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Approximation of Alcohol-Based Hand Sanitizer Volume Using a Toothpaste Cap
Practice Gap
The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.1 Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.
The Technique
Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.2 The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.
Practice Implications
The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Kampf G, Ruselack S, Eggerstedt S, et al. Less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection. BMC Infect Dis. 2013;13:472.
Practice Gap
The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.1 Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.
The Technique
Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.2 The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.
Practice Implications
The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.
Practice Gap
The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.1 Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.
The Technique
Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.2 The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.
Practice Implications
The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Kampf G, Ruselack S, Eggerstedt S, et al. Less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection. BMC Infect Dis. 2013;13:472.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Kampf G, Ruselack S, Eggerstedt S, et al. Less and less-influence of volume on hand coverage and bactericidal efficacy in hand disinfection. BMC Infect Dis. 2013;13:472.
Hand Hygiene in Preventing COVID-19 Transmission
Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.1,2
Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.6 Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.7 Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.8
Alcohol-based sanitizers and detergents or antimicrobials in soaps may cause ICD of the hands by denaturation of stratum corneum proteins, depletion of intercellular lipids, and decreased corneocyte cohesion. These agents alter the skin flora, with increased colonization by staphylococci and gram-negative bacilli.9 Clinical findings include xerosis, scaling, fissuring, and bleeding. Physicians may evaluate severity of ICD of the hands using the
Cleansing the hands with alcohol-based sanitizers has consistently shown equivalent or greater efficacy than antimicrobial soaps for eradication of most microbes, with exception of bacterial spores and protozoan oocysts.11 In an in vivo experiment, 70% ethanol solution was more effective in eradicating rotavirus from the fingerpads of adults than 10% povidone-iodine solution, nonmedicated soaps, and soaps containing chloroxylenol 4.8% or chlorhexidine gluconate 4%.12 Coronavirus disease 2019 is a lipophilic enveloped virus. The lipid-dissolving effects of alcohol-based sanitizers is especially effective against these kinds of viruses. An in vitro experiment showed that alcohol solutions are effective against enveloped viruses including severe acute respiratory syndrome coronavirus, Ebola virus, and Zika virus.13 There are limited data for the virucidal efficacy of non–alcohol-based sanitizers containing quaternary ammonium compounds (most commonly benzalkonium chloride) and therefore they are not recommended for protection against COVID-19. Handwashing is preferred over alcohol-based solutions when hands are visibly dirty.
Alcohol-based sanitizers typically are less likely to cause ICD than handwashing with detergent-based or antimicrobial soaps. Antimicrobial ingredients in soaps such as chlorhexidine, chloroxylenol, and triclosan are frequent culprits.11 Detergents in soap such as sodium laureth sulfate cause more skin irritation and transepidermal water loss than alcohol14; however, among health care workers, alcohol-based sanitizers often are perceived as more damaging to the skin.15 During the 2014 Ebola outbreak, use of alcohol-based sanitizers vs handwashing resulted in lower hand eczema severity index scores (n=108).16
Propensity for ICD is a limiting factor in hand hygiene adherence.17 In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.18 Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.21 Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.22
Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.
- Centers for Disease Control and Prevention. Coronavirus disease 2019. how to protect yourself & others. https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. Updated April 13, 2020. Accessed April 21, 2020.
- World Health Organization. Coronavirus disease (COVID-19) advice for the public. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Updated March 31, 2020. Accessed April 21, 2020.
- Carøe TK, Ebbehøj NE, Bonde JPE, et al. Hand eczema and wet work: dose-response relationship and effect of leaving the profession. Contact Dermatitis. 2018;78:341-347.
- Larson E, Friedman C, Cohran J, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997;26:404-412.
- Lampel HP, Patel N, Boyse K, et al. Prevalence of hand dermatitis in inpatient nurses at a United States hospital. Dermatitis. 2007;18:140-142.
- Callahan A, Baron E, Fekedulegn D, et al. Winter season, frequent hand washing, and irritant patch test reactions to detergents are associated with hand dermatitis in health care workers. Dermatitis. 2013;24:170-175.
- Lan J, Song Z, Miao X, et al. Skin damage among healthcare workers managing coronavirus disease-2019 [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1215-1216.
- Katz RJ, Landau P, DeVeaugh-Geiss J, et al. Pharmacological responsiveness of dermatitis secondary to compulsive washing. Psychiatry Res. 1990;34:223-226.
- Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513-521.
- Held E, Skoet R, Johansen JD, et al. The hand eczema severity index (HECSI): a scoring system for clinical assessment of hand eczema. a study of inter- and intraobserver reliability. Br J Dermatol. 2005;152:302-307.
- Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, et al. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46.
- Ansari SA, Sattar SA, Springthorpe VS, et al. Invivo protocol for testing efficacy of hand-washing agents against viruses and bacteria—experiments with rotavirus and Escherichi coli. Appl Environ Microbiol. 1989;55:3113-3118.
- Siddharta A, Pfaender S, Vielle NJ, et al. virucidal activity of world health organization-recommended formulations against enveloped viruses, including Zika, Ebola, and emerging coronaviruses. J Infect Dis. 2017;215:902-906.
- Pedersen LK, Held E, Johansen JD, et al. Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection. Br J Dermatol. 2005;153:1142-1146.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Wolfe MK, Wells E, Mitro B, et al. Seeking clearer recommendations for hand hygiene in communities facing Ebola: a randomized trial investigating the impact of six handwashing methods on skin irritation and dermatitis. PLoS One. 2016;11:e0167378.
- Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of hand hygiene improvements. J Infect Public Health. 2008;1:4-10.
- McCormick RD, Buchman TL, Maki DG. Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers. Am J Infect Control. 2000;28:302-310.
- Berndt U, Wigger-Alberti W, Gabard B, et al. Efficacy of a barrier cream and its vehicle as protective measures against occupational irritant contact dermatitis. Contact Dermatitis. 2000;42:77-80.
- Kampf G, Ennen J. Regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing. BMC Dermatol. 2006;6:1.
- Gammon J, Hunt J. The neglected element of hand hygiene - significance of hand drying, efficiency of different methods, and clinical implication: a review. J Infect Prev. 2019;20:66-74.
- Elston DM. Letter from the editor: occupational skin disease among healthcare workers during the coronavirus (COVID-19) epidemic [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1085-1086.
Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.1,2
Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.6 Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.7 Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.8
Alcohol-based sanitizers and detergents or antimicrobials in soaps may cause ICD of the hands by denaturation of stratum corneum proteins, depletion of intercellular lipids, and decreased corneocyte cohesion. These agents alter the skin flora, with increased colonization by staphylococci and gram-negative bacilli.9 Clinical findings include xerosis, scaling, fissuring, and bleeding. Physicians may evaluate severity of ICD of the hands using the
Cleansing the hands with alcohol-based sanitizers has consistently shown equivalent or greater efficacy than antimicrobial soaps for eradication of most microbes, with exception of bacterial spores and protozoan oocysts.11 In an in vivo experiment, 70% ethanol solution was more effective in eradicating rotavirus from the fingerpads of adults than 10% povidone-iodine solution, nonmedicated soaps, and soaps containing chloroxylenol 4.8% or chlorhexidine gluconate 4%.12 Coronavirus disease 2019 is a lipophilic enveloped virus. The lipid-dissolving effects of alcohol-based sanitizers is especially effective against these kinds of viruses. An in vitro experiment showed that alcohol solutions are effective against enveloped viruses including severe acute respiratory syndrome coronavirus, Ebola virus, and Zika virus.13 There are limited data for the virucidal efficacy of non–alcohol-based sanitizers containing quaternary ammonium compounds (most commonly benzalkonium chloride) and therefore they are not recommended for protection against COVID-19. Handwashing is preferred over alcohol-based solutions when hands are visibly dirty.
Alcohol-based sanitizers typically are less likely to cause ICD than handwashing with detergent-based or antimicrobial soaps. Antimicrobial ingredients in soaps such as chlorhexidine, chloroxylenol, and triclosan are frequent culprits.11 Detergents in soap such as sodium laureth sulfate cause more skin irritation and transepidermal water loss than alcohol14; however, among health care workers, alcohol-based sanitizers often are perceived as more damaging to the skin.15 During the 2014 Ebola outbreak, use of alcohol-based sanitizers vs handwashing resulted in lower hand eczema severity index scores (n=108).16
Propensity for ICD is a limiting factor in hand hygiene adherence.17 In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.18 Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.21 Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.22
Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.
Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.1,2
Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.6 Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.7 Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.8
Alcohol-based sanitizers and detergents or antimicrobials in soaps may cause ICD of the hands by denaturation of stratum corneum proteins, depletion of intercellular lipids, and decreased corneocyte cohesion. These agents alter the skin flora, with increased colonization by staphylococci and gram-negative bacilli.9 Clinical findings include xerosis, scaling, fissuring, and bleeding. Physicians may evaluate severity of ICD of the hands using the
Cleansing the hands with alcohol-based sanitizers has consistently shown equivalent or greater efficacy than antimicrobial soaps for eradication of most microbes, with exception of bacterial spores and protozoan oocysts.11 In an in vivo experiment, 70% ethanol solution was more effective in eradicating rotavirus from the fingerpads of adults than 10% povidone-iodine solution, nonmedicated soaps, and soaps containing chloroxylenol 4.8% or chlorhexidine gluconate 4%.12 Coronavirus disease 2019 is a lipophilic enveloped virus. The lipid-dissolving effects of alcohol-based sanitizers is especially effective against these kinds of viruses. An in vitro experiment showed that alcohol solutions are effective against enveloped viruses including severe acute respiratory syndrome coronavirus, Ebola virus, and Zika virus.13 There are limited data for the virucidal efficacy of non–alcohol-based sanitizers containing quaternary ammonium compounds (most commonly benzalkonium chloride) and therefore they are not recommended for protection against COVID-19. Handwashing is preferred over alcohol-based solutions when hands are visibly dirty.
Alcohol-based sanitizers typically are less likely to cause ICD than handwashing with detergent-based or antimicrobial soaps. Antimicrobial ingredients in soaps such as chlorhexidine, chloroxylenol, and triclosan are frequent culprits.11 Detergents in soap such as sodium laureth sulfate cause more skin irritation and transepidermal water loss than alcohol14; however, among health care workers, alcohol-based sanitizers often are perceived as more damaging to the skin.15 During the 2014 Ebola outbreak, use of alcohol-based sanitizers vs handwashing resulted in lower hand eczema severity index scores (n=108).16
Propensity for ICD is a limiting factor in hand hygiene adherence.17 In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.18 Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.21 Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.22
Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.
- Centers for Disease Control and Prevention. Coronavirus disease 2019. how to protect yourself & others. https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. Updated April 13, 2020. Accessed April 21, 2020.
- World Health Organization. Coronavirus disease (COVID-19) advice for the public. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Updated March 31, 2020. Accessed April 21, 2020.
- Carøe TK, Ebbehøj NE, Bonde JPE, et al. Hand eczema and wet work: dose-response relationship and effect of leaving the profession. Contact Dermatitis. 2018;78:341-347.
- Larson E, Friedman C, Cohran J, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997;26:404-412.
- Lampel HP, Patel N, Boyse K, et al. Prevalence of hand dermatitis in inpatient nurses at a United States hospital. Dermatitis. 2007;18:140-142.
- Callahan A, Baron E, Fekedulegn D, et al. Winter season, frequent hand washing, and irritant patch test reactions to detergents are associated with hand dermatitis in health care workers. Dermatitis. 2013;24:170-175.
- Lan J, Song Z, Miao X, et al. Skin damage among healthcare workers managing coronavirus disease-2019 [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1215-1216.
- Katz RJ, Landau P, DeVeaugh-Geiss J, et al. Pharmacological responsiveness of dermatitis secondary to compulsive washing. Psychiatry Res. 1990;34:223-226.
- Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513-521.
- Held E, Skoet R, Johansen JD, et al. The hand eczema severity index (HECSI): a scoring system for clinical assessment of hand eczema. a study of inter- and intraobserver reliability. Br J Dermatol. 2005;152:302-307.
- Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, et al. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46.
- Ansari SA, Sattar SA, Springthorpe VS, et al. Invivo protocol for testing efficacy of hand-washing agents against viruses and bacteria—experiments with rotavirus and Escherichi coli. Appl Environ Microbiol. 1989;55:3113-3118.
- Siddharta A, Pfaender S, Vielle NJ, et al. virucidal activity of world health organization-recommended formulations against enveloped viruses, including Zika, Ebola, and emerging coronaviruses. J Infect Dis. 2017;215:902-906.
- Pedersen LK, Held E, Johansen JD, et al. Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection. Br J Dermatol. 2005;153:1142-1146.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Wolfe MK, Wells E, Mitro B, et al. Seeking clearer recommendations for hand hygiene in communities facing Ebola: a randomized trial investigating the impact of six handwashing methods on skin irritation and dermatitis. PLoS One. 2016;11:e0167378.
- Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of hand hygiene improvements. J Infect Public Health. 2008;1:4-10.
- McCormick RD, Buchman TL, Maki DG. Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers. Am J Infect Control. 2000;28:302-310.
- Berndt U, Wigger-Alberti W, Gabard B, et al. Efficacy of a barrier cream and its vehicle as protective measures against occupational irritant contact dermatitis. Contact Dermatitis. 2000;42:77-80.
- Kampf G, Ennen J. Regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing. BMC Dermatol. 2006;6:1.
- Gammon J, Hunt J. The neglected element of hand hygiene - significance of hand drying, efficiency of different methods, and clinical implication: a review. J Infect Prev. 2019;20:66-74.
- Elston DM. Letter from the editor: occupational skin disease among healthcare workers during the coronavirus (COVID-19) epidemic [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1085-1086.
- Centers for Disease Control and Prevention. Coronavirus disease 2019. how to protect yourself & others. https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. Updated April 13, 2020. Accessed April 21, 2020.
- World Health Organization. Coronavirus disease (COVID-19) advice for the public. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Updated March 31, 2020. Accessed April 21, 2020.
- Carøe TK, Ebbehøj NE, Bonde JPE, et al. Hand eczema and wet work: dose-response relationship and effect of leaving the profession. Contact Dermatitis. 2018;78:341-347.
- Larson E, Friedman C, Cohran J, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997;26:404-412.
- Lampel HP, Patel N, Boyse K, et al. Prevalence of hand dermatitis in inpatient nurses at a United States hospital. Dermatitis. 2007;18:140-142.
- Callahan A, Baron E, Fekedulegn D, et al. Winter season, frequent hand washing, and irritant patch test reactions to detergents are associated with hand dermatitis in health care workers. Dermatitis. 2013;24:170-175.
- Lan J, Song Z, Miao X, et al. Skin damage among healthcare workers managing coronavirus disease-2019 [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1215-1216.
- Katz RJ, Landau P, DeVeaugh-Geiss J, et al. Pharmacological responsiveness of dermatitis secondary to compulsive washing. Psychiatry Res. 1990;34:223-226.
- Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513-521.
- Held E, Skoet R, Johansen JD, et al. The hand eczema severity index (HECSI): a scoring system for clinical assessment of hand eczema. a study of inter- and intraobserver reliability. Br J Dermatol. 2005;152:302-307.
- Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, et al. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46.
- Ansari SA, Sattar SA, Springthorpe VS, et al. Invivo protocol for testing efficacy of hand-washing agents against viruses and bacteria—experiments with rotavirus and Escherichi coli. Appl Environ Microbiol. 1989;55:3113-3118.
- Siddharta A, Pfaender S, Vielle NJ, et al. virucidal activity of world health organization-recommended formulations against enveloped viruses, including Zika, Ebola, and emerging coronaviruses. J Infect Dis. 2017;215:902-906.
- Pedersen LK, Held E, Johansen JD, et al. Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection. Br J Dermatol. 2005;153:1142-1146.
- Stutz N, Becker D, Jappe U, et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. Br J Dermatol. 2009;160:565-572.
- Wolfe MK, Wells E, Mitro B, et al. Seeking clearer recommendations for hand hygiene in communities facing Ebola: a randomized trial investigating the impact of six handwashing methods on skin irritation and dermatitis. PLoS One. 2016;11:e0167378.
- Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of hand hygiene improvements. J Infect Public Health. 2008;1:4-10.
- McCormick RD, Buchman TL, Maki DG. Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers. Am J Infect Control. 2000;28:302-310.
- Berndt U, Wigger-Alberti W, Gabard B, et al. Efficacy of a barrier cream and its vehicle as protective measures against occupational irritant contact dermatitis. Contact Dermatitis. 2000;42:77-80.
- Kampf G, Ennen J. Regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing. BMC Dermatol. 2006;6:1.
- Gammon J, Hunt J. The neglected element of hand hygiene - significance of hand drying, efficiency of different methods, and clinical implication: a review. J Infect Prev. 2019;20:66-74.
- Elston DM. Letter from the editor: occupational skin disease among healthcare workers during the coronavirus (COVID-19) epidemic [published online March 18, 2020]. J Am Acad Dermatol. 2020;82:1085-1086.
Practice Points
- Alcohol-based sanitizers are as or even more effective as handwashing with soap and water for preventing disease transmission of enveloped viruses such as severe acute respiratory syndrome coronavirus.
- Although perceived as more irritating, alcohol-based sanitizers are less likely to cause irritant contact dermatitis of the hands than handwashing with soap and water.
- Use of humectants, moisturizers, and/or emollients in combination with alcohol-based sanitizers allows for effective hand hygiene without irritating the skin.
Transillumination for Improved Diagnosis of Digital Myxoid Cysts
Practice Gap
Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.1 Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.
Technique
The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.2
Practice Implications
Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.3 When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.
- Dermatol Surg. 2008;34:364-369.
- Erne HC, Gardner TR, Strauch RJ. Transillumination of hand tumors: a cadaver study to evaluate accuracy and intraobserver reliability. Hand (N Y). 2011;6:390-393.
- Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br. 1997;22:222-225.
Practice Gap
Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.1 Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.
Technique
The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.2
Practice Implications
Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.3 When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.
Practice Gap
Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.1 Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.
Technique
The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.2
Practice Implications
Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.3 When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.
- Dermatol Surg. 2008;34:364-369.
- Erne HC, Gardner TR, Strauch RJ. Transillumination of hand tumors: a cadaver study to evaluate accuracy and intraobserver reliability. Hand (N Y). 2011;6:390-393.
- Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br. 1997;22:222-225.
- Dermatol Surg. 2008;34:364-369.
- Erne HC, Gardner TR, Strauch RJ. Transillumination of hand tumors: a cadaver study to evaluate accuracy and intraobserver reliability. Hand (N Y). 2011;6:390-393.
- Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br. 1997;22:222-225.
