key: cord-0746445-hx8c0mxj authors: Emami, Amir; Javanmardi, Fatemeh; Keshavarzi, Abdolkhalegh; Pirbonyeh, Neda title: Hidden threat lurking behind the alcohol sanitizers in COVID‐19 outbreak date: 2020-06-07 journal: Dermatol Ther DOI: 10.1111/dth.13627 sha: 924f58f623d81db29da1165f73944bac3030d25a doc_id: 746445 cord_uid: hx8c0mxj The ongoing COVID‐19 pandemic has made various challenges for communications all over the world. Nowadays hand hygiene practices with alcohol sanitizers are an unavoidable reality for many people, which cause skin dryness and flaking. The current short communication has been explained about monitoring the quality control of alcohol concentrations and hand rub formulation, which needs more attention and should consider meticulous in this crisis. the hands of some health care workers may become persistently colonized by some pathogenic flora such as Staphylococcus aureus, Gramnegative bacilli, or some other kind of microorganisms. In the recent pandemic, COVID-19, which is stands for "coronavirus disease 2019," is introduced as the cause of world acute respiratory infection crisis and outbreak. 2 In this context, public health guideline recommended by World Health Organization emphasized on frequent and correct washing hands with standard hand rubs to prevent transmission and reduce the spread of the mentioned pandemic diseases. Based on these protocols and recommendations, use of alcohol-based hand rubs has become very common around the world. Although it is true that hand hygiene is the most important way to break the infection chain transmission but using proper solution with the standard formula should be consider strongly. Although handwashing with water and soup is the most recommended procedure but due to lack of access in some situations, Ethanol-containing hand rubs are used frequently as a substitute for mentioned method. In the recent crisis due to the fact that the consumption of hand rub solutions has greatly increased in the world, several cases of related risks have been proposed, which are discussed in this article, so evaluation the alcohol concentrations should be considered in quality control procedures meticulous. Due to the fact that handwashing can be performed with different methods and compounds, so this instruction should be considered and assay both in terms of behavior and the risk of production formula. Governments and health policy makers should encourage local production but monitoring the hand rub formulations to have enough efficiency and safety. Another problem about hand rubs is skin complications. Due to the excitement in the world and overuse, the alcohol-based hand rubs have caused adverse effects on the skin of many people who used it frequently. Figure 1 For example, it has been cleared that methanol is used instead of ethanol in some products. While methanol itself is not a type of toxin, but when adsorbed to the human body, it metabolized by dehydrogenase enzymes into formaldehyde and formic acid. These end products are toxic and may cause metabolic acidosis, brain injury, blindness, cardiovascular instability, and death. 3, 4 Methanol toxication most frequently results via oral, industrial inhalation, and transdermal routes. One of the dangers of widespread use of alcoholic solutions in society especially by ordinary people is eliminating many skin normal florae that are very important for the health system, and this is because those such compounds do not differentiate between foe and friend bacteria. 5 Another important point about alcohol products is its production based on the nonstandard formula, especially situation-based protocols. In standard alcohol-based hand sanitizers, varying amounts (60%-80% most effective, higher, and less are not most effective) and types of alcohols are used. In these compounds, isopropyl alcohol, ethanol (ethyl alcohol), n-propanol, or a combination of two of these are used. 6 This group of sanitizers is found effective at killing many types of bacteria including Gram-positive and Gram-negative types and also different virus families including influenza A virus, rhinovirus, hepatitis A virus, HIV, and coronaviruses. However, they have virtually no activity against bacterial spores, protozoan oocysts, and very poor activity against nonenveloped (nonlipophilic) viruses. 7, 8 Although alcohols with the mentioned points are rapidly germicidal when applied, but have no significant residual activity and F I G U R E 1 Demonstrating a contact dermatitis in two cases and an exacerbation of atopic dermatitis on the palm regrowth of bacteria occurs after use of alcohol sanitizers. For this reason, some compounds such as chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan are added to alcoholbased formulations to increase persistent activity of hand rubs. According to the recent crisis, Food and Drug Administration released a temporary compound producing guideline for certain alcohol-based hand sanitizer products during COVID-19 pandemic on March 14, 2020, as the public health emergency. 9 Based on such emergency instructions, produced antiseptics solutions have not proper effect and cannot cover all introduced pathogens especially all kinds of nosocomial infections. Although this single alcoholbased sanitizers with no persistent compounds may be effective on the infectious agent causing the 2020 crisis (SARS-CoV-2), according to its limited activity against certain groups of microorganisms, this will cause selection pressure on ethanol-resistant microorganisms. This clonal selection, especially in hospital settings, will lead us to emerge and re-emerge of some controlled microorganisms that will cause a new crisis. Situation report 32-Coronavirus disease 2019 (COVID-19). WHO Frequent hand washing for COVID-19 prevention can cause hand dermatitis: management tips Transdermal spirit (methanol) poisoning: a case report Bilateral total optic atrophy due to transdermal methanol intoxication The increasing use of alcohol-based hand sanitizers WHO Guidelines on Hand Hygiene in Health Car Replace hand washing with use of a waterless alcohol hand rub? Can we contain the COVID-19 outbreak with the same measures as for SARS? United state Pharmacopeia (USP): USP General Chapter 795-Pharmaceutical Compounding -Nonsterile Preparations The authors declare no potential conflict of interest. All authors drafted part of the manuscript and approved the final version.