Products for Hand Hygiene and Antisepsis: Use by Health Professionals and Relationship With Hand Eczema

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Batalla, I. García-Doval, C. de la Torre" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Batalla" "email" => array:1 [ 0 => "anacebey@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "García-Doval" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "de la Torre" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario de Pontevedra, Pontevedra, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Productos de higiene y antisepsia de manos: su empleo y relación con el eccema de manos en los profesionales sanitarios" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3310 "Ancho" => 2673 "Tamanyo" => 479643 ] ] "descripcion" => array:1 [ "en" => "Indications for the use of hand hygiene products and an algorithm for the therapeutic management of contact dermatitis. The figure shows a dynamic model of how the dermatitis will progress to a more severe condition if not properly treated. ICD indicates irritant contact dermatitis." ] ] ] "textoCompleto" => "IntroductionThe hands of health care personnel act as vectors in the transmission of microorganisms and are one of the main mechanisms of transmission of nosocomial infection.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> Hand hygiene is the most important measure for the prevention of nosocomial infection and one of the cornerstones of programs for the control and prevention of infections in hospitals. Proper hand hygiene can reduce the transmission of infection by up to 40%.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3–7</a> However, compliance with antisepsis protocols among health professionals needs to be improved. Diverse reasons are cited for this lack of compliance, including lack of time and lack of familiarity with the recommendations, but skin irritation caused by hygiene products is one of the reasons why personnel perform hand hygiene on less than half of the occasions when it is indicated.<a class="elsevierStyleCrossRefs" href="#bib0010">2–4,6</a>We describe the different products available for hand hygiene, their use in everyday clinical practice, and their relationship with hand eczema in health care personnel.Products Available for Hand Hygiene and Antisepsis, and Methods of UseHand Hygiene ProductsThe most widely used hand hygiene products can be classified into the following 3 categories:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Hydroalcoholic liquid rubs. These rubs contain alcohol (most often ethanol, n-propanol, and isopropanol), which acts as an antiseptic. They also contain surfactants, which add a wetting, emulsifying, and foaming action, and emollients or other skin conditioning agents to prevent the skin from drying.<a class="elsevierStyleCrossRefs" href="#bib0020">4,8,9</a></li><li class="elsevierStyleListItem" id="lsti0010">b)Alcohol-based gel rubs. Another type of hand sanitizing product is the alcohol-based antiseptic in a gel formulation. These products are very similar in composition to the liquid rubs and have an alcohol content of between 60% and 75%. The alcohol most often used is ethanol, but some of these products combine ethanol with 1-propanol or 2-propanol. The consistency of these gels is achieved by way of a thickening system that increases their viscosity. This thickening system does not penetrate the skin and after continuous application the hands are coated in a moist layer of the amine salts of polyacrylic acid.<a class="elsevierStyleCrossRef" href="#bib0050">10</a></li><li class="elsevierStyleListItem" id="lsti0015">c)Antiseptic soaps. The active ingredients in antiseptic soaps are usually chlorhexidine and triclosan.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Other components used are chloroxylenol, hexachlorophene, iodides such as povidone-iodine, and quaternary ammonium compounds.<a class="elsevierStyleCrossRef" href="#bib0055">11</a></li></ul>Antimicrobial Efficacy of Hand Hygiene ProductsThe antimicrobial efficacy of each type of hand hygiene product is different.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">a)Hydroalcoholic liquid rubs. Alcohols, such as ethanol, 1-propanol, and 2-propanol have a broad spectrum of antimicrobial activity. They are bactericidal, virucidal, fungicidal, and mycobactericidal, but have virtually no sporicidal activity. In addition, the alcohols are fast-acting (20–30seconds) and they reduce the colonization of the skin more effectively than washing with soap and water.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3,4,6,8,9,12,13</a> Hydroalcoholic solutions are also suitable for surgical antisepsis. They immediately achieve a level of efficacy similar to that of soaps and detergents, but the effect is more long-lasting.<a class="elsevierStyleCrossRefs" href="#bib0025">5,9,14</a> The guidelines of the World Health Organization Center for Disease Control and Prevention clearly recommend the use of water-alcohol solutions for hygienic hand antisepsis.<a class="elsevierStyleCrossRefs" href="#bib0040">8,11,13,15</a></li><li class="elsevierStyleListItem" id="lsti0025">b)Alcohol-based gel rubs. The literature reviewed indicated that most of the alcohol-based gel rubs on the market have significantly less antibacterial activity than hydroalcoholic solutions.<a class="elsevierStyleCrossRefs" href="#bib0005">1,5</a> However, there are currently some alcohol-based gel products marketed for hand hygiene in a 30-second application that do meet European Standard EN 1500. Alcohol-based gels with the same spectrum of antimicrobial activity as hydroalcoholic liquid rubs are suitable and effective for use in hospitals.<a class="elsevierStyleCrossRefs" href="#bib0005">1,16</a></li><li class="elsevierStyleListItem" id="lsti0030">c)Antiseptic soaps. The antimicrobial spectrum of chlorhexidine and triclosan is narrower than that of the hydroalcoholic solutions and their microbial activity is slower.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> A number of comparative studies have shown chlorhexidine to be a better antiseptic than povidone-iodine because of its faster action and greater residual antimicrobial activity.<a class="elsevierStyleCrossRef" href="#bib0085">17</a></li></ul>For the purposes of this article we will use the term alcohol-based products to refer to both liquid and gel alcohol-based rubs, but with the stipulation that the alcohol-based gels used must have at least the same antimicrobial efficacy as the hydroalcoholic solutions.Hand Hygiene in Everyday Clinical PracticeThere are 3 types of hand hygiene procedures<a class="elsevierStyleCrossRefs" href="#bib0005">1,4,15</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">a)Social or hygienic washing with plain soap and water. This type of handwashing does not eliminate certain microorganisms, even after several washes.</li><li class="elsevierStyleListItem" id="lsti0040">b)Washing with water and antiseptic soap. Handwashing with antiseptic soap removes dirt, organic matter, transient flora, and some of the resident flora; it also has some residual antimicrobial activity.</li><li class="elsevierStyleListItem" id="lsti0045">c)Antisepsis with alcohol-based hand rubs. Prior to use, there should be no visible dirt on the hands and after application the hands must be rubbed together until the alcohol has evaporated and they are completely dry. All personnel must learn the appropriate application technique, which involves coating the entire surface of the hands to ensure efficacy. The correct procedure is described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRef" href="#bib0020">4</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul>The indications for the different hand hygiene procedures are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,4,10,15,18,19</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows instructions for the use of the different types of hand hygiene products.<a class="elsevierStyleCrossRefs" href="#bib0005">1,11,13,19</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Other important aspects that must be taken into consideration with respect to hand hygiene are outlined below.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050">1.Hot water should not be used to wash hands.<a class="elsevierStyleCrossRefs" href="#bib0020">4,19</a></li><li class="elsevierStyleListItem" id="lsti0055">2.As indicated above, hands should not be dried following the application of alcohol-based products (the alcohol should be allowed to evaporate).<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li><li class="elsevierStyleListItem" id="lsti0060">3.The use of alcohol-based products excludes hand washing and hands should not be washed before or after applying such products.<a class="elsevierStyleCrossRefs" href="#bib0020">4,11,13</a></li><li class="elsevierStyleListItem" id="lsti0065">4.Handwashing before antisepsis predisposes the skin to toxic reactions and removes the natural sebum layer that protects the skin, thereby increasing skin irritation and dryness; handwashing may also decrease bactericidal efficacy.<a class="elsevierStyleCrossRefs" href="#bib0065">13,20</a></li><li class="elsevierStyleListItem" id="lsti0070">5.Handwashing with soap and water after hygienic hand disinfection will, in addition to removing the superficial sebum layer, also remove the emollients that are included in the alcohol-based product, thereby increasing the risk of dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0020">4,13</a></li><li class="elsevierStyleListItem" id="lsti0075">6.Alcohol-based products should not be used on wounds as they may damage the tissue.<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li><li class="elsevierStyleListItem" id="lsti0080">7.Hands should be washed before eating and after using the restroom. Sanitization with alcohol-based products in these circumstances is not suffiicient.<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li><li class="elsevierStyleListItem" id="lsti0085">8.The use of gloves does not obviate the need for hand hygiene and is not a substitute for antisepsis; in fact, gloves should only be worn when necessary. Hands should always be dry before gloves are put on as damp hands increase irritation and the rate of glove perforation.<a class="elsevierStyleCrossRef" href="#bib0095">19</a></li><li class="elsevierStyleListItem" id="lsti0090">9.In view of the possibility of microbial colonization and cross-transmission of nosocomial infections, the following points should not be forgotten: rings and bracelets are easily colonized; gloves must be worn when touching mucous membranes or nonintact skin; the same pair of gloves should never be used with a different patient or with the same patient when moving from a contaminated to a clean site.<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li></ul>Hand Eczema in Health Care PersonnelHand Hygiene Products and Skin IrritationFrequent and repeated use of hand hygiene products, particularly soaps and other detergents, is the leading cause of irritant contact dermatitis among health workers. These products can damage the skin through denaturation of stratum corneum proteins, changes in intercellular lipids, as well as decreased corneocyte cohesion and stratum corneum water-binding.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> As a result, they provoke changes in the skin flora of the hands and favor transient colonization. Damage can be exacerbated by the use of hot water, failure to apply hand cream, and drying hands with poor quality paper towels.<a class="elsevierStyleCrossRefs" href="#bib0020">4,11</a>Alcohols have practically no irritant effect and are considered to be among the safest antiseptics.<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a> There is no difference in the dermal tolerance of these products between atopic and nonatopic patients and, even in pre-irritated skin, the damage caused by alcohols is very low.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14,21</a> The low irritancy potential and better skin tolerance of commonly used alcohols as compared to soaps and detergents have been demonstrated by patch tests and bioengineering methods such as the measurement of transepidermal water loss (a measure of skin barrier disruption) and corneometry, which measures skin hydration.<a class="elsevierStyleCrossRefs" href="#bib0030">6,8,11–14,21,22</a> The authors of various studies have reported no increase in skin barrier disruption or erythema after patch tests with 1-propanol, 2-propanol, and ethanol; however, a slight decrease in corneometric values was observed, indicating a decrease in skin hydration.<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a> The drying effect of alcohol can be reduced or eliminated by the use of emollients such as glycerin. Alcohol-based sanitizers must contain emollients and they consequently have moisturizing properties despite their high alcohol content.<a class="elsevierStyleCrossRefs" href="#bib0025">5,22</a>The risk of sensitization to alcohol is low even in high-risk groups such as health care personnel.<a class="elsevierStyleCrossRefs" href="#bib0060">12,14,21</a> Contact allergy to alcohol is very rare, and only sporadic cases of type IV hypersensitivity to ethanol, 1-propanol, and 2-propanol have been reported.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> Isolated cases of contact urticaria and anaphylactoid reactions have also been reported. However, commercially available alcohol-based products are rarely pure, and it is the impurities and contaminants that are responsible for most reactions to such products.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Why Do Most Health Professionals Believe That Alcohol-Based Products Are Strong Irritants That Cause Dermatitis?Even though the use of alcohol-based rubs has been promoted as an effective antiseptic procedure offering excellent dermal tolerance and the possibility of increasing the frequency of performing correct hand hygiene, acceptance of these products has been poor.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> One reason for this is that products containing alcohol produce a burning sensation when applied to pre-irritated skin. The alcohol easily penetrates the skin through the disrupted barrier and stimulates receptors that cause a burning sensation even though the product does not increase irritation or damage the skin. Increasingly, this effect has led health care workers to wash their hands rather than use alcohol-based rubs despite the minimal irritancy potential of these products. However, while handwashing does not cause discomfort or give rise to an immediate sensation of irritation, it further disrupts the skin barrier function and perpetuates the vicious circle that often leads to irritant dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14,19–21</a> The presence of irritation is interpreted by some users as an allergy, which leads them to consult a specialist and undergo patch testing with negative results.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13,19,21</a>The burning sensation experienced when alcohol-based products are applied should be interpreted as a sign of changes in skin barrier function and a predictor of hand dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0065">13,19–21</a>The Importance of Using Alcohol-Based Products to Prevent Hand Eczema Among Health ProfessionalsThe dermatologist should be aware that alcohol-based products are not the leading cause of dermatitis among health professionals, but rather an important factor in the prevention and treatment of this condition. Alcohol rubs are an essential tool for the control of nosocomial infections and dermatologists should not contribute to the misconceptions that reduce their correct and frequent use.Medical personnel who report discomfort when they apply alcohol-based products should be prescribed treatment for irritant dermatitis (which is usually subclinical) and advised to continue using alcohol-based products whenever these are indicated.Several studies have shown that it is not enough to simply introduce alcohol-based products into the workplace to reduce the prevalence of occupational dermatitis and increase compliance with recommended hand hygiene procedures: educational programs explaining the mechanisms of irritation and irritants and the advantages of alcohol-based rubs over handwashing are also important.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,6,11–13,19,23–25</a>Other important measures shown to increase compliance with the use of alcohol-based sanitizing rubs are ensuring the availability of and ease of access to these products,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> and avoiding their introduction during winter months. When temperatures are low and the weather is more humid, hands are more likely to become dry, and users may attribute these changes to the new products rather than to climatic factors.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Summarizing the information in this paper, we propose an algorithm for the selection of hand hygiene products and the management of the skin conditions associated with the use of such products (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>ConclusionsHand hygiene products are essential for the control of nosocomial infection. However, these products—particularly soaps and detergents—are the leading cause of irritant contact dermatitis in health care personnel.<a class="elsevierStyleCrossRefs" href="#bib0055">11,17,20,23</a> We recommend the use of alcohol-based products as standard procedure for hand hygiene because their low irritancy potential and superiority to other products in terms of dermal tolerance have been demonstrated; they also more effectively reduce the bacterial load.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6,8,11,13,15,25</a> Despite the widespread availability of alcohol-based products in the workplace, compliance remains low.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> As dermatologists, we can play an important role by using and providing a model for the use of these sanitizing rubs in our work. It is important that we correctly inform and advise the medical personnel who consult us for irritant contact dermatitis and stress the low irritancy potential of alcohol-based products.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres95762" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82921" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95763" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82922" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Products Available for Hand Hygiene and Antisepsis, and Methods of Use" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Hand Hygiene Products" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Antimicrobial Efficacy of Hand Hygiene Products" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Hand Hygiene in Everyday Clinical Practice" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Hand Eczema in Health Care Personnel" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Hand Hygiene Products and Skin Irritation" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Why Do Most Health Professionals Believe That Alcohol-Based Products Are Strong Irritants That Cause Dermatitis?" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "The Importance of Using Alcohol-Based Products to Prevent Hand Eczema Among Health Professionals" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of Interest" ] 9 => array:2 [ "identificador" => "xack35214" "titulo" => "Acknowledgment" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-02-04" "fechaAceptado" => "2011-06-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82921" "palabras" => array:5 [ 0 => "Alcohol" 1 => "Irritant dermatitis" 2 => "Occupational dermatitis" 3 => "Hand antisepsis" 4 => "Handwashing" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82922" "palabras" => array:5 [ 0 => "Alcohol" 1 => "dermatitis irritativa" 2 => "dermatitis ocupacional" 3 => "antisepsia de las manos" 4 => "lavado de manos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Hand hygiene is the most important measure for the prevention of nosocomial infection. We describe the different products available for hygiene and antisepsis of the hands and the use of these products in daily practice. Hand hygiene products such as soaps and detergents are a cause of irritant dermatitis in health professionals. This irritation is one of the principal factors affecting their use in clinical practice. Alcohol-based products are better tolerated and less irritant than soap and water; irritation should not therefore be a limiting factor in the use of these products and they are to be recommended in place of soap and water. Informative and continued education programs could increase their use." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La higiene de manos es la medida más importante para la prevención de la infección nosocomial. Describimos los diferentes productos para la higiene y antisepsia de las manos y su modo de empleo en la práctica clínica habitual,. Los productos de higiene de manos, sobre todo jabones y detergentes, son causa de dermatitis irritativa en los profesionales sanitarios. Esta irritación cutánea que producen es uno de los principales motivos que condicionan su empleo en condiciones reales. Los productos de base alcohólica presentan mejor tolerancia dérmica y son menos irritantes que el lavado con agua y jabón, por lo que la irritación no debe ser un factor limitante para la utilización de éstos, que deben recomendarse en mayor medida que el lavado con agua y jabón. Los programas educacionales de información y formación continuada podrían aumentar su utilización." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Batalla A, et al. Productos de hygiene y antisepsia de manos: su empleo y relación con el eccema de manos en los profesionales sanitarios. Actas Dermosifiliogr. 2012;103:192–7." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3310 "Ancho" => 2673 "Tamanyo" => 479643 ] ] "descripcion" => array:1 [ "en" => "Indications for the use of hand hygiene products and an algorithm for the therapeutic management of contact dermatitis. The figure shows a dynamic model of how the dermatitis will progress to a more severe condition if not properly treated. ICD indicates irritant contact dermatitis." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Adapted from Delgado-Gil et al.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and WHO Guidelines on Hand Hygiene in Health Care.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Alcohol-Based Rubs: Instructions for Use \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Apply 3mL from the dispenser and rub for 20–30seconds. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Rub the wrists and rub palm against palm. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Rub the palm of each hand with the back of the other hand. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Rub palm against palm with interlinked fingers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Rub the backs of the fingers against the palm of the other hand. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Rub the thumb of the left hand by rotating it in the clasped palm of the right hand and vice versa. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7. Rub the tips of the fingers on the left hand by using a rotating movement on the palm of the right hand and vice versa. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab182062.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Instructions for Using Alcohol-Based Rubs." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Source: Adapted from Kampf<a class="elsevierStyleCrossRef" href="#bib0005">1</a>, Cabrillana Molina et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, Delgado-Gil et al.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, Pietsch<a class="elsevierStyleCrossRef" href="#bib0050">10</a>, Boyce et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>, Pedersen et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> and Kampf et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antisepsis with alcohol-based products<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use in the following 5 situations: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Before contact with the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Before any clean or sterile procedure on the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Following any activity involving a risk of exposure to the patient's body fluids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. After contact with the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. After contact with material or surfaces in the patient's environment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Social washing (plain soap and water) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the hospital setting: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- When hands are visibly soiled with proteinaceous material \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Before eating \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- After using the restroom \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Washing with antiseptic soap and water \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antisepsis before surgery<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab182061.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Alcohol-based products can also be used for surgical antisepsis<a class="elsevierStyleCrossRefs" href="#bib0025">5,9,14</a> (the term alcohol-based products includes hydroalcoholic solutions and alcohol-based gels, provided that the latter have at least the same antimicrobial activity as the solutions)." ] ] ] "descripcion" => array:1 [ "en" => "Indications for Different Hand Hygiene Procedures." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Source: Adapted from Kampf<a class="elsevierStyleCrossRef" href="#bib0005">1</a>, WHO Guidelines on Hand Hygiene in Health Care<a class="elsevierStyleCrossRef" href="#bib0055">11</a>, and Kampf et al.<a class="elsevierStyleCrossRefs" href="#bib0065">13,19</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Washing With Plain Soap and Water \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Antisepsis With Alcohol-Based Products \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Use non-alkaline soft soap. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Only apply rub to clean dry skin. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Use cold water. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Rub product into the skin until dry (about 20–30seconds). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Scrub hands long enough to remove visible dirt but at the same time for as short a time as possible (about 40–60seconds). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Do not wash hands immediately after application. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Eliminate residual soap completely. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Do not use brushes.<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydrating creams 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Practical Dermatology

Products for Hand Hygiene and Antisepsis: Use by Health Professionals and Relationship With Hand Eczema

Productos de higiene y antisepsia de manos: su empleo y relación con el eccema de manos en los profesionales sanitarios

A. Batalla

Corresponding author

anacebey@yahoo.es

Corresponding author.

, I. García-Doval, C. de la Torre

Servicio de Dermatología, Complejo Hospitalario de Pontevedra, Pontevedra, Spain

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including lack of time and lack of familiarity with the recommendations&#44; but skin irritation caused by hygiene products is one of the reasons why personnel perform hand hygiene on less than half of the occasions when it is indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the different products available for hand hygiene&#44; their use in everyday clinical practice&#44; and their relationship with hand eczema in health care personnel&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Products Available for Hand Hygiene and Antisepsis&#44; and Methods of Use</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hand Hygiene Products</span><p id="par0015" class="elsevierStylePara elsevierViewall">The most widely used hand hygiene products can be classified into the following 3 categories&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hydroalcoholic liquid rubs&#46;</span> These rubs contain alcohol &#40;most often ethanol&#44; n-propanol&#44; and isopropanol&#41;&#44; which acts as an antiseptic&#46; They also contain surfactants&#44; which add a wetting&#44; emulsifying&#44; and foaming action&#44; and emollients or other skin conditioning agents to prevent the skin from drying&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#44;9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Alcohol-based gel rubs&#46;</span> Another type of hand sanitizing product is the alcohol-based antiseptic in a gel formulation&#46; These products are very similar in composition to the liquid rubs and have an alcohol content of between 60&#37; and 75&#37;&#46; The alcohol most often used is ethanol&#44; but some of these products combine ethanol with 1-propanol or 2-propanol&#46; The consistency of these gels is achieved by way of a thickening system that increases their viscosity&#46; This thickening system does not penetrate the skin and after continuous application the hands are coated in a moist layer of the amine salts of polyacrylic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Antiseptic soaps&#46;</span> The active ingredients in antiseptic soaps are usually chlorhexidine and triclosan&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Other components used are chloroxylenol&#44; hexachlorophene&#44; iodides such as povidone-iodine&#44; and quaternary ammonium compounds&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Antimicrobial Efficacy of Hand Hygiene Products</span><p id="par0035" class="elsevierStylePara elsevierViewall">The antimicrobial efficacy of each type of hand hygiene product is different&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">a&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hydroalcoholic liquid rubs&#46;</span> Alcohols&#44; such as ethanol&#44; 1-propanol&#44; and 2-propanol have a broad spectrum of antimicrobial activity&#46; They are bactericidal&#44; virucidal&#44; fungicidal&#44; and mycobactericidal&#44; but have virtually no sporicidal activity&#46; In addition&#44; the alcohols are fast-acting &#40;20&#8211;30<span class="elsevierStyleHsp" style=""></span>seconds&#41; and they reduce the colonization of the skin more effectively than washing with soap and water&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;6&#44;8&#44;9&#44;12&#44;13</span></a> Hydroalcoholic solutions are also suitable for surgical antisepsis&#46; They immediately achieve a level of efficacy similar to that of soaps and detergents&#44; but the effect is more long-lasting&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9&#44;14</span></a> The guidelines of the World Health Organization Center for Disease Control and Prevention clearly recommend the use of water-alcohol solutions for hygienic hand antisepsis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#44;13&#44;15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">b&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Alcohol-based gel rubs&#46;</span> The literature reviewed indicated that most of the alcohol-based gel rubs on the market have significantly less antibacterial activity than hydroalcoholic solutions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> However&#44; there are currently some alcohol-based gel products marketed for hand hygiene in a 30-second application that do meet European Standard EN 1500&#46; Alcohol-based gels with the same spectrum of antimicrobial activity as hydroalcoholic liquid rubs are suitable and effective for use in hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">c&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Antiseptic soaps&#46;</span> The antimicrobial spectrum of chlorhexidine and triclosan is narrower than that of the hydroalcoholic solutions and their microbial activity is slower&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A number of comparative studies have shown chlorhexidine to be a better antiseptic than povidone-iodine because of its faster action and greater residual antimicrobial activity&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">For the purposes of this article we will use the term <span class="elsevierStyleItalic">alcohol-based products</span> to refer to both liquid and gel alcohol-based rubs&#44; but with the stipulation that the alcohol-based gels used must have at least the same antimicrobial efficacy as the hydroalcoholic solutions&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hand Hygiene in Everyday Clinical Practice</span><p id="par0060" class="elsevierStylePara elsevierViewall">There are 3 types of hand hygiene procedures<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;15</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">a&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Social or hygienic washing with plain soap and water&#46;</span> This type of handwashing does not eliminate certain microorganisms&#44; even after several washes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">b&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Washing with water and antiseptic soap&#46;</span> Handwashing with antiseptic soap removes dirt&#44; organic matter&#44; transient flora&#44; and some of the resident flora&#59; it also has some residual antimicrobial activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">c&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Antisepsis with alcohol-based hand rubs&#46;</span> Prior to use&#44; there should be no visible dirt on the hands and after application the hands must be rubbed together until the alcohol has evaporated and they are completely dry&#46; All personnel must learn the appropriate application technique&#44; which involves coating the entire surface of the hands to ensure efficacy&#46; The correct procedure is described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">The indications for the different hand hygiene procedures are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;10&#44;15&#44;18&#44;19</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows instructions for the use of the different types of hand hygiene products&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#44;13&#44;19</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Other important aspects that must be taken into consideration with respect to hand hygiene are outlined below&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Hot water should not be used to wash hands&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">As indicated above&#44; hands should not be dried following the application of alcohol-based products &#40;the alcohol should be allowed to evaporate&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The use of alcohol-based products excludes hand washing and hands should not be washed before or after applying such products&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11&#44;13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">4&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Handwashing before antisepsis predisposes the skin to toxic reactions and removes the natural sebum layer that protects the skin&#44; thereby increasing skin irritation and dryness&#59; handwashing may also decrease bactericidal efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">5&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Handwashing with soap and water after hygienic hand disinfection will&#44; in addition to removing the superficial sebum layer&#44; also remove the emollients that are included in the alcohol-based product&#44; thereby increasing the risk of dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">6&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Alcohol-based products should not be used on wounds as they may damage the tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">7&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Hands should be washed before eating and after using the restroom&#46; Sanitization with alcohol-based products in these circumstances is not suffiicient&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">8&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">The use of gloves does not obviate the need for hand hygiene and is not a substitute for antisepsis&#59; in fact&#44; gloves should only be worn when necessary&#46; Hands should always be dry before gloves are put on as damp hands increase irritation and the rate of glove perforation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">9&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">In view of the possibility of microbial colonization and cross-transmission of nosocomial infections&#44; the following points should not be forgotten&#58; rings and bracelets are easily colonized&#59; gloves must be worn when touching mucous membranes or nonintact skin&#59; the same pair of gloves should never be used with a different patient or with the same patient when moving from a contaminated to a clean site&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hand Eczema in Health Care Personnel</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hand Hygiene Products and Skin Irritation</span><p id="par0140" class="elsevierStylePara elsevierViewall">Frequent and repeated use of hand hygiene products&#44; particularly soaps and other detergents&#44; is the leading cause of irritant contact dermatitis among health workers&#46; These products can damage the skin through denaturation of stratum corneum proteins&#44; changes in intercellular lipids&#44; as well as decreased corneocyte cohesion and stratum corneum water-binding&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> As a result&#44; they provoke changes in the skin flora of the hands and favor transient colonization&#46; Damage can be exacerbated by the use of hot water&#44; failure to apply hand cream&#44; and drying hands with poor quality paper towels&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Alcohols have practically no irritant effect and are considered to be among the safest antiseptics&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> There is no difference in the dermal tolerance of these products between atopic and nonatopic patients and&#44; even in pre-irritated skin&#44; the damage caused by alcohols is very low&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14&#44;21</span></a> The low irritancy potential and better skin tolerance of commonly used alcohols as compared to soaps and detergents have been demonstrated by patch tests and bioengineering methods such as the measurement of transepidermal water loss &#40;a measure of skin barrier disruption&#41; and corneometry&#44; which measures skin hydration&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;11&#8211;14&#44;21&#44;22</span></a> The authors of various studies have reported no increase in skin barrier disruption or erythema after patch tests with 1-propanol&#44; 2-propanol&#44; and ethanol&#59; however&#44; a slight decrease in corneometric values was observed&#44; indicating a decrease in skin hydration&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> The drying effect of alcohol can be reduced or eliminated by the use of emollients such as glycerin&#46; Alcohol-based sanitizers must contain emollients and they consequently have moisturizing properties despite their high alcohol content&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;22</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The risk of sensitization to alcohol is low even in high-risk groups such as health care personnel&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;21</span></a> Contact allergy to alcohol is very rare&#44; and only sporadic cases of type IV hypersensitivity to ethanol&#44; 1-propanol&#44; and 2-propanol have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Isolated cases of contact urticaria and anaphylactoid reactions have also been reported&#46; However&#44; commercially available alcohol-based products are rarely pure&#44; and it is the impurities and contaminants that are responsible for most reactions to such products&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Why Do Most Health Professionals Believe That Alcohol-Based Products Are Strong Irritants That Cause Dermatitis&#63;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Even though the use of alcohol-based rubs has been promoted as an effective antiseptic procedure offering excellent dermal tolerance and the possibility of increasing the frequency of performing correct hand hygiene&#44; acceptance of these products has been poor&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> One reason for this is that products containing alcohol produce a burning sensation when applied to pre-irritated skin&#46; The alcohol easily penetrates the skin through the disrupted barrier and stimulates receptors that cause a burning sensation even though the product does not increase irritation or damage the skin&#46; Increasingly&#44; this effect has led health care workers to wash their hands rather than use alcohol-based rubs despite the minimal irritancy potential of these products&#46; However&#44; while handwashing does not cause discomfort or give rise to an immediate sensation of irritation&#44; it further disrupts the skin barrier function and perpetuates the vicious circle that often leads to irritant dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14&#44;19&#8211;21</span></a> The presence of irritation is interpreted by some users as an allergy&#44; which leads them to consult a specialist and undergo patch testing with negative results&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;19&#44;21</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The burning sensation experienced when alcohol-based products are applied should be interpreted as a sign of changes in skin barrier function and a predictor of hand dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19&#8211;21</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Importance of Using Alcohol-Based Products to Prevent Hand Eczema Among Health Professionals</span><p id="par0165" class="elsevierStylePara elsevierViewall">The dermatologist should be aware that alcohol-based products are not the leading cause of dermatitis among health professionals&#44; but rather an important factor in the prevention and treatment of this condition&#46; Alcohol rubs are an essential tool for the control of nosocomial infections and dermatologists should not contribute to the misconceptions that reduce their correct and frequent use&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Medical personnel who report discomfort when they apply alcohol-based products should be prescribed treatment for irritant dermatitis &#40;which is usually subclinical&#41; and advised to continue using alcohol-based products whenever these are indicated&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Several studies have shown that it is not enough to simply introduce alcohol-based products into the workplace to reduce the prevalence of occupational dermatitis and increase compliance with recommended hand hygiene procedures&#58; educational programs explaining the mechanisms of irritation and irritants and the advantages of alcohol-based rubs over handwashing are also important&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;6&#44;11&#8211;13&#44;19&#44;23&#8211;25</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Other important measures shown to increase compliance with the use of alcohol-based sanitizing rubs are ensuring the availability of and ease of access to these products&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and avoiding their introduction during winter months&#46; When temperatures are low and the weather is more humid&#44; hands are more likely to become dry&#44; and users may attribute these changes to the new products rather than to climatic factors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Summarizing the information in this paper&#44; we propose an algorithm for the selection of hand hygiene products and the management of the skin conditions associated with the use of such products &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">Hand hygiene products are essential for the control of nosocomial infection&#46; However&#44; these products&#8212;particularly soaps and detergents&#8212;are the leading cause of irritant contact dermatitis in health care personnel&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17&#44;20&#44;23</span></a> We recommend the use of alcohol-based products as standard procedure for hand hygiene because their low irritancy potential and superiority to other products in terms of dermal tolerance have been demonstrated&#59; they also more effectively reduce the bacterial load&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;8&#44;11&#44;13&#44;15&#44;25</span></a> Despite the widespread availability of alcohol-based products in the workplace&#44; compliance remains low&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> As dermatologists&#44; we can play an important role by using and providing a model for the use of these sanitizing rubs in our work&#46; It is important that we correctly inform and advise the medical personnel who consult us for irritant contact dermatitis and stress the low irritancy potential of alcohol-based products&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hand hygiene is the most important measure for the prevention of nosocomial infection&#46; We describe the different products available for hygiene and antisepsis of the hands and the use of these products in daily practice&#46; Hand hygiene products such as soaps and detergents are a cause of irritant dermatitis in health professionals&#46; This irritation is one of the principal factors affecting their use in clinical practice&#46; Alcohol-based products are better tolerated and less irritant than soap and water&#59; irritation should not therefore be a limiting factor in the use of these products and they are to be recommended in place of soap and water&#46; Informative and continued education programs could increase their use&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La higiene de manos es la medida m&#225;s importante para la prevenci&#243;n de la infecci&#243;n nosocomial&#46; Describimos los diferentes productos para la higiene y antisepsia de las manos y su modo de empleo en la pr&#225;ctica cl&#237;nica habitual&#44;&#46; Los productos de higiene de manos&#44; sobre todo jabones y detergentes&#44; son causa de dermatitis irritativa en los profesionales sanitarios&#46; Esta irritaci&#243;n cut&#225;nea que producen es uno de los principales motivos que condicionan su empleo en condiciones reales&#46; Los productos de base alcoh&#243;lica presentan mejor tolerancia d&#233;rmica y son menos irritantes que el lavado con agua y jab&#243;n&#44; por lo que la irritaci&#243;n no debe ser un factor limitante para la utilizaci&#243;n de &#233;stos&#44; que deben recomendarse en mayor medida que el lavado con agua y jab&#243;n&#46; Los programas educacionales de informaci&#243;n y formaci&#243;n continuada podr&#237;an aumentar su utilizaci&#243;n&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Batalla A&#44; et al&#46; Productos de hygiene y antisepsia de manos&#58; su empleo y relaci&#243;n con el eccema de manos en los profesionales sanitarios&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;192&#8211;7&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3310
            "Ancho" => 2673
            "Tamanyo" => 479643
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Indications for the use of hand hygiene products and an algorithm for the therapeutic management of contact dermatitis&#46; The figure shows a dynamic model of how the dermatitis will progress to a more severe condition if not properly treated&#46; ICD indicates irritant contact dermatitis&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from Delgado-Gil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and WHO Guidelines on Hand Hygiene in Health Care&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Alcohol-Based Rubs&#58; Instructions for Use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; Apply 3<span class="elsevierStyleHsp" style=""></span>mL from the dispenser and rub for 20&#8211;30<span class="elsevierStyleHsp" style=""></span>seconds&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Rub the wrists and rub palm against palm&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; Rub the palm of each hand with the back of the other hand&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; Rub palm against palm with interlinked fingers&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; Rub the backs of the fingers against the palm of the other hand&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; Rub the thumb of the left hand by rotating it in the clasped palm of the right hand and vice versa&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; Rub the tips of the fingers on the left hand by using a rotating movement on the palm of the right hand and vice versa&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182062.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Instructions for Using Alcohol-Based Rubs&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from Kampf<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; Cabrillana Molina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; Delgado-Gil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; Pietsch<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; Boyce et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; Pedersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and Kampf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antisepsis with alcohol-based products<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use in the following 5 situations&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; Before contact with the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Before any clean or sterile procedure on the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; Following any activity involving a risk of exposure to the patient&#39;s body fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; After contact with the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; After contact with material or surfaces in the patient&#39;s environment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Social washing &#40;plain soap and water&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In the hospital setting&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- When hands are visibly soiled with proteinaceous material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Before eating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- After using the restroom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Washing with antiseptic soap and water&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antisepsis before surgery<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182061.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Alcohol-based products can also be used for surgical antisepsis<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9&#44;14</span></a> &#40;the term <span class="elsevierStyleItalic">alcohol-based products</span> includes hydroalcoholic solutions and alcohol-based gels&#44; provided that the latter have at least the same antimicrobial activity as the solutions&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Indications for Different Hand Hygiene Procedures&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from Kampf<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; WHO Guidelines on Hand Hygiene in Health Care<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; and Kampf et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Washing With Plain Soap and Water&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Antisepsis With Alcohol-Based Products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Use non-alkaline soft soap&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Only apply rub to clean dry skin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Use cold water&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Rub product into the skin until dry &#40;about 20&#8211;30<span class="elsevierStyleHsp" style=""></span>seconds&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Scrub hands long enough to remove visible dirt but at the same time for as short a time as possible &#40;about 40&#8211;60<span class="elsevierStyleHsp" style=""></span>seconds&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Do not wash hands immediately after application&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Eliminate residual soap completely&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Do not use brushes&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hydrating creams should be used between hygiene procedures&#44; particularly at the end of the shift&#46;</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182063.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Brushes may be used for surgical antisepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recommendations for Hand Hygiene in Hospitals&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2012.04.004

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Year/Month	Html	Pdf	Total

2024 November	29	11	40
2024 October	266	46	312
2024 September	281	42	323
2024 August	330	71	401
2024 July	375	35	410
2024 June	364	62	426
2024 May	265	33	298
2024 April	286	34	320
2024 March	354	37	391
2024 February	330	56	386
2024 January	320	41	361
2023 December	263	19	282
2023 November	312	40	352
2023 October	363	35	398
2023 September	260	37	297
2023 August	193	25	218
2023 July	194	40	234
2023 June	168	21	189
2023 May	242	28	270
2023 April	214	26	240
2023 March	337	30	367
2023 February	248	20	268
2023 January	169	22	191
2022 December	92	47	139
2022 November	56	36	92
2022 October	51	19	70
2022 September	55	39	94
2022 August	48	45	93
2022 July	51	46	97
2022 June	60	27	87
2022 May	284	58	342
2022 April	338	61	399
2022 March	428	62	490
2022 February	343	49	392
2022 January	352	47	399
2021 December	288	62	350
2021 November	282	46	328
2021 October	325	69	394
2021 September	269	49	318
2021 August	192	45	237
2021 July	160	32	192
2021 June	227	30	257
2021 May	212	63	275
2021 April	327	124	451
2021 March	236	47	283
2021 February	158	42	200
2021 January	130	23	153
2020 December	107	16	123
2020 November	81	33	114
2020 October	92	21	113
2020 September	103	12	115
2020 August	97	25	122
2020 July	103	20	123
2020 June	137	31	168
2020 May	155	31	186
2020 April	69	25	94
2020 March	54	22	76
2020 February	3	2	5
2020 January	0	3	3
2019 December	4	4	8
2019 November	0	1	1
2019 October	0	2	2
2019 September	5	1	6
2019 June	2	2	4
2019 May	1	17	18
2019 April	0	1	1
2019 March	2	5	7
2019 January	2	0	2
2018 December	4	0	4
2018 November	2	0	2
2018 October	3	0	3
2018 September	4	3	7
2018 August	0	2	2
2018 July	0	4	4
2018 June	0	2	2
2018 May	0	5	5
2018 April	0	2	2
2018 March	28	2	30
2018 February	97	2	99
2018 January	103	7	110
2017 December	86	9	95
2017 November	76	8	84
2017 October	70	7	77
2017 September	59	6	65
2017 August	73	13	86
2017 July	52	8	60
2017 June	60	13	73
2017 May	56	11	67
2017 April	43	16	59
2017 March	27	24	51
2017 February	89	16	105
2017 January	51	8	59
2016 December	64	12	76
2016 November	84	15	99
2016 October	103	24	127
2016 September	176	14	190
2016 August	89	12	101
2016 July	45	13	58
2016 June	9	22	31
2016 May	6	14	20
2016 April	8	2	10
2016 March	8	2	10
2016 February	12	3	15
2016 January	11	0	11
2015 December	12	1	13
2015 November	20	1	21
2015 October	14	8	22
2015 September	10	1	11
2015 August	18	4	22
2015 July	56	7	63
2015 June	68	6	74
2015 May	95	14	109
2015 April	77	7	84
2015 March	73	12	85
2015 February	52	9	61
2015 January	71	12	83
2014 December	101	16	117
2014 November	56	8	64
2014 October	67	20	87
2014 September	62	20	82
2014 August	62	15	77
2014 July	84	28	112
2014 June	121	31	152
2014 May	104	20	124
2014 April	73	20	93
2014 March	31	16	47
2014 February	33	17	50
2014 January	15	11	26
2013 December	28	6	34
2013 November	26	14	40
2013 October	19	5	24
2013 September	20	7	27
2013 August	13	15	28
2013 July	10	18	28
2013 June	14	29	43
2013 May	15	26	41
2013 April	25	22	47
2013 March	20	29	49
2013 February	42	9	51
2013 January	34	6	40
2012 December	25	4	29
2012 November	10	10	20
2012 October	10	8	18
2012 September	2	1	3

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