|Year : 2020 | Volume
| Issue : 9 | Page : 1318-1323
Does preoperative chemical depilation make any difference in postoperative wound infection?
CC Okoli1, SN Anyanwu1, CD Emegoakor1, GU Chianakwana1, E Ihekwoaba1, MD Ughasoro2, OA Egwuonwu1, H Nzeako1
1 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
2 Department of Pediatrics, University of Nigeria Enugu Campus, Enugu, Nigeria
|Date of Submission||31-Mar-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||10-Sep-2020|
Dr. C C Okoli
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Preparation for surgery has traditionally included the removal of body hair from the intended surgical wound site. The effect of this practice on postoperative wound infection is yet to be fully elucidated.Aims: This study sought to determine if preoperative chemical depilation reduces the risk of surgical site infection (SSI). Methodology: Two methods of preoperative hair removal: razor shaving and depilatory cream were compared. The eligible patients were randomized into two groups and the presence of postoperative wound infection was evaluated using the Southampton wound grading system. Data were analyzed using SPSS version 21 Chicago-Illinois, statistical significance was inferred at Pvalue ≤ 0.05. Results: In total 100 patients were analyzed with 20 patients excluded due to co-morbidities and noncompletion of the study. The overall prevalence of SSI was 18.0% (7 (14.0%) and 11 (22.0%) in the depilatory cream and razor shaving groups, respectively). The difference in the rate of SSI was not statistically significant (P = 0.436). Hair was completely removed in 47 (94.0%) compared to 38 (76.0%) patients in the razor shaving group (P = 0.012) while skin injuries were noted in 21 (42.0%) vs 1 (2.0%) patients who had razor shaving and chemical depilation(P = <0.0001), respectively. Conclusion: There was no significant difference in SSI rates in patients that had preoperative chemical depilation when compared with razor shaving.
Keywords: Depilatory cream, razor shaving, surgical site infection
|How to cite this article:|
Okoli C C, Anyanwu S N, Emegoakor C D, Chianakwana G U, Ihekwoaba E, Ughasoro M D, Egwuonwu O A, Nzeako H. Does preoperative chemical depilation make any difference in postoperative wound infection?. Niger J Clin Pract 2020;23:1318-23
|How to cite this URL:|
Okoli C C, Anyanwu S N, Emegoakor C D, Chianakwana G U, Ihekwoaba E, Ughasoro M D, Egwuonwu O A, Nzeako H. Does preoperative chemical depilation make any difference in postoperative wound infection?. Niger J Clin Pract [serial online] 2020 [cited 2020 Sep 24];23:1318-23. Available from: http://www.njcponline.com/text.asp?2020/23/9/1318/294674
| Introduction|| |
Operative procedures in low and middle-income countries (LMIC) have many challenges different from those encountered in western countries. Despite accounting for ~ 26% of global surgical procedures, they are responsible for the greater proportion of the world's burden of adverse surgical outcomes with most of these surgical needs recorded in rural and marginalized populations. Despite being faced by several challenges including severely constrained costs of operations, low numbers of trained theatre staff, absence of essential equipment, as well as relying on rudimentary facilities, high rate of surgical site infection (SSI) remains a major challenge for the surgeons in these countries. To put this into context, the reported prevalence of SSI in clean surgical operations developed countries was less than 4.0%, compared with 5.4–25.0%,,,, reported in low and middle-income countries. In western clime, hospitals have well-established protocols and guidelines to prevent SSIs, while hospitals in LMIC either lack these measures or they are poorly implemented. Some of these measures such as the use of prophylactic antibiotics, use of incised drapes, proper theatre and ward designs despite their proven benefits are usually associated with an initial increased cost of patient care particularly in the absence of adequate health insurancees.
Unsurprisingly, many researchers are exploring the effectiveness of other low-cost preoperative measures that can effectively reduce the rate of SSIs. Some of these suggested measures including different methods of preoperative nasal decolonisation, antiseptic skin preparation, and pre-operative hair removals have been evaluated with mixed outcomes. It has been our practice to routinely remove hairs in hair-bearing areas by razor shaving. Though most guidelines have recommended against the use of razor shaving as part of preoperative skin preparation because of the reported increased risk of SSIs., These guidelines by the National Institute for Health and Care Excellence (NICE) and the United States Center for Disease Control (CDC) strongly recommend that hair removal when needed should be done using electric clippers with a single-use head on the day of surgery rather than razors., Besides cost, the critics of clipping argue that effectiveness of clipping depends on the optimal skill of application and may result in raking of the skin, causing damage which can serve as a portal of entry for infection. They also suggest that surgical clipping clean -up may have significant logistic concerns for operating room efficiency. Patient preparation and instrument table must be delayed until the hair clean-up is completed. Although the use of a vacuum-assisted hair collection device may help to minimize particle dispersion and reduce clean-up time, it is not widely available in our setting. On the other hand, preoperative chemical depilation relies less on skill and particle dispersion is less likely. Two studies in India and Nigeria showed promising results of preoperative chemical depilation with the authors reporting a significant reduction in SSI when compared with razor shaving.
With this in mind, the authors aimed to determine if preoperative chemical depilation makes a significant reduction in the SSI rate in our centre when compared with razor shaving with the mind of policy change on the choice of preoperative hair removal in hair-bearing areas of the body.
| Materials and Method|| |
Study design and Setting: This was an 18-month hospital-based prospective study carried out at a tertiary hospital in Nigeria from August 2015 to January 2017.
The expected total number of patients required in the study was 100. The sample size was calculated using the statistical formula shown below.
nf= n/(1 + n/N)
Where nf = the desired sample size when the study population is less than 10,000.
n = the desired sample size when the population is more than 10,000.
N = the estimate of population size which is 120 on the average (number ofoperated clean surgical wounds)
Subject Selection: All the consecutive patients planned for clean operations requiring access through hair-bearing areas of the body who met the inclusion criteria were randomly assigned to two groups (depilatory cream and razor groups). The first patient was selected by simple balloting method by picking from a sealed envelope containing two folded papers containing the two methods of preoperative hair removal. The next patient was automatically assigned to the alternate group.
Exclusion Criteria: The following subjects were excluded, subjects who had emergency operations, declined consent, clean-contaminated, contaminated or dirty surgical wounds, the presence of significant comorbidities such as jaundice, immunosuppressive disease, diabetes mellitus and noncompletion of the study.
Ethical Consideration: The Research and Ethical Committee of Nnamdi Azikiwe University Teaching Hospital approved the study (NAUTH/CS/66/VOL6/127). Written informed consent was obtained from all the subjects who were recruited into the study.
Methodology: Patients in the depilatory cream group had hair removed using Veet cream (Reckitt Benckiser Dublin UK, Batch No 8037870; active ingredient is potassium thioglycolate), while the patients in the razor shaving had their hair removed with a razor blade (Tiger brand).
During the out-patient clinic, a small discrete area in the same region of the body for the incision was tested with the depilatory cream by applying the cream on it. All the patients were asked to report any form of rash, erythema and itching.
Preoperative care: On the day of surgery, for the depilatory cream group, the cream was then applied thickly and evenly over the area to be treated and left undisturbed for 6 min based on the instruction in the manual. For scalp hair, the cream was left in-situ for 12 minutes. After the appropriate time had elapsed, a small portion of the cream was removed to test the effectiveness of the treatment, and if the hair came off easily, the remaining cream was scraped off using a dry gauze. For the patients in the razor shaving group, the site for the incision was first made wet and then gently shaved with a razor blade. Both hair removals were done on the day of the surgery in the preoperative room before induction of anaesthesia by a dedicated research assistant. The durations for both procedures were recorded.
Before the making of skin incision, the operating surgeons (2 senior registrars selected for the study) would assess the site of incision for the adequacy of hair removal, the presence of macroscopic bleeding skin injuries, erythema, and rash. The operating surgeons were blinded to the technique of depilation.
Adequacy of hair removal was classified using the four-point Likert scale (Excellent, good, fair, and poor), based on the presence of remnant hair.
“Excellent” hair removal was defined as the absence of visible hair at the region of incision and dressing application.
“Good” was defined as the presence of minimal hair without interference with either incision or dressing application.
“Fair” refers to the presence of hair with interference with incision but not dressing application.
“Poor” refers to “the presence of hair that interfered with incision or dressing application.” Further hair removal was not carried out irrespective of the Likert grade.
The presence of skin injuries: Those patients who had severe erythema, bleeding cuts or obvious macroscopic skin cuts were said to have skin injuries.
The findings were recorded on a prestructured Pro-forma and kept in a sealed envelope bearing only the patient's hospital number.
Postoperative care: Wounds were directly inspected by the investigator on the third, fifth, and seventh days. All patients were followed-up for 30 days. Patients who did not complete the 30-day follow up were excluded in the final analysis. The Southampton Wound Infection Scoring System was employed for grading infections when present. Grade I wound infection was taken as the presence of undue wound redness and swelling, Grade II as the discharge of serous or haemoserous fluids from the surgical wound, Grade III as the discharge of pus from the wound, and Grade IV as the discharge of pus and wound dehiscence.
Data Processing and Analysis: Statistical analysis was done using statistical package for social sciences (SPSS) version 21 Chicago Illinois. Results of categorical data obtained were represented in tables, while the mean ± standard deviation was used for continuous data. The relationships between different categorical variables were determined using Chi-square tests or Fisher's Exact tests were appropriate. Statistical significance was inferred at a P value of ≤ 0.05.
| Results|| |
[Figure 1] shows the flow charts of the 120 patients who had clean surgeries involving hair-bearing areas and were assessed for eligibility during the study period, 11 patients were excluded because of the presence of comorbidities and failure to give consent, while 9 (7.5%) did not complete the study. A total 40% of the subjects in the razor shaving and chemical depilation groups belonged to the 31–40 age category as depicted in [Figure 2]. The average age of the patients in the razor shaving group was 44.5 ± 15.96 years, which is similar to the mean age of patients in the depilatory cream group (39.44 ± 13.26 years). The difference in the mean age was found not to be statistically significant (P = 0.764). The median age in razor shaving and depilatory cream groups was 42 years and 37 years, respectively. There were more females than males recruited in the study. Females constituted 55 (55.0%) of the participants, while males comprised of 45 (45.0%) participants thereby giving a Male: Female ratio of 1:1.2. However, there was an equal number of males and females in the depilatory cream group (ratio of 1:1) unlike in the razor shaving group which had more females (1:1.5). The part of the body operated on included the abdomen, groin, scalp, and axilla. Most of the patients were discharged the following day and they were all followed up for 30 days at the outpatient clinic after discharge. The duration of in-patient stay was longer in patients who had intra-abdominal surgeries (7.14 ± 2.8 days) including splenectomy, but less for patients who had herniorrhaphy, excision biopsy of skin lesions and axillary dissection following mastectomy. (4.0 ± 1.8 days), as shown in [Figure 3].
None of the patients reacted adversely to the Veet cream after the initial sensitisation done for them. In total 85 patients had preoperative hair removal that was assessed to be adequate. Satisfactory hair removal was more likely after use of depilatory cream (94.0%) than after preoperative hair removal by razor shaving (76.0%). The difference in the proportion was statistically significant (P = 0.012). Chemical depilation was found to be very effective for removal of axillary, truncal and extremity hairs, but ineffective when used on scalp hair, while razor shaving of groin hair was mostly inadequate. (see [Table 1] for details). Shaving was better for removal of scalp hair. Chemical depilation caused less macroscopic skin injuries when compared with preoperative razor shaving. Razor shaving caused macroscopic skin injuries in 42.0% of the patients, only 1 patient who underwent chemical depilation developed erythema when the cream came in contact with the scrotal skin during removal of groin hair. The difference was found to be statistically significant (P = 0.001). There was no incidence of macroscopic skin injury after chemical depilation. None of the patients complained of itching and discomfort postdepilation with either cream or razor shaving [Table 1]. The prevalence of surgical site infection in this study was 18.0%. All the infections were detected within the first 7 postoperative days. There was no case of delayed onset wound infection. All the infections were treated by daily wound dressing. Only 1 patient required secondary wound closure because of complete wound breakdown. Of the 50 patients who underwent chemical depilation, 6 patients developed superficial surgical site infection (grade 13). while out of the 50 patients that underwent preoperative razor shaving, 11 developed grade 13 superficial surgical site infection [Figure 4]. The difference in the rate of infection was not statistically significant (P = 0.436). Only one of the patients that developed surgical site infection in the depilatory cream group had wound dehiscence.
| Discussion|| |
SSIs are complications of surgery that can cause significant postoperative morbidity and mortality. They are costly to health services while being inconvenient, painful and potentially fatal to affected patients. The present study failed to show any statistically significant difference in the prevalence of surgical site infection between the two methods of preoperative hair removal, although, more SSIs were recorded in the group of patients who were in the razor shaving group. Previous studies that compared razor shaving and depilation cream for preoperative Skin preparation reported varying results. While Suvera et al. reported no difference between the two methods, Adisa et al., Tanner et al., and Lefebvre et al. stated that razor shaving independently increased the risk of SSI. Some authors have even reported that razor shaving to be very effective and superior to clipping in scrotal surgeries. From these contradicting reports, it may be suggested that the benefit of a choice of preoperative hair removal on the reduction of SSI may be absent or minimal when compared to other validated risk reduction strategies stated in the literature. We believe that development of SSI is a complex process which is dependent on several factors relating to patients, and surgical environment and that in centres with a high burden of SSIs like ours, the true benefits of different methods of preoperative hair removal on SSI will be difficult to demonstrate. Factors like poor theatre and ward designs, use of fake and/or unstandardised method of dilution of anti-septics used for skin preparation, poor sterilising techniques of biomedical materials, and lack of effective hospital infection control unit etc., which are yet to be eradicated from our practice may mask the benefits of different methods of preoperative hair removal. A prospective study to investigate the factors responsible for high infection rates of clean surgeries may help to throw more light in this current situation.
It is pertinent to state that the prevalence of postoperative wound infection in our study was comparable with other reports from our region which ranged from 5.4 to 25.0%,,,, Factors contributing to the high prevalence of SSI in our study could not be explained since it was outside the scope of the index study. Most of the surgical site infections were detected post-discharge. This agrees with other reports in literature because of the nature of the procedures performed in this study. In the index study, majority of the patients were discharged either same day or next day following the surgery, hence most of the SSIs were detected during the surgical out-patient follow-up visits.
There was no case of allergic reaction in the index study in patients depilatory cream group. Skin injuries inflicted by chemical depilation usually appears in form erythema particularly in patients that reacted adversely to it. However, a patient developed redness in the scrotal skin when the scrotal skin inadvertently came in contact with the depilatory cream during shaving of groin hairs for a hernia. This concurs with text in usage manual, which advised the cream should not be used in such sensitive areas. With regards to the patient, the depilatory cream was subsequently washed off with water. The erythema cleared with no further treatment. Allergic reactions are said to be one of the major shortcomings of the use of depilatory creams. In allergic individuals, they are capable of extensive skin reactions characterized by erythema and itching. These reactions are more frequent when the creams allowed to stay beyond the recommended period. Preoperative chemical depilation was found to be more effective in hair removal. A finding supported by other studies in the literature., Although, the benefit of this in the risk reduction of surgical site infection could not be seen in the study.
In conclusion, the use of depilatory cream for preoperative hair removal did not have any significant reduction in the risks of SSIs in our study.
Implications for further research
This study gave an insight into the possible struggles of third world surgical practice residents. Future studies should be aimed to investigate the deficiencies in existing policies and surveillance of causes and prevention of SSIs in our centre. Our study is mainly limited by the collection of data from one centre. However, it is our thoughts that surgical practice in developing countries closely mirrors each other in terms of the distribution of their health services and infrastructure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]