We appreciate the comments made by García-Gavín et al.1 concerning the article “Products for Hand Hygiene and Antisepsis: Use by Health Professionals and Relationship With Hand Eczema.”2

The focus of the article in question was skin irritation in health care professionals caused by hygiene and antisepsis products, particularly alcohol-based sanitizers. Skin irritation is one of the main reasons for the scant use of these products in clinical practice. Alcohol-based hand rubs are better tolerated by the skin than soap and water, and the guidelines of the Centers for Disease Control and Prevention and the World Health Organization clearly recommend the use of these products over traditional handwashing.3

It has been reported previously2 that such irritation may be erroneously diagnosed by health professionals as an allergic reaction.4–8 That said, this does not mean that these products can never cause true allergies. Cases have been reported of allergic contact dermatitis associated with alcohol-based products. In addition to the published cases of allergy to isopropanol,9 there have also been reports of allergic contact dermatitis caused by ethanol, 1-propanol, and 2-propanol.3,4 However, given the large number of people using alcohol-based rubs today, the incidence of such allergies, while certainly not negligible and potentially considerable, is low, and in most cases the allergy is caused by impurities, contaminants, or additives.3–5,8 Therefore, the possibility that a user may develop an allergy should not be an obstacle to recommending the use of these products. For example, in a study of 50 nurses who reported erythema, desquamation, blistering, itching, or stinging after using alcohol-based products, none had a positive reaction to ethanol, 1-propanol, or 2-propanol on patch testing.7 When, in the same study, the nurses underwent patch testing with the products they were using at the workplace, only 3 exhibited a mild positive reaction after application of 2 of the products (Desmanol and Sterillium). When the components of these products were tested separately in 2 of these patients, a positive reaction was observed to the cetearyl octanoate in Desmanol and no reactions were seen at 72hours in the case of the components of Sterillium.

Moreover, we should not forget that the most common causes of allergic contact dermatitis in health care professionals are the substances found in gloves, such as latex, rubber, and starch, or the ingredients in antiseptic soaps, including glutaraldehyde, formaldehyde, and glyoxal.10

As indicated in the management algorithm in our article on this topic, irritant contact dermatitis favors the development of allergic contact dermatitis. Thus, reducing irritation and preserving the integrity of the skin barrier will reduce the risk of sensitization.2

We agree entirely that when there is a temporal relationship in the case of lesions that are persistent or are exacerbated by the use of alcohol-based products, patch tests should be performed to rule out the possibility of an allergy to the alcohol component of the product used or the additives it contains. As García-Gavín et al.1 point out, the repeated open application test is a quick, practical, and economical alternative diagnostic method.

In conclusion, we believe that the possibility that certain patients may develop allergic contact dermatitis to alcohol-based products should not distract from the main message of our article2: hygiene is mandatory in health care and the use of alcohol-based sanitizers causes less irritation than handwashing with soap and water. Moreover, irritation should not be considered a limiting factor in the use of such products.