When hand sanitisers become a double-edge sword

Preventative measures are critical to allay the next, albeit completely different wave, of allergic contact hand eczema – another unintended health consequence of COVID-19. The rise in the use of alcohol-based hand sanitisers has increased the incidence of hand eczema. This article highlights the importance of prioritising adequate skincare, especially amongst those working in healthcare facilities.

When COVID-19 started spreading across the globe, the World Health Organisation (WHO) and the Centers for Disease Control and Prevention recommended that the best way to prevent COVID-19 infection is through physical distancing, wearing cloth masks, as well as frequent and proper handwashing and surface decontamination.

The call for regular handwashing led to an exponential rise in the use of alcohol-based hand sanitisers, which has increased the incidence of hand eczema in healthcare workers as well as the general population.

Hand eczema characteristically presents as a red, itchy, sometimes burning or even tender, rash. The rash may be dry with cracked and scaly skin or wet with blisters, oozing and crusting. Certain individuals, such as those with underlying atopic (a general disposition to develop) eczema, are at greater risk of developing alcohol rub hand eczema due to the inherent impaired barrier function of the skin characterising this condition.

In a study from Hubei province in China, 434 healthcare workers were interviewed, with 321 (74%) reporting that they sanitise their hands more than 10 times per day. Of those healthcare workers, 246 (76.6%) reported symptoms of hand eczema, with the most common being irritant-contact hand eczema and less commonly allergic-contact hand eczema.

Another study from Milan (Italy) reported that from 9 March to 4 May 2020 there were 24 new cases of hand eczema in the general population related to the use of alcohol-based sanitisers. Some of the issues with alcoholbased hand sanitisers include the use of non-standard formulae (meaning that methanol is used instead of ethanol); types of alcohol such as isopropyl alcohol vs. ethanol; as well as varying amounts of alcohol (<60%). The various recipes making the rounds on social media in the early days of lockdown illustrate this point.

“Irritant” contact hand eczema may develop in anyone whose hands are exposed to irritants such as water, soap, or alcohol hand sanitisers. “Allergic” contact hand eczema, on the contrary, will only develop in those who have been primed to develop skin irritation to certain substances such as nickel, latex or colophony (found in adhesives, cosmetics and printing ink).

An intact skin usually deters from the development of the latter form of hand eczema. Irritants assist in disrupting the skin barrier, improving the likelihood of developing allergic-contact hand eczema.

Alcohol rub hand eczema can become a debilitating and painful disease, resulting in work absenteeism which can severely impair the delivery of essential services. The increased frequency of handwashing and use of alcohol-based hand sanitiser associated with COVID-19 prevention dramatically increases the likelihood of developing allergic-contact hand eczema, which may greatly impact quality of life as well as cause occupational difficulties in the long run.

Apart from the discomfort of dry, itchy skin, the breaks in the skin can serve as a point of entry for COVID-19 because of viral receptors in the blood vessels of the skin. Painful, dry skin could also inadvertently decrease hand hygiene compliance which further increases the risk of disease transmission in these individuals. Prevention is therefore essential. It has become clear that the COVID-19 pandemic will persist for the foreseeable future. Equally clear has been the gargantuan impact of this viral infection. Therefore, the importance of following protective guidelines, such as outlined by health and government organisations, is undeniable and should be closely adhered to.

The WHO has recommended a 60 percent alcohol-containing hand sanitiser with 1.45 percent glycerol as a moisturising agent to protect healthcare workers, and now the frequently sanitising public, from the complications of excessive alcohol hand rub usage. The minimum amount of glycerol required to decrease the risk of hand eczema is not known, although studies have shown that even lower levels than the recommended 1.45 percent glycerol were effective to protect the skin from excessive drying.

Further recommendations include the use of an emollient-containing hand cream immediately after sanitising. Although this is a useful measure to prevent alcohol rub dermatitis, one study showed that only approximately one in five healthcare workers did so after using alcohol-based hand rub. This figure is highly unlikely to be higher among the general public. Sanitising stations are located everywhere in hospitals and public areas and have been an important means of combating the spread of COVID-19. However, moisturisers are few and far between, hence the increased incidence of alcohol rub hand eczema during the pandemic. Adequate skin care could increase hand hygiene compliance and should therefore be prioritised, especially among healthcare workers.