Is It Time to Stop Using Powder as a Donning Agent for Gloves?
Denise M. Korniewsicz, DNSc, RN, FAAN, and Christopher D. Martin, BSN, RN
The use and demand for gloves used in clinical settings has increased dramatically since the implementation of Universal Precautions in 1987. Now glove use has increased from one billion pairs per year to 10 billion pairs.1 The increased use of gloves among healthcare workers (HCWs) has led to a variety of complications such as: elevated costs, adverse events (latex allergy, contact dermatitis, occupational asthma), and issues related to waste disposal. As a result, glove manufacturers have developed new gloves made of alternative materials such as neoprene, nitrile, thermoplastic elastomers, natural rubber, latex, and vinyl. With the variety of glove choices available today, HCWs need to have an understanding not only of the newer synthetic gloves available but an understanding of the "donning" agents used to lubricate gloves. Often, the lubricants may be responsible for creating adverse reactions such as skin dermatitis or inflammation at the site or as in the case of surgical gloves post operative wound infections or surgical adhesions.
Reports on the adverse effects of powder in gloves have been documented in the literature prior to 19502, and subsequent case studies have been conducted throughout the years to evaluate the effect of cornstarch3,4,5 on patients and HCWs. Current research has been targeted toward glove powders and the adverse reactions observed after routine surgery, complications associated with wound healing, and the ability of cornstarch to act as an airborne vector for latex proteins.6 Other important issues related to powder include proposed legislation to limit or eliminate the use of powdered latex gloves in clinical practice settings. As for the newer non-latex, powder-free synthetic gloves, the issues of interest are primarily surrounded around their performance and higher cost rather than the lubricants associated with donning.
Use of Cornstarch
Allegiance synthetic powder-free glove, PF Esteem
Although gloves may contain a variety of other powders such as calcium carbonate or lactose, one of the most common donning agents used has been absorbable USP powdered cornstarch. The use of cornstarch as a lubricant has been to provide the user with the ease of donning the glove; however, cornstarch is difficult to absorb. Currently, the Food and Drug Administration (FDA) has recommended a reduction in the amount of powder a manufacturer is allowed to use,1 since cornstarch has been associated with occupational asthma and latex allergenicity.7
Cornstarch is not completely absorbed when used as a donning agent for surgical gloves, since the sterilization process effects the starch molecules. Irradiation, the current sterilization technique, causes starch molecules to remain intact, smooth and circular. In contrast, during the older autoclaving techniques (steam and gas), the molecules were damaged leaving the entire molecule uneven and pitted which allowed for easier tissue absorption and limited the occurrence of infection or inflammation.8 Irradiation causes the cornstarch to remain intact and less absorbable when in contact with tissue.
When cornstarch is in direct contact with a surgical site or open wound, it produces a foreign-body reaction for the duration of its presence.5 Depending on the surgical site involved, adhesions and granulomas have been reported especially when introduced in the peritoneal cavity.5 As a result, patients can develop surgical complications such as intestinal obstructions, increased peritoneal or abdominal pain or peritonitis. Although the literature6,8,9 has been wrought with adverse events associated with cornstarch, and dangers associated with cornstarch in the healthcare environment, the FDA has not banned the use of cornstarch as a donning agent for gloves.10
Cornstarch has been used as a lubricant in latex gloves for three reasons: to help remove the glove from the manufacturer's mold during processing; to prevent decay while in storage; and to help when donning gloves. Although the first and second reasons are of no concern to the healthcare worker, the third (donning) is used as a marketing strategy. There has been some concern with latex powered gloves vs. non-latex, powder-free synthetic gloves on the basis of donning, durability, and price. The manufacturing process used for producing synthetic gloves is similar to that of contact lenses, using a material known as a "hydrogel polymer."8 The hydrogel polymer allows for trouble-free donning due to its smooth inner surface and easy glide-on feel. The hydrogel polymer has been readily accepted among HCWs and seems to be preferred.
The greatest concern about the use of non-latex, powder-free gloves is the current market price. Currently, healthcare institutions are reluctant to allocate resources toward purchasing synthetic gloves, since the cost is greater than natural rubber latex gloves. To facilitate a changeover within a healthcare institution, all of the current gloves would have to be pulled, all clinical areas would have to be cleaned thoroughly, and the entire setting would have to be restocked with the new product. The average, cost of non-latex, powder-free gloves exceeds that of latex powdered gloves by $2.14 per box of 100 count or a 32% increase for an entire fiscal year.6 Although these estimates are sizable, the benefits must be compared to the legal costs associated with HCW disability and workman's compensation cases.
Latex Allergy and Cornstarch
Currently, between 7% and 17% of HCW suffer from Type I or Immediate hypersensitivity to natural rubber latex proteins11, while 7-10% may have delayed hypersensitivity11 to chemicals in gloves and over 50% may suffer from irritant dermatitis (Figure 1, a hand with glove powder reaction.)12 Experimental and clinical evidence indicates that the absorbent cornstarch powder on latex medical gloves acts as an airborne carrier of natural latex allergens resulting in cutaneous, conjunctival, and/or respiratory allergic reactions to latex.6 The clinical presentation of a latex allergy can range from a mild contact urticaria to fatal anaphylaxis.7 Cornstarch powder has been reported on items such as sutures, instrument tips, and at the wound/incision sites even though not visually present.13 Hermesch6 reported that after switching from powdered to powder-free gloves for an entire week, the levels of airborne powder was statistically lower.
In the operating room environment, it has been common practice to wash the gloved hands of the surgeon and scrub personnel in a basin of sterile water, then wipe them dry with a lint-free towel.13 This glove washing practice was recommended to remove the powder from the outside of the glove, thus eliminating any cornstarch-induced surgical complications. Stein13 found that even after the usual 1-to 2-minute rinse, powder still would appear on the gloves 10 to 30 minutes later due to the constant movement of the hands during a surgical procedure. As a result, the powder and latex protein can continue to be spread by the gloved hands of the surgeon or scrub person to instruments, trays, light fixtures, or other equipment.
There have been several legislative attempts to ban the use of glove powder in the states of Oregon, Nebraska, New York, Wisconsin, and Indiana; however, all of the attempts have been unsuccessful. There have also been attempts to limit the high level of proteins in latex powdered gloves to eliminate or reduce the number latex allergic responses each year. It has been reported by manufactures of non-latex, powder-free synthetic gloves that over 1,600 of allergic reactions have occurred associated with latex allergy and 23 deaths have been reported to the FDA.14 Arguments against this type of legislation, particularly among the manufactures of powdered latex gloves, has centered on their position on the personal preferences of HCW ignoring the claims that their products may be the cause of some of the adverse reactions.
The use of glove powder remains controversial however the future seems to lean toward alternate donning agents to irradicate the use of powder. Currently, research laboratories throughout the world, are developing alternative donning agents as well as synthetic polymers to replace natural rubber latex gloves. The majority of the research has been directed toward duplicating natural rubber latex gloves, since they provide adequate comfort, less hand fatigue, reseal properties and are popular among the HCW community. Future goals for medical and surgical gloves are to create a barrier that provides complete protection for the wearer and patient without the adverse reactions associated with latex or powder when used. Although the solutions for the future are difficult, the glove of the future must be cost effective and provide adequate barrier protection, safety, and comfort.
Adenna vinyl powdered exam glove, VNX
Ultrafree Max sterile latex powder-free glove
Tronex latex free powdered glove, Syntech
Gimble puncture resistant, powdered glove
Figure 1: An example of irritant dermatitis reaction from glove powder
Digitcare chemotheraphy powder-free latex glove, Digit-Safety
The future glove may depend on thinking "outside the box" and entertaining ideas such as the elimination of gloves altogether. Perhaps a protective spray, like that for household furniture, could be applied directly on the hands prior to a procedure or the use of a special soap that would produce a protective skin coating. Other hand barrier protection may include dipping the hands into a solution that would adhere to the skin to provide a "natural coating" on the hands. Methods such as these may be in our future and eventually universal products would be developed that addresses today's concern about powder, comfort, fit and barrier effectiveness.
Dr. Denise M. Korniewicz is a professor at the University of Maryland,
School of Nursing in Baltimore, Maryland. Christopher D. Martin is a graduate
research assistant at the University of Maryland, School of Nursing.
For a complete list of references click here