Fingernail Polish and Infection Control

Fingernail Polish and Infection Control

Amy Lucas, MSN, RN, CCNS, CCRN-K - CRMH Clinical Nurse Specialist

Background & Significance

The nail enhancement business earns billions of dollars each year (Reinecke & Hinshaw, 2020) and there are many options to choose from that vary in price, durability, and ease of application and removal. One of the cheapest and easiest products to use is nail polish. Per Carilion policy, fingernail length should be less than ¼ inch long, nail polish should be freshly applied with no chipping (Centers for Disease Control and Prevention, 2002; World Health Organization, 2009). Healthcare workers should understand what is allowed by policy and how the choice can affect patient outcomes. This article discusses the evidence behind the current recommendations for traditional and gel nail polish. Traditional nail polish is a varnish applied to the nail plate that dries through evaporation (Wałaszek et al., 2018; Wood & Van Wicklin, 2015). This is inexpensive, easy to apply and offers many color options. Traditional polish tends to lose integrity quickly, in some cases within a day of application (Blackburn et al., 2020). Gel polish, sometimes called Shellac, is a varnish that is applied to the nail plate but must be cured under an ultra-violet (UV) light to dry (Wałaszek et al., 2018, Reinecke & Hinshaw, 2020). Gel polishes are more expensive and can last for two weeks without chipping, but once integrity is lost, removal is more difficult (Wood & Van Wicklin, 2015). While traditional nail polishes can be removed at home in a matter of minutes, removal of gel polish requires soaking in acetone or being filed off, which is usually done in the salon (Wood & Van Wicklin, 2015). While nail polish can lead to complications such as dermatitis or malignancy related to the UV light (Putek et al., 2020; Reinecke & Hinshaw, 2020), the biggest concerns for healthcare facilities are related to infections. Chips in nail polish or the gap between the color and the cuticle as the nail grows could harbor pathogens. There are concerns that an impaired gel polish manicure will be maintained instead of repaired due to the cost and time involved, increasing the risk for contamination and for spreading infection. There have also been concerns that those with enhanced nails may not perform adequate hand hygiene to protect the manicure (McNeil et al., 2001; Ward, 2007).

Literature Review

A literature search was performed using Carilion’s HERO database and ancestry search. Keywords used included: fingernail and infection control or hand hygiene, fingernail and infection control, fingernail and healthcare worker, nail enhancement and infection, nail polish and hand hygiene, gel nails and infection. Ten articles were identified that studied the impact of fingernail polish on infection prevention. Most of the studies were qualitative or correlational, but there were a few well-controlled studies and one Cochrane Review.

There is little evidence that freshly applied traditional nail polish increases risk of infection for patients, though there is an association between long fingernails and increased bacterial load. Fagernes and Lingaas (2011) cultured a convenience sample of direct care staff during their shift and did not find any impact from nail polish but found nail length significantly associated with increased bacteria. Hardy et al. (2017) performed a randomized crossover trial in a veterinary clinic comparing polished to non-polished fingers and found that the only variable associated with higher bacterial counts was nail length greater than 2mm. A Cochrane review published in 2014 was unable to determine if nail polish affected the number of bacteria on the skin after a surgical scrub (Arrowsmith & Taylor, 2014). Tank & Çelik (2018) also looked at polish and the surgical scrub by comparing cultures taken at baseline and after performing a surgical scrub. While

samples taken from hands with nail polish after performing a surgical hand scrub did grow more bacteria, the difference did not reach statistical significance when compared to the cultures taken before the scrub or to the other hand that was not polished. Blackburn, et al (2020) performed a randomized study of oncology nurses and found fewer bacteria on polished nails versus unpolished nails when the polish was one day old, but the polish rapidly degraded after the first day and was associated with an increase in all types of bacteria with the gram-positive bacteria reaching statistical significance. Studies examining gel polish found unclear results. A review of the literature published between 1978 and 2018 found few studies and contradictory results but the main findings were that traditional polish could impact quality of a surgical scrub if the polish was damaged, and that gel polish may be associated with lower quality of hand scrub (Olivares et al., 2020). Hewlett et al (2018) studied workers after applying gel polish and traditional polish each to one finger, and the others natural. Both gel and traditional polish became more contaminated over time with the amount plateauing in the second week. The traditional polish had the most bacteria prior to hand hygiene on day 7 but the gel polish had a smaller decrease in bacteria after hand hygiene than either natural or traditional polished nails. Ultimately, there was not a statistically significant difference between the three options after hand hygiene but this was because there were fewer bacteria on the gel nails pre-cleaning. The final two studies looked at natural, polished, and artificial nails with both sampling staff who already had the nail enhancements in place. Artificial nails were found to harbor more bacteria than either polished or natural nails, however in one study there was not a clear delineation between uv-cure polish and uv-cured artificial nails in the results making it difficult to tell if the increased bacteria was associated with a specific type of uvcured product after hand hygiene (Edel et al., 1998; Wałaszek et al., 2018). The study designs and amount of control varied but they found similar results. Freshly applied traditional nail polish does not appear to increase risk of spreading pathogens however, breaks down soon after application. Gel polish also appears not likely to contribute to the spread of infection but there is concern for findings that hand hygiene does not remove as many bacteria. It is unclear if this is related to a characteristic of the polish or an unconscious action by the wearer but could lead to spread of pathogens. More research is needed to further investigate this phenomenon. Long nails were associated with increased bacteria in several studies.

Implications for Practice

The Carilion Hand Hygiene Policy is an Infection Control Department policy and applies to all employees who provide direct care or who interact with items that will be used for patients. This policy is consistent with evidence. Healthcare workers can safely use nail polish as long as the integrity is intact and the nails are short. Those who work wearing impaired polish or long nails risk not only professional consequences but risk patient safety.

References

Arrowsmith, V.A., Taylor, R. (2014). Removal of nail polish and finger rings to prevent surgical infection. In Cochrane Database of Systematic Reviews (Vol. 2014, Issue 8). John Wiley and Sons Ltd. https:// doi.or/10.1002/14651858.CD003325.pub3 Blackburn, L., Acree, K., Bartley, J., DiGiannantoni, E., Renner, E., & Sinnott, L.T. (2020). Microbial growth on the nails of direct patient care nurses wearing nail policy. Oncology Nursing Forum, 47(2), 155-164. https:// doi.org/10.1188/20.ONF. 155-164 Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in Health-Care Setting Recommendations of the Healthcare Infection Control Practices Centers for Disease Control and Prevention. MMWR, 51(RR-16), 1-45

Edel, E. ;, Houston, S. ;, Kennedy, V. ;, & LaRocco, M. (1998). Impact of a 5-minute scrub on the microbial flora found on artificial, Ppolished, or natural fingernails of operating room personnel. Nursing Research, 47(1), 54–59. https: ovidsp.dc2.ovid.com ovid-a/ovidweb.cgi Fagernes, M., & Lingaas, E. (2011). Factors interfering with the microflora on hands: A regression analysis of samples from 465 healthcare workers. Journal of Advanced Nursing, 67(2), 297–307. https://doi.org/10.1111/j.1365 2648.2010.05462.x

Hardy, J. M., Owen, T. J., Martinez, S. A., Jones, L. P., & Davis, M. A. (2017). The effect of nail characteristics on surface bacterial counts of surgical personnel before and after scrubbing. Veterinary Surgery, 46(7), 952–961. https: doi.org/10.1111 vsu.12685 Hewlett, A. L., Hohenberger, H., Murphy, C. N., Helget, L., Hausmann, H., Lyden, E., Fey, P. D., & Hicks, R. (2018). Evaluation of the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of health care workers American Journal of Infection Control, 46(12), 1356–1359. https://doi.org/10.1016/j.ajic.2018.05.022 McNeil, S. A., Foster, C. L., Hedderwick, S. A., & Kauffman, C. A. (2001). Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clinical Infectious Diseases, 32, 367–372. https://academic.oup.com/cid/article-abstract/32/3/367/282937 Olivares, F., Vergara, T., Véliz, E., & Dabanch, J. (2020). Impacto del uso de anillos y uñas esmaltadas en la calidad de la hygiene de manos en el personal de salud. Revista Chilena Infectologia, 37(1), 23–31. www.revinf.cl Putek, J., Przybyła, T., Szepietowski, J. C., Baran, W., & Batycka-Baran, A. (2020). Side-effects associated with gel nail polish: A self-questionnaire study of 2,118 respondents. Acta Dermato-Venereologica, 100(18), 1–5. https://doi. org/10.2340/00015555-3684 Reinecke, J. K., & Hinshaw, M. A. (2020). Nail health in women[Formula presented]. International Journal of Women’s Dermatology, 6(2), 73–79. https://doi.org/10.1016/j.ijwd.2020.01.006 Tank, D. Y., & Çelik, S. (2018). Effect of use of nail polish on bacterial colonization after surgical handwashing in operating room nurses: A preliminary study. Cukurova Medical Journal, 43(3), 698–705. https://doi.org/10.17826 cumj.383360 Wałaszek, M. Z., Kołpa, M., Różańska, A., Jagiencarz-Starzec, B., Wolak, Z., & Wójkowska-Mach, J. (2018). Nail microbial colonization following hand disinfection: A qualitative pilot study. Journal of Hospital Infection, 100(2), 207 210. https:doi.org/10.1016/j.jhin.2018.06.023 Ward, D. J. (2007). Hand adornment and infection control. British Journal of Nursing, 16(11), 654–656. http:// web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=1&sid=24206a4c-2426-4b49-a445-87c8bc02142a 40sessionmgr103 Wood, A., & Van Wicklin, S. A. (2015). Clinical Issues-June 2015. AORN Journal, 101(6), 701–708. https: doi.org/10.1016/j.aorn.2015.03.004 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. https://www.ncbi.nih.gov/books/NBK144013/