Abstract
Skin hygiene, particularly of the hands, is a primary mechanism for reducing contact and fecal-oral transmission of infectious agents. Widespread use of antimicrobial products has prompted concern about emergence of resistance to antiseptics and damage to the skin barrier associated with frequent washing. This article reviews evidence for the relationship between skin hygiene and infection, the effects of washing on skin integrity, and recommendations for skin care practices.
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- Alam N., Wojtyniak B., Henry F. J., Rahaman M. M. Mothers' personal and domestic hygiene and diarrhoea incidence in young children in rural Bangladesh. Int J Epidemiol. 1989 Mar;18(1):242–247. doi: 10.1093/ije/18.1.242. [DOI] [PubMed] [Google Scholar]
- Ayliffe G. A., Noy M. F., Babb J. R., Davies J. G., Jackson J. A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection. J Hosp Infect. 1983 Sep;4(3):237–244. doi: 10.1016/0195-6701(83)90024-5. [DOI] [PubMed] [Google Scholar]
- BLANK I. H. Factors which influence the water content of the stratum corneum. J Invest Dermatol. 1952 Jun;18(6):433–440. doi: 10.1038/jid.1952.52. [DOI] [PubMed] [Google Scholar]
- Bartzokas C. A., Paton J. H., Gibson M. F., Graham F., McLoughlin G. A., Croton R. S. Control and eradication of methicillin-resistant Staphylococcus aureus on a surgical unit. N Engl J Med. 1984 Nov 29;311(22):1422–1425. doi: 10.1056/NEJM198411293112207. [DOI] [PubMed] [Google Scholar]
- Bruun J. N., Solberg C. O. Hand carriage of gram-negative bacilli and Staphylococcus aureus. Br Med J. 1973 Jun 9;2(5866):580–582. doi: 10.1136/bmj.2.5866.580. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bryan J. L., Cohran J., Larson E. L. Hand washing: a ritual revisited. Crit Care Nurs Clin North Am. 1995 Dec;7(4):617–625. [PubMed] [Google Scholar]
- Byrne D. J., Napier A., Cuschieri A. Rationalizing whole body disinfection. J Hosp Infect. 1990 Feb;15(2):183–187. doi: 10.1016/0195-6701(90)90129-c. [DOI] [PubMed] [Google Scholar]
- Doebbeling B. N., Stanley G. L., Sheetz C. T., Pfaller M. A., Houston A. K., Annis L., Li N., Wenzel R. P. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992 Jul 9;327(2):88–93. doi: 10.1056/NEJM199207093270205. [DOI] [PubMed] [Google Scholar]
- Dugard P. H., Scheuplein R. J. Effects of ionic surfactants on the permeability of human epidermis: an electrometric study. J Invest Dermatol. 1973 May;60(5):263–269. doi: 10.1111/1523-1747.ep12722895. [DOI] [PubMed] [Google Scholar]
- Ehrenkranz N. J., Taplin D., Butt P. Antibiotic-resistant bacteria on the nose and skin: colonization and cross-infection. Antimicrob Agents Chemother (Bethesda) 1966;6:255–264. [PubMed] [Google Scholar]
- Ekanem E. E., Akitoye C. O., Adedeji O. T. Food hygiene behaviour and childhood diarrhoea in Lagos, Nigeria: a case-control study. J Diarrhoeal Dis Res. 1991 Sep;9(3):219–226. [PubMed] [Google Scholar]
- Evans C. A. Persistent individual differences in the bacterial flora of the skin of the forehead: numbers of propionibacteria. J Invest Dermatol. 1975 Jan;64(1):42–46. doi: 10.1111/1523-1747.ep12540897. [DOI] [PubMed] [Google Scholar]
- Feachem R. G. Interventions for the control of diarrhoeal diseases among young children: promotion of personal and domestic hygiene. Bull World Health Organ. 1984;62(3):467–476. [PMC free article] [PubMed] [Google Scholar]
- Frantz S. W., Haines K. A., Azar C. G., Ward J. I., Homan S. M., Roberts R. B. Chlorhexidine gluconate (CHG) activity against clinical isolates of vancomycin-resistant Enterococcus faecium (VREF) and the effects of moisturizing agents on CHG residue accumulation on the skin. J Hosp Infect. 1997 Oct;37(2):157–164. doi: 10.1016/s0195-6701(97)90185-7. [DOI] [PubMed] [Google Scholar]
- Grunewald A. M., Gloor M., Gehring W., Kleesz P. Damage to the skin by repetitive washing. Contact Dermatitis. 1995 Apr;32(4):225–232. doi: 10.1111/j.1600-0536.1995.tb00673.x. [DOI] [PubMed] [Google Scholar]
- Grunewald A. M., Gloor M., Gehring W., Kleesz P. Efficacy of barrier creams. Curr Probl Dermatol. 1995;23:187–197. doi: 10.1159/000424315. [DOI] [PubMed] [Google Scholar]
- Gwaltney J. M., Jr, Moskalski P. B., Hendley J. O. Hand-to-hand transmission of rhinovirus colds. Ann Intern Med. 1978 Apr;88(4):463–467. doi: 10.7326/0003-4819-88-4-463. [DOI] [PubMed] [Google Scholar]
- Haggerty P. A., Muladi K., Kirkwood B. R., Ashworth A., Manunebo M. Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. Int J Epidemiol. 1994 Oct;23(5):1050–1059. doi: 10.1093/ije/23.5.1050. [DOI] [PubMed] [Google Scholar]
- Hall G. S., Mackintosh C. A., Hoffman P. N. The dispersal of bacteria and skin scales from the body after showering and after application of a skin lotion. J Hyg (Lond) 1986 Oct;97(2):289–298. doi: 10.1017/s0022172400065384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hartmann A. A. Tägliches Baden und Verhalten der Hautflora. Quantitative und qualitative Untersuchungen der aeroben Hautflora. Arch Dermatol Res. 1979 Jun 25;265(2):153–164. doi: 10.1007/BF00407880. [DOI] [PubMed] [Google Scholar]
- Hobson D. W., Woller W., Anderson L., Guthery E. Development and evaluation of a new alcohol-based surgical hand scrub formulation with persistent antimicrobial characteristics and brushless application. Am J Infect Control. 1998 Oct;26(5):507–512. doi: 10.1016/s0196-6553(98)70024-0. [DOI] [PubMed] [Google Scholar]
- Holbrook K. A., Odland G. F. Regional differences in the thickness (cell layers) of the human stratum corneum: an ultrastructural analysis. J Invest Dermatol. 1974 Apr;62(4):415–422. doi: 10.1111/1523-1747.ep12701670. [DOI] [PubMed] [Google Scholar]
- Höffler U., Gloor M., Peters G., Ko H. L., Bräutigan A., Thurn A., Pulverer G. Qualitative and quantitative investigations on the resident bacterial skin flora in healthy persons and in the non-affected skin of patients with seborrheic Eczema. Arch Dermatol Res. 1980;268(3):297–312. doi: 10.1007/BF00404292. [DOI] [PubMed] [Google Scholar]
- KLAUDER J. V., GROSS B. A. Actual causes of certain occupational dermatoses. III. A further study with special reference to effect of alkali on the skin, effect of soap on pH of skin, modern cutaneous detergents. AMA Arch Derm Syphilol. 1951 Jan;63(1):1–23. doi: 10.1001/archderm.1951.01570010004001. [DOI] [PubMed] [Google Scholar]
- Kaiser A. B., Kernodle D. S., Barg N. L., Petracek M. R. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg. 1988 Jan;45(1):35–38. doi: 10.1016/s0003-4975(10)62391-0. [DOI] [PubMed] [Google Scholar]
- Larson E. L. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995 Aug;23(4):251–269. doi: 10.1016/0196-6553(95)90070-5. [DOI] [PubMed] [Google Scholar]
- Larson E. L., Eke P. I., Laughon B. E. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother. 1986 Oct;30(4):542–544. doi: 10.1128/aac.30.4.542. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Larson E. L., Hughes C. A., Pyrek J. D., Sparks S. M., Cagatay E. U., Bartkus J. M. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998 Oct;26(5):513–521. doi: 10.1016/s0196-6553(98)70025-2. [DOI] [PubMed] [Google Scholar]
- Larson E. L., McGinley K. J., Foglia A., Leyden J. J., Boland N., Larson J., Altobelli L. C., Salazar-Lindo E. Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru. Am J Infect Control. 1992 Apr;20(2):65–72. doi: 10.1016/s0196-6553(05)80003-3. [DOI] [PubMed] [Google Scholar]
- Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control. 1988 Jan;9(1):28–36. [PubMed] [Google Scholar]
- Larson E., Friedman C., Cohran J., Treston-Aurand J., Green S. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997 Sep-Oct;26(5):404–412. doi: 10.1016/s0147-9563(97)90027-3. [DOI] [PubMed] [Google Scholar]
- Larson E., Silberger M., Jakob K., Whittier S., Lai L., Della Latta P., Saiman L. Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses. Heart Lung. 2000 Mar-Apr;29(2):136–142. [PubMed] [Google Scholar]
- Larson E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Infect Dis. 1999 Nov;29(5):1287–1294. doi: 10.1086/313468. [DOI] [PubMed] [Google Scholar]
- Larson E. Social and economic impact of infectious diseases--United States. Clin Perform Qual Health Care. 1997 Jan-Mar;5(1):31–37. [PubMed] [Google Scholar]
- Lauharanta J., Ojajärvi J., Sarna S., Mäkelä P. Prevention of dryness and eczema of the hands of hospital staff by emulsion cleansing instead of washing with soap. J Hosp Infect. 1991 Mar;17(3):207–215. doi: 10.1016/0195-6701(91)90232-w. [DOI] [PubMed] [Google Scholar]
- Leyden J. J., McGinley K. J., Nordstrom K. M., Webster G. F. Skin microflora. J Invest Dermatol. 1987 Mar;88(3 Suppl):65s–72s. doi: 10.1111/1523-1747.ep12468965. [DOI] [PubMed] [Google Scholar]
- Lodén M. Barrier recovery and influence of irritant stimuli in skin treated with a moisturizing cream. Contact Dermatitis. 1997 May;36(5):256–260. doi: 10.1111/j.1600-0536.1997.tb00213.x. [DOI] [PubMed] [Google Scholar]
- MURRAY J., CALMAN R. M. Control of cross-infection by means of an antiseptic hand cream. Br Med J. 1955 Jan 8;1(4905):81–83. doi: 10.1136/bmj.1.4905.81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mackenzie I. Preoperative skin preparation and surgical outcome. J Hosp Infect. 1988 Apr;11 (Suppl B):27–32. doi: 10.1016/0195-6701(88)90153-3. [DOI] [PubMed] [Google Scholar]
- Maki D. G. The use of antiseptics for handwashing by medical personnel. J Chemother. 1989 Apr;1 (Suppl 1):3–11. doi: 10.1080/1120009x.1989.11738936. [DOI] [PubMed] [Google Scholar]
- Meberg A., Schøyen R. Bacterial colonization and neonatal infections. Effects of skin and umbilical disinfection in the nursery. Acta Paediatr Scand. 1985 May;74(3):366–371. doi: 10.1111/j.1651-2227.1985.tb10985.x. [DOI] [PubMed] [Google Scholar]
- Meers P. D., Yeo G. A. Shedding of bacteria and skin squames after handwashing. J Hyg (Lond) 1978 Aug;81(1):99–105. doi: 10.1017/s0022172400053808. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Moken M. C., McMurry L. M., Levy S. B. Selection of multiple-antibiotic-resistant (mar) mutants of Escherichia coli by using the disinfectant pine oil: roles of the mar and acrAB loci. Antimicrob Agents Chemother. 1997 Dec;41(12):2770–2772. doi: 10.1128/aac.41.12.2770. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Morrison A. J., Jr, Gratz J., Cabezudo I., Wenzel R. P. The efficacy of several new handwashing agents for removing non-transient bacterial flora from hands. Infect Control. 1986 May;7(5):268–272. doi: 10.1017/s0195941700064195. [DOI] [PubMed] [Google Scholar]
- NOBLE W. C., DAVIES R. R. STUDIES ON THE DISPERSAL OF STAPHYLOCOCCI. J Clin Pathol. 1965 Jan;18:16–19. doi: 10.1136/jcp.18.1.16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Noble W. C. Dispersal of skin microorganisms. Br J Dermatol. 1975 Oct;93(4):477–485. doi: 10.1111/j.1365-2133.1975.tb06527.x. [DOI] [PubMed] [Google Scholar]
- Ojajärvi J. Effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing. J Hyg (Lond) 1980 Oct;85(2):193–203. doi: 10.1017/s0022172400063221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ojajärvi J., Mäkelä P., Rantasalo I. Failure of hand disinfection with frequent hand washing: a need for prolonged field studies. J Hyg (Lond) 1977 Aug;79(1):107–119. doi: 10.1017/s0022172400052906. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Parry M. F., Hutchinson J. H., Brown N. A., Wu C. H., Estreller L. Gram-negative sepsis in neonates: a nursery outbreak due to hand carriage of Citrobacter diversus. Pediatrics. 1980 Jun;65(6):1105–1109. [PubMed] [Google Scholar]
- Paulson D. S. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect Control. 1993 Aug;21(4):205–209. doi: 10.1016/0196-6553(93)90033-z. [DOI] [PubMed] [Google Scholar]
- Rotter M. L., Koller W. Test models for hygienic handrub and hygienic handwash: the effects of two different contamination and sampling techniques. J Hosp Infect. 1992 Mar;20(3):163–171. doi: 10.1016/0195-6701(92)90084-y. [DOI] [PubMed] [Google Scholar]
- Rotter M. L., Larsen S. O., Cooke E. M., Dankert J., Daschner F., Greco D., Grönross P., Jepsen O. B., Lystad A., Nyström B. A comparison of the effects of preoperative whole-body bathing with detergent alone and with detergent containing chlorhexidine gluconate on the frequency of wound infections after clean surgery. The European Working Party on Control of Hospital Infections. J Hosp Infect. 1988 May;11(4):310–320. doi: 10.1016/0195-6701(88)90083-7. [DOI] [PubMed] [Google Scholar]
- Rudland S., Little M., Kemp P., Miller A., Hodge J. The enemy within: diarrheal rates among British and Australian troops in Iraq. Mil Med. 1996 Dec;161(12):728–731. [PubMed] [Google Scholar]
- Russell A. D., Hammond S. A., Morgan J. R. Bacterial resistance to antiseptics and disinfectants. J Hosp Infect. 1986 May;7(3):213–225. doi: 10.1016/0195-6701(86)90071-x. [DOI] [PubMed] [Google Scholar]
- SPEERS R., Jr, BERNARD H., O'GRADY F., SHOOTER R. A. INCREASED DISPERSAL OF SKIN BACTERIA INTO THE AIR AFTER SHOWER-BATHS. Lancet. 1965 Feb 27;1(7383):478–480. doi: 10.1016/s0140-6736(65)91609-0. [DOI] [PubMed] [Google Scholar]
- Sattar S. A., Tetro J., Springthorpe V. S. Impact of changing societal trends on the spread of infections in American and Canadian homes. Am J Infect Control. 1999 Dec;27(6):S4–21. doi: 10.1016/s0196-6553(99)70037-4. [DOI] [PubMed] [Google Scholar]
- Schlüter-Wigger W., Elsner P. Efficacy of 4 commercially available protective creams in the repetitive irritation test (RIT). Contact Dermatitis. 1996 Apr;34(4):278–283. doi: 10.1111/j.1600-0536.1996.tb02200.x. [DOI] [PubMed] [Google Scholar]
- Sempértegui F., Estrellá B., Egas J., Carrión P., Yerovi L., Díaz S., Lascano M., Aranha R., Ortiz W., Zabala A. Risk of diarrheal disease in Ecuadorian day-care centers. Pediatr Infect Dis J. 1995 Jul;14(7):606–612. doi: 10.1097/00006454-199507000-00011. [DOI] [PubMed] [Google Scholar]
- Shahid N. S., Greenough W. B., 3rd, Samadi A. R., Huq M. I., Rahman N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res. 1996 Jun;14(2):85–89. [PubMed] [Google Scholar]
- Stingeni L., Lapomarda V., Lisi P. Occupational hand dermatitis in hospital environments. Contact Dermatitis. 1995 Sep;33(3):172–176. doi: 10.1111/j.1600-0536.1995.tb00540.x. [DOI] [PubMed] [Google Scholar]
- Tuffnell D. J., Croton R. S., Hemingway D. M., Hartley M. N., Wake P. N., Garvey R. J. Methicillin resistant Staphylococcus aureus; the role of antisepsis in the control of an outbreak. J Hosp Infect. 1987 Nov;10(3):255–259. doi: 10.1016/0195-6701(87)90006-5. [DOI] [PubMed] [Google Scholar]
- Uveges R. E., Grimwood R. E., Slawsky L. D., Marks J. G., Jr Epidemiology of hand dermatitis in dental personnel. Mil Med. 1995 Jul;160(7):335–338. [PubMed] [Google Scholar]
- Voss A., Widmer A. F. No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol. 1997 Mar;18(3):205–208. doi: 10.1086/647590. [DOI] [PubMed] [Google Scholar]
- Webster J., Faoagali J. L., Cartwright D. Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan. J Paediatr Child Health. 1994 Feb;30(1):59–64. doi: 10.1111/j.1440-1754.1994.tb00568.x. [DOI] [PubMed] [Google Scholar]
- Wilhelm K. P., Freitag G., Wolff H. H. Surfactant-induced skin irritation and skin repair. Evaluation of the acute human irritation model by noninvasive techniques. J Am Acad Dermatol. 1994 Jun;30(6):944–949. doi: 10.1016/s0190-9622(94)70114-8. [DOI] [PubMed] [Google Scholar]
- Zafar A. B., Butler R. C., Reese D. J., Gaydos L. A., Mennonna P. A. Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. Am J Infect Control. 1995 Jun;23(3):200–208. doi: 10.1016/0196-6553(95)90042-x. [DOI] [PubMed] [Google Scholar]
- Zelickson A. S., Zelickson B. D., Zelickson B. M. Measurements by transmission electron microscopy of "dry" skin before and after application of a moisturizing cream. Am J Dermatopathol. 1982 Jun;4(3):205–208. doi: 10.1097/00000372-198206000-00004. [DOI] [PubMed] [Google Scholar]