COMMENTARY

Hand Sanitizer Loses to Good Old-Fashioned Soap and Water

Hansa Bhargava, MD

Disclosures

October 20, 2016

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Hi. I'm Dr Hansa Bhargava, medical editor for Medscape and WebMD. Today we're going to talk about hand sanitizers. It seems that many of our patients are using hand sanitizers and wipes daily. They're looking for a convenient way to kill bacteria and germs when soap and water is not available, or even when it is. But are hand sanitizers as helpful as handwashing? And is there harm? Let's take a look.

The US Food and Drug Administration (FDA) recently issued a proposal[1] requesting manufacturers to conduct additional scientific testing to make sure that no unknown safety issues exist. Most of these sanitizers contain three active ingredients: isopropyl alcohol, benzalkonium chloride, and either ethanol or ethyl alcohol. Although they have been proven effective in killing microbes, there has never been a comprehensive study evaluating their safety.

A question that I've been asked by patients is, "Can passive alcohol absorption occur through the skin?" Hand sanitizers work best when the solution remains on the skin and dries naturally without being wiped or washed off. But could it be absorbed? What is the long-term effect of that residue, especially in children? In the past, researchers with the French School of Public Health also raised concerns[2] about whether intensive use of hand sanitizers, such as in healthcare settings, could lead to passive alcoholization. Because the absorbed alcohols are highly water-soluble, there was some concern that the alcohol would be rapidly distributed to vascular organs such as the brain and liver. Fortunately, in October 2015, a meta-analysis[3] concluded that evidence to date demonstrates no definitive findings of toxicity.

What about children? Are these products safe for them? Could they get alcohol poisoning? Several manufacturers have added scents such as strawberry, grape, and even bacon, which has unfortunately become an enticement for children. The alcohol level in hand sanitizers can range from 45% to 95%, which is very dangerous, especially if ingested. Sadly, poison control centers across the US have reported that the number of cases of children under the age of 12 ingesting hand sanitizer has quadrupled in the past few years.[4] In fact, more than 15,000 exposures were reported in 2015. Parents should be made aware that different flavors and smells in hand sanitizers can lead kids to not just using them, but eating them, too.

We've talked about safety, but what about efficacy? What your patients may not know is that hand sanitizers are not as effective against some of the most virulent infections out there—for example, norovirus.[5] One study[6] has even reported limited effectiveness against influenza B. In fact, the Centers for Disease Control and Prevention explicitly recommends hand hygiene with soap and water as the first way to prevent infections before the use of hand sanitizers for the average person.[7] If there is no running water, hand sanitizers should have at least 60% alcohol to reduce the amount of germs.

So, what does the FDA want to do? The FDA's proposed rule does not require any consumer products to be removed from the market. It does require manufacturers who want to continue marketing these products to provide the FDA with additional data on the active ingredients' safety and effectiveness, including data to evaluate absorption. Hand sanitizers are convenient and easy to use, but our patients should know that the most effective cleansing still comes from good old-fashioned soap and water.

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