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Review: evidence from ⩽2 low quality studies suggests no difference in surgical site infection with or without preoperative hair removal; depilatory cream and clipping are better than shaving
  1. Margaret Heaton, RN, MA
  1. University of Huddersfield
 Huddersfield, UK

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 Q Does preoperative hair removal result in fewer surgical site infections (SSIs) than not removing hair? What is the relative effectiveness of different methods of hair removal?

    METHODS

    Embedded ImageData sources:

    Cochrane Wounds Group Specialised Register (to October 2005), Cochrane Library (Issue 3, 2005), Medline (1966–2005), EMBASE/Excerpta Medica (1980–2005), CINAHL (1982–2005), and ZETOC database of conference proceedings (1993–2005); bibliographies of relevant studies; and manufacturers of hair removal products.

    Embedded ImageStudy selection and assessment:

    randomised controlled trials (RCTs) of adults having surgery in a designated operating theatre that compared hair removal by any method (shaving, clipping, or depilatory cream) with no hair removal or with another hair removal method; hair removal at different times before surgery; or hair removal in different settings (eg, operating room, anaesthetic room, ward, or home). Quality assessment of individual studies was based on randomisation method, allocation concealment, blinding, withdrawals and drop out rates, clear inclusion and exclusion criteria, and duration of follow up. 11 RCTs (n = 4486) met the selection criteria; none had high quality.

    Embedded ImageOutcome:

    primary outcome was postoperative SSI (superficial incisional, deep incisional, or organ/space infections identified using both clinical and laboratory findings).

    MAIN RESULTS

    Meta-analysis of 2 trials showed no difference between shaving and no hair removal for SSIs (table); 1 trial of abdominal surgery found no difference between depilatory cream and no hair removal (n = 267, 7.9% v 7.8%). Meta-analyses showed that shaving increased SSIs compared with clipping or depilatory cream (table). A single study found no difference between shaving on the day of surgery and 1 day before surgery (n = 520, 10% v 8.8% at 30 d after surgery) or clipping on the day of surgery and 1 day before surgery (n = 457, 3.2% v 7.5% at 30 d after surgery).

    CONCLUSIONS

    Evidence from ⩽2 low quality studies suggests that preoperative hair removal by shaving or depilatory cream does not differ from no hair removal for surgical site infections (SSIs). Hair removal using depilatory cream or clipping was associated with fewer SSIs than shaving with a razor. A single study showed no difference for hair removal on the day of surgery or removal 1 day before surgery.

    Commentary

    SSIs burden patients with undesirable morbidity, lengthen hospital stays, and increase treatment costs. SSIs are the result of intrinsic and extrinsic factors. Modification of intrinsic factors and some extrinsic factors may be difficult, but hair removal is an extrinsic factor that can easily be modified.

    The review by Tanner et al offers 3 clear messages that will encourage modification. Firstly, leaving body hair intact is unlikely to increase SSI rates. Secondly, shaving patients’ body hair increases SSI rates more than either clipping or using a depilatory cream. Thirdly, the timing of hair removal, whether immediately before a procedure or a day before surgery, does not influence SSI rates.

    The findings of this review have important implications for infection control and can inform both policy and individual decision making in both elective and acute surgery. Institutional policy should guide practitioners to leave hair intact. Uncertainty about the quality of some of the included studies will no doubt lead some practitioners to question policy based on the comparison of hair removal and no removal. As a consequence, there is a possible role for further research comparing hair removal with no removal. Additionally, some may point out that the studies in this review primarily involved patients having abdominal surgery, which may be viewed as a “dirtier” surgical site than forearms or lower limbs. Such thinking raises the issue of generalisability, but the real issue is one of particularising the evidence to individuals, not generalisation. Practitioners should ask why the evidence should not be applied, rather than why it should be applied. Policies can create room for such questioning by promoting the use of clipping or depilatory cream when individual practitioners believe it is appropriate. Shaving, whether wet or dry, should always be avoided.

    Preoperative hair removal v no hair removal or comparison of different methods of hair removal for surgical site infection*

    
 
 Q Does preoperative hair removal result in fewer surgical site infections (SSIs) than not removing hair? What is the relative effectiveness of different methods of hair removal?

    View Abstract

    Footnotes

    • For correspondence: Dr J Tanner, Derby City General Hospital, Derby, UK. judith.tanner{at}derbyhospitals.nhs.uk

    • Sources of funding: Theatre Nurses’ Trust Fund UK and Association for Perioperative Practice UK.

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