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Hand hygiene (previously termed hand washing) continues to be the sentinel infection control practice. The importance of this fundamental procedure was initially appreciated as a result of hospital-based investigations conducted in the 1800s that were able to demonstrate a relationship between hand washing and a decline in hospital patient infections. Semmelweis, Holmes, and other pioneers were able to establish the initial foundation for future research with their insightful epidemiological and clinical findings from studies conducted in hospital wards.1
An important component of later investigations was the introduction of a variety of antimicrobial chemicals to augment hand-washing procedures aimed at preventing cross-contamination and cross-infection. Even with the addition of antimicrobials ranging from the historical lime and soda chlorides to current, less toxic antiseptics, however, the primary purpose of hand hygiene remains the same—removal of transient microorganisms from the skin.2 Accumulated clinical and science-based knowledge continues to reinforce the importance of fundamental information. Among these are:
1. Microorganisms transferred from the hands of treatment providers are responsible for a significant percentage of healthcare-associated infections in in-patient facilities. Organisms on the hands of healthcare professionals (HCP) are responsible for many of the over 2 million healthcare-associated (previously termed nosocomial) infections each year in the United States. Most of the documented infections in the scientific literature occur within in-patient settings, such as hospitals and long-term care facilities.
2. Hand hygiene is the single most important infection-control practice in preventing person-to-person transmission of microbial pathogens. Numerous studies also have shown that proper hand antisepsis substantially decreased infection rates among patients in hospital settings. Included in this segment of the literature were investigations further demonstrating increased hand hygiene compliance when personnel used waterless, alcohol-based hand rubs. Recommendations concerning techniques are periodically modified as our understanding of cross-infection increased, along with pertinent information regarding development of new, effective, antimicrobial hand hygiene antiseptics.2,3
Accumulated documentation in the scientific literature strongly supports a connection between improved hand hygiene practices and reduction of infections among patients.2 With specific regard to dentistry, however, there is little documented information describing microbial transmission from the hands of dental healthcare workers (DHCW) to patients. As a result, epidemiological and clinical findings from acute-care sites provide the majority of the knowledge base for hand hygiene infection-control recommendations concerning DHCW and patient risks. The Centers for Disease Control and Prevention (CDC) periodically issues specific guidelines for hand hygiene. The most recent, comprehensive hand hygiene update is found in the 2002 Guideline for Hand Hygiene in Health-Care Settings,2 and applies to all workers in all healthcare settings. Similar recommendations were included in the 2003 CDC Guidelines for Infection Control in Dental Health-Care Settings.4 They state:
“Perform hand hygiene with either a non-antimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer’s instructions.”
Features of Hand-Hygiene Agents
Many products are available to accomplish the basic goals of hand cleaning and antisepsis. A few important criteria to consider for product selection are listed below (Table 1).5,6
Evaluation should initially look at product choices based on the treatment procedure(s) performed and level of exposure anticipated. Surgical procedures require a much higher level of antimicrobial activity than those classified as nonsurgical. This is illustrated by the recommendation of offering clinicians three acceptable choices when performing nonsurgical patient treatment: plain liquid soap and water; an antimicrobial soap and water; or a waterless high alcohol-based hand antiseptic when hands are clean. Because the majority of routine dental procedures are classified as nonsurgical, clinicians are afforded a variety of hand hygiene products that can accomplish infection control goals in this area.
With regard to these hand hygiene choices, washing with plain liquid soap is adequate and effective, as this agent has detergent properties that allow it to function as a mechanical cleanser in the removal of dirt, blood, saliva, and other organic forms of debris. An important aspect to consider, especially for those healthcare personnel with dry, sensitive skin, is that the non-antimicrobial soap chosen should contain ingredients that minimize skin irritation and drying.5-7 Products that contain emollients can assist in lubricating tissues and, thus, reduce adverse dermal problems (eg, Hand Essentials™ Lotion Soap, Hu-Friedy, www.hu-friedy.com; VioNexus™ Foaming Soap, Metrex, www.metrex.com; Moist SURE™ Lotion Soap, Sultan Healthcare, www.sultanhealthcare.com). Because many people who would consider this type of hand wash product have previously developed dermatitis and chapped hands from using other hand hygiene formulations, it is important that the mild lotion soap be pH balanced, maintain epithelial integrity, and contain moisturizing conditioners for sensitive skin.
The most frequently used classes of antimicrobial antiseptics currently available for use as hand wash agents are chlorhexidine gluconate, parachlorometaxylenol, and triclosan. Each of these antiseptics has an antimicrobial spectrum of activity that includes the majority of microorganisms encountered in healthcare facilities.2 Most healthcare workers routinely wash their hands using a product containing one of the above antimicrobials, which target microbes able to contaminate and/or colonize epithelial tissues (such as Hand Essentials™ Antibacterial Soap; Moist SURE Lotion Soap, and VioNexus). The feasibility for frequent use in healthcare settings without adversely affecting hands, excellent cleaning, and quick rinsing should be considered during personnel evaluation of products.
The Centers for Disease Control and Prevention (CDC) and Association for Practitioners in Infection Control and Epidemiology (APIC) and other recommending organizations also recommend alcohol-based hand products as an option for routine use and not just when soap and water are unavailable.2,4 The chemistry of alcohols allows them to rapidly function as effective broad-spectrum, protein-denaturing agents and lipid solvents. These characteristics serve to enhance their cidal range to include a wide range of bacteria and viruses, such as Mycobacterium tuberculosis, herpes viruses, and other enveloped viruses. Alcohol-based hand rubs have been demonstrated to be highly effective and assist in improving adherence to hand-hygiene protocols in healthcare settings. The 2002 CDC hand-hygiene guidelines state that alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, and cause less skin irritation.2 Alcohol-based hand rubs are available as low-viscosity rinses, gels, and foams for use in healthcare settings (eg, VioNexus™ Antiseptic Handwash; Moist SURE Liquid Sanitizer; SaniTyze™ Hand Sanitizer, Crosstex, www.crosstex.com). When evaluating products in this category, consideration should include ones that contain emollients to prevent skin damage, which potentially can lead to irritation dermatitis.8
Available products in this category typically contain varying concentrations of either ethanol or isopropanol that range from 60% to 70%. Their microbicidal effect declines rapidly when concentrations fall below 50%, with the optimum bactericidal concentration being 60% to 90%. Within this range it has been determined that higher concentrations of alcohol are associated with greater in vitro antimicrobial activity. In contrast to other currently available alcohol-based hand antiseptics, Sterillium Comfort GelTM (Hu-Friedy) contains a much higher ethanol concentration at 85%. Alcohol concentration, the amount of product applied, and compliance with prescribed procedure times are major factors that can affect hand-hygiene effectiveness. Current infection-control guidelines recommend vigorous rubbing of hands after application of the waterless alcohol-based hand antiseptics, allowing hands to remain wet for 15 to 20 seconds.2,4 As hand hygiene among healthcare professionals continues to be an ongoing infection-control problem, available agents that can accomplish hand antisepsis with shorter contact intervals would appear to promote better compliance without diminishing effectiveness. In the case of Sterillium Comfort Gel, it was found that when time-related studies were performed, this 85% ethanol-based gel was able to accomplish a broad-spectrum antibacterial effect in 15 seconds.9
One of the most troublesome problems faced by HCPs is the development of hand dermatitis. This condition is called by many terms, including non-specific irritation dermatitis and irritation contact dermatitis. It remains the most common form of harmful skin reaction, and is often found to be job-related in its onset and progression (Figure 1). Signs and symptoms may initially develop, resolve, and reappear multiple times. Common manifestations include:
• Dry, chapped hands
• Itchy, red, scaly, inflamed skin, which can be seen in the more sensitive hand areas (ie, knuckles, dorsum surface of hands)
• Cracked, abraded skin on hands that can bleed and hurt
These may also signal either a non-specific dermal irritation or onset of a true allergic reaction. Appropriate diagnosis by a qualified physician is necessary to determine what treatment is required. The keys for preventing hand dermatitis are to understand how hand dermatitis develops, what factors contribute to its progression, and how to prevent or resolve it.
Most dental professionals perform hand-hygiene procedures 20 to 30 or more times a day by washing with either soaps or antimicrobial antiseptic preparations, or using waterless alcohol-based hand rubs and sprays. Hands can become dry over time even when using a mild liquid soap if proper care is not taken. Keep in mind that healthy intact skin is the primary barrier to prevent infection. Damage to the epithelium can cause changes in the presence of the normal skin microbial flora. This can result in colonization by “transient” organisms, which typically have a greater potential for causing harmful infections. Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa represent two feared examples of this type of acquired pathogen. Frequent use of many types of soaps and antiseptics is associated with irritation dermatitis, especially among those HCPs who have a history of skin problems. In affected persons, the keratinized epithelium can subsequently become red and sore from acute inflammation, leading to more drying, even cracking and bleeding. Symptoms usually develop gradually over a period of days to weeks and are localized to the areas of exposure. Most of these adverse manifestations stop at the boundary of the glove cuff with the skin.10,11
In addition to frequent washing and use of harsh chemicals, dermal reaction can result from: not completely rinsing antiseptics off skin after washing; irritation from cornstarch powder in gloves; excessive perspiration while wearing gloves; improper washing techniques; using hot water for hand washing; and failure to dry hands completely.
The degree of skin irritation varies considerably and can be reduced substantially by choosing hand-hygiene products with emollients and using appropriate hand lotions designed for healthcare professional use that reduce dryness.12 Antimicrobials such as chlorhexidine gluconate, parachorometaxylenol (PCMX), or iodophors can also contribute to non-specific irritation dermatitis. Even alcohols, which are among the safest antiseptics, can still cause drying and skin irritation for those with poor skin conditions.
Preventing hand dermatitis requires compliance with recommended hand-hygiene procedures and routine care of hands. Washing with a hand-wash agent or waterless product that is the least irritating can help prevent initial drying of skin. Soap should be rinsed off completely after washing and hands dried thoroughly. This becomes even more important when a person has dermatitis. The irritated area is basically a wound, comprised of acute inflammatory cells, dead and dying cells, and epithelial tissue under repair. This site can tend to hold the soap more tenaciously than intact keratinized tissues. When the person subsequently puts on gloves, the hands will tend to perspire, thus re-activating the bound soap, causing itching and more irritation. This harmful sequence can be short-circuited by using extra effort to rinse and remove the chemical.13 Lotions are also routinely recommended to minimize drying from multiple procedures and repeated glove use.2,4 Petroleum-based lotions can adversely react with latex gloves by increasing their permeability and making them tacky. Thus, water-based formulations offer a better choice for use during the workday. As with other areas of hand hygiene, there are a variety of water-based lotions and creams available (eg, Septodont Hand Cream©, Septodont, www.septodontusa.com; VioNex© Skin Lotion, Metrex; Glove Relief, Sultan Healthcare, www.sultanhc.com; Essensoy, Cranberry, www.cranberryusa.com). It should be noted here that in addition to providing lubricating moisturizers, another valuable feature to evaluate is the ability of the lotion/cream to help block excessive trans-epidermal water loss (e-TEWL) and to provide relief to dry skin but not occlude the skin’s natural breathability (eg, Hand Essentials™ Skin Repair Cream, Hu-Friedy).
You can address the hand dermatitis problem and possibly even prevent it, by instituting an ongoing evaluation of hand care in your practice. This can include answering the following questions:
1. Are hand lotions used by DHCPs to prevent skin dryness associated with hand hygiene?
2. Has the compatibility of the available lotion and antiseptic hand hygiene products been considered?
3. Has an adverse effect of petroleum-based lotion and other oil emollients on gloves been observed or considered during product selection?
4. Are personnel washing with cool or tepid water? If DHCPs are using hot water, this can leave skin pores open and hasten removal of skin oils, thereby inducing inflammation and irritation.
Remember the basic principle here. Hand hygiene is the single most important infection-control procedure you perform. Maximize the total effect you can achieve by minimizing potentially harmful practices.
1. Semmelweis I. Etiology, concept, and prophylaxis of childbed fever. Carter KC, 1st ed. 1983; The University of Wisconsin Press, Madison, WI.
2. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings. MMWR 2002;51(RR-16):1-46.
3. Andrews NA, Cuny E, Molinari JA, Harte JA. Antisepsis and hand hygiene. In: Cottone’s Practical Infection Control in Dentistry. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2010:123-140.
4. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings–2003. MMWR. 2003;52(RR-17):1-68.
5. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Inf Control. 1982;10:93-99.
6. Molinari JA. What do you look for in hand hygiene products? Dent Econ. 2010;10:46.
7. Ojajarvi J. The importance of soap selection for routine hand hygiene in hospital. J Hyg (Lond). 1981;86:275-283.
8. Boyce JM, Kellher S, Vallande N. Skin irritation and dryness associated with two hand hygiene regimens: soap-and-water handwashing versus with an alcohol hand gel. Infect Control Hosp Epidemiol. 2000;21:442-448.
9. Kampf G, Hollingsworth A. Comprehensive bactericidal activity of an ethanol-based hand gel in 15 seconds. Ann Clin Micro Antimicobials. 2008;7:1-6.
10. Elston DM. Hand dermatitis. J Am Acad Dermatol. 2002;47:291-299.
11. Heyman WR. Hand dermatitis. J Am Acad Dermatol. 2006;54:1078-1080.
12. Kampf G, Muscatiello M, Hantschel D, Rudolf M. Dermal tolerance and effect on skin hydration of a new ethanol based gel. J Hosp Infect. 2002;52:297-301.
13. Kampf G, Loffler H. Prevention of irritant contact dermatitis among health care workers by using evidence-based hand hygiene practices: a review. Indust Hlth. 2007;45:645-652.
About the Author
John A. Molinari, PhD
Director of Infection Control
THE DENTAL ADVISOR
Ann Arbor, Michigan