A Scientific Basis for Selecting Hair Removal Techniques

Richard F. Edlich M.D., PhD
Distinguished Professor of Plastic Surgery and Professor of Biomedical Engineering
University of Virginia School of Medicine

Elise M. Jackson, B.S.
Research Project Coordinator
University of Virginia School of Medicine

Jarrett Arnette B.S.
Urologic Research Project Coordinator
University of Virginia School of Medicine

The origin of the practice of removing hair from the operative site has not been clearly documented. Stephen Smith’s (1823-1922) account of the surgical practice at Bellevue Hospital, New York City in the 1850’s dates it as at least pre-Listerian1: “The patient was often put on the (operating table) unbathed and grimy with dirt; superfluous hair was sometimes shaved off.” Consequently, if only for aesthetic reasons, it seemed then that wounds might heal more kindly if hair was removed. Preoperative hair removal has been an established practice since the beginning of the 20th century.2 Since the days of Lister and Semmelweis, skin hair was believed to be a source of contamination.More recent scientific studies have confirmed their suspicions.3-5 In 1965, Summers, Lunch, and Block3 found that 20% of the hair carriers of pathogenic bacteria were not nasal carriers. They also noted that approximately 50% of medical staff and 60% of inpatients carried pathogenic bacteria in their hair, of which Staphylococcus aureus was by far the most common. However, Eschericia coli, Streptococcus veridans, Proteus vulgaris, Pseudomonis, and even beta-hemolytic streptococci were identified.Most of the S. aureus from the hospital staff was penicillin and streptomycin resistant. The patients who were hair carriers of pathogenic bacteria had wound infections more commonly than non-carriers. Consequently, these investigators suggested that organisms in the hair may be more virulent than organisms isolated from the nose and that they were inclined to be resistant to antibiotics.One year later, Noble4 found that hair carriage was more common in people with hospital contacts than those who had no such hospital contacts.

In 1973, Dineen and Drusin5 attributed two outbreaks of postoperative wound infections to hospital staff members carrying Staphylococcus aureus in their hair.One doctor was identified as a carrier of pathogens that elicited 11 severe wound infections on a general surgical ward.In addition, a staff nurse on the renal-transplant ward was found to be the carrier for pathogens that produced five minor wound infections. During epidemics of wound infections, these investigators concluded that it is important to take cultures routinely from hair and subungual spaces in addition to nose and throat.Moreover, these investigators emphasized that it is also important to reduce the amount of shedding from the scalp hair in the operating room, and this is best achieved by covering the hair (preferably with a hood) so that the hair and scalp are not exposed during the operative procedure.

Removal of hair also facilitates operative surgery by preventing hair from becoming entangled in sutures and the wound during closure.6-7 Finally, if strands of hair become incarcerated in the dermis of the skin, foreign body reactions and granulomas may be encountered.Consequently, the practice of hair removal has been adopted as standard preoperative care.

It is the purpose of this manual to provide a scientific basis for the selection of hair removal techniques.

TECHNICAL CONSIDERATIONS OF HAIR REMOVAL

Technologic advances in medicine have allowed hair removal to be achieved by a variety of means, which include razor, depilatories, and electric clippers. Scientific investigations have demonstrated that these hair removal techniques have considerable influence on the incidence of surgical infection.In addition, manufacturers have made numerous technologic advances that have allowed hair removal without cross contamination.

Razor Shaving

Razor shaving, on either wet or dry skin, remains the most common method of preoperative hair removal.8Numerous studies have demonstrated that razor shaving is associated with a decrease in skin integrity due to nicks and cuts that occur on the skin surface.These gross and microscopic razor injuries liberate resident dermal bacteria into the operative field and make the skin environment more favorable to bacterial proliferation.9 The most important determinant of razor performance is the amount of exposure of the razor blade with respect to the razor head.The exposure of the surgical prep razor blade is so great that the infundibulum of the hair follicle is transected, so that the wounded hair follicles provide access and substrate for bacteria.In addition, the impermeable corneal layer is damaged and the exudate provides a moist field for bacterial proliferation.Inoculation of shaved skin results in dermatitis. In contrast, skin shaved with a recessed blade is refractory to bacterial contamination.7

Razor preparation of irregular or bony areas, such as the extremities, frequently results in inadequate hair removal or injury.10Additionally, shaving results in a firm, chisel-edged tip of hair as hair regrowth occurs. This sharply pointed hair shaft contrasts with the softly pointed hair tip found after depilatory hair removal. Consequently, over half of patients complain of discomfort, prickling, and itching during regrowth of hair after razor shaving.11 Wet shaving is preferable to dry shaving because the hair is softer and less abrasion occurs on the skin surface.Soaking the hair in lather (2% hexachlorophene solution) four minutes prior to shaving allows the keratin to absorb three to four times its weight in water, making it more likely to result in a soft, blunt ended hair stubble.9,12

In 1971, Seropian and Reynolds10 demonstrated the increase in skin trauma following razor hair removal, finding that 16.1% of razor prepped patients experienced skin abnormalities (irritation, inflammation, nicks, and scratches), while only 1.3% of patients prepped with depilatory experienced such abnormalities (Figure 1).


Figure 1. The frequency of skin abnormalities after razor hair removal was more than ten-foldgreater than that following the use of a depilatory.

Among these skin abnormalities, depilatory preparation caused only irritation, while razor preparation resulted in irritation, nicking, and scratching of the skin Table 1.

Abnormal Skin Conditions Razor Depilatory
Irritation 2 2
Nicks 30 0
Scratchs 8 0
Table 1. Skin Conditions Induced by Hair Removal Techniques10.

DEPILATORY CREAMS

The studies of two scientific reports10,11 demonstrated the superiority of depilatory creams to razor shaving for preoperative hair removal.Depilatory creams use chemical agents to remove hair below the skin's surface. Their success in hair removal has been attributed to three factors. First, this method of hair removal leaves a softly pointed hair shaft that does not cause as much discomfort during hair regrowth as the chisel-edged hair tip remaining after razor shaving.11 Second, many depilatory creams have been shown to have bacteristatic and bactericidal properties.11 Finally, depilatory creams preserve skin integrity to a greater extent than razor preparation.

In their prospective clinical study that evaluated hair removal techniques, Seropian and Reynolds10 compared infection rates after either razor hair removal or a depilatory to no hair removal in 406 patients. These investigators found that the lowest infection rates (0.6%) were associated with no attempt at hair removal or with use of a depilatory cream. This low infection rate was considerably less than the 5.6% infection rate encountered in patients subjected to razor hair removal (Figure 2).


Figure 2. The infection rate following preoperative razor hair removal was nearly four times greater than that encountered with a depilatory. Patients subjected to no preoperative hair removal had a comparable rate of infection to patients subjected to a depilatory.

After razor preparation, the infection rate was 3.1% when done just prior to surgery, 7.1% when done up to 24 hours prior to surgery, and 20% when done over 24 hours before surgery. (Figure 3).


Figure 3. Patients subjected to preoperative hair removal immediately before surgery exhibited the lowest incidence of infection.

In 1976, Powis, Waterworth, and Arkell11 performed a prospected, randomized, clinical evaluation of depilatory creams.In their study of 92 patients, preoperative hair removal by a depilatory cream was compared with routine shaving.Although the incidence of wound infection was similar in both groups, the investigators favored depilation over razor shaving. The superiority of depilatory creams was attributed to three factors. First, it was effective, atraumatic, non-toxic, and could be self-administered. Because it did not support bacterial growth, it could be used safely on granulated wounds. Finally, depilation was associated with a significant reduction in skin surface bacteria and proved to be cheaper than shaving. These investigators demonstrated an increase in count of bacterial colonies after razor preparation as opposed to depilatory preparation.S. aureus was the most common single organism encountered.When the numbers of these colonies were considered, the colony count in the depilatory group was significantly lower than the count in the shaved group (Figure 4).


Figure 4. At the end of the operative procedure, the bacterial colony swab count of skin subjected to razor preparation was nearly three-fold greater than that of skin prepared by a depilatory.


ELECTRIC CLIPPERS

In September, 1967, Cruse and Foord14 commenced a prospective study of all surgical wounds at the Foothills Hospital in Calgary, Alberta Canada. This clinical review that ultimately involved 23,649 patients identified the technique of hair removal as an important determinant of infection. Patients who were shaved had an infection rate of 2.3%. This rate of infection was higher than in patients who had no shave, but had their hair clipped (1.7%). In patients who had no shave or clipping, the infection rate was only 0.9% (Figure 6). The investigators appropriately concluded that shaving hair should be kept to a minimum in operative procedures.

Figure 6. Patients subjected to preoperative razor hair removal had the highest incidence of infection.

In 1983, Alexander and associates15 conducted the first controlled, clinical study in which clippers were used for hair removal.Their study examined the influence of preoperative shaving versus clipping on wound infection rates in 1,013 patients undergoing elective operations at a single hospital. Patients were prospectively randomized to be either shaved or clipped the night before or the morning of the operation. The incidence of infection was determined at the time of discharge as well as 30 days after surgery. The infection rate for patients receiving hair removal by clipping the morning of the operation was 1.8% at the time of discharge, less than that of the other techniques for hair removal (Figures 7 and 8).

Figure 7. Patients subjected to razor hair removal had a higher infection rate than those subjected to clipper hair removal.

Figure 8. The infection rate in patients subjected to preoperative hair removal immediately before surgery was significantly less than that encountered in patients subjected to preoperative hair removal the night before surgery.

The incidence of infection almost doubled for all groups by the time of the 30-day follow up. When the patients were inspected by the operating room nurses for the presence of nicks or scratches, the patients subjected to hair removal by clippers in the morning had skin that was judged to be normal in 96% of the patients. In contrast, razor hair removal in the morning was judged to be the worst, with only 86% of the patients displaying normal skin.

One year later, Masterson et al6 emphasized that there were important technical considerations in the selection of surgical clippers. Recent advances in the design of surgical clippers have made them especially suitable for preoperative hair removal. The clipper blade assembly can now be easily removed from its mounting assembly on its electric motor so it can be cleaned. They demonstrated that clipper blade assemblies could be subjected to considerable bacterial contamination after a single use. High levels of bacterial contamination were recovered from three of 12 clipper blade assemblies containing more than 100,000 bacteria per clipper blade assembly. Because this number of bacteria is sufficient to elicit bacterial infection in surgical wounds, the investigators recommended that a clean clipper blade assembly be used in each operative procedure. Their studies served as a catalyst for the manufacturers to develop clean, disposable clipper blade assemblies.

More recent studies have further demonstrated the superiority of hair clipping over shaving on more specific patient populations. In 1991, Sellick, Stelmach, and Mylotte16 compared wound infection rates of adults following various open heart surgeries. After noting an increase in deep wound infection rates in 1988 (1.2% for deep sternotomies and 1.6% for deep venectomies), it was discovered that electric clippers had fallen into disuse the prior year, 1987. Hospital and operating room policies were consequently changed during January 1989 to exclude razor preparation of skin for surgical procedures. When hair removal was reinstituted with electric clippers with disposable clipper blade assemblies in 1989, there was a noticeable decline in deep wound infection rates (0.2% for deep sternotomies and 0.4% for deep venectomies).

In 1992, Ko et al17 investigated the effects of hair removal methods on suppurative mediastinitis after cardiopulmonary bypass operations in 1,980 patients. They found the infection rate was significantly greater in the group that was manually shaved (1.3%) as opposed to electrically clipped (0.4%). In 1996, De Geest et al18 examined the clinical comparison of razor, clipper, and depilatory cream protocols in 82 patients undergoing coronary artery bypass graft (CABG) surgery. When the number of macroscopic skin lesions were counted after each preoperative procedure, 20.6% of the razor protocol patients had macroscopic skin lesions, compared to 13.8% of the clipper protocol patients and none of the cream protocol patients (Figure 9). The investigators concluded that the razor method should be eliminated from surgical practice.

Figure 9. In cardiovascular surgical patients, the frequency of macroscopic skin lesions was highest following razor hair removal.

RECOMMENDED PREOPERATIVE HAIR REMOVAL

On the basis of the results of numerous scientific studies, many prestigious organizations have recommended preoperative hair removal by electric clippers. In 1992, the Recommended Practices of the Association of Operating Room Nurses (AORN)12 stated that “If hair is to be removed, it should be done so in a manner that preserves skin integrity. Hair removal by shaving can disrupt skin integrity. Clippers or chemical depilatory agents have less potential of disrupting skin integrity; therefore, clippers or chemical depilatory agents are the preferred methods of hair removal when absence of hair at the operative site is desired. An electric or battery powered clipper with a disposable or reusable head that can be disinfected between patients is acceptable. A chemical depilatory agent needs to be applied before the arrival in the practice setting. Manufacturers’ written instructions regarding skin testing before using the chemical depilatory should be followed.Shaving is done only when other methods of hair removal are not available.”

In 1996, the Association for Professionals in Infection Control and Epidemiology (APIC)19 stated “interventions that have been associated with reduced microbial contamination of the wound and, subsequently, putatively reduced infection risk include: …depilatory or clipping in preference to shaving for hair removal at the operative site… hair removal immediately before, rather than substantially before, surgery.” In addition, the American College of Surgeons (ACS) recommends either no hair removal or morning-of-surgery hair clipping at the surgical site.16

In 1999, the Centers for Disease Control (CDC)20 states under its recommendations for prevention of surgical site infection, “if hair is to be removed, remove immediately before the operation, preferably with electric clippers”. The CDC ranks this as a Category IA recommendation, one that is "strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies."

SCIENTIFIC BASIS FOR SELECTION OF SURGICAL CLIPPERS

On the basis of our extensive clinical evaluations of electric clippers, we have concluded that the surgical electric clipper must have the following characteristics:

1. The electric clipper must be powered by an electric or battery powered motor. The rechargeable electric clippers are favored for use in the operating room because they do not use an insulated wire that is susceptible to damage in the operating room (Fig.10).

Figure 10. Baxter Surgical Clipper 4407 without electrical cord.

2. The electric or battery powered motor should have a running time of at least one hour for hair removal on large or difficult skin surfaces.

3. The electrically powered motor must be designed so that it can be submerged in an antimicrobial solution for disinfection.


Figure 11. Each hair clipper has a disposable clipper blade assembly.

4. The hair clipper must have disposable, clean clipper blade assemblies with oscillating teeth that cut scalp or skin hair without nicking (Fig. 11).

5. Because scalp hair is thicker, coarser, more plentiful in some patients, the special clipper blade assemblies for cutting scalp hair is imperative (Fig. 12).

Figure 12. The Baxter Specialty Surgical Clipper 4411 has been specially designed so that its clipper blade assembly can cut hair.

6. The width of the disposable clipper blade assembly should be at least 3.75 cm wide so that hair removal can be accomplished in an expeditious manner (Fig.13).

Figure 13. The Baxter Surgical clipper 4407 has a clipper blade assembly whose width (3.75 cm) is much wider than that of the 3M clipper blade assembly (3 cm).

7. We prefer a stable, rather than rotatating clipper blade assembly head because a fixed clipper blade assembly head allows operating personnel to cut hair as close to the skin surface as possible without nicking the skin (Fig.14).

Figure 14. The 3M clipper 9661 has a pivoting clipper blade assembly that may not follow the curvature of the bony prominences.

OTHER CONSIDERATIONS FOR HAIR REMOVAL

When hair removal is accomplished, the healthcare professional and the patient should take the following precautions:

  1. The healthcare worker must wear powder-free examination gloves because of the well documented dangers of cornstarch powder to the healthcare worker and patient.21,22 When the healthcare worker or patient is sensitized to latex, the healthcare worker should wear latex-free, powder-free examination gloves.

  2. While electric clipping can be performed with either wet or dry hair, we prefer electric clipping of dry hair because hair clipping can be accomplished more quickly in a dry environment.

  3. Hair clipping should be performed in a room outside the operating room to limit the dispersal of hair in the operating room.

  4. Hair clipping should be performed by healthcare professionals immediately before the operative procedure.

It is important to emphasize that this procedure should always be accomplished by a healthcare professional, not the patient, in accordance with the institution's policies. Small23 describes the patient complications occurring after a patient was instructed by hospital personnel to cut his hair with electric clippers. The patient, who was 37 years old, was admitted to the hospital for an elective splenectomy to treat hypersplenism. Before surgery, the patient had evidence of bacterial infections of his skin. Even though it was not the policy of the hospital to have the patient perform his own preoperative hair removal, the nursing personnel gave the patient an electric clipper to remove hair from his abdomen. When the patient removed the hair with the electric clipper, he nicked and scratched himself extensively, resulting in bleeding. This traumatic skin preparation in the presence of skin bacterial infection precipitated development of sepsis after surgery that led to the patient’s death. After a malpractice suit was filed against the hospital, the court held the hospital liable for breach by the nurses of its preoperative hair removal protocol. Further, the sepsis which caused the patient’s death was determined to be a direct result of the improper skin preparations. This case reinforces the importance of strict adherence to hospital’s policies and protocols which have been put in place to protect patients’ safety.

Because electric clippers allow hair to be cut close to the skin's surface without nicking the skin or damaging the hair follicle like razor shaving, the use of electric clippers is especially appropriate in cases of pseudofolliculitis barbae. Pseudofolliculitis barbae is a common cutaneous infection that is caused by ingrown hairs producing an inflammatory foreign body reaction characterized by papules and pustules at the point of hair penetration.24 As discussed above, shaving hair results in a sharply pointed hair shaft below the skin's surface. This allows the tip to inject itself into the side of the hair follicle upon regrowth, carrying with it bacteria and foreign material into the skin. In a black person, this is particularly problematic due to the helical nature of the hair follicle. Consequently, the hair grows out of the side of the hair follicle and curls up into the skin, producing an ingrown hair. Any individual with hair that is short, coarse, and kinky may experience this phenomenon, although it is most common in the bearded area of black men.9,24 Because electric clippers leave a short stubble of hair that is blunt ended and above the surface of the skin, it can be expected that clipping hair would reduce the incidence of pseudofolliculitis.

Despite the overwhelming evidence of the dangers of razor hair removal, it is extremely disappointing that most hospitals resort to this dangerous practice. In a 1996 survey by the OR Manager8, the editors reported that almost three-quarters (73%) of respondents indicated that patients are subjected to razor hair removal before surgery. For this reason, we are starting a global, public educational campaign that alerts society to the dangers of razor hair removal before surgery. This program will also articulate the benefits of hair removal by electric clippers as well as depilatories. We are encouraging hospitals to assume a principled leadership position in which they abandon the use of the dangerous practice of razor hair removal. One hospital in the Commonwealth of Virginia has announced that it will be the first hospital in the world to abandon the use of razor hair removal. A global website is being developed that will identify all hospitals who assume this leadership position in protecting their patients against a preventable hospital complication. This patient care program has enormous cost-saving potential as it reduces the incidence of surgical infection. Substantial morbidity of surgical site infections has been well established. Patients with wound infections have an average hospital stay that is six days longer than patients without infections, costing an additional $2,656 in 1984 dollars.19 In 1983, Alexander et al15 reported that for each 1,000 surgical patients, a savings of $274,780 would be realized if hair were removed exclusively by clippers the morning of surgery. Assuming that at least half of all surgical patients have hair removed, they concluded that if preoperative shaving were abandoned in favor of morning hair clipping or depilatory, the annual savings in the United States could be more than $3 billion.

CONCLUSION

Recent advances in the design of surgical clippers have made them especially suitable for atraumatic preoperative hair removal, which is associated with a lower incidence of infection than that encountered with razor shaving. Hair removal by depilatories, although an effective method, can cause allergic reactions and delayed wound healing if spillage into the wound occurs. For these reasons, we prefer hair removal by electric clippers over the use of a depilatory. More importantly, we have abandoned the use of preoperative shaving because it potentiates the development of wound infection. Hair removal should always be performed by a healthcare professional in accordance with the institution's policies. While numerous, prestigious, medical leadership organizations have recommended abandoning razor hair removal, the majority of patients still are subjected to this dangerous hair removal technique that invites the development of wound infection. One hospital has taken a leadership position to abandon the use of razor hair removal. A global website is being developed to warn society of the dangers of razor hair removal and provide an inventory of hospitals that have abandoned this harmful, life-threatening practice that leads potentially to infection, sepsis, and even death.

For more information about the Baxter Surgical Clippers with detachable clipper blade assembly, contact:

Allegiance Healthcare
Skin and Preparation Division
1500 Waukegan Rd.
McGaw Park, IL 60085
1-800-353-0146

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  2. Treatment of wounds. In: Esmarch F, Kowalzig E. Surgical technic: a textbook on operative surgery. New York: MacMillan; 1901:13-5.

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  4. Noble WC. Staphylococcus aureus on the hair. J Clin Path 1966; 19:570-2.

  5. Dineen P, Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet 1973; 2:1157-9.

  6. Masterson TM, Rodeheaver GT, Morgan RF, Edlich RF. Bacteriologic evaluation of electric clippers for surgical hair removal. Am J Surg 1984; 148:301-2.

  7. Edlich RF, Rodeheaver GT, Thacker JG. Technical factors in the prevention of wound infections. In: Howard RJ, Simmons RL, eds. Surgical infectious diseases, 3rd ed. Norwalk: Appleton & Lange; 1995:423-63.

  8. The OR Manager 1996; 12(9):3.

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  11. Powis SJA, Waterworth TA, Arkell DG. Preoperative skin preparation: clinical evaluation of a depilatory cream. Br Med J 1976; 2:1166-8.

  12. Recommended practices: skin preparation of patients. AORN J 1992; 56:937-41.

  13. Almersjö O, Hultén L, Rydberg B, Wahlqvist L, Åhrén C. Wound healing after depilation with a keratolytic cream. Acta Chir Scand 1967; 133:355-62.

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  16. Sellick JA, Stelmach M, Mylotte JM. Surveillance of surgical wound infection following open heart surgery. Infect Control Hosp Epidemiol 1991; 12:591-6.

  17. Ko W, Lazenby D, Zelano JA, Isom W, Krieger KH. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 1992; 53:301-5.

  18. De Geest S, Kesteloot K, Adriaenssen G et al. Clinical and cost comparison of three postoperative skin preparation protocols in CABG patients. Prog Cardiovasc Nurs 1996; 11(4):4-16.

  19. Sheretz RJ, Streed SA, Gledhill KS. Surgical site infections. In: Olmsted RN, ed. APIC infection control and applied epidemiology, 1st ed. St. Louis: Mosby; 1996:11-1 - 11-5.

  20. CDC Recommendations. Infection Control and Hospital Epidemiology 1999:266.

  21. Ruhl CM, Urbancic JH, Foresman PA et al. A new hazard of cornstarch, an absorbable dusting powder. J Emerg Med 1994; 12:11-4.

  22. Kelly KJ, Walsh-Kelly CM. Latex allergy: a patient and health care system emergency. Ann Emerg Med 1998; 32:723-9.

  23. Small SP. Preoperative hair removal: a case report with implications for nursing. J Clin Nurs 1996; 5(2):79-84.

  24. Edlich RF, Haines PC, Nichter LS, Silloway KA, Morgan RF. Pseudofolliculitis barbae with keloids. J Emerg Med 1986; 4:283-6.