Hand washing or alcohol sanitiser?

This morning going through my collection of information on hand decontamination collected over some considerable time I came across one paper that I had forgotten about. In this study a comparison was made between a non-antiseptic skin cleanser and an alcohol-based skin rub. Results showed:

‘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.’

‘The alcohol-based rinse was more effective than the non-antiseptic soap in reducing the colony count immediately after hand washing (mean log change from before to after hand decontamination was +0.122 after the hand washes with soap compared with -0.342 after the hand rubs with the alcohol-based rinse).

‘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.’

 Winnefeld M, Richard MA, Drancourt M, Grob JJ, Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use, British Journal of Dermatology, 143 (3), 2008

Note that this dates from 2008, long before the Covid-19 pandemic with its emphasis on hand washing!

Food for thought?

Certainly there are variations in individual peoples' skin. However, certain factors tend to be common. For example, the hydrolipidic film in the surface layers of the skin is only around 2 - 3 microns thick. Any detergent, e.g. a liquid soap, will remove this on hand washing. This is common to almost all skin, albeit more pronounced among those known as atopic. It can take the skin quite some time to regenerate this layer and until this happens the skin cannot retain the moisture needed to act effectively as a barrier. This is common for all skin types although some, e.g. atopics, are more affected than others. Certainly the study was done using bacteria. Viruses are smaller and several studies have shown that they can actually be more difficult to remove with hand washing. Indeed, I have more than one study that shows that even where hand washing has been carried out with considerable determination it has been shown that it has failed to remove embedded transient micro-organisms. The drying effect of the loss of the hydro-lipidic film and subsequent effects within the skin can also reduce the population of commensal flora and it is these that help create a surface condition that hinders the colonisation of the skin by transient micro-organisms. These effects are common with only minor variations across different types of skin. The alcohol sanitiser, if properly formulated, does not result in the removal of the skin's hydrolipidic film and can actually act as a moisturiser. Incidentally, this is only one of a number of studies that have reached the same conclusion. What is missing in the official guidance on hand washing is any mention of action to restore the skin's natural barrier properties following hand washing. I have had numerous approaches from occupational health practitioners seeking guidance on action to restore skin damaged by frequent hand washing since the start of the Covid-19 pandemic. Incidentally, using UV tracer it is surprising how many people fail to rinse their hands adequately leaving behind a residue of skin cleanser plus some of the micro-organisms they should have removed. The NICE accredited guidance for NHS England on infection prevention recommends for hand decontamination that alcohol sanisiter be used with hand washing reserved for just  two specific situations.

Steve - if you look at the various peer-reviewed publications on infection prevention, particularly those concerned with the healthcare sector, it quickly becomes apparent that the major problem is that of 'compliance'. Many, many efforts have been made to achieve compliance but no-one has yet come up with a total solution. Just one simple example of what you find. Last summer I spent several days as an in-patient on a cardiology ward. From my bed I watched nurses washing their hands. Over three days not one washed their hands in a way that I would consider adequate (and note that the NICE accredited guidance recommends alcohol sanitiser not hand washing for most hand decontamination in healthcare institutions!). Inadequate hand washing results in the skin cleanser and micro-organisms that need to be removed being left on the hands! Now watch television and note how many people you see who are simply not wearing their facial covering correctly - usually with the top of the covering below the nose! We still have lots of work to achieve the standards of care that we really need.

If you read the study (Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use, Winnefeld, Richard, Drancourt and Grob, British Journal of Dermatology, Vol 143, Issue3, 2008) you will better understand why the authors came to this conclusion. To quote: “Moreover, after 40% of the hand washes with soap, contaminant micro-organisms were isolated, which had not been present before, Serrtia marcesens, Acinetobacter sp., Enterobacter sp., Citrobacter so. Were isolated in eight, three, four one and three cases respectively. Yeasts were retrieved once. Contamination occurred only in 10% of the evaluated alcohol-based hand rinses. Acinetobacter appeared three times, Enterobacter sp. Once and Staphylococcus aureus once.”

A similar conclusion was reach in Chamberlain, Halablab, Gould, Miles, Distribution of bacteria on hands and the effectiveness of brief and thorough decontamination procedures using non-medicated soap. Zbl Bakt 1997, 285, 565-75.

In addition, in a review article in the International Journal of Cosmetic Science (Hand hygiene compliance and irritant dermatitis: a juxtaposition of healthcare issues, March 2012) the authors found that the irritant effect of hand washing damaged the skin barrier. “Irritated hands had significantly more colony-forming units than normal hands. Total bacteria counts were higher as skin damage increased.”

And from the WHO:

“The study revealed that touching intact areas of moist skin transferred enough organisms to the nurses’ hands to allow subsequent transmission to catheter material despite handwashing with plain soap and water; by contrast, alcohol-based handrubbing was effective and prevented crosstransmission to the device.” – WHO Guidelines on Hand Hygiene in Health Care, page 22

These are just examples that show that the whole topic of hand hygiene, or rather hand decontamination, is not quite as simple as many assume. If you need more PM me with contact details and I will respond.