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S YS T E M AT I C R E V I E W

Effectiveness of interventions for preventing occupational


irritant hand dermatitis: a quantitative systematic review
Zoi Papadatou 2  Hector Williams 2  Kay Cooper 1,2
1
The Scottish Centre for Evidence-based Multi-professional Practice: a Joanna Briggs Institute Centre of Excellence, 2School of Health Sciences,
Robert Gordon University, Aberdeen, Scotland

ABSTRACT

Objective: The aim of this review was to identify, appraise and synthesize the best available evidence on the
effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions
(a combination of two or more of the interventions listed here) in preventing occupational irritant hand dermatitis
(OIHD) in wet workers, comparing each intervention to an alternative intervention or to usual care (workers’ regular
skin care regimen).
Introduction: The most significant occupational skin problem potentially encountered in wet work occupations is
occupational dermatitis. When the skin comes into contact with hazardous substances at work, this can cause
occupational dermatitis. Substances which may cause occupational dermatitis include cleaning products, organic
solvents, metalworking fluids, cement, flour, adhesives, other chemicals and even certain plants. Occupational skin
disease has adverse effects on quality of life and the long term prognosis for skin health is poor unless workplace
exposures are addressed. To date, no systematic review has been undertaken to determine the effectiveness of
interventions for the primary prevention of OIHD in wet workers.
Inclusion criteria: The review included any workers from healthcare (e.g. nurses, doctors and allied health
professionals) and also people in different wet work occupations (e.g. hairdressers, florists, catering workers, metal
workers) at similar risk of OIHD. Studies that assessed the following interventions in the primary prevention of OIHD
in wet workers at the workplace and at home (before and after work) were included:
 Use of moisturizers, for example, high and low lipid content moisturizers.
 Barrier creams, for example, barrier creams which may contain substances such as liquid paraffin lotion, lanolin
oil, silicone or hydrocarbon.
 Gloves (rubber and/or cotton).
 Education, for example, seminars and training courses (face-to-face or online).
Types of studies considered were experimental study designs including randomized controlled trials, non-random-
ized controlled trials, quasi-experimental, and before and after studies. Primary outcome measures were OIHD
incidence, and secondary outcome measures were product evaluation and change of occupation because of OIHD
versus staying in the occupation.
Methods: Published and unpublished literature in the English language was sought between 2004 and 2017. The
databases searched included: COCHRANE CENTRAL, MEDLINE, CINAHL, AMED and Embase. The search for unpub-
lished studies included: Google Scholar, Open DOAR and Robert Gordon University’s thesis database, ‘‘OPEN AIR’’.
Results: There were no studies located that met the inclusion requirements of this review.
Conclusion: There is currently no evidence available to determine the effectiveness of interventions to prevent
OIHD amongst wet workers that met this review’s inclusion criteria.
Keywords Contact dermatitis; hand dermatitis; occupational allergic contact dermatitis; occupational irritant;
occupational skin disease
JBI Database System Rev Implement Rep 2018; 16(6):1398–1417.

Correspondence: Zoi Papadatou, z.papadatou@rgu.ac.uk


There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2017-003405

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SYSTEMATIC REVIEW Z. Papadatou et al.

Introduction States, also keep registers of OSD. However, due


ccupational skin disease (OSD) accounts for to under-diagnosis and under-reporting of the dis-
O one fifth of all diseases reported to the United
Kingdom (UK) Occupational Disease and Intelli-
ease, it has been difficult to evaluate the actual
international incidence as well as the prognosis of
gence Network (ODIN) with occupational contact OSD.4
dermatitis (OCD) including both occupational irri- The evidence suggests that OSD is a significant
tant hand dermatitis (OIHD) and occupational problem amongst the working population, partic-
allergic contact dermatitis (OACD) representing ularly healthcare workers (HCWs).7 Intact skin on
the majority of those reported.1 Occupational irri- the hands and forearms is a requirement for HCWs
tant hand dermatitis appears to be more frequent undertaking certain roles as it reduces the risk of
than OACD due to the different mechanism of skin healthcare associated infection (HAI).8 In addition,
damage.2 Occupational irritant hand dermatitis is a number of healthcare associated tasks have the
caused by a skin irritant applied to the skin for a potential to result in OSD, some of which may be
sufficient time and in sufficient concentration, severe and resistant to treatment.9 Consideration of
whereas OACD is caused by sensitizers penetrating HCWs’ skin and skincare is therefore important
the skin layers and provoking a chain of immuno- both for patient and staff health and safety. The
logical events which soon after (usually within seven two most common causes of OSD are working
days) cause an allergy.2 The main causes of OIHD with wet hands, and contact with soaps and clean-
are the nature of the substance and the degree, ing materials.7 The Health and Occupation
duration and frequency of exposure, as well as Research Network (THOR) includes a scheme
factors such as under-hydration or over-hydration known as EPIDERM in which dermatologists
of the barrier layer of the skin which can determine record any new cases of OSD they come across in
the susceptibility of the individual.2 The main signs the UK.7 Data available from EPIDERM between
of OIHD are redness, swelling, blistering, flaking, 2002 and 2013 show significant variations in inci-
cracking and itching.2 Clinical investigation and dence rates of occupational dermatitis.7 High inci-
diagnosis of OSD include medical examination, dence is defined as >30 incidents per 100,000
patch testing, prick testing, blood testing and skin workers per year.7 The five occupations with the
biopsy.2 The focus of this review was prevention higher rates between 2004 and 2013 were: i) florists
of OIHD as it is more prevalent than OACD in (110 cases per 100,000 workers per year), ii) hair-
wet workers. dressers and barbers (88 cases per 100,000 workers
The UK’s Health and Safety Executive (HSE) has per year), iii) cooks (70 cases per 100,000 workers
the following definition for wet work: ‘‘prolonged or per year), iv) beauticians (64 cases per 100,000
frequent contact with water, particularly in workers per year), and v) metal working machine
combination with soaps and detergents, can cause operatives (61 cases per 100,000 workers per
dermatitis (e.g. a long time spent washing up or year).7 Other occupations with high incidence rates
frequent hand washing). ‘‘Wet work’’ is the term used (over 30 new cases per 100,000 workers per year)
to describe such tasks in the workplace. . .’’’3(para.1). include dental practitioners, nurses, dental nurses
Occupational skin disease constitutes a significant and podiatrists.7 It is crucial to mention that the
public health concern in industrial countries as it data cited above concern the reported incidents
is the most common occupational hazard,4 with of the UK which are restricted to more severe
occupational hand dermatitis being the most fre- cases and as such are subject to a degree of under-
quent work-related skin disease in many Western reporting.7 Similarly, in 2001 a Freedom of Infor-
countries.5 It is therefore a major occupational mation Request in the US Food and Drug
health concern in terms of clinical and economic Administration’s Adverse Event Reporting System
consequences. For example, it is estimated that four regarding adverse reactions to popular alcohol-
million working days are lost every year due to OSD based hand rubs identified only one reported case
in the UK.1 Work-related skin and respiratory dis- attributed to the product.8 Recognition of OSD
eases account for a significant part of the work- differs in each country and OSD reporting is
related ill-health (WRIH) of the UK.6 Several Euro- subject to diverse policies and practices throughout
pean and Asian countries, as well as the United the world. Despite these existing differences,

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SYSTEMATIC REVIEW Z. Papadatou et al.

underreporting of OSD appears to be a recognized address and incorporate biopsychosocial factors to


and common theme. support employees in returning to or staying healthy
in work.10 In occupations where there is high risk of
Impact OIHD, the prevention strategies are usually well
Occupational-related skin problems (including defined. When substances have skin-damaging
OIHD) can cause long term ill-health and have potential, the Control of Substances Hazardous to
adverse career implications for all wet workers.2,7,10 Health Regulations (COSHH) apply in the UK, and
For example, there are certain occupational skin the employer must make an assessment of the risks to
diseases caused by specific substances which can any employee liable to exposure to a substance
result in chronic skin disease, increased risk of devel- hazardous to health.2 Recognition and registration
oping allergic dermatitis, development of inflamma- of skin disease on a national level depends heavily on
tory conditions such as urticaria or even ulcerative the standards and criteria used to recognize occupa-
and degenerative skin diseases.2 Furthermore, this tional disease in each of the countries within the EU.
can impact adversely on the treatment of patients It is therefore difficult to compare systems or infor-
and also the cost to health services.1 Reliable and mation about the recognition of occupational dis-
continuous health surveillance for individuals at risk eases. On a global level, the International Labour
of developing skin reactions is essential in terms of: i) Organization (ILO) continues to provide guidance
creating a framework for early detection of skin via conventions and policies regarding coherent
problems, and ii) controlling for the exposure to national occupational safety and health policies to
substances which have the potential to cause harm.2 promote health and improve working conditions.
Early intervention and assessment is crucial to Conventions particular to workplace skin exposures
achieving successful, long term outcomes for HCWs include the application of procedures for recogni-
with or without pre-existing skin conditions. Brown1 tion, notification and prevention.11 Strategies to
identified the high prevalence of OCD in all indus- prevent OSD may include automation of processes
tries in the UK and acknowledges the health impact (depending on industry and occupation), replace-
as well as the economic consequences. He encour- ment of the need for employees to expose skin to
aged further evaluation of preventative measures in irritants and/or replacement of dangerous substances
order to reduce the prevalence of OCD. In 2008 skin (less toxic, less irritant, less allergic).2 Other strate-
diseases were listed as the second most common gies for prevention of OSD include changing the
occupational health problem in Europe as published employee’s behavior, for example, encouraging
in the European Risk Observatory report by the changes to the frequency of hand washing, appro-
European Agency for Safety and Health at Work. priate use of personal protective equipment such as
Occupational skin diseases were considered one of rubber gloves and/or cotton liners where indicated,
the most emerging risks related to the exposure to use of barrier creams, use of moisturizers and raising
chemical, physical and biological risk factors with awareness of the risks of OSD.2 Personal protective
high economic costs, calculated to be five billion equipment can vary in form, for example, it can be
euros per year in the European Union (EU).11 gloves, aprons, overalls, hats, masks, safety boots,
etc.10 Protective gloves contain substances that can
Intervention strategies act as sensitizers to the skin. The HSE has provided
Vocational rehabilitation is described as anything guidance on the selection of gloves.12 Barrier creams
that assists an employee with a health condition or are a topical preparation applied to the skin in order
disability to return to, stay in, or move into work.10 to provide a barrier.2 They often contain lanolin,
Extensive evidence supports that work is good for paraffin, silicones or polyethylene glycols.10 Barrier
health and that the benefits of work to health out- creams are used to protect employees against work-
weigh the risks of work as well as the effects of related skin disease; however, occasionally the sub-
worklessness and unemployment.10 Keeping stances contained in these creams can themselves
employees healthy at work is a balance between cause sensitization.2-10 Moisturizers, or emollients,
health promotion and focus on work.10 Prevention are used for regenerative skin care before, during
strategies, for example, compliance with health and (when indicated and when they do not compromise
safety regulations and rehabilitation interventions the employee’s task) and after work.2

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SYSTEMATIC REVIEW Z. Papadatou et al.

Systematic reviews pentaacetic acid (chelator) cream prevented nickel,


This section provides an overview of currently pub- chrome and copper dermatitis. Potent or moderately
lished systematic reviews on the incidence, preva- potent steroids effectively treated allergic contact
lence, prevention and effectiveness of interventions dermatitis (ACD). There were no macrolide immu-
(as described above) amongst wet workers. The nomodulator trials that met the inclusion criteria.15
terms ‘‘incidence’’ and ‘‘prevalence’’ are clearly A limited number of interventions effectively pre-
defined in the field of epidemiology as: i) prevalence: vented or treated OICD and OACD, but well-con-
quantifying instances of a given disease, or other trolled, outcome-blinded studies, particularly in the
conditions, in a given population at a designated area of ACD prevention, were recommended.15
time, and ii) incidence: quantifying new instances.13 Smedley et al.16 performed a systematic review of
One systematic review has been published on the 11 international RCTs on the management of occu-
prevention of OIHD amongst wet workers, and two pational dermatitis focussing on HCWs. Whilst a
other systematic reviews have addressed the man- number of conclusions were drawn, five in particular
agement of skin disease in the workplace. Bauer can be regarded as the most relevant to the proposed
et al.14 conducted a Cochrane review of randomized review. First, HCWs should seek early treatment for
controlled trials (RCTs) published between 2003 dermatitis. Second, in severe cases of acute dermati-
and 2011. Four international studies met the inclu- tis, work adjustments should be applied. Third,
sion criteria. The overall review produced positive HCWs with dermatitis should follow a particular
findings in respect of primary prevention of OIHD: skin program (for hand hygiene and hand care).
the beneficial effects of using barrier creams and Fourth, the need for further research on the risk of
emollients, and an absence of harmful effects. None HCWs to transfer infection to patients is evident.
of the RCTs identified any problems with the effi- Fifth, it remains unclear to what extent health sur-
cacy of glove use. Due to the lack of statistical veillance is effective in reducing dermatitis. Two key
significance that emerged from the review, Bauer limitations of the literature were identified by Smed-
et al.14 concluded that there was a need for larger ley et al.16 The first was non-statistical significance
studies to determine if primary prevention is effective of the findings (large studies failed to determine
and, if so, which is the best preventive measure. The whether primary prevention is helpful), and there-
main limitations of the review were the: i) limited fore a comprehensive review that includes evidence
number of RCTs; ii) methodological weaknesses of from other quantitative study designs may be useful
the studies identified, for example, short-term stud- in synthesizing a broad range of evidence. The sec-
ies and the application of interventions restricted to ond was a lack of intervention uniformity.
healthy people; and iii) complete absence of studies Despite a lack of robust evidence regarding the
which support or refute the use of gloves as primary prevention of OIHD provided by previous system-
prevention. The fundamental forms of prevention atic reviews, useful guidance can be drawn by con-
that emerged from the review were the change of ducting a further systematic review as initial
workers’ behavior by use of creams, reduction of literature searching has identified studies17,18 con-
hand washing as well as refraining from wet work. ducted since the publication date of these previous
Saary et al.15 conducted a systematic review of reviews that may be suitable for inclusion in a new
international studies published between 1960 and synthesis. Due to the emergence of recent literature
2003 to provide the Workplace Safety and Insurance and the specific nature of the previous systematic
Board (WSIB) of Ontario, Canada, with evidence- reviews conducted on this topic,14-16 there is a need
based recommendations regarding treatment deci- to: i) identify and appraise a broader range of liter-
sions for OCD.15 Forty-nine studies conducted in a ature, including recent intervention studies, focused
range of countries met the inclusion criteria. Barrier on the prevention of OIHD amongst wet workers;
creams containing dimethicone or perfluoropo- and ii) focus on the strategy and effectiveness of
lyethers, cotton liners and softened fabrics prevented measures to prevent OIHD amongst HCWs. The aim
irritant contact dermatitis (ICD). Lipid-rich moistur- of this systematic review was therefore to identify
izers both prevented and treated irritant CD. Topical findings from RCTs and other quantitative study
skin protectant and quaternium 18 bentonite (orga- designs that could contribute to the evidence of the
noclay) prevented dermatitis. Diethylenetriamine effectiveness of interventions aimed at preventing

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SYSTEMATIC REVIEW Z. Papadatou et al.

OIHD. The objectives, inclusion criteria and meth- liquid paraffin lotion, lanolin oil, silicone or
ods of analysis for this review were specified in hydrocarbon.
advance in a previously published protocol.19  Wearing gloves (rubber and/or cotton).
 Education (e.g. seminars and training courses;
Objective face-to-face or online delivery).
Due the variability in regimens, any dosage/inten-
The objective of this quantitative systematic review
sity of preventive intervention for any length of time
was to identify, appraise and synthesize the best
was considered for inclusion in this review, including
available evidence on the effectiveness of moistur-
complex interventions that combined more than one
izers, barrier creams, protective gloves, skin protec-
of the above interventions.
tion education and complex interventions (a
combination of two or more of the interventions
Comparator
listed here) in preventing OIHD in wet workers,
This review considered studies that compared one
comparing each intervention to an alternative inter-
type of intervention to another. Studies that com-
vention or to usual care (workers’ regular skin care
pared an intervention to a control group who did not
regime). The specific review question was: what is
receive any intervention were also considered.
the effectiveness of moisturizers, barrier creams,
protective gloves, skin protection education and
Types of studies
complex interventions in preventing OIHD in wet
This review considered for inclusion any experimen-
workers?
tal study design including randomized controlled
trials, non-randomized controlled trials, quasi-
Inclusion criteria experimental, and before and after studies.
Participants
In keeping with previous systematic reviews in this Outcomes
area,14-16 participants included any workers from Primary outcome measures included:
healthcare (e.g. nurses, doctors and allied health OIHD incidence, defined as the proportion of wet
professionals) and also those from different wet workers who have developed any signs or symptoms
work occupations (e.g. hairdressers, florists, catering of OIHD incidence diagnosed by an investigator, a
workers, metal workers) at similar risk of OIHD11 health professional, or the participants themselves.
due to, for example, frequent hand washing, skin OIHD severity, defined as:
contact with substances contained in soaps and/or  Clinical evaluation (severity/improvement) of the
hand gels and/or prolonged use of gloves. We signs or symptoms either by the investigator or
intended to include primary prevention studies the participant. Any widely accepted clinical
where participants had no pre-existing skin condi- assessment or self-report measure was considered
tions. We also intended to include mixed population for inclusion, such as questionnaires and clinical
(pre-existing and no pre-existing skin conditions) examinations of hands,20-23 telephone interviews
studies where the data for participants without and questionnaires based on the Nordic Occupa-
pre-existing skin conditions could be extracted tional Skin Questionnaire (NOSQ-2002),24 and
separately. self-administered questionnaires.25
 Adverse outcomes (e.g. infections, severe irrita-
Intervention tion or allergy to products applied in the studies)
This quantitative systematic review considered stud- assessed by the participants and/or clinicians and/
ies that measured the effectiveness of the following or outcome assessors reported in the studies.
interventions in the primary prevention of OIHD in Secondary outcome measures included:
wet workers at the workplace and at home (before  Product evaluation (proportion of participants
and after work): satisfied with the products given in the study
 Use of moisturizers, for example, high and low including cosmetic, preventive and therapeutic
lipid content moisturizers. properties of the products). Any information
 Use of barrier creams, for example, barrier which was recorded in the studies that rated the
creams which may contain substances such as quality of the products was considered as a means

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SYSTEMATIC REVIEW Z. Papadatou et al.

of measurement either from the participants, or Assessment of methodological quality, and data
the clinicians or other outcome assessors. Product extraction and synthesis
evaluation recorded in studies would provide an As no studies were located that met the eligibility
insight into any changes to participants’ symptoms criteria for this review, assessment of methodologi-
and is therefore considered a means of measuring cal quality, data extraction and synthesis were not
product effectiveness.14 performed.
 Change of occupation because of OIHD versus
staying in the occupation that may have been Results
recorded in the studies, where the reason for Study inclusion
changing occupation has been clearly stated Following the comprehensive electronic database
as OIHD. search, a total of 5418 relevant titles were obtained
by the authors; 1854 duplicates were removed. Fol-
Methods lowing title and abstract screening of the remaining
Search strategy articles (n ¼ 3564), 3508 were excluded at that stage.
Published and unpublished literature in the English Fifty-six full-text papers were retrieved for further
language was sought between 2004 and 2017. This review. Of these 56 articles, the reviewers excluded
search covered the period employed by Bauer et al.14 all 56 after full text review as they did not meet the
up to the present day as well as the period since the inclusion criteria. For example, some studies26-28
HSE guidance note on skin disease was last were excluded due to the population not being
amended. The medical guidance note titled, ‘Medi- wet workers. The majority of the remainder did
cal aspects of occupational skin disease’,2 released not meet the inclusion criteria of being prevention
from the UK HSE in 1998 which has been re-printed studies due to recruiting mixed populations of par-
with amendments most recently in 2004, is the most ticipants with and without pre-existing skin condi-
pertinent guideline on skin disease in the UK. The tions; on close inspection it was apparent that data
HSE, although being a UK enforcing agency, is from participants without pre-existing skin condi-
internationally recognized and collaborates closely tions could not be extracted separately. A common
with various European and international bodies theme that was observed during closer inspection of
regarding occupational health and safety. A three- the excluded studies was the variety of methods used
step search strategy was utilized in eight databases. for reporting and scoring the existence and severity
An initial limited search of MEDLINE and CINAHL of pre-existing skin conditions. The excluded studies
was undertaken using the initial keywords: ‘‘derma- with the reasons for exclusion are documented in
titis’’ ‘‘occupational health’’ and ‘‘occupational skin Appendix II. Figure 1 outlines the different stages of
disease’’. This was followed by analysis of the text identification and retrieval of relevant studies for
words contained in the title and abstract, and of the inclusion in this systematic review, in keeping with
index terms used to describe the articles. A second published guidleines.29
search using all identified keywords and index terms
was then undertaken across all included databases:
COCHRANE CENTRAL, MEDLINE, CINAHL, Discussion
AMED, Embase. The search for unpublished studies Despite finding a number of studies30-40 with pub-
included: Google Scholar, Open DOAR, and Robert lished evidence of interventions focused on the effec-
Gordon University’s thesis database, ‘‘OPEN AIR’’. tiveness of interventions for the prevention of
See Appendix I for the detailed search strategy used occupational skin disease, we were unable to extract
in all databases. Thirdly, the reference list of all and analyze separately the data from participants
identified reports and articles was searched for without pre-existing skin conditions in order to
additional studies. address the review objective of exploring the effec-
The search resulted in literature on occupations tiveness of interventions aimed at preventing (rather
not relevant to this review. Initial screening identi- than reducing) incidence of OIHD. Pre-existing
fied which occupations were included in these stud- skin conditions provide a risk factor for develop-
ies and only included for further screening those who ing further skin irritation and potentially skin
were considered wet workers. disease.41 Although skin improvements/changes

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SYSTEMATIC REVIEW Z. Papadatou et al.

Records idenfied through Addional records idenfied


database searching through other sources
(n = 4853) (n = 565)

Records aer duplicates removed


(n = 5418 - 1854 = 3564)

Records screened Records excluded


(n = 3564) (n = 3508)

Full-text arcles assessed Full-text arcles excluded,


for eligibility with reasons
(n = 56) (n = 56)

Studies included in
qualitave synthesis
(n = 0)

Studies included in
quantave synthesis
(meta-analysis)
(n = 0)

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews
and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097.
Figure 1: PRISMA flow diagram of study selection and inclusion process

were identified in the majority of the intervention educational intervention employed questionnaires,
groups in the excluded studies, it was not possible to clinical examination of the hands, measurement of
ascertain whether they were attributed to the effec- transdermal water loss (TEWL) and patch testing for
tiveness of the intervention at primary prevention or evaluation. Despite the fact that the study showed
its effectiveness in reducing pre-existing symptoms. promising results from the use of an educational
The evaluation of the severity of skin disease program, the decrease in skin symptoms occurring
amongst participants at baseline varied between after the intervention was not statistically signifi-
the excluded studies.30-40 For example, participants cant. In before-after studies, although tested tools
in a study conducted by Held et al.42 which tested an such as the hand eczema severity index (HECSI)43

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SYSTEMATIC REVIEW Z. Papadatou et al.

were used to evaluate the skin of the participants, it with a history of atopic disease and allergies and
was frequently based on self-reported responses30-40 nurses working in intensive care units who are at
(answered on questionnaires at baseline and follow- increased risk of hand dermatitis due to the nature of
up) and not always confirmed by visual skin checks their work (wet work). The second study protocol,46
from truly blinded experts. It is evident that these also a cluster RCT taking place in Netherlands,
studies30-40 had not purely focused on primary pre- focuses on nurses performing wet work. The study
vention; rather they had included participants with aims to assess the effectiveness of the intervention
and without pre-existing skin conditions. It is there- which consists of the facilitation of creams being
fore not possible to conclude from their findings made available at the wards combined with the
whether the interventions prevented OIHD from continuous electronic monitoring of their consump-
developing or only prevented it from worsening in tion with regular feedback on skin care performance.
pre-existing cases. Separate subgroup analyses based This study will also recruit mixed population
on the presence or absence of pre-existing skin con- participants.
ditions would have allowed data from these studies Although the current is an ‘‘empty review’’ where
to be included in the review and we strongly recom- no studies were located meeting a priori inclusion
mend that researchers include subgroup analyses in criteria, the authors strongly believe that benefits can
future studies. be drawn from the gaps in the current evidence base.
However, it is important to note that studies
which investigated the effectiveness of interventions Limitations of the review
aimed at preventing skin disease in nursing, baking The lack of evidence may have been a result of the
and hairdressing apprentices30,41,44 discussed and search itself. The search was restricted to English
analyzed the prevalence of skin symptoms before language papers only. No primary prevention stud-
and during training and concluded that existing skin ies published to date have provided evidence of
symptoms was a risk factor for developing further effectiveness of any types of interventions where
irritations. Suggestions for either excluding or ana- data from mixed populations (participants with
lyzing separately participants with pre-existing skin pre-existing and without pre-existing skin condi-
symptoms are essential to evaluating the true effec- tions) were analyzed separately. Although the search
tiveness of interventions aimed at primary preven- terms used were developed in consultation with an
tion of OIHD. Homogeneity in clinically assessing occupational health physician specialized in skin
and evaluating skin severity may lead to improved disease at the workplace as well as a librarian, it
outcomes that may be transferred across wet work is well known that the literature in this area is not
professions. standardized and difficult to locate. There is there-
Intervention studies involving different wet work fore a chance that literature was not captured in part
occupations showed promising results despite the fact due to these reasons. Our initial literature searching
that they included mixed populations of participants. during protocol development suggested that there
It is evident that more research is needed to further would be literature to include in the review; how-
investigate compliance after such educational inter- ever, in order to address the specific review question
ventions in different work settings.21 This may have of interest (primary prevention of OIHD) we
an impact on preventing OIHD as well as controlling employed rigorous inclusion/exclusion which all
skin symptoms for those wet workers who have pre- studies, on close inspection, failed to meet. Our
existing skin symptoms in the long term. scoping search did find three previous systematic
The protocols of two large RCTs45,46 were iden- reviews, suggesting that there is literature on this
tified that are presumably currently in progress. The topic. However, one of these reviews was published
first study protocol,45 a cluster RCT in UK, aims to before our lower date range,15 one focused on the
test whether a web-based behavioral change pro- management of OIHD16 which by definition
gram coupled with provision of hand moisturisers includes participants with pre-existing skin condi-
can reduce the prevalence of hand dermatitis after tions, and the one which did focus on prevention14
one year when compared to standard care in nurses included studies of mixed populations, thereby not
at high risk of OIHD. The study plans to recruit fulfilling the definition of primary prevention. It is
mixed populations of participants: student nurses therefore clear that there is an abundance of evidence

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SYSTEMATIC REVIEW Z. Papadatou et al.

in relation to preventing OIHD from worsening should either investigate participants without pre-
or from recurring, but there is currently a lack of existing skin conditions or, if including a mixed
evidence relating to the primary prevention of population, present a separate analysis for partici-
OIHD, and high quality primary research studies pants without pre-existing conditions. There is also a
are urgently required. need for researchers to reach a consensus on methods
It is possible that amending the inclusion criteria of assessing severity of skin conditions to enable
might have located studies for inclusion, for exam- synthesis of findings from future studies.
ple, including non-wet workers, mixed populations
or non-experimental study designs. However, we Acknowledgements
had identified a need to explore the evidence on
The reviewers would like to acknowledge Robert
the effectiveness of primary prevention in OIHD Gordon University for providing the opportunity for
in wet workers from high quality studies at low risk
Zoi Papadatou to undertake the JBI Comprehensive
of bias. Adhering to the a priori protocol has enabled
Systematic Review Training Program.
us to highlight the lack of evidence and urgent need
for this to be addressed by the scientific community
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study with a 3-year training period. Contact Derm 2006; McCrone P, et al. A behavioural change package to prevent
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vention study. Contact Derm 2001;44(5):297–303. 46. Soltanipoor M, Kezic S, Sluiter JK, Rustemeyer T. The effec-
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Appendix I: Search strategy


MEDLINE (EBSCOhost), 2004 to 2017, date of last search 04.01.2018 (all fields)
1 ‘‘Hand’’ [MeSH] OR ‘‘hand’’
2 ‘‘Skin’’ [MeSH] OR ‘‘skin’’
3 ‘‘Epidermis’’ [MeSH] OR ‘‘epiderm’’
4 ‘‘Dermis’’ [MeSH] OR ‘‘derm’’
5 2 OR 3 OR 4
6 ‘‘Disease’’ [MeSH] OR ‘‘disease’’
7 ‘‘Disorder’’
8 ‘‘Condition’’
9 6 OR 7 Or 8
10 ‘‘Work’’ [MeSH] OR ‘‘work’’
11 ‘‘Occupations’’ [MeSH] OR ‘‘occupation’’
12 ‘‘Job’’
13 10 OR 11 OR 12
14 1 AND 5 AND 9 AND 13

Embase (Ovid) 2004 to 2017, date of last search 04.01.2018 (all fields)
1 Hand/ OR hand.mp
2 Skin/ OR skin.mp
3 Epidermis/ OR epiderm.mp
4 Dermis/ OR derm.mp
5 2 OR 3 OR 4
6 Disease/ OR disease.mp
7 Disorder .mp
8 Condition .mp
9 6 OR 7 OR 8
10 Work/ OR work.mp
11 Occupation/ OR occupation.mp
12 Job .mp
13 10 OR 11 OR 12
14 1 AND 5 AND 9 AND 13

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AMED 2004 to 2017, date of last search 06/01/2018 (all fields)

1 ((MH) ‘‘Hand’’ OR ‘‘hand’’)


2 ((MH) ‘‘Skin’’ OR ‘‘skin’’)
3 ((MH) ‘‘Epidermis’’ OR ‘‘epiderm’’)
4 ((MH) ‘‘Dermis’’ OR ‘‘derm’’)
5 2 OR 3 OR 4
6 ((MH) ‘‘Disease’’ OR ‘‘disease’’)
7 ‘‘Disorder’’
8 ‘‘Condition’’
9 6 OR 7 OR 8
10 ((MH) ‘‘Work’’ OR ‘‘work’’)
11 ((MH) ‘‘Occupations’’ OR ‘‘occupation’’)
12 ‘‘Job’’
13 10 OR 11 OR 12
14 1 AND 5 AND 9 AND 13

CINAHL 2004 to 2017, date of last search 06/01/2018 (all fields)

1 ((MH) ‘‘Hand’’) OR ‘‘hand’’


2 ((MH) ‘‘Skin’’) OR ‘‘skin’’
3 ((MH) ‘‘Epidermis’’) OR ‘‘epiderm’’
4 ((MH ‘‘Dermis’’) OR ‘‘derm’’
5 2 OR 3 OR 4
6 ((MH ‘‘Disease’’ OR ‘‘disease’’
7 ‘‘Disorder’’
8 ‘‘Condition’’
9 6 OR 7 OR 8
10 ((MH ‘‘Work’’) OR ‘‘work’’
11 ((MH ‘‘Occupations’’) OR ‘‘occupation’’
12 ‘‘Job’’
13 10 OR 11 OR 12
14 1 AND 5 AND 9 AND 13

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Cochrane Central 2004 to 2017, date of last search 06/01/2018 (all fields)

1 ((MeSH) [Hand]) AND ((MeSH) [skin]) OR ‘‘dermis’’


2 ((MeSH) [Disease] OR ‘‘condition’’
3 ((MeSH) [Work] OR ((MeSH) [occupation]

GOOGLE Scholar 2004 to 2017, date of last search 11/01/2018


Search terms: (occupational skin disease AND wet workers AND intervention)
https://scholar.google.co.uk/scholar?q=occupational+skin+disease+AND+wet+workers+AND+interven-
tion&hl=en&as_sdt=1%2C5&as_ylo=2016&as_yhi=2017
Search terms: (dermatitis AND wet workers AND intervention)
https://scholar.google.co.uk/scholar?q=dermatitis+AND+wet+workers+AND+intervention&hl=e-
n&as_sdt=1%2C5&as_ylo=2016&as_yhi=2017

Gray literature search strategy 2004 to 2017, date of last search 11/01/2018
Robert Gordon University’s thesis database OpenAIR
Search terms: (occupational skin disease AND wet workers AND intervention)
Search terms: (dermatitis AND wet workers AND intervention)
All excluded

OpenDOAR 2004 to 2017, date of last search 11/01/2018


Search terms: (occupational skin disease AND wet workers AND intervention)
Search terms: (dermatitis AND wet workers AND intervention)

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Appendix II: Excluded studies and reasons for their exclusion

Aalto-Korte K, Ackermann L, Henriks-Eckerman ML, Välimaa J, Reinikka-Railo H, Leppänen E, et al. 1,2-


Benzisothiazolin-3-One in Disposable Polyvinyl Chloride Gloves for Medical use. Contact Dermatitis
2007;57(6):365-370.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Abramovits W, Granowski P. Innovative management of severe hand dermatitis. Dermatol Clin
2010;28(3):453-465.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Agthe N, Terho K, Kurvinen T, Routamaa M, Peltonen R, Laitinen K, et al. Microbiological efficacy and
tolerability of a new, non-alcohol-based hand disinfectant. Infect Control Hosp Epidemiol 2009;30(7):685-
690.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Ahmed-Lecheheb D, Cunat L, Hartemann P, Hautemanière A. Prospective observational study to assess
hand skin condition after application of alcohol-based hand rub solutions. Am J Infect Control
2012;40(2):160-164.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Al-Niaimi F, Chiang YZ, Chiang YN, Williams J. Latex allergy: assessment of knowledge, appropriate
use of gloves and prevention practice among hospital healthcare workers. Clin Exp Dermatol 2013;38(1):
77-80.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Antelmi A, Young E, Svedman C, Zimerson E, Engfeldt M, Foti C, et al. Are gloves sufficiently protective
when hairdressers are exposed to permanent hair dyes? An in vivo study. Contact Dermatitis
2015;72(4):229-236.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions,
intervention and comparison did not match the inclusion criteria.
Apfelbacher CJ. No difference in skin condition between workers exposed and not exposed to glove
occlusion in a semiconductor company. Br J Dermatol 2015;172(4):855-856.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Apfelbacher CJ, Soder S, Diepgen TL, Weisshaar E. The impact of measures for secondary individual
prevention of work-related skin diseases in health care workers: 1-year follow-up study. Contact Dermatitis
2009;60(3):144-149.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Arbogast JW, Fendler EJ, Hammond BS, Cartner TJ, Dolan MD, Ali Y, et al. Effectiveness of a hand care
regimen with moisturizer in manufacturing facilities where workers are prone to occupational irritant
dermatitis. Dermatitis 2004;15(1):10-17.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.

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Baumeister T, Weistenhöfer W, Drexler H, Kütting B. Prevention of work-related skin diseases: Tele-


dermatology as an alternative approach in occupational screenings. Contact Dermatitis 2009;61(4):224-
230.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Bearman G, Rosato AE, Duane TM, Elam K, Sanogo K, Haner C, et al. Trial of universal gloving with
emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant
organisms in a surgical intensive care unit. Infect Control Hosp Epidemiol 2010;31(5):491-497.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
criteria, intervention and comparison did not match the inclusion criteria.
Bregnhøj A, Menné T, Johansen JD, Søsted H. Prevention of hand eczema among Danish hairdressing
apprentices: An intervention study. Occup Environ Med 2012;69(5):310-316.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Brown T, Rushton L, Williams HC, English JSC. Intervention development in occupational research: An
example from the printing industry. Occup Environ Med 2006;63(4):261-266.
Reason for exclusion: type of population (not wet workers) did not match the inclusion criteria.
Chau JPC, Thompson DR, Twinn S, Lee DT, Pang SW. An evaluation of hospital hand hygiene practice and
glove use in Hong Kong. Journal of Clinical Nursing 2011;20(9-10):1319-1328.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Clemmensen KKB, Randbøll I, Ryborg MF, Ebbehøj NE, Agner T. Evidence-based training as primary
prevention of hand eczema in a population of hospital cleaning workers. Contact Dermatitis 2015;72(1):47-
54.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Davis DD, Harper RA. Using gloves coated with a dermal therapy formula to improve skin condition.
AORN J 2005;81(1):157-166.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Dehdasthi A, Khavanin A. Prevention of skin exposure to metal working fluid in a tool manufacturing plant:
An intervention approach. Dermatitis 2011;22(5):307.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Dulon M, Pohrt U, Skudlik C, Nienhaus A. Prevention of occupational skin disease: a workplace intervention
study in geriatric nurses. Br J Dermatol 2009;161(2):337-344.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Flyvholm M, Mygind K, Sell L, Jensen A, Jepsen KF. A randomised controlled intervention study on
prevention of work related skin problems among gut cleaners in swine slaughterhouses. Occup Environ Med
2005;62(9):642-649.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Girard R, Bousquet E, Carré E, Bert C, Coyault C, Coudrais S, et al. Tolerance and acceptability of 14
surgical and hygienic alcohol-based hand rubs. J Hosp Infect 2006;63(3):281-288.

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SYSTEMATIC REVIEW Z. Papadatou et al.

Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Held E, Wolff C, Gyntelberg F, Agner T. Prevention of work-related skin problems in student auxiliary
nurses. An intervention study. Contact Dermatitis 2001;44:297-303.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Held E, Mygind K, Wolff C, Gyntelberg F, Agner T. Prevention of work related skin problems an
intervention study in wet work employees. Occup Environ Med 2002;59(8):556-561.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Hovmand Lysdal S, Johansen JD, Flyvholm MA, Søsted H. Occupational skin exposure and use of protective
gloves among hairdressers. Contact Dermatitis 2012;66(s2):48.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Ibler KS. Prevention of Occupational Hand Eczema among Danish Healthcare Workers. Ph.D. Thesis 2012
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Jungbauer FHW, Van Der Harst JJ, Groothoff JW, Coenraads PJ. Skin protection in nursing work:
promoting the use of gloves and hand alcohol. Contact Dermatitis 2004;51(3):135-140.
Reason for exclusion: objective of study did not match the review objective.
Korniewicz DM, El Marsi M. Effect of aloe-vera impregnated gloves on hand hygiene attitudes of health care
workers. Medsurg Nursing: Official Journal Of The Academy Of Medical-Surgical Nurses 2007;16(4):247-
252.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Kutting B, Baumeister T, Weistenhöfer W, Pfahlberg A, Uter W, Drexler H. Effectiveness of skin protection
measures in prevention of occupational hand eczema: results of a prospective randomized controlled trial
over a follow-up period of 1 year. Br J Dermatol 2010;162(2):362-370.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Kwok T, Arrandale V, Skotnickigrant S. Repeated mechanical trauma to the hands: The use of anti-
impaction gloves for treatment and return to work. Dermatitis 2009;20(5):278-283.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Loffler H, Bruckner T, Diepgen T, Effendy I. Primary prevention in health care employees: a prospective
intervention study with a 3-year training period. Contact Dermatitis 2006;54(4):202-209.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Lowney A, Bourke JF. A study of occupational contact dermatitis in the pharmaceutical industry. Br J
Dermatol 2011;174(3):654-656.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Lysdal SH, Johansen JD, Flyvholm MA, Søsted H. A quantification of occupational skin exposures and the
use of protective gloves among hairdressers in Denmark. Contact Dermatitis 2012;66(6):323-334.

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SYSTEMATIC REVIEW Z. Papadatou et al.

Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Modak S, Gaonkar TA, Shintre M, Sampath L, Caraos L, Geraldo I. A topical cream containing a zinc gel
(allergy guard) as a prophylactic against latex glove-related contact dermatitis. Dermatitis 2005;16(1):22-
27.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Mygind K, Sell L, Flyvholm MA, Jepsen KF. High-fat petrolatum-based moisturizers and prevention of
work-related skin problems in wet-work occupations. Contact Dermatitis 2006;54(1):35-41.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions,
intervention and comparison did not match the inclusion criteria.
Oreskov KW, Sosted H, Johansen JD. Glove use among hairdressers: difficulties in the correct use of gloves
among hairdressers and the effect of education. Contact Dermatitis 2015;72(6):362-366.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Palomaki E, Uitti J, Virtema P, Voutilainen R, Heinijoki L, Savolainen A. Decreasing irritation symptoms by
replacing partially coated acoustic glass wool boards with fully coated boards. Scand J Work Environ Health
2008;s4:64-68.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Pedersen LK, Held E, Johansen JD, Agner T. Less skin irritation from alcohol-based disinfectant than from
detergent used for hand disinfection. Br J Dermatol 2005;153(6):1142-1146.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Pittet D, Allegranzi B, Sax H, Chraiti MN, Griffiths W, Richet H. Double-blind, randomized, crossover trial
of 3 hand rub formulations: Fast-track evaluation of tolerability and acceptability. Infect Control Hosp
Epidemiol 2007;28(12):1344-1351.
Reason for exclusion: objective of study did not match the review objective.
Schliemann S, Kleesz P, Elsner P. Protective creams fail to prevent solvent-induced cumulative skin irritation -
results of a randomized double-blind study. Contact Dermatitis 2013;69(6):363-371.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Sell L, Flyvholm MA, Lindhard G, Mygind K. Implementation of an occupational skin disease prevention
programme in Danish cheese dairies. Contact Dermatitis 2005;53(3):155-161.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions)
did not match the inclusion criteria.
Sharma V, Mahajan VK, Mehta KS, Chauhan PS. Occupational contact dermatitis among construction
workers: results of a pilot study. Indian J Dermatol Venereol Leprol 2014;80(2):159-161.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Skudlik C, Weisshaar E, Scheidt R, Elsner P, Wulfhorst B, Schönfeld M, et al. First results from the
multicentre study Rehabilitation of Occupational Skin Diseases - Optimization and Quality Assurance of
Inpatient Management (ROQ). Contact Dermatitis 2012;66(3):140-147.
Reason for exclusion: type of population (not wet workers),; intervention and comparison did not match the
inclusion criteria.

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SYSTEMATIC REVIEW Z. Papadatou et al.

Skudlik C, Weisshaar E, Scheidt R, Wulfhorst B, Diepgen TL, Elsner P, et al. Multicenter study ‘‘Medical-
Occupational Rehabilitation Procedure Skin - Optimizing and quality assurance of inpatient-management
(ROQ)’’. Journal of the German Society of Dermatology 2009;7(2):122-127.
Reason for exclusion: objective of study did not match the review objective.
Sosted H. Prevention of hand eczema among hairdressers. Contact Dermatitis 2012;66:25.
Reason for exclusion: objective of study did not match the review objective.
Spring P. Successful management of hand eczema with the systemic retinoid alitretinoin. Contact Dermatitis
2012;66:75.
Reason for exclusion: type of population (not wet workers), intervention and comparison did not match the
inclusion criteria.
Steengaard SS, Bregnhøj A, Johansen JD. Hand eczema among hairdressing apprentices in Denmark
following a nationwide prospective intervention programme: 6-year follow-up. Contact Dermatitis
2016;75(1):32–40.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Thomas K, English J. Avoiding hand eczema in healthcare workers. BMJ 2012;345:e8370-e8370.
Reason for exclusion: objective of study did not match the review objective.
Turner S, McNamee R, Agius R, Wilkinson SM, Carder M, Stocks SJ. Evaluating interventions aimed at
reducing occupational exposure to latex and rubber glove allergens. Occup Environ Med 2012;69(12):925-
931.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Twedell D, Daniels SM. Maintaining healthy hands. Journal of continuing education in nursing
2010;41(1):14-15.
Reason for exclusion: objective of study did not match the review objective.
Van Der Meer EWC, Boot CRL, Twisk JWR, Coenraads PJ, Jungbauer FHW, Van Der Gulden JWJ, et al.
Hands4U: The effectiveness of a multifaceted implementation strategy on behaviour related to the preven-
tion of hand eczema-a randomised controlled trial among healthcare workers. Occup Environ Med
2014;71(7):492-499.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Van Der Meer EWC, Boot CRL, Van Der Gulden JW, Knol DL, Jungbauer FHW, Coenraads PJ, et al.
Hands4U: the effects of a multifaceted implementation strategy on hand eczema prevalence in a healthcare
setting. Results of a randomized controlled trial. Contact Dermatitis 2015;72(5):312-324.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Vena GA, Cassano N, Vestita M, Alessandrini G, Calvi C, Carrino N, et al. Clinical evaluation of the efficacy
of a barrier cream containing polyvinylpyrrolidone in chronic hand eczema. Eur J Inflamm 2008;6(3):129-
134.
Reason for exclusion: type of population (participants not wet workers), intervention and comparison did
not match the inclusion criteria.
Vigan M. Hand dermatitis and therapeutic education in a dermato-allergology unit: The ‘‘School for hands’’.
Nouvelles Dermatologiques 2009;28(10 PART 1):445-449.
Reason for exclusion: objective of study did not match the review objective.

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©2018 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.


SYSTEMATIC REVIEW Z. Papadatou et al.

Visscher M, Canning J, Said D, Randy Wickett R, Pattie Bondurant, P. Effect of hand hygiene regimens on
skin condition in health care workers. Am J Infect Control 2006;34(10):111-123.
Reason for exclusion: type of population (mixed population, with and without pre-existing skin conditions),
intervention and comparison did not match the inclusion criteria.
Visscher M, Davis J, Wickett R. Effect of topical treatments on irritant hand dermatitis in health care
workers. Am J Infect Control 2009;37(10):842.e1-842.e11.
Reason for exclusion: objective of study did not match the review objective.
Williams C, Wilkinson SM, McShane P, Lewis J, Pennington D, Pierce S, et al. A double-blind, randomized
study to assess the effectiveness of different moisturizers in preventing dermatitis induced by hand washing to
simulate healthcare use. Br J Dermatol 2010;162(5):1088-1092.
Reason for exclusion: type of population did not match the inclusion criteria: not wet workers.
Winker R, Salameh B, Stolkovich S, Nikl M, Barth A, Ponocny E, et al. Effectiveness of skin protection
creams in the prevention of occupational dermatitis: Results of a randomized, controlled trial. Int Arch
Occup Environ Health 2009;82(5):653-662.
Reason for exclusion: type of population did not match the inclusion criteria: mixed population – with and
without pre-existing skin conditions.

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©2018 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.