You Need Hands!
Published: 10th Oct 2004
Most of us will tend to take our hands for granted unless some problem arises. Yet they are not only extremely important, but are a part of the body very often at risk.
To understand the importance to us of our hands try a simple experiment. First thing in the morning have someone wrap both your hands in bandages so that you cannot use them. Now see how you get through the day! You can probably imagine the difficulties that this will cause you. Just dressing and eating breakfast present challenges and almost certainly will require the help of someone else.
So perhaps your hands are something that you need to consider more and take greater care of. After all, you only have one pair and they are not replaceable.
Hands and the working environment
In our daily life our hands will be exposed to many different hazards. Some of these will occur only, or mainly, at work, some in the home or in our hobbies or free time activities. In principle we can divide these hazards into two main groups: physical and chemical.
The obvious physical hazards are those such as cuts and lacerations, impact damage and abrasions, that arise when working with machinery or tools or handling sharp objects. Perhaps less obvious are the hazards arising from extremes of temperature or vibration. We can separate these into two main categories, according to whether the affected hand can recover or not i.e. irreversible and reversible. Another grouping would be according to the time element. Does the damage occur immediately or does it accumulate over time?
Obviously cuts, grazes and impact damage leading to bruising occur almost immediately. Other damage can take much longer to appear. Take the case of someone handling rotating machinery, such as an angle grinder. Short term there will be no obvious effect, but should that person work regularly and for extended periods with the grinder, the vibration will eventually affect circulation in his hands, leading to what is known as vibration white finger. This can be a permanent condition that may make further employment in the same trade impossible.
Bear in mind that any physical damage to the skin will increase the potential for chemicals to gain access to the lower vulnerable layers of the skin, and into the body itself where damage can then occur to internal organs.
It is inevitable that our hands come in contact with chemicals. Water is a chemical, even though many never think of it as such. Call it by a chemical name e.g. dihydrogen monoxide and people will react quite differently! Few would consider water a hazardous substance for the skin, yet dermatologists will tell you that water is an irritant to the skin, and wet work is well known as a common cause of occupational skin disease.
We can divide the hazard that a chemical presents to the skin into two main groups, depending upon the time element. Acute effects are those which occur within a very short time. Chronic effects occur only after a longer period, possibly with multiple exposures with no preliminary indication of the damage that is being done. Frequently, where the effect is reversible, the acute effect will tend to be of short duration, whereas the chronic effect may take much longer to heal.
In practice, awareness of acute effects is relatively high, since it is these chemicals that have risk phrases (Rxx) assigned to them and these should be shown on the safety data sheet. The hazard is sufficiently obvious that employer and user are aware of the damage that can occur and will take the appropriate precautions to avoid skin contact.
Unfortunately the same cannot be said for those chemicals where the effect is chronic. Frequently these chemicals will not be listed as hazardous and may not even appear on the safety data sheet. Neither employer nor worker will be aware of the potential for contact between the hands and the chemical to result in damage to health, damage that may be permanent and sufficiently serious that that worker can no longer continue in his or her present occupation.
Water will rarely be considered as a hazardous substance, yet, as already stated, wet work is a common cause of occupational skin disease. This has been recognised in Germany where, if contact with water or work which involves contact with wet objects is for more than 25% of the working shift (in total), a special regulation applies(1) and particular precautions have to be taken.
For the employer this presents a special problem. Since the chemical will not be classified as hazardous and will not normally appear on the safety data sheet it is all too easy to assume that it presents no risk of damage to health, even where contact with the hands may be considerable and for extended periods. Thus it may not even appear in the risk assessment for the particular task. It is only when the dermatitis finally appears that the employer will become aware of the risk and the action that should have been taken.
One way of dealing with this problem is to consider the use to which a chemical will be put. If it is to be used for cleaning or degreasing it will also defat the skin, almost without exception. In other words, even if nothing is shown on the safety data sheet the chemical should be classified as an irritant. If it is a sealant or adhesive then there is a high probability that it will contain chemicals that can cause allergic skin reactions.
Of course, irrespective of what has to appear legally on the safety data sheet, in the U.K. any supplier is required - according to section 6 of the Health and Safety at Work, etc. Act 1974 - to provide sufficient information for the user to know the hazards and be able to use the chemical safely for the purpose for which it was supplied. The Approved Code of Practice for COSHH states clearly that limiting the information to those chemicals with risk phrases is not adequate for compliance.
"Many commonly supplied substances, classified in one or more of the ways described above, are listed in Part I of the Approved Supply List; Information approved for the classification and labelling of substances and preparations dangerous for supply. However, that document should not be regarded as a complete listing of chemicals covered by COSHH as it deals only with substances subject to CHIP and even then omits many substances and all preparations."
ACoP to the Control of Substances Hazardous to Health Regulations (Fourth Editions), paragraph 13
This is something about which suppliers are often surprisingly ill-informed and with which they frequently do not comply. Contact with suppliers to obtain additional information is often necessary for a skin exposure risk assessment.
Is the skin problem allergic or irritant?
Occupational skin diseases almost always take the form of contact dermatitis, of which there are two main types: irritant contact dermatitis and allergic contact dermatitis. A less common allergic skin reaction, not considered dermatitis, is that of contact urticaria. Of these, irritant contact dermatitis is by far the most common and is almost always due to contact with many different chemicals, both at work and at home, each of which is contributing to a breakdown of the skin. A further complication is that many common chemicals can cause both irritant and allergic contact dermatitis and, of course, contact with more than one chemical, each with its own hazard, can combine to produce a skin problem. Thus diagnosis is not always easy, or even certain. Indeed in many cases a diagnosis, even by a specialist dermatologist, may include a large element of guesswork.
Assuming that a visible change has occurred in the skin on your hands, in the form of an itchy rash, possibly with scaly, rough skin or even blisters, how do you now decide what this is? This is very important. Unfortunately, this presents many people with a problem. It is a fact that many GPs do not possess the knowledge or experience to accurately diagnose a skin problem. Furthermore, such a diagnosis may require time, for example to conduct a "patch test" to identify whether the skin problem is really an allergy and which chemical is the real cause. It may be necessary for the medical practitioner to visit the workplace to study the working environment so as to be certain that all possible causes have been identified. Unless the right diagnosis is made it is difficult to be certain of the true cause. Any subsequent treatment could then actually make the problem worse.
Since what we are concerned with is 'contact dermatitis' and since it follows that "No contact means no contact dermatitis" ideally what we should be concerned with is identifying those workplaces and tasks where such contact occurs and finding ways to eliminate or reduce this to a level where any risk of adverse effects in the skin is minimised.
Assessing the risk
This is what risk assessment for dermal exposure attempts to achieve. However, here again life is not simple. The way in which contact can occur is often not easy to identify. There is little guidance as to what constitutes an acceptable level of exposure. Exposure limits such as MEL and OES refer only to respiratory exposure and have no relevance for the skin.
Managing the risk
Of course, the ideal way of ensuring that a chemical does not cause damage to the hands is to ensure that there is no contact. However in real life this is an unachievable goal. Indeed some contact with some chemicals is essential and desirable. Hand washing in hospitals is an essential element in preventing cross infection. Most of us will also need to wash our hands regularly to remove soiling that could otherwise cause damage to our skin or contaminate the objects, such as food, that we will be handling. Yet all skin cleansers will defat the skin to some degree and, as we know, excessive exposure to water can lead to a breakdown in the skin, resulting in dermatitis. The frequent hand washing for hospital staff is a common cause of occupational contact dermatitis.(4)
So given that risk elimination is not possible probably the best we can do is risk minimisation. Since some contact with chemicals is unavoidable we should start by considering how we can limit the contact so as not to create an unacceptable risk.
In the case of hospital workers, changing the hand hygiene routine so that an alcohol rub is used more frequently, with a consequent reduction in hand washing frequency, can result in less skin damage. The results have been an improvement in infection control combined with a reduction in skin problems.(5)
Where possible we should structure the equipment and the way the work is done to eliminate or minimise any skin contact. Often this can be achieved by very simple changes that need not cost a great deal. In many cases such actions have even resulted in a reduction in operating costs.(6)
Selection and use of gloves
Of course, it is not always possible to engineer out the exposure. In such cases we may need to resort to the use of gloves. Selection and use of gloves for chemical protection has been described in a previous article(7). It is important to recognise that the data on gloved performance published by manufacturers is that determined according to the official European Standard (EN374-3). The actual performance achieved under actual working conditions may vary considerably, depending upon many factors, the most important of which is the nature of the task for which the gloves are being provided. At least one study has shown how glove performance achieved in practice can vary widely from the data provided by the manufacturers.(8)
Small pads can be placed on the hand inside the glove. In some cases the pad will change colour in the presence of the chemical, in other cases it will be necessary to use something such as an activated carbon pad to detect the chemical. In both cases, this can be used to detect when, under actual working conditions, the chemical can first be detected inside the glove. This will enable the employer to create a safe working practice where gloves are changed at appropriate intervals to ensure adequate worker protection.
Skin care is still sometimes promoted by suppliers of skin care products as the panacea, the simple answer to possible skin damage. This is simply not the case. There is little purpose served in providing better products in the washroom if conditions in the workplace are putting the workers' health at risk from skin exposure.
What skin care can do is play a role in helping to minimise any damage that might be occurring. It achieves this firstly by removing harmful chemicals from the skin with the least harm to the skin itself. Secondly, the skin can be assisted to recover its normal barrier properties by the frequent use of an appropriate skin conditioning product.
The concept that the skin can be adequately protected from chemical hazards in the workplace by the use of so-called 'barrier' or 'protective' creams is now no longer considered valid. Evidence of many studies and tests has shown that these creams have little or no protective effect, even under laboratory conditions. The U.K. Health and Safety Executive take the view that:
"Pre-work creams cannot be relied upon for primary protection of the skin as there is no information on the rate of penetration of chemicals through creams. Also, people habitually miss areas of their exposed skin when applying creams and so complete skin cover cannot be guaranteed. It is not always obvious if the barrier has been removed, damaged or thinned. Because of this pre-work creams should not be regarded as PPE. They cannot give the same level of protection as gloves and should not be used as an alternative to properly selected PPE."
Assessing and managing risks at work from skin exposure to chemical agents", U.K. Health and Safety Executive, 2001, ISBN 0-7176-1826-9
Skin condition monitoring
If we can identify damage to the skin before this results in dermatitis then we can, at least in theory, take pre-emptive action. Unfortunately, with allergic reactions this is simply not possible, since there is no indication of impending sensitisation. All we can do is ensure that we identify the allergic reaction at the earliest possible stage and take appropriate action to prevent it getting worse. In practice this will probably mean referral to a contact dermatitis clinic for patch testing so as to identify the causative substance and then action to eliminate any future contact between this substance and the person's skin.
With irritant damage there are now techniques that enable us to identify sub-clinical, i.e. invisible, damage so that action can be taken before the contact dermatitis appears.
Traditionally skin condition monitoring has consisted of someone with appropriate experience and training conducting a visual (and perhaps tactile) examination of the workers skin to identify any visible changes. At the same time the examiner can establish whether the worker has noticed any changes or irritation, etc. This technique still has an important role to play. However, in recent years it has been increasingly complemented by the employment of skin bio-engineering techniques.
Skin bio-engineering is a term coined by dermatologists to describe scientifically based techniques used to measure a variety of skin condition parameters. For occupational health purposes the two most important are skin hydration and trans-epidermal water loss. Skin hydration is considered to be an important indicator of overall skin condition. Trans-epidermal water loss is moisture that is lost through the skin under normal conditions (not to be confused with sweating). Dermatologists consider this an indicator of skin barrier function.
These two measurement techniques have been used in dermatological research for some years but were considered too sensitive and complex - and the equipment too expensive - to be a practical proposition for occupational health. However, simpler instruments have become available designed specifically for use in an occupational health clinic. These will provide quantitative data on real skin condition and will indicate where contact with irritants is causing deterioration in skin condition that, if left unchecked, could result in occupational contact dermatitis.
Elements of a skin management system
It should be obvious from all of this that what is needed is a comprehensive approach to the prevention of damage to health from workplace skin exposure. We can call this a "skin management system". The diagram below shows the different elements to make up such a system.
This starts with a skin management policy, a document that recognises the importance of this aspect of health and safety and sets out the aims and objectives of the organisation. It includes information on the roles that different members of the organisation will play and creates a framework within which those responsible for health and safety can work to develop and maintain a safe and healthy workplace, at least as far as skin exposure and its consequences are concerned.
Remember that we have our hands for twenty-four hours each day, seven days each week and fifty two weeks each year. It is the same skin at work and away from work. Chemicals hazardous to the skin exist away from the workplace as well as at work but are not always easily identified as such. A visit to your local DIY store or garden centre will reveal numerous chemicals that in the workplace would be the subject of a risk assessment. Whilst contact with these may not be on a day-to-day basis it may be fairly intense and sufficient at least to contribute to a breakdown of the skin. It can then be very difficult to distinguish between the occupational and non-occupational elements of a particular skin problem. Thus protecting our hands is, in effect, a full time activity.
Our hands are wonderful, complex objects, essential to providing us with a good quality of life and allowing us, as humans, to achieve the many technical and social advances that we have been able to make. We should not take them for granted, but consider how important they are to us and ensure that what we do does not cause them irreparable damage.
(1) Technische Regeln für Gefahrstoffe TRGS531 - Gefährdung der Haut durch Arbeit im feuchten Milieu, published by BauA, Germany
(2) Assessing and managing risks at work from skin exposure to chemical agents, HSG205, ISBN 0-7176-1828-9, HSE Books
(3) Technical Bulletin No. 11, Risk Assessment for Dermal Exposure, EnviroDerm Services, WR11 8QY
(4) Larson E, Friedman C, cohran J, Treston-Aurand J, Green S; Prevalence and correlates of skin damage on hands of nurses, Heart Lung, 1997, 26, 404-412
(5) Guideline for Hand Hygiene in Health-Care Settings, Centers for Disease Control and Prevention, published in Morbidity and Mortality Weekly Report, Oct. 2002, p 18
(6) Essentials of Occupational Skin Management, C.L.Packham, ISBN 1-85988-045-2
(7) Vaughan N; Helping Hands, Health & Safety International, April 2004
(8) Packham CL, Spoors R, Rowell FJ; Performance of chemical protective gloves under actual working conditions: a preliminary study, unpublished paper, 1996
Chris Packham's interest in the interaction between the skin and the working environment dates from 1979. Chris combines an engineering background with an intense interest in occupational dermatology.
Chris is a Fellow of the Royal Society for the Promotion of Health, a member of the European Society of Contact Dermatitis and the International Institute of Risk and Safety Management. He is a member of the British Occupational Hygiene Society's Special Interest Group on Personal Protective Equipment and the BOHS representative on the Health and Safety Executive's working group on "Controlling skin diseases by correct selection and use of PPE". Chris is also involved with the work of the American Industrial Hygiene Association's Dermal Exposure Assessment subcommittee.
Published: 10th Oct 2004 in Health and Safety International