The Prevalence and Risk Factors of Self-reported Hand Eczema in Health Care Versus Non-health Care Workers during the COVID-19 Pandemic in Latvia

1. INTRODUCTION

In response to the global outbreak of an infectious disease caused by the SARS-CoV-2 virus, the World Health Organization (WHO) declared a pandemic on 11 March 2020 [1]. To mitigate the spread of Coronavirus infection (COVID-19), significant changes in social behavior were made. The WHO issued guidelines that currently advocate various preventive measures, including maintaining social distance, avoiding touching the face, wearing masks, using disposable gloves, and practising frequent hand hygiene with soap or alcohol-based disinfectants [2]. Frequent contact with soap, water, and disinfectants can lead to irritant contact dermatitis, which can change the integrity of the skin and weaken its natural protective functions. These actions can disrupt the epidermal pH, deplete the lipid barrier, and escalate trans-epidermal water loss. Additionally, repetitive use of gloves can potentially lead to irritant contact dermatitis due to the combination of heat and moisture, or result in allergic contact dermatitis due to the skin's sensitivity to the rubber compounds present in the gloves [3-5].

Hand dermatitis (HD) or hand eczema (HE) can manifest in various degrees, ranging from mild dryness and itchiness symptoms to more severe forms characterized by the presence of deep-seated vesicles, blisters, fissures, and bleeding on the hands [6]. This type of skin damage significantly impacts an individual's quality of life, as it can be quite painful when interacting with objects using their hands [7]. Previous studies have identified specific factors that increase the risk of HD, including frequent hand washing, use of gloves, history of atopy, and previous HE [5, 8-11].

Before the COVID-19 pandemic, studies on the prevalence and incidence of HE among the general population in various European countries revealed that the estimated annual prevalence rates ranged from 6.5% to 17.5% [12]. However, looking retrospectively, from the beginning of the COVID-19 outbreak until nowadays, there has been a noticeable uptrend in the reported prevalence of contact dermatitis in studies conducted in different countries [10, 13-15].

To our knowledge, there are insufficient number of local researches conducted to assess the prevalence of HE among the general population in Latvia during the COVID-19 pandemic. Our study aims to broaden the scope of the study population to include both healthcare workers (HCWs) and non-HCWs. This decision was made due to the observation that alterations in hand hygiene routines have been noticeable not only among HCWs but also among the general population [6, 16].

Therefore, the objective of this study was to investigate skincare habits and hand hygiene and to pinpoint the factors that could impact the occurrence of HE, considering the adoption of novel hand hygiene practises and the diverse range of hand hygiene methods used throughout the COVID-19 pandemic. Additionally, this study aimed to determine the associations between new-onset HE and gender, age, occupation, smoking status, personal and family history of atopy, and personal history of HE. We hypothesized that heightened hand hygiene measures could lead to a more frequent occurrence of skin damage among the general population.

2. MATERIALS AND METHODS

3. RESULTS

4. DISCUSSION

The predominant focus of research on hand hygiene since the onset of the COVID-19 pandemic has centered around HCWs [11, 20-22]. However, the general population has also experienced the impact of this phenomenon [6, 8].To date, there have been no comparable studies carried out to explore the connection between the prevalence and associated factors of HE among the general population of Latvia throughout the COVID-19 pandemic.

When comparing the overall frequency of soap-based handwashing, disinfectant use, skin moisturizer application, and rubber glove usage before and at the time of the pandemic, this study revealed a remarkable rise in all these practices (p<0.001). The majority of participants (38%) noted, that they washed their hands more than 11–20 times daily at the time of the pandemicConcordant findings were observed in a study conducted in Mecca region and Germany [10, 11]. Furthermore, a significant proportion of our study participants (28.8%) reported using daily disinfection 11-20 times per day during the pandemic. In comparison to research papers, which included only HCWs conducted by Guertler et al., (2020) and Reinholz et al., (2021) frequency of hand disinfection usage is lower. On the other hand, a population-based study by ZahrAllayali et al., (2021) showed that the majority of participants (34%) use hand disinfectant only 5-10 times per day [10, 11, 23]. Regarding the use of rubber gloves, the majority of participants (55.6%) reported using them more than 4 times per week. This was in agreement with a population-based study in Saudi Arabia [10]. Also, our data showed an increased daily use of moisturizers (p<0.001). Before the pandemic, only 12.8% of the total number of participants admitted using skin moisture more than 5 times per day. Meanwhile, during the pandemic, more than a third (39.3%) reported moisturizing at least 5 times per day. Nevertheless, it is important to note that our study does not provide conclusive evidence regarding whether the skin moisturizer application among participants was prompted by therapeutic reasons in response to the development of HE or as a preventive measure.

This study showed an association between the everyday frequency of soap-based handwashing (p<0.05), hand disinfection (p<0.01), weekly usage of rubber gloves (p<0.05), and new-onset HE. Frequent exposure to soap, water, and disinfectants has the potential to modify the skin's integrity. It can compromise the skin's natural defenses by shifting the pH of the epidermis, diminishing the lipid barrier, and augmenting trans-epidermal water loss, ultimately culminating in the development of contact dermatitis [4]. Also, prolonged wearing of gloves may cause maceration and irritant contact dermatitis of the hand skin by over-hydrating the stratum corneum layer [3]. Additionally, wearing latex gloves could develop skin reactions through immunoglobulin E-mediated hypersensitivity to latex, and latex allergy [24]. Around one-third (35.4%) noted, that they washed their hands 11–20 times daily and had HE. A previous study by Alkhalifah et al., (2022) showed that washing hands with soaps more than 5 times per day was associated with high odds of developing HE (OR, 3.32; 95% CI, 1.79-6.14; P <0.001) [8]. Similar results have been documented in other research articles [5, 10]. The present study also revealed that the majority of new-onset HE cases (28.1%) were observed in the group of participants who used hand disinfection 21-30 times per day. Many studies confirmed that skin conditions were notably more prevalent among those individuals who used sanitizers several times per day [6, 23]. Meanwhile, new-onset HE was strongly associated with frequent rubber glove use (more than 4 times per week). Similar results were observed in population-based studies in Saudi Arabia [8] and Thailand [5].

Despite many studies claiming that female gender is a factor that increases the risk of HE [4-6, 8, 25], our study did not find any statistically significant association between gender and new-onset HE. That was in agreement with other studies that reported that the prevalence of HE was not associated with gender [26, 27]. Most cases (77.1%) of HE during COVID-19 were reported in the age group 18-30 years (p<0.05). Comparable findings were observed in the research conducted by Alkhalifah et al., 2022 [8]. A previous study by Park et al., 2016, claimed that HE is more prevalent among people in their 20s and 30s [28], which is consistent with our results. The reason for the early occurrence of HE is likely tied to the fact that individuals with a heightened predisposition, whether they have a history of skin atopy or not, tend to develop hand eczema at a young age when they come into contact with skin irritants and contact allergens [29]. Additionally, between the ages of 20 to 29, many young adults not only encounter occupational exposure but also experience skin irritation on their hands due to wet work activities at home [28].

Surprisingly, there were no statistically significant associations between occupation and new-onset HE in our study. Regarding smoking status, personal, and family history of atopy, personal history of HE, and new-onset HE there were no statistically significant associationseither. Our study showed controversial data compared to similar studies regarding HE-associated risk factors such as atopic dermatitis, allergic rhinitis, and a past history of eczema [5, 8].

This study found that 18.3% of the respondents ever reported HE (atopic dermatitis, allergic contact dermatitis, or irritant contact dermatitis). The prevalence was slightly higher than in the general population of most of Europe before the COVID-19 outbreak, as reported by a review of researches [12]. In particular, 53.2% of the respondents with a history of HE revealed symptoms worsening throughout the pandemic. This number is higher than previously reported worsening cases (31.3%) in a similar study [10].

Regarding new-onset HE, in our study it was found in 37.4% of cases. This finding resembled the results of the prevalence reported in previous population-based studies by Alsaidan et al., (2020) and Alkhalifah et al., (2022) 34.8% and 34.2% respectively [6, 8].

Clinically, HE is characterized by signs of erythema, vesicles, papules, scaling, fissures, and symptoms of itch, dryness and pain [30]. Dryness, erythema, and itching (34.6%, 24.9%, and 21.8%, respectively) were the most commonly linked symptoms with HE in this study. Similarly, a prior investigation focusing on the onset of occupational HE among HCWs revealed that the predominant clinical characteristics of skin damage were the same [11].

Considering that the COVID-19 virus is an ongoing issue, maintaining proper hand hygiene remains crucial. However, it is equally important to implement effective strategies to prevent HE.-Identifying alternative methods of hand hygiene that are gentle on the skin, such as using mild, fragrance-free soaps or cleansers, can help minimize the risk of HE. Additionally, moisturizing the hands regularly with appropriate emollients can help restore and maintain the natural protective barrier of the skin. Providing education and awareness about the prevention of HE-can also be beneficial in reducing its occurrence worldwide, including Latvia.

The study has several limitations that should be taken into consideration when interpreting the results. One notable limitation is the reliance on an online survey-based approach, which may introduce sampling bias. By using self-administered questionnaires distributed through social media, the study could inadvertently exclude individuals who lack access to the Internet.Surprisingly, the majority of participants (69.3%) were HCWs, so all participants were not objectively represented. Since individuals had the freedom to choose whether or not to participate in this study, i.e. self-select into the study, we have no ability to make generalizations from our sample. As the link was published on social media, the response rate could not be calculated accurately. Another limitation concerns the demographic makeup of the study participants. With a significant majority (more than 80%) of respondents being female, the study may not accurately represent the entire population in terms of sex distribution. One possible interpretation is based on findings related to online survey response patterns, which indicate that women tend to participate in larger numbers compared to men [31]. Additionally, the study's sample size is relatively small, which might limit the robustness and generalizability of the findings. Furthermore, the reliance on self-reported symptoms introduces the possibility of recall bias. Moreover, according to the European Society of Contact Dermatitis guidelines, the diagnosis of HE is based on medical history, clinical examination, and performance of skin tests [32]. As an online survey was conducted, with no dermatologist confirming the diagnosis, reported symptoms may not represent a true diagnosis of eczema.

Given these limitations, it is important to acknowledge that further research is needed to fully understand the topic under investigation.

CONCLUSION

According to our results, the skin of the study population was negatively affected by COVID-19 precautions. The prevalence of new-onset HE during the COVID-19 pandemic was 37.4% which supported our hypothesis about an increase in the prevalence of HE in the general population throughout the COVID-19 pandemic. Therefore, our suggestion is to raise awareness about skin protective methods and promote the adoption of innovative infection prevention strategies in Latvia. This includes emphasizing the importance of regular skin moisturization for hand protection and exploring the potential of using less harsh skin disinfectants.

Several factors were statistically significantly associated with new-onset HE, including young age (18-30 years), regular use of gloves in daily life, frequent hand washing, and disinfection.

Unexpectedly, there was no statistically significant association between new-onset HE and gender, occupation, smoking status, personal and family history of atopy, and lastly personal history of HE.

REFERENCES