How irritant is alcohol?

Introducing the model of repeated exposure of skin to antiseptics: Randomised pilot trial

INTRODUCTION

Intensified hand hygiene measures were recommended for preventing the spread of SARS-CoV-2. However, these measures can lead to skin damage and the development of hand eczema, particularly among health professionals.

OBJECTIVES

This pilot study aimed to evaluate the effects of repeated antiseptic use on healthy skin under controlled conditions and to assess the emollient use.

METHODS

Twelve healthy volunteers (nine females, age = 22.3 ± 2.8 years (mean ± SD), Fitzpatrick phototypes II and III) with no skin diseases were recruited. Antiseptic was applied daily for 3 weeks on the volar sides of forearms. Emollient cream was also applied daily. Skin assessments were performed using non-invasive methods (transepidermal water loss-TEWL, skin hydration, erythema and melanin content).

RESULTS

Prolonged antiseptic use increased TEWL, decreased hydration and elevated erythema and melanin levels. Emollient cream significantly reduced TEWL and improved hydration on antiseptic-treated sites, and also enhanced hydration on intact skin.

CONCLUSIONS

Prolonged use of antiseptics can have adverse effects on the skin, including barrier disruption and inflammation. Emollient showed promise in improving skin hydration and reducing the damage caused by antiseptics. Further research with a larger sample is needed to confirm these findings and assess emollient efficacy during frequent antiseptic use.

A comparative study on the effect of alcohol-based hand sanitizers in spray and gel formulation on the skin: A prospective, randomised, crossover trial

BACKGROUND

Many formulations of Alcohol-based hand rubs (ABHRs), such as liquid, gel, and spray have been developed and used for preventing infections. This study aimed to compare skin irritation from using ABHRs in gel and spray formulations.

METHOD

This was a prospective, randomised, crossover trial conducted to investigate the effect of skin irritation caused by ABHRs in gel compared to spray formulation after 21 days of using each formulation. Clinical outcomes were assessed using subjective Larson's skin assessment score and Frosch and Kligman observer skin assessment score, as well as bioengineering measures: transepidermal water loss (TEWL) and skin capacitance on days 3, 7, 14, and 21.

RESULTS

Among 38 participants, both formulations showed no significant change in clinical scores and skin capacitance during the study. However, TEWL increased significantly from baseline on day 3 (p = 0.029) for the spray formulation and on day 21 (p = 0.019) for the gel formulation, with no statistically significant difference between the formulations (p = 0.46).

CONCLUSION

Our research supports the safety of gel and spray ABHRs for regular use, with the only potential issue being mild skin irritation. For those with sensitive skin, the gel formulation is preferable.

Using patients' observations to evaluate healthcare workers' alcohol-based hand rub with Pulpe'friction audits: a promising approach?

Background

Hand hygiene plays an important role in the transmission of nosocomial infections from healthcare workers (HCW) to patients. Patients could play a key role in improving hand hygiene by sharing their experience of the HCW's practices. Already in 2019, the French national mission of transversal support for actions to prevent healthcare-associated infections proposed the national "Pulpe'friction" audit, to assess HCW's reported practices, social representations, and barriers to using alcohol-based hand rubs (ABHR). This audit consisted of a positive discussion between an auditor and the HCW as well as patients, which led the HCW to declare their real practices and the barriers they faced in the field and the patients to report about the HCW's ABHR practices and the information they received about when they should perform hand hygiene.

Objective

To assess whether an association existed between HCW's reported ABHR compliance and patients' declarations about HCW's compliance in the Pulpe'friction audit data.

Methods

Data from Pulpe'friction were collected from 1st January to 31st December 2019, before the COVID-19 pandemic. Mixed linear models were performed to analyze the association between self-reporting by HCW and patients, regarding hand rubs performed by HCW prior to patient care.

Results

There was a positive association between patients' observations and HCW's declared practices regarding the frequency of with which professionals performed hand rubs before patient contact. This indicates that professional and patient statements show the same tendency. The positive association was found in hospitals for patients under 45 and over 64 years old and for paramedics, but not for physicians and not in nursing homes or long-term care facilities. Patients felt more motivated to observe and evaluate HCWs' practices if they had received information about how to correctly wash their hands.

Conclusion

Patients agreed to be involved in the evaluation or professional practices. The patients' observations were positively associated with HCWs reports. New indicators taking patients' observations into account could be interesting.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

Characterization of Cleaning and Disinfection Product Use, Glove Use, and Skin Disorders by Healthcare Occupations in a Midwestern Healthcare Facility

Healthcare facility staff use a wide variety of cleaning and disinfecting products during their daily operations, many of which are associated with respiratory or skin irritation or sensitization with repeated exposure. The objective of this study was to characterize the prevalence of cleaning and disinfection product use, glove use during cleaning and disinfection, and skin/allergy symptoms by occupation and identify the factors influencing glove use among the healthcare facility staff. A questionnaire was administered to the current employees at a midwestern Veterans Affairs healthcare facility that elicited information on cleaning and disinfection product use, glove use during cleaning and disinfection, skin/allergy symptoms, and other demographic characteristics, which were summarized by occupation. The central supply/environmental service workers (2% of the total survey population), nurses (26%,), nurse assistants (3%), and laboratory technicians (5%) had the highest prevalence of using cleaning or disinfecting products, specifically quaternary ammonium compounds, bleach, and alcohol. Glove use while using products was common in both patient care and non-patient care occupations. The factors associated with glove use included using bleach or quaternary ammonium compounds and using cleaning products 2-3 or 4-5 days per week. A high frequency of glove use (≥75%) was reported by workers in most occupations when using quaternary ammonium compounds or bleach. The use of alcohol, bleach, and quaternary ammonium compounds was associated with skin disorders (p < 0.05). These research findings indicate that although the workers from most occupations report a high frequency of glove use when using cleaning and disinfection products, there is room for improvement, especially among administrative, maintenance, and nursing workers. These groups may represent populations which could benefit from the implementation of workplace interventions and further training regarding the use of personal protective equipment and the potential health hazards of exposure to cleaning and disinfecting chemicals.

Comparing surgeons' skin tolerance and acceptability to alcohol-based surgical hand preparation vs traditional surgical scrub: A matched quasi-experimental study

BACKGROUND

We aimed to compare the tolerance and acceptability of alcohol-based surgical hand preparation versus handscrubbing with antimicrobial soap and water by surgeons.

METHODS

Matched quasi-experimental trial in an academic quaternary care hospital in Ribeirão Preto, Brazil, from April 1 to October, 31, 2017. Participants were cardiac and orthopedics surgeons from the study facility. In the first study phase, they performed handscrubbing with either 2% chlorhexidine (CHG) or 10% iodopovidone (PVP-I) and, in the second phase, they performed handrubbing with alcohol-based handrub (ABHR). Surgeons' skin tolerance and acceptability were evaluated using WHO-validated tools. Data were analyzed using the MacNemar's test within STATA.

RESULTS

A total of 33 surgeons participated to the "per protocol" population; the majority were male (94%); mean age of 35 years (SD, 8.5). On product tolerance, there was a minimal variation in redness, scaliness, fissures, and visual evaluation of the skin when handrubbing with ABHR was compared to handscrubbing with either PVP-I or CHX. Regarding acceptability, participants rated better handrubbing with ABHR than handscrubbing with PVP-I when assessing product smell (66.6% vs 0%, p=0.002), color (73.3% vs 0%, p=0.001), product texture (60% vs 0%, p=0.004), skin dryness (60% vs 0%, p=0.004), ease of application (66.6% vs 0%, p=0.002) and overall satisfaction (66.6% vs 6.7% p=0.011). Participants rated similarly handrubbing with ABHR and handscrubbing with CHX, except for product texture, where handrubbing rated better (71,4% vs. 0%, p=0.002). Handrubbing with ABHR was preferred by 73.3%.

CONCLUSION

Although handrubbing and handscrubbing were equally well tolerated by surgeons, alcohol-based surgical hand preparation fell into the personal preference for most of them.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (ReBEC), RBR-8ym9yj.

Indirect consequences of coronavirus disease 2019: Skin lesions caused by the frequent hand sanitation and use of personal protective equipment and strategies for their prevention

The coronavirus disease 2019 (COVID‐19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) enforced the use of hand sanitation and of personal protective equipment, such as masks and visors, especially by health‐care professionals, but also by the general public. However, frequent hand sanitation and the prolonged and continuous use of personal protective equipment are responsible for constant frictional and pressure forces on skin causing lesions, the most reported being acne, facial itching, dryness, and rash. Thus, it is important to find measures to prevent skin lesions, in order to improve the quality of life of health‐care professionals and of the general public. This article gathers the current information regarding measures to prevent human to human transmission of COVID‐19, reviews the most common skin lesions caused by the use of hand sanitizers and different types of personal protective equipment, and the possible preventive measures that can be used on a daily basis to minimize the risk of developing skin‐related pathologies. Daily skin care routines and the incorporation of a dressing between the skin and the personal protective equipment to serve as a protective barrier are some of the applied measures. Moisturizers and dressings improve the skin's ability to respond to constant aggressions. Lastly, the need for additional studies to evaluate the lubrication properties of different types of dressings is discussed. The understanding of what kind of dressing is more suitable to prevent pressure injuries is crucial to promote healthy skin and wellbeing during pandemic times.

Hand hygiene and hand eczema: a systematic review and meta-analysis

Hand eczema is a common inflammatory condition of the skin that has been linked to hand hygiene. This systematic review and meta-analysis aims to determine the risks of hand eczema associated with hand hygiene, including frequency of handwashing, wet-work and use of alcohol hand rub. A comprehensive search of MEDLINE, EMBASE and Cochrane Library was performed for cohort, case-control or cross-sectional studies that analysed the association between hand hygiene and risk of hand eczema. Results of individual studies were presented in respective forest plots and pooled summary relative risks were estimated using a random-effects model. Forty-five studies were included in analysis. Handwashing at least 8-10 times daily significantly increased risk of hand eczema (relative risk [RR] 1.51; 95% confidence interval [CI]: 1.35-1.68; P < .001). The risk was related to handwashing frequency, with higher pooled RR of 1.66 (95%CI: 1.51-1.83; P < .001) with increased handwashing at least 15-20 times daily. However, use of alcohol-based hand sanitizer was not significantly associated with risk of hand eczema. Given the widespread implementation of hand hygiene practices during the COVID-19 pandemic, there is a pertinent need to understand skin care habits specific to the hands to avoid a greater incidence of hand eczema. This article is protected by copyright. All rights reserved.

Assessment of hand hygiene strategies on skin barrier function during COVID-19 pandemic: a randomized clinical trial

INTRODUCTION

COVID-19 has increased the frequency of hand washing. There is scarce evidence regarding the impact of different hand hygiene procedures on skin barrier function in clinical practice.

OBJECTIVE

To compare the impact on skin barrier function of different hand hygiene measures in health care workers in daily practice.

METHODS

A randomized controlled clinical trial was conducted. Participants were randomized to sanitize their hands with water and soap, alcohol-based hand sanitizers (ABHS) or disinfectant wipes during their 8-hour work-shift. Epidermal barrier functional parameters, like transepidermal water loss (TEWL), and the microbial load were assessed before and immediately after the workday. Tolerance and acceptability of each product were recorded after work.

RESULTS

Sixty-two participants were included and 20, 21 and 21 were randomized respectively to use water and soap, ABHS and disinfectant wipes. After the 8-hour shift, TEWL increase was higher with disinfectant wipes than with soaps or ABHS (+5.45vs + 3.87vs-1.46 g·h^-1 ·m^-2 respectively, P = .023). Bacteria and fungi colony-forming unit (CFU) count reduction was lower for water and soap group than for ABHS and disinfectant wipes. Disinfectant wipes were considered more difficult to use (P = .013) compared to water and soap and ABHS.

CONCLUSION

Daily hand hygiene with ABHS showed the lowest rates of skin barrier disruption and the highest reduction of CFU. This article is protected by copyright. All rights reserved.

Virgin coconut oil as prophylactic therapy against alcohol damage on skin in COVID times

Background

Increased frequency of using alcohol‐based hand sanitizers (ABHS) by consumers during COVID times have resulted in increased incidences of skin issues on palms.

Objective

(1) To quantify skin damage with increased usage frequency of ABHS by consumers and (2) To evaluate Virgin Coconut Oil (VCO) as natural prophylactic agent to counter the adverse effects.

Methods

In‐home usage study was carried out with 60 volunteers for a 15‐day intervention—Control Group: 6 applications per day of ABHS and Test Group: Overnight VCO use (6–8 drops) followed by 6× usage per day of ABHS. This leg included dermatological evaluation and WHO Self‐Assessment Scale for skin health. Another leg of measurement included non‐invasive instrumental study (Moisture & TEWL Probes, Tape Strip for protein content and IR spectroscopy for protein & lipid content) on forearm of 12 subjects (25–60 years age) with and without VCO application and repeated alcohol exposure.

Results

In‐home usage study established consumer experiencing skin protective effect of VCO in the context of ABHS onslaught. 25% increase in perceived moisture content was recorded for VCO users, using WHO Self‐Assessment Scale. Instrumental studies confirmed an increase in TEWL and decrease in lipids & protein content. Overnight VCO application resists the extraction which builds up with repeated application.

Conclusions

Current work provides evidence of compromised hand skin barrier with ABHS daily usage. Overnight VCO application helps prepare the skin for next day alcohol use. Based on the findings, a regimen of overnight VCO application on hands as a natural prophylactic is recommended.

Production of first- and second-generation ethanol for use in alcohol-based hand sanitizers and disinfectants in India

Emergence of "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" causing "COVID-19" or "coronavirus disease 19" as pandemic has got worldwide attention towards hygiene as the first line of defense for the infection control. It is first line of defense not only from COVID-19 but also from other infectious diseases caused by deadly pathogens such as cholera, hepatitis, tuberculosis, polio, etc. Absence of any particular vaccine or treatment let World Health Organization (WHO) recommend to the public to maintain social distancing along with regularly washing their hands with soap, sanitize their hands (where washing is not possible), and disinfect their belongings and buildings to avoid the infection. Out of various formulations available in the market, WHO has recommended alcohol-based hand sanitizers, which mainly comprise of ethanol, isopropyl alcohols, and hydrogen peroxides in different combinations due to their high potential to kill the broad range of pathogens including bacterial, viral, fungal, helminthes, etc. Therefore, alcohol-based sanitizers are in high demand since centuries to prevent infection from pathogenic diseases. Ethanol is the most common and popular alcohol in terms of vanishing wide range of pathogens, convenient to use and its production. Ethanol is produced worldwide and is used in various sectors, e.g., beauty and cosmetics, food and beverages, and as the most demanding gasoline additive. The present review is focused on the ethanol production in India, its diversified applications emphasizing hand sanitizers with discussions on formulation of sanitizer and disinfectants, and viability of lignocellulosic and food grain-based ethanol. The review article also emphasizes on the technological details of 1G and 2G ethanol production, their associated challenges, and inputs for the improved ethanol yields so as to strengthen the supply chain of ethanol in India, and making "Atmanirbhar Bharat" (Self-reliant India) campaign of Indian government successfully viable.

How irritant are n-propanol and isopropanol? - A systematic review

BACKGROUND

The use of alcoholic-based hand rubs (ABHRs) is an important tool for hand hygiene, especially in times of the COVID-19 pandemic. Possible irritant effects of ABHR may prevent their use by persons at risk of infection.

METHODS

This systematic review is based on a PubMed search of articles published between January 2000 and September 2019 in English and German, and a manual search, related to the irritation potential of alcohol-based disinfectants restricted to n-propanol (1-propanol) and its structural isomer isopropanol (isopropyl alcohol, 2-propanol).

RESULTS

The majority of the included studies show a low irritation potential of n-propanol alone. However, recent studies provide evidence for significant barrier damage effects of repeated exposure to 60% n-propanol in healthy, as well as atopic skin in vivo. The synergistic response of combined irritants, (ie, a combination of n-propanol or isopropanol with detergents such as sodium lauryl sulfate) is greater, compared with a quantitatively identical application of the same irritant alone.

CONCLUSION

While recent studies indicate a higher risk of skin irritation for n-propanol and isopropanol than reported in the past, this risk still seems to be lower than that for frequent handwashing with detergents, as recommended by some to prevent COVID-19 infections.

Efficacies of the original and modified World Health Organization-recommended hand-rub formulations

The World Health Organization (WHO) hand-rub formulations have been in use around the world for at least the past 10 years. The advent of coronavirus disease 2019 (COVID-19) has further enhanced their use. We reviewed published efficacy data for the original and modified formulations. Only efficacy data according to the European Norms (EN) were found. The bactericidal efficacy of the original formulations was, under practical conditions, partly insufficient (EN 1500, only effective in 60 s; EN 12791, efficacy too low in 5 min). The first modification with higher alcohol concentrations improves their efficacy as hygienic hand rub (effective in 30 s). The second (0.725% glycerol) and third (0.5% glycerol) modification improves their efficacy for surgical hand preparation (effective in 5 and 3 min). The original and second modified formulations were tested and demonstrate activity against enveloped viruses including severe acute resiratory syndrome coronavirus 2 (SARS-CoV-2) in 30 s. The ethanol-based formulation is also active against some non-enveloped test viruses in 60 s (suspension tests, EN 14476). In-vivo data on the formulations would provide a more reliable result on the virucidal efficacy on contaminated hands but are currently not available. Nevertheless, the most recent modifications should be adopted for use in healthcare.

Salvianolic Acid B in Microemulsion Formulation Provided Sufficient Hydration for Dry Skin and Ameliorated the Severity of Imiquimod-Induced Psoriasis-Like Dermatitis in Mice

Psoriasis is a chronic inflammatory skin disorder with a pathogenesis involving the interleukin-23/interleukin-17 axis. Salvianolic acid B exerts several pharmacological effects, such as antioxidation, anti-inflammation, and antitumor effects. The anti-psoriatic effects of salvianolic acid B have not been reported. In this study, we aimed to determine the optimum vehicle for salvianolic acid B, investigate its therapeutic effect on psoriatic-like skin conditions, and explore its underlying mechanisms of action. BALB/c mice were administered topical imiquimod to induce psoriasis-like skin and were then randomly assigned to control, vehicle control, salvianolic acid B in vehicles, and 0.25% desoximetasone ointment treatment groups. Barrier function, cytokine expression, histology assessment, and disease severity were evaluated. The results showed that salvianolic acid B-containing microemulsion alleviated disease severity, reduced acanthosis, and inhibited interleukin-23/interleukin-17 (IL-23/IL-17) cytokines, epidermal proliferation, and increased skin hydration. Our study suggests that salvianolic acid B represents a possible new therapeutic drug for the treatment of psoriasis. In addition, such formulation could obtain high therapeutic efficacy in addition to providing sufficient hydration for dry skin.

Hand Sanitizers: A Review on Formulation Aspects, Adverse Effects, and Regulations

Hand hygiene is of utmost importance as it may be contaminated easily from direct contact with airborne microorganism droplets from coughs and sneezes. Particularly in situations like pandemic outbreak, it is crucial to interrupt the transmission chain of the virus by the practice of proper hand sanitization. It can be achieved with contact isolation and strict infection control tool like maintaining good hand hygiene in hospital settings and in public. The success of the hand sanitization solely depends on the use of effective hand disinfecting agents formulated in various types and forms such as antimicrobial soaps, water-based or alcohol-based hand sanitizer, with the latter being widely used in hospital settings. To date, most of the effective hand sanitizer products are alcohol-based formulations containing 62%-95% of alcohol as it can denature the proteins of microbes and the ability to inactivate viruses. This systematic review correlated with the data available in Pubmed, and it will investigate the range of available hand sanitizers and their effectiveness as well as the formulation aspects, adverse effects, and recommendations to enhance the formulation efficiency and safety. Further, this article highlights the efficacy of alcohol-based hand sanitizer against the coronavirus.

Skin barrier function after repeated short-term application of alcohol-based hand rub following intervention with water immersion or occlusion

BACKGROUND

Alcohol-based hand rub (ABHR) is recommended for hand hygiene, and application on dry skin is generally well tolerated. However, hydration of the skin may lead to increased susceptibility to ABHR.

OBJECTIVES

To evaluate if increased skin hydration changes skin barrier response to ABHR, as compared to application on dry skin.

METHODS

Twenty healthy volunteers participated in a 3-day experimental setup. Intervention areas on the forearms were exposed to either water immersion or occlusion followed by repeated exposures to ABHR. Skin barrier function was assessed by measurement of transepidermal water loss (TEWL), electrical conductance, pH, and erythema at baseline and day 3.

RESULTS

The area exposed to water immersion preceding ABHR showed a significant increase in TEWL from baseline to day 3 (P = .04), and for the occluded area the same trend was found (P = .11), with an additional decrease in electrical conductance (P = .03). No significant differences were found for the control area. The assessments did not differ significantly between intervention and control sites.

CONCLUSION

Our results indicate that extensive skin hydration may lead to increased susceptibility to ABHR. Further evaluation of this observation is important, since ABHRs are widely used, particularly among health care workers in whom hand eczema is a huge problem.

Barrier damaging effects of n-propanol in occlusion-modified tandem repeated irritation test: Modulation by exposure factors and atopic skin disease

BACKGROUND

Recent studies provide evidence for significant and previously underestimated barrier damaging effects of repeated exposure to 60% n-propanol in healthy skin in vivo.

OBJECTIVES

To investigate further the cumulative effects of a range of n-propanol concentrations relevant at the workplace in healthy and atopic dermatitis (AD) individuals, and study the modulation of the outcomes by co-exposure and host-related factors.

METHODS

Healthy adult and AD volunteers were exposed to n-propanol concentrations from 30% to 75% in occlusion-modified tandem repeated irritation test with measurements of erythema, transepidermal water loss, capacitance, and the natural moisturizing factor (NMF) levels at baseline and after 96 hours.

RESULTS

n-Propanol exerted significant barrier damaging effects even at the lowest concentration in both groups. Exposure to all n-propanol concentrations significantly reduced the NMF levels. Preceding low-grade trauma by occlusion/water exposure reduced the skin irritation threshold in both groups. The differences in the severity of the barrier function impairment after exposure to the same concentrations under the same conditions between the AD and control groups were significant.

CONCLUSIONS

The negative effects of cumulative exposure to n-propanol in healthy and atopic skin shown in the study suggest the need for critical re-evaluation of its irritant properties in vivo.

[Prevention of hand eczema]

Apart from endogenous factors, hand eczema is often caused by irritant or allergic contact dermatitis related to occupational or non-occupational exposure to skin hazards. This enables several complementary approaches on the level of primary, secondary and tertiary prevention. A high priority is set on identification and subsequent reduction or elimination of causative exposures. Important preventive approaches include legal regulations, technical and organizational measures as well as correct use of adequate personal protective equipment (e.g. protective gloves). Interventions based on health education are conducted to improve individual protective behaviour. Even though evidence-based proof of effectiveness is limited, preventive measures are considered of particular importance for avoidance of occupational hand eczema and its adverse sequelae. Therefore, a complex, step-wise approach to occupational skin diseases has been established in Germany. In recent years, the positive impact of secondary and tertiary preventive measures of this approach has been demonstrated.

Glycerol content within the WHO ethanol-based handrub formulation: balancing tolerability with antimicrobial efficacy

Background

The World Health Organization (WHO) ethanol-based handrub (EBHR) formulation contains 1.45% glycerol as an emollient to protect healthcare workers’ (HCWs) skin against dryness and dermatitis. However, glycerol seems to negatively affect the antimicrobial efficacy of alcohols. In addition, the minimal concentration of glycerol required to protect hands remain unknown. We aim to evaluate the tolerance of HCWs to the WHO EBHR formulation using different concentrations of glycerol in a tropical climate healthcare setting.

Methods

We conducted a cluster-randomized, double-blind, crossover study among 40 HCWs from an intensive care unit of a tertiary-care hospital in Brazil, from June 1st to September 30, 2017. We tested the WHO EBHR original formulation containing 1.45% glycerol against three other concentrations (0, 0.5, and 0.75%). HCWs used one formulation at a time for seven working days during their routine practice and then had their hands evaluated by an external observer using the WHO scale for visual inspection. Participants also used a WHO self-evaluation tool to rate their own skin condition. We used a generalized estimating equations of the logit type to compare differences between the tolerability to different formulations.

Results

According to the independent observation, participants had 2.4 times (95%CI: 1.12–5.15) more chance of having a skin condition considered good when they used the 0.5% compared to the 1.45% glycerol formulation. For the self-evaluation scale, participants were likely to have a worst evaluation (OR: 0.23, 95%CI: 0.11–0.49) when they used the preparation without glycerol compared to the WHO standard formulation (1.45%), and there were no differences between the other formulations used.

Conclusion

In a tropical climate setting, the WHO-modified EBHR formulation containing 0.5% glycerol led to better ratings of skin tolerance than the original formulation, and, therefore, may offer the best balance between skin tolerance and antimicrobial efficacy.

Functional Fragments of AIMP1-Derived Peptide (AdP) and Optimized Hydrosol for Their Topical Deposition by Box-Behnken Design

Aminoacyl-tRNA synthetase complex-interacting multifunctional protein 1 (AIMP1)-derived peptide (AdP) has been developed as a cosmeceutical ingredient for skin anti-aging given its fibroblast-activating (FA) and melanocyte-inhibiting (MI) functions. However, a suitable strategy for the topical delivery of AdP was required due to its low-permeable properties. In this study, FA and MI domains of AdP (FA-AdP and MI-AdP, respectively) were determined by functional domain mapping, where the activities of several fragments of AdP on fibroblast and melanocyte were tested, and a hydrosol-based topical delivery system for these AdP fragments was prepared. The excipient composition of the hydrosol was optimized to maximize the viscosity and drying rate by using Box-Behnken design. The artificial skin deposition of FA-AdP-loaded hydrosol was evaluated using Keshary-Chien diffusion cells equipped with Strat-M membrane (STM). The quantification of the fluorescent dye-tagged FA-AdP in STM was carried out by near-infrared fluorescence imaging. The optimized hydrosol showed 127-fold higher peptide deposition in STM than free FA-AdP (p < 0.05). This work suggests that FA- and MI-AdP are active-domains for anti-wrinkle and whitening activities, respectively, and the hydrosol could be used as a promising cosmetic formulation for the delivery of AdPs to the skin.

Tandem repeated irritation test (TRIT) studies and clinical relevance: Post 2006

Background/Aims: Single or multiple applications of irritants can lead to occupational contact dermatitis, and most commonly irritant contact dermatitis (ICD). Tandem irritation, the sequential application of two irritants to a target skin area, has been studied using the Tandem Repeated Irritation Test (TRIT) to provide a more accurate representation of skin irritation. Objective: Here we present an update to Kartono's review on tandem irritation studies since 2006. Methods: We surveyed the literature available on PubMed, Embase, Google Scholar, and the UCSF Dermatology library databases since 2006. Results and discussion: The studies included discuss the tandem effects of common chemical irritants, organic solvents, occlusion as well as clinical relevance - and enlarge our ability to discern whether multiple chemical exposures are more or less likely to enhance irritation.

Effect of hand lotion on the effectiveness of hygienic hand antisepsis: Implications for practicing hand hygiene

BACKGROUND

Skin protection products should be used after washing hands with soap, during breaks, after work, and during leisure time. Aside from their beneficial effects, skin care products may also interact with alcohol-based hand disinfectants by reducing their efficacy. The aim of this study was to investigate the effect of a hand lotion on the effectiveness of hygienic hand antisepsis using an alcohol-based handrub.

METHODS

The effect of a protective hand lotion against an isopropyl alcohol-based handrub was investigated in 20 healthy volunteers according to the European standard test procedure EN 1500 in the following combinations: handwashing and application of hand lotion, only application of hand lotion, and no washing and no hand lotion (control), each for 5 minutes or 1 hour before hand antisepsis. The difference in microbiologic before-and-after values were expressed as log reduction factor.

RESULTS

The effectiveness of hand antisepsis was not significantly affected in any of the groups using the tested hand lotion.

CONCLUSIONS

Hand antisepsis may be delayed for 5 minutes after hand lotion application. Shorter time intervals might be possible but were not tested.

Comparative assessment of local tolerance of alcohols commonly used in alcohol-based hand rubs for hand hygiene

Hand hygiene plays a key role in nosocomial infection prevention. To achieve users' adherence, products' dermal tolerance is essential. We aimed at making a comparative assessment of skin irritation and phototoxicity of the 3 alcohols commonly used in alcohol-based hand rubs (Ethanol, Propan-2-ol, Propan-1-ol) at 60, 70, 80 or 85% w/w in water or with co-formulates (hydrating, emollient and skin protective agents). In vitro validated OECD methods 439 and 432 were used. For irritation, EpiSkin™ Small Model was the chosen Reconstructed Human Epidermis (RhE). For phototoxicity, co-formulates alone or in mixture with and without alcohol were tested using BALB/c 3T3 cell cultures. Whilst Ethanol and Propan-2-ol could not be differentiated and displayed good skin tolerance profiles, Propan-1-ol based products lead to significant viability impairments of RhE at 60, 70 or 80% and at 60% in the presence of co-formulates. However, these results could not be reproduced in another RhE model. Taking also into account bibliographic data on Propan-1-ol, this suggests that our results are probably related to a lack of specificity of the used RhE. Therefore, it can be relevant in case of significant results to use two different RhE models before performing any classification and/or performing any complementary tests.

Implementation of the WHO multimodal Hand Hygiene Improvement Strategy in a University Hospital in Central Ethiopia

Background

The burden of health-care associated infections in low-income countries is high. Adequate hand hygiene is considered the most effective measure to reduce the transmission of nosocomial pathogens. We aimed to assess compliance with hand hygiene and perception and knowledge about hand hygiene before and after the implementation of a multimodal hand hygiene campaign designed by the World Health Organization.

Methods

The study was carried out at Asella Teaching Hospital, a university hospital and referral centre for a population of about 3.5 million in Arsi Zone, Central Ethiopia. Compliance with hand hygiene during routine patient care was measured by direct observation before and starting from six weeks after the intervention, which consisted of a four day workshop accompanied by training sessions and the provision of locally produced alcohol-based handrub and posters emphasizing the importance of hand hygiene. A second follow up was conducted three months after handing over project responsibility to the Ethiopian partners. Health-care workers’ perception and knowledge about hand hygiene were assessed before and after the intervention.

Results

At baseline, first, and second follow up we observed a total of 2888, 2865, and 2244 hand hygiene opportunities, respectively. Compliance with hand hygiene was 1.4% at baseline and increased to 11.7% and 13.1% in the first and second follow up, respectively (p < 0.001). The increase in compliance with hand hygiene was consistent across professional categories and all participating wards and was independently associated with the intervention (adjusted odds ratio, 9.18; 95% confidence interval 6.61-12.76; p < 0.001). After the training, locally produced alcohol-based handrub was used in 98.4% of all hand hygiene actions. The median hand hygiene knowledge score overall was 13 (interquartile range 11–15) at baseline and increased to 17 (15–18) after training (p < 0.001). Health-care workers’ perception surveys revealed high appreciation of the different strategy components.

Conclusion

Promotion of hand hygiene is feasible and sustainable in a resource-constrained setting using a multimodal improvement strategy. However, absolute compliance remained low. Strong and long-term commitment by hospital management and health-care workers may be needed for further improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0165-9) contains supplementary material, which is available to authorized users.

Effect of different alcohols on stratum corneum kallikrein 5 and phospholipase A2 together with epidermal keratinocytes and skin irritation

OBJECTIVES

The aim of this exploratory study was to investigate the effect of ethanol, isopropanol and n-propanol on stratum corneum (SC) enzymes and keratinocytes in vitro together with their effects on skin condition and function.

METHODS

Activities of kallikrein 5 (KLK5) and phospholipase A2 (PLA2) as well as keratinocyte metabolic activity, interleukin-1α (IL-1α) and tumor necrosis factor-α (TNF-α) were measured in vitro in the presence and absence of the different alcohols. We also measured transepidermal water loss (TEWL), skin capacitance, visual dryness and visual redness on the volar forearms of 25 Caucasian women following application of the alcohols 20 and 100 times per day over a period of 14 days in a clinical study.

RESULTS

Reduced activities of KLK5 and PLA2 were observed in the presence of the alcohols. The greatest denaturing effect was always observed for n-propanol (P < 0.001), and in the case of PLA2, the effect of isopropanol was greater than ethanol (P < 0.001). Equally, ethanol had the mildest effects on keratinocyte metabolic activity and cytokine secretion (P < 0.001) and n-propanol always produced the most severe changes in normal and differentiated keratinocytes. These in vitro findings supported the clinical results where the major effects were on the induction of skin irritation (increased dropout rates) and ranked the intolerance of the different alcohols as follows: n-propanol > isopropanol > ethanol. At the high application frequencies, the effect of the different alcohols on transepidermal water loss (TEWL) and skin capacitance was similar, but at the low application frequencies, n-propanol had a significant effect on TEWL and capacitance values (P < 0.05). Equally, n-propanol and isopropanol produced significantly more skin redness at the low application frequencies.

CONCLUSIONS

Clearly, isopropanol and n-propanol caused significant SC and keratinocyte perturbation in vitro together with damage to skin condition and function in vivo whereas ethanol did not. As a result, we show that ethanol-based sanitizers are better tolerated by skin, particularly in high-use settings, than other alcohols and should be the active ingredient of choice.

Self-reported hand eczema among dental workers in Japan - a cross-sectional study

BACKGROUND

Dental workers are considered to have a high risk of developing occupational hand eczema.

OBJECTIVES

To estimate the prevalence of work-related hand eczema and associated risk factors in dental workers in Japan.

METHODS

A self-administered questionnaire was sent by mail to all dental clinics of Kumamoto City, Japan. In addition, patch testing with 24 dentistry-related allergens was offered.

RESULTS

In total, 46.4% of dental workers (n = 528: response 31.4%, based on 97 clinics) reported a lifetime history of chronic hand eczema. The 1-year prevalence was 36.2%. According to logistic regression analysis, the most important risk factors for the 1-year prevalence were a personal history of atopic dermatitis [odds ratio (OR) 4.7, 95% confidence interval (CI): 2.2-8.8], asthma and/or allergic rhinitis (OR 2.0, 95%CI: 1.3-3.0), dry skin (OR 1.7, 95%CI: 1.1-2.7), shorter duration of work (OR 2.0, 95%CI: 1.2-3.5 for up to 10 years versus >20 years), and washing hands >10 times per day (OR 1.6, 95%CI: 1.0-2.5). Fifty-four workers were patch tested. Rubber chemicals and acrylates were the most frequent occupationally relevant contact allergens.

CONCLUSIONS

Dental workers in Japan have a high prevalence of hand eczema. Health education to prevent hand eczema and more frequent patch testing are needed.

Optimal evaluation time point for patch testing to predict skin irritation of commercial topical drugs

To develop patch testing (PT) that better reflects the skin irritation resulting from repeated applications, we methodically classified PT results and examined correlations between these results with results from repeated application tests. A total of 115 commercial topical drugs were used for patch testing. In two groups of 30 healthy individuals with normal back skin, 55 or 60 commercial topical drugs were applied to the back for 24 h. Skin reactions were scored for each group at 2 and 24 h after patch removal. Based on time-dependent changes in skin reaction at each evaluation time, PT results were classified into six different types. For repeated application testing, a total of 17 products with different types of PT results were selected. A total of 104 healthy individuals divided into three groups (n = 22-52 each) received application of 6-7 test materials, differing for each group, for 3 weeks on both arms. Incidences of positive symptoms induced by repeated drug application excluding transient erythema showed a greater correlation with reaction levels at 24 h after patch removal than 2 h after patch removal. Many test materials that triggered a high incidence of positive symptoms after repeated application also exhibited erythema or greater reaction up to 24 h after patch removal. PT offers a useful test system for predicting skin irritation that develops after repeated application of topical drug. Moreover, assessment at 24 h after patch removal is suggested as the optimal evaluation time point to reflect the results of repeated application tests.

Systemic mistakes in hand hygiene practice in Ukraine: detection, consequences and ways of elimination

Aim: Every year, millions of people around the world suffer from different infectious diseases, considerable part of which are hospital-acquired infections. WHO considers hand hygiene as a priority measure aimed to reduce the level of infection. We evaluated various aspects related to the situational behavior and prioritization regarding hand hygiene measures among the healthcare workers of Ukraine.

Method: Identification of system mistakes in hand hygiene was carried out first of all by direct and indirect observation of the activities of medical and pharmaceutical personnel in their everyday practice as well as during their participation in trainings on routine hand hygiene. Questionnaires also were used to estimate the level of hand hygiene compliance of participants of the study. During this period 112 training courses, 315 master-classes and presentations on proper hand hygiene were realized. The target audience included health care workers of medical centers, clinics, maternity hospitals, health care organizations and staff of pharmacies and pharmaceutical manufacturing enterprises in all regions of Ukraine. 638 respondents took part in anonymous survey on hand hygiene practice.

Results: The most common mistakes were to regard hand washing and hand disinfection equally, to wash hands before doing a hand disinfection, to neglect the five moments for hand hygiene and to ignore hand hygiene before and after wearing protective gloves. Practitioners, medical attendants, pharmacy and pharmaceutical industry workers highlighted the need for practical and understandable instructions of various hand hygiene procedures, including the clarification of the possible technical mistakes. This became a ground for us to create individual master classes on hand hygiene for each cluster of healthcare workers.

Conclusions: Changing hand hygiene behavior and attitude is possible by beginning to observe clinical practice and by involving healthcare workers in teaching and training.

Effect of the hand antiseptic agents benzalkonium chloride, povidone-iodine, ethanol, and chlorhexidine gluconate on atopic dermatitis in NC/Nga mice

Antiseptic agents can cause skin irritation and lead to severe problems, especially for individuals with atopic diatheses. We investigated the effect of 4 different antiseptic agents using an atopic dermatitis (AD) model mouse. NC/Nga mice were subcutaneously injected with mite allergen (Dp) to induce AD-like skin lesions (ADSLs), and an application of 0.2% (w/v) benzalkonium chloride (BZK), 10% (w/v) povidone-iodine (PVP-I), 80% (v/v) ethanol (Et-OH), or 0.5% (v/v) chlorhexidine gluconate (CHG) was applied to the ear envelope. BZK induced a significant increase in the severity of the clinical score, infiltration of inflammatory cells, local expression of inflammatory cytokines in subcutaneous tissue, and total serum immunoglobulin (Ig) E. PVP-I increased the clinical score, number of mast cells, and production of inflammatory cytokines, and total serum IgE. Et-OH increased the clinical score and number of inflammatory cells, but showed no effect on serum IgE levels. No differences in any parameters were observed between CHG and the vehicle. Collectively, the results suggest the severity of the ADSL was related in part to the strength of the immunoreaction. These findings suggest that CHG could offer the lowest risk of inducing ADSL in individuals with atopic dermatitis and that medical staff and food handlers with AD could benefit from its use.

Cohort Study of Adherence to Correct Hand Antisepsis Before and After Performance of Clinical Procedures

Objective.

To investigate the rate of adherence by hospital staff members to the correct use of alcohol-based hand rub before and after performance of clinical procedures.

Design.

A cohort study conducted during the period from 2006 through 2007 and 2 cross-sectional studies conducted in 2006 and 2007.

Setting.

Århus University Hospital, Skejby, in Århus, Denmark.

Participants.

Various hospital staff members.

Methods.

Following an ongoing campaign promoting the correct use of alcohol-based hand rub, we observed rates of adherence by hospital staff to the correct use of alcohol-based hand rub. Observations were made before and after each contact with patients or patient surroundings during 5 weekdays during the period from 2006 through 2007 in 10 different hospital units. A logistic regression model was used to estimate the rate of adherence to the correct use of alcohol-based hand rub before and after performance of a clinical procedure.

Results.

A total of 496 participants were observed during 22,906 opportunities for hand hygiene (ie, 11,177 before and 11,729 after clinical procedures) that required the use of alcohol-based hand rub. The overall rates of adherence to the correct use of alcohol-based hand rub were 62.3% (6,968 ofthe 11,177 opportunities) before performance and 68.6% (8,041 ofthe 11,729 opportunities) after performance of clinical procedures. Compared with male participants, female participants were significantly better at adhering to the correct use of alcohol-based hand rub before performance (odds ratio [OR] 1.51 [95% confidence interval {CI}, 1.09–2.10]) and after performance (OR, 1.73 [95% CI, 1.27–2.36]) of clinical procedures. In general, the rate of adherence was significantly higher after the performance of clinical procedures, compared with before (OR, 1.43 [95% CI, 1.35–1.52]). For our cohort of 214 participants who were observed during 14,319 opportunities, the rates of adherence to the correct use of alcohol-based hand rub were 63.2% (4,469 of the 7,071 opportunities) before performance and 69.3% (5,021 of the 7,248 opportunities) after performance of clinical procedures, and these rates increased significantly from 2006 to 2007, except for physicians.

Conclusion.

We found a high and increasing rate of adherence to the correct use of alcohol-based hand rub before and after performance of clinical procedures following a campaign that promoted the correct use of alcohol-based hand rub. More hospital staff performed hand hygiene with alcohol-based hand rub after performance of clinical procedures, compared with before performance. Future campaigns to improve the rate of adherence to the correct use of alcohol-based hand rub ought be aware that certain groups of hospital staff (eg, male staff members) are known to exhibit a low level of adherence to the correct use of alcohol-based hand rub.

Hand hygiene--evaluation of three disinfectant hand sanitizers in a community setting

Hand hygiene is acknowledged as the single most important measure to prevent nosocomial infections in the healthcare setting. Similarly, in non-clinical settings, hand hygiene is recognised as a key element in helping prevent the spread of infectious diseases. The aim of this study was to evaluate the efficacy of three different disinfectant hand sanitizers in reducing the burden of bacterial hand contamination in 60 healthy volunteers in a community setting, both before and after education about the correct use of hand sanitizers. The study is the first to evaluate the efficacy and ease of use of different formulations of hand rubs used by the general population. The products tested were: Sterillium (perfumed, liquid), desderman pure gel (odorless, gel) and Lavit (perfumed, spray). Sterillium and desderman are EN1500 (hygienic hand rub) certified products (available in pharmacy) and Lavit is non EN1500 certified and available in supermarkets. The two EN1500 certified products were found to be significantly superior in terms of reducing bacterial load. desderman pure gel, Sterillium and Lavit reduced the bacterial count to 6.4%, 8.2% and 28.0% respectively. After education in the correct use of each hand rub, the bacterial load was reduced even further, demonstrating the value of education in improving hand hygiene. Information about the testers' perceptions of the three sanitizers, together with their expectations of a hand sanitizer was obtained through a questionnaire. Efficacy, followed by skin compatibility were found to be the two most important attributes of a hand disinfectant in our target group.

Reducing transcranial direct current stimulation-induced erythema with skin pretreatment: considerations for sham-controlled clinical trials

OBJECTIVES

Transcranial direct current stimulation (tDCS)-induced erythema (skin reddening) has been described as an adverse effect that can harm blinding integrity in sham-controlled designs. To tackle this issue, we investigated whether the use of topical pretreatments could decrease erythema and other adverse effects associated with tDCS.

MATERIALS AND METHODS

Thirty healthy volunteers were recruited, and four interventions were applied 30 min prior to tDCS in a Latin square design: placebo, ketoprofen 2%, hydroxyzine 1%, and lidocaine 5%. TDCS was applied for 30 min (2 mA, anode and cathode over F3 and F4, respectively) in two active sessions with a minimum 1-week interval. The Draize erythema scoring system scale was used to assess erythema intensity; a tDCS questionnaire was used to assess other adverse effects (e.g., tingling, itching, burning sensation, and pain).

RESULTS

We found that ketoprofen (but not hydroxyzine or lidocaine) significantly attenuated tDCS-induced erythema regarding intensity and duration, with a medium effect compared with placebo. Erythema was overall mild, short-lived (lasting 18-24 min after tDCS ending), and more intense under the anode. Subjects with darker skin color also tended to present less intense tDCS-induced erythema. The prevalence of other adverse effects was low and did not differ between dermatological groups.

CONCLUSIONS

Ketoprofen 2% topical pretreatment might be an interesting strategy to reduce tDCS-induced erythema and might be useful for blinding improvement in further sham-controlled tDCS trials.

Wet work and hand eczema in apprentice nurses; part I of a prospective cohort study

BACKGROUND /OBJECTIVES

Environmental exposure and personal susceptibility both contribute to the development of hand eczema. Here, we report an investigation on wet work exposure and its influence on the risk of developing hand eczema in apprentice nurses.

METHODS

A prospective cohort study was performed among 721 Dutch apprentice nurses. Participants recorded wet work exposure and symptoms of hand eczema using specially designed diary cards.

RESULTS

For 533 apprentice nurses, a follow-up time of 1-3 years was completed. Diary cards were supplied by 383 students. The 1-year period prevalence of hand eczema was 23% in the first year, 25% in the second year and 31% in the third year of follow-up. Eighty-one new cases of hand eczema developed, most of which occurred during the first year of follow-up. In approximately one-third of the participants, wet work exposure exceeded the national guidelines. Frequent hand washing during traineeships [odds ratio (OR) 1.5; 90% confidence interval (CI) 1.0-2.3], frequent hand washing at home (OR 2.3; 90% CI 1.5-3.7) and having a side job involving wet work (OR 1.6; 90% CI 1.0-2.4) were independent risk factors for hand eczema.

CONCLUSION

As a considerable number of apprentice nurses had already developed hand eczema during traineeships, more attention should be paid to skin protection in vocational education.