Are hand sanitizers a safe compromise for soap and water? Not always. Hand sanitizers containing ethanol or isopropanol are safe, as long as you are using known brands as directed, according to Michael Beuhler, MD, medical director of NC Poison Control, the state’s poison control center and an organization affiliated with Atrium Health. The Centers for Disease Control and Prevention (CDC) agrees, hand sanitizers are an important tool in your arsenal against COVID-19 when you cannot otherwise wash your hands with soap and water.
The biggest concerns now are the dangers of ingesting hand sanitizers — especially for children and teens — which can be fatal. Investigating the root of the problem among both children and adults, the U.S. Food and & Drug Administration (FDA) has issued a list of hand sanitizers which should not be used or sold to the general public.
“Reports of issues with hand sanitizers have steadily gone up since March at North Carolina Poison Control,” says Dr. Beuhler.
From 2019 to 2020 the volume of people experiencing adverse effects from hand sanitizer has nearly doubled.
“There were 3,000 calls relating to hand sanitizer this past March, where last year the same time there were 1,800. They continue to rise,” Dr. Beuhler says. “Usually hand sanitizer calls would typically fall off in June or July, but they didn’t this year. Nationally in July there were 5,000 calls versus 1,500 the year before. People are concerned about the safety of hand sanitizers.”
Most notably reported are hand sanitizers that contain methanol — a specific type of alcohol that can have side effects such as nausea, vomiting or headaches. More serious effects include blindness, seizures or damage to the nervous system if enough methanol is taken internally.
“If it’s being used as it’s supposed to be used externally on the skin, the amount of methanol that gets into your skin is still minimal, since it basically evaporates,” reports Dr. Beuhler. “Our adult bodies can deal with that little bit of methanol. But with a lot of methanol taken internally, our bodies cannot deal with it.”
Another dangerous chemical found in hand sanitizer when consumed or used improperly is 1-propanol. This ingredient is a type of alcohol used to make cleaners, and can be toxic to humans if swallowed. Side effects include decreased breathing and heart rate — and even death. It can also irritate your skin or eyes, if exposed.
According to Dr. Beuhler, it’s not likely for enough to get through the skin under normal use conditions. But, if a hand sanitizer you have is on the FDA’s list, it should be discarded.
Overall, the main concerns health-wise for all hand sanitizers, regardless of their ingredients, is:
- A child who gets more than a lick or taste
- Someone who is drinking it to get intoxicated
“Adults drinking hand sanitizers is all-around just bad, and those with methanol, especially, are potentially fatal,” says Dr. Beuhler. “But the real issue is the adverse concerns with children drinking hand sanitizers.”
He points out that in the distribution of calls about hand sanitizer cases this year, the majority of the calls involve children.
“If a little kid drinks enough of it — not just a taste or a lick — that can be a problem,” says Dr. Beuhler. “Consumption of any alcohol at 70% can cause a child to stop breathing because their bodies cannot properly process blood sugar following drinking alcohol. And these are alcohol-based hand sanitizers.”
Three Categories of Safety
Dr. Beuhler explains North Carolina Poison Center — along with the FDA’s — position regarding safe choices of hand sanitizers in the market now:
Category 1: Perfectly safe when used as directed.
“If it’s a normal-use hand sanitizer, and the product is a known brand that isn’t on the FDA’s list, there’s no real issue — just use it the way you should,” Dr. Beuhler says.
Those in this category are alcohol-based hand sanitizers in the United States that contain either ethanol (also known as ethyl alcohol) or isopropanol.
“When we use these hand sanitizers, there is potentially a small amount of exposure to these alcohols through inhalation because as you use them, they evaporate, and you can inhale a little bit of it. But the amount there is miniscule,” says Dr. Beuhler. “And, besides, you will find ethanol in very small amounts already in foods and other sources in your routine environment. Isopropanol, as well, is very close to other metabolites (a natural substance necessary for metabolism) in the body. The amounts you are being exposed to through inhalation is very low,” he says as they evaporate during normal use as directed.
“The amount you are exposed to through skin exposure is even lower. So, we really don’t see a substantial concern under normal use circumstances for adult usage.”
But, always with use for children, there must be precautions. “Skin in children has a different thickness than in an adult. A child’s skin, in terms of their surface area, is different compared to their whole volume. So, that could potentially be a problem, but that also would be a fringe event involving unusual very large skin application, and we don’t generally see that.” Dr. Beuhler explains
“So, concern about unhealthy exposure under normal circumstances to these hand sanitizers is really low. And these two acceptable agents under normal conditions (ethanol and isopropanol) are of minimal toxicity at worst.”
Category 2: Middle range, so use cautiously, or if in doubt, just get rid of it.
“If it’s a sanitizer used on your hands in the normal method, and it’s not a name brand or we’re not certain what’s going on, that’s this middle category — a cautionary one. So, we are telling people to use these cautiously, or just get rid of it,” Dr. Beuhler says.
Category 3: On FDA’s list, stop using it and discard safely (treat it as hazmat).
“The last category would be those hand sanitizers known to contain methanol or 1-propanol in it. Then we say stop using it, and you should discard it safely (treat as hazmat per FDA),” Dr. Beuhler advises.
Why are Methanol and 1-Propanol so Dangerous in Hand Sanitizers?
1-Propanol
The FDA says ingesting hand sanitizers that contain 1-propanol can be toxic and life-threatening. “Ingesting 1-propanol can cause central nervous system depression, which can result in death. Symptoms of 1-propanol exposure can include confusion, decreased consciousness and slowed pulse and breathing. Animal studies indicate that the central nervous system depressant effects of 1-propanol are two to four times as potent as alcohol (ethanol).”
Methanol
According to Dr. Beuhler, ingesting even ethanol and isopropanol (the alcohols present in category 1 safe hand sanitizers above) can send you to the emergency room and cause severe internal damage. But, far worse results occur when ingesting methanol. People have died or have been blinded upon ingesting this agent.
“Methanol is unforgiving as a toxin. Methanol in the body is converted to an acid, and it’s toxic to neurons, specifically your retina, but it also can cause brain injury. Regarding blindness, there may be some improvement, but that’s dependent on your general state of health and nutrition and how long you have gone without treatment — but often the damage is permanent,” says Dr. Beuhler.
The CDC says there can be a delay (between one hour and as much as three days) before recognizing adverse symptoms from methanol poisoning. And its toxicity worsens over time. As Dr. Beuhler explains, adverse effects can become more severe if left untreated, perhaps even irreversible.
Initial adverse health effects due to methanol poisoning include drowsiness, a reduced level of consciousness (central nervous system depression), confusion, headache, dizziness and the inability to coordinate muscle movement. Other adverse health effects may include nausea, vomiting, and heart and respiratory failure.
When Should You Call for Help?
People should contact NC Poison Control about hand sanitizers for the following reasons:
- When a child gets a taste or lick of hand sanitizer accidentally
- When someone is concerned about having been exposed to a hand sanitizer containing methanol
- When someone has developed irritation or burning after using a hand sanitizer
- When someone gets a splash of sanitizer in the eye or rubs the eyes with hands still wet with sanitizer
“The Poison Center is available for everybody to call about concerns about exposures or poisonings. So if someone drinks hand sanitizer by accident, if their kid or teen gets into it and drinks it, if they’re using the product in extreme ways outside the norm, these would be reasons potentially to call and discuss it with us. And if your issue is dermal-only with normal use, the problem is likely something else, but you can call us so we can help you figure it out.”
When you call Poison Control, you are talking with a highly-trained specialist in poisonings, either a nurse, a pharmacist and sometimes even physicians.
North Carolina Poison Control has help available 24/7. If you suspect someone might be poisoned by a hand sanitizer, contact North Carolina Poison Control at 1-800-222-1222 or chat online with them by visiting www.NCPoisonControl.org.
Tips to Protect Yourself and Others from Hand Sanitizer Poisoning
“If used as directed on your hands, hand sanitizers are generally safe products, even if using them 5-7 times a day,” says Dr. Beuhler. “The methanol and 1-propronol don’t go through your skin on your hands to any significant degree that we have to worry about toxicity. But I do think it’s important to focus on the fact that hand sanitizers need to be kept well out of reach of children — even if it’s a safe brand. There is still enough ethanol it can really hurt a child if not properly used and is ingested. And adolescents should be educated as to the dangers of drinking it.”
Use the following recommendations next time you purchase and use hand sanitizer:
1. Look for hand sanitizers that contain between 70-95% alcohol (those containing ethanol, also known as ethyl alcohol, or isopropyl alcohol)
2. Do not purchase hand sanitizer with methanol or 1-propanol in the ingredients
3. If you have purchased hand sanitizers listed in the FDA warning, stop using them immediately and dispose of them in appropriate hazardous waste containers
4. Do not flush them down the toilet or pour them down the drain
5. Never drink hand sanitizer — these should only be used to clean hands
6. One to two pumps per application should be sufficient for hand hygiene
7. Let hands dry completely if you need to rub your eyes
8. Always supervise children who are using hand sanitizer
9. Educate others about all these safety concerns for themselves, their families and their friends
10. Be careful where it’s stored (do not leave hand sanitizers in a hot car – the alcohol will evaporate and at best reduce its effectiveness)
