• The rise in the use of alcohol-based hand sanitisers has increased the incidence of hand eczema
• Hand eczema presents as a red itchy, sometimes burning or even tender, rash
• Adequate skincare should, therefore, be prioritised, especially among healthcare workers

When Covid-19 started spreading across the globe, the World Health Organisation (WHO) and the Centers for Disease Control and Prevention recommended that the best way to prevent Covid-19 infection is through physical distancing, wearing cloth masks, as well as frequent and proper handwashing and surface decontamination. 

The call for regular handwashing led to an exponential rise in the use of alcohol-based hand sanitisers, which has increased the incidence of hand eczema in healthcare workers as well as the general population.

Two kinds of hand eczema

Hand eczema characteristically presents as a red itchy, sometimes burning or even tender, rash. The rash may be dry with cracked and scaly skin, or wet with blisters, oozing and crusting. Certain individuals, such as those with underlying atopic (a general disposition to develop) eczema, are at greater risk of developing alcohol rub hand eczema due to the inherent impaired barrier function of the skin characterising this condition. 

In a study from Hubei province in China, 434 healthcare workers were interviewed, with 321 (74%) reporting that they sanitise their hands more than 10 times per day. Of those healthcare workers, 246 (76.6%) reported symptoms of hand eczema, with the most common being irritant contact hand eczema and less commonly allergic contact hand eczema. 

Another study from Milan reported that from 9 March to 4 May 2020 there were 24 new cases of hand eczema in the general population related to the use of alcohol-based sanitisers.

Some of the issues with alcohol-based hand sanitisers include the use of non-standard formulae (meaning that methanol is used instead of ethanol); types of alcohol such as isopropyl alcohol vs. ethanol; as well as varying amounts of alcohol (<60%). The various recipes making the rounds on social media in the early days of lockdown illustrate this point. 

“Irritant” contact hand eczema may develop in anyone whose hands are exposed to irritants such as water, soap, or alcohol hand sanitisers. “Allergic” contact hand eczema, on the contrary,  will only develop in those who have been primed to develop skin irritation to certain substances such as nickel, latex or colophony (found in adhesives, cosmetics and printing ink).

Debilitating and painful disease

An intact skin usually deters from the development of the latter form of hand eczema. Irritants assist in disrupting the skin barrier, improving the likelihood of developing allergic contact hand eczema. 

Alcohol rub hand eczema can become a debilitating and painful disease, resulting in work absenteeism which can severely impair the delivery of essential services. The increased frequency of handwashing and use of alcohol hand sanitiser associated with Covid-19 prevention dramatically increases the likelihood of developing allergic contact hand eczema, which may greatly impact quality of life as well as cause occupational difficulties in the long run. 

Apart from the discomfort of dry, itchy skin, the breaks in the skin can serve as a point of entry for Covid-19 because of viral receptors in the blood vessels of the skin. Painful, dry skin could also inadvertently decrease hand hygiene compliance which further increases the risk of disease transmission in these individuals. Prevention is therefore essential. 

It has become clear that the Covid-19 pandemic will persist for the foreseeable future. Equally clear has been the gargantuan impact of this viral infection. Therefore, the importance of following protective guidelines, such as outlined by health and government organisations, is undeniable and should be closely adhered to.  

The WHO has recommended a 60% alcohol-containing hand sanitiser with 1.45% glycerol as a moisturising agent to protect healthcare workers, and now the frequently sanitising public, from the complications of excessive alcohol hand rub usage. The minimum amount of glycerol required to decrease the risk of hand eczema is not known, although studies have shown that even lower levels than the recommended 1.45% glycerol were effective to protect the skin from excessive drying.

Moisturisers few and far between

Further recommendations include the use of an emollient-containing hand cream immediately after sanitising. Although this is a useful measure to prevent alcohol rub dermatitis, one study showed that only approximately one in five healthcare workers did so after using alcohol hand rub. This figure is highly unlikely to be higher among the general public. 

Sanitising stations are located everywhere in hospitals and public areas and have been an important means of combating the spread of Covid-19. However, moisturisers are few and far between, hence the increased incidence of alcohol rub hand eczema during the pandemic.

Adequate skin care could increase hand hygiene compliance and should therefore be prioritised, especially among healthcare workers. Furthermore, preventative measures are critical to allay the next, albeit completely different wave, that of allergic contact hand eczema – another unintended health consequence of Covid-19. 

*Dr Suretha Kannenberg is a Consultant Dermatologist in the Division of Dermatology at Stellenbosch University. Sergio Alves and Allison Arendse are 5th-year medical students in the same division. This is a revised version of their article recently published in the South African Medical Journal.

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• Understanding immunity to SARS-CoV-2 infection is essential to understanding how it contributes to protection against reinfection
• Earlier studies indicated that immunity is short-lived, but the latest studies suggest otherwise
• One of these studies shows that immunity might last years, possibly decades

Scientists have been scurrying to understand immunity against reinfection with SARS-CoV-2 (the virus that can lead to Covid-19).

It is still not entirely clear how long contracting the virus confers immunity, with early studies suggesting a period of a few months, which, therefore, means that it may only provide temporary protection against reinfection.

One of these studies, for instance, found that antibody levels “waned quite rapidly” after infection in the British population, suggesting a risk of multiple infections, Health24 reported.

However, newer studies indicate immunity could last longer.

Some protection against reinfection 

According to a study published in the renowned journal Nature Medicine, people who have recovered from Covid-19 have powerful and protective killer immune cells, even when antibodies are not detectable. 

This, the authors wrote, “represents major determinants of immune protection on an individual as well as population level”.

In this study, a research team at the Medical Center – University of Freiburg in Germany found that after recovery from SARS-CoV-2 infection, immune cells are formed which remain in the body and could mediate a rapid immune response in case of reinfection.

“These so-called memory T-cells after SARS-CoV-2 infection look similar to those after a real flu,” said study co-author Dr Maike Hofmann, a scientist at the Department of Medicine II at the Medical Center – University of Freiburg.

“We are therefore confident that the majority of people who have survived SARS-CoV-2 infection have some protection against reinfection with SARS-CoV-2,” he added.

Study co-author, Dr Christoph Neumann-Haefelin, Head of the Gerok Liver Center at University Hospital Freiburg, also expressed optimism about their results, suggesting that immunity against the new coronavirus can be achieved after an infection, and that, “similarly, vaccines currently being tested in trials could provide significant protection against SARS-CoV-2″.

What another recent study shows

Another, perhaps more hopeful, study shows that immunity might last years, possibly even decades.

In this study, the team of researchers at the La Jolla Institute of Immunology in California, and the Icahn School of Medicine at Mount Sinai in New York, investigated multiple compartments of circulating immune memory to SARS-CoV-2 in 185 Covid-19 cases, including 41 cases more than six months post-infection.

They found that eight months after infection, most people who recovered still had enough immune cells to fight off the virus and prevent illness.

In other words, there was a very slow rate of decline of these cells, demonstrating that they persist in the body for a very long time.

Although the research, published online in pre-print server bioRxiv, has not been peer-reviewed nor published in a scientific journal, the New York Times refers to it as “the most comprehensive and long-ranging study of immune memory to the coronavirus to date”.

“That amount of memory would likely prevent the vast majority of people from getting hospitalised disease, severe disease, for many years,” said Shane Crotty, a virologist at the La Jolla Institute of Immunology, with Dr Deepta Bhattacharya, an immunologist at the University of Arizona, believing that it’s not an unreasonable prediction to think that these immune memory components would last for years.

The Times also points to another recent study that showed that survivors of SARS, also caused by a coronavirus, still carry important immune cells 17 years after being infected. The results of this study have led scientists to be hopeful that studying antibodies may be largely beneficial in an effort to develop drugs to prevent or treat Covid-19.

While scientists continue in the global race to develop a Covid-19 vaccine to help bring the pandemic under control, these findings that immunity to the virus might not be so short-lived after all are likely to come as a relief to experts.

READ | Covid-19: Two of the vaccine front runners have already reported promising evidence – so what now?

READ | Coronavirus and the immune system: SA study to shed light

READ | What if we don’t find a vaccine for Covid-19?

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Compiled by Zakiyah Ebrahim

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