The American Journal of Medicine
Volume 121, Issue 10 , Pages 831-832, October 2008

Coming Clean: Waterless Hand Cleaners—Which to Choose?

  • Marcia R. Silver, MD, FACP

      Affiliations

    • I have received honoraria and consulting fees from Amgen, Inc, and Shire.

Case Western Reserve University School of Medicine, MetroHealth Medical Center, Division of Nephrology and Hypertension, Cleveland, Ohio

Article Outline

 

Bravo to all the medical care institutions that are finally taking hand washing seriously! This is vitally important for patient safety and is likely to reduce bad outcomes and overall costs to the medical care system.

However, there are still choices that need to be made sensibly as we implement these practices. We must remember not only that waterless hand cleaners do not remove body substances such as blood, saliva, urine, and feces, but also that they do not kill or remove the spore forms of bacteria that can cause Clostridium difficile infections. Hand washing with real soap and running water for 15 seconds still has an important role. Paper towel dispensers should not require the user to crank a handle or push a lever to dispense towels. By touching those handles and levers that cannot be considered clean, we recontaminate our just-washed hands the same way we would if we turned off the faucet by handling the water controls.

Now consider the composition of the waterless hand cleaners. The active ingredient in many of them is ethyl alcohol (62%). This is the same alcoholic substance found in alcoholic beverages, so most of us are fairly confident that if we absorb a little of it, and it can be absorbed through the skin,1 it is unlikely to be harmful. An alternative product in this class contains the active ingredient isopropyl alcohol in similar proportion. That alcohol is the one we are familiar with as rubbing alcohol and also is the one found in the alcohol swabs commonly used for cleaning the skin for phlebotomy, intravenous catheters, and injections. It too can be absorbed through the skin.2 Blood levels of 0.5 to 1.8 mg/L were recorded in 10 adult subjects who applied isopropyl alcohol gel hand cleaners every 10 minutes for only 4 hours.3 In the past, isopropyl alcohol was used for “alcohol baths” to reduce fevers in children and adults. That procedure was stopped because it was found to be toxic, causing confusion and delirium, stupor, coma, myocardial depression with hypotension, gastrointestinal bleeding, and neuropathy.4, 5, 6 There are few data on what might be the long-term results of repeated daily exposure.7

Another substance found in some of the waterless hand cleaner formulations is parabens. The role of parabens in skin lotions, cosmetics, and drugs is as a preservative. It is well absorbed from the skin and excreted in the urine.8 Recent studies have demonstrated that parabens may have some estrogenic actions in various animal models, raising the question of its safety, especially for women who have been treated for estrogen-receptor positive breast cancer.9, 10 Many such women take drugs (aromatase inhibitors) to prevent their bodies from making estrogenic substances, and these aromatase inhibitors have been shown to decrease the rates of breast cancer recurrence.11 Some premenopausal women at high risk of developing breast cancer undergo oophorectomy or take anti-estrogen drugs to decrease their risk of developing breast cancer.12 One recent study demonstrated measurable levels of parabens in excised breast tissue samples.13 Although there are limited data, and some have argued that the estrogenic potency of parabens is too low to have a significant effect at the likely exposures from cosmetics, drugs, and skin creams, it seems prudent to avoid unnecessary exposure to possibly harmful substances. In the case of waterless hand cleaners, regular use will probably result in dramatically larger volume exposures than the use of most cosmetics. It is not hard to imagine 50 to 100 uses per shift for a nurse in active patient care.

Adverse effects of parabens might not be limited to women. Oishi14 demonstrated decreased testosterone levels and sperm production in an animal model exposed to parabens.

Another issue that should be considered is that some substances can increase skin absorption of other substances. This phenomenon is called absorption enhancement or permeation enhancement and is of interest to those developing methods for delivering drugs through topical applications.15 Alcohols have been demonstrated to act as permeation enhancers. So, if one adds parabens to an alcohol-based hand cleaner, absorption of the parabens might be significantly increased. At least 1 study in the literature shows just this effect in a laboratory model of guinea pig skin, with ethanol increasing parabens absorption through the skin.16

We live in a country where regulation of the use of chemicals is limited, especially for substances that have been in common use for many years and were therefore grandfathered under the Toxic Substances Control Act, passed by Congress in 1976. There is debate about whether the current statute gives the Environmental Protection Agency (EPA) sufficient authority to regulate commercial use of chemicals, based on principles of protecting health and the environment. Although some argue the existing law provides the agency ample authority to restrict the production or use of chemicals deemed a threat, in practice, there have been no such bans since 1991. In that year a federal court overturned the EPA's ban on the use of asbestos, a known human carcinogen. The court claimed the EPA failed to consider less economically burdensome regulatory alternatives.17 In an environment where there is little regulation, consumers must be cautious and thoughtful.

Because alcohol is a good antiseptic, one must wonder why parabens would be needed in hand-cleaning preparations anyway. Because there are effective products commercially available without this additive, it seems prudent to use those rather than expose large numbers of health care workers, mostly women (although men are not immune to breast cancer and other chronic illnesses), to the potential added risk of much greater parabens exposure and absorption.

Thinking about these issues made me wonder whether there might be estrogen receptors in skin. An electronic search of this question revealed that indeed there are and that new information about various classes of such receptors has been developed.18, 19 Could it be that parabens is not an “inactive ingredient,” as it is usually listed on the labels of over-the-counter cosmetics, hand-cleaning gels, prescription drugs, and so forth, but rather has an unintended effect of enhancing the skin and hair follicle response to products such as skin lotions and shampoos through its estrogenic actions? As we now know from studies of estrogens in postmenopausal women, estrogenic substances can have both beneficial and adverse effects, requiring careful evaluation of the balance of burdens and benefits before use.

I propose that we ask the purchasing agents for our hospitals and clinics to choose waterless hand cleaners with the active ingredient ethyl alcohol rather than isopropyl alcohol, and that they choose products without parabens added. Such products are readily available and seem to be the most prudent choices given the currently available information. Additional research into the long-term effects of frequent small exposures to the chemicals discussed in this essay (especially parabens and the various alcohols) should be pursued.

Hand cleanliness is critically important to our patients' welfare. Just as in patient care decisions, where Primum non nocere, or First do no harm, should be our guiding principle, we should choose hand-cleaning products that will do the job well with the least likely risk of harm. In this case, it is the medical care workers who assume the risk. For this new use involving exposures orders of magnitude larger than those previously widely experienced, we should choose the equally effective products that seem most likely to be formulated without ingredients that are possibly harmful. Nothing here stated should be construed as an excuse to refrain from consistent and careful hand cleaning in medical care settings according to guidelines.20 The consequences of failures in hand hygiene can be dire.21 This discussion applies to the choice of products, and good choices are readily available.

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References 

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PII: S0002-9343(08)00446-4

doi:10.1016/j.amjmed.2008.03.043

The American Journal of Medicine
Volume 121, Issue 10 , Pages 831-832, October 2008

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