Effect of preoperative hair removal vs. no removal on surgical site infections: a systematic review and meta-analysis

Abdulsalam Aleid; Saud Nayef Aldanyowi; Abdulmajeed Aljabr; Hasan Ali Abdullah Alaidarous; Zainab Aleid; Abdulaziz Alharthi; Mutlaq Alsubaie; Lama AlOraini; Abdulrahman Almoslem; Abbas Al Mutair

doi:10.12688/f1000research.158369.1

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Systematic Review

Effect of preoperative hair removal vs. no removal on surgical site infections: a systematic review and meta-analysis

[version 1; peer review: 2 approved]

Abdulsalam Aleid ¹, Saud Nayef Aldanyowi¹, Abdulmajeed Aljabr², [...] Hasan Ali Abdullah Alaidarous³, Zainab Aleid¹, Abdulaziz Alharthi⁴, Mutlaq Alsubaie⁵, Lama AlOraini⁶, Abdulrahman Almoslem¹, Abbas Al Mutair⁷

Abdulsalam Aleid ¹, Saud Nayef Aldanyowi¹, [...] Abdulmajeed Aljabr², Hasan Ali Abdullah Alaidarous³, Zainab Aleid¹, Abdulaziz Alharthi⁴, Mutlaq Alsubaie⁵, Lama AlOraini⁶, Abdulrahman Almoslem¹, Abbas Al Mutair⁷

PUBLISHED 05 Dec 2024

Author details Author details

¹ King Faisal University, Al Ahsa, Eastern Province, Saudi Arabia
² King Saud bin Abdulaziz for Health Science, Riyadh, Riyadh, Saudi Arabia
³ Albaha University, Albaha, Albaha, Saudi Arabia
⁴ Alhada Armed Military Hospital, Taif, Makkah, Saudi Arabia
⁵ National Guard Hospital, Al Ahsa, Eastern province, Saudi Arabia
⁶ King Fahad Specialist Hospital, Buraidah, AlQassim, Saudi Arabia
⁷ Almoosa Specialist Hospital, Al Ahsa, Eastern Province, Saudi Arabia

Abdulsalam Aleid
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Saud Nayef Aldanyowi
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abdulmajeed Aljabr
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Hasan Ali Abdullah Alaidarous
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Zainab Aleid
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abdulaziz Alharthi
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Mutlaq Alsubaie
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Lama AlOraini
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abdulrahman Almoslem
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abbas Al Mutair
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

The practice of preoperative hair removal has been debated regarding its role in Surgical Site Infection (SSI) prevention. This study aimed to compare the different hair removing modalities and investigate the effect of preoperative hair removal on SSI rates.

Methods

A systematic review and meta-analysis were conducted according to PRISMA guidelines. Three databases—PubMed, Web of Science, and Cochrane Library—were searched for relevant studies comparing preoperative hair removal to no hair removal. Studies eligible for inclusion were randomized controlled trials (RCTs) and cohort studies reporting SSI rates. Odds ratios, mean differences, and p-values were analyzed using a random effect model.

Results

Seventeen studies involving 5,407 patients were included. No statistically significant difference in SSI rates was found between the hair removal and no removal groups (OR = 1.066, 95% CI 0.646–1.758, p = 0.803). When comparing clipping to no hair removal, there was no significant difference (OR = 0.967, 95% CI 0.642–1.455, p = 0.870). Razor shaving was associated with higher skin damage and slightly increased SSI risk compared to clipping but not statistically significant (OR = 0.749, 95% CI 0.346–1.623, p = 0.464). Depilatory creams, however, were favored over razor shaving (OR = 3.235, 95% CI 1.543–6.785, p = 0.002), as they were linked to less skin damage and easier application.

Conclusion

Preoperative hair removal does not significantly impact SSI rates. Clipping appears to be a safer alternative to shaving, while depilatory creams show promise as an effective, less damaging option.

Keywords

Surgical site infection, hair removal, clipping, depilatory cream, razor shaving, meta-analysis.

Corresponding author: Abdulsalam Aleid

Competing interests: No competing interests were disclosed.

Grant information: 'This work was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia [Grant No. KFU241652]'
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Aleid A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Aleid A, Aldanyowi SN, Aljabr A et al. Effect of preoperative hair removal vs. no removal on surgical site infections: a systematic review and meta-analysis [version 1; peer review: 2 approved]. F1000Research 2024, 13:1487 (https://doi.org/10.12688/f1000research.158369.1) First published: 05 Dec 2024, 13:1487 (https://doi.org/10.12688/f1000research.158369.1) Latest published: 05 Dec 2024, 13:1487 (https://doi.org/10.12688/f1000research.158369.1)

Introduction

Surgical site infections (SSIs) has been linked to influence patient morbidity, healthcare cost, length of hospital stays, and increased fatalities in extreme cases.^1,2 The practice of removing axillary hair prior to surgery has been widely discussed and examined, particularly in relation to its impact on the rate of surgical site infections.^3,4 Given the pressing need to evaluate the impact of preoperative hair removal techniques on surgical site infection outcomes, additional research has been recommended to definitively establish the effectiveness of these techniques.^5,6 This systematic review and meta-analysis sought to compare the effectiveness of different pre-operative hair removing techniques in reducing the incidence of surgical site infections (SSI), with the goal of enhancing patient care and improving post-operative results.

Methods

This systematic review and meta-analysis were carried out in strict accordance with the PRISMA 2020 guidelines (DOI: 10.6084/m9.figshare.27331266) as described by Page et al. (2021).⁷ The study was also registered in PROSPERO (CRD42024547805).

Study search

A comprehensive electronic search for medical literature began on February 26th, 2024, to investigate the effects of hair removal versus no removal on surgical site infection (SSI) rates. Predetermined keywords ensuring high-quality and relevant results were employed, including surgical site infections, hair removal, razor shaving, depilatory creams, and preoperative therapies.

The literature search was conducted across three databases: PubMed, Web of Science (WoS), and the Cochrane Library. Truncation symbols and relevant MeSH terms were incorporated to ensure the search was comprehensive. To ensure a comprehensive and unbiased literature search, two independent reviewers employed EndNote 20 to identify and exclude duplicates from the initial search results. Reviewers then screened the remaining articles’ titles and abstracts against predetermined eligibility criteria. Subsequently, full texts of relevant articles underwent scrutiny for content quality. Any discrepancies arising during the screening process were resolved through discussion or consultation with a third party.

Study screening and selection

Methodological guidelines were followed during the study selection and data collection phases to guarantee the validity and dependability of the systematic review and meta-analysis as guided by (Kim, 2023),⁸ and (Muka et al., 2019).⁹ After conducting the literature search and screening process, studies meeting the predefined criteria were selected for inclusion.

Two independent authors assessed the full texts of the articles to determine eligibility for inclusion in the systematic review and meta-analysis. In cases of disagreement regarding the inclusion of studies, a third author was consulted to resolve conflicts and achieve consensus.

Eligibility criteria

Inclusion criteria included studies comparing preoperative hair removal with no hair removal, hair removal using razor when compared to other modalities (e.g., clipping, depilatory creams), those examining outcomes related to surgical site infections (SSIs) or complications from hair removal. Study designs included in this meta-analysis were randomized controlled trials (RCTs) and cohort studies. The target population consisted of adult patients undergoing any type of surgery, with the primary outcome being SSIs and the intervention being hair removal versus no removal. Studies were excluded if they were not in English or lacked full-text access. Also, case reports, case series, commentaries, expert opinions, review articles, systematic reviews/meta-analysis, economic analysis, cadaver studies, narrative review, and any study with less than 10 patients were all excluded.

Data extraction

After the review process, the eligible studies were subjected to data extraction using a standardized data extraction form that used study characteristics to analyze data from the articles. The form specifically highlighted the methods of research adopted by each study (study designs), the sample sizes used by each study, age, sex, the specific method used to remove hair, and the results obtained. The two reviewers worked independently to retrieve the data to avoid inaccuracies in the process.

Outcomes measured

The primary outcomes focused on comparing different hair removal techniques individually against no hair removal, as well as assessing various combinations of methods, to determine which approach is most effective in preventing SSI.

Statistical analysis

We conducted a meta-analysis using Review Manager version 5.4, pooling the dichotomous variables to calculate the odds ratio (OR). A p-value of 0.05 or lower was considered statistically significant, with 95% confidence intervals (CI). Heterogeneity was assessed using I², with significance determined by the p-value.

Results

Literature search

A comprehensive search across various databases identified 6,058 initial records. After removing duplicates (n = 1,214) and non-English publications, title and abstract screening excluded 3,972 articles for irrelevance. Full-text review of the remaining studies (n = 872) identified issues like irrelevant information, invalid methodologies, and insufficient data, leading to the exclusion of 855 articles. This rigorous process yielded 17 final studies that met the eligibility criteria and were included in this systematic review and meta-analysis ( Figure 1).

Figure 1. PRISMA flowchart of the literature search and studies selection process.

Characteristics of the included studies

Seventeen studies met the eligibility criteria and were analysed for design, sample characteristics (sample size, age, gender), surgery type (e.g., abdominal, cranial), intervention methods (e.g., razor, clipping), follow-up period, and findings. The basic characteristics of the included studies are given in Table 1(extended data). Each study’s contribution to SSI prevention was assessed individually. Study designs included randomized controlled trials (RCTs), prospective RCTs, prospective comparative cohorts, prospective non-inferiority trials, and clinical trials. These studies encompassed 5,407 patients, with 265 developing SSI. Patient ages ranged from 6 months to 88 years, with a median of 44 years. The studies investigated various surgeries: cranial, spinal, abdominal, Lichtenstein hernia repair, intracranial, genital, appendectomy, chest, VP shunt insertion, and external/middle ear surgeries. Intervention methods included razor shaving, clipping, and depilatory creams. Follow-up periods varied greatly, ranging from 3 days to 10 months.

Statistical analysis

The analysis comparing hair removal versus no removal found no statistically significant difference, with an overall odds ratio (OR) of 1.066 [95% CI 0.646, 1.758; P = 0.803], and the heterogeneity was below 50% ( Figure 2). In a comparison of preoperative clipping to no hair removal, two studies, Abouzari et al. (2009)¹⁰ and Kowalski et al. (2016),¹¹ showed no notable difference between the two methods, with an OR of 0.967 [95% CI: 0.642-1.455; P = 0.870] and no heterogeneity (I²=0.0%; P= 0.981) ( Figure 3). Additionally, when comparing hair clipping to razor shaving, the analysis favored hair clipping but indicated no statistically significant difference, yielding an overall OR of 0.749 [95% CI 0.346, 1.623; P = 0.464], with heterogeneity remaining under 50% (I²=34.363%; P= 0.179) ( Figure 4). In contrast, depilatory cream was preferred over razor shaving, resulting in an overall OR of 3.235 [95% CI; 1.543, 6.785; P = 0.002], and the heterogeneity among studies was zero (I²=0.0%; P = 0.473) ( Figure 5). Overall, the meta-analysis exhibited low publication bias, with studies showing large effect sizes across analyses. The comparison of hair removal versus no hair removal did not demonstrate any defined publication bias, as the studies were moderately scattered with minimal concentration around the mean effect size in the funnel plots. Furthermore, subgroup analysis plots revealed a few large studies that were uniformly distributed from the mean effect size ( Figures 6, 7, and 8).

Figure 2. Forest plot of the effect of hair removal VS no removal on SSI.

Figure 3. Forest plot of the effect of hair removal using clipping to no hair removal on SSI.

Figure 4. Forest plot of the effect of clipping and Razor shaving on SSI.

Figure 5. Forest plot of the effect of Razor shaving and using depilatory cream on SSI.

Figure 6. Publication bias for studies in hair removal vs no hair removal meta-analysis.

Figure 7. Publication bias for studies in clipping vs razor shaving meta-analysis.

Figure 8. Publication bias for studies in razor shaving vs depilatory cream meta-analysis.

Discussion

In recent years, numerous studies have explored the effect of preoperative hair removal on the occurrence of surgical site infections (SSIs).^12–15 However, the results presented lack conclusiveness and consistency, leaving this intervention entirely obscure in the realm of surgical medicine.^4,16–21 Some studies have reported a general lack of significant difference between shaved and non-shaved groups.^{6,14,16,22–26} Others have even reported possible risks of SSIs with razor-shaving.^22,27–31 Moreover, multiple studies recommended excluding hair removal from preoperative preparation practices unless necessary.^6,14,20,32

Preoperative hair removal has long been considered a routine preventive treatment against surgical site infections.³³ However, more current studies have revealed a contrary opinion on this event.^{6,15,32,34–36} The current review included studies comparing surgery with and without preoperative hair removal. The analysis found no significant difference in infection rates between the two groups. This suggests that removing hair before surgery may not offer any advantage in terms of preventing infections. Similarly, surgery with hair removal using clippers to surgery with no hair removal showed no significant difference in infection rates. These findings suggest that hair removal before surgery may be unnecessary. These findings support the results attained by Tang et al. (2001),³⁷ and Horgan et al. (1999).³⁸ Specifically, the study by Tang et al. (2001)³⁷ lacked a significant difference between the shaved group and the unshaved one in all parameters that were investigated using a sample size of 90 patients. Additionally, the study by Horgan et al. (1999)³⁸ presented no cases of SSI development in both the experimental and control groups.

Further analysis was done for the comparison groups involving different hair removal methods: shaving to clipping, shaving by using depilatory cream, and clipping by using depilatory cream. The primary outcomes were the development of SSI, whereas the secondary outcomes considered damage to the skin, effectiveness of hair removal, cost of the method, and simplicity of the procedure associated with each method in hair removal. In this meta-analysis, six studies were reviewed to compare hair clipping with razor shaving for preoperative hair removal.^27,39–43 The meta-analysis revealed no clear advantage between the two methods, though the results slightly favored clipping. Notably, in the razor shaving group, significant skin damage was observed, which increased the likelihood of surgical site infections (SSIs) due to the compromised integrity of the skin. A comparison of razor shaving and depilatory cream was conducted using data from four studies aimed at evaluating the two methods.^40,44–46 The findings revealed notable differences between them, with depilatory creams being generally preferred. Depilatory creams were found to offer greater ease of use, cause less skin trauma, and ensure effective hair removal. Due to these advantages, depilatory cream is recommended over razor shaving for preoperative hair removal, as it is linked to reduced skin damage and a lower risk of surgical site infections (SSIs). In a study conducted by Turhan et al. (2022), depilatory creams were compared to hair-clipping techniques. The researchers concluded that there was no significant difference between the two methods in terms of their effectiveness for hair removal. This similarity was observed in both the overall results and the effect size analysis.⁴⁰

The overall heterogeneity in these meta-analyses was relatively low, with moderate variation observed in the primary comparison of hair removal versus no hair removal and the analysis of shaving. This variation may stem from differences between the individual studies. For example, studies with comparable sample sizes, follow-up durations, and participant demographics, such as sex, tended to produce more consistent results. On the other hand, studies with greater differences in these factors showed higher levels of heterogeneity.^47,48

The traditional belief that preoperative hair removal reduces infection has been challenged in recent years.⁶ Contrary to this long-held view, recent studies, including findings from our meta-analysis, indicate that hair removal may not be essential, as there was no significant difference in infection rates between patients who underwent hair removal and those who did not. The study also suggests that if hair removal is needed, using clippers is better than shaving with a razor.⁶ Razors may increase the risk of infection by causing nicks and irritation. Depilatory creams seem like a promising alternative because they remove hair without damaging the skin, but more studies are needed on their long-term effects.⁴⁹

Several limitations were observed in studies investigating the connection between preoperative hair removal and SSIs. One key issue was the inconsistency in the quality of the evidence, with some studies not utilizing proper blinding or control groups. Additionally, many studies were constrained by small sample sizes. These shortcomings highlight the need for more robust studies to better understand the effect of preoperative hair removal on SSIs. Future studies should focus on well-designed randomized controlled trials (RCTs) that implement standardized hair removal techniques and include larger patient populations to clarify its role in SSI prevention.

Conclusion

This systematic review and meta-analysis revealed no substantial difference in surgical site infection (SSI) rates between patients who had preoperative hair removal and those who did not. However, razor shaving was linked to a higher risk of SSIs when compared to clipping, but it was not statistically significant. Clipping emerged as the preferred method for hair removal when necessary, while depilatory creams showed promise as a potential alternative to shaving. These results question the conventional view that preoperative hair removal prevents infections, suggesting it should be avoided unless deemed necessary.

Ethical statement

Not applicable as this review involves already published studies and no ethical issue.

Data availability statement

Underlying data

No data are associated with this article.

Extended data

Repository name: Figshare, Effect of preoperative hair removal vs. no removal on surgical site infections: a systematic review and meta-analysis, DOI: https://doi.org/10.6084/m9.figshare.27331266.v2.⁵⁰

This project contains the following data:

- Table 1: Basic characteristics of included studies

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Reporting guidelines

Repository name: Figshare, Effect of preoperative hair removal vs. no removal on surgical site infections: a systematic review and meta-analysis, DOI: https://doi.org/10.6084/m9.figshare.27331266.v2.⁵⁰

This project contains the following data:

- PRISMA_hair removal_checklist

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgment

The authors acknowledge the Deanship of Scientific Research at King Faisal University for obtaining financial support for research, authorship, and the publication of research under Research Proposal Number (KFU241652).

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