al. 2000).

Serum tests may not be entirely sensitive because of differences in the latex proteins from different sources (Nedorost 2009). Prick or scratch testing should be performed only in the presence of appropriate emergency assistance because of the risk for anaphylaxis.

Due to legal regulations, extensive prevention measures by national professional associations, and hospital-wide interventions, the incidence of latex allergies were reduced in many countries (Reunala et al. 2004). Recent low prevalence rates of latex allergic health-care professionals suggest that the peak of the latex epidemic has already passed (Reunala et al. 2004; Allmers et al. 2004).

Contamination of gloves: Holes or pores may be difficult to detect, resulting in contamination inside the glove. Studies conducted in a surgical setting demonstrated perforations on 17% of gloves. This was correlated with the detection of blood under gloves in 13% of surgeons (Naver and Gottrup 2000). In the majority, the glove perforations (83%) remained undetected by the surgeon (Thomas et al. 2001). Therefore, it is important to emphasize, that even if someone is using gloves, it is necessary to conduct auxiliary hand disinfections. Moreover, protective effects depend on the thickness of the glove: Thicker gloves increase the breakthrough time and offer therefore a higher level of protection (Mellström and Boman 2006). It was shown in a surgical environment that double gloving (wearing two pairs of surgical gloves) or a glove liner between the two pairs of gloves reduced breaks in the gloves significantly. Wearing two pairs of gloves provides an additional barrier and is proposed to reduce the risk of contamination by decreasing the number of perforations to the innermost glove (Caillot et al. 1999). Extra-thick gloves (e.g., orthopedic gloves) seem to be as good as two pairs (Tanner and Parkinson 2006).

3.4.2 Prevention Strategies of Infectious Diseases

Hand Hygiene: Ways to Accomplish Hand Hygiene
In 1847, Ignaz Phillip Semmelweis, a Hungarian-born obstetrician demonstrated with his pioneering work the role of contagions on the hands of physicians in the spread of puerperal fever and that appropriate hand hygiene does prevent infections and maternal deaths (Semmelweis 1988). Since then, hand hygiene has been considered an important measure to prevent cross-transmission of microorganisms and nosocomial infections. Despite this, the majority of the observational studies report low compliance rates of mostly less than 50% to hand hygiene among health-care professionals (Hugonnet and Pittet 2000). Risk factors for noncompliance with hand hygiene are tabulated in Table 4.
Table 4

Predictive factors for noncompliance with hand hygiene. (According to Hugonnet and Pittet 2000)

1. Professional category, lowest noncompliance among physicians and nurses

2. Hospital ward, lowest in intensive care units

3. Time of the day/week, lowest during weekends

4. Heavy workload and

5. Male gender

6. Wearing gloves

Bacteria found on the hands can be divided into two categories: the resident and transient flora. The resident flora permanently exists in the stratum corneum and exposes under normal conditions a low pathogenetic potential. It contributes to resistance to colonization by other potentially pathogenic microorganisms. The resident flora includes coagulase-negative staphylococci, Corynebacterium, or Micrococcus species and is relatively resistant to removal by hand washing (Katz 2004). On the other hand, there is the transient (contaminant) flora. Compared with the resident flora, the transient flora colonizes more readily pathogenic organisms and is responsible for most nosocomially acquired infections. The transient flora has a short-term survival rate on the skin and is more susceptible to hand washing. The aim of hand hygiene is to decrease hand colonization with transient flora. The ideal technique should be quick in performance, safe in the reduction of contamination at the lowest possible level of side effects on the skin.

Hand Wash
Hand hygiene can be achieved either through hand washing or hand disinfection (Table 5). Hand washing refers to the action of washing hands with an unmedicated soap and water, or water alone to remove dirt and reduce transient flora to prevent cross-transmission. A simple hand wash has basically no effect on the resident flora.
Table 5

Hand hygiene strategies

1. Hand wash

(a) Social hand wash

Cleaning of hands with unmedicated soap and water for removal of dirt and organic substances

(b) Hygienic (Europe) or antiseptic (US) hand wash

Cleaning of hands with antimicrobial or medicated soap and water (scrub)

2. Hygienic hand disinfection (Europe)

Cleaning of hands with alcohol-based hand rub into dry hands without water

Hand washing with a soap should be performed when hands are visibly dirty, contaminated with proteinaceous material, or are soiled with body fluids such as blood (Katz 2004; Kampf and Kramer 2004; Kampf and Löffler 2007; Stutz et al. 2009). The use of mild non-alkaline soap and tepid water is preferable for the washing procedure as they offer gentle cleaning conditions.

Antiseptic hand wash: surgical scrub: The surgical hand scrub is a specialized form of hand hygiene and aims to reduce infections by removing debris and reducing the resident flora from the hands of the surgical team for the procedure duration (Katz 2004). Most commonly used agents are 2–4% chlorhexidine and 1–2% triclosan (Kampf and Kramer 2004). The traditional 10-min surgical scrub, using brushes and harsh chemicals, is commonly associated with skin irritation.

Hand disinfection: In contrast, hand disinfection is recommended, if the hands are not visibly soiled for routinely decontaminating hands. The most important clinical situations for hand disinfection are as follows (Katz 2004; Kampf and Kramer 2004; Kampf and Löffler 2007):
  • Before
    • Having direct contact with patients

    • Donning sterile gloves when inserting a central vascular catheter

    • Inserting urinary catheters

  • After
    • Contact with body fluid or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled

    • Contact with patients

    • Removing gloves

    • Contact with inanimate objects

Possible Side Effects of Hand Hygiene on Human Skin

Following the application of alcohol-based hand rubs, health-care professionals frequently complain about burning sensations (Lübbe et al. 2000; Kampf and Löffler 2007) due to a borderline irritated skin with a disrupted skin barrier. When alcohol penetrates into the epidermis, it stimulates interoceptors, resulting in a burning sensation that is often followed by the avoidance of disinfection but “compensated” by frequent hand washes (Lübbe et al. 2000). In addition, cleansers, soaps, and water used for hand washing tend to interact with skin proteins, reducing the natural moisturizing factors and thus the ability to bind and retain water. This may diminish the skin barrier function with subsequent irritant contact dermatitis.

Therefore, hand washing in health care should be the exception for routine decontamination of hands and a well-formulated, alcohol-based hand rub is preferable.

4 Skin Cancer in Health-Care Professionals Caused by Ionizing Radiation

4.1 Overview of Biological Effects of Radiation to the Skin

Exposure of the skin to X-rays may result in two effects: (1) The development of inflammatory/cell-killing effects and/or (2) Induction of malignancies. The probability of inflammatory/cell-killing effects, such as skin desquamation and ulceration, is dose related (deterministic effect Table 6). This threshold is relatively high for the skin but can be exceeded in interventional procedures and long-term diagnostic procedures. Malignancy may occur even at low doses, and the exact dose–response relationship is not known (stochastic effect) (Wagner et al. 1994).
Table 6

Biological effects of radiation. (Adapted from Wagner et al. 1994)

Deterministic effects (e.g., erythema)

 A minimum number of cells must be affected before the biological response is observed

 Threshold dose dependent

 As dose increases above the threshold, the likelihood of inducing an effect and its severity increases

Stochastic effects (e.g., neoplasmas)

 Monoclonal in nature: Single cell changes initiate the biological process that leads to the effect

 No (known) threshold dose: The likelihood of inducing the effect, but not the severity, increases with dose

 Repair of sub-permanent damage prior to further accumulation of radiation damage reduces the potential for the effect

Following the irradiation of the skin with single doses of X-rays, several distinct waves of radiation response may be seen, depending on the total dose, the dose rate, and the pattern of exposure. The potential risks of skin damage resulting from X-rays have been identified, and their times of onset as well as associated threshold doses are given in Table 7. Generally, rapidly dividing stem cell populations (e.g., basal cells) are more sensitive to radiation than mature cells and healing is more prompt in younger individuals due to their larger normal tissue reserves.
Table 7

Overview of radiation effects to the skin. (Adapted from Wagner et al. 1994)

Skin

 Shortly after exposure of single doses of >2 Gy, an early transient erythema may develop due to increase in vascular permeability, it peaks at about 24 h

 A late erythema begins 7–10 days after exposure as a consequence of the inflammation secondary to the death of epithelial basal cells, it peaks at second week and may progress into a prolonged pigmentation if doses exceed 10 Gy in single fraction

 Late skin effects occur 6–10 weeks following single absorbed doses in excess of 15 Gy and comprise a late phase of dusky or mauve erythema

 The likelihood of dermal necrosis increases beyond the threshold of about 18 Gy

 Necrosis is the result of vascular damage in the dermis and develops 10–16 weeks after the exposure

 Dermal atrophy and telangiectasia occur late; the single dose thresholds have been estimated at 10.5 and 12.5 Gy

Hair

 Sensitivity is increasing as hair growth rate increases, thus, scalp hair is more sensitive than eyebrows

 A temporary epilation of anagen hair occurs after single doses of 3–5 Gy, and if doses exceed 7 Gy, permanent epilation may appear

4.1.1 Chronic Irradiation of Physicians’ Hands

Late deterministic effects to skin of the hands are a principal radiation concern of radiologists. Effects may result from long-term irradiation even without producing erythema. The threshold dose for dermal necrosis and telangiectasia subsequent to protracted irradiation is about 30 Gy (Wagner et al. 1994). Limiting annual hand exposure to less than 0.5 Gy should be adequate to prevent such effects (Wagner et al. 1994). Leaded surgical gloves during procedures provide a small amount of protection but may be detrimental if they lead to false confidence about placing hands more frequently into the beam as they are protected. Preferable prevention includes the use of a radiation ring monitor, refrainment from placing the hands in the direct beam, and working on the exit beam side of the patient (Wagner et al. 1994).

4.1.2 Radiation-Induced Skin Cancer

Radiation-induced skin cancer is a concern to the radiation staff that accumulates a high dose to the hands over an extended period of time. Most reports on radiation-induced skin cancers in humans involve accumulated doses in excess of 5 Gy (Wagner et al. 1994). The latent period for radiogenic skin cancer ranges from 4 years to more than 40 years (Panizzon and Goldschmidt 1991). Squamous and basal cell carcinomas are the chiefly associated types of cancer that are attributed to radiographic and radiotherapy exposure. Squamous cell carcinomas appear on the hands and arms (Fig. 1), while basal cell cancers dominate the area of the head and neck, particularly in areas unshielded by hair or clothing. For X-ray-induced cancers, basal cell cancers outnumber squamous cell cancers by at least 5:1. Melanoma is thought not to be related to ionizing radiation exposures. Skin usually exposed to ultraviolet radiation is more sensitive to X-rays (Wagner et al. 1994).
Fig. 1

(a, b) Multiple squamous cell carcinomas on the hand of an 83-year-old radiologist

4.2 Possible Risks and Prevention Methods

Radiological staff receives doses from scattered radiation. Staff doses correlate with patient doses, higher patient doses resulting in more scattered radiation in the interventional suite. Staff doses in the room can be considerably increased if inappropriate X-ray equipment or inadequate personal protection is used (Cousins and Sharp 2004). Staff doses will be increased by increasing the field size and tube potential (Cousins and Sharp 2004).The easiest way to reduce staff dose is operational and can be easily performed by staff positioning as exposure levels decrease with distance from the patient that is a source of scattered radiation. During image acquisition, staff should be positioned behind a protective screen.

Staff working in interventional radiology should wear adequate physical protection. This should comprise a lead apron which distributes the weight across the individual’s shoulders, or hangs the skirt on the bony pelvis, sparing the spine from the full weight of the apron. The lead apron equivalent to 0.35-mm lead will give the wearer substantial protection (Johnson et al. 2001). Photochromic sunglasses and spectacles with a high lead content afford the wearer with some degree of eye protection. Lead rubber or other protective gloves give some protection to the hands.

4.2.1 Staff Dosimetry

Dosimetry for staff is based on a personal dosimeter reading at waist level under a lead apron, which will yield an estimate of effective dose for most instances. To receive additional, more accurate information on individual organs that are likely to receive highest dose such as the fingers, thyroid, and eyes (Cousins and Sharp 2004), additional dosimeter at collar level (above the lead apron) may be necessary.

In addition to continual dose monitoring and shielding personnel, health-care professionals exposed to ionizing radiation should undergo regular medical examinations.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Lilla Landeck
    • 1
    Email author
  • Britta Wulfhorst
    • 1
  • Swen-Malte John
    • 2
  1. 1.Department of Dermatology, Ernst von Bergmann General HospitalTeaching Hospital fo the Charité-University Medicine BerlinPotsdamGermany
  2. 2.Institute for Health Research and Education, Department of Dermatology, Environmental Medicine and Health TheoryUniversity of OsnabrueckOsnabrückGermany

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