Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Skin Antisepsis - Chlorhexidine/Alcohol versus Povidone/Iodine

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Rabih Darouiche, MD and colleagues published an article entitled "Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis" in the New England Journal of Medicine (N Engl J Med 2010;362:18-26). They sought to compare preoperative skin cleansing with chlorhexidine-alcohol (C-A) to cleansing with povidone-iodine (P-I). The outcomes measured were the presence of any surgical-site infection within 30 days after surgery, as well as individual types of surgical-site infections. Povidone is polyvinylpyrrolidone.

The results indicated that the overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group (9.5%) than in the povidone-iodine group (16.1%). Relevant to outdoor medicine, the C-A group was significantly more protective than the P-I group with respect to both superficial incisional infections and deep incisional infections.

What is the relevance of this for wilderness medicine? One familiar trade name for P-I is Betadine; one for C-A is Hibiclens. In the study reported in the New England Journal article, these substances were used to clean the skin prior to making a surgical incision prior to an operation. They were not used to clean out a wound. Does this situation arise outdoors? Yes, it does. For instance, one may need to cleanse the skin overlying a problematic blister prior to draining the fluid from it. If one had C-A and P-I, it would be wise (based upon this report) to select the C-A.

Sometimes health care providers add P-I to disinfected or sterile fluid to use as irrigation for wounds that are felt to be contaminated by bacteria (mostly) or viruses. We're not entirely sure how much benefit is obtained by wound irrigation with anti-bacterial agents, but somehow it seems somehow helpful (which it indeed may be) to run colored fluid through the wounds. Although it certainly wasn't studied in this particular investigation, I wonder if C-A would be better, the same, or worse at preventing infection than P-I if added to irrigation fluid. This could probably be determined with another study directed to answer this question. Be aware that there is another, new skin and wound cleanser (Microcyn) entering the market that is advertised to have a very impressive spectrum of activity against microorganisms and that is not supposed to be toxic to tissues in open wounds.

To the best of my knowledge, other than for what is claimed by the manufacturers of Microcyn, any strong antiseptic placed full-strength into an open wound can be tissue toxic, so that must be kept in mind whenever one is working around a cut, sore, or ulcer. This study cited above involved intact skin treated preoperatively with these antiseptics, so until we have more data, we must not automatically extrapolate to the situation described in the preceding paragraph.
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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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