Excerpts from “Death By Pedicure,” by Dr. Robert Spalding

 

A serious problem

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At this time, an estimated one million unsuspecting clients walk out of their chosen salon with infections – bacterial, viral, and fungal. Depending on the state of their immune systems and overall health, they may experience an annoying itchy infection that requires drug treatment – or a life-threatening outbreak that requires a trip to the emergency room. Many may never connect their infections with a salon treatment. As a podiatrist, a doctor who specializes in the treatment of foot problems, it took me a while to make this connection. 

 

As nail techs began referring more and more clients with foot problems to me, I began paying attention to the sources of my patients’ nail infections.  Several nail techs suggested I serve as a professional medical resource for the national website, www.beautytech.com. I was invited to seminars and national beauty trade shows where I answered questions about nail health and nail disease from a medical perspective. Over a period of eight years, I discovered entrenched patterns, processes, and procedures in the industry that vary from untruthful and unhealthy to outright unlawful.

 

In this book I’ll share with you what I’ve learned, and include many chapters that go deep into specific areas, so that the big picture of what’s involved is clear to all. Right now let’s start by visiting a nail salon where we’ll see the problems unfold before our eyes.

 

                                                        We’ll call our hypothetical salon Let’s Nail It! 

 

“Jack,” a CEO, has active hepatitis C. He scratches the bumpy tiny lesions on the top of his head, then an itchy mosquito bite on his arm. In so doing, he acquires a small amount of pink serous fluid (infectious discharge) under his fingernails. He comes in regularly for a nail-maintenance manicure. 

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“Sara,” a teenager, wants a natural manicure for a weekend dance date. She hopes the nail tech will do something about the rough hands and split cuticles she has from horseback riding and barn duties. She wants soft hands for her date. 

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“Mrs. Taylor” has diabetes, but no health insurance. Her daughter, nail tech Amy’s best friend, requested that Amy cut her mom’s thick toenails because she can’t afford to see a doctor. Mrs. Taylor doesn’t want her nails painted, just trimmed and sanded so that her feet fit comfortably in her shoes.

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Amy asks her first client, Jack, to go to the bathroom and scrub under his nails with a brush. This is standard procedure. Jack goes to the bathroom, relieves himself, and quickly washes his hands, but doesn’t remember to use the scrub brush to clean under his nails. He sits at the table and offers his hands. Amy retrieves the nail nippers and a pointed nail instrument from the ultraviolet light box. She cuts Jack’s nails and cleans under them, including the one harboring pink serous viral fluid, and finishes the manicure. After Jack leaves, she puts the nail nipper and the cleaning instrument in the sterilizer box for the required ten-minute treatment.

 

Sara comes in and is sent to the restroom to wash her hands, which she does, though lightly, as the soap stings when it gets into the cracked skin of her fingers. She sits down at the nail table. Amy retrieves the nail nippers that have been in the sterilizer for ten minutes and trims the dead tissue around the girl’s fingers and nails. Some of Jack’s hepatitis viral particles now reside in Sara’s split cuticles. Amy recommends a certain oil to help the cuticles, and tells Sara to use a moisturizer on her hands and to not get them wet. Sara leaves happy with her softer, oil-massaged hands. 

 

Mrs. Taylor walks in as Sara walks out. Amy picks a sanding burr from the sterilizer box and sands Mrs. Taylor’s cracked calluses. Then, as she trims the thick nails with the nipper she just used on Sara, Amy notices a soft black-green tarry substance and some redness under a big-toe toenail. As she clips more nail away, the now-exposed redness appears to be dried old blood and what looks to be a soupy mix “with a peanut butter smell.” Concerned, Amy stops, puts the tools into the sanitizer, and lets Mrs. Taylor know that that’s the best she can do, that to go deeper might hurt her toe. She washes the toes in soapy water and rubs them with softening cream. 

 

Amy, relieved to be going home in twenty minutes, buries the nippers and sanding burrs in the glass beads of her new dry heat sterilizer. Below the beads is a heat filament that unevenly heats to 215 degrees Fahrenheit, which she was incorrectly told sterilizes everything. Pleased, she flicks on its switch for the first time, cleans her table, and puts her nail products in order again.

 

                                                        What’s not right with this day in “Let’s Nail It!” salon?

 

Jack’s arrival in the salon, infected as he is with active hepatitis C, alerts us to a nail salon’s number one problem: infection. But neither Jack nor his infection is the problem here. Jack is at the same or greater risk of infection as a healthy client. Indeed, having a second infective organism introduced into Jack’s immune-compromised body could result in an unpleasant medical event. 

 

The problem is the transmission of infection from one client to another. Breaks in the skin can be microscopic or highly visible. They can come in with the client – cuts, scratches, hangnails, bitten nails, insect bites, paper cuts, split cuticles – or be created in the salon. Nail techs using callus cutting tools and nail nippers, files, cuticle pushers, and electric burrs and drills, can and do scratch and nick skin and draw blood. Called portals of entry, breaks in the powerful immune system organ called skin can allow infective organisms to enter.

 

Let’s see how this happens: Sara, the teenager, was nail tech Amy’s next client after Jack. Amy did not break Jack’s skin, he had no obvious infections, and she had put the clippers and nail tools she used – both contaminated with microscopic amounts of Jack’s hepatitis C material – into her brand new ultraviolet light sterilizer box for the required ten-minute treatment. She followed the rules. How is it, then, that young Sara walked out of the salon thirty minutes later with Jack’s hepatitis C cells making themselves at home in her split cuticles?

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Problems identified:

1. Inadequate interview with client: Amy didn’t ask Jack if he had a blood-borne disease.

2. Basic sanitation: (a) Amy sent Jack to the restroom to scrub under his nails with soap, water and a nail brush. He didn’t, and Amy didn’t double check. (b) The nippers were contaminated. The serous fluid contaminated with Jack’s hepatitis C virus stayed under his fingernails. Microscopic clumps of it were stuck on the nippers when Amy trimmed Sara’s cuticles and nails. (c) Equipment was not sterilized. Amy put the nail nippers in her newly bought UV light “sterilizer” box. The ultraviolet light of a “sterilizer” box is not designed to kill 100 percent of all infective organisms.

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Some infective microorganisms are easy to kill. Some are not. Thanks to the industry-wide confusion about the definition of the term “sterilize,” Amy thinks her instruments are sterilized, when, in fact, she has no clue. She doesn’t know that Jack has active hepatitis C, nor that his hep C virus material is on the nippers. To handle this essentially medical situation, she would have to know that the nippers are contaminated with hepatitis C virus, and know whether or not ultraviolet light is a powerful enough disinfectant to kill that particular virus. Is this part of her job description? No!

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The third client, Mrs. Taylor, Amy’s best friend’s mother, has diabetes. Amy agreed to work with her as a favor to her friend. Mrs. Taylor came in right on Sara’s heels, and Amy, caught up in the warm interaction with her friend’s mom, forgot to put the nippers she just used on Sara back in the UV sterilizer box.

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Problems identified: 

1. Amy stepped outside the law when she agreed to work with a client with a medical condition, diabetes, and a classically related symptom – thick, fungus-infected nails. Most state laws forbid nail techs to touch clients who have nail or skin problems, and they are told to refer such clients to a doctor. Amy didn’t. Most state regulations forbid nail techs to work on thick, fungus-infected toenails without written consent from a physician. Depending on what state she lives in, Amy may have broken the law by agreeing to work with her friend’s mom. 

2. She also forgot to put the nippers in the “sterilizer” box, and she may have exposed an immune-compromised older lady with no health insurance to Jack’s hepatitis C virus.

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                                                              Vital health practices for the consumer

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Here we get into the crux of the nail salon problem: transmission of infective organisms from client to client via unclean instruments and equipment. Only one word – sterilized – describes a nail instrument that is 100% free of all infective organisms. 

 

Sterilize

To be sterile is to be 100% free from living microorganisms. To sterilize is to completely destroy all microorganisms on non-living (inanimate) surfaces. The term does not apply to skin. One cannot sterilize skin without destroying the skin itself.

APIC’s [Association for Professionals in Infection Control and Epidemiology] Disinfection and Sterilization Principles states: “The sterilization process completely eliminates or kills all microorganisms, and is done by using sterilizers that provide steam under pressure [as in an autoclave*], ethylene oxide (ETO) and other gases, or by using liquid chemicals for prolonged soaking times. Sterilized items are considered to remain sterile until the package they are in is torn, wet, or damaged. Sterility is a function of intact packaging and time.” 

*autoclave: A device that sterilizes by steam pressure, usually at 250˚F (121˚C) for a specified length of time. Every item in an autoclave is in a package that maintains its sterility until the package is opened.

 

Disinfect

Bear with us as we go more deeply into information that clarifies our understanding of what it takes to disinfect/sterilize nail equipment. 

From APIC: Microbes – Different types of microorganisms vary in how easy they are killed by disinfectants. Some are very hard to kill with disinfectants, while others can easily be killed by many disinfectants and even soaps. This list of microorganisms starts with the hardest to kill and ends with the easiest to kill:

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• Bacterial spores*: Bacillus subtilis

• Mycobacteria: Tuberculosis

• Non-lipid or small viruses: Polio virus, Hepatitis A virus

• Fungi: Aspergillus

• Vegetative Bacteria**: Pseudomonas Staphylococcus aureus

• Lipid or Medium-Sized Viruses: Herpes simplex virus, Hepatitis B virus 

  Human immunodeficiency virus (HIV)

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*Medline Plus: A spore is a reproductive cell produced by plants (fungi, moss, ferns) and some protozoa and bacteria. The spore often fully develops after a state of dormancy or hibernation. Spores have thick walls and are very resistant to high temperatures, humidity, and other unfavorable conditions. Chemical disinfection kills bacteria, but does not destroy their spores. Sterilization destroys spores as well as bacteria, and requires high temperatures and high pressures. In health-care settings, sterilization is usually accomplished using an autoclave.

 

Knowledge of this hierarchy – of easier, harder, hardest to kill microorganisms – will allow us to understand the hierarchy of measures needed – cleaning, disinfection, sterilization – to free nail-tech instruments of microorganisms.

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