SKIN PREPARATION IN THE
SURGICAL PATIENT
Clinton Warner, MD
Atlanta, Georgia
A historical review of skin antisepsis is given.
Current practices, rationales for skin antisepsis
as a segment of total wound care, and bacterio-
logical factors are discussed. The results of a
telephone survey of current practices of 16 med-
ical centers around the country are presented.
Discussion and conclusions relative to survey
results and skin care agents are given. Charac-
teristics of an ideal skin preparation yet to be
obtained and some common myths relating to
this subject are discussed.
Many canards and rituals and much dogma exist
in modern medicine. There are systems, procedures,
methods, and techniques for caring for patients. When
one asks, "Why do we do this?" many times the an-
swer is, "Because we have always done it this way."
Some procedures and methods of doing things have
persisted in medicine; others have been accepted for
a brief, intense period and then have quickly faded
from the scene. Two practices that have come and
gone are the use of tacky mats at operating room
entrances and, for more senior citizens, the use of the
"freezing machine" for duodenal ulcer disease.
The process of testing new procedures-drugs,
techniques, methods-is generally beneficial. It serves
Presented at the 92nd Annual Convention and Scientific Assembly
of The National Medical Association, New Orleans, August 1-6,
1987. Requests for reprints should be addressed to Dr. Clinton
Warner, Southwest Professional Building, 505 Fairburn Rd, SW,
Suite 205, Atlanta, GA 30331-2099.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988
as a quality-control mechanism that continually re-
views newly accepted procedures, rejects those that
do not stand the tests, and adds to the great body of
information that is accessed in caring for patients.
REDUCING THE POTENTIAL FOR
WOUND SEPSIS
There are many methods of preparing skin in sur-
gical patients. Over the years they have changed con-
siderably. The objective of all of these efforts is to
minimize the potential for wound sepsis.
The ancient Egyptians regarded wound care with
considerable interest.' They recommended the use of
honey because of the presence of inhibine, a secretory
product of the salivary glands of bees, which has an
antibacterial effect. Some dyes were also used, as well
as wine. Carbolic acid was used in the Listerian period.
Throughout more recent years many substances and
agents have been used to prepare skin for surgery.2
The preparations in general use today are few and
will be discussed individually.
Clinical studies have not conclusively proven the
superiority of any agent currently used. Stated another
way, the ideal antiseptic agent has yet to be devel-
oped-all commonly used ones have some short-
comings.
BACTERIAL COLONIZATION
What are we trying to do when we prepare skin
preoperatively? Is there any real benefit in this "rit-
ual"? It has been said that a simple soap and water
wash followed by application of a one-minute alcohol
wipe is as effective as any of the commonly used but
899
SKIN PREPARATION
more costly agents. Certainly a reduction in the tran-
sient bacterial flora of the skin can be accomplished
by either method, but has either method been shown
to be beneficial in lowering subsequent wound infec-
tions? It is well known that colonization of an open
wound with bacteria does not necessarily lead to in-
vasive wound sepsis. Other factors, such as surgical
techniques and discipline, the local condition of the
wound at the close of the operation, and host im-
munity factors, are much more important in deter-
mining the onset of wound infection. Nevertheless,
it would seem to make sense to quickly, effectively,
and inexpensively reduce the quantitative pool of skin
bacteria prior to invading the skin.
The skin cannot be sterilized because approxi-
mately 20 percent of the resident flora are beyond
the reach of surgical scrubs and antiseptics. The mi-
croorganisms on the skin are composed of transient
and resident flora. Most of the resident flora are quite
superficial, but 10 to 20 percent are found in the
deeper layers of the skin. The pilosebaceous units ap-
pear to be the major source of resident flora. These
organisms cannot be completely removed or de-
stroyed with detergents or antiseptics. They are usu-
ally of low virulence and are rarely implicated in sur-
gical infections. Detergent scrubbing of the skin has
been shown to markedly reduce or eliminate patho-
genic organisms, most ofwhich are found in the more
easily removed transient flora. Years ago the major
infection problem in hospitals was gram-positive
bacteria. Now, gram-negative bacteria as a group, in-
cluding Escherichia coli, Pseudomonas aeruginosa,
Klebsiella, Enterobacter and Proteus species, make
up the majority of pathogens found in surgical
wounds. The most frequently isolated single pathogen
is still Staphylococcus aureus.3
Antibiotic usage developing over the decades has
generated selective pressure on which organisms will
be most prevalent within an institution and to which
antibiotics these organisms may be sensitive or resis-
tant. For example, penicillinase-producing S aureus
replaced penicillin-sensitive S aureus associated with
penicillin usage; E coli followed the introduction of
penicillinase-resistant penicillins; Klebsiella followed
ampicillin; and Pseudomonas followed the first- and
second-generation cephalosporins. The use of current
third- and fourth-generation penicillins and cepha-
losporins has seen the emergence of Serratia, Entero-
bacter, and Pseudomonas species resistant to these
drugs. So, while the names of etiologic agents and
their antimicrobial susceptibilities remain in flux, the
900 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988
problem persists. The incidence of infections occur-
ring at any one given site, however, has seemed rel-
atively stable of late, which hopefully reflects the im-
plementation of standardized infection-control
policies and procedures.4
WOUND INFECTIONS
Currently the risk of developing a surgical wound
infection is largely determined by three factors: (1)
the amount and type of microbial contamination of
the wound; (2) the condition of the wound at the end
of the operation, which is largely determined by sur-
gical technique and disease processes encountered
during the operation; and (3) host susceptibility. These
factors interact in a complex manner. A wound in
healthy tissue is surprisingly resistant to infection even
when contaminated with many microorganisms, but
a wound containing foreign or necrotic material is
highly susceptible to infection even if a few micro-
organisms are present. All measures intended to pre-
vent surgical wound infections are directed at the
three factors just mentioned. More infections can be
prevented, though, by influencing the practices of the
surgical team than by using any particular antiseptics
or antibiotics.
One important preoperative and postoperative
measure to prevent wound infection is the treatment
of active infections, even if they are at a site remote
from the surgical wound. The patient in such a cir-
cumstance has a greater risk of wound infection than
an uninfected patient. Other measures include keep-
ing the preoperative hospital stay short and avoiding
hair removal whenever possible. In general, the hair
should not be removed; the skin should just be pre-
pared. Bathing the patient with antimicrobial-con-
taining products has been suggested as an effective
preoperative measure because it reduces colonization
for typical wound pathogens such as S aureus. There
is debate about whether this practice actually results
in reduction in wound infections. But it is certainly
a simple, easy, and economical way to prepare the
skin. Maybe bathing should become one of the rituals.
Although bathing has not been proven to reduce
wound infections, it does make sense. One Swedish
study concluded that "it is unethical to perform high-
risk surgery without preoperative whole-body disin-
fection with chlorhexidine."5
Wound infections can cause important legal and
economic liability to surgeons. Numerous studies in
the literature allude to the increased costs associated

with wound infections in surgery, resulting in pro-
longed hospitalization and loss of productivity, not
to mention the elements of human suffering in terms
of pain and, many times, disability.
Increased costs and lengthened hospital stays re-
sulting from wound infections did not get the atten-
tion of hospital administrators and governing boards
in the days prior to diagnostic related groups. Ad-
ministrators and members of governing boards would
say, "Well, it's unfortunate that our wound infection
rates are up, but really, that's a matter for the medical
staff." These costs could be passed on to the patient
in those days. In fact, hospitals were actually making
money on surgical wound infections. Obviously, this
is not the case today. One can now get not only the
attention but the keen interest of any administrator
if wound infection matters are to be discussed.
It cannot be emphasized in this context too much
that a surgical wound with healthy tissue will tolerate
a fair amount of contamination without developing
infection. A surgical wound with foreign material or
necrotic tissue is very likely to develop infection with
only minimal contamination. Therefore, the impor-
tance of good technique again becomes apparent. The
excessive use of sutures in surgical wounds should be
prohibited. Surgeons sometimes tend to forget that
sutures-all sutures-are foreign bodies. However,
that does not preclude the proper handling of tissue,
adequate hemostasis, and the elimination of dead
space. But this does not always have to be done with
sutures. All these things are important, probably more
important than preparation of the skin. Good surgical
techniques cannot be emphasized too strongly.
SCRUBBING THE SKIN
The question of whether to scrub or paint the skin
is often debated. Regardless of which technique is
used, more and more information is appearing that
indicates that with effective antiseptics, scrubbing is
not absolutely necessary-particularly the long, de-
laying scrubs that prolong operating time. Many
studies indicate that there is no place for the iodine
scrub, for example; they indicate that simple painting
with an alcohol wipe, followed by Betadine, is prob-
ably as good as any other preparation. Surgical rituals
are sometimes prolonged and expensive and can put
surgeons at risk both medically and economically.
There is no question that a ten-minute scrub of an
abdomen may not be absolutely necessary in a routine
surgical case.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988
SKIN PREPARATION
A common feature of all surgical scrubbing tech-
niques is that they take time. Scrubbing often occurs
after induction of anesthesia, delaying the operation.
Substitution of an equally efficacious, faster skin-
preparation method would reduce patient risk by de-
creasing anesthesia time and improving operating-
room use and efficiency. The ideal agent would be
one that could be supplied quickly and yield good
results with a decrease of risk factors as well as cost
factors.6
The ideal antiseptic can be defined as a safe, fast-
acting, broad-spectrum, antimicrobial-containing
preparation that significantly reduces the number of
microorganisms on intact skin. That definition begs
the question of whether reducing organisms on the
skin ultimately results in reduced surgical wound in-
fections.
Again, the most important measure to prevent
wound infections is operative technique. Poor tech-
nique can result in inadvertent contamination of the
wound. For example, an accidental perforation of the
bowel during an abdominal operation may prolong
the operation and may result in a wound that cannot
adequately resist infection because it contains devi-
talized tissues or foreign bodies.3 Because the risk of
wound infection increases with the length of the op-
eration, an expeditious operation is important. Any
mention of surgical technique applies not only to the
surgeon's skill in handling the wound but also to his
or her skill in supervising the surgical team and
maintaining the professional decorum that facilitates
expeditious and successful operations. Poor discipline
in the operating room can result in mistakes and
sloppy aseptic technique. When a surgeon is finished
training, surgical habits are not easy to change; but
improvement may be stimulated by calculating and
informing surgeons of their case-specific rates of
wound infections. Surveillance of wound infection
rates and reporting in general, when instituted, cause
an overall decrease in wound infections. This sur-
veillance is even more productive if the reporting is
case specific. Well-run infection-control programs are
cost effective.
It is difficult to sterilize skin without damaging it.
By scrubbing abraded epidermis, bacteria harboring
in hair follicles rise to the surface, contaminating the
previously prepared area. Scrubbing removes the
outer layer of the epidermis and exposes nearly twice
as many bacteria. This is inconvenient and messy
and may result in dampness, which facilitates trans-
mission of bacteria. Furthermore, the pooling of sub-
901
SKIN PREPARATION

stances such as povidone-iodine-containing com- TABLE 1. MEDICAL CENTERS SURVEYED BY

pounds can lead to skin irritation around pressure TELEPHONE CONCERNING PRACTICES
points and can loosen electrocardiographic monitor- FOR SKIN PREPARATION FOR SURGERY
ing leads and the grounding pads for electrical surgical Howard University Crawford W. Long
units. The scrub itself is vigorous and, in theory, could King-Drew Medical Center Hospital, Emory
cause dissemination of malignant cells if a tumor is Sloan-Kettering University
massaged, and release ofhormones from an endocrine Cancer Center Duke University Hospital
lesion such as a pheochromocytoma. Finally, some Mayo Clinic University of Arizona
regions are difficult to prepare adequately; for ex- Stanford University Hospital University of Michigan
Johns Hopkins University of Kansas
ample, circumferential scrubbing of the extremities Meharry Medical College Massachusetts General
is hard to do.7 Egleston Hospital, Emory Charity Hospital, New
The only point to be made about prophylactic an- University Orleans
timicrobials is this: Prophylaxis is not generally in- Jackson Memorial
dicated in clean operations unless the consequences Hospital
are severe or life-threatening, as in a prosthetic im-
plant or orthopedic or cardiovascular surgery.
It might be wise to remember that when looking were obtained from the operating room supervisor
at clean operations with wound infection rates of 3 or charge nurse. Some of the responses reflected the
percent or less, distinguishing a small difference be- notion that medicine contains many rituals and much
tween two antiseptic skin preparations requires a very dogma. The medical centers surveyed are listed in
large number of patients. Even if such small differ- Table 1.
ences turn out to be statistically significant, they are
likely to be clinically insignificant. The expense in-
volved in productive studies is unrealistic in relation RESULTS
to their value. Therefore, such studies are unlikely to The questions asked in the survey and the respon-
be done, or if they are done, are more unlikely to be dents' answers follow.
corroborated.8
Studies of the comparative efficiency of skin prep- 1. What agent do you use most in preparation of
aration materials measure the differences in the re- the skin for surgery? All used iodine or povidone-
duction of the concentration of the bacteria on the iodine.
skin. The assumption is that reduction in bacterial 2. Who determines the agent to be used? Hospi-
concentration is associated with a reduction in the tal-6; surgeons-6; nursing-2; combination-2.
risk of infection. That may be a broad assumption, 3. What drapes, if any, are used? Disposable-6;
but it does not seem totally wrong. various-8; loban- 1; Steri-drape- 1.
The use of polyester body drapes or visible, trans- 4. Do any surgeons use something other than what
parent drapes often impregnated with antiseptics such is commonly used? If so, what? Methylene blue, 70
as loban and Surgikos has been very reliable to date percent alcohol-1; Hiblicans-3; 2 percent iodine/
and results in low infection rates. Drapes were found alcohol- 1; Phisohex- 1.
to be equivalent in some studies to the most rigorous 5. Is it your procedure to shave or to clip for skin
efforts in skin preparation.9 They are being used in preparation? If so, when? Shave or clip: Neither-2;
more and more centers. The more recent ones seem shave-I1; clip-3. When: Preoperative- 12; hold-
to adhere better, and their use will probably increase. ing area- 1; operating room- 1.
Their use would certainly shorten preoperative time.
DISCUSSION
METHODS Of the 16 arbitrarily selected but geographically
What are the current common practices in the representative medical centers in this country, almost
United States in regard to surgical skin preparation? 70 percent still shave the skin as a component of sur-
To answer this question, a simple survey was done. gical skin preparation. This emphasizes the point
Sixteen major medical centers in the United States made previously about rituals and how embedded in
were randomly surveyed by telephone. Responses the consensus surgical psyche they can be.

902 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988

Although the use of iodine-containing compounds
was virtually universal, it is mildly disturbing to note
that in less than 40 percent of the institutions the
operating surgeons make decisions in this area that,
undoubtedly and undeniably, affect surgical out-
comes. Where is the surgical temperament that used
to challenge and resist any third-party forces or influ-
ences that did not coincide with the surgeon's judg-
ment of what was best for the patient? Perhaps this
noticeable absence is partially compensated by the
evidence that some measure of surgical independence,
creativity, and innovation was exhibited by seven in-
dividual surgeons who reportedly varied from the
prescribed hospital protocol. It is not the purpose of
this discussion to pursue or even raise such complex
issues. Indeed, the small size of this survey does not
purport to do more than symbolically view possible
trends in this minute but important component of
surgical practice.
Several agents were commonly used. Elemental io-
dine is a potent antiseptic with a broad spectrum of
antimicrobial activities. It tends to be chemically ac-
tive and is irritating to the skin. It is also inactivated
by blood and organic matter. lodophors are the result
of complexing iodine to a polymer.9 This process cre-
ates a water-soluble agent that slowly releases free io-
dine. The result is a less irritating form of iodine that
is more stable and does not tend to stain. Of that
group, Betadine is the most commonly used. A de-
tergent is added to produce a surgical scrub. These
agents are very effective and have been used exten-
sively. They are effective against a wide range of gram-
positive and gram-negative bacteria. Of the com-
monly used antiseptics for the skin, the iodophors are
said to be the most effective agents for eliminating
spores. However, spore destruction is achieved only
with moist contact for more than 15 minutes. The
iodophors are not without their problems. There have
been reports of irritation, stability may vary, and re-
sidual activity is not always maintained. Skin reac-
tions are not uncommon, and acidosis in the trial
and use of iodophors in burn patients has been re-
ported.
Chlorhexidine gluconate has been used extensively
in Europe since 1954. It has proved to be a very ef-
fective and safe antiseptic. It is used in this country
under the name of Hiblicans, which is 4 percent
chlorhexidine gluconate with 4 percent isopropyl al-
cohol in a sudsy base. Hibitane is a chlorhexidine
tincture, for use as a skin preparation. Chlorhexidine
is effective against a wide variety of gram-positive and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988
SKIN PREPARATION
gram-negative bacteria, molds, yeasts, and viruses. It
is sporacidal only at elevated temperatures. It acts
rapidly and immediately reduces bacterial flora of the
skin. One of the advantages of chlorhexidine is that
it tends to bind to protein in the stratum corneum of
the skin, leaving a persistent residue that, unlike Phi-
sohex, is not subject to removal with alcohol. It is
safe to use on the skin, and significant problems of
irritation, allergy, or photosensitivity have not been
reported. Chlorhexidine does not appear to be ab-
sorbed through the skin. This nonabsorptive property
is probably due to the protein-binding characteristic
mentioned earlier. There has been at least one re-
ported case of contamination in clinical use of a for-
mulation of chlorhexidine, which occurred in Japan,
where acromabacter xylozoxidans was cultured from
models of chlorhexidine on a surgical ward with an
outbreak of infection due to the same organism.
Chlorhexidine can be toxic to the middle ear if applied
directly, resulting in deafness. And the sudsy base of
Hibitane can irritate the eyes. Hibitane has been de-
scribed as an agent that combines the broad antibac-
terial spectrum of alcohol and iodine with the pro-
longed action of Phisohex, which is still being used
today, but not frequently.
Ethanol is an active agent against all common
pathogenic bacteria but not against dried pores. The
problem with alcohol is that the maximum effect is
not achieved through the usual clinical application.
Ethanol 70 percent can destroy 90 percent of the cu-
taneous bacteria in two minutes if moisture is main-
tained during the entire two minutes. However, the
usual single wipe with ethanol results in at least 75
percent cutaneous bacterial reduction. Alcohols are
organic solvents and they remove a fair amount of
oil and debris. They are probably not much more
effective than ordinary soap and water but are more
convenient for procedures such as simple needle
punctures. Alcohols are not adequate if used alone
for surgical preparation according to some, but they
can increase the effectiveness of other antiseptics when
added to them as a tincture.'0
CONCLUSIONS
The list below briefly summarizes and highlights
the steps that should be taken regarding skin prepa-
ration-or protection-in the surgical patient prior
to invading or violating the skin with an incision.
1. For elective surgery, all known extraoperative
bacterial infections should be controlled or at least
treated. Total body baths with Hiblicans are indicated.
903
SKIN PREPARATION
2. Hospital stays should be short, especially pre-
operative stays.
3. Do not remove hair unless so thick it will in-
terfere with the procedure. If necessary, clip.
4. Wash the operative site with total Hiblicans
body bath before surgery. Apply antiseptic of choice.
When possible cover the rest of patient with sterile
nonabsorbent drapes.
5. Minimize the number and movements of op-
erating room personnel.
6. Operating room should have proper ventilation,
20 air changes per hour. Suite should be under pos-
itive pressure relative to surrounding area.
7. Surgery should be expeditious. Use as few su-
tures as needed. Staple closure when possible. Do not
leave dressing on longer than 24 hours.
8. Do not close skin over "dirty wounds."
9. Drain by stab wound, not through incision.
10. Do not use prophylaxis for clean wounds un-
less infections occur that can be severe or life-threat-
ening, such as cardiovascular or orthopedic proce-
dures using implant devices.
11. Do not allow patients to be unnecessarily ex-
posed to personnel, other patients with transmissible
wound or skin infections, or conditions that increase
risk of sepsis. Do not use tacky mats. Shoe covers are
not necessary.
12. All surgical cases should be classified, and sur-
geons should be periodically notified of their case-
specific rates. Any undue increase should be seriously
investigated epidemiologically. It is not necessary to
follow for infections after discharge from hospital.
13. The surgeon should assume control of oper-
ating room procedures, discipline, and protocol that
may affect or increase the risk of sepsis for the patient.
14. In true emergency situations, distinguished
904 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988
from urgent ones, all of the above can be waived.
Thoracotomy for cardiac massage, for example, in
unprepared skin does not necessarily result in wound
infection.
Finally, consider an interesting socioeconomic po-
litical thought. The 1985 guidelines published by the
Centers for Disease Control for prevention of wound
infections did not recommend by name any antiseptic
agent-the 1981 guidelines did. Does this demon-
strate, perhaps, any clout or pressure by commercial
interests to delete these recommendations?
Literature Cited
1. Mango G. The Healing Hand: Man and Wound in the An-
cient World. Cambridge, Mass: Harvard University Press, 1975,
pp 63-1 88.
2. Craig C. Preparation of the skin for surgery: Today's OR.
Nurse 1986; 8:17-20.
3. Garner J. CDC Guidelines for the Prevention and Control
of Nosocomial Wound Infections, revised. Atlanta: Centers for
Disease Control, 1985, p 74.
4. Harris A, Levin S. Where we've been, where we are, and
what we can expect in the future, editorial. J Nosocom Infect
1987; 4:2-3.
5. Brandberg A. Preoperative Preparation Before Arrival in
Theatre in Optimizing the Topical Approach. Oxford: Medical Ed-
ucation Services, 1985, pp 8-10.
6. Zdeblick T, Lederman M, Jacobs M, et al. Preoperative
Use of Povidone-lodine, a Prospective Randomized Study. Clinical
Orthopedics and Related Research No. 213, December 1986,
pp 211-215.
7. Geelhoed G, Sharpe K, Simon G. A comparative study of
survival skin preparation methods. Surg Gynecol Obstet 1983;
157:265-268.
8. Condon R. Development of a safe and effective one-minute
preoperative skin preparation. Arch Surg 1986; 121:616.
9. Fairclough J, Johnson D, Mackie I. The prevention of
wound contamination by skin organisms by the preoperative ap-
plication of an iodophor impregnated plastic adhesive drape. J
Int Med Res 1986; 14:105-109.
10. Seben J. Surgical antiseptics. J Am Acta Dermatol 1983;
9:759-765.