Hygiene of the Skin: When Is Clean Too Clean?

Elaine Larson, Columbia University School of Nursing, New York, New York, USA.


Emerging Infectious Diseases. 2001;7(2) 

In This Article

When Is Clean Too Clean?

Even with use of antiseptic preparations, which substantially reduce counts of hand flora, no reductions beyond an equilibrium level are attained[66]. The numbers of organisms spread from the hands of nurses who washed frequently with an antimicrobial soap actually increased after a period of time; this increase is associated with declining skin health[67]. In a recent survey, nurses with damaged hands were twice as likely to be colonized with S. hominis, S. aureus, gram-negative bacteria, enterococci, and Candida spp. and had a greater number of species colonizing the hands[64].

The trend in both the general public and among health-care professionals toward more frequent washing with detergents, soaps, and antimicrobial ingredients needs careful reassessment in light of the damage done to skin and resultant increased risk for harboring and transmitting infectious agents. More washing and scrubbing are unlikely to be better and may, in fact, be worse. The goal should be to identify skin hygiene practices that provide adequate protection from transmission of infecting agents while minimizing the risk for changing the ecology and health of the skin and increasing resistance in the skin flora.

Bathing or showering cleans the skin by mechanical removal of bacteria shed on corneocytes. Bacterial counts are at least as high or higher after bathing or showering with a regular soap than before. Frequent bathing has aesthetic and stress-relieving benefits but serves little microbiologic purpose. Mild, nonantimicrobial soap should suffice for routine bathing. Bathing with an antimicrobial product reduces rates of cutaneous infection and could be beneficial when skin infections are likely or before certain surgical procedures. With those exceptions, available data do not support a recommendation for bathing with antimicrobial products.

No single recommendation for hand hygiene practices in the general population would be adequate. The potential advantage of sustained antimicrobial activity for certain occupations (e.g., food handlers and child-care providers) must be balanced with the theoretical possibility of emergence of resistant strains and perhaps other, as yet unrecognized, safety issues.

An alternative to detergent-based antiseptic products is the use of alcohol hand rinses, which have recently become widely available over the counter. Their advantages include rapid and broad-spectrum activity, excellent microbicidal characteristics, and lack of potential for emergence of resistance. Alcohol-based products could be recommended for use among persons who need immediate protection after touching contaminated surfaces or before and after contact with someone at high risk for infection.

Since hands are a primary mode of fecal-oral and respiratory transmission, specific indications for use of antiseptic hand products by the general public are close physical contact with persons at high risk for infection (e.g., neonates, the very old, or immunosuppressed); close physical contact with infected persons; infection with an organism likely to be transmitted by direct contact (diarrhea, upper respiratory infection, skin infections); or work in a setting in which infectious disease transmission is likely (food preparation, crowded living quarters such as chronic-care residences, prisons, child-care centers, and preschools).

Detergent-Based Antiseptics or Alcohol. Because of increasingly vulnerable patient populations, the demand for hand hygiene among health-care professionals has never been greater. However, frequent handwashing is not only potentially damaging to skin, it is also time-consuming and expensive[68]. Finnish investigators demonstrated that after frequent washing the hands of patient-care providers became damaged and posed greater risk to themselves and patients than if they had washed less often. A mild emulsion cleansing rather than handwashing with liquid soap was associated with a substantial improvement in the skin of nurses' hands[69]. Alcohol-based formulations are superior to antiseptic detergents for rapid microbial killing on skin[66,67,70,71,72] and, with the addition of appropriate moisturizers, are probably milder[67,73,74]. Since alcohols are rapid acting, are broad spectrum, and require no washing or drying, damage caused by detergents and mechanical friction from toweling is avoided.

Use of Lotions and Moisturizers. Moisturizing is beneficial for skin health and reducing microbial dispersion from skin, regardless of whether the product used contains an antibacterial ingredient[75,76,77]. Because of differences in the content and formulations of lotions and creams, products vary greatly in their effectiveness[78,79]. Lotions used with products containing chlorhexidine gluconate must be carefully selected to avoid neutralization by anionic surfactants[80]. The role of emollients and moisturizers in improving skin health and reducing microbial spread is an area for additional research.

To improve the skin condition of health-care professionals and reduce their chances of harboring and shedding microorganisms from the skin, the following measures are recommended: 1) For damaged skin, mild, nonantimicrobial skin cleansing products may be used to remove dirt and debris. If antimicrobial action is needed (e.g., before invasive procedures or handling of highly susceptible patients) a waterless, alcohol-based product may be used. 2) In clinical areas such as the operating room and neonatal and transplant units, shorter, less traumatic washing regimens may be used instead of lengthy scrub protocols with brushes or other harsh mechanical action. 3) Effective skin emollients or barrier creams may be used in skin-care regimens and procedures for staff (and possibly patients as well). 4) Skin moisturizing products should be carefully assessed for compatibility with any topical antimicrobial products being used and for physiologic effects on the skin[81].


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