Take care of your hands! We get this message from the first day of massage school and hear constant reminders along the way, but still we struggle with the best ways to prevent the transmission of pathogens by way of the skin. And we aren’t alone. Even with massive amounts of research on best practices, studies of medical personnel show that established hand hygiene protocols are often underused, or inappropriately used, leading to an increased risk of infection for both caregivers and patients. In this edition of Pathology Perspectives, we take a look at infectious agents, hand hygiene, and the best options for keeping ourselves and our clients safe.

Our Microbiome
Bacteria live everywhere around and inside us: on the surface of our skin, in the mucous membranes of our digestive, respiratory, and urogenital tracts, and in all our orifices. Researchers sometimes call them our “indigenous microbiota.” Amazingly, the bulk of the genetic material we carry around isn’t ours; it belongs to our resident bacteria.  
Bacteria that colonize humans are often categorized in three groups: commensals, mutualistic bacteria, and pathogens.
• Commensal bacteria: These inhabit our skin, mouth, gut, and other mucous membranes, but under normal circumstances they neither benefit nor harm us. Those circumstances can change, however, and some commensal bacteria have been seen to become pathogenic.
• Mutualistic bacteria: These are organisms that provide us with some benefits, as we do them: we have a symbiotic relationship. Many of the bacteria in our gut are mutualistic; we give them a home and they help digest some substances and synthesize vitamin K for us. Some of the mutualistic species on our skin provide benefit just by taking up space: they inhibit the growth of other species that are more aggressive or parasitic.
• Pathogenic bacteria: These are organisms that can cause damage, usually because they actively attack healthy cells, or because the substances they excrete are severely toxic and damaging. Most of us are familiar with the major players in this category: one of the most problematic is methicillin-resistant Staphylococcus aureus (MRSA); more on this cootie can be found in “Mercy, Mercy MRSA!” (Massage & Bodywork, July/August 2008, page 112.)

It’s All About the Relationships
Our relationships to bacteria can change depending on circumstances and location. Some microbes that are perfectly harmless or even helpful in one place may become pathogenic in another. The inherent strength or resilience of the person being colonized is another variable. Most people can tolerate or thrive with certain levels of resident bacteria, but those who are immune-compromised have lower tolerance and a higher risk of potentially dangerous infection.
In the context of massage therapy, this becomes a significant issue when one of the people in the massage relationship is at risk for a problem: maybe the client is in a weakened state, or maybe the therapist has an open wound in an area that contacts the client’s skin during a session. Even when both client and therapist are vital and healthy, a risk of disease transmission still exists if someone has been exposed to virulent, transmissible pathogens outside the massage environment.

Transmission Received
Microorganisms have many ways to move from one host to another. For the purposes of this discussion, we will focus on how skin-borne pathogens pass from one person to another.

Direct Contact
Some diseases are spread by direct contact between bodies. Mononucleosis is a viral infection that is spread most efficiently through direct salivary contact—which is why it is sometimes called the “kissing disease.” When we pet a dermatophyte-carrying kitten, we may introduce parasitic fungi to our skin, and end up with a raging case of ringworm. Even if our clients are healthy, we can pick up their passengers through our own untended hangnails and develop a serious infection.
The risk of spreading something infectious by direct contact is the main reason we learn that open or compromised skin—on the client or the practitioner—is at least a local caution for massage: many organisms that are benign on the surface of the skin can be threatening if they gain access to the blood or lymph systems.

Indirect Contact
Indirect contact refers to the transmission of a microorganism by way of a transfer mechanism: a living vector (like a malaria-carrying mosquito), or an inanimate fomite (like a staph-carrying dollar bill). Common fomites include money, grimy keyboards, oily doorknobs, light switches, or—from a massage therapy perspective—unswabbed face cradles. In many ways, indirect contact is a more potent mechanism for disease transmission than direct contact, because it can be much more difficult to control.
In some cases, humans can be the vectors that transfer pathogens by way of indirect contact. Think of a parent whose toddler has impetigo: this is a very common, very contagious bacterial skin infection. When this person takes a break from caring for a fussy child and comes in for a massage with unwashed hands, the practitioner may unknowingly be exposed to this infection, or the client could leave some potent bacteria on the doorknob for the next client to pick up. Other conditions that may spread through indirect contact include conjunctivitis (pinkeye), herpes simplex, hepatitis A and B, and many others.  

Transmission Interrupted
Pathogenic bacteria are good at finding ways to be transmitted from one person to another. As keepers of a safe environment, it is our job to create barriers to that transmission.
This all begins with proper hand hygiene. Countless resources exist to explain what good hand hygiene looks like, but in a nutshell, it is this: warm running water with plain soap for 30 seconds, with manual friction that addresses all surfaces of the hand, including between the fingers, the cuticles, and under the nails. This is followed by thorough drying with a clean, single-use towel. And this happens before and after every skin-to-skin interaction.
If this is not practical, an alternative is the use of an alcohol-based hand gel, using a palmful of gel, and manual friction that mimics handwashing until all the gel has evaporated. This reduces the number of active bacteria on the hands, but it will not necessarily remove the dirt, so it is not a complete substitute for washing with soap and water.
Obviously, nail and cuticle care is critical for massage therapists. These are potential vulnerabilities, as even short nails can harbor bacterial colonies, and minor hangnails can become delicious portals of entry for hungry bacteria.
These hygiene practices should be completely ingrained in every massage therapist. Sadly, we probably have all seen circumstances in which these protocols are not followed carefully. For a quick review of what not to do in hygienic practices, take a look at “Hygiene Fact and Fiction” (Massage & Bodywork, May/June 2012, page 36).

Building a Barrier
When a weak point is obvious—maybe because the practitioner has a scraped knuckle, or the client has a large abrasion, it is necessary to put a physical barrier between the two surfaces so that the massage can occur. That physical barrier can take several forms, but the most common options include local bandages, liquid bandages, finger cots, and gloves. We will look at advantages and disadvantages of each.
• Bandages: From gauze-and-tape from a first-aid kit to store-bought Band-Aids, these devices cover open wounds with the purpose of reducing the risk of infection and stopping bleeding. They can be effective, but in a massage setting, they are easily dislodged and the vulnerable area may become contaminated. As a mechanism to protect any area that might be contacted during a massage session, they are not appropriate.
• Liquid bandages: This is typically a chemical that is applied to a dry wound (not a fresh, bleeding one). The chemical creates a barrier and holds the edges of the wound together. Liquid bandages are not impermeable, and the use of oils or lotions may dissolve the chemical seal. They can be safe for wounds that are not part of skin-to-skin contact during massage, but they are not effective barriers to direct contact.
• Finger cots: These are single-use individual sheaths that cover single fingers. The most easily available finger cots are made of latex, but vinyl or nitrile finger cots may be purchased through medical suppliers. Finger cots can be effective protection for hangnails and scraped knuckles—the bane of massage therapists everywhere—but if they don’t fit well they can be uncomfortable, or they can easily slip off, leaving the lesion uncovered.
• Gloves: Nonsterile medical gloves are made of latex, vinyl, or nitrile. Latex gloves are inexpensive and easily available. They are also the most likely to cause unpleasant or even dangerous allergic reactions in practitioners or clients. People with a long history of medical procedures are at the highest risk for latex allergies. Gloves are often the most practical way to limit contamination risk.

What Gloves Can’t Do
It is important to remember that using gloves is only one part in the effort to reduce the risk of disease transmission. Gloving is one step, and not even the most important one (that would be effective handwashing). Gloves may have minute defects or tears. Pathogens may be released when gloves are removed carelessly; it is important to use appropriate safety protocols when putting on and taking off gloves. Using gloves does not remove the risk of transferring pathogens from one location to another—if we touch a contaminated surface with a gloved hand, and then touch a vulnerable spot like an open wound, we are perfectly capable of spreading disease.
Gloves also don’t eliminate the need to wash hands. Sadly, many health-care providers forget this; some research suggests that the use of gloves leads to increased carelessness in high-risk environments.

When You Have to Glove
Some circumstances call for the use of gloves regardless of the relative health of the therapist or client. OSHA’s standards call for it when faced with “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.” This includes intraoral work, if this is within your scope of practice.
The nature of our work is also a risk factor for skin damage. Many massage therapists develop hand dermatitis after long-term exposure to some massage lubricants, or it may be related to frequent handwashing. The only way to work safely with this kind of compromised skin is to use gloves until the skin is healthy again.
Many oncology clinics require massage therapists to always use gloves—not because of body fluid contact, but to reduce the risk of infection for their immune-compromised patients, and to minimize the exposure to any chemotherapy drugs that may be expressed in the patients’ perspiration.
It is safe to say that most massage therapists would prefer not to have to use gloves, but when it is necessary, a few guidelines are important to remember:
1. Don’t assume that using gloves means you can take shortcuts in the rest of your hygienic practices. Wash your hands before and after each session, clean your surfaces, and ensure that nothing touched by one client is touched by another until it has been cleaned.
2. Experiment to find the glove and fit you like the best. If you don’t like one product, don’t give up; there may be another brand, another material, or a different fit that works better for you and your clients.
3. Communicate clearly with your clients about why you use gloves. Some people will interpret their use as a judgment, that they are somehow dirty or unworthy of being touched skin-to-skin. Alternatively, they may have anxiety about cleanliness, and using gloves may aggravate this worry. Explain exactly what circumstances led to the decision; this exchange can go a long way toward enlisting the client as a partner in the process.          

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.