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12.2 ALLERGIC CONTACT DERMATITIS RELATED TO HAND HYGIENE PRODUCTS Allergic reactions to products applied to the skin (contact allergy) may present as delayed type reactions (allergic contact dermatitis) or less commonly as immediate reactions (contact urticaria). The most common causes of contact allergies are fragrances and preservatives, with emulsifiers being less common 435-438 . Liquid soaps, hand lotion, ointments or creams used by HCWs may contain ingredients that cause contact allergies 436,437 . Allergic reactions to antiseptic agents including quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol and alcohols 211,257,259,266,435,439- 444 as well as possible toxicity in relation to dermal absorption of products 355,445 have been reported. Allergic contact dermatitis attributable to alcohol-based handrubs is very uncommon. Surveillance at a large hospital in Switzerland where a commercial alcoholbased handrub has been used for more than 10 years failed to identify a single case of documented allergy to the product 350 . In late 2001, a Freedom of Information Request for data in the FDA’s Adverse Event Reporting System regarding adverse reactions to popular alcohol-based handrubs in the USA yielded only one reported case of an erythematous rash reaction attributed to such a product (J. M. Boyce, personal communication). However, with the increasing use of such products by HCWs, it is likely that true allergic reactions to such products will occasionally be encountered. There are a few reports of allergic dermatitis resulting from contact with ethyl alcohol 446-448 and one report of ethanol-related contact urticaria syndrome 258 . More recently, Cimiotti and colleagues reported adverse reactions associated with an alcohol-based handrub preparation. In most cases, nurses who had symptoms were able to resume use of the product after a brief hiatus 259 . This study raises the alert for possible skin reactions to alcohol-based handrub preparations. Allergic reactions to alcohol-based formulations may represent true allergy to the alcohol, or allergy to an impurity or aldehyde metabolite, or allergy to another product constituent 257 . Allergic contact dermatitis or immediate contact urticarial reactions may be caused by ethanol or isopropanol 257 . Allergic reactions may be caused by compounds that may be present as inactive ingredients in alcohol-based handrubs, including fragrances, benzyl alcohol, stearyl or isostearyl alcohol, phenoxyethanol, myristyl alcohol, propylene glycol, parabens, or benzalkonium chloride 257,435,449-453 . 12.3 METHODS TO REDUCE ADVERSE EFFECTS OF AGENTS There are two primary strategies for minimizing hand hygiene-related irritant contact dermatitis among HCWs: selecting less irritating hand hygiene products and using moisturizing skin care products following hand cleansing. 12.3.1 SELECTING LESS IRRITATING PRODUCTS Because HCWs must clean hands frequently, it is important for health-care facilities to provide products that are both efficacious and as safe as possible for the skin. The tendency of products to cause skin irritation and dryness is a major factor influencing their acceptance and ultimate use by HCWs 82,190,454-457 . For example, concern about the drying effects of alcohol was a major cause of poor acceptance of alcohol-based handrubs in hospitals 239,458 . Although many hospitals have provided HCWs with plain soaps in the hope of minimizing dermatitis, frequent use of such products has been associated with even greater skin damage, dryness and irritation than some antiseptic preparations 155,188,190 . One strategy for reducing exposure of HCWs to irritating soaps and detergents is to promote the use of alcohol-based handrubs containing humectants. Several studies have demonstrated that such
products are tolerated better by HCWs and are associated with a better skin condition when compared with either plain or antiseptic hand products 188,190,253,256,262,360,430,459,460 . With rubs, the shorter time required for hand antisepsis may increase acceptability and compliance 461 . In settings where the water supply is unsafe, waterless hand antisepsis presents additional advantages over soap and water 462 . 12.3.2 REDUCING SKIN IRRITATION Certain hand hygiene practices can also increase the risk of skin irritation and should be avoided. For example, routinely washing hands with soap and water immediately before or after using an alcohol-based product is not only unnecessary but may lead to dermatitis 463 . Additionally, donning gloves while hands are still wet from either washing or applying alcohol increases the risk of skin irritation. For these reasons, HCWs should be reminded not to wash their hands before or after applying alcohol and to allow their hands to dry completely before putting on gloves. A recent study demonstrated that HCW education regarding proper skin care management was effective in preventing occupational skin disorders 464 . No product, however, is free of potential risk. Hence, it is usually necessary to provide an alternative for use by individuals with sensitivity or reactions to the hand hygiene product available in the institution. 12.3.3 USE OF MOISTURIZING SKIN CARE PRODUCTS The effects of hand hygiene products on skin vary considerably, depending upon factors such as the weather and environmental conditions. For example, in tropical countries and during the summer months in temperate climates, the skin remains more moisturized than in cold, dry environments. The effects of products also vary by skin type. In one recent study, nurses with darker skin were rated as having significantly healthier skin and less skin irritation than nurses with light skin, both by their own self-assessment as well as by observer rating 465 . Results of a prevalence survey of 282 Chinese hospital nurses suggested that hand dermatitis was less common among this group when compared with those in other parts of the world 466 . Hence, the need for moisturizing products will vary across health-care settings, geographical locations and respective climate conditions, and individuals. For HCWs who are at risk of irritant contact dermatitis or other adverse reactions to hand hygiene products, additional skin moisturizing may be needed. Hand lotions and creams often contain humectants, fats and oils that increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of the skin 429,467 . Several controlled trials have shown that regular use of such products can help prevent and treat irritant contact dermatitis caused by hand hygiene products 468-470 . Importantly, in the trial by McCormick and colleagues 469 , improved skin condition resulting from frequent and scheduled use of an oil-containing lotion led to a 50% increase in hand cleansing frequency among HCWs. These investigators emphasized the need to educate HCWs regarding the value of regular, frequent use of hand-care products. However, most of the hand moisturizing agents are not sterile so may easily become contaminated, and have been associated with outbreaks in the neonatal ICU setting 471 . In particular, if the lotion is poured from a large bottle into smaller bottles, the smaller containers should be washed and disinfected between uses and not topped up. Recently, barrier creams have been marketed for the prevention of hand hygiene-related irritant contact dermatitis. Such products are absorbed into the superficial layers of the epidermis and are designed to form a protective layer that is not removed by standard hand cleansing. Evidence of the efficacy of such products, however, is equivocal 468,469,472 . Furthermore, such products are expensive. Therefore, their use in health-care settings,
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The WHO Guidelines on Hand Hygiene
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CONTENTS INTRODUCTION . ...........
Page 7 and 8: 17. Organizing an education program
Page 11: INTRODUCTION The WHO Advanced Draft
Page 14 and 15: Handwashing. Washing hands with pla
Page 16 and 17: still considered the standard of ca
Page 18 and 19: treatment selectively removes glyce
Page 20 and 21: of the organism on their hands. Mak
Page 22 and 23: 6. MODELS OF HAND TRANSMISSION 6.1
Page 24 and 25: In the 1960s, a prospective, contro
Page 26 and 27: for its ability to reduce the relea
Page 28 and 29: 8.2 SHORTCOMINGS OF TRADITIONAL TES
Page 30 and 31: tions of short-chain aliphatic alco
Page 32 and 33: 9.1.3 WATER QUALITY The physical, c
Page 34 and 35: Case study: experience of Egypt The
Page 36 and 37: and both reduced viral counts on ha
Page 38 and 39: activity of chlorhexidine is not se
Page 40 and 41: protein synthesis and alteration of
Page 42 and 43: in micelle structures formed by sur
Page 44 and 45: In all the studies that included pl
Page 46 and 47: isopropyl alcohol) were applied to
Page 48 and 49: 3) Glycerol is added using a measur
Page 50 and 51: in 2005 the costs of an alcohol-bas
Page 52 and 53: infection, risk factors that are la
Page 54 and 55: 11.4.4 SIDE-EFFECTS OF THE SURGICAL
Page 56 and 57: • Repeat the process on the other
Page 60 and 61: particularly when resources are lim
Page 62 and 63: Handrubs are available as gels, sol
Page 64 and 65: 14. HAND HYGIENE PRACTICES AMONG HE
Page 66 and 67: quantified in observational studies
Page 68 and 69: According to behavioural theories (
Page 70 and 71: of water with special leaves) outsi
Page 72 and 73: Furthermore, according to Phra Depv
Page 74 and 75: 16. BEHAVIOURAL CONSIDERATIONS 16.1
Page 76 and 77: and community factors must be consi
Page 78 and 79: i. ii. iii. iv. v. vi. a) b) Educat
Page 80 and 81: tion precautions 580 . There are al
Page 82 and 83: follow the intent 588 . Studies hav
Page 84 and 85: 18. FORMULATING STRATEGIES FOR HAND
Page 86 and 87: 18.2 DEVELOPING A STRATEGY FOR GUID
Page 88 and 89: 1998 (P
Page 90 and 91: HCWs routinely to wear vinyl gloves
Page 92 and 93: quality gloves, reuse, shortage of
Page 94 and 95: • To test for holes, gloves shoul
Page 96 and 97: Figure l.20.2: Blood safety: crucia
Page 98 and 99: Consensus recommendations are that
Page 100 and 101: D. Wash hands with either plain or
Page 102 and 103: 5. SKIN CARE A. B. C. Include infor
Page 107 and 108: PART III. OUTCOME MEASUREMENTS 1. M
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2. HAND HYGIENE AS A QUALITY INDICA
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can be seen during routine work. Da
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Case study: United Kingdom national
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PART IV. PROMOTING HAND HYGIENE ON
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ated to reinforce its principles (t
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6. PRINCIPLES OF COUNTRYWIDE HAND H
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As many international and national
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debate that resulted in increasing
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23. Lee YL et al. Colonization by S
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Interscience Conference on Antimicr
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122. Vicca AF. Nursing staff worklo
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171. Kauppinen J et al. Hospital wa
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224. Krilov LR et al. Inactivation
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276. Thomas L et al. Development of
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326. Johnson S et al. Prospective,
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34th Interscience Conference on Ant
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423. Kampf G, et al. Influence of a
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474. West DP et al. Evaluation of a
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524. Muto C et al. Hand hygiene rat
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578. Babcock HM et al. An education
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Interscience Conference on Antimicr
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679. Hirschmann H et al. The influe
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729. Martin LS, McDougal JS, Loskos
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Table I.8.1: Basic experimental des
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Table I.9.1: Waterborne pathogens a
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Table I.9.3: Virucidal activity of
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Table I.9.4: Studies comparing the
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Table I.9.6: Studies comparing the
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Table I.14.1: Hand hygiene frequenc
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Table I.14.2: Hand hygiene adherenc
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Table I.15.1: Hand hygiene indicati
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Table I.18.1: Strategies for succes
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Table l.20.1: Possible problems and
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Table I.21.1. Hand hygiene research
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Table I.21.1: Hand hygiene research
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Table I.21.2: Unsolved issues for r
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Table III.2.1: Quality indicators r
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Table V.3.1: Examples of public inf
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Table V.4.1: Examples of national p
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Table V.5.1: The public information
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APPENDIX 1. DEFINITIONS OF HEALTH-C
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APPENDIX 2. HAND AND SKIN SELF-ASSE
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Data in coloured cells can be chang
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NHS NICU n-P NPSA NA NS OPD PACU PA
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AUTHORS: John Boyce Saint Raphael H
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Garance Upham People’s Health Mov
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