Overzealous hand hygiene during the COVID 19 pandemic causing an increased incidence of hand eczema among general population.

To the Editor: Proper hand hygiene is one of the enhanced preventive measure to halt the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) COVID-19. However, an overzealous use of sanitizers and frequent hand washing may cause hand eczema (HE) owing to a disrupted skin barrier. We aim to report a rise in the incidence of new-onset HE among the general population due to overzealous hand hygiene.

We have been using telemedicine for consultations with new patients since the lockdown was initiated in our country, India. During the period from March 24, 2020, through April 5, 2020, we diagnosed 16 patients (9 male, 7 female) with new-onset HE who were not involved in any health care–associated occupations. The diagnoses were based on history and clinical photos/video. Ten patients were diagnosed with irritant contact dermatitis, 5 patients had allergic contact dermatitis, and 1 patient exhibited mixed patterns. Almost all patients admitted excess use of hand sanitizers and/or hygiene. Almost all sanitizers contained alcohol as a main ingredient. The most common symptoms reported were itching, burning sensation, and dryness, and the most common signs observed were erythema, scaling, and vesiculation (Table I ). We observed a peculiar pattern of HE: erythema and fine scaling initially started in the web spaces of fingers (ie, interdigital eczema) and on the palms, which is quite pathognomic for dermatitis induced by sanitizers. This may be due to trapping of the sanitizer in these spaces and because a dollop is taken in the palms first.

Table I

Patient demographic and clinical profiles and contents of sanitizers

No.	Age, years/sex	History of allergies	Type of dermatitis	Symptoms	Signs	Approximate frequency of application per day	Alcohol content of sanitizer	CHG or triclosanpercentage	Added emollients and moisturizer/other additives
1	61/F	None	ICD	Itching, dryness, skin tightness, and slight burning	Fine scaling all over the hands (more in palms), with erythematous foci in the interdigital space	5-6 times	70% v/v ethanol	2.5% v/v solutionequivalent to CHG 0.5% w/v	Present (not specified)
2	30/M	Alcohol flushing and urticaria	ACD	Itching and skin tightness	Erythema, taut skin, and papules	Immediate with 1 application	70% v/v ethanol	2.5% v/v solutionequivalent to CHG 0.5% w/v	None
3	14/F	None	ICD	Itching followed by burning and smarting	Interdigital fissuring and bleeding, crusting and papules, and lichenified patches over the dorsum of the hands and wrists	8-9 times	69.4% w/w denatured alcohol	None	PEG, PEG/PPG-17/6, tetrahydroxypropyl ethylene diamine
4	33/M	None	ACD	Itching with bumps	Exudation, erosions, and crusting with papular eruptions at the base of the fingers and wrists	20-24 times	68% isopropyl alcohol	None	Honey extract, palm extract, olive extract, coconut fruit extract, wheat amino acids, retinyl palmitate, tocopheryl acetate, glycerin, carbomer, cellulose, hydroxyethyl urea
5	56/M	Not known	ICD	Itching and burning	Vesiculations, excoriations, and bleeding	5-6 times	91% w/v (alcohol)	None	None
6	24/F	Asthma, penicillin sensitive	ACD	Itching and dryness	Fine scaling and erythema with unclear borders	2-3 times	62.25% (ethyl alcohol 95% v/v, IP 55% w/w; isopropyl alcohol IP 10% w/w)	None	Vitamin E
7	73/F	None	ICD	Burning, pain, and tightness	Crusting and pustules on a background of erythema, concentrated around web spaces—clearly demarcated areas of erythema	12-14 times	60% isopropyl alcohol	None	Hrivera (Coleus vettiveroides), coriander, lime, ushira (Vetiveria zizanioides)
8	42/M	None	ICD	Itching and oozing	Vesicles with exudation and erythema	Immediate with 3 applications	70% w/v (alcohol)	None	None
9	33/M	History of chronic urticaria treated by albendazole	ICD	Itching and redness all over the hands	Vesiculation, crusting	Immediate	70% v/vethanol	Triclosan 0.5% w/v	None
10	17/F	None	ICD	Itching and skin peeling	Erythema with mild scaling	17-19times	1- Propanol and 2- propanol: total alcohol concentration of 75% (disinfectant)	None	Mecetronium ethyl sulfate 2%
11	66/M	None	ICD	Itching, burning after application of sanitizer, skin tightness	Erythema, infiltration, and rhagades (interdigital eczema)	6-9 times	69.4% w/w denatured alcohol	None	PEG, PEG/PPG-17/6, tetrahydroxypropyl ethylenediamine
12	72/M	Asthma	ICD	Intense itching with increases on sun exposure and burning with reapplication	Palmar surface fine scaling, some evidence of photoexacerbation—dorsum of hand showing hyperkeratosis, hyperpigmentation, and papules (maybe due to plant extracts)	3-4 times	60% isopropyl alcohol	None	Hrivera (Coleus vettiveroides), coriander, lime, ushira (Vetiveria zizanioides), neem extracts
13	27/M	None	ICD	Itching followed by burning and stinging	Clearly delineated patches of erythema and flaking	Immediate with 2-3 applications	70% w/v isopropyl alcohol	0.5% w/v	Vitamin E
14	46/M	None	ICD + ACD	Itching and redness with face burning and smarting	Interdigital erythema, fissures, and bleeding; itching and flaking; redness around eyes and nasal ala	7-8 times	70% v/v ethanol	2.5% v/v solutionEq equivalent to CHG 0.5% w/v	Present (not specified)
15	38/F	GI upset with kiwi and egg	ACD	Itching and hand swelling	Contact urticaria	Immediate reaction	None	None	0.125% benzalkonium chloride
16	20/F	None	ICD	Itching, redness, and“skin wrinkling”	Scaling, clustered papulovesicles, hyperkeratosis, or fissuring on a background of hyperkeratosis	9-10 times	62.25% (ethyl alcohol 95% v/v, IP 55% w/w; isopropyl alcohol IP 10% w/w)	None	Vitamin E

ACD, Allergic contact dermatitis; CHG, chlorhexidine gluconate; F, female; GI, gastrointestinal; ICD, irritant contact dermatitis; IP, isoparaffin; M, male; PEG, polyethylene glycol; PPG, polypropylene glycol; v/v, volume/volume; w/w, weight/weight.

A recent study from China showed high prevalence of HE (74.5%) among health care workers managing COVID-19, and the risk factors included frequent hand hygiene. Frequent hand hygiene leads to gradual depletion of surface lipids, resulting in deeper action of detergents into the superficial skin layers. Irritant contact dermatitis is more commonly reported with iodophors, chlorhexidine, chloroxylenol, triclosan, and alcohol-based products, whereas allergic contact dermatitis has been reported with quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol, and alcohols. In our patients, we could not perform patch testing, and follow-up was not done.

The overzealous hand hygiene amidst the COVID-19 pandemic may lead to increased cases of HE, but what is feared is that the disrupted skin barrier may create a route of entry for COVID-19, as the cell receptor for SARS-CoV-2 entry (ie, angiotensin-converting enzyme 2) is present in large quantities in the blood vessels of the skin, basal layer of the epidermis, and hair follicles.

Rational hand washing for 20 seconds with sanitizers containing ethanol is warranted. Sanitizers should be allowed to dry first, and then hypoallergenic hand cream/emollients should be applied to prevent the trapping of sanitizers in web spaces. , Also, most people have a habit of washing hands before or just after sanitizer application, which should be avoided because damp hands increase the permeability of sanitizers/detergent, leading to an increased chances of HE.

Although hand hygiene is of the utmost importance in our fight against COVID-19, the general public should be made aware of proper and rational hand hygiene and warned against excess hand hygiene.