New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective
Recommendation 8: hair removal
Removal of hair from the intended site of surgical incision has traditionally been part of the routine preoperative preparation of patients. Hair is perceived to be associated with poor cleanliness and SSIs. Although hair removal might be necessary to facilitate adequate exposure and preoperative skin marking, the method used can cause microscopic trauma of the skin and increase the risk of SSIs. We did a systematic review to investigate whether the method (eg, using clippers, depilatory cream, or shaving with razors) and timing of hair removal versus no hair removal affect the incidence of SSIs. 15 RCTs or quasi-RCTs85,86,87,88,89,90,91,92,93,94,95,96,97,98,99 comparing the effects of preoperative hair removal versus no hair removal or different methods of hair removal (shaving, clipping, and depilatory cream) were identified and several meta-analyses were done.
The three hair removal methods did not affect the incidence of SSIs compared with no hair removal. The combined ORs were 1·78 (95% CI 0·96–3·29) for shaving, 1·00 (0·06–16·34) for clipping, and 1·02 (0·42–2·49) for depilatory cream. The quality of evidence was rated as moderate. However, when hair is removed, clipping significantly reduces SSIs compared with shaving (OR 0·51; 0·29–0·91). Because they have similar potential to cause microscopic skin trauma, no hair removal and clipping were combined in an additional meta-analysis, which showed that they are associated with significantly reduced prevalence of SSIs compared with shaving (combined OR 0·51; 0·34–0·78). No recommendation regarding the timing of hair removal could be formulated as only one study assessed this question with no relevant results, but the panel suggested that removal by clipping shortly before surgery is the safest approach, if required.