WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE Figure I.13.1 Surgical hand preparation technique with an alcohol-based handrub formulation (Cont.) 60
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE 14. Skin reactions related to hand hygiene There are two major types of skin reactions 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. 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. HCWs with skin reactions or complaints related to hand hygiene should have access to an appropriate referral service. 14.1 Frequency and pathophysiology of irritant contact dermatitis Irritant contact dermatitis is extremely common among nurses, ranging in prevalence surveys from 25% to 55%, and as many as 85% relate a history of having skin problems. 572,573 Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is an important cause of chronic irritant contact dermatitis among HCWs. 574 Cutaneous adverse reaction was infrequent among HCWs (13/2750 exposed HCWs) exposed to an alcohol-based preparation containing chlorhexidine gluconate and skin emollient during a hand hygiene culture change, multimodal programme; 548 it represented one cutaneous adverse event per 72 years of HCW exposure. 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. An example of a hand skin self-assessment tool is given in Appendix 3. In addition, two similar protocols to assess skin tolerance and product acceptability by HCWs after use of an alcohol-based handrub are included in the Implementation Toolkit of the <strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy. 575 The method is based on: 1) objective evaluation of dermal tolerance by an investigator using a validated scale; 2) subjective evaluation by the HCW of his/ her own skin conditions and of the product characteristics. The simpler protocol is meant to be used to assess a single product in the short term (3–5 days after use) and in the longer term (1 month after use); it is easy to implement under ordinary conditions. A more investigational protocol has been designed to make a fast-track comparison of two or more products using a double-blind, randomized, cross-over methodology. 504 Hand hygiene products damage the skin by causing denaturation of stratum corneum proteins, changes in intercellular lipids (either depletion or reorganization of lipid moieties), decreased corneocyte cohesion and decreased stratum corneum water-binding capacity. 574,576 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. 577 Frequent handwashing 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. 577 Damage to the skin also changes skin flora, resulting in more frequent colonization by staphylococci and Gram-negative bacilli. 79,219 Although alcohols are safer than detergents, 262 they can cause dryness and skin irritation. 48,578 The lipid-dissolving effect of alcohols is inversely related to their concentration, 577 and ethanol tends to be less irritating than n-propanol or isopropanol. 578 Numerous reports confirm that alcohol-based formulations are well tolerated and often associated with better acceptability and tolerance than other hand hygiene products. 504,548,579-584 In general, irritant contact dermatitis is more commonly reported with iodophors 220 Other antiseptic agents that may cause irritant contact dermatitis, in order of decreasing frequency, include chlorhexidine, chloroxylenol, triclosan, and alcoholbased 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. 585 Graham and colleagues reported low rates of cutaneous adverse reactions to an alcohol-based handrub (isopropyl alcohol 70%) formulation containing chlorhexidine (0.5%) with emollient. 548 Information regarding the irritancy potential of commercially prepared hand hygiene products, which is often determined by measuring the 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 handwashing, 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. 586,587 Shear forces associated with wearing or removing gloves and allergy to latex proteins may also contribute to dermatitis of the hands of HCWs. 577 In a recent study conducted among ICU HCWs, the short-term skin tolerability and acceptability of the <strong>WHO</strong>-recommended alcohol-based formulations (see Section 12) were significantly higher than those of a reference product. 504 Risk factors identified for skin alteration following handrub use were male sex, fair and very fair skin, and skin alteration before use. 61
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REFERENCES 35. Jroundi I et al. Pre
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