Onset of occupational hand eczema among healthcare workers during the SARS‐CoV‐2 pandemic: Comparing a single surgical site with a COVID‐19 intensive care unit

Abstract Background As a result of the COVID‐19 outbreak, hygiene regulations have been revised and hand sanitation has been intensified. Objective To investigate the onset of hand eczema during the COVID‐19 pandemic in healthcare workers (HCWs) directly involved in intensive care of COVID‐19 patients and HCWs without direct contact with COVID‐19 patients. Hereby, we aim at increasing awareness about occupational hand eczema and preventive measures that can be adopted. Method A survey was distributed amongst 114 HCWs at a single surgical centre and at a COVID‐19 intensive care unit of the university hospital Ludwig Maximilian University Munich, Germany. Participants were questioned about the daily frequency of hand hygiene prior to and during the pandemic. Participants self‐reported the onset of hand eczema and associated symptoms. Results Our study revealed a significant increase in hand washing, disinfection, and use of hand cream across all participants (P‐value <.001), regardless of having direct contact with COVID‐19 patients. A high prevalence of symptoms associated with acute hand dermatitis of 90.4% was found across all HCWs, whereas hand eczema itself was underreported (14.9%). Conclusion The increase in hand sanitation during the COVID‐19 pandemic impairs the skin of the hands across all HCWs, independent of direct intensive care of affected patients.

and an increase in the frequency of hand washing and disinfection. 2 While these measures are indispensable to prevent transmission of COVID-19, they also have negative implications.
For example, excessive sanitizing of hands using soap or alcoholbased products leads to a disruption of the skin flora and the natural protective skin barrier. [3][4][5] This accounts for a large number of occupational skin diseases (OSDs), mostly irritant and allergic contact dermatitis. [6][7][8][9][10][11] While hand eczema affects all HCWs, surgeons and surgical nursing staff are especially prone to the disease. 12,13 Obviously, healthy hands are particularly important for a surgeon and any impairment imposes significant limitations on their ability to practice. 14,15 Recently, reports have addressed cutaneous complications related to increased hand hygiene measures and prolonged time of wearing of PPE amongst HCWs treating patients with COVID-19. [16][17][18][19] However, we hypothesized that an exacerbation of occupational skin injury across all disciplines might be observed, independent of having direct contact with patients that have tested positive to SARS-CoV-2.
The present study evaluated whether the recommendations for increased hand sanitation affected HCW's hand washing and disinfection frequency at a single surgical centre. Additionally, we investigated whether this correlated with an onset of hand eczema and associated symptoms. Moreover, our results were compared to HCWs involved in direct intensive care of COVID-19 patients.

| Design of questionnaire
Basic information regarding gender, age, occupation (physician or nurse), smoking behaviour, and clinical history of type IV hypersensitivity and atopic diathesis (asthma, allergic rhinitis, atopic dermatitis) were obtained.

| Symptoms associated with hand eczema
Our data show a high prevalence of self-reported symptoms associated with hand eczema across all HCWs. Dryness was reported most frequently (83.2%), followed by erythema (38.6%), itching (28.9%), burning (21.1%), scaling (18.4%), fissures (9.6%), and pain (4.4%. ( Table 2). Comparison of the Non-C and C group revealed no significant difference in self-reported symptoms between the groups. Interestingly, although the majority of participants suffered from symptoms associated with hand eczema (90.4%, n = 103/114), only 14.9% of HCWs (n = 17/114) actively recognized the symptoms as an onset of the disease. (Tables 2 and 3) Of these participants, 70.6% (n = 12/17) reported the date of onset, and this revealed that only two HCWs suffered from hand eczema for more than 50 days. (Table 4).

| Hand washing and disinfection
The overall frequency of hand washing before and during the pandemic showed a highly significant increase from 5-10x per day to 10-20x per day for all HCWs (P < .001). (Table 5) Both groups (Non-C and C) were comparable with regard to hand washing frequency, and showed no significant difference (P = .70) ( Table 6).
With regard to all HCWs, we found that the overall frequency of hand disinfection increased significantly after the COVID-19 outbreak (before COVID-19: median 10-20x per day, during COVID-19: median 20-30x per day; P < .001) ( Table 5). Detailed analysis of the Non-C and C group showed slightly higher rates of disinfection in HCWs treating COVID-19 patients, however, without significance (P = .09) ( Table 7).

| Application of hand creams
When comparing the overall frequency of hand cream application before and during the COVID-19 pandemic, our data indicate that application of skin care increased significantly from a mean of 1x per day to 1-2x daily (P < .001) ( Table 5). HCWs in the Non-C group Self-reported symptoms of hand eczema according to treatment of COVID-19 patients

Symptoms
Non-COVID n = 74 n (%) COVID n = 40 n (%) Total n = 114 n (%) P-value T A B L E 3 Self-reported onset of hand eczema according to treatment of COVID-19 patients applied hand cream more frequently compared to the C group (P = .074) ( Table 8).

| DISCUSSION
During the ongoing COVID-19 pandemic, first scientific reports have identified skin injuries in "front line" HCWs related to PPE use and intensified hand hygiene regulations. [16][17][18][19] However, the current situation is likely to cause an increase in cutaneous complications in all HCWs, regardless of direct treatment of COVID-19 patients. Accordingly, increasing HCWs´awareness of this disease is vital and the need for preventive measures cannot be over stressed. 20,21 The present study revealed a highly significant increase in hand washing and disinfection frequency across all HCWs after the start of the COVID-19 outbreak, indicating that the proposed hygiene regulations have been implemented across all investigated disciplines (HCWs at a surgical clinic vs ICU). We found no significant difference with regard to the frequency of hand sanitation when comparing the Non-C and C group, further stressing that the increase of hygienic safety precautions affects HCWs in general. In terms of hand disinfection, our data revealed slightly higher rates in the C group (P = .09), which could be related to the frequent change of PPE with hand disinfection involved in every step, (ie, when changing protective face visors, masks, gloves and gowns).
As hypothesized, our data show a high prevalence of characteristic symptoms for acute hand eczema 22 19 Here, we show that the high frequency of hand hygiene also strongly affects hand skin status of workers who are not directly involved in the care of COVID-19 patients.
Interestingly, only 15% of our study population stated they had  In line with this, we found a higher frequency of hand cream application after COVID-19 outbreak for all HCWs. However, although frequency of skin care increased from 1x to 1-2x daily, rates are still rather low. Diepgen et al recommend the frequent application of lipid rich moisturizers during the working day and especially after work and at night. 22 Based on evidence from clinical and experimental studies, skin protection in general should include protective gloves when performing wet work with a cotton glove worn underneath when glove use is expected to be longer than 10 minutes. Hands should be washed in lukewarm, not hot, water and dried thoroughly. 24,25 Interestingly, the Non-C group showed significantly higher rates of hand cream application as compared to the C group.
Time is a scarce resource in intensive care and accessibility might also be an issue, which could account for lower rates of skin care in the C group.
Skincare measures should be taken very seriously to prevent a potential chronic and relapsing state of hand eczema, 26  should explore whether symptoms can be related to certain hand sanitizing products, in order to determine whether one product is preferable to another.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.