Skin Preparation Recommendations


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Subject: Skin Preparation Recommendations

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In this context, antiseptics are chemical agents primarily used to decrease the risk of infection in surgical wounds. Alcohol and iodophors have rapid action against bacteria but little persistent activity, whereas chlorhexidine is slower to act but persists on the stratum corneum. Most antiseptics are not suitable for open wounds because they may impede wound healing by direct cytotoxic effects. 
Patient characteristics associated with an increased risk of surgical site infections include remote site infections, colonization, diabetes, cigarette smoking, systemic steroid use, obesity, extremes of age, poor nutritional status, and preoperative transfusion of certain blood products. Apply greater vigilance when performing office procedures on patients with these risk factors. Preoperative shaving for hair removal is associated with higher rates of surgical site infections. Clipping hair immediately before a surgical procedure has the lowest rates of associated infection and should be considered the preferred preparatory activity for hair removal. 
Several effective antiseptic agents are available for preoperative skin preparation, including alcohol-containing products, the iodophors (e.g., povidone-iodine), and chlorhexidine gluconate
  • Alcohol is readily available, inexpensive, and the most rapid-acting skin antiseptic. It does not have any increased risk for the pregnant patient but must be allowed to dry completely to achieve a bacteriocidal effect. Drying also prevents any risk for ignition with use of electrocautery or lasers. Disadvantages include potential for spores to be resistant and potential for flammable reactions.

  • Iodophors (Betadine, others) provide broad-spectrum coverage, are associated with lack of microbial resistance, and provide a bacteriostatic effect as long as they exist on the skin. They are effective against methicillin-resistant S aureus (MRSA) and Enterococcus species. Significant resistance to povidone-iodine has not been documented. They were formulated to be less irritating and allergenic than pure iodine solutions but are also less active. They require at least 2 minutes of contact to release free iodine, which exerts the antibacterial activity. Povidone-iodine absorption through mucous membranes has been linked to fetal hypothyroidism, although there are reports of contact dermatitis. They may also impair wound healing.

  • Chlorhexidine gluconate (Hibaclens, others) offers broad-spectrum coverage against bacteria, yeast, and molds. It appears to provide greater reduction in skin microflora than povidone-iodine and remains active for hours after application. It does not have any increased risk for the pregnant patient. It should be used with caution around the eyes because of a risk for conjunctival irritation, keratitis, or corneal ulceration. It can cause ototoxicity if the patient has a perforated tympanic membrane.

For injections and superficial procedures, alcohol is adequate skin prep. For larger, full-thickness procedures, iodophors or chlorhexidine gluconate are usually preferred, typically applied in a spiral pattern that extends further outward with each application. The following recommendations are provided for applying skin preparation agents: 
  • Remove gross contamination from the skin, including soil, debris, or devitalized tissue.

  • Apply the skin-cleansing agent in concentric circles, starting from the intended surgical site.

  • Extend the area of skin cleansing to a wide enough area to cover the proposed operation, allowing for extension of the surgical field for the creation of additional incisions or drains.

  • Do not rub or scrub the skin during application of the antiseptic agent. Damaging the skin during application can lead to increased surgical site infections.


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Sweeney SM, Maloney ME. Pregnancy and dermatologic surgery. Dermatol Clinics .  2006;24(2):205–214. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.