Hand washing or alcohol sanitising; which is more effective?

This debate has been going on for years and there are still those who insist that hand washing is the most effect answer. The following is an extract from one of the many papers that I have of my system, all of which reach a similar conclusion.

‘Self-assessment of skin condition and grade of skin damage worsened significantly more in the group using soap than in the group using alcoholic disinfectant. The alcohol-based rinse was significantly more effective than liquid soap in removing transient contaminant micro-organisms.

Conclusions: In everyday hospital practice alcohol-based disinfectant is more effective and better tolerated than non-antiseptic soap; soap is at risk of spreading contamination, and skin comfort strongly influences the number and the quality of hand hygiene procedures.’

Winnefield M, Richard MA, Drancourt M, Grob JJ, British Journal of Dermatology, Vol 143, 3, first published June 2008

So why is there still so much emphasis from ‘official’ sources and on the media on frequent hand washing?

Way back in March when the lockdown occurred and the official advice was to wash your hands frequently I was inundated with requests for guidance from OH practitioners in how to deal with the increase in skin damage (irritant contact dermatitis) that they were encountering in their workforce (mostly not NHS) due to the increase in hand washing. Some were OH practitioners working in schools with real problems with children for the same reason. So it isn't just the NHS. In my conversations with dermatologists this is a topic that has arisen on several occasions and their view seems to be that washing hands more than 20 times in a single day can result in a significant accumulation of irritant damage, initially at an asymptomatic level, that ultimately results in a clinical damage situation. To some extent this can be resolved by the use of a moisturising lotion every time the hands are washed to replace the micro-scopically thin hydro-lipic film in the outermost skin layers that the soap will have removed, but this is an additional complication and, of course, a cost.

Biker 1 – With regard to which method to use you are correct. Alcohol sanitiser is not a cleanser and is easily inactivated by organic soiling. Even the NICE accredited guidance on infection prevention for NHS England (epic3 - downloadable from Internet) covers this.

Recommendation SP7 states:

"Use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used:

• when hands are visibly soiled or potentially contaminated with body uids; and

• when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn"

My concern is twofold. First is the effectiveness at hand decontamination. All the many studies I have seen are clear on this. Alcohol is the more effective. Indeed, to quote one such study (peer reviewed and published in the British Journal of Dermatology) ‘Surprisingly, hand washing with soap seems to increase the total bacterial count on hands.’ This is not the only study to have found this.

There is also the issue of ensuring correct procedures are followed.

Hand washing –

Water temperature must be not higher than 380C as anything over this has a negative effect on the skin’s barrier properties.

Wet hands – apply soap – rub hands following the correct method for at least 20 seconds – rinse hands sufficiently well to remove all traces of soap (often not done, as observed by me when in hospital recently) – dry hands completely – apply moisturising lotion and rub well in. Time measured in one study ≥60 seconds.

Alcohol sanitiser -

Apply sanitiser – rub hands using correct method until hands dry. Time measured in the study 25 seconds.

Comment in the study was that it was much easier to ensure proper hand hygiene with the alcohol sanitiser.

Add to this the fact that for hand washing we need a washbasin with water supply whereas with the sanitiser this can be using a small container taken from our pocket.

You would be surprised where methychloroisothiazolinone (MCI) and (MI) crop up. For example, you have changed from that solvent based paint to a water based one on the basis that this was safer. What you haven't realised is that water  based paints require a preservative and this is commonly an isothiazolinone (there are several different types). 

Now with the solvent based paint once the paint has dried it is inert. With the water based paint the MCI/MI will still be in the paint and will be released slowly over quite some time. If the release is into a closed environment, e.g. a room with window and door closed, the airborne concentration can build to a level where it can cause facial allergic contact dermatitis. This not uncommon. 

In one study they found that a significant release was still taking place ten days after the paint had been applied!

Both MCI and MI are well established sensitisers and can cause allergic reactions at very low concentrations

Items such as paints and adhesives will consider their VOC (solvent) emissions to air whilst timber based products consider their Formaldehyde emission rates.

Interesting to see if industry will eventually be required to give preservative emissions over time.

After almost a year of constant hand washing, I definitely can say that alcohol sanitizing seems to be a better choice. As for my personal experience, I have concerns about public restroom soap. I am afraid to use it if it’s a block of regular soap. I’m fine with the stuff in dispensers (like these). Tell me that I’m not the only one, please.

#11 Reported funded advertising link