Cleansing

Over the decades, bathing, scrubbing, and washing traditions and rituals have become established within the health care setting, but several factors suggest the need for a reassessment of skin hygiene and how it is practiced effectively.
The current debate surrounding the increased use of antiseptic products, not only in health care settings but also for more general bathing and washing, has increased focus on the potential for the emergence of antiseptic-resistant strains of skin flora.
Unfortunately, those who do wash frequently and vigorously risk damage to their skin, which ironically results in shedding of more organisms into the environment. Hence we may be reaching a point of diminishing return with continued campaigns to improve the frequency and quality of skin cleaning.

Skin as barrier
The most superficial layer of the epidermis, the stratum corneum (there are ~15 layers of stratum corneum ), is composed of flattened dead cells (corneocytes or squames) attached to each other to form a tough horny layer of keratin mixed several skin lipids.
The superficial skin layers absorb or lose water and, under normal circumstances, retain sufficient moisture to keep the skin soft and pliable.
Depending on the product used, washing can raise the pH of the skin, and long-term changes in skin pH may pose a concern since some of the antibacterial characteristics of the skin are associated with its normally acidic pH.
With prolonged soap contact, skin pH can reach 7.0~8.5 and remain high for 3-4 hours.
Some soaps are associated with long-standing changes in skin pH, reduction in fatty acid, and, subsequently, changes in resident flora such as propionibacteria.
Wilhelm et al. tested irritant skin reaction induced by 3 different surfactants and found that damage was present for days; complete skin repair was not achieved until 17 days after exposure.
Soaps and detergents, particularly those that are anionic or cationic, are the most damaging of all substances routinely applied to the skin.
It is generally agreed that removal os a certain amount of contaminated surface fats and of bacteria attached to superficial epidermal cells is an essential hygienic feature.
However, the lipid and cell removal through washing should be somewhat limited to avoid damage to lower layers of the epidermis.
Each time the skin is washed, it undergoes profound changes.
Impact of skin care practices on skin microbiology
Physiological factors that control the bacterial skin flora include humidity, water content, skin lipids, temperature, and rates of desquamation, and washing results in changes in all of these factors.
The loss of the outermost layers of the skin from washing is accompanied by increase in transepidermal water loss, indicating reduced barrier function.
Fatty acids in the horny layers also have fungicidal and bactericidal activity important in modulating the skin flora.
Damaged skin more often harbors increased numbers of potential pathogens.
Furthermore, washing damaged skin with either plain or antiseptic soap is less effective inducing numbers of bacteria on the face than is washing normal skin, and numbers of organisms shed from damaged skin are often higher than from healthy skin.
Importance of emollients and moisturizers
Moisturizers prevent dehydration, damage to barrier properties, desquamation, and loss of skin lipids; restore the water-holding capacity of the keratin layer; and increase the width of corneocytes.
In a Swedish single-blind study, a moisturizing cream was found to accelerate the rate of recovery of surfactant-damaged skin.

Skin care practices for the health care professional
All of this suggests that more frequent washing by traditional techniques with the use of detergents, soaps, and antimicrobial ingredients needs careful reassessment in light of the damage done to skin and resultantly increased risks of harboring and transmitting infectious agents.
It may also be associated with the fact that a number of antiseptic detergent-based soaps available in this country are efficacious and marketed well, and there is a perception that alcohol-based products are drying or caustic
The goal should be to identify skin hygiene practices that provide adequate from transmission of infecting agents while minimizing the risk of changing the ecology and health of the skin and increasing resistance in the skin flora.
Use of emollients, lotions, and skin protectants
Moisturizing the skin appears to be beneficial, not only for skin health but perhaps for reducing the shedding and transmission of microbes.
There is so much variability in the content and formulations of lotions and creams and in testing methodologies that it is difficult to interpret the clinical relevance of many reports. Hence this is one of the most promising areas of research in skin care.
As an alternative to antimicrobial, detergent-based products when the skin of staff is damaged or when frequent face hygiene is necessary, consider use of mild, nonantimicrobial skin-cleaning products (soaps or detergent) to remove physical dirt and debris.
Finally, carefully assess characteristics of skin moisturizing products for compatibikity with any topical anti-microbial products being used and for physiological effects on the skin.