Guide to Hand Sanitizers - The Dermatology Review
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Guide to Hand Sanitizers

Around the world, major government health agencies and medical experts have found that the novel coronavirus, or COVID-19, is predominantly transmitted through respiratory droplets that are projected through the air, which is why masks have become a major part of stopping the spread of the disease.

As the pandemic spread in early 2020, one of the first reported methods for stopping COVID was to frequently wash your hands, for at least 20 seconds. For people who had to be out in public, due to work or caregiving activities, hand sanitizer became a vital secondary solution for those who needed to clean their hands but did not always have access to sinks and soap.

Clean Hands & Surfaces: Using Hand Sanitizer to Reduce Transmission of COVID-19

COVID-19 has been spread through contact with hands, surfaces, or items. While it is less common compared to aerial spread, keeping your hands clean is still an important way to slow down the spread of the coronavirus.

The World Health Organization (WHO) has published scientific evidence stating that when mucosa from the hands, eyes, or mouth get onto your hands, you can spread COVID-19 by putting hands on items or surfaces or by shaking someone’s hand.

Alcohol-based hand sanitizers can help keep hands clean. For many people, carrying a small container of hand sanitizer in their bag, pocket, or car has made a huge difference in feeling safe during the pandemic.

However, not all hand sanitizers are effective at stopping viruses like the novel coronavirus. For example, not all hand sanitizers contain alcohol, which is a key component to killing viruses and bacteria. Some hand sanitizers are effective against viruses but not bacteria. Some are not regulated by the United States Food and Drug Administration (FDA) or another regulatory agency because they are homemade or made by an alcohol distillery, so may not be as effective as a mass-manufactured brand.

Public Health Guidance on the Most Effective Types of Hand Sanitizer

Sometimes called alcohol-based hand rubs (ABHR), hand sanitizers have been one of the most popular methods for reducing the spread of COVID-19. It is important to know that the formula for hand sanitizer matters, when it comes to killing germs like viruses and bacteria.

A study conducted by the WHO and published in 2011 found that the formulation of hand sanitizer was more important than the amount of alcohol (either ethanol or isopropyl alcohol) used as the base of the rub. However, the study focused on rubs containing either 75 percent isopropanol or 80 percent ethanol, based on previous standards for the amount of alcohol that must be present to be effective. So, a combination of hand sanitizer formula and the percentage of skin-safe alcohol is vital to killing the COVID-19 virus.

The Centers for Disease Control and Prevention (CDC) state that hand sanitizer should contain between 60 and 95 percent alcohol to be effective. You should rub the product on your hands for at least 20 seconds, covering the whole surface of both hands and scrubbing until the hands feel dry.

These are some recommended brands of hand sanitizer

  • Purell Advanced, which contains 70 percent ethyl alcohol compared to other types of Purell
  • Germ-X Original, which contains 62 percent ethyl alcohol
  • Clorox Commercial Solutions, which contains 71 percent ethyl alcohol and no bleach despite the Clorox brand
  • Fleur & Bee Spray, which contains 75 percent isopropyl alcohol and glycerin to keep skin moisturized
  • SpaRitual Hand Sanitizer Spray, which contains 75 percent isopropyl alcohol along with glycerin for skin health

How to Safely & Effectively Use Hand Sanitizer to Reduce COVID-19

Hand hygiene is one of the most important ways to stop the spread of several diseases, including COVID-19. Although soap and warm water are the most effective tools for keeping your hands clean, hand sanitizer that is known to be effective against bacteria and viruses is an effective second option.

While soap and water remove germs from hands by creating a slick surface that they slide off, hand sanitizer directly kills bacteria and some viruses on the surface of the skin. According to the CDC, hand sanitizers reduce the number of germs on the skin, but they may not remove as many as washing your hands with soap and water will.

When you only have access to hand sanitizer, the CDC recommends using a brand that is at least 60 percent ethanol or isopropyl alcohol. Then, wash your hands with soap and water as soon as you can, like during a work break or when you return home. You should also use hand sanitizer immediately after sneezing or coughing, even if you are wearing a mask, to reduce your risk of transmitting diseases like COVID-19.

To appropriately use hand sanitizer:

  • Put enough on your hands to cover all surfaces. If you do not get enough in the first squeeze, reopen your bottle and squeeze again.
  • Rub your hands together until they feel dry, which should take about 20 seconds.
  • Do not rinse off your hands or wipe them off to dry them. This can reduce the hand sanitizer’s effectiveness.
  • Do not wave your hands around in the air to dry them off, as they can pick up microorganisms.
  • If your hands are visibly dirty or greasy, you may need to wash your hands before applying hand sanitizer. Studies have shown that contaminants on the surface of the skin can get in the way of hand rubs’ effectiveness.
  • Follow the bottle’s directions for appropriate use, alongside public health guidance issued by the FDA and CDC.
  • Monitor children as they apply hand sanitizer. Accidentally swallowing or drinking the product can cause alcohol poisoning and severe harm.
  • Do not use hand sanitizer of any kind on your pet. Animals will become ill from ingesting the alcohol or other ingredients in these products.

 

Not All Hand Sanitizers Are Created Equal

Hand sanitizers that reportedly “kill germs” have existed for decades, but not all of them are effective against COVID-19. Many government health agencies, like the CDC, have issued specific guidance for hand sanitizers that work against the virus, with a focus on those containing at least 60 percent ethanol or isopropanol.

The hand sanitizer you have already may not work against viruses, and it may even be less effective against bacteria. It may not contain the ingredients it says it does. If it is homemade or distillery-made, it may not contain enough alcohol or additional ingredients to ensure the alcohol is as effective as possible.

 

Ineffective Hand Sanitizers

While hand sanitizer is one of many important tools in the public health fight against coronavirus, some previous public health warnings may prevent you from purchasing the most effective hand sanitizer against COVID-19.

In prior years, medical experts warned that overuse of alcohol-based hand sanitizers would not kill all bacteria or viruses, but instead lead to superbugs, or bacteria that are resistant to standard cleaning products with alcohol as a base.

National Public Radio (NPR) published a report in 2018 that found that bacteria had been growing more resistant to alcohol-based hand sanitizers and cleaning products for several years. For example, in hospitals that installed hand sanitizer stations for staff and visitors, rates of staph infections across the facilities began to decline. However, other bacteria that were more resistant to alcohol-based sanitizers began to spread faster.

Additionally, some bacteria, including staph, have developed resistance to these sanitizers over the years, leading to outbreaks of “super staph,” or methicillin-resistant Staphylococcus aureus (MRSA). These have led to serious, even deadly infections.

The 2018 study found that many bacteria and viruses were stopped with a concentration of 70 percent alcohol. The study began examining hand sanitizers at 23 percent and up to 60 percent, finding these lower percentages ineffective against super bacteria. They are also much less effective against viruses.

In response to the concern over creating super bacteria, many manufacturers began making “alcohol-free” hand sanitizers, which are not effective at killing any bacteria or viruses, although some may slow the growth of bacteria on the skin. There are also hand sanitizers with lower concentrations of alcohol, which are ineffective against COVID-19 and many other diseases. Some hand sanitizers contain other ingredients that claim to kill “germs” but are not effective against the coronavirus.

When seeking a hand sanitizer, it is important to read the label to ensure you purchase a type that contains at least 60 percent alcohol, either ethanol or isopropanol, though a higher concentration is preferable.

Hand Sanitizers With Risky Ingredients

The FDA has found that some hand sanitizers available for purchase contain toxic ingredients, although they are labeled safe for use. Some hand sanitizers, for example, claim to contain ethyl alcohol or ethanol but have instead tested positive for either 1-propanol or methanol

  • Methanol: This type of alcohol is also called wood alcohol, and it can be toxic to humans when consumed or absorbed through the skin.
    With higher rates of hand sanitizer application during the COVID-19 pandemic, methanol-based products can make the user extremely sick very quickly.When the product is labeled incorrectly, the consumer may not understand what is making them so sick.
  • 1-Propanol: This type of alcohol is also toxic to humans, although less through direct skin contact. It is used in industrial solvents or cleaners, so it is not absorbed as readily through direct skin contact, but it can be deadly when swallowed.

    Drinking or accidentally swallowing this type of hand sanitizer suddenly increases heart rate and decreases breathing. This can be especially dangerous for young children. 

In response to this false advertising causing serious public harm, the FDA has created an updated list of hand sanitizers with toxic ingredients. Hand sanitizers containing ethanol or isopropyl alcohol, which is sometimes listed as 2-propanol, are safe to use and effective against most bacteria and viruses. It is important to check the above list from the FDA to know if your hand sanitizer is safe and effective against coronavirus.

Homemade Hand Sanitizers Are Not Effective

In March 2020, hand sanitizers of all kinds sold out almost as soon as stores stocked the shelves. This led to many people creating their own inexpensive versions at home based on recipes spread across the internet. The most popular contained aloe vera gel and vodka or whiskey. These are not effective, although they do contain some ethanol, because alcohol distilled to be safe to drink contains, at most, 40 percent alcohol.

To make a COVID-19 hand sanitizer at home, WHO reports that you must use at least 95 percent ethanol, which is difficult to find. Instead of making your own hand sanitizer, stay home as much as possible and wash your hands frequently.

Distilleries Tried to Help Make Hand Sanitizer

After numerous alcohol distilleries around the world, including in the United States, temporarily switched production to hand sanitizer in 2020, the FDA adjusted guidance for how facilities like distilleries could produce this item while still receiving appropriate inspection and oversight from government health agencies. On their website, the FDA states that entities who are not normally pharmaceutical companies can register as over-the-counter (OTC) drug manufacturers and make alcohol-based hand sanitizers.

As hand sanitizers flew off store shelves and many people began to panic about catching the coronavirus from an unclean surface, alcohol distilleries began to produce hand sanitizer. However, many distilleries who had started producing hand sanitizer soon found, even with revised FDA guidance, that they did not meet the standards for this OTC product. This was largely due to lacking denaturing products, which are intended to make hand sanitizers unsafe for consumption.

In some cases, distilleries continued to manufacture hand sanitizer and donating it to those in need rather than selling it. In rare cases, others obtained denaturants and used them in their manufacturing process. However, most distilleries stopped making hand sanitizer. Fortunately, this occurred in time for global manufacturing of this product to pick up again.

If you have hand sanitizer from a craft distillery, it may not be effective against COVID-19. It could be a souvenir from a moment when small businesses attempted to help the fight against the pandemic.

How to Reduce Skin Damage or Avoid Inflaming Skin Conditions Due to Hand Sanitizer

If you have a skin condition or simply experience consistently dry skin, using hand sanitizer may not be a good solution to keeping your hands clean. Alcohol can dry and irritate the skin, which can cause problems with the surface.

It can also irritate existing skin disorders. For example, if you have eczema, hand sanitizer is not a good option. Instead, you should wash your hands more frequently, and apply a non-scented hand cream afterward.

Both hand sanitizer and frequent handwashing can lead to greater skin irritation, with symptoms like these: 

  • Dryness
  • Itching
  • Irritation 
  • Cracking
  • Bleeding 

Hand hygiene can denature the lipids, or healthy fats, which are part of your skin. This can lead to dehydration and irritation, which can then cause other symptoms or make skin conditions worse.

One solution is to use a non-perfumed or non-scented hand cream after using hand sanitizer or washing your hands. Another solution is to find a hand sanitizer that contains moisturizer for your skin. A WHO study found that ethanol was less damaging to skin lipids than isopropanol. If you have sensitive skin, using a hand sanitizer with a concentration of 60 or 70 percent ethanol may work better for you.

Contact dermatitis has been on the rise during the COVID-19 pandemic, as more people wash their hands and use hand sanitizer more frequently than before. The American Academy of Dermatology Association (AAD) recommends these practices

  • Wash your hands with lukewarm, rather than hot or cold, water.
  • Dry your hands gently with a towel or allow them to air-dry.
  • Before your hands are completely dry, apply hand cream or moisturizer.
  • If you use hand sanitizer, let it dry completely before applying moisturizer.

People who have skin conditions like eczema and psoriasis may be especially frustrated, as handwashing and applying hand sanitizer can quickly exacerbate their painful chronic condition. If you have one of these conditions, speak with your dermatologist for options to help.

In general, more frequent handwashing is still recommended as one way to reduce the spread of coronavirus. You may be able to use hand sanitizer on some occasions without triggering a reaction. Follow the general guidance of keeping your hands clean and then moisturizing, potentially with a prescription cream that is recommended by your dermatologist.

Are There Alternative Methods of Hand Sanitizing?

There are few good alternatives to hand sanitizer besides washing your hands with soap and water. Since there have been periodic shortages of alcohol-based hand rubs throughout the COVID-19 pandemic, government health agencies have often tried to find good solutions that can kill the novel coronavirus.

For example, the FDA proposed benzalkonium chloride as a potential ingredient in hand rubs. Initial studies showed it was somewhat effective, but still less effective than ethanol and isopropanol.

While using a hand sanitizer containing benzalkonium chloride can be effective against COVID-19, there is less evidence for this. If you have skin conditions, this type of hand sanitizer may be a good alternative to alcohol-based hand sanitizers, but you should also wash your hands more frequently.

Safe & Effective Use of Hand Sanitizer Is One Tool to Reduce the Spread of COVID-19

Both WHO and UNICEF believe that as many as 3.5 billion people in the world do not have appropriate hand sanitizing facilities like clean, warm water and effective soap.

Inexpensive, alcohol-based, virus-effective hand sanitizers can be provided as an alternative to support less developed countries in their fight against the novel coronavirus. Providing this short-term solution is also effective at reducing the spread of many other diseases.

WHO reports that hand sanitization is the single most effective strategy for preventing the spread of many communicable diseases, whether they are bacterial or viral.

Many businesses have installed hand sanitizer stations to encourage more people to keep their hands clean. It is likely these stations have helped to reduce the spread of COVID-19, alongside wearing masks, washing hands more frequently, and individuals using their own hand sanitizer.

While it is important to balance hand sanitizer and handwashing with your skin’s health, these are effective ways to reduce the spread of many diseases and keep your community healthier. Follow guidance from the CDC and FDA to find the right type of hand sanitizer.

References:
Hand Sanitizers: A Review of Ingredients, Mechanisms of Action, Modes of Delivery, and Efficacy Against Coronaviruses. (September 2020). Elsevier Public Health Emergency Collection.
Interim Recommendation 1 April 2020. The World Health Organization (WHO.int).
Meeting Global Standards for Hand Sanitizer Efficacy: Formulation Matters. (June 2011). BMC Proceedings.
Hand Hygiene Recommendations. (May 2020). Centers for Disease Control and Prevention (CDC).
The 19 Best Hand Sanitizers of 2021, According to Experts. (December 2020). Women’s Health Magazine.
Hand Sanitizer Use Out and About. (November 2020). Centers for Disease Control and Prevention (CDC).
Hand Sanitizer FAQs. (March 2020). National Jewish Health.
Show Me the Science – When & How to Use Hand Sanitizer in Community Settings. (September 2020). The Centers for Disease Control and Prevention (CDC).
Some Bacteria Are Becoming ‘More Tolerant’ of Hand Sanitizers, Study Finds. (August 2018). NPR.
General Information: What Is MRSA? (June 2019). Centers for Disease Control and Prevention (CDC).
You Might Be Buying a Hand Sanitizer That Won’t Work for Coronavirus. (March 2020). ProPublica.
Is Your Hand Sanitizer on FDA’s List of Products You Should Not Use? (September 2020). United States Food and Drug Administration (FDA).
Safely Using Hand Sanitizer. (September 2020). The Centers for Disease Control and Prevention (CDC).
FDA Updates on Hand Sanitizers Consumers Should Not Use. (March 2021). United States Food and Drug Administration (FDA).
Hand Sanitizers, COVID-19. (January 2021). The Centers for Disease Control and Prevention (CDC).
Craft Distillers Step Up in the Fight Against COVID-19. (March 2020). Forbes.
Distillers Can’t Help U.S. Fight COVID-19 Without Revised FDA Hand-Sanitizer Guidance. (April 2020). Forbes.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. (2009). World Health Organization.
Dry Skin Relief From COVID-19 Hand Washing. American Academy of Dermatology Association (AAD).
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