An Overview of Skin Antiseptics Used in Orthopaedic Surgery Procedures

Joseph Letzelter, MD; J. Bradford Hill, MD; Jacques Hacquebord, MD


J Am Acad Orthop Surg. 2019;27(16):599-606. 

In This Article

Skin Antiseptic Solutions: A Brief Background


Chlorhexidine, also known as 1,6-bis(4-chloro-phenylbiguanido)hexane, is a cationic polybiguanide. Its mechanism of action is based on releasing a positively charged chlorhexidine cation, which can then bind to the negatively charged bacterial cell wall, thus exerting its bactericidal effect. At high concentrations, it can cause membrane disruption, resulting in cell death. It is active against gram-positive and gram-negative organisms, facultative anaerobes, aerobes, and yeast. Although it is effective against gram-positive organisms at low concentrations, higher concentrations are needed for gram-negative bacteria and fungi.[5]

Chlorhexidine can have both bactericidal and bacteriostatic effects and is often used in combination with alcohol. A study published in the New England Journal of Medicine in 2010 found that infection in general surgery cases occurred markedly less in patients who had chlorhexidine-alcohol antiseptics used than in patients who had povidone-iodine used as a surgical site preparation solution.[6] The authors attributed the increased protection offered by chlorhexidine-alcohol to its more rapid action, persistent activity despite exposure to bodily fluids, and residual effect. Limitations of chlorhexidine-alcohol include its slow onset of antimicrobial activity, skin irritation, and potential to damage tissue on contact.[7]

The purchase price of chlorhexidine antiseptic was reported to be $6.07 per 26-mL single-use applicator of 2% chlorhexidine gluconate/70% isopropyl alcohol and $1.68 per 113 g bottle of 4% chlorhexidine, which is higher than a comparable iodine surgical antiseptic solution. The reported cost of povidone-iodine solution is $1.42 per 118-mL surgical scrub with 7.5% povidone-iodine (Table 1).


Two main SASs contain iodine: povidone-iodine and iodine povacrylex. Iodine works in conjunction with the carrier polymer povidone, forming the skin antiseptic agent povidone-iodine. Povidone is used to prolong the effects of iodine. Povidone-iodine, also sold as Betadine, covers a broad spectrum for its antiseptic use. It has bactericidal effects against bacteria, fungi, and viruses. Povidone-iodine contains 9% to 12% iodine and works by releasing iodine, which results in the death of microorganisms.[8]

Povidone-iodine can be used for the prevention of infections for surgical skin preparation and management of infections in decubitus and stasis ulcers. Nonsterile povidone-iodine has limited use because of a long history of contamination with Propionibacterium cepacia.[9] Thus, sterile povidone-iodine should always be used, especially in open wounds. It should be noted that iodine is absorbed into the body in varying degrees depending on the condition of the patient's skin. Therefore, it can interact with diagnostic tests of the thyroid, including radioiodine diagnostics. It is contraindicated in patients with hyperthyroidism or other thyroid diseases after patients have been treated with radioiodine.[10]

The other iodine SAS is iodine povacrylex, which is combined with alcohol for added antiseptic effect. Some downsides of iodine include less persistence on skin compared with chlorhexidine antiseptics and slow onset of its antimicrobial effects.


Alcohol provides the most rapid reduction in bacterial count of all the antiseptic solutions. In fact, some articles attribute much of the efficacy of chlorhexidine-alcohol antiseptics to the alcohol component, which is often overshadowed by the conversation regarding whether chlorhexidine or iodine antiseptic solutions are superior.[11] Despite its more rapid onset, alcohol also tends to have a shorter duration of action than chlorhexidine and iodine, explaining why it is often used in combination with other antiseptic agents. Although it is also a broad-spectrum antibiotic like chlorhexidine and iodine antiseptics, alcohol is poorly sporicidal.[12] In addition, alcohol antiseptics are highly flammable and require drying before progression of surgery for risk of fire in the OR. Additional deliberation should be taken when considering using alcohol-based antiseptics for surgeries involving the use of cauterization for making deeper incisions.