Hand Care Issues

Intact skin is a first line defence mechanism against infection. Damaged skin can not only lead to infection in the host, but can also harbour higher numbers of micro-organisms than intact skin and hence increase the risk of transmission to others. Damaged skin on HCWs is an important issue and needs to be seriously addressed (click here for an example of a skin care questionnaire for healthcare workers).

There are two major types of skin reactions associated with hand hygiene. Irritant contact dermatitis; which includes symptoms that can vary from mild to debilitating, including dryness, irritation, itching, and even cracking and bleeding. The other being allergic contact dermatitis, which is rare and represents an allergy to some ingredient in a hand hygiene product. In its most serious form allergic contact dermatitis may be associated with symptoms of anaphylaxis (1).

The vast majority of skin problems among HCWs that are related to HH are due to “irritant contact dermatitis” (27). Irritant contact dermatitis is primarily due to frequent and repeated use of HH products - especially soaps, other detergents, and paper towel use, which result in skin drying. The initial use of ABHR among such HCWs often results in a stinging sensation. However, recent studies have suggested that the ongoing use of emollient-containing ABHR leads to improvement in irritant contact dermatitis in approximately 70% of affected HCWs (28) Also, the use of an oil-containing lotion or a barrier cream three times a shift can substantially protect the hands of vulnerable healthcare workers against drying and chemical irritation, preventing skin breakdown (75).

It is important to ensure that the selected ABHR, soaps, and moisturising lotions are chemically compatible to minimise skin reactions among staff (17).

Factors that may contribute to dermatitis include:

  • Fragrances and preservatives. Commonly the cause of contact allergies; these should be kept to a minimum or eliminated when selecting an ABHR
  • Washing hands regularly with soap and water immediately before or after using an ABHR is not only unnecessary, but may lead to dermatitis (58)
  • Donning gloves while hands are still wet from either handwashing or applying ABHR increase the risk of skin irritation (1)
  • Using hot water for handwashing
  • Failure to use supplementary moisturisers
  • Quality of paper towels

The management of hand care problems associated with the use of HH products requires early re cognition and a systematic approach to ensure success. 

Strategies for minimising occupational hand dermatitis include:

  • Use of a HH product that contains skin emollient to minimise the risk of skin irritation and drying
  • Educating staff on the correct use of HH products
  • Educating staff on caring for their hands, including the regular use of skin moisturisers both at work and at home - such moisturising skin-care products need to be compatible with ABHR
  • Providing a supportive attitude towards staff with skin problems

ABHR produces the lowest incidence of irritant contact dermatitis of all the HH products currently available (1, 58). True allergy to ABHR is rare and allergy to alcohol alone has not been reported (58).

Although some reports have suggested that irritant contact dermatitis can occur in up to 30% HCWs (29); the incidence of this problem among a recent study of Victorian HCWs was extremely low (0.47%), representing one cutaneous adverse event per 72 years of HCW exposure (28)

HCWs should be encouraged to notify the HH Program Officer if skin irritation occurs following the use of ABHR. All complaints should be taken seriously and a review process instigated. All hospitals should have access to referral for follow up that may include: an Occupational Dermatologist, local Doctor, or emergency department for HCWs with persistent skin problems. For WHO consensus recommendations on skin care see Appendix 6 in the HHA Manual.


Further Information

http://www.occderm.asn.au/ The website of the Occupational Dermatology Education and Research Centre

Practical Steps for healthcare workers with contact dermatitis - Flow chart for management from the Occupational Dermatology Education and Research Centre

Cutaneous Absorption

Recent studies have demonstrated minimal rates of cutaneous alcohol absorption such that there should be no concern for HCWs (21,30). A recent study suggested that isopropanol might be less likely to be absorbed than ethanol. Thus, HCWs concerned about absorption for religious reasons may elect to use an ABHR that contains isopropanol rather than ethanol (21).

Cultural and religious factors strongly influence attitudes to community handwashing which, according to behavioural theorists are likely to have an impact on compliance with hand hygiene during health care (1, 55). In some religions, and even within the same religion, various degrees of interpretation exist concerning alcohol prohibition. In general, those religions with an alcohol prohibition in everyday life demonstrate a practical view accepting the most valuable approach to optimal patient care. Consequently, no objection is raised against the use of alcohol based products for environmental cleaning, disinfection or hand hygiene.

When implementing a hand hygiene campaign with an ABHR in a healthcare setting where religious groups are represented, it is important to include focus groups on this topic to allow HCWs to raise concerns about the use of ABHRs, help them to understand the evidence underlying this recommendation, and to identify possible solutions to overcome obstacles (1). The same process should be used when implementing ABHRs into areas where there may be a cultural problem with alcohol abuse.