modified in Italic bold type) One Together(2019) Surgical Skin Preparation - Quality improvement tool, Available in the resources section at: Thankfully, there are good products in all price categories – spending less won’t necessarily harm your skin, while spending won’t necessarily help it. It’s more about the formulations and investing your time so that you can choose the right products for your skin. The secret is knowing which products are worth the spend – in most cases, if you’re going to splurge on anything, your best bet is your treatment serum, where the formulations are more sophisticated and therefore worthy of the higher price point. Key steps for a morning skincare routine: 1. Cleanser ChloraPrep® with Tint 2% Chlorhexidine gluconate /70% alcohol should only be used in children over 44 weeks gestational age for skin prepping appropriate areas ( see appendix 2) Fleischer W, Reimer K. Povidone-iodine in antisepsis-state of the art. Dermatology 1997; 195(Suppl 2):3-9.

Bacterial log reduction after saline challenge. *P < .003 for soak condition. Reproduced with permission from Stahl JB et al. 9 Actives will break down dead skin cells and encourage new cells to surface,” says Renée. “It makes sense to wear these at night when your skin is out of the sun and while your skin is naturally regenerating. Apply skin antiseptic following IFUs and using sterile technique. Remember that strict adherence to sterile technique applies to preoperative skin antisepsis, says Ms. deKay, adding that employing single-use antiseptic dosing and drip towels before prepping and removing them after prepping is paramount. “More solution is not necessarily better, so use only what each antiseptic applicator identifies as the area it will cover,” she says. “Although, if a skin surface area is larger than indicated by the products, another applicator may be necessary.” Sodium hypochlorite was the first antiseptic used to prevent infection, as demonstrated in the 19th century by the pioneering work of Ignaz Semmelweis, who used it to disinfect hands, lowering the incidence and mortality of puerperal fever [32]. In the 20th century, 0.5% sodium hypochlorite (Dakin’s solution) was used to treat traumatic injuries during the First World War [11]. Subsequently, it became widely used, yet its medical use as an antiseptic has been limited due to its instability, which necessitated the addition of large quantities of stabilisers [32]. In addition, Eusol (an acronym for Edinburgh university solution of lime) was one of several hypochlorite solutions that was used in the management of open wounds left to heal by secondary intention [33]. Eusol consisted of a chlorinated lime (calcium hypochlorite) and boric acid solution containing between 0.25% weight / volume of available chlorine with a pH between 7.5 and 8.5 [33]. Dakin’s solution has a higher pH and is based on sodium hypochlorite but contains no boric acid [33]. “It is likely that the exponential rise in the number of procedures performed in the aesthetic sector will continue to rise, which will continually reinforce the importance of ‘getting the basics right’ in terms of good skin practice.”At the time of publication (April 2019), 10% povidone-iodine alcoholic solution (Videne alcoholic tincture) was licensed for 'topical application'. 10% povidone-iodine (Betadine Alcoholic solution) was licensed for 'antiseptic skin cleanser for major and minor surgical procedures'. Other formulations of povidone-iodine alcoholic solution were off label for this use. See NICE's information on prescribing medicines. The Royal College of Surgeons and the MHRA recommends the use of licensed medicines to prepare the skin prior to surgery. The MHRA has issued the following clarification, which the College fully endorses:

Iodine based formulations are highly effective for surgical procedures owing to their broad antimicrobial properties, yet the residual, and temporary discolouration of skin following application may be challenging in terms of practicality for practitioners administering aesthetic injectable treatments. Chlorine based and Hypochlorous solutions Place cotton wool ball in the external ear canal prior to skin prep. Start with external ear then extend to edge of hairline, cheek and jaw. Remove cotton wool ball if operating through the canal and document Cunarro Alonso JM, et al. Paper presented at: XIII National Symposium on Pressure Ulcers and Wounds Heritage; 2010; Spain.The antiseptic used should have a broad spectrum of activity. The antiseptic solution is applied with a painting motion along with a gentle rubbing action to aid mechanical removal of microbes, chemical killing action with persistent biocidal properties which inhibit new growth of microorganisms on the skin. Friction has been shown to increase the antibacterial effect of an antiseptic (WHO 2009). Assessment of the state of the skin must be made and a clinical judgement made of the degree of friction possible to avoid damage. Skin preparation solutions must be allowed to dry before the drapes are fixed in place and an incision is made, which will allow sufficient time for the antiseptic to destroy the microorganisms on the skin. Start at umbilicus then discard this applicator/swab/sponge - work out in concentric circles. Cover up to nipple line and down to upper thighs and down abdominal sides dependent on procedure

Do not use Chlorhexidine gluconate or alcohol skin prep near or on/in the eyes – it may cause corneal damage Leeds Medicines Advisory Service, St James' University Hospital, Leeds Teaching Hospitals NHS Trust There was no evidence on the use of skin antiseptics in babies. However, the committee were aware of risks, such as burns, associated with their use in this population, and wished to highlight this. The committee noted that the MHRA has published advice on the use of chlorhexidine for skin disinfection in premature babies. In contrast, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a warning in 2012 for the use of chlorhexidine in light of a risk of anaphylactic reaction due to chlorhexidine allergy [18]. A subsequent warning was published in 2017 by the US FDA reiterating a similar concern, reporting 52 cases of worldwide anaphylaxis due to chlorhexidine gluconate [19]. In addition, in the 46 years between January 1969 and June 2015, the FDA reports 43 cases worldwide. These statistics reinforce the need for a comprehensive medical consultation, which includes details regarding known sensitivities and allergies. Isopropyl alcoholOnce an antiseptic product is implemented, she suggests creating an audit tool with key elements of performance and to develop a plan to train auditors, complete audits and report findings.

The manufacture and supply of a medicinal product containing chlorhexidine should be in accordance with Human Medicines Regulations. The product should have a marketing authorisation and there are restrictions on how it may be used. Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin asepsis. J Antimicrob Chemother 2014; 69:2017-21. Riccio LN, Swenson BR, Sawyer RG. The importance of isopropyl alcohol in skin preparation solutions. Infecti Control Hospi Epidemiol 2011; 32(4):405-6. The committee also took into consideration the potential side effects of mupirocin (such as a burning sensation and local reactions) and the cautions identified for the use of chlorhexidine solution in people with existing skin conditions and in preterm newborn babies. The committee noted that the Medicines and Healthcare products Regulatory Agency (MHRA) has published MHRA advice on the use of chlorhexidine for skin disinfection in premature babies. There are times when patient dignity may require hair to be removed in the OR, such as for OB/GYN or urology procedures,” adds Mr. Graves. In these situations, he reminds staff that vacuum-assisted clippers should be used to suction hair upon removal to prevent infection risk in the OR.Some standardisation of approach is helpful. Whilst using to the original expiry date isn't supported by the manufacturer's information, storage for up to 6 months at elevated temperatures would be supportable. The first step in your skincare routine is also arguably the most important – after all, it doesn’t matter how frequently you apply your various serums and moisturisers, they can’t do their job if you’re applying them to clogged pores and dead skin cells. Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: An evidence based review (2016) (Accessed March 2022) This is the first RCT to specifically examine the effect of alcohol swab skin cleansing on the incidence of local skin reactions and infection in children undergoing vaccine injections. We found no evidence of a difference in the rate of local skin reactions and no cases of cellulitis or infectious abscess when alcohol swabs were and were not used” (pp997) No matter which skin prep product you choose, Mr. Graves stresses the importance of standardizing it for the majority of surgeries when not contraindicated to support correct use. “Reducing variability with products and having the antiseptic vendor come in to do staff in-services on the proper application per manufacturer instructions for use is important to help team members follow specific requirements for actions such as drying time,” he says.