Should we re-evaluate the need for preoperative surgical site hair removal?

Surgical procedures are carried out routinely in outpatient dermatology. Preparation of the surgical site is important to reduce risk of surgical site infections (SSIs). Traditionally, routine removal of body hair has been carried out as its presence is thought to interfere with the exposure and identification of incision site, suturing and application of adhesive drapes and dressings. Types of hair removal include clippers which cut hair without skin contact, razors which involve a blade drawn in contact with skin and depilatory creams which are applied onto skin. The use of depilatory creams can be time-consuming and can cause potential allergic reactions to individuals with sensitive skin. Orsi et al. (Orsi GB, Ferraro F, Franchi C. Preoperative hair removal review. Ann Ig 2005; 17: 401-12) in a systematic literature review suggest preoperative shaving with a razor is associated with a significantly higher SSIs and hair removal should be carried out either by a clipper or depilatory cream. Shaving causes small skin abrasions that after delay can then become infected by multiplying microorganism and so should ideally be performed immediately before surgery, rather than in advance, reducing risk of SSIs. A Cochrane review by Tanner et al. (Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011;(11):CD004122) investigated preoperative hair removal to reduce SSIs. A total of 14 trials (n = 3838) were identified where a comparison of shaving (of either body or scalp hair) vs. no hair removal found no significant difference in rates of surgical site infection between groups. However, there are limitations as none of the trials used standardized definitions of SSIs and of note, only 2 of the 14 trials were published within the last 20 years. SSIs may prolong the length of wound healing and subsequently increase cost of care. To our knowledge, although several preoperative measures are used to reduce the number of infection complications following surgery, the scientific basis for some of these measures has not always been present. We felt more clinical trials need to be carried out to identify if there is any necessity for preoperative hair removal. As suggested in National Institute for Health and Care Excellence (NICE) surgical site infection guidelines (2013), hair removal prior to surgery should only be carried out if necessary and using electric clippers with a single-use head done on the day of surgery.