Allan Deutsch
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HAS BEEN well known for more than 150 years that washing heavily
contaminated hands with an antiseptic agent between patient contacts
may reduce health-care-associated transmission of contagious diseases
more effectively than hand washing with plain soap and water.
However, most antiseptic agents will cause a large percentage of
health care workers (HCWs) some degree of skin irritation.
The primary functions of the skin are to reduce
water loss, to provide protection against abrasive action and
microorganisms, and to act as a permeability barrier to the
environment. The skin is a dynamic structure. Barrier
function does not simply arise from the dying, degeneration, and
compaction of the underlying epidermis. Substantial evidence now
confirms that the formation of the skin barrier is under homeostatic
control. Anything that disrupts the skin barrier, such as
irritants of any nature, will alter the protective function of the
skin. Non-antimicrobial soaps may be associated with considerable
skin irritation and dryness (CDC 92, 96, 98), although adding
emollients to soap preparations may reduce their propensity to cause
irritation.
Skin Reactions Related To Hand Hygiene
There are two major types of
skin reaction associated with hand hygiene. The first and most
common type includes symptoms that can vary from quite mild to
debilitating, including dryness, irritation, itching, and even cracking
and bleeding (Figure 1). This array of symptoms is referred to as
irritant contact dermatitis. The second type of skin reaction,
allergic contact dermatitis, is rare and represents an allergy to some
ingredient in a hand hygiene product. Symptoms of allergic
contact dermatitis can also range from mild and localized to severe and
generalized. In its most serious form, allergic contact
dermatitis may be associated with respiratory distress and other
symptoms of anaphylaxis. Therefore it is sometimes difficult to
differentiate between the two conditions.
Frequency and Pathophysiology of Irritant Contact Dermatitis
In some surveys, about 25 percent of nurses have
reported symptoms or signs of dermatitis involving their hands, and as
many as 85 percent give a history of having skin problems. Frequent and
repeated use of hand hygiene products, particularly soaps and other
detergents, is an important cause of chronic irritant contact
dermatitis among HCWs. Cutaneous adverse reactions were
infrequent among HCWs exposed to an alcohol-based preparation
containing chlorhexidine gluconate and skin emollient during a
hand hygiene culture change, multimodal program. The potential of
detergents to cause skin irritation varies considerably and can be
reduced by the addition of humectants. Irritation associated with
antimicrobial soaps may be attributable to the antimicrobial agent or
to other ingredients of the formulation. Affected HCWs often
complain of a feeling of dryness or burning, skin that feels “rough,”
and erythema, scaling, or fissures.
Hand hygiene products damage the skin by causing
denaturation of stratum corneum proteins, changes in intercellular
lipids, decreased corneocyte cohesion, and decreased stratum corneum
water-binding capacity. Among these, the main concern is the
depletion of the lipid barrier that may be consequent to contact with
lipid-emulsifying detergents and lipid-dissolving alcohols.
Frequent hand-washing leads to progressive depletion of surface lipids
with resulting deeper action of detergents into the superficial skin
layers. During dry seasons and in individuals with dry skin, this
lipid depletion occurs more quickly. Damage to the skin also
changes skin flora, resulting in more frequent colonization by
staphylococci and Gram-negative bacilli.
Although alcohols are safer than detergents, they
can cause dryness and skin irritation. The lipid-dissolving effect of
alcohols is inversely related to their concentration, and ethanol tends
to be less irritating than n-propanol or isopropanol.
Other antiseptic agents that may cause irritant
contact dermatitis, in order of decreasing frequency, include
chlorhexidine, chloroxylenol, triclosan, and alcohol-based
products. Skin that is damaged by repeated exposure to detergents
may be more susceptible to irritation by all types of hand antisepsis
formulations, including alcohol-based preparations.
Information regarding the irritancy potential of
commercially prepared hand hygiene products, which is often determined
by measuring transepidermal water loss of persons using the
preparation, may be available from the manufacturer. Other
factors that may contribute to dermatitis associated with frequent hand
cleansing include using hot water for hand washing, low relative
humidity (most common in winter months in the northern hemisphere),
failure to use supplementary hand lotion or cream, and perhaps the
quality of paper towels. Shear forces associated with wearing and
removing gloves and with allergy to latex proteins may also contribute
to dermatitis of the hands of HCWs.
References:
- Centers for Disease Control and Prevention.
Guideline for Hand Hygiene in Health-Care Settings: Recommendations of
the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51 (No.
RR-16):(inclusive page numbers)
- World Alliance for Patient Safety, WHO
Guidelines on Hand Hygiene in Health Care (Advanced Draft), Global
Patient Safety Challenge 2005-2006: “Clean Care is Safer Care”
November - December 2007
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FIGURE 1: Cracked finger due to excessive dryness and washing irritation.
FIGURE 2: Glove’n Care with emollients from the Dead Sea is the
number-one-selling hand cream in the dental profession. Scrub’n
Glove with the same emollients is an antibacterial soap that also
relieves irritation.
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