Vice President, Professional Education and Clinical Affairs, Ansell, US.
Next to healthy intact skin, medical gloves are the first line of defence against infectious pathogens, providing a protective barrier for both the healthcare provider and the patient. The World Health Organization (WHO), the U.S. Occupational Health and Safety Administration’s (OSHA) Blood-borne Pathogen Standard, the European Agency for Safety and Health at Work (EU-OSHA), the National Institute for Healthcare and Care Excellence (NICE - UK) and the Australian National Occupational Health and Safety Commission (NOHSC) all define PPE as the specialised clothing or other equipment worn by employees to protect themselves against a hazard; the use of PPE such as medical gloves is required whenever there is a risk of occupational exposure to blood or other potentially infectious material. However, in some users, medical gloves have been associated with skin irritation. Adverse skin reactions to medical gloves include latex protein allergy (Type I, immediate hypersensitivity to natural rubber latex proteins), chemical allergy (Type IV, allergic contact dermatitis (ACD)), and general skin irritations.
Most hospital allergy management programs concentrate on the understanding and treatment of latex protein allergy. Latex allergyis mediated by the allergic antibody IgE, which is directed against retained proteins in latex products; it is triggered by direct skin contact, mucosal surface contact, or inhalation. The prevalence of latex allergy in the healthcare population has been reported to be as high as 17 per cent. Latex allergy symptoms may include hives, angioedema, rhinitis, conjunctivitis, asthma, and anaphylaxis with or without death. This allergy may be life threatening and therefore, is the problem that has captured the attention of healthcare personnel.
However, chemical allergy remains an even more important cause of disability and loss of work hours to the healthcare provider. Identified in the 1930s, this chemical allergy is still not well understood. Chemical allergy is an expansive allergic condition which represents approximately 30 per cent of occupationally-induced skin diseases thereby making it a significant occupational hazard. Chemical allergy is the second largest occupational disability reported to OSHA. Occupational skin disease (OSD) is the second most common work-related problem presenting to general practitioners in Australia (Hendrie & Driscoll 2003). A survey of UK National Health Service (NHS) staff showed that 43 per cent had signs or symptoms of irritant contact dermatitis or allergic contact dermatitis, while 10 per cent showed latex hypersensitivity. (Johnson G.,Time to take the gloves off? Occupational Health (London), 1997; 49: 25-28).
Of particular concern to healthcare providers is that this allergy may predispose some individuals to even greater risk of blood-borne pathogen infection as it compromises the body's most efficacious barrier, skin. The breakdown of the dermis may also permit the passage of latex proteins into the body thereby facilitating latex protein hypersensitivity in some individuals.
Chemical allergy is due to an immunological reaction to a residual chemical leached from the finished glove products. The chemical involved penetrates the skin, resulting in vesiculation, erythema, swelling, cracking and itching of the skin at the site of contact. This dermatitis frequently extends beyond the area of contact (e.g., the forearm in a healthcare provider wearing a glove). The response is delayed rather than immediate, usually occurring in 6-48 hours after initial contact, although symptoms can last up to 4 days. Continued exposure may lead to chronic dermatitis manifested as dry, irritated, cracked, pruritic skin with erythema. Chemical allergy is more common than latex protein allergy and it may precede latex protein allergy in up to 40 per cent of individuals with latex protein allergy (Thompson R. 2000).
A common factor contributing to the development of chemical allergy is a pre-existing skin condition, such as irritant contact dermatitis, which represents about 70 per cent of all the reported dermatitis cases and is caused by a number of factors such as frequent hand washing, aggressive scrubbing techniques and inadequate hand drying.
Chemical residuals in gloves are frequently responsible for the development of chemical allergy. These chemicals used in the manufacture of gloves fall into broad classifications of accelerators, accelerator activators, stabilisers, antidegradants, retarders, fillers and extenders. It is the accelerator group chemicals (especially thiurams and carbamates) that induce the majority of the skin dermatitis reactions and to a lesser degree the thiazoles, aldehydamines and guanidines. The residues from these accelerators have become a major concern because of their ability to sensitise users and elicit chemical allergic reactions. Over 80 per cent of reported glove-associated allergic contact dermatitis is attributable to chemical accelerators (Heese, A 1991).
The use of chemical accelerators in gloves is not limited to the manufacture of natural rubber latex gloves. They are also used to manufacture synthetic gloves such as nitrile, neoprene or polyisoprene gloves. Historically, without the use of chemical accelerators, many of the qualities that healthcare workers seek in NRL and most synthetic gloves (e.g., barrier performance as demonstrated by tensile strength; elasticity) would not exist. Chemical accelerators used in the manufacture of both NRL and synthetic medical gloves transform the original raw liquid state to a very thin, strong, elastic glove film; they also accelerate the bonding process of the gloving material during the manufacturing process. Accelerator chemicals help to tighten the glove matrix, improve and enhance barrier performance, and stabilise the raw gloving material.
Strategies to Manage Chemical Allergy
The key to managing allergies and adverse glove reactions in healthcare professionals lies in education and awareness programs, correct recognition and appropriate action. Healthcare providers should be encouraged to report any symptoms. Individuals experiencing recurrent or persistent dermatitis should consult with their doctor in order to establish a specific diagnosis. A diagnosis is made by a medical history, physical exam, and patch testing with the offending glove chemicals. Chemical allergy is completely curable. If specific allergens are identified and appropriate strategies are implemented for allergen avoidance, such as selecting accelerator-free gloves or gloves manufactured without the causative agent or accelerator many individuals will not require treatment. Further, healthy, intact skin plays a very important role in prevention of chemical allergies. Instituting a regular skin care regimen to keep hands healthy is highly recommended.
Today, in response to the growing chemical allergy concern, new research and technologies have led to the development of accelerator-free synthetic gloves; these surgical and examination gloves are the latest innovation in the ongoing effort by glove manufacturers to provide strong effective barrier protection without causing allergic reactions.As noted above, since the majority (over 80 per cent) of reported glove-associated chemical allergy is attributable to chemical accelerators, the removal of accelerators from gloves does offer the potential for helping to decrease the prevalence of chemical allergy.
Protecting healthcare providers and patients from transmission of potentially infectious agents is a primary goal for all healthcare facilities; the appropriate selection and use of PPE are key practices in achieving this goal. Medical gloves are the most common type of PPE used as a means of protection by healthcare workers in complying with the WHO & OSHA Blood-borne Pathogen Standards. The frequent use of gloves has resulted in an increase in reports related to several glove-related issues–particularly allergies and other sensitivities–which continue to be a concern among healthcare staff. Today, the growing impact of chemical allergies as an occupational hazard among healthcare workers is clear, considering that 30 per cent of glove-related reactions are chemical allergies, whereas 17 per cent are latex allergies. Chemical allergies may compromise intact skin and therefore, predispose some individuals to an even greater risk of blood-borne pathogen infection. Skin breakdown can also permit the passage of latex proteins into the body, thereby facilitating latex protein hypersensitivity in some individuals. Chemical allergies to glove products are generally associated with the accelerators that are used in the manufacturing process to give gloves many of the qualities that health care workers desire.
Chemical exposure and the resultant skin disorders can be inconvenient as well as costly; fortunately, they are also unnecessary and can be preventable. Today, in response to the growing interest in chemical allergy, new technologies have led to the development of accelerator-free gloves. These gloves are the latest innovation in the ongoing effort by glove manufacturers to provide effective barrier protection without causing allergic reactions. By understanding the clinical implications of chemical allergies related to glove use, healthcare providers can select and use glove products that promote the highest degree of safety and efficacy for their patients and themselves.
Patty Taylor received her bachelor’s degree from the University of Western Ontario with major emphasis in psychology and sociology. She is a registered nurse with international experience focusing on peri-operative safety, quality and education. Being an active member of professional associations and networking groups for more than 30 years is a key factor in her professional growth and success.