Hand hygiene.pdf

ated with respiratory distress and other symptoms of anaphylaxis. Therefore it is sometimes
difficult to differentiate between the two conditions.
12.1 FREQUENCY AND PATHOPHYSIOLOGY OF IRRITANT CONTACT
DERMATITIS
In some surveys, about 25% of nurses have reported symptoms or signs of dermatitis
involving their hands, and as many as 85% give a history of having skin problems 426 . Frequent
and repeated use of hand hygiene products, particularly soaps and other detergents, is an
important cause of chronic irritant contact dermatitis among HCWs 427 . Cutaneous adverse
reaction were infrequent among HCWs (13/2750 exposed HCWs ) exposed to an alcoholbased
preparation containing chlorhexidine gluconate and skin emollient during a hand
hygiene culture change, multimodal programme 428; 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 selfassessment
tool is given in Appendix 2.
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
427,429 . 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 430 .
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 430 . Damage to the skin also changes
skin flora, resulting in more frequent colonization by staphylococci and Gram-negative
bacilli 35,154 .
Although alcohols are safer than detergents 188 , they can cause dryness and skin irritation
1,431 . The lipid-dissolving effect of alcohols is inversely related to their concentration 430 ,
and ethanol tends to be less irritating than n-propanol or isopropanol 431 .
In general, irritant contact dermatitis is more commonly reported with iodophors 155 (see
Part I, Section 9.7). 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 432 . 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 428 .
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
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 433,434 . Shear forces associated with wearing or removing gloves and allergy to latex
proteins may also contribute to dermatitis of the hands of HCWs 430 .