Hygiene of the Skin: When is Clean Too Clean?
By Prof. Elaine Larson, Columbia University School of Nursing

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.

For over a century, skin hygiene, particularly of the hands, has been accepted as a primary mechanism to control the spread of infectious agents. Although the causal link between contaminated hands and infectious disease transmission is one of the best-documented phenomena in clinical science, several factors have recently prompted a reassessment of skin hygiene and its effective practice.

In industrialized countries, exposure to potential infectious risks has increased because of changing sociologic patterns (e.g., more frequent consumption of commercially prepared food and expanded child-care services). Environmental sanitation and public health services, despite room for improvement, are generally good. In addition, choices of hygienic skin care products have never been more numerous, and the public has increasing access to health related and product-related information.

The trend in both the general public and among health-care professionals toward more frequent washing with detergents, soaps and antimicrobial ingredients needs careful reassessment in light of the damage done to skin and resultant increased risk for harbouring and transmitting infectious agents. More washing and scrubbing are unlikely to be better and may, in fact, be worse. The goal should be to identify skin hygiene practices that provide adequate protection from transmission of infecting agents while minimizing the risk for changing the ecology and health of the skin and increasing resistance in the skin flora.

Bathing and showering cleans the skin by mechanical removal of bacteria shed on corneocytes. Bacterial counts are at least as high or higher after bathing or showering with a regular soap than before. Frequent bathing has aesthetic and stress-relieving benefits but serves little microbiologic purpose. Mild, non-antimicrobial soap should suffice for routine bathing. Bathing with an antimicrobial product reduces rates of cutaneous infection and could be beneficial when skin infections are likely or before certain surgical procedures. With those expections, available data do no support a recommendation for bathing with anti-microbial products.

No single recommendation for hand hygiene practices in the general population would be adequate. The potential advantage of sustained antimicrobial activity for certain occupations (e.g. food handlers and child-care providers) must be balanced with the theoretical possibility of emergence of resistant strains and perhaps other, as yet unrecognized safety issues.

From the public health perspective, more frequent use of current hygiene practices may not necessarily be  better (i.e., perhaps sometimes clean is “too clean”), and the same recommendations cannot be applied to all users or situations. Future investigation is likely to improve understanding of the interaction between skin physiology, microbiology, and ecology and the role of the skin in the transmission of infectious diseases.
- Reprinted from Volume Eight of Deb Canada’s Corporate Newsletter.

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