CD11: Irritant hand dermatitis to alcohol gel in healthcare workers: consideration of inherent genetic polymorphism

Ying Teo, Roberto Corso, Louise Cunningham, Christos Tziotzios, Ian White and John McFadden

St John’s Institute of Dermatology, London, UK

A Chinese healthcare worker presented with a history of burning sensation on her hands within minutes of using alcohol gel sanitizer, which she used frequently. There was erythema and fissuring on the palms and digits; this notably improved during periods away from work. Patch testing to an extended European baseline series (Chemotechnique allergens in IQ Chambers™), healthcare worker series and medicament series were negative. Within 30 min of patch application of various alcohol gels on unaffected forearm skin, clear macular erythema was visible at tested sites, resolving within hours. Two further patients of Chinese ethnicity, a 15-year-old student and her father, who works as an operating theatre nurse, presented with hand dermatitis and were similarly tested with alcohol gel. Both developed a positive response at sites of alcohol gel patch testing at 30 min. Testing to other allergens was negative except limonene in the student with no definitive hand exposure to it. In all three patients, no symptoms were associated with the erythematous response on patch testing. Of note, both adult patients described flushing with alcohol ingestion. The avoidance of alcohol gel resulted in the resolution of hand dermatitis in all three patients. Ten unaffected European and five ethnic Chinese healthcare workers were additionally tested to the same hand sanitizer gel. In this control cohort, one of 10 (10%) of European ancestry and four of five (80%) of Chinese ethnicity developed a similar visible erythema within 30 min. All the Chinese controls with a positive response experienced flushing with alcohol consumption, while none of the Europeans experienced this. Alcohol intolerance (flushing, headache, nausea, tachycardia) is common among East Asians (Chinese, Japanese, Korean), affecting up to 30% of the population. Alcohol (ethanol) is initially metabolized by alcohol dehydrogenase (ADH) to acetaldehyde, before further metabolism to acetic acid by aldehyde dehydrogenase (ALDH), predominantly by mitochondrial ALDH2 in the liver. Genetic polymorphism of ALDH results in decreased or absence of enzymatic activity and therefore accumulation of acetaldehyde, giving rise to the associated unpleasant systemic symptoms. ADH and ALDH are also present in human skin, and a clear difference in erythema following topical ethyl alcohol application between alcohol-tolerant and alcohol-intolerant Japanese individuals has been previously demonstrated. It is therefore conceivable that frequent and continued use of hand sanitizers containing alcohol may contribute to irritant dermatitis in some individuals, with an inherent reduction in cutaneous acetaldehyde clearance.