by Cathleen Terhune Alty, RDH
Hand dermatitis can wreak a devastating effect on a pair of hands designed to provide compassionate care. Take care of the hands that take care of others.
One aspect of dental hygiene practice that is rather unique is the healing we provide to oral tissues with our hands. Sometimes, though, the hands that heal need healing because of harsh soaps, latex gloves, or cleaning solutions. Redness, itching, rash, dryness, chapping, and edema are often shrugged off as part of the job description. These are signs, however, that signal something is amiss. Ignoring the problem will not make it go away, and it will probably get worse.
Hand dermatitis is a common problem in dental hygiene as well as other health professions. Occupational Safety and Health Administration studies show that as many as one in three health care workers may have some form of hand irritation. Contact dermatitis is one of the 10 leading occupational illnesses. We know how important it is for the skin to remain intact and healthy when working. So what are the causes, how can we avoid them, and what treatment is available if we do have these symptoms?
Contact dermatitis - If you develop a red, itchy rash on your hands, it may or may not be an allergic reaction. The most common hand irritation is called irritant contact dermatitis, or non-specific contact dermatitis. It causes redness, dryness, and skin chapping. In more chronic cases, fissures and blisters may develop. It is usually reversible if treated promptly.
The most common causes are direct contact with chemical irritants such as gloves and hand-washing soaps. It is not an immunologic response because the body is reacting to the presence of chemicals. It's not a reaction to a specific allergen to which a person has developed a sensitivity. If ignored, physicians say it can progress to hypersensitivity and allergy. Irritant contact dermatitis tends to worsen with frequent washing, inadequate hand drying, excessive sweating and bacterial proliferation under gloves, and other physical irritations.
Some hand irritations are allergy-induced. The most common allergic reaction is delayed hypersensitivity, which is a form of allergic contact dermatitis (ACD). As a true allergy, it is a T-lymphocyte mediated reaction. Rather than a reaction to an allergen such as proteins in latex rubber, this is a response to the residual chemicals in gloves, whether latex, vinyl, or another material. Common chemicals that may cause an allergic reaction that are added to latex and non-latex gloves are accelerators (which give strength and elasticity) and antioxidants (which prolong the glove life).
According to the American Academy of Dermatology, approximately 3,000 chemicals are well documented as specific causes of ACD; 25 are responsible for half of all cases. Hypoallergenic gloves may mean sensitizing chemicals are not used in processing, but not that the gloves are latex-free. Other causes of ACD are plants such as poison ivy; metals such as nickel found in jewelry, dyes, and fabric finishes; preservative chemicals such as formaldehyde; fragrances; and topical corticosteroids.
The reaction usually begins as a red rash on the back of hands, peaking at about 48 hours after contact with the allergen. Skin may become fissured and develop blisters. Long-term exposure to the allergen may cause the skin to thicken and become leathery. The National Ambulatory Medical Care Survey conducted in 1995 estimated that 8.4 million outpatient visits to physicians were for allergic contact dermatitis, which was the second most frequent dermatologic diagnosis.
Contact urticaria - Another allergy response is immediate hypersensitivity, also called contact urticaria. It occurs quickly, within 30 minutes of exposure. Symptoms include redness, itching and swelling. Asthma, runny nose, and itchy eyes may occur with mucus membrane exposure. This is an immunoglobulin E (IgE) response, commonly caused by the proteins in latex rubber. This can be a much more serious reaction as it can quickly lead to hives, anaphylaxis, and respiratory distress and can be fatal.
Exposure to an allergen is required to develop sensitivity, but this exposure time can vary from a few minutes to a few years. Therefore, doctors say anyone can develop an allergy at any time and it is impossible to predict who will become sensitized and their threshold for anaphylaxis. The likelihood of something causing an allergy depends on its allergic potential and concentration and the individual's predisposition to developing allergies and previous levels of exposure. Generally, the higher the allergen levels, the higher the risk. Once someone is allergic, the person may experience reactions at a very low level of concentration. Skin that is already irritated is more susceptible to allergen penetration than healthy, intact skin.
Latex allergy - The most common allergy reaction in dental personnel is from latex. In 1998, the Food and Drug Administration mandated that all medical devices be labeled for latex content. Latex is found in certain gloves, as well as rubber dams, anesthetic stoppers and vial seals, prophy cups, nitrous/oxygen nose pieces, gutta-percha, orthodontic elastics, and equipment tubing. The National Institute for Occupational Safety and Health (NIOSH) issued an advisory in 1997 recommending use of non-latex gloves for activities not likely to involve contact with infectious materials and use of powder-free latex gloves with reduced protein content when necessary. Glove powder has been scrutinized for many years because it can carry latex proteins and remain suspended in the air.
People most at risk for developing a latex allergy include people who have frequent, prolonged and intimate contact with latex devices, as well as those with a general predisposition to develop allergies (known as atopic individuals) or with a history of pre-existing skin lesions such as eczema and psoriasis. Risk factors also include medical conditions that expose a person to latex (such as Spina Bifida, abdominal/urinary tract problems and multiple surgeries). Persons with food allergies, particularly to tropical and stone fruits (bananas, melon, avocado, kiwi, peach, cherry, pineapple, papaya, chestnuts, and hazelnuts - all of which have protein structures similar to latex) also are at risk for developing a latex allergy.
Avoiding hand irritation and allergies means caring for your hands, including the following specific steps:
- Check them frequently for cuts, abrasions, rash, and other problems.
- Cover all cuts and abrasions, and make sure hands are dry before putting on gloves.
- Avoid direct contact with concentrated chemicals.
- Protect hands when gardening and doing other outdoor activities, especially when the weather is cold and windy.
- Drink plenty of fluids and don't bite nails to avoid hangnails.
- Change gloves frequently to allow skin to breathe and wash between each change.
- Rinse soap thoroughly from hands and pat hands dry instead of rubbing.
- Minimize direct contact with other dental chemicals (monomer, antimicrobials, disinfectants, and ultrasonic solutions).
- Try different combinations of gloves, soaps, and hand creams instead of using the same brands.
When faced with pain or roughness, many of us will turn to over-the-counter hand creams for relief. Hand creams may help soothe and soften hands, but some may reduce glove barrier protection or cause bacteria to grow quicker while wearing gloves. Make sure the cream isn't causing an irritation to your hands. Cool salt-water compresses or a lukewarm oatmeal soak can bring some relief to ACD. Oral antihistamines may help diminish rash, but avoid topical antihistamines as they may further exacerbate the condition.
Even stress can set off a chain reaction of hand irritation. If you develop hand irritation, it is prudent to see a physician. If you think you may have a latex allergy or sensitivity, it is important that you get tested. Working in a dental office can be a potentially dangerous place for a latex-sensitive person who is unaware. Although there is no cure for latex sensitivity, there are therapeutic remedies for clinical symptoms. Various tests can be conducted to determine if the hand irritation is allergy-based. The North American Contact Dermatitis Group (NACDG) recommends patch testing be done to identify the external allergens that are causing symptoms, although skin biopsy of lesions may be necessary. Treatment usually ranges from avoiding exposure to chemicals and allergens to topical or systemic corticosteroids. Time off to allow hands to heal may be necessary.
Cathleen Terhune Alty, RDH, is a frequent contributor. She is based in Clarkston, Mich.
Hand dermatitis is a general term that describes three different skin reactions:
Irritant or non-specific contact dermatitis (ICD)
- Skin damage from direct contact with chemical irritants
- Redness, dryness, and chapping of skin to "weeping" lesions
- May appear similar to allergic contact dermatitis
Allergic contact dermatitis (ACD)
- Also called delayed (type IV) hypersensitivity
- It is a T-lymphocyte mediated reaction
- Usually caused by chemical contact
- Red rash on back of hands, reaching a maximum up to 48 hours after contact
Allergic contact urticaria (hives)
- IgE response occurs quickly, within 30 minutes of exposure
- Often caused by proteins in latex gloves
- Appear as varied sized, plaque-like wheals
- Redness, itching, and edema
- Most serious reaction
Source: British Dental Association, June 1998 Fact file
For more information on hand dermatitis and latex allergies, check out these online resources:
- American Academy of Dermatology, "Skin Pathology: Acute Inflammatory Dermatoses," www.aad.org
- "Allergic Contact Dermatitis," www.emedicine.com
- "Latex Hypersensitivity among Students in U.S. Dental Schools," www.dentalnews.com