DISCUSSION
atopic eczema, hand dermatitis, hand eczema, dermatitis, eczema
ATOPIC ECZEMA, ATOPIC DERMATITIS, HAND DERMATITIS, SECONDARY, SKIN CONDITION, CONTACT DERMATITIS, HAND ECZEMA, OXIDATIVE STRESS, DERMATITIS, ECZEMA
Our study involved 2 groups of consecutive patients who were investigated for hand dermatitis; the population was in the majority constituted by women (66.7% in both groups) due to the higher prevalence of health care workers (50%) in our population and in line with other reports on higher risk professions.Job changes due to hand dermatitis were reported in 11.1% of cases and 6.2% of controls, which could be an expression of worst-hand eczema. Moreover, cases presented a higher prevalence of atopic eczema in childhood and higher values in TEWL measured at the hand and forearm (reaching statistical significance in both cases) than controls. It is well known that atopic eczema is a predisposing factor for hand dermatitis due to the impaired skin barrier these patients haveBoth groups were characterized by a high prevalence of smoking habits (>24%), and smoking is considered a risk factor for eczema, probably in relation to the inflammatory effects of smoking that cause oxidative stress and cytokine release.Cases and controls presented a similar distribution of hand eczema sites, similar exposure to irritants as reported by the frequency of hand washing per day, and a general irritant score at work and out of work defined according to the Uter et al questionnaire.During the follow-up period, younger subjects were lost because of mild dermatitis. However, 52.5% and 40% of the subjects who participated in the first follow-up reported improvement in hand eczema in the cases and controls, respectively. These percentages increased to 63% and 50% in the case and control groups, respectively, at the second follow-up. Therefore, for both groups, the training received and the regular use of emollients were effective in reducing signs of hand eczema.Going in detail and analyzing objective data, the HECSI score improved in higher percentages in workers treated with a CC (54.8%) than in those treated with other emollients (26.7%), and a similar trend was observed for TEWL measurements on the hand and forearm. Moreover, the median HECSI score values significantly increased in controls at the third follow-up, but only a few patients participated in the final examination, probably those with more symptoms. Notably, our patients were characterized mainly by mild dermatitis (HECSI score ≤11), for which the benefit of the interventions was higher.Educational interventions are important to teach workers to avoid exposure to irritants and to increase the use of emollient and protective creams, and many studies have reported its effectiveness in preventing hand dermatitis in hairdressers,Our previous study on secondary prevention of hand dermatitisThe statistical analysis performed using the generalized estimated equation during the follow-up confirmed the effectiveness of the treatment with CCs versus OCs (OR = 2.6; 95% CI 1.30–0.2), whereas age inversely associated with improvement, to confirm that intervention was more effective for young people, as reported by Soltanipoor et al in their cluster-randomized trial on the effectiveness of a skin care program for the prevention of contact dermatitis in health care workers.Many studies have confirmed the effectiveness of CC as a treatment for impaired skin barrier function.In atopic dermatitis, the water barrier function is altered due to a dysregulation of lipid composition of SC with a reduction of ultra-long acyl chain ceramides (>C24) and an increase of long acyl chain ceramides (<C24). The barrier function can be restored with topical application of CC.In our study, the use of a CC resulted in a higher percentage of subjects with an improvement in dermatitis, with a reduction in HECSI score and a decrease in TEWL values at both sites analyzed, confirming a positive effect on the skin barrier. Analyzing our results considering The application of a formulation containing 1 or 2 ceramides and a fatty acid on regenerating the SC resulted in a denser lateral lipid packing of the SC lipids in compromised skin, and the strongest effect was observed after application of a formulation containing a single ceramide. Several other formulations consisting of ceramides, fatty acids, and cholesterol have been reported to enhance barrier repair, using TEWL as a barrier repair parameter.In our case, we used a cream formulated using one ceramide, ceramide 3, fatty acid, and cholesterol in a 3:1:1 ratio, which resulted in effective barrier repair in the majority of treated workers after 3 months. Nevertheless, improvement of the skin condition was also seen in the group treated only with OCs, because the use of emollients associated with better protection of the skin can be effective in improving skin condition. However, in this group at the 3 months' follow-up, we found an increase in the HECSI score, meaning that for some patients, hand dermatitis was the worst.After the training, workers did not reduce contact with irritants and wet work, meaning that it was very difficult to change their habits during work and outside the work. Wet work, glove use, contact with detergents, and disinfectants are intrinsic factors in many occupations such as health care workers, hairdressers, and food handlers, and it is very difficult to change irritant exposure mainly at work.The results obtained in our study were mainly related to the better hydration of the skin than to a reduction in contact with irritants. This result is probably related not only to the hydrating action of the cream but also to the skin barrier-restoring action due to the 3 biomimetic balanced lipids contained in Ceramol cream.In a study by Sultanipoor et al,Our study has several strengths. There are few available data in the literature that compare personalized training and CC for secondary prevention of hand dermatitis using a standardized protocol to score hand dermatitis and TEWL as markers of improvement in skin condition. The second strength is the dermatological examination of skin conditions performed during follow-up.Moreover, our study has some limitations.The first limitation is the high number of subjects lost to the first and second follow-up. The majority of patients presented with milder hand dermatitis and did not return for follow-up visits because they solved, at least in part, their skin problems. The second limitation is the short follow-up period; the 3 months' period was possible to register an improvement in hand dermatitis, but a longer follow-up period would permit the evaluation of the persistence of the improvement over longer time frames. A third limitation could be the higher values for TEWLS found in cases than in controls, with a possible easier positive effect due to the intervention. Another limitation could be the lack of analytical measures of compliance with the regimen (ie, quantity of creams used per day) because only personal declaration of patients was used.