Is it really such a big problem?
In our last post, we mentioned that foams and gels were developed because rinses often caused skin irritation and dryness. Skin-related problems used to be one of the first things healthcare workers (HCW) think about when talking about alcohol-based handrubs (ABHR). But what is the situation today?
Many HCW report that ABHR causes skin irritation. The drying effect of ABHR is a major cause of poor acceptance [1]. Li et al. 2015 reported that one of the top three complaints against using ABHR in rural China is skin irritation [2].
Alcohols can really cause dryness, because they have lipid-dissolving effects. Ethanol tends to be less irritating than propan-1-ol or propan-2-ol (read more about the composition of handrubs here) [1]. Applying 100% propan-1-ol has an aggressive effect on hands. Although in a study, where a more realistic 60% concentration was applied, it only caused problems on pre-irritated hands [3].
Commercially available ABHR contains protective additives; glycerol, humectants, emollients or other skin-conditioning agents to reduce, or eliminate the drying effect of alcohol [4]. Even the two WHO recommended handrub formulations (which were developed for local production, where commercial products are not available or affordable) contain glycerol as humectant to improve the acceptability of the formulations [5].
Chamorey et al. 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, as it shown in Figure 1 [3].
Figure 1.: Dose–effect curves of skin dryness and irritation according to the frequency of use of ABHR. (Source: Chamorey et al.)
The WHO provides study protocols for testing the acceptability and tolerability of new ABHRs. Testing the skin tolerance is an important part of both of these protocols. Probably the first formal report on applying one of these WHO test methods was a study by Wolfensberger et al. in 2015. During the study, participants used at least 30 ml of a new ABHR per day. After a month, their hands were significantly less dry than at the baseline point (91% vs. 64% of HCW’s hand were “not” or “incidentally” dry, respectively) [6].
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].
How it is possible that studies did not find evidence that ABHR causes skin-related problems, while HCWs often report it? According to Kampf et Löffler, 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 layer of 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 [7].
Skin irritation is also depending on skin type. Darker skins were found significantly healthier in a study, and irritation were observed more often in the case of light skins [1].
The use of hand lotions and cream helps to prevent and treat irritation and dryness caused by hand hygiene products. Nevertheless, it should be kept in mind that moisturizing agents may easily become contaminated [1]. In 1995, an outbreak of Pseudomonas aeruginosa was reported in a neonatal intensive care unit. The P. aeruginosa was transmitted by a contaminated hand lotion, and when it was applied to the disinfected hands, and led to direct infections of infants [8].
Conclusion:
It is commonly thought that alcohol-based handrubs cause skin irritation and dryness. The fact is that ABHR typically contains additives that can help prevent skin-related problems. By contrast, ABHR is better tolerated as soaps, medicated soaps and hand scrubs contains chlorhexidine. There are a few rules of applying ABHR; do not use it on damaged skin, do not wash hands right before or after the use of ABHR, and let the hands dry before take on gloves. Keeping these simple rules can prevent most of the ABHR-caused skin-related problems.
Read our previous post on different composition of handrubs.
References
1: WHO Guidelines on Hand Hygiene in Health Care. ISBN 978 92 4 159790 6. 2009
2: Li Y. et al.: Self-reported hand hygiene practices, and feasibility and acceptability of alcohol-based hand rubs among village healthcare workers in Inner Mongolia, China. The Journal of Hospital Infection, 90(4):338-43. 2015 DOI: 10.1016/j.jhin.2015.04.006
3: Chamorey E. et al.: A prospective multicenter study evaluating skin tolerance to standard hand hygiene techniques. American Journal of Infection Control, 39(1):6-13. 2011. DOI: 10.1016/j.ajic.2010.03.021
4: Kampf G. and Kramer A.: Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clinical Microbiology Reviews, 17(4):863-93. 2004. DOI: 10.1128/CMR.17.4.863-893.2004
5: Suchomel M. et. al.: Testing of the World Health Organization recommended formulations in their application as hygienic hand rubs and proposals for increased efficacy. American Journal of Infection Control, 40(4):328-31. 2012. DOI: 10.1016/j.ajic.2011.06.012
6: Wolfensberger A et al.: Evaluating the tolerability and acceptability of an alcohol-based hand rub – real-life experience with the WHO protocol. Antimicrobial Resistance and Infection Control, 4:18. 2015. DOI: 10.1186/s13756-015-0052-9
7: Kampf G. and Löffler H.: Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. The Journal of Hospital Infection, 55(1):1-7. 2003. PMID: 14505602
8: Becks V.E. and Lorenzoni N.M.: Pseudomonas aeruginosa outbreak in a neonatal intensive care unit: a possible link to contaminated hand lotion. American Journal of Infection Control, 23(6):396-8. 1995. PMID: 8821117