Regardless of the season, healthcare workers in a long-term care environment are susceptible to dry skin and irritant contact dermatitis by nature due to the high frequency of hand hygiene. But winter can be a particularly taxing time especially when there is failure adapt to hand hygiene best practices.
Low relative humidity and colder temperatures lead to a decrease in skin barrier function and increased susceptibility to mechanical stress. Hand washing with soap and water feels soothing, and healthcare workers may revert to it as a primary means of hand hygiene. But when they do, it dissolves oils and lipids naturally present in the skin and further disrupt the natural skin barrier. Consequently, when alcohol-based hand rub (ABHR) is applied to already-damaged skin, an immediate stinging sensation is experienced due to channels of exposure to nerves and tissues in the deeper layers of the skin.
As a result, HCW may limit or avoid use of ABHR, unknowingly exacerbating the problem and setting themselves up for progressive skin damage.
Fall is an optimal time to reinforce good hand hygiene behavior and skin care. ABHR should be the primary vehicle for hand hygiene, except when hands are visibly soiled. That’s a key to maintaining skin health. In addition, moisturizers are a critical, but often overlooked aspect of long-term care hand hygiene programs. The Centers for Disease Control and Prevention recommends that “Provid[ing] HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing.” This is a 1A recommendation, meaning it is strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
The guidelines around cleaning hands are clear, but vague for lotion use. Selecting appropriate moisturizing agents can be confusing and needs to be carefully considered in the clinical environment. The goal of moisturization is to create a protective layer on the skin surface, reduce water loss from skin, and protect it during the next cleanser or water exposure. The term “moisturizer” is very broad to include lotions, creams, and ointments.
So what’s the difference? Ointments are comprised of 80% oil and 20% water and are designed to form an occlusive barrier to seal moisture into the skin. The downside of the high oil content is that they are greasy, messy, and not practical during clinical care. However, they can be beneficial when left in contact with the skin for an extended period, such as during sleep.
Creams are 50% oil and 50% water, and therefore feel somewhat greasy. Lotions are like creams but are less thick due to their higher water content. They are readily absorbed, and evaporate more quickly, making them the ideal choice for a healthcare environment. Especially in winter months, your workers may need different combinations of moisturizers for optimal skin care; for example, a lotion during the work shift and the addition of a cream or ointment at night.
There is also no guidance around frequency of application and it may depend on various factors. In one study, subjects used a cream immediately after each wash which resulted in decreased skin dryness and roughness over a two-week period. Lotion application after every soap and water wash is likely not feasible in a healthcare setting, but lotions should be used as frequently as possible for optimum benefit. Bottom line: the more, the better.
Lastly, there is confusion around the appropriateness of moisturizers containing petrolatum as it relates to glove compatibility. Petrolatum-based oils are known to deteriorate certain glove materials like natural rubber latex. Other materials like nitrile are not affected by petrolatum oils. The quality of the petrolatum and the amount present in the moisturizer can affect compatibility.
The safest course of action is for facilities to choose healthcare-grade lotions and to solicit glove compatibility data from lotion manufacturers, thereby ensuring that there are no potential deleterious effects on glove integrity or on the efficacy of antiseptic agents used in the facility.
Megan J. DiGiorgio MSN, RN, CIC, FAPIC, is the Clinical Manager at GOJO Industries. She has worked in infection prevention for almost 15 years.
