Accepted Manuscript

A descriptive survey on microbiological risk in beauty salons

Laura Mancini, Mario Figliomeni, Camilla Puccinelli, Cristina

Romanelli, Fabrizio Volpi, Anna Maria D'Angelo, Silvana
Caciolli, Emilio D'Ugo, Elisabetta Volpi, Roberto Giuseppetti,
Stefania Marcheggiani

PII: S0026-265X(17)30165-0
DOI: doi: 10.1016/j.microc.2017.02.021
Reference: MICROC 2707
To appear in: Microchemical Journal
Received date: 9 September 2016
Revised date: 10 February 2017
Accepted date: 17 February 2017

Please cite this article as: Laura Mancini, Mario Figliomeni, Camilla Puccinelli, Cristina
Romanelli, Fabrizio Volpi, Anna Maria D'Angelo, Silvana Caciolli, Emilio D'Ugo,
Elisabetta Volpi, Roberto Giuseppetti, Stefania Marcheggiani , A descriptive survey on
microbiological risk in beauty salons. The address for the corresponding author was
captured as affiliation for all authors. Please check if appropriate. Microc(2017), doi:
10.1016/j.microc.2017.02.021

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A descriptive survey on microbiological risk in beauty salons

Laura Mancini1, Mario Figliomeni1, Camilla Puccinelli1, Cristina Romanelli2, Fabrizio Volpi1,
Anna Maria D'Angelo1, Silvana Caciolli1, Emilio D'Ugo1, Elisabetta Volpi1, Roberto Giuseppetti1,
Stefania Marcheggiani1

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Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena, 299

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00161 Rome, Italy. 2 Notified Body 0373, Istituto Superiore di Sanità, Viale Regina Elena, 299
00161 Rome, Italy

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Corresponding author: laura.mancini@iss.it

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Keywords: microbiological risk, beauty salons, descriptive survey
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Abstract
Beauty salons are an employment sector with potential exposure to biological agents. The beauty
industry (beauty salons, health farms etc.) has grown considerably in the past decade. This,
however, led to a proportional increase in the number of people who could become infected in case
of accidental contact with infected material. Indeed, such activities may pose health risks to both
workers and clients if the appropriate precautions are not followed. The study investigated
microbiological risk and infection-control practices in 120 beauty salons in Rome. Information was
gathered using a questionnaire that covered occupational safety measures, for an evaluation of
microbiological risk. Infection among clients was identified by the staff of 67.5% of centers. Of
these, 30.8% reported either fungal infections or dermatitis. Most (89.2%) of the centers that

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encountered mycosis also found dermatitis, while 10.8% reported only mycosis. Of the beauty
centers 31.7% took microbiological risk management measures. This study showed the importance
of the relationship between microbiological risk and health, highlighting the need for

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training/information for beauty salon staff as well as clients.

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Introduction
Beauty salons are an employment sector with potential exposure to biological agents, given the
nature of the treatments, that are carried out directly on the body of individuals who can host
pathogens and opportunistic microorganisms [1]. Diseases can be spread through direct contact with
bodily fluids from: coughing, sneezing, contaminated blood, pus, sores, cuts or grazes. Many
bacteria, viruses, fungi and yeasts are associated with this kind of activity. The bacteria commonly
identified in manicure, for instance, are Streptococcus spp., Enterococcus spp., Micrococcus spp.,
Bacillus spp., Enterobacter spp., Klebsiella spp., Acinetobacter spp., Citrobacter spp., Escherichia
coli [1; 2], Mycobacterium fortuitum [3; 4; 5], while the yeasts are Candida spp. and Rhotorula spp.
[1]. Similarly, in pedicure, bacteria, viruses and fungi have been identified. Bacteria like

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Mycobacterium chelonae [6] and Mycobacterium mageritense [3; 7; 8; 9] viruses like HBV and
HCV [10, 11], and fungi such as Rhizopus spp. [2]. Notably, the risk of transmission in the event of
accidental contact with infected material is high in the case of bloodborne pathogens, due to the

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high viral loads typically present in the blood [12].
The beauty industry has grown considerably in the past decade, leading to a proportional increase in

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the number of exposed subjects who could potentially become infected through accidental contact
with contaminated material or cross-infection.
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In Italy, the industry currently serves 40 million customers a year in more than 30.000 beauty salons
employing over 70.000 individuals [13]. The microbiological risk in a beauty center varies
depending on the activity and, crucially, on the level of implementation of hygiene procedures, such
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as the use personal protective equipment (PPE), and the sanitization, sterilization and disinfection of
instruments and medical devices. Particularly significant is the risk of cross-infection. Due to the
nature of a beauty therapist’s work, daily physical contact with clients is very common, often in the
context of invasive procedures. Microbiological risk in the beauty centers is rarely addressed and
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remains an important problem [14]. Hands dermatitis, for example, is a well-recognized condition
and frequently observed in professional beauty salons, hairdressers and barbers [15, 16]. The
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environment of beauty salons, due to the frequent exposure to invasive procedures, for
environmental contamination, linked to the production of potentially contaminated aerosols,
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represents an area at risk. An outbreak of community-associated USA300 methicillin-resistant

Staphylococcus aureus was reported to have occurred in the Netherlands, involving 11 cases,
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among them a beautician, two of her customers, and eight indirect contacts [17].
Environmental contamination linked to the production of potentially infectious aerosols, the use of
sharp instruments which, if not accurately sanitized, can cause bloodborne infections such as
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hepatitis B, hepatitis C and HIV, and inadequate sanitation of premises, furniture and linens are
some areas of possible intervention.
Equipment used in professional beauty salons must comply with state laws: in Italy, Decree,
n.110/2011 [18] regulates electromedical equipment used by beauticians. It includes provisions for
the safe operation of many devices and of equipment used in professional beauty salons, and
requires that such instruments be checked regularly and used only by experienced, properly trained,
staff.

The aim of this study was to investigate the activities of beauty salons in the context of
microbiological risk. It is a survey on the knowledge and practice of beauty salon staff in the
province of Rome, regarding microbiological risk and its management.
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An observational, descriptive survey was carried out to assess beauticians knowledge on the
transmission of infections, on infection control procedures, sterilization and disinfection equipment
(disposables, barrier measures, protective clothing), the protection of beauty salon staff
(management of risk from sharp instruments), and risk management in the case of infection among
clients.

Methods
The study was conducted from April to July of 2014. Two hundred beauty salons were randomly
selected throughout Rome (at least one for each postal code). A questionnaire was administered to

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the managers, or in some cases a senior beautician. The Interviews, one per beauty center, were
performed "in situ" by our researchers. ID codes were used to protect the privacy of the centers and

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interviewees.

The interview consisted of 9, multiple choice or open-ended questions (Table 1). The first 3

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questions addressed the type of beauty salon (small, family run business or franchise), the staff's
level of education and professional training and the number and gender of habitual and occasional
clients. Question 4 pertained to the equipment and instruments available to the staff, to the
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frequency of maintenance, and to the use of PPE in this context. Question 5 touched upon the
methods used to sterilize materials and/or instruments. Waste management (waste sorting, including
infectious waste) was addressed in question 6. A question ascertaining whether workers had
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encountered cases of mycosis, dermatitis or other infectious conditions among the clients, and how
the microbiological risk was managed in such cases, was also present (question 7). Question 8
addressed the protocols followed during the treatment of clients, with particular regard to health and
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hygiene. Question 9 evaluated the use of medical devices in beauty salon (as defined in EU
Directive 93/42/EEC [19] and subsequent amendments).
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Statistical analysis
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A correspondence analysis (CA) was performed on data relating to PPE, sterilization and
disinfection of instruments, protocols of beauty treatment applied. Subsequently, correlations
between the two main axes of the CA and data on type of beauty salon and the staff's level of
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training were investigated. Analyses were performed using the PAST software v 3.12 (2016) [20].
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Results

One-hundred and twenty of the 200 salons approached, agreed to participate in the survey.
Summary results of each question have been reported in table (Table 1).

Most of beauty salon, 95 %, investigated were small or family run business companies. As for the
beautician’s level of education, all have operators with beautician degree and only in one center was
the staff specialized. Customers were either habitual or occasional, generally of both sexes, with a
slightly higher proportion of women.

Personal protective equipment was used by therapists in 99 % of beauty salons. Most interviewees

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(68%) did not specify the kind of PPE employed; 13 % reported the use of gloves, and 10%
mentioned gloves and masks. In 95% of the participating beauty salons, clients were also given

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PPE. The PPE used was disposable; only one salon reported that they sterilize plates for electrical
stimulation after use.

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In response to the question on sterilization methods, more than 95% of the centers use more than
one method of decontamination. Almost all beauty salons used immersion disinfectants (98.3%),
followed by autoclave (64.7%). Quartz sterilization was used by about 32% of centers, and UV by
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9.2% . Regarding the waste managements, all beauty salon performed waste management according
to regulations.
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The responses to the question on microbiological risk revealed that, in 30.8 % of the salons
surveyed, cases of either fungal infection or dermatitis among the clients had been identified by the
staff. Eighty-nine point two percent of beauty salons having encountered mycosis also had cases of
dermatitis, while 10.8% reported having seen only mycosis among their clients. None of the salons
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saw dermatitis cases alone. Risk management was applied in 31.7% of surveyed salons: in the
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salons which infections were identified, in the 67.5 % of salons, clients were advised to contact a
physician or a dermatologist.
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As far as the decontamination of bowls following pedicure/manicure, 62.5% of salons employed all
three methods - rinsing, disinfection and sterilization, some (1.7%) only sterilize, while others
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(1.7%) only disinfect. Some (4.2%) beauty salons reported alternative methods as well, such as the
use of disposables (towels, sheets etc.). The remainder of the salons (29.9%) employed a
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combination of methods. For reusable materials, over 86% of the surveyed salons use either
sterilization or disinfection methods.

For the use of medical devices, 87% of the centers do not use such devices, while 13% use
disposable and reusable ones. Who employ reusable devices as well, sterilizing and disinfecting
them after use. The medical devices used belong to the non-sterile class, or the lowest risk category.

The CA (Figure 1) performed on PPE, decontamination methods and microbiological risk

management yielded no significant assemblages in terms of sterilization and disinfection
techniques. Furthermore, microbiological risk management was not a discriminating factor in this
analysis. The only beauty salon (ID 31) graphically isolated was the only one that did not employ
sterilizing systems, such as autoclave, but only performed disinfection using quartz.
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The correlation analysis (Table 2) found no associations between either the type of beauty salon
(small or franchising) or the therapist's level of education on the one hand, and infection-control
measures (decontamination techniques, microbiological risk management, use of PPE).

Discussion

The questionnaire was designed as a tool for evaluation studies of health policy in population
surveys. It was intended to be applicable to a wide range of types and severity of conditions. In this
case, the survey resulted in a first descriptive account of hygienic conditions and microbiological
risk management practices in beauty salons in Rome.

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The vast majority of beauty therapists reported using PPE (98%), providing clients with the
equipment (95%) and using either sterilization or disinfection (95%). Sanitization is the most basic

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level of microbiological decontamination and should be carried out before disinfection (the second
level) and sterilization (the third). A beauty salon should sterilize all metal tools, metal implements

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and plastic tools. The use of chemicals is the most popular and effective way of sterilizing beauty
tools and implements. The absence of a correlation between beauty therapists’ level of education
and training or type of beauty salon, and sterilization techniques, or PPE use, suggests a good level
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of care in Rome's beauty salons. The need to regulate the activities of beauty salons with health
standards and guidelines arises from the consideration that such activities, if not conducted in
accordance with best practice, could pose a risk to public health. Microbiological risk in beauty
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salons varies depending on the activity. Particularly relevant in esthetic centers is the risk of cross-
infection [15, 16]. From a microbiological point of view, the most frequent risks to be considered
are those that result from: inadequate hygiene procedures, such as failure to use PPE, and
inadequate sanitization, sterilization and disinfection of the instruments and medical devices used.
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The category of these materials includes small tools, sharp instruments, removable parts of
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equipment that come into direct contact with the client, but also non-disposable gowns and drapes.
The beauty centers that participated in the present study often used a combination of sterilization
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and disinfection methods depending on the type of activities performed by the center and its needs.
In some cases, sterilization is required - performed with validated methods and preceded by rinsing
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to lower the initial bioburden. In other cases, disinfection is sufficient.

Conclusions
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We investigated microbiological risk and infection-control measures in beauty salons in Rome.

Overall, the survey conducted outlines an encouraging situation which, clearly, may also be
improved, in light of the following findings: a limited ability to recognize infection in a patient;
little use of microbiological tests to ascertain the quality of sterilization; low levels of knowledge on
medical devices among members of the staff.

With a view to protect public health, beyond conforming to the standards of hygiene and safety
conditions in the working environment, special attention should be paid to the enforcement of
infection-control measures and procedures during activities that may pose a risk to customers and
professionals. Such procedures should be followed with the utmost care, so as to ensure aseptic
conditions.
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To conclude, activities such as those performed in beauty salons may pose a risk to the health of
workers, clients. An easy-reference summary of both national and regional regulations covering
infection control and microbiological risk assessment for the beauty industry is likely to prove an
important contribution to public health.

Author Contributions

Laura Mancini, Stefania Marcheggiani and Cristina Romanelli conceived, designed and supervised
the project. Mario Figliomeni, Anna Maria D'Angelo, Silvana Caciolli, Emilio D'Ugo, Roberto
Giuseppetti, Elisabetta Volpi performed the field sampling. Camilla Puccinelli and Fabrizio Volpi

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analyzed the data. Laura Mancini, Stefania Marcheggiani and Mario Figliomeni co-authored the
paper. All authors revised and approved the manuscript and agree with its submission to

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Microchemical Journal

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Acknowledgements

This study was funded by the Italian Ministry of Health. We would like to thank all National Trade
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Associations involved and all the beauty salons that opened their doors to the research team and
supported it during field work. Our gratitude also goes to Cinzia Grasso and Massimiliano Bugarini
for their technical support.
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Conflict of interest
The authors declare no conflict of interest.
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Table 1. Survey description and summary results

Number Question Question’s Structure Summary Results

1 multiple-choice question (4 possible 95 % of beauty salon investigated are small

1 Type of beauty salon
answers) or family run business
Beauty therapists' level of
2 1 open-ended question All therapists have at least beautician degree
education
2 multiple-choice questions (2 possible Clients are generally of both sexes, also
3 Gender and type of clients
answers each) habitual and occasional.
In 99 % of beauty salon therapists used PPE

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Infection-control measures
4 4 open-ended questions
for workers and customers
In 95% of beauty salon clients are given PPE

95% of the centers use more than one

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1 multiple-choice question (3 possible
5 Sterilization methods
answers) and 1 open-ended question
method of decontamination: immersion
disinfectants and autoclave are respectively
the most used.

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1 multiple-choice question (3 possible
6 Waste management
answers) and 1 open-ended question
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7 Microbiological risk 2 open-ended questions
Infection-control
5 multiple-choice questions (2 possible
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All beauty salon performed waste
management according to Regulations.
30.8% of beauty salon recognized
microbiological risk intended as mycosis and
dermatitis
31.7 % of beauty salon performed risk
management
62.5 % of beauty salon employed Rinsing,

8 procedures during
answers each), 2 open-ended questions disinfection and sterilization
treatments
3 multiple-choice questions (2 possible 87% of the centers do not use medical
9 Use of medical devices
answers each), 1 open-ended question devices
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Table 2. Correlation between CA results and type of beauty salon, and beauty therapists' level of
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education and training

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Correlation factor r
Beauticians' level of
Type of beauty salon education and training
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Axis 1 -0.020 0.154

Axis 2 0.024 -0.090
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Figure 1. Correspondence Analysis performed on PPE, decontamination methods and

microbiological risk management data (Axis 1= total of variance 48.6 %; Axis 2= total of
variance 20. 5% ).

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Highlights

The potential exposure for human health to biological agents in beauty salons
The activities of beauty salons in relation to the microbiological risk.
Mainly identified risk factors found are fungal infections or dermatitis in users.
Highlight the need for training/information for operators and beauty salon goers.

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