Actas Dermosifiliogr.

2012;103(9):845---847

LETTERS TO THE EDITOR

Hand Eczema Due to Hygiene and sanitizing is required (An Goossens, personal communica-
tion). In fact, in our own department we have diagnosed 2
Antisepsis Products: Not Only an Irritative young nurses with allergic contact dermatitis to isopropyl
Etiology夽 alcohol.
It is important to remember that, in addition to iso-
Productos de higiene, antisepsia y eccema de propyl alcohol, commercial alcohol-based hand rubs may
manos: no solo etiología irritativa contain other ingredients, such as emulsifiers, additives
(lanolin, propylene glycol, bisabolol), and perfumes, and
To the Editor: that the allergenic potential of these components may be
even greater than that of the alcohol.6,7
We read with interest the recent article by Batalla et al.1 For all these reasons----and as Batalla et al.1 clearly
on the use of hand hygiene and antisepsis products among indicate in their algorithm----the role of allergic contact
health care professionals and the relationship between dermatitis should not be overlooked when patients who
these products and hand eczema. While we are in full habitually use alcohol-based sanitizers present with hand
agreement with the central message of the article and the eczema. Consequently, patch testing is recommended in the
authors’ algorithm for the management of patients with case of persistent and clearly associated lesions. A practical
intolerance to alcohol-based products, we would like to add alternative diagnostic technique available to any specialist
the following points. is a repeated open application test with the actual prod-
Since 2009, when the World Health Organization pub- uct used by the patient.8 It is very possible that the cause
lished its guidelines on hand hygiene for health care is allergic if the patient develops lesions after twice-daily
professionals,2 there has been a marked upswing in the dis- application (morning and evening) on an area of approxi-
tribution and use of alcohol-based products because of the mately 5 cm2 on the anterior forearm, for at least 2 weeks.
numerous advantages they offer over traditional handwash- Finally, we would like to thank the authors of this excel-
ing. lent review on a very current issue of great relevance to
The hand rubs that have achieved the greatest commer- dermatologists, who must be aware of the issues involved
cial success (e.g., Sterillium and Manorapid r.f.u.) are those and up to date on the methods for diagnosing and treating
that contain isopropyl alcohol (Chemical Abstract Service these patients.
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 References
some authors to even doubt whether isopropyl alcohol was
in fact an allergen in humans.4 1. Batalla A, García-Doval I, de la Torre C. Productos de higiene
However, the marked increase in the use of products con- y antisepsia de manos: su empleo y relación con el eccema
taining isopropyl alcohol has led to a substantial increase in de manos en profesionales sanitarios. Actas Dermosifiliogr.
exposure. At the same time, it has been found that isopropyl 2012;103:192---7.
alcohol is potentially an important allergen, especially when 2. Pittet D, Allegranzi B, Boyce J, World Health Organization World
Alliance for Patient Safety First Global Patient Safety Challenge
used directly on the skin although also in the case of occu-
Core Group of Experts. The World Health Organization guidelines
pational exposure.5 on hand hygiene in health care and their consensus recommen-
In Europe, there are already numerous reports of health dations. Infect Control Hosp Epidemiol. 2009;30:611---22.
professionals who have been diagnosed with contact allergy 3. Vujevich J, Zirwas M. Delayed hypersensitivity to isopropyl alco-
to this substance, especially nurses and nursing assistants hol. Contact Dermatitis. 2007;56:287.
working in highly specialized units where frequent hand 4. Gerberick GF, Ryan CA, Kern PS, Schlatter H, Dearman RJ, Kim-
ber I, et al. Compilation of historical local lymph node data for
evaluation of skin sensitization alternative methods. Dermatitis.
2005;16:157---202.
夽 Please cite this article as: García-Gavín J, et al. Productos de 5. García-Gavín J, Lissens R, Timmermans A, Goossens A. Allergic
higiene, antisepsia y eccema de manos: no solo etiología irritativa. contact dermatitis caused by isopropyl alcohol. A missed aller-
Actas Dermosifiliogr. 2012;103:848-9. gen? Contact Dermatitis. 2011;65:101---6.

1578-2190/$ – see front matter © 2012 Elsevier España, S.L. and AEDV. All rights reserved.
846 LETTERS TO THE EDITOR

6. Travassos AR, Claes L, Boey L, Drieghe J, Goossens A. Non- J. García-Gavín,∗ L. Pérez-Pérez, A. Zulaica
fragrance allergens in specific cosmetic products. Contact
Dermatitis. 2011;65:276---85. Unidad de Alergia Cutánea y Fotoparche, Complejo
7. Nardelli A, Drieghe J, Claes L, Boey L, Goossens A. Fragrance Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
allergens in ‘‘specific’’ cosmetic products. Contact Dermatitis.
2011;64:212---9.
8. Nakada T, Hostynek J, Maibach H. Use tests: ROAT (repeated
∗
Corresponding author.
open application test)/PUT (provocative use test): an overview. E-mail address: juangavin@gmail.com (J. García-Gavín).
Contact Dermatitis. 2000;43:1---3.

Response to: «Hand Eczema Due to of 2 of the products (Desmanol and Sterillium). When the
components of these products were tested separately in 2
Hygiene and Antisepsis Products: Not Only
of these patients, a positive reaction was observed to the
an Irritative Etiology»夽 cetearyl octanoate in Desmanol and no reactions were seen
at 72 hours in the case of the components of Sterillium.
Réplica a: « Productos de higiene, antisepsia y Moreover, we should not forget that the most common
eccema de manos: no solo etiología irritativa» causes of allergic contact dermatitis in health care profes-
sionals are the substances found in gloves, such as latex,
To the Editor: rubber, and starch, or the ingredients in antiseptic soaps,
including glutaraldehyde, formaldehyde, and glyoxal.10
We appreciate the comments made by García-Gavín et al.1 As indicated in the management algorithm in our article
concerning the article ‘‘Products for Hand Hygiene and Anti- on this topic, irritant contact dermatitis favors the develop-
sepsis: Use by Health Professionals and Relationship With ment of allergic contact dermatitis. Thus, reducing irritation
Hand Eczema.’’2 and preserving the integrity of the skin barrier will reduce
The focus of the article in question was skin irritation the risk of sensitization.2
in health care professionals caused by hygiene and anti- We agree entirely that when there is a temporal rela-
sepsis products, particularly alcohol-based sanitizers. Skin tionship in the case of lesions that are persistent or are
irritation is one of the main reasons for the scant use of exacerbated by the use of alcohol-based products, patch
these products in clinical practice. Alcohol-based hand rubs tests should be performed to rule out the possibility of an
are better tolerated by the skin than soap and water, and the allergy to the alcohol component of the product used or
guidelines of the Centers for Disease Control and Prevention the additives it contains. As García-Gavín et al.1 point out,
and the World Health Organization clearly recommend the the repeated open application test is a quick, practical, and
use of these products over traditional handwashing.3 economical alternative diagnostic method.
It has been reported previously2 that such irritation In conclusion, we believe that the possibility that certain
may be erroneously diagnosed by health professionals as patients may develop allergic contact dermatitis to alcohol-
an allergic reaction.4---8 That said, this does not mean that based products should not distract from the main message of
these products can never cause true allergies. Cases have our article2 : hygiene is mandatory in health care and the use
been reported of allergic contact dermatitis associated with of alcohol-based sanitizers causes less irritation than hand-
alcohol-based products. In addition to the published cases washing with soap and water. Moreover, irritation should not
of allergy to isopropanol,9 there have also been reports of be considered a limiting factor in the use of such products.
allergic contact dermatitis caused by ethanol, 1-propanol,
and 2-propanol.3,4 However, given the large number of peo- References
ple using alcohol-based rubs today, the incidence of such
allergies, while certainly not negligible and potentially con-
1. García-Gavín J, Pérez-Pérez L, Zulaica A. Productos de higiene,
siderable, is low, and in most cases the allergy is caused by antisepsia y eccema de manos: no solo etiología irritativa. Actas
impurities, contaminants, or additives.3---5,8 Therefore, the Dermosifiliogr. 2012;103:845---6.
possibility that a user may develop an allergy should not 2. Batalla A, García-Doval I, de la Torre C. Productos de higiene
be an obstacle to recommending the use of these products. y antisepsia de manos: su empleo y relación con el eccema
For example, in a study of 50 nurses who reported ery- de manos en los profesionales sanitarios. Actas Dermosifiliogr.
thema, desquamation, blistering, itching, or stinging after 2012;103:192---7.
using alcohol-based products, none had a positive reaction 3. Stutz N, Becker D, Jappe U, John SM, Ladwig A, Spornraft-
to ethanol, 1-propanol, or 2-propanol on patch testing.7 Ragaller P, et al. Nurses’ perceptions of the benefits and
When, in the same study, the nurses underwent patch adverse effects of hand disinfection: alcohol-based hand rubs
vs hygienic handwashing: a multicentre questionnaire study
testing with the products they were using at the workplace,
with additional patch testing by the German Contact Dermatitis
only 3 exhibited a mild positive reaction after application Research Group. Br J Dermatol. 2009;160:565---72.
4. Kramer A, Hübner N, Below H, Heidecke CD, Assadian O. Improv-
ing adherence to surgical hand preparation. J Hosp Infect.
夽 Batalla A, García-Doval I. Réplica a: «Productos de higiene, 2008;70 Suppl. 1:35---43.
antisepsia y eccema de manos: no solo etiología irritativa». Actas 5. Kampf G, Löffler H. Prevention of irritant contact der-
Dermosifiliogr. 2012;103:850-1. matitis among health care workers by using evidence-based