Dr Deborah Lee from Dr Fox Online Pharmacy, reveals the risks of using alcohol-based hand sanitiser
During the COVID-19 pandemic, the government advised us to wash our hands ‘regularly’ with soap and water. However, in situations where this was not possible, the use of an alcohol-based hand sanitiser (ABHS) gel was a recommended alternative.
How often is ‘regularly?’ Research, such as a recent 2020 study published in Wellcome Open Research, suggested that to reduce the risk of coronavirus infections, we should be handwashing at least six to 10 times per day.
So, have we been doing it? In August 2020, one poll reported that 78% of UK residents were indeed washing their hands more frequently. But it was not just handwashing. Sales of ABHS had increased by a whopping 255%!
- What effect has this had on the nation’s hands?
- What are the dangers of using ABHG?
- How should AHBG be used?
Definition of ABH
An ABHS is defined as – ‘an alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth (World Health Organization – WHO).
The active ingredients in these hand gels are usually isopropanol, ethanol, n-propanol, or a combination. Alcohol works as an antimicrobial because it can destroy foreign proteins present in invading organisms.
Ethanol is said to be a more effective antiviral agent, whereas propanol is a more effective antibacterial.
Consequently, many hand-sanitising products contain a mixture of both, and this may have an additional synergistic benefit.
To be fully effective as an antimicrobial hand gel, the gel must contain a minimum of 60% alcohol. However, the higher the percentage of alcohol in the product, the greater the efficacy and some contain up to 95% alcohol.
ABHSs also contain humectants, such as glycerin, which help prevent the skin from becoming too dry, and moisturisers, such as aloe vera, which help the skin retain water.
An ABHS is a biocidal product and has to comply with the regulations of the biocidal product (BPR).
How does it work?
The COVID-19 virus is a tiny organism, encapsulated in an outer lipid membrane. Soap and water, and alcohol, both kill the COVID virus by disrupting this outer lipid coat.
Below are some examples of alcohol-based hand gels in common use, that contain at least 60% alcohol:
- Carex hand gel – contains 70% alcohol.
- Cuticura hand gel – contains 66% ethanol.
- Dettol hand gel – contains 63% ethanol.
Medical grade alcohol-based sanitisers contain 70% alcohol or above. The use of alcohol-based hand sanitisers is a particular issue for those working in the healthcare profession, some of whom have to wash their hands 100 times a day.
Application of an 85% alcohol-based gel to the skin for 15 seconds reduces contamination with bacteria by 5 to the log 10. The addition of other germicides such as chlorhexidine, or triclosan can extend protection for a further length of time.
First choice soap and water
Washing your hands with soap and water dislodges dirt and grime, as well as killing viruses, bacteria and other microorganisms. ABHSs are not so effective at removing dirt and grime, and in fact, work less efficiently when skin surfaces are dirty and grimy.
Concerns about the use of ABHS
There is a surprisingly long list of concerns about the use of ABHS. These are listed below –
• ABHS is a cause of allergic dermatitis
There are many possible allergens in ABHS. This could be an allergy to the alcohol itself, or other substances within it, such as fragrances, preservatives, thickeners, or softeners. Exposure to these allergens results in local contact dermatitis – red, sore inflamed hands – with reddened, dry skin that cracks easily, or even blisters and often feels itchy. It can also cause urticaria syndrome.
• Repeated use leads to dry hands
Repeatedly applying ABHS leads to problems with the skin of the hands. This is because alcohol doesn’t just destroy the lipid layer of the viral capsule, it also dissolves the lipid barrier of the skin. As the skin barrier function deteriorates, this allows deeper penetration of alcohol and other allergens into the skin layers. With the barrier function lost, the skin cannot retain water and quickly becomes dried out. In dry weather, and for people with dry skin, these effects are even more pronounced.
• Alcohol alters the skin pH and changes the skin microflora
Furthermore, alcohol alters the pH of the skin, resulting in a change in skin flora and making the hands more likely to harbour staphylococci and gram-negative bacteria – organisms that can cause skin infections.
• AHBS in people with skin disease
Those who already suffer from skin conditions such as eczema or psoriasis are at increased risk of developing complications from using AHBS. Handwashing with simple, unscented soap and water, has to be their first choice. However, if they need to use AHBS, they should always allow the gel to dry on the hands first, and then apply copious amounts of moisturiser. They are often advised to wear gloves to protect their hands, so they do not need to wash their hands so often.
• Effect of ABHS on different skin types
Hands may age prematurely due to the drying effect on the skin from repeated use, coupled with swelling due to inflammation, which results in accentuated wrinkling of the skin of the hands.
Darker skin is more likely to tolerate ABHS because the skin pigment melanin confers some skin protection against the effects of ageing. People with fairer skin may be more likely to develop problems related to its use.
• Effects of AHBS on nails
Rubbing alcohol gel into thin, brittle nails is also likely to exacerbate nail damage. This could be a specific issue for people who already have nail disease, for example, people with psoriasis, or autoimmune conditions.
• Possible long-term health effects of ABHS
Other potentially dangerous products found in alcohol-based sanitisers include phthalates and parabens. There are reports that high exposure to phthalates can cause lowered testosterone levels and an increase in abnormal sperm. Parabens too have been linked to lowered fertility outcomes and may increase the risk of cancer.
• ABHS can result in alcohol intoxication
When the hands come into contact with ABHS, the alcohol is absorbed through the skin into the bloodstream. Alcohol is broken down in the liver to the main metabolite acetaldehyde. This can be detected in the blood soon after using the product, although levels are usually very low.
However, people with acetaldehyde dehydrogenase deficiency will be more at risk from using alcohol-based hand gel as they cannot metabolise alcohol.
Inflamed or broken skin is also likely to absorb alcohol more readily. In children, alcohol-based sanitisers can result in alcohol poisoning.
There have been reports of young people consuming alcohol gel and becoming intoxicated. Alcohol is detectable in the blood of healthcare workers who use ABHS thirty times a day.
Inhalation of alcohol hand gel can irritate the inside of the noses, the airways and the lungs.
Overuse could potentially lead to high concentrations of alcohol in the blood, resulting in symptoms such as dizziness, confusion, coma and collapse.
• Uncertainty of AHBS use by pregnant women
It is not known if AHBS is safe to use in pregnant women. This is due to concerns that alcohol could harm the foetus.
• ABHS is flammable
It should be recognised that AHBS is flammable and should not be used around naked flames such as matches and cigarette lighters.
• ABHS is dangerous to the eye
Care must be taken not to splash ABHS in the eyes, as it can cause chemical burns to the eye.
• Increase in antibiotic resistance
One of the unfortunate longer-term effects of the use of AHBS is an increase in antibiotic resistance. For example, a 2018 research study, demonstrated that the bacteria Enterococcus faecium – which is one of the leading causes of hospital-acquired infections – is becoming more resistant to ABHSs. Some bacteria are already resistant to disinfectants used in hospitals.
The problem of antibiotic resistance is not new. However, the COVID-19 pandemic has increased the risk of antibiotic resistance, which was already killing 700,000 people per year, around the world. Many hospitals are giving antibiotics to COVID patients, not to treat COVID, but because of possible secondary bacterial infections. In 2018, 2.8 million antibiotic-resistant infections were reported. The use of ABHS will only make this worse.
To help reduce the development of antibiotic resistance, it’s imperative users read and follow the instructions with ABHSs, just as they would when taking a course of antibiotics. It’s vital to keep the ABHS in contact with the skin for the full 20 seconds. It’s also very important not to dilute or combine products.
Instructions for using ABHS
Your first choice should be to wash your hands with soap and warm water for at least 20 seconds and dry your hands thoroughly on a paper towel, or under a hand drier.
If you cannot wash your hands then using an alcohol-based sanitiser is an alternative.
Check you are using a brand that contains at least 60% alcohol. Alcohol may be labelled as propan-2-ol, isopropanol, isopropyl alcohol, propan-1-ol, or ethanol.
You should avoid alcohol-based hand sanitiser if:
- You have a skin condition affecting your hands or nails.
- You have very dry, broken, or inflamed skin on your hands.
- You are allergic to alcohol or any of the constituents of the ABHS.
- You suffer from alcohol dehydrogenase deficiency.
- Consider an alcohol-free option instead.
- Use the alcohol-based hand sanitiser from time to time, instead of washing your hands, but washing hands is preferable, and it is not advisable to do both.
- Apply enough of the gel to cover your whole hands. Rub your hands together as if washing your hands to coat the entire amount of skin on the hands. Keep rubbing until the skin on your hands are dry.
- Always apply a good emollient (moisturiser) after the alcohol gel has dried. This is extremely important to help restore the barrier function of the skin.
Should you use an alcohol-free hand sanitiser instead?
Alcohol-free hand sanitisers are not as effective against COVID-19 as alcohol-based sanitisers. These usually contain either benzalkonium chloride or chlorhexidine di-gluconate which are better at destroying norovirus than coronavirus.
The best agents for killing coronaviruses are soap and water, bleach, alcohol, sodium hydroxide, and other detergents.
Final thoughts
It seems so simple that if we need to prevent infections, we slap on an effective antimicrobial such as ABHS. But when you dig deeper, you can see that there are problems and pitfalls with this strategy, that may come back to haunt us now and in the future.
For those of us in the healthcare field, we need to be correctly advising patients, as well as taking care of our own hand hygiene. There are a lot of salient points in this article that affect everyday clinical practice, and the practical application of ABHS for the wider population.
