








key: cord-305500-uit5k7qs
authors: Elsner, Peter; Fartasch, Manigé; Schliemann, Sibylle
title: Dermatological recommendations on hand hygiene in schools during the COVID‐19 pandemic
date: 2020-07-12
journal: J Dtsch Dermatol Ges
DOI: 10.1111/ddg.14170
sha: 
doc_id: 305500
cord_uid: uit5k7qs

nan

Dear editors, the COVID 19 pandemic brings new requirements for hygiene to professions and spheres of life, which, unlike the health care system, have in the past been less visible as a focus of public health efforts on infection prevention.

This applies particularly to schools, in addition to all professions with exposure to the public. Though children have been reported to have more asymptomatic COVID-19 infections, milder illnesses, faster recovery and a better prognosis than adults [1], transmission through close contact in schools remains possible, and there have been preventive closures of schools in many states despite unclear evidence for such measures in containment of the COVID-19 pandemic [2] .

The gradual reopening of schools in Germany after the March/April 2020 shutdown is to be based on individual school hygiene plans in accordance with the specifications of the ministries of education. These hygiene plans envisage -in analogy to the prevention recommendations of the Robert Koch Institute (RKI) -frequent "thorough hand hygiene by handwashing with soap for 20-30 seconds". Washing of the hands is deemed sufficient for infection prophylaxis and should be the preferred method "within the framework of resource conservation". Hand disinfection is only recommended as an exception if "thorough hand washing is not possible". There is no mention of skin care in the hygiene plans.

These hygiene plans pose great challenges for schools, since in the past such plans were often not drafted, adapted or updated in the respective schools, and since hygiene in the sanitary areas was often only monitored by the health authorities on a case-related basis, whereby "complaints made could usually be confirmed" [3] . Health authority inspection criticized the frequent lack of soap and disposable towels [4], which make proper hand hygiene impossible [3] . Wash basins in classrooms are often less well equipped than in school toilets [4] . On the other hand, intervention studies have confirmed the importance of hand hygiene in schools, showing that appropriate intervention can lead to a decreased number of days of absence due to illness, especially caused by gastrointestinal, but also respiratory infections [5, 6] . However, health education campaigns such as the "Hygiene tips for kids" show that targeted training measures, in particular those including teachers and parents, are necessary for the effective use of hygiene facilities, beyond their mere provision [7] . Educational material developed during this project could also be used for instruction on hand hygiene in COVID-19 infection [7] . There is no scientific evidence on the preventive effectiveness of hand hygiene for COVID-19 infection; the Robert Koch Institute, with regard to preventive measures in health care facilities, refers to the recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) [8] , which in turn refers to its recommendation on hand hygiene from 2000 [9] . In its 2016 recommendation on hand hygiene in health care facilities, KRINKO points out that viricidal disinfectants should be used depending on the type of viruses expected, whereby enveloped viruses, including COVID-19, are affected by all alcohols in a concentration-dependent manner [10] . The RKI regularly publishes a list of tested and approved disinfectants and procedures for hygienic hand disinfection [11] . The medical indications for hygienic hand disinfection (immediately before direct patient contact, immediately before aseptic procedures, immediately after contact with potentially infectious material, after contact with the immediate patient environment and after direct contact with the patient) [10] can only be applied to a limited extent to hand washing/disinfection in schools. Regarding the frequency of hand hygiene, the RKI refers to the Federal Center for Health Education (www.infektionsschutz.de), which recommends, without substantiating evidence, washing hands with soap and water for at least 20 seconds in the following circumstances to prevent COVID-19 infection:

-upon coming home, -after blowing one's nose, sneezing or coughing, -before preparation of meals, -before eating and after using the bathroom, -before and after contact with other people, especially if they are ill, -before putting on and after taking off the mouth-and-nose cover.

For hand hygiene in schools, any skin contact with potentially virus-contaminated surfaces should be added as an additional circumstance.

Although from a dermatological viewpoint there are hardly any studies on the effects of different approaches to hygiene on children's skin health, a broad body of evidence from occupational dermatology does exist that can be transferred to the hygiene plans of schools.

There is consensus from numerous epidemiological and skin physiological studies that repeated exposure to detergents in the form of frequent hand washing significantly increases the risk of hand eczema [12] . The use of alcohol-based disinfectants is less irritating than skin cleansing with common 

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Correspondence Clinical Letter detergents [13] [14] [15] . Working in damp conditions, defined by the Technical Rules for Hazardous Substances (TRGS) 401 as an activity that is hazardous to the skin, includes activities in which a worker frequently or intensively cleans his or her hands; under such conditions, a worker must be provided with suitable protective measures [16] . The AWMF Guideline "Occupational Skin Products" summarizes the available evidence on skin protection, skin care and skin cleansing in the occupational context [17] ; it states that a preventive effect of skin protection and skin care products on the epidermal barrier in case of detergent-induced irritation can be proven both in epidemiological intervention studies and in experimental skin physiological investigations. With regard to training measures for skin protection, skin care and skin cleansing, extensive competence, of which schools may avail themselves, is available both in the training and advice centers of the accident insurance institutions [18] and in the skin protection centers [19] [20] [21] managed by dermatologists. A negative impact on the hygienic effect of an alcohol-based disinfectant by the subsequent application of a skin care product has not been proven. Specific recommendations for skin care products for use after washing/disinfection are not possible due to a lack of relevant study-based evidence; more research is needed here.

A dermatological recommendation for the hygiene plans of schools regarding COVID-19 prevention, grounded in the application of the outlined occupational dermatological and skin physiological evidence, is that these should include a concept for the maintenance of the students' skin health. This is all the more important as up to 30% of children suffer from atopic eczema or an atopic disposition [23] and thus face an increased risk of hand eczema.

From a dermatological viewpoint, the following recommendations can be made:

1. In the absence of visible contamination of the hands, disinfection with a virucidal alcohol-based hand sanitizer should be given priority over washing with soap or washing lotions (detergents) since alcohol-based disinfectants affect the epidermal barrier less. 2. In order to enable infection control by hand disinfection in schools comprehensively, sanitizer dispensers should be installed not only in washrooms but also in classrooms and corridors (especially in front of canteens, sports rooms), especially since the capacity of school toilets and washrooms is limited due to the distance requirement in COVID-19 prevention. 3. After each washing and disinfection, a skin care product that supports regeneration of the skin barrier should be applied. 4. Children with atopic eczema should follow the same hygiene recommendations as normal persons; however, greater attention should be paid to consistent skin care after washing and disinfection.

5. For hand washing/disinfection/skin care to be effective, it has to be done correctly; this requires health education instruction, for which sufficiently competent consultants are available in Germany through hygiene institutes, health authorities, training and advice centers of accident insurance providers and skin protection centers.

Finally, students and parents should be advised that upon the occurrence of hand eczema as a result of intensified hand hygiene, students should be given prompt dermatological care. According to the current ESCD guidelines for diagnosis, prevention and treatment of hand eczema [24] , guideline compliant treatment should be carried out promptly to prevent chronicity. 

schools: a prospective cohort study

The effect of handhygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review

Infektionsprävention im Rahmen der Pflege und Behandlung von Patienten mit übertragbaren Krankheiten

Mitteilung der Kommission für Krankenhaushygiene und Infektionsprävention am Robert Koch-Institut

Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI)

Liste der vom Robert Koch-Institut geprüften und anerkannten Desinfektionsmittel und -verfahren

Exposures related to hand eczema: a study of healthcare workers

Effects of disinfectants and detergents on skin irritation

Tandem application of sodium lauryl sulfate and n-propanol does not lead to enhancement of cumulative skin irritation

Hand disinfection in hospitals -benefits and risks

Gefährdung durch Hautkontakt Ermittlung -Beurteilung -Maßnahmen. TRGS 401

S1 guideline on occupational skin products: protective creams, skin cleansers, skin care products (ICD 10: L23, L24)-short version

Das Hautschutzprogramm in den Schulungs-und Beratungszentren der Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege

Rehabilitation bei Berufsdermatosen

Prävention im Hautschutzzentrum -ein Konzept zur erfolgreichen Vermeidung von Berufsunfähigkeit

Haut Optimal" -Abgestufte Hautschutzberatung am Telefon, mittels Beratungsmobil und Seminar

Effect of hand lotion on the effectiveness of hygienic hand antisepsis: Implications for practicing hand hygiene

Pathophysiology of atopic dermatitis

Guidelines for diagnosis, prevention and treatment of hand eczema



