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ARE YOU ALLERGIC TO HOSPITAL LINEN?

By Nathan Schiff, PhD
Associate Editor - Institutional

Dear Dr. Schiff,
Our Regional Health Care Laundry randomly receives requests for "special linen" because some patients claim that they have an "allergic" reaction  to hospital linens and gowns.

 The requisitioner is usually adamant that we either:

1. Sterilize their linens via steam autoclaving
2. Process the garments with "special" chemical neutralizers or
3. "Super rinse" with extra, double or triple water rinses.

Our laundry performs tests, daily, to check the final pH of the washed laundry. Environmentally friendly hydrogen peroxide is routinely used for stain removal, bleaching and sanitization, and hypochlorite is never used.
We do not want to intentionally contribute to or cause allergic skin reactions for patients. However we feel that the previous practice of double water rinsing or steam autoclaving or provision of "non-allergic" linens are impractical and misleading.

 What would you suggest?   

Brian

 Psychological Linen
Several possibilities need to be examined, including the one referred to as "Psychological Linen". In this situation, the patient believes that all regular linens are "bad", despite the precautions taken to insure that the linens are properly laundered.

 Chemically, pH is Key
The most common cause of irritation is skin contact with residual alkalinity from the detergent which may not been properly rinsed off. Since human skin perspiration is slightly acidic, the target pH of washed linens should be 5.5 to 6.0. For this reason, it is common practice to sour the linen with an acid to neutralize it and maintain a slightly acidic pH.  

Physical Factors Contributing to Skin Irritation
Over drying linen or hospital gowns leaves them with a harsh, abrasive-type of feel, which can mechanically irritate sensitive skin. Over drying also causes the smaller sized fibers to "pile" or migrate towards the surface  Piling results in irritation by virtue of the abrasive or sand paper-like effect that these tiny fibers exert on the skin.

 The True Allergic Reactions
The reactions described above result from exposure to a physical or chemical skin irritant.  A true allergic reaction occurs when an individual is exposed to a specific chemical (antigen), to which, for some unknown reason, his body is uniquely sensitive. The body's immune system reacts by building up antibodies towards the antigen which results in the allergic reaction. Once the individual has been sensitized to a chemical, subsequent exposure to even very small amounts, causes the allergic reaction and all of its discomforts to automatically express itself.  

Chemical Candidate for Allergic Reactions

1. Enzymatic Detergents
 Proteases, used in some detergents, are enzymes which digest protein stains and can trigger an allergic reaction. The body rapidly recognizes them as foreign proteins and antibodies are built up towards them. This results in the typical allergy reaction involving skin irritation and localized swelling and redness.  

 2. Fabric Softeners
Fabric softeners are often chemical combinations of tallow-base fatty acids and various amines. Unless otherwise recommended by a physician, hospital linens and garments are treated with fabric softeners, to reduce their harshness and potential abrasive skin action. Fabric softeners are also known to cause allergic reactions in individuals so predisposed. Because of consumer demands, fabric softeners are often formulated with different fragrances. These oil based fragrances contain detergents and solvents to solubilize them. The fragrances can elicit an allergic reaction or dissolve some of the natural oils in the skin, allowing easier entry of other allergy causing chemicals into the body.

  3.  Detergent Reactions
Laundry products can contain a wide blend of detergents; some of which are protein based or are marginally soluble in water and act by dissolving oily types of soils. These detergents are then emulsified by other components of the product and are removed during rinsing When improper rinsing occurs, residual amounts of detergent remain on the garments and either act as antigens, causing allergic reactions to occur or act as skin irritants. Autoclaving the fabrics will not help, since these chemicals could easily withstand the temperatures used.

Resolving The Issue
Request that your chemical supplier do a complete fabric analysis. In this procedure, a known weight of garment is boiled for 10 minutes in a water/solvent mixture and the liquid is then evaporated to dryness. The resulting residue is then re-dissolved in a minimal amount of water/solvent and analyzed in an FTIR instrument.
This device passes a beam of different wavelengths of infra red light through the dissolved residue. It then  records any changes in the beams intensity when it exits the residue solution. The results are scanned onto a permanent record (scan). From their position on the scan, different classes of chemicals can be easily identified. This procedure, when conducted on an annual basis, can also be used as a tool to verify that your own internal quality procedures are on target. Have your supplier provide you with a copy of the scan and have an outside lab verify your suppliers interpretation of the scan. 
If the scan shows that no residual organic chemicals are present, you might want to revisit the role that "Psychological Linen" plays in causing a skin irritation.