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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the recent article by Batalla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on the use of hand hygiene and antisepsis products among health care professionals and the relationship between these products and hand eczema&#46; While we are in full agreement with the central message of the article and the authors&#8217; algorithm for the management of patients with intolerance to alcohol-based products&#44; we would like to add the following points&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since 2009&#44; when the World Health Organization published its guidelines on hand hygiene for health care professionals&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> there has been a marked upswing in the distribution and use of alcohol-based products because of the numerous advantages they offer over traditional handwashing&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The hand rubs that have achieved the greatest commercial success &#40;e&#46;g&#46;&#44; Sterillium and Manorapid r&#46;f&#46;u&#46;&#41; are those that contain isopropyl alcohol &#40;Chemical Abstract Service number 67-63-0&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Before these products were developed&#44; isopropyl alcohol was rarely used in medical or cosmetic preparations&#46; Type IV hypersensitivity reactions were&#44; therefore&#44; rare<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> leading some authors to even doubt whether isopropyl alcohol was in fact an allergen in humans&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; the marked increase in the use of products containing isopropyl alcohol has led to a substantial increase in exposure&#46; At the same time&#44; it has been found that isopropyl alcohol is potentially an important allergen&#44; especially when used directly on the skin although also in the case of occupational exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In Europe&#44; there are already numerous reports of health professionals who have been diagnosed with contact allergy to this substance&#44; especially nurses and nursing assistants working in highly specialized units where frequent hand sanitizing is required &#40;An Goossens&#44; personal communication&#41;&#46; In fact&#44; in our own department we have diagnosed 2 young nurses with allergic contact dermatitis to isopropyl alcohol&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is important to remember that&#44; in addition to isopropyl alcohol&#44; commercial alcohol-based hand rubs may contain other ingredients&#44; such as emulsifiers&#44; additives &#40;lanolin&#44; propylene glycol&#44; bisabolol&#41;&#44; and perfumes&#44; and that the allergenic potential of these components may be even greater than that of the alcohol&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For all these reasons&#8212;and as Batalla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> clearly indicate in their algorithm&#8212;the role of allergic contact dermatitis should not be overlooked when patients who habitually use alcohol-based sanitizers present with hand eczema&#46; Consequently&#44; patch testing is recommended in the case of persistent and clearly associated lesions&#46; A practical alternative diagnostic technique available to any specialist is a repeated open application test with the actual product used by the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is very possible that the cause is allergic if the patient develops lesions after twice-daily application &#40;morning and evening&#41; on an area of approximately 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> on the anterior forearm&#44; for at least 2 weeks&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally&#44; we would like to thank the authors of this excellent review on a very current issue of great relevance to dermatologists&#44; who must be aware of the issues involved and up to date on the methods for diagnosing and treating these patients&#46;</p></span>"
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Journal Information
Vol. 103. Issue 9.
Pages 845-846 (November 2012)
Vol. 103. Issue 9.
Pages 845-846 (November 2012)
Letter to the Editor
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Hand Eczema Due to Hygiene and Antisepsis Products: Not Only an Irritative Etiology
Productos de higiene, antisepsia y eccema de manos: no solo etiología irritativa
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J. García-Gavín
Corresponding author
juangavin@gmail.com

Corresponding author.
, L. Pérez-Pérez, A. Zulaica
Unidad de Alergia Cutánea y Fotoparche, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
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To the Editor:

We read with interest the recent article by Batalla et al.1 on the use of hand hygiene and antisepsis products among health care professionals and the relationship between these products and hand eczema. While we are in full agreement with the central message of the article and the authors’ algorithm for the management of patients with intolerance to alcohol-based products, we would like to add the following points.

Since 2009, when the World Health Organization published its guidelines on hand hygiene for health care professionals,2 there has been a marked upswing in the distribution and use of alcohol-based products because of the numerous advantages they offer over traditional handwashing.

The hand rubs that have achieved the greatest commercial success (e.g., Sterillium and Manorapid r.f.u.) are those that contain isopropyl alcohol (Chemical Abstract Service number 67-63-0).

Before these products were developed, isopropyl alcohol was rarely used in medical or cosmetic preparations. Type IV hypersensitivity reactions were, therefore, rare3 leading some authors to even doubt whether isopropyl alcohol was in fact an allergen in humans.4

However, the marked increase in the use of products containing isopropyl alcohol has led to a substantial increase in exposure. At the same time, it has been found that isopropyl alcohol is potentially an important allergen, especially when used directly on the skin although also in the case of occupational exposure.5

In Europe, there are already numerous reports of health professionals who have been diagnosed with contact allergy to this substance, especially nurses and nursing assistants working in highly specialized units where frequent hand sanitizing is required (An Goossens, personal communication). In fact, in our own department we have diagnosed 2 young nurses with allergic contact dermatitis to isopropyl alcohol.

It is important to remember that, in addition to isopropyl alcohol, commercial alcohol-based hand rubs may contain other ingredients, such as emulsifiers, additives (lanolin, propylene glycol, bisabolol), and perfumes, and that the allergenic potential of these components may be even greater than that of the alcohol.6,7

For all these reasons—and as Batalla et al.1 clearly indicate in their algorithm—the role of allergic contact dermatitis should not be overlooked when patients who habitually use alcohol-based sanitizers present with hand eczema. Consequently, patch testing is recommended in the case of persistent and clearly associated lesions. A practical alternative diagnostic technique available to any specialist is a repeated open application test with the actual product used by the patient.8 It is very possible that the cause is allergic if the patient develops lesions after twice-daily application (morning and evening) on an area of approximately 5cm2 on the anterior forearm, for at least 2 weeks.

Finally, we would like to thank the authors of this excellent review on a very current issue of great relevance to dermatologists, who must be aware of the issues involved and up to date on the methods for diagnosing and treating these patients.

References
[1]
A. Batalla, I. García-Doval, C. de la Torre.
Productos de higiene y antisepsia de manos: su empleo y relación con el eccema de manos en profesionales sanitarios.
Actas Dermosifiliogr, 103 (2012), pp. 192-197
[2]
D. Pittet, B. Allegranzi, J. Boyce, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts.
The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations.
Infect Control Hosp Epidemiol, 30 (2009), pp. 611-622
[3]
J. Vujevich, M. Zirwas.
Delayed hypersensitivity to isopropyl alcohol.
Contact Dermatitis, 56 (2007), pp. 287
[4]
G.F. Gerberick, C.A. Ryan, P.S. Kern, H. Schlatter, R.J. Dearman, I. Kimber, et al.
Compilation of historical local lymph node data for evaluation of skin sensitization alternative methods.
Dermatitis, 16 (2005), pp. 157-202
[5]
J. García-Gavín, R. Lissens, A. Timmermans, A. Goossens.
Allergic contact dermatitis caused by isopropyl alcohol. A missed allergen?.
Contact Dermatitis, 65 (2011), pp. 101-106
[6]
A.R. Travassos, L. Claes, L. Boey, J. Drieghe, A. Goossens.
Non-fragrance allergens in specific cosmetic products.
Contact Dermatitis, 65 (2011), pp. 276-285
[7]
A. Nardelli, J. Drieghe, L. Claes, L. Boey, A. Goossens.
Fragrance allergens in “specific” cosmetic products.
Contact Dermatitis, 64 (2011), pp. 212-219
[8]
T. Nakada, J. Hostynek, H. Maibach.
Use tests: ROAT (repeated open application test)/PUT (provocative use test): an overview.
Contact Dermatitis, 43 (2000), pp. 1-3

Please cite this article as: García-Gavín J, et al. Productos de higiene, antisepsia y eccema de manos: no solo etiología irritativa. Actas Dermosifiliogr. 2012;103:848-9.

Copyright © 2012. Elsevier España, S.L. and AEDV
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