Myth busting in hand hygiene

Myth 1: Alcohol-based handrub (ABHR) causes skin problems

Fact: ABHR typically contains additives that can help prevent skin-related problems. By contrast, ABHR is better tolerated as soaps, medicated soaps and hand scrubs containing chlorhexidine.

Skin-related problems used to be one of the first things healthcare workers (HCW) think about when talking about alcohol-based handrub. Many HCW report that ABHR causes skin irritation.

Alcohols can really cause dryness because they have lipid-dissolving effects. Commercially available ABHR contains protective additives; glycerol, humectants, emollients or other skin-conditioning agents to reduce, or eliminate the drying effect of alcohol [Kampf and Kramer 2004].

Chamorey et al. 2011 found in a multi-centered study in France that frequency of ABHR use was not associated with increased hand dryness or irritation of hands. Instead, intensive use of ABHR (more than 20 times a day) has a significant protective effect. By contrast, handwashing with soap and water are significantly related to skin irritation. Hand scrubs contain chlorhexidine and medicated soaps are definitely more irritating than ABHRs [WHO 2009].

How it is possible that studies did not find evidence that ABHR causes skin-related problems, while HCWs often report it? According to Kampf and Löffler 2003, the problems are mainly caused by the inappropriate use of ABHR. There are some simple rules that can help prevent skin damage:

  • Do not use ABHR on damaged skin. Skin damage is not always visible, and it can be well tolerated by HCW while ABHR is not applied. After the use of ABHR, symptoms can intensify. It can mistakenly identify as a side-effect of ABHR, but it is actually the result of preexisting skin disorders.
  • Do not wash hand right before the use of ABHR. ABHR should only be applied on dry (non-wet) skin, as skin remains moist after handwashing. In addition, hand wash can remove the superficial sebum layer of the skin, and thereby it enhances skin irritation and dryness.
  • Do not wash hands right after the ABHR use. ABHR contains protective additives to eliminate the drying effect of alcohols. With a handwashing event, these additives are also washed off of the hands.
  • Hands should be dry before gloves are put on, should not be wet, neither by water nor by ABHR. Gloves should be worn only as long as necessary.


Myth 2: Alcohol from ABHR absorbs through the skin

Fact: Only in insignificant quantity

Dermal absorption of nicotine and opioids are well-known, so systemic absorption of alcohol after using ABHR sounds believable. Studies do not confirm this theory; several studies examined blood alcohol level after hand hygiene events and found undetectable or insignificant changes [Stewardson et al. 2011]. Many products in our daily life contain alcohol, such as mouthwash, aftershave, fruit juices, chocolate, etc. Consumption of one non-alcoholic beverage result a peak blood ethanol concentration comparable than resulting from the intensive use of ABHR. Nobody has to worry about “losing a driving license after consuming apple juice, shaving or working a 12-hour shift in the hospital before driving” [Pires et al. 2016].


Picture: HCW using ABHR in King Abdulaziz Medical City, Ryhad, Saudi Arabia. (Source: WHO)

Myth 3: Using ABHR is not allowed to Muslims

Fact: It is allowed, as it is not for ingestion but for preventing the spread of infections

After the UK National Patient Safety Agency (NPSA) called for the universal application of ABHR in 2004, concerns about the use of ABHR have been expressed to the NPSA by Muslim HCW, patients and relatives.

Risk assessment before the launch of the “cleanyourhands” campaign identified use of alcohol among Muslim HCW as a possible problem in clinical practice. Ahmed et al. 2006 summarize the results from consultation of experts and religious leaders, and literature search.

Enormous taboo has become attached to the consumption of alcohol for all Muslims, as alcohol is clearly designated as haram (forbidden). Although, anything that is for curing people is allowed. For example, cocaine is permitted as a local anaesthetic (halal, allowed), but forbidden as a recreational drug.

During the 6th meeting of the Muslim Scholars’ Board of the World Muslim League in Saudi Arabia, 2002, one of the topics was “medicines containing alcohol and narcotics”. World Muslim League declared medicines that contain alcohol permissible if no substitute exists.

Furthermore, alcohol is wildly used in household cleaning agents and in perfumes without restriction for Muslims. In these cases, alcohol is not for ingestion.

ABHR are used in more than 200 public hospitals in Saudi Arabia and more in the Gulf states. These hospitals have not reported any inability to comply because of religious beliefs.


Myth 4: ABHR can cause fire

Fact: It can happen, but it is extremely rare

Rocos and Donaldson 2012 studied surgical fires to explore the role of ABHR. Operating rooms are oxygen-rich environment what increase the risk of fire. The National Reporting and Learning Service (NRLS) database, a national database in England and Wales where five million reported patient safety incidents were interrogated. 13 fire incidents were reported between 2004 and 2011 during surgical procedures, and in 11 cases some flammable skin preparation fluid (chlorhexidine solution or povidone-iodine solution) were presented; ignited or made the fire worse. To avoid these incidents, alcohol-based products should not be allowed to pool. Skin should be completely dried before electrosurgery commences.

Boyce and Pearson 2003 tried to estimate how common ABHR-related fire accidents are. They sent a questionnaire to SHEA, APIC and EIN members and asked to report ABHR-related fire incidences. 798 facilities responded, representing 1.430 hospital-years of ABHR use. During this period, no ABHR-related case has occurred. The survey was repeated in Germany by Kramer and Kampf 2007. The reported period represented 25.038 hospital years, with overall consumption of 35 million litres (9.2 M gallons) ABHR. During this period, there were a total of 7 fire incidents reported. None of them was caused by static electricity, and none of the fires led to major injuries. Four cases were related to smoking; HCW did not wait till ABHR evaporated, before handling fire (match or cigarette lighter). Two cases arose from vandalism, and one from a patient’s suicidal intention.

HCW should be educated about the risk associated with ABHR and open flames.