The impact of glove-induced contact dermatitis is a concern for occupational health and infection-prevention professionals. While many factors are responsible, Luce Ouellet of Ansell looks at the role of gloves in causing this adverse reaction, and what can be done to avoid this skin condition.
Intact skin is the best barrier against microorganisms. Medical examination gloves cover an average of 1,500cm2 of skin and prevent 77% of hand contamination. However, adverse reactions to gloves may range from a mild irritation to a serious allergic response. Properly designed and conducted studies to determine the prevalence of dermatitis are rare, but surveys indicate that up to 70% of hospital staff self-report hand dermatitis, and 30% of healthcare workers report contact dermatitis to natural rubber latex and synthetic rubber products.
Optimise gloving practice
The four major types of skin reactions associated with gloves are: immediate hypersensitivity (type I allergy or latex allergy), delayed hypersensitivity (type IV allergy or contact dermatitis), irritant contact dermatitis, or a combination of the above. A type I hypersensitivity response is a reaction to residual latex proteins found in natural rubber latex. The reaction is immediate, typically occurring between five and 30 minutes after the initial contact. The symptoms include swelling and redness localised to the site of exposure, as well as non-specific symptoms of itching and burning. The symptoms can spread to areas remote to the site of contact with the glove, and may be accompanied by conjunctivitis, rhinitis and/or bronchial obstruction.
In rare cases, symptoms of anaphylaxis can occur. In 2002, an immediate type I response latex allergy represented up to 33% of all glove-induced dermatitis. To limit the transfer of latex proteins, manufacturers now produce dip-moulding polyurethane and silicone inner coating in powder-free latex gloves.
Representing up to 20% of all glove-induced dermatitis, a type IV allergy is a reaction to a specific allergen, such as the chemical residue from the glove manufacturing process. Reactions are typically induced by chemical accelerators used in natural rubber latex, nitrile, polyisoprene, polychloroprene and polyurethane gloves. Studies present positive patch test readings to accelerators for fragrance mix (13%), thiurams mix (8%), carbamate mix (4%) and mercapto mix (1%).
Other hand dermatitis is sparked by polyvinyl chloride or vinyl gloves made of plastic composites. Phthalates in these gloves induce delayed contact dermatitis. Other causes of sensitivity include lanolin used as a glove softener, polyoxypropylene glycol used as a coagulant in the manufacturing process and colouring pigments. The response is delayed rather than immediate, and usually occurs between six and 48 hours after the initial contact. Symptoms can last for up to four days and may include swelling, cracking, itching, weeping and dryness of the skin at the site. Although dermatitis can extend beyond the area of contact, a type IV response begins when the antigens, such as residual chemicals leached from the glove, penetrate the skin and trigger the formation of T-cells sensitised to specific antigens. Repeated exposure to the antigen in allergic individuals can reactivate sensitised T-cells and produce an inflammatory response, causing type IV allergy symptoms.
Common factors
Irritant contact dermatitis is the most common factor, representing up to 40% of all glove-induced dermatitis. Irritant contact dermatitis is a non-immune reaction, which affects some surgical glove users.
Long-term glove occlusion can increase transepidermal water loss of the skin and affect the skin’s barrier function. In addition, the occlusion nature of gloves will keep breakthrough chemicals in contact with the skin. Under occlusion, the permeation of chemicals and the response of irritants and allergens in the skin can be heightened considerably. Therefore, it is important to select a glove according to the length of time it will be worn and its durability. Controlling the extent of glove usage will limit transepidermal water loss, and a more resistant glove material will prevent high leakage rates.
Alkaline gloves alter the normal skin surface pH level of 5.5. Studies demonstrate that the pH average of powder-free gloves is 5.8, where powdered gloves average a pH of 7.5. Alkaline gloves have demonstrated increased skin dryness and irritation. In addition, mechanical irritation is mainly created by glove powder. Studies have also shown that glove powder significantly alters the skin’s roughness. Finally, endotoxin levels differ between gloves. It has been shown that glove endotoxin contamination may alter the skin’s integrity.
Recreational and occupational factors
In practice, it is not uncommon for endogenous irritant and allergic aetiologies to coexist in the development of certain eczemas. It is important to seek in the history, or by a home or workplace visit, any recreational and occupational factors that may exacerbate any of the above described symptoms. The management of irritant contact dermatitis principally involves the protection of the skin from the irritants. The most common irritants are soaps and detergents, although water itself can be an irritant. The principles of management involve avoidance, protection and substitution.
Some recommendations from occupational health officials to minimise the impact of glove-induced contact dermatitis are to:
- purchase powder-free, low-protein, natural rubber
- latex gloves
- purchase powder-free, low-accelerator and low-chemical-content synthetic gloves
- refer persistent eczema to a specialist contact clinic in the diagnosis of contact dermatitis
- identify causal agents through patch testing
- avoid allergens
- reduce exposure to skin-damaging substances
- remove gloves carefully: do not flip, snap or toss gloves
- clean and dry hands before and after glove use
- change gloves between patients and tasks, and after each procedure
- limit the length of time that the glove is in use
- apply water-based hand moisturisers regularly, ensuring the product is compatible with gloves.
In conclusion, several studies have confirmed that the long-term prognosis for occupational contact dermatitis is poor. A Swedish study showed that 25% of 555 patients investigated for occupational contact dermatitis, over a ten-year period, maintained permanent symptoms. In a large study in Western Australia, 55% of 949 patients showed consistent dermatitis after two years. Milder cases of contact dermatitis were treated successfully upon the ease of avoidance and early interventions. Studies in the US have shown a decline in the number of workers’ compensation claims for natural rubber latex-related illness following institutions’ transitions from powdered to powder-free gloves. This effect could have been due to decreased skin and mucosal exposures of employees to latex allergens.
Countries with guidelines for low-protein, powder-free, natural rubber latex glove use have seen dramatic declines in the incidence of latex-induced responses in end-users.
Preventing skin dermatitis by different measures of avoiding the irritants still represents our best therapeutic solution.