Hand dermatitis: when clean hands become sore hands

Washing your hands is one of the best things you can do for your health. Doing it twenty or thirty times a day is one of the worst things you can do for your hands. If yours are dry, red, cracked and stinging, you probably have irritant hand dermatitis, and you’re in a very large club. Here’s what’s happening under the skin and how to stop it.

What washing does to your skin barrier

The outer layer of your skin, the stratum corneum, is a wall of flattened dead cells held together by lipids, the fats that act like mortar between bricks. That wall keeps water in and irritants out.

Soap and detergent are designed to dissolve fats. That’s how they lift grease off your hands, and it’s also why they lift out some of the mortar every time. Water alone does damage too, by swelling the cells and washing away the skin’s natural moisturizing molecules. Hot water is worse than lukewarm.

One wash is nothing. The skin replaces what it lost. But wash every few minutes and the loss outruns the repair. DermNet, a dermatology reference used by clinicians, describes the spiral: water loss and inflammation lead to further impairment of barrier function. Once the barrier is broken, everything irritates more, including the soap you were using without trouble a month ago.

What irritant hand dermatitis looks like

Dermatitis and eczema mean the same thing: inflamed skin. “Irritant” means the cause is physical wear from water, soap, detergent, cold or friction, not an allergy.

Early on, the hands feel tight and dry, especially over the knuckles and between the fingers, where water pools and towels miss. Then comes redness, fine scaling, and cracks that catch on fabric. The British Association of Dermatologists’ patient leaflet notes the skin can become very itchy, often with burning, and sometimes painful. In the acute phase there can be swelling and small blisters; long-term, the skin thickens and splits.

The Association says hand dermatitis affects about one in every 20 people. It’s much more common in some jobs than others.

Who gets it: health workers, parents, cleaners

DermNet lists the usual suspects: health care workers, cleaners, hairdressers, caterers, construction workers and parents of young children. What they share is “wet work”: hands in water or gloves for hours a day.

The pandemic showed how fast it can happen. A 2020 study published in the journal Contact Dermatitis surveyed 114 health care workers at a surgical centre and a COVID-19 intensive care unit. Hand washing, disinfection and hand cream use all rose significantly, and symptoms of acute hand dermatitis were found in 90.4 percent of participants. Only 14.9 percent said they had hand eczema, which tells you how normal sore hands had become. The damage appeared whether or not the person was caring for COVID-19 patients; the extra hand hygiene was enough.

Parents of babies get the same exposure without the hospital: diaper changes, bottles, baths, wiping surfaces. Add a Canadian winter, with dry indoor air and cold outdoor air pulling moisture from the skin, and January is when a lot of hands give out.

There’s also a genetic side. People who had eczema as children have a weaker barrier to begin with, and DermNet notes they’re more susceptible to the irritant form.

Sanitizer or soap: which is gentler?

This one surprises people. The US Centers for Disease Control and Prevention, in its hand hygiene guidance for health care workers, states that alcohol-based hand sanitizer is less irritating and drying to skin than soap and water.

That sounds backwards because alcohol stings. But the sting is a sign of cracks that are already there; the alcohol didn’t make them. Washing strips lipids and leaves the skin wet, then the towel adds friction. Sanitizer evaporates, and modern formulas include humectants (ingredients that hold water) to soften the effect.

So when your hands are not visibly dirty, using sanitizer instead of washing is a legitimate way to reduce wear. When they are dirty, after the toilet, or when the germ in question resists sanitizer (norovirus, for example), you still need soap. The point isn’t to avoid washing; it’s to stop washing when a rub would do.

Moisturize after every wash

If you take one thing from this article, take this: put moisturizer on every time you wash, not just at bedtime. The Eczema Society of Canada’s advice is to apply a rich moisturizer immediately after hand washing, bathing, wet work and anytime in between. The CDC’s guidance for health workers says lotions and creams can prevent and decrease the dryness that comes from cleaning your hands, and that facilities should provide them.

Why every time? Because the moisturizer replaces the lipids the wash just removed, while the skin is still slightly damp and can trap the water. Waiting until evening leaves the barrier open all day.

Practical details that make it stick:

• Keep a tube at every sink and in your coat pocket. The moisturizer you’ll actually use is the one within reach.
• Creams during the day, ointments at night. The British Association of Dermatologists suggests a thicker, greasier product at bedtime, with cotton gloves over it if you like, to hold it on.
• Fragrance-free. Broken skin is far more likely to become sensitized to fragrance, and a reaction on top of dermatitis is hard to untangle.
• Small amount, rubbed in fully. A film that leaves your hands slippery just gets washed off at the next sink.

You can browse hand creams whose claims have been reviewed, and if you wear gloves at work, moisturize before putting them on as well as after taking them off.

Gloves, water temperature and other protection

Gloves are the other half of prevention, and they have rules of their own:

• Wear them for wet work. Dishes, cleaning, bathing kids, handling produce. DermNet and the Eczema Society both recommend it.
• Put cotton liners under them. Sweat trapped inside a rubber or vinyl glove is wet work by another name. Both organizations recommend thin cotton gloves underneath.
• Keep sessions short. The British Association of Dermatologists suggests gloves for no more than about 20 minutes at a stretch.
• Choose vinyl or nitrile over latex if you react to rubber, which is a common allergy in people with hand dermatitis.

Then the small habits: lukewarm water rather than hot, a mild or soap-free cleanser, patting dry rather than rubbing, drying between the fingers, and taking rings off to wash, since soap trapped under a ring is a classic cause of a rash on one finger. Warm gloves outdoors in winter count as prevention too.

When it’s more than irritation

Sometimes sore hands aren’t just wear. A rash that persists despite good care, or that flares in a pattern (after a particular glove, cream or job), may be allergic contact dermatitis. That’s an immune reaction to a specific substance, and DermNet lists nickel, fragrances and rubber accelerators among the common culprits. Patch testing, done by a dermatologist, is how you find out.

Cracks that bleed, weeping, yellow crusting or swelling can mean the broken skin has become infected. And hand dermatitis often needs prescription treatment; the British Association of Dermatologists’ leaflet notes that mild steroid creams generally don’t work on thick palm skin, so stronger ones are usually prescribed. None of that is something to sort out from a blog.

The rule of thumb: if it isn’t better after two weeks of moisturizing after every wash and protecting your hands from wet work, see your doctor or pharmacist.

Clean hands and sore hands don’t have to go together. Wash when you need to, sanitize when you can, moisturize every single time, and give your hands gloves for the wet jobs. The barrier heals quickly once you stop taking it apart faster than it can rebuild.