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The cold and flu season, coupled with the recent threats of Methicillin-resistant Staphylococcus aureus (MRSA) and H1N1, has Americans washing their hands more often — and hopefully for the recommended 15 to 20 seconds. While frequent hand washing does halt the spread of many infectious diseases, it comes with an unwelcome side effect (exacerbated in dry, winter weather): it can lead to damaged skin, or irritant contact dermatitis.
According to the U.S. Centers for Disease Control and Prevention (CDC), frequent and repeated use of hand-hygiene products,
particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among healthcare workers. A recent study conducted by the National Institute for Occupational Safety & Health (NIOSH) and the American Academy of Dermatology supports this claim.
"Our findings confirm that healthcare workers who wash their hands repeatedly (eight or more times a day) are at an increased risk of developing hand dermatitis, which can take months to heal," says Dr. Susan T. Nedorost, associate professor of dermatology at University Hospitals Case Medical Center in Cleveland.
In fact, 63 percent of the healthcare workers in the study suffered from dermatitis.
Dry, cracked hands may not sound serious, but they can be. Dermatitis affects the integrity of the skin as a barrier to bacteria and pathogens. In clinical settings, hand dermatitis can not only lead to increased risk of infection for the sufferer, but to reduced compliance with hand washing guidelines, increasing the spread of pathogens.
Dermatitis is not just a problem in healthcare settings. Some experts estimate that up to 35 percent of all occupational diseases are skin diseases, and allergic and contact dermatitis constitutes the majority of those cases. Medical expenses for contact dermatitis alone are estimated to be more than $1.4 billion, and productivity losses are estimated to be another $500 million.
Some industries — including medical, construction, foodservice and cleaning — have increased incidence of dermatitis either because of the exposure to harsh chemicals or detergents, or because of increased hand washing requirements. Latex allergy, a childhood history of eczema (a skin inflammation involving scaly and itchy rashes), being prone to sunburn, or even age can increase chances of getting dermatitis, but the single most common cause is repeated exposure to water.
Experts say that reducing hand hygiene is not the answer, prevention is. That's where jan/san distributors can help by providing the appropriate products, especially during cold, winter months.
Frequent wetting and drying removes the oils that make the skin pliable and protect hands from cracks. Hand sanitizers have rapidly gained popularity as a convenient and waterless replacement for traditional hand washing. As a result, they are being placed everywhere from grade schools to hospitals to grocery stores.
Hand sanitizers can't replace hand washing in every situation, but a study published in the "Infection Control and Hospital Epidemiology Journal" found that irritation and dryness increased significantly when nurses washed their hands with a soap product, while "an alcoholic-hand-gel regimen was well tolerated and did not result in skin irritation and dryness."
The CDC recommends alcohol-based hand sanitizers, especially in healthcare settings, and states that alcohol-based rinses or gels containing emollients caused substantially less skin irritation and dryness than the soaps or antimicrobial detergents tested.
"In my opinion, in low humidity conditions, the rapid evaporation of water is more damaging than the irritant effects of the surfactants," Nedorost says. "So, it is better to use an alcohol-based or other waterless hand sanitizer as opposed to frequent washing."
Although alcohol-based sanitizers don't dry out hands as much as soaps and detergents, alcohol can sting already compromised skin. And the CDC says that frequent use of alcohol-based formulations for hand antisepsis can cause drying of the skin unless emollients, humectants or other skin-conditioning agents are added to the formulations. Many manufacturers currently do add emollients to alcohol-based sanitizers.
Non-alcohol based hand sanitizers are also available and these alternatives can be less harsh to skin. While early non-alcohol-based hand rubs got off to a slow start (they were not as effective at germ killing in trials as alcohol-based ones), more recent advanced formulations have been developed, most notably, quat-based sanitizers (Benzalkonium Chloride). Sanitizers with Benzalkonium Chloride as the active ingredient may even out-perform alcohol with a greater sustained antibacterial activity.
"Not only are quat-based sanitizers less drying on the skin than alcohol based, but the germ killing properties last longer than alcohol-based products," says Linda Silverman, president of Maintex Inc., City of Industry, Calif.
In addition, since non-alcohol sanitizers are not flammable and non-toxic, they can be used in institutional settings such as schools or prisons where alcohol-based formulations are commonly banned, says Ed Corr, vice president of Corr Distributors Inc., Tonawanda, N.Y.
Another way to reduce dryness is to apply foam-based sanitizers rather than a gel formulation.
"Foams work well in reducing dermatitis because generally less product is used in each application, and thus there is less chemical contact," says Silverman.
Soap Still Matters
There are certain situations where using hand sanitizers as a replacement for soap and water are not recommended, including after using a restroom, before handling food, and anytime hands are visibly soiled.
Foodservice facilities, especially, should use soap rather than sanitizer to clean hands. Food proteins and fatty materials, commonly found on foodservice workers hands, can significantly reduce the effectiveness of an alcohol gel. So in foodservice settings, where bacteria and enteric viruses such as Norovirus are the primary concerns, the Food and Drug Administration (FDA) Model Food Code Rules and Regulations state that hand sanitizers may be used by food workers in addition to, but not in place of, proper hand washing. And because hand sanitizers are considered to be a food additive, only products approved by the FDA may be used in foodservice settings.
When soap is recommended, distributors should encourage products that reduce dryness — such as soaps with emollients and stand-alone moisturizers.
"Neutral pH hand soaps with milder surfactant systems and lanolin derivates make an excellent choice," says Silverman. "To improve skin condition sometimes aloe vera is added, but while it apparently has more healing properties, lanolin is a better moisturizer."
However, these products should be matched to their institutional setting. For example, according to Occupational Safety and Health Administration (OSHA) directives, some moisturizers that contain anionic surfactants or emulsifiers may interfere with the antibacterial effect of chlorhexidine gluconate (CHG) on the skin, and some petroleum-based moisturizers may cause deterioration of latex gloves. So, in clinical settings, these types of moisturizers should be avoided. According to CDC guidelines, as a simple rule of thumb: if the first ingredient of the moisturizer is water, then it is probably water-based not petroleum-based.
Most people experience dry hands in winter when the cold air chaps skin and low humidity removes moisture. However, for some, dermatitis is a year-round problem because their field requires frequent hand washing. Distributors should talk with their customers to find out if more hand sanitizers or different soap products are necessary, especially in healthcare facilities, to help relieve the pain caused by dry, cracked hands.
Lisa Anderson Mann is a freelance writer based in northern California.