The combination of a continuous stream of academic and research studies pointing to the “downside” of alcohol-based hand sanitizers, coupled with heightened awareness on equally-effective, yet safer, environmentally friendlier, and arguably, more cost-efficient hand sanitizer products has resulted in a major shift away from flammable, alcohol-based products, and towards alcohol-free products.

hand-sanitizer1-featured.jpgA Nielson Co. report showed the retail market of hand sanitizer during a 52 week period of the 2009 Swine Flu pandemic generated as much as $180 million, a 70 percent increase from the previous year.

Alcohol-free hand sanitizers most often utilize the organic compound benzalkonium chloride as the active ingredient.

Benzalkonium chloride and its cousins have been recognized for a long time as effective antibacterial and antiseptic agents and are proven to be upwards of 99.99 percent effective.

It is essentially nontoxic to be applied to the skin or mucous membranes. Benzalkonium Chloride is used primarily in hand or face washes, as well as a disinfectant

“Benzalkonium chloride-based hand sanitizers demonstrated greater sustained degerming activity than gelled alcohol gel hand sanitizers that actually became less effective with repeated use and made the skin dirtier, not cleaner due to removal of protective natural skin oils and entrapment of dead skin cells by the polymer thickeners used in the gelled alcohol products,” reported Mason Chemical Company.

“I don’t know why we always seem to stress alcohol-based hand sanitizers,” said Dr. Richard Tooker, chief medical officer for Kalamazoo County, Michigan.  “It may be to keep public education easier and less complicated. I personally don’t like them because I have eczema and it really dries and inflames my skin, increasing my risk for infection.”

For years the U.S. Centers For Disease Control (CDC) has provided nominal guidance on alcohol-free hand sanitizers.

“When reviewing the [ironic] cautionary statements provided by makers of alcohol-based products that include “recommend washing hands before applying”, coupled with their acknowledging flashpoint liability, and the increasing news media reports connecting alcohol-based products to unintended ingestion and alcohol-poisoning, as well as intended product ‘re-purposing’ by those with substance abuse issues, the decisions to switch to non-alcohol products have been easily supported,” stated Jay Berkman, company spokesman for MGS Brands.

For some of these same reasons, in January 2009, the U.S. Naval Submarine Command officially prohibited alcohol-based sanitizers onboard their fleet of submarines.

Berkman first and foremost advocates washing with soap and water, however when that is not an option he would “unquestionably choose a non-alcohol hand sanitizer over one with alcohol.”

“It’s true that alcohol-free sanitizers are often slightly more expensive when compared to legacy alcohol-gels, but they are noticeably more cost efficient,” said Berkman when discussing whether we will see an increase in alcohol-free hand sanitizers in the future.  “The industry is currently comprised of small players and most aren’t producing in large quantities, but there are now 16 or 17 brands penetrating the market which is more than we saw several years ago. The consumer is becoming more and more aware of the product.”

  • Superb and unbiased reporting!. On the alcohol free front, there are various brands easily available; “Hy5”, “Soapopular” seem to be the leaders. And, with yet another hand hygiene emergency taking place in California (whooping cough “epidemic”), for those reaching for hand sanitizer: use an alcohol-free product, especially when considering kids!

  • The US CDC, Mayo Clinic, and WHO all maintain that the public should use alcohol based hand sanitizers as the first choice when soap and water are not available.
    * The Mayo Clinic (2007) recommends consumers use only alcohol-based hand sanitizers, and never “waterless” products which use benzalkonium chloride or triclosan, which may lead to “super germs”.
    * The United States CDC (2001) reports that the “recent increase of surface antibacterial agents or biocides into healthy households may contribute to the resistance problem (to germs), and specifically mentions benzalkonium chloride and triclosan as chemicals that may promote antibiotic-resistant bacteria and viruses, such as recent virulent MRSA strains”.
    * The CDC also reports the germ-resistance concern is “irrelevant with (germ-killing) substances that do not leave residues (e.g., alcohols, bleaches, and peroxides.”
    One needs to be concerned about these non-alcohol hand sanitizers that leave toxins on the hands, where as alcohol has been used safely for disinfection for hundreds of years and simply evaporates away.

  • benfamod

    Robert: In due respect, in September 2009, the CDC actually updated its position on the topic of alcohol-free hand sanitizers when confronted by school systems throughout the United States that will not allow alcohol-based hand sanitizer products within their venues. The CDC stated “..for schools that prohibit alcohol-based hand sanitizers, non-alcohol products can be [equally] effective..”
    The BAC based products are typically water-based, which demonstrates they are truly “rinse-free”, while makers of alcohol-based products recommend “washing hands prior to applying”. Who would apply skin-destroying alcohol to their hands if they’ve just washed them??
    RE: Reistancy. The studies in your comment re: certain pathogens develop a resistancy to benzalkonium chloride (i)were not in connection with hand sanitizer application, and (ii) did not qualify the concentrations of BAC in connection with those studies. Most misinterpret those few studies.
    It would seem that the topic in question is about an effective and safer alternative to alcohol, not analyzing a chemotherapy protocol. Too much of anything (including water) is not good.

  • Benfamod: In your post, can you tell us which “makers of alcohol-based products recommend ‘washing hands prior to applying'”? The CDC guideline (2009) is for consumers to “use an alcohol-based hand sanitizer when hands are not visibly dirty”, and in other cases recommends washing with soap and water only.
    Health care workers have a more thorough hand sanitizing procedure before surgery, so perhaps that is to what you were referring.
    As far as drying out the hands, the British Journal of Dermatology (L.K. Pedersen, et al, 2005) found “Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection”. The Mayo Clinic speculates that some consumers notice their hands might be drier when using hand sanitizer regularly simply because they are not washing their hands often or properly. In some studies in the USA, fewer than 20% of diners got up to wash their hands before eating, but hand sanitizer- whether using alcohol or other toxins- makes proper hygiene so much more convenient.

  • benfamod

    Robert: The leading manufacturer of alcohol gels, GOJO Industries, advises end users to wash their hands before applying. RE: study that found “less skin irritation from alcohol sanitizer than from detergent..” Duh!..That’s sort of like saying a .38 bullet will do less damage than a .44 magnum..The alcohol-free sanitizers (other than perhaps those using Triclosan) are NOT detergent ingredients. My wife is a professional health care worker..she, along with every single of her co-workers will be happy to raise their hands and display the irritation that’s resulted from years of having to use alcohol sanitizer.

  • Lester

    There are a few misconceptions in the above comments:
    1. Most topical antiseptic agents are compromised by the presence of soil and therefore it is necessary to wash the hands if they are visibly soiled. The antimicrobial efficacy of both benzalkonium chloride (BAC)and alcohols is reduced in the presence of materials such as proteins (e.g. blood), grease, dirt etc.
    2. BAC can only be used up to 0.12% in topical leave-on formulations according to the FDA. At this concentration the typical percent reduction in only 99.9% in 15 seconds under extremely ideal conditions. In the real world, this reduction may be insufficient to lower the number of pathogens to a level below an infectious dose. A typical alcohol gel product usually achieves a 99.999% reduction and some of the newer alcohol-based technologies can reach a >99.99999% reduction in the challenge organism in 15 seconds. In addition these newer alcohol-based products are formulated with very sophisticated emollients, film formers and preservative systems that overcome all the problems mentioned in comments above.

  • I think alcohol-free hand sanitizers are a great idea, especially when it comes to children. I once read a blog post about a 4-year-old who licked some alcohol-based hand sanitizer off her hand and became very sick and even intoxicated. Plus, alcohol-free hand sanitizers decrease the risk of fires associated with other flammable alcohol-based sanitizers.

  • JRook

    Robert Main’s frequency of blog posts representing a clear biased towards Alcohol sanitizers appear more marketing oriented than reflective of current science and use knowledge. Nurses almost universally dislike Alcohol based sanitizers, regardless of manufacturers because they dry out their skin. Transparent marketing ploys of claiming “contains ALOE or Vitamin E” as though they reduce the skin drying effect is inconsistent with people who use it regularly. The science around Benzalkonium Chloride (BZK), the active ingredient in the leading non-alcohol sanitizers 4HourProtection and MicroArmor reflects dramatic improvements over earlier versions. Their active ingredient has been shown to be more effective than alcohol on a wider range of bacteria and viruses, including gram negative bacteria. They both use plant derived BZK and contain skin conditioners and moisturizers that rather than mask drying effects actually improve skin condition. As far as safety BZK is the active ingredient in Bactine, the antiseptic use for over 30 years by moms on their children on open wounds. So it is clearly the safest ingredient for available for external hand and skin sanitizers.

  • JRook

    Lester your information regarding the percentage of Benzalkonium Chloride identified by the FDA TFM is false the correct range is .10 to .13%. Additionally, your efficacy data is dated and reflects much earlier versions of BZK. The quality and efficiency of the active ingredient is equally as important as the percentage used. The more responsible companies have actually reduced the amount of Benzalkonium Chloride used to .10% and have 15 sec. kill rates of up to 99.9999% for many of the bacteria and viruses of most concern. Your statement that the newer alcohol products contain other chemical emollients, film foamers and preservatives adds safety concerns regarding these added ingredients. Also, the real world results from heavy users of alcohol sanitizers like nurses and other health care professions still reflects dramatic skin drying and reduction in skin integrity.

  • Concerned

    I am genuinely concerned that so much “science” gets thrown around regarding products designed to mitigate pathogens which may have human health effects. Benzalkonium Chloride has not been used for YEARS in hand hygiene due to a (I believe it was) Pseudomonas outbreak connected to its application (If I recall correctly, the solution was contaminated with Pseudomonas and caused a number of people to be come infected. This happened because of BZK’s poor efficacy against gram-negative bacteria). There have been some recent studies of hand wipes imbibed with a BZK solution being as efficacious as hand washing (NOT as efficacious as alcohol). The comment about the label language that says “wash hands before applying” is thanks to a governmental system which is-for good reason-extremely cautious. In fact, recent studies have shown alcohol-based hand hygiene solutions to reduce the transfer rate of infectious organisms better than hand washing (with either non-antibacterial or antibacterial soap). Lastly, BZK is an OK disinfectant for surfaces, but it is in fact limited in its efficacy and is inactivated by organic matter (which is BAD for skin surfaces!). It’s also an allergen for some people (but what isn’t these days?)…and is extremely irritating to the eyes and skin (and I can’t wait for someone to say “but not in the concentrations we’re recommending!…repeated exposure results in hypersensitivity)

  • Lester

    JROOK- I stand corrected on the max levels of BZK as per the FDA TFM of 0.13% and not 0.12%. The newer alcohol products such as Surgicept have been shown to be be “skin friendly” clinically and have been found to be preferable to conventional hand antiseptic products in field trials. The efficacy of benzalkonium chloride(BZK)-based products is highly formulation dependent and they often include other antimicrobials and preservative as “innactives” to boost the kill. BZK formulations are easily contaminated with Pseudomonas sp. unless well preserved. I have not found any BZK-based formulations to date that are as effective against different MRSA variants as are alcohol-based sanitizers. The use of alcohol-free sanitizers should be limited to non-critical areas such as schools, public spaces, prisons, etc. Until more scientifically unbiased studies are done comparing alcohol and alcohol-free sanitizers (in the same study using in vivo and in vivo methodologies), healthcare facilities should use the former exclusively.