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Evaluation of a chemical depilatory for preoperative preparation of five hundred fifteen surgical patients
Evaluation of a Chemical Depilatory for Preoperative Preparation of Five Hundred Fifteen Surgical Patients AARONPRIGOT, M.D., ARTHUR L. GARNES,M.D. ANDUzo NWAGBO, M.D., New Yorlz, New York From tbe Department of Surgery of tbe Harlem Hospital Center, Department of Hospitals, New York, New York. Tbis investigation was supported, in part, by a grant from Crookes-Barnes Laboratories, Wayne, New Jersey. Tbe trade name of tbis company for tbe depilatory cream is Surgex. @
HAVINGhas been the traditiona method of remova in preparing body surfaces for surgery. AIthough generaIIy satisfactory, it is attended by some disadvantages. It is time consuming and adequate remova of hair may be diffrcuIt in the body foIds, axiIIae, pubic, perinea1 and scrota1 regions. When infection is present, shaving over a sensitive area may be extremeIy painfu1. If the shaving technic is not skilIfuIIy performed, the skin may be excoriated, offering an idea1 porta of entry for infection. The shaving equipment may not be sterile, and there is the possibility of transferring pathogenic microorganisms from one patient to another. AIthough to the surgeon, the preparation of the body surface for operation is onIy a step in the tota care of the surgical patient; nevertheIess, the sense of indignity and the apprehensions engendered in the patient by the shaving procedure are worthy of consideration
S hair
[Il.
ChemicaI methods offer an intriguing possibiIity for the remova of hair in the preoperative preparation of the patient and may avoid some of the deficiencies of shaving. ChemicaI depiIation has been known since antiquity. The primitives used singeing, minera1, vegetabIe or animaI matter in ointment and paste American
Journal
of Surgery.
Volume
104, December
1962
900
form to remove hair or prevent its regrowth [2]. The Papyrus Ebers, a rich source of antique medica recipes and arts, Iists items such as “burnt Ieaf of lotus in oi1,” “she11 of tortoise with the fat of hippopotamus,” and “the blood of oxen and goats mixed with stibium and maIachite” [3]. Authoritative reIigious orders and socia1 customs among the civiIizations of the Medi., terranean and Orient between 2400 and 3000 B.C. subscribed to the remova of body hair [4--61. An earIy and weII-known depiIatory is Rhusma Turcortum, a mixture of orpiment (natura1 arsenic trisuIfide), quick Iime and starch in paste form with water, has been extensiveIy used by OrientaI harem women, as we11 as among certain present day African tribes [7,8]. MetaIIic sulfides [9,ro] were used for cosmetic depiIation for a Iong time, but these substances were maIodorous, unpredictabIe in their action, and had a high incidence of IocaI irritation and systemic toxicity. Modern fashions in women’s appare1 necessitate the remova of superffuous hair from Iegs, arms and axiIIae throughout the year. Shaving for cosmetic purposes is beset by many of the disadvantages that obtain when this procedure is used in medica practice. This Ied to the demand for a convenient, nontoxic and nonirritating method of hair remova1. The main obstacIe to the development of a safe chemica1 for depiIation is the simiIar proinacious character of hair and skin. Both contain keratin and are subject to attack by
EvaIuation
of a ChemicaI
DepiIatory
the same chemical agents in approximateIy the same degree. The disintegration of hair is accomplished chemicaIIy by the rupture of the S-S linkage, converting the cystine in keratin to cysteine [11,r2]. Factors favoring chemical depiIation are the greater content of keratin in the hair than in the skin and the fact that the hair offers many surfaces for attack; whereas, the skin presents onIy one phase. It was not unti1 the introduction of the thiogIycoIIates into the cosmetic heId that reliabie and reIativeIy safe, nontoxic chemical depiIatories became avaiIabIe [I?-r~]. Investigations of these preparations discIosed properties that suggested their use for preoperative hair remova in surgica1 practice. The use of a rhemica1 depiIatory is not new in the medica field. In 1952 Vista1 [ r6] reported his experience with such a compound in 460 patients. The idea1 chemica1 agent for the remova of hair in the preparation of body surfaces for surgery shouId be nontoxic IocaIIy and systemicahy, of a low order of aIIergenicity; shouId not interfere with wound heaIing; and it should be effective in Iess time and attended by Iess discomfort than shaving. A depiIatory cream designed to meet these criteria was submitted for cIinica1 evaIuation. The cream is a homogenate mixture of caIcium thioglycoIIate, caIcium and strontium hydroxides in an emoIIient base, preserved with bithiono1. It was supplied for hospita1 use in coIIapsibIe meta tubes. The cream has a pleasant odor and its viscosity faciIitates topica1 appIication. BacterioIogic, anima1 and in vivo experiments were undertaken prior to the use of this depiIatory in the preparation of patients for surgery. BACTERIOLOGIC
for Preoperative
Preparation
no effect against the gram negative cultures. However, when the cream was streaked in bIood agar ptates, it failed to reveal any contaminants. When bacteria1 cuItures were made from the skin surfaces from which the hair was to be removed, and cultures repeated after depilation, the same organisms were recovered as originally identified, but in lesser numbers. It was, therefore, concluded that, aIthough the cream was sterile and did not support bacterial growth, its antiseptic properties hvere not significant from a clinica point of view. ANIMAL
EXPERIMENTS
_ Rabbits were empIoyed in experiments to test the depiIatory efficiency of the cream, the IeveI of tolerance and its effect on wound heaIing. Hair was removed from one side of the backs of Iive rabbits by the conventional method of shaving and from the other side with the depiIatory. The animaIs were anesthetized and paired g cm. incisions to the subcutaneous tissue were made on each side, observing the usual surgica1 precautions, and the incisions were then sutured. The wounds on both sides healed without incident and the sutures were removed on the tenth postoperative dav. In a second experiment to determine the effect on granuIating wounds, operative sites were prepared as above in Iive animals, and simiIar incisions were made on each side, but these were not sutured. A greater amount of subcutaneous tissue was, therefore, exposed and the wounds were aIlowed to heal by secondary intention. There was no diIl’erence in the heahng process of the two Iesions in each of these rabbits. AI1 wounds were healed by the twenty-Iirst postoperative day. In these experiments the use of the depilatory prior to anesthesia produced no evidence of pain reaction in these animaIs and no local irritation either pre- or postoperatively was noted. The efficiency of hair removal was of a high order, much of the ceIIuIar debris was removed aIong with the hair, Ieaving the body surface clean and smooth.
STUDIES
The cream was tested for microbicida activity, empIoying the standard seria1 diIution and the agar plate cup method with brainheart infusion broth and agar, respectiveIy. The test organisms were two strains each of Staphylococcus aureus, Bacillus subtilis, Aerobatter aerogenes and Escbericbia coli. AI1 were cIinica1 isolates recovered from hospitarized patients, rather than laboratory strains. Some inhibition of growth of gram positive strains was demonstrated, but the cream had
In
ViVO
EXPERIMENTS
To determine the incidence of aIIergic re.sponse to the cream, IOO patients were sub901
Prigot, Garnes and Nwagbo TABLE RESULTS
OF
PATCH
TEST
DEPILATORY
examination. No discernible difference in the histoIogic sections was observed. In these patients the incisions on both sides heaIed without incident.
I FOR
ALLERGENICITY
OF
CREAM
Conditions
Patients Tested
Reactions METHOD
With history of aIIergy Hay fever ................... Asthma. .................... Contact dermatitis ........... Dermatitis medicamentosa .... No history of allergy. .......... TotaI .......................
22
0
5
3
3
0
50
I
IO0
APPLICATION
The custom in many hospitaIs is for the patient undergoing elective surgery to be prepared the night before. At HarIem HospitaI the majority of our patients have acute surgica1 conditions requiring the use of the depiIatory just prior to the emergency operation. The time factor, as between preparation twelve to fifteen hours before surgery and immediateIy before, presented no probIems. With long or thick hair growth, as on the head or in the axiIIary, pubic or perinea1 regions, the hair may be cIipped with scissors before the appIication of the depilatory. The desirabiIity of this preIiminary step may be judged with greater accuracy as experience with the compound increases. In a11 patients the cream was appIied and spread evenIy with a tongue depressor, Ieaving a generous Iayer on the surface. After a minimum of ten minutes, the cream with the softened hair was removed with gauze or a tongue depressor, and the area then washed with water. The usua1 procedures for presurgica1 antisepsis were then foIlowed. The minimum period of ten minutes before removal of the cream was determined through triaIs with various time intervaIs. It was observed that shorter periods of contact gave less satisfactory resuIts in hair removal. Longer periods did not enhance the effectiveness of the cream. However, it is noteworthy that proIonged contact with the skin had no deleterious effect. This is because of the infhrence of the emoIIient components in the cream which act as a protective coIIoid upon topical application.
0
20
OF
4
jetted to skin tests. Fifty of these patients had historres of alIergy; the remaining fifty reported that they had never experienced such manifestations. ApproximateIy I gm. of the depiIatory was spread over an area of I cm. of skin of the arm, covered with an adhesive bandage, and allowed to remain in contact with the skin for one hour. If erythema, edema or rash appeared at the site of apphcation, the patient was deemed sensitive to the depiIatory. In Table I, it wiI1 be noted that three patients in the contact dermatitis group showed a positive reaction, and one patient in the group with no aIIergy history demonstrated a IocaI response. Two important considerations were reIated to this toIerance test, one of a positive and one of a negative nature. One patient, in whom irritation had previousIy developed in the axiIIae foIIowing the use of a commerciaIIy avaiIabIe depiIatory, had no untoward reaction when this cream was empIoyed. Another patient, a seventy-seven year oId man with a history of ahergic skin manifestations, demonstrated a simiIar reaction in this test. When the depiIatory cream was later inadvertentIy used for the remova of hair prior to surgery, erythema and contact dermatitis deveIoped in the patient, necessitating the postponement of the operation. In further explorations, the depiIatory cream was aIso used in the presurgica1 preparation of twenty maIe patients who were to have biIatera1 inguina1 herniorrhaphy. The inguina1 region on one side was prepared by shaving, and the other side was prepared with the depiIatory cream. At the time of operation, sections of skin from each side were removed for histoIogic
CLINICAL
USE
AND
RESULTS
To estabhsh the efhciency of this depiIatory cream, it was empIoyed for the presurgica1 remova of hair in 515 patients, in six it was used twice for two stage operations. Of two other patients, whose pathoIogic condition required successive operative procedures, one had four applications of the depiIatory in eighteen weeks, and the other had three appIi-
902
EvaIuation
of a ChemicaI
Depilatory
cations in a twelve week period. The cream was used a total of 526 times in 31s patients. The surgical procedures involved and observations on the efficiency of the cream in removing hair are presented in Table II. Depilatory efficiency was classified as excellent, fair or poor. It was considered excellent when the operative site was left clean and smooth and no ancillary shaving was required. It was listed as fair when a few hairs remained on the skin surface, because of either natural resistance in the hair texture of the individual or to inexpert application of the cream. The classification of poor was reserved for those patients in whom hair removal was unsatisfactory and additional shaving had to be performed, or when the cream was removed before the expiration of ten minutes because of Iocal discomfort. Review of the surgica1 or obstetrica procedures in Table II shows that all areas of the body surface and many different pathologic conditions were involved. The results in terms of hair removal were considered exceIIent in 470 patients (89.5 per cent), fair in forty-five patients (8.55 per cent) and poor in eIeven patients (2.1 per cent). No deIeterious effect was observed when the cream was applied around lacerations or over inflamed sites such as abscesses or areas of ceIlulitis. Because of the ease of application and remova1, its use was attended by less discomfort or pain than shaving, especiaIIy notable in those patients whose pathologic condition was painful or Iocated in body crevices or normally sensitive regions. In the vast majority of our patients, operative sites were ahdomina1 or inguinal. Many of the exploratory Iaparotomies were for stab wounds of the abdomen, lysis of adhesions for intestinal obstruction, or incision and drainage of intra-abdominal abscesses. No difficulty was encountered even in such painful conditions as appendiceal abscesses, incarcerated herniae or prolapse of intra-abdominal contents through a stab wound. The rapidity of hair removal with minimal discomfort to these patients was noteworthy. The cream was also highly effective when used before surgery on the head, neck or face. SpeciaI precautions were observed to avoid contact with the eyes or remova of the eyebrows or eyeIashes. ShouId the cream touch the ocular membranes, immediate and thor-
for Preoperative
Preparation TABLE
FFFECTIVENESS
II
OF
A
DEPiLATORY
Exploratory laparotomy.. Inauinal herniorrhzwhv Genital procedures iw&nent) Rectal procedures.. Abdominal vroceduws.. Head. neck and face.. . . . ..I Genital procedures (men) Amputations and open reduction of fractures. Breast Cholecvstectomy.. Thora& ,xr,ccdures.
1..
Abdominal-Perineal.. Prostatcctamy..
Tendon transplant Skin grafting: Total.
(hand)
I’KESURGICAI CREAM
~ / ! 1
-z -I 26 30 JO ._ 1.$
i ~ i I
21 61 36 30 23
, ,
60
i
32
3
2‘
I
24
i
I
i
3
I
,1 I__-Y. .; *526 /
* 5~5 patients, some had more than one application. patients with perineal prep;u;~tion t Includes ten delivery.
beforr
ough washing with water is recommended to avoid chemica1 conjunctivitis. In five patients undergoing plastic surgery with autografts of skin, the cream was used for the remova of hair from the donor as well as the recipient sites. There were no complications and no interference with the “take” of the grafts. A limited survey was made of the usefulness of the depilatory cream in obstetrical practice. In the perinea1 preparation of ten patients, the usual routine was followed, cutting off excessively Iong or thick hair with scissors, and then applying the cream. In this group, depilation generalIy was satisfactory, but some discomfort (stinging) was reported when the cream inadvertentIy came in contact with the mucous membrane of the labia minora. The depilatory was not used when delivery appeared imminent, as a precaution against irritating the eyes of the newborn infant. In eight of the eleven patients in whom the depilatory results were classified as poor in Table II, there were associated side reactions of such a nature as to necessitate the removal of the cream, and the preparation of the operative site was completed by shaving.
Prigot,
Garnes
and Nwagbo
TABLE SIDE REACTIONS
FOLLOWING
-
THE
USE
III
OF A
PRESURGICAL
-
DEPILATORY
CREAM
Type of Side Reactions *No. of Applications
Operative Procedure or Site of Surgery
ExpIoratory Iaparotomy. ........ InguinaI herniorrhaphy. ......... Genital procedures (women1 ) ..... Rectal procedures ............... Abdominal procedures ........... Head, neck and face ............. GenitaI procedures (men). ....... Amputations and open reduction o i fractures ..................... Breast .........................
ChoIecystectomy................ Thoracic procedures ............. Appendectomy
..................
Gastrectomy................... Lumbar region and back ......... Abdominal-PerineaI. ............
Prostatectomy.................. Tendon Transplant (hand). Skin grafting ...................
No. of Patients with Side Reactions
Burning Sensation
6 4 4 4 3 I
72 71 26 30 49 24
Stinging Erythema
36 30 23 29 30 13 2
-
SIight
3 2
2
2
I
2
4
I I
Severe
3 2
I I
2
I
I I
21
61
Rash
Prllritis
I
I
I
I
I I
I
I
I
I
I I
I
I
I
I
I
I
3 I
......
5 *526
TotaI ........................
_37
25
I4
-
IO
-
* 513 patients, some had more than one application. t Includes ten patients who had perinea1 preparation
SIDE
Urticaria
9
7
5
4
-
before debvery.
ever, if the patient reported the subjective reaction as painfuI or if there was objective evidence, such as erythema or rash, the cream was immediately removed and the preparation of the operative site was completed by shaving. The incidence of side effects, whether minor or severe, is recorded in TabIe III for comparison with the number of applications; the operative site was identified by the body area or the type of surgica1 procedure. The depiIatory cream was empIoyed for preoperative preparation 526 times in 515 patients. Thirtyseven reported side effects, of which the most frequent were burning or stinging or transitory erythema. These accounted for more than 60 per cent of the undesirabIe manifestations. Erythema, urticaria, pruritis, burning and stinging generaIIy disappeared within a matter of minutes after remova of the cream. In a few instances some discomfort persisted for two hours. In nine patients in whom a rash
REACTIONS
As previousIy noted, patients with histories of aIIergy were tested prior to the preoperative use of the cream. Three of the five patients whose reported aIIergies were manifested mainIy by dermatitis or eczema, had positive reactions to the patch test, and were not considered good candidates for further use of the depiIatory cream. It was our opinion that the innocuous character of the cream demonstrated in the patch test justified its routine use in the preparation of a11 surgica1 patients,‘with the exception of those cited above. AI1 patients were carefuIIy observed for immediate or deIayed reactions attributabIe to the depiIatory. CompIaints of minor discomfort, such as transitory stinging or burning were disregarded, provided the sensations, operative site remained free of erythema. How904
EvaIuation
of a ChemicaI
DepiIatory
developed, this followed the usual course contact dermatitis, lasting from three days Ihur patients, to two weeks in one patient.
of in
An analysis of the side effects associated with preoperative hair removal with the depilatory cream discloses that some complaints were caused by factors other than the chemical compound itself. The following case reports are
illustrative: A twenty-one year old woman (L. R., Hospital No. oz-o6og) was hospitalized for a right inguinai hernia. On April 8, 1962, in preparation for surgery, the depilatory cream was applied to remove hair from the pubic and inguinal region. The nurses’ aide performing this procedure inadvertently placed some of the cream on the labia minor and the resultant burning sensation necessitated the immediate removal of the depilatory. Hair removal was completed by shaving. In this patient, inexpert application undoubtedIy the cause of the side reaction the unsuccessful chemical remova of the
was and hair.
A forty-seven year old man (M. K., HospitaI No. 61-8735) was admitted with a tender anal lesion. On June 6, 1961, he was prepared for biopsy, the perineal hair was removed with the depilatory cream. The patient did not complain of discomfort during this procedure nor was there any evidence of local reaction. The biopsy of anal tissue revealed squamous cell carcinoma, and an abdominal perineal operation with dissection of the inguinal nodes was contemplated. On July 3rd, in preparation for surgery, a blood transfusion was given, immediately followed by chills, fever, generalized erythema and edema. The patient responded satisfactorily to antihistamine therapy for the transfusion reaction. The next day the hair over the operative site was removed with the depilatory cream, the second such appIication this patient had received, and localized erythema, edema and dermatitis developed. This reaction was not attended by discomfort, and the subsequent surgical procedure was without incident. To check on the possibIe allergenicity of the cream, a skin test was performed during the patient’s postoperative phase. A small amount of the cream was placed on his arm and left undisturbed for an hour. No reaction, either subjective or objective was observed. In view
cluded
that
of this
negative rest&, it was conthe Iocal side effects folIowing the
for Preoperative
Preparation
second preoperative use of the depilatory were related to the temporary extreme sensitivity of the patient from the transfusion reaction. The last case for which a special review is of interest, is that of a patient who had four applications of the depiIatory cream. Twice it was applied to the right chest with no allergic manifestation. The third time, it was applied to the head with the subsequent development of a dermatitis on the left side of the head. On the fourth occasion, the cream was again applied to the chest with the reaction of a mild, temporary erythema. A woman (J. McG., Hospital No. 61-15o5o) forty-seven years of age was admitted to Harlem Hospital on September 4, rg6r, with a bronchopleural fistula and a right empyema cavity. On October 3, the right chest was prepared for closed thoracotomy, and the cream was used for hair removal, with satisfactory results. On October 17, a right thoracoplasty was performed. Since there had been no significant regrowth in the interval, the depilatory was not employed before the procedure On November g, the patient had a convulsion and subsequent weakness of the extremities on the left side. She was aphasic and disoriented. These developments, considered with her prolonged systemic infection, led to a diagnosis of brain abscess, and the patient’s head was prepared for surgery on November IO. The depilatory was applied over the proposed operative site with no complaint from the patient. However, when the nurse removed the cream by wiping and then washing the area, it was noted that the left side of the scalp was blanched and excoriation rapidly developed. The operation was postponed and the patient received interim antibiotic therapy. Her general condition improved and the localized scalp dermatitis subsided. Skin tests were subsequently conducted in which small amounts of the cream were left on the body and the right side of the head for prolonged periods. No untoward reaction occurred. In view of the prior successful use of the cream and the negative skin tests, as well as the limitation of the adverse reaction to the left side of the head, it was concluded that the nurse empIoyed in the solution with which the cream was washed off, a substance which gave rise to a Iocal irritation. The patient remained in the hospital and on February 6, 1962, and again on the thirteenth of that month, revisions of the thoracotomy wound were performed. On each occasion the depiIatory was used for preoperative preparation with only a slight erythema which did not inconvenience the patient nor interfere with surgery.
Prigot,
Garnes
and Nwagbo reactions and emphasize precautions in the topica appIication of any chemica1 substance.
These subsequent applications of the cream without significant aIIergic manifestations confirm our impression that some other factor precipitated the episode of IocaI irritation which had occurred the previous November. As previously noted, in eight instances it was necessary to remove the depiIatory cream immediateIy when severe IocaI reactions occurred, and the preoperative preparation of these patients was compIeted by shaving. In two other patients, the surgicaI procedures were postponed temporarily because of late aIIergic manifestations.
CONCLUSION
This cream is superior to shaving technics in depiIation of operative sites and resuIted in surgica1 fields free of hair, celIuIar debris and derma1 excoriation. With precautions to avoid contact with mucous membranes or use in highly alIergic individuaIs, we recommend it as a useful adjunct and an advance in the management of the surgica1 patient. REFERENCES
I.
SUMMARY
Physician as patient. Ann. Int. Med., 55: 1039,
1961. 2. YUST, W. EncycIopediaBritannica, 14th ed., voI. 16, p. 33. Chicago, 1949. 3. EBELL, B. (Translator): The Papyrus Ebers, Levin & Munksgaard, Copenhagen, H. MiIford, London, 1937. 63: 76: 80. 4. CHAPLET, H. Epilatories. Par&m Moderne, 24: 427,
A hair removing cream was empIoyed in the preoperative preparation of 515 patients. The necessitated depilation surgical procedures which involved a11 regions of the body. The superiority of the cream over shaving technics was established in 470 of 526 applications, the body surfaces were Ieft cIean and smooth with no scratching nor excoriation of the skin. In appearance and odor the cream is acceptable to patients. Nurses report that its consistency and ease of appIication and remova facihtated the preparation of surgica1 patients, hair was removed from body crevices, infIamed or sensitive areas, and around Iacerations with rapidity and without discomfort. AIthough the bacteria1 inhibitory properties are Iimited, the compound is steriIe. In animal studies, it effectively removed hair and ceIIuIar debris, was nonirritating and nontoxic and did not interfere with the heaIing of experimenta wounds. HistoIogic comparison of dermaI sections from the same patient, one operative site shaved and the other prepared with the depiIatory, revealed no tissue reaction to the chemical compound. In pIastic surgery and autografts of the skin, there was no interference with the “take” of the graft. A low order of alIergenicity was found in patch tests in IOO patients. Side reactions in preoperative hair removal are reported thirtyseven times in 526 appIications. The majority of these manifestations were miId in character and of short duration. Three case histories detaiI other factors accountabIe for adverse
709, 779. 835, ‘930. and present. 5. DOWNING, J. G. Cosmetics-past J. A. M. A., 102: 2089, 1934. 6. FRIEDMANN, M. Zur Geschicte der Engernung ungewuenschter Haare. Dermat. Wocbenscbr., 90: 45’. 1930. 7. PIESSE, G. The Art of Perfumery, 3rd ed., p. 313. London, 1892. Longmans, Green. 8. VOLK, R. and WINTER, F. Lexikon der kosmetschen Praxis. p. 107. Wien, 1936. J. Springer. 9. MOORE, E. K. and KOPPENHOEFER,R. Studies on the chemistry of Iiming. VI. The inffuence of various suIfides on unhairing with calcium hydroxide suspensions. J. Am. Leatber Cbem. Assn., 28: 206, 1933. IO. JANISTYNE, H. Modern depiIatories. Soap, Perfumery @ Cosmetics, I I : 419, 1938. _ II. FRUTON. J. S. and CLARK. H. T. Chemical reactivity’ of cystine and its derivatives. J. Biol. Cbem.. 106: 667, 1934. _-. 12. MERCE;, E. H. Some experiments in the orientation and hardening of keratin in the hair foIIicle. Biocbim. et Biopb;. acta, 3: 161, 1949. studies of keratin 13. STOVES, J. L. HistochemicaI fibres. Proc. Roy. Sot., London s.B., 626: 132, 1945. 14. STOVES, J. L. The roIe of disulfides and mercaptans in hair chemistry. J. Sot. Cosmet. Cbem., 3: 17% 1952. 15. ROSENTHAL, N. A. and OSTER, G. Recent progress in the chemistry of disuIfides. J. Sot. Cosmet. Cbem., 5: 286, 1;54. 16. VESTAL. P. W. Preooerative Dreoaration of the skin with a depiIatory cream and a detergent. Am. J. Surg., 3: 398, 1952. I
906
I
HAVINGhas been the traditiona method of remova in preparing body surfaces for surgery. AIthough generaIIy satisfactory, it is attended by some disadvantages. It is time consuming and adequate remova of hair may be diffrcuIt in the body foIds, axiIIae, pubic, perinea1 and scrota1 regions. When infection is present, shaving over a sensitive area may be extremeIy painfu1. If the shaving technic is not skilIfuIIy performed, the skin may be excoriated, offering an idea1 porta of entry for infection. The shaving equipment may not be sterile, and there is the possibility of transferring pathogenic microorganisms from one patient to another. AIthough to the surgeon, the preparation of the body surface for operation is onIy a step in the tota care of the surgical patient; nevertheIess, the sense of indignity and the apprehensions engendered in the patient by the shaving procedure are worthy of consideration
S hair
[Il.
ChemicaI methods offer an intriguing possibiIity for the remova of hair in the preoperative preparation of the patient and may avoid some of the deficiencies of shaving. ChemicaI depiIation has been known since antiquity. The primitives used singeing, minera1, vegetabIe or animaI matter in ointment and paste American
Journal
of Surgery.
Volume
104, December
1962
900
form to remove hair or prevent its regrowth [2]. The Papyrus Ebers, a rich source of antique medica recipes and arts, Iists items such as “burnt Ieaf of lotus in oi1,” “she11 of tortoise with the fat of hippopotamus,” and “the blood of oxen and goats mixed with stibium and maIachite” [3]. Authoritative reIigious orders and socia1 customs among the civiIizations of the Medi., terranean and Orient between 2400 and 3000 B.C. subscribed to the remova of body hair [4--61. An earIy and weII-known depiIatory is Rhusma Turcortum, a mixture of orpiment (natura1 arsenic trisuIfide), quick Iime and starch in paste form with water, has been extensiveIy used by OrientaI harem women, as we11 as among certain present day African tribes [7,8]. MetaIIic sulfides [9,ro] were used for cosmetic depiIation for a Iong time, but these substances were maIodorous, unpredictabIe in their action, and had a high incidence of IocaI irritation and systemic toxicity. Modern fashions in women’s appare1 necessitate the remova of superffuous hair from Iegs, arms and axiIIae throughout the year. Shaving for cosmetic purposes is beset by many of the disadvantages that obtain when this procedure is used in medica practice. This Ied to the demand for a convenient, nontoxic and nonirritating method of hair remova1. The main obstacIe to the development of a safe chemica1 for depiIation is the simiIar proinacious character of hair and skin. Both contain keratin and are subject to attack by
EvaIuation
of a ChemicaI
DepiIatory
the same chemical agents in approximateIy the same degree. The disintegration of hair is accomplished chemicaIIy by the rupture of the S-S linkage, converting the cystine in keratin to cysteine [11,r2]. Factors favoring chemical depiIation are the greater content of keratin in the hair than in the skin and the fact that the hair offers many surfaces for attack; whereas, the skin presents onIy one phase. It was not unti1 the introduction of the thiogIycoIIates into the cosmetic heId that reliabie and reIativeIy safe, nontoxic chemical depiIatories became avaiIabIe [I?-r~]. Investigations of these preparations discIosed properties that suggested their use for preoperative hair remova in surgica1 practice. The use of a rhemica1 depiIatory is not new in the medica field. In 1952 Vista1 [ r6] reported his experience with such a compound in 460 patients. The idea1 chemica1 agent for the remova of hair in the preparation of body surfaces for surgery shouId be nontoxic IocaIIy and systemicahy, of a low order of aIIergenicity; shouId not interfere with wound heaIing; and it should be effective in Iess time and attended by Iess discomfort than shaving. A depiIatory cream designed to meet these criteria was submitted for cIinica1 evaIuation. The cream is a homogenate mixture of caIcium thioglycoIIate, caIcium and strontium hydroxides in an emoIIient base, preserved with bithiono1. It was supplied for hospita1 use in coIIapsibIe meta tubes. The cream has a pleasant odor and its viscosity faciIitates topica1 appIication. BacterioIogic, anima1 and in vivo experiments were undertaken prior to the use of this depiIatory in the preparation of patients for surgery. BACTERIOLOGIC
for Preoperative
Preparation
no effect against the gram negative cultures. However, when the cream was streaked in bIood agar ptates, it failed to reveal any contaminants. When bacteria1 cuItures were made from the skin surfaces from which the hair was to be removed, and cultures repeated after depilation, the same organisms were recovered as originally identified, but in lesser numbers. It was, therefore, concluded that, aIthough the cream was sterile and did not support bacterial growth, its antiseptic properties hvere not significant from a clinica point of view. ANIMAL
EXPERIMENTS
_ Rabbits were empIoyed in experiments to test the depiIatory efficiency of the cream, the IeveI of tolerance and its effect on wound heaIing. Hair was removed from one side of the backs of Iive rabbits by the conventional method of shaving and from the other side with the depiIatory. The animaIs were anesthetized and paired g cm. incisions to the subcutaneous tissue were made on each side, observing the usual surgica1 precautions, and the incisions were then sutured. The wounds on both sides healed without incident and the sutures were removed on the tenth postoperative dav. In a second experiment to determine the effect on granuIating wounds, operative sites were prepared as above in Iive animals, and simiIar incisions were made on each side, but these were not sutured. A greater amount of subcutaneous tissue was, therefore, exposed and the wounds were aIlowed to heal by secondary intention. There was no diIl’erence in the heahng process of the two Iesions in each of these rabbits. AI1 wounds were healed by the twenty-Iirst postoperative day. In these experiments the use of the depilatory prior to anesthesia produced no evidence of pain reaction in these animaIs and no local irritation either pre- or postoperatively was noted. The efficiency of hair removal was of a high order, much of the ceIIuIar debris was removed aIong with the hair, Ieaving the body surface clean and smooth.
STUDIES
The cream was tested for microbicida activity, empIoying the standard seria1 diIution and the agar plate cup method with brainheart infusion broth and agar, respectiveIy. The test organisms were two strains each of Staphylococcus aureus, Bacillus subtilis, Aerobatter aerogenes and Escbericbia coli. AI1 were cIinica1 isolates recovered from hospitarized patients, rather than laboratory strains. Some inhibition of growth of gram positive strains was demonstrated, but the cream had
In
ViVO
EXPERIMENTS
To determine the incidence of aIIergic re.sponse to the cream, IOO patients were sub901
Prigot, Garnes and Nwagbo TABLE RESULTS
OF
PATCH
TEST
DEPILATORY
examination. No discernible difference in the histoIogic sections was observed. In these patients the incisions on both sides heaIed without incident.
I FOR
ALLERGENICITY
OF
CREAM
Conditions
Patients Tested
Reactions METHOD
With history of aIIergy Hay fever ................... Asthma. .................... Contact dermatitis ........... Dermatitis medicamentosa .... No history of allergy. .......... TotaI .......................
22
0
5
3
3
0
50
I
IO0
APPLICATION
The custom in many hospitaIs is for the patient undergoing elective surgery to be prepared the night before. At HarIem HospitaI the majority of our patients have acute surgica1 conditions requiring the use of the depiIatory just prior to the emergency operation. The time factor, as between preparation twelve to fifteen hours before surgery and immediateIy before, presented no probIems. With long or thick hair growth, as on the head or in the axiIIary, pubic or perinea1 regions, the hair may be cIipped with scissors before the appIication of the depilatory. The desirabiIity of this preIiminary step may be judged with greater accuracy as experience with the compound increases. In a11 patients the cream was appIied and spread evenIy with a tongue depressor, Ieaving a generous Iayer on the surface. After a minimum of ten minutes, the cream with the softened hair was removed with gauze or a tongue depressor, and the area then washed with water. The usua1 procedures for presurgica1 antisepsis were then foIlowed. The minimum period of ten minutes before removal of the cream was determined through triaIs with various time intervaIs. It was observed that shorter periods of contact gave less satisfactory resuIts in hair removal. Longer periods did not enhance the effectiveness of the cream. However, it is noteworthy that proIonged contact with the skin had no deleterious effect. This is because of the infhrence of the emoIIient components in the cream which act as a protective coIIoid upon topical application.
0
20
OF
4
jetted to skin tests. Fifty of these patients had historres of alIergy; the remaining fifty reported that they had never experienced such manifestations. ApproximateIy I gm. of the depiIatory was spread over an area of I cm. of skin of the arm, covered with an adhesive bandage, and allowed to remain in contact with the skin for one hour. If erythema, edema or rash appeared at the site of apphcation, the patient was deemed sensitive to the depiIatory. In Table I, it wiI1 be noted that three patients in the contact dermatitis group showed a positive reaction, and one patient in the group with no aIIergy history demonstrated a IocaI response. Two important considerations were reIated to this toIerance test, one of a positive and one of a negative nature. One patient, in whom irritation had previousIy developed in the axiIIae foIIowing the use of a commerciaIIy avaiIabIe depiIatory, had no untoward reaction when this cream was empIoyed. Another patient, a seventy-seven year oId man with a history of ahergic skin manifestations, demonstrated a simiIar reaction in this test. When the depiIatory cream was later inadvertentIy used for the remova of hair prior to surgery, erythema and contact dermatitis deveIoped in the patient, necessitating the postponement of the operation. In further explorations, the depiIatory cream was aIso used in the presurgica1 preparation of twenty maIe patients who were to have biIatera1 inguina1 herniorrhaphy. The inguina1 region on one side was prepared by shaving, and the other side was prepared with the depiIatory cream. At the time of operation, sections of skin from each side were removed for histoIogic
CLINICAL
USE
AND
RESULTS
To estabhsh the efhciency of this depiIatory cream, it was empIoyed for the presurgica1 remova of hair in 515 patients, in six it was used twice for two stage operations. Of two other patients, whose pathoIogic condition required successive operative procedures, one had four applications of the depiIatory in eighteen weeks, and the other had three appIi-
902
EvaIuation
of a ChemicaI
Depilatory
cations in a twelve week period. The cream was used a total of 526 times in 31s patients. The surgical procedures involved and observations on the efficiency of the cream in removing hair are presented in Table II. Depilatory efficiency was classified as excellent, fair or poor. It was considered excellent when the operative site was left clean and smooth and no ancillary shaving was required. It was listed as fair when a few hairs remained on the skin surface, because of either natural resistance in the hair texture of the individual or to inexpert application of the cream. The classification of poor was reserved for those patients in whom hair removal was unsatisfactory and additional shaving had to be performed, or when the cream was removed before the expiration of ten minutes because of Iocal discomfort. Review of the surgica1 or obstetrica procedures in Table II shows that all areas of the body surface and many different pathologic conditions were involved. The results in terms of hair removal were considered exceIIent in 470 patients (89.5 per cent), fair in forty-five patients (8.55 per cent) and poor in eIeven patients (2.1 per cent). No deIeterious effect was observed when the cream was applied around lacerations or over inflamed sites such as abscesses or areas of ceIlulitis. Because of the ease of application and remova1, its use was attended by less discomfort or pain than shaving, especiaIIy notable in those patients whose pathologic condition was painful or Iocated in body crevices or normally sensitive regions. In the vast majority of our patients, operative sites were ahdomina1 or inguinal. Many of the exploratory Iaparotomies were for stab wounds of the abdomen, lysis of adhesions for intestinal obstruction, or incision and drainage of intra-abdominal abscesses. No difficulty was encountered even in such painful conditions as appendiceal abscesses, incarcerated herniae or prolapse of intra-abdominal contents through a stab wound. The rapidity of hair removal with minimal discomfort to these patients was noteworthy. The cream was also highly effective when used before surgery on the head, neck or face. SpeciaI precautions were observed to avoid contact with the eyes or remova of the eyebrows or eyeIashes. ShouId the cream touch the ocular membranes, immediate and thor-
for Preoperative
Preparation TABLE
FFFECTIVENESS
II
OF
A
DEPiLATORY
Exploratory laparotomy.. Inauinal herniorrhzwhv Genital procedures iw&nent) Rectal procedures.. Abdominal vroceduws.. Head. neck and face.. . . . ..I Genital procedures (men) Amputations and open reduction of fractures. Breast Cholecvstectomy.. Thora& ,xr,ccdures.
1..
Abdominal-Perineal.. Prostatcctamy..
Tendon transplant Skin grafting: Total.
(hand)
I’KESURGICAI CREAM
~ / ! 1
-z -I 26 30 JO ._ 1.$
i ~ i I
21 61 36 30 23
, ,
60
i
32
3
2‘
I
24
i
I
i
3
I
,1 I__-Y. .; *526 /
* 5~5 patients, some had more than one application. patients with perineal prep;u;~tion t Includes ten delivery.
beforr
ough washing with water is recommended to avoid chemica1 conjunctivitis. In five patients undergoing plastic surgery with autografts of skin, the cream was used for the remova of hair from the donor as well as the recipient sites. There were no complications and no interference with the “take” of the grafts. A limited survey was made of the usefulness of the depilatory cream in obstetrical practice. In the perinea1 preparation of ten patients, the usual routine was followed, cutting off excessively Iong or thick hair with scissors, and then applying the cream. In this group, depilation generalIy was satisfactory, but some discomfort (stinging) was reported when the cream inadvertentIy came in contact with the mucous membrane of the labia minora. The depilatory was not used when delivery appeared imminent, as a precaution against irritating the eyes of the newborn infant. In eight of the eleven patients in whom the depilatory results were classified as poor in Table II, there were associated side reactions of such a nature as to necessitate the removal of the cream, and the preparation of the operative site was completed by shaving.
Prigot,
Garnes
and Nwagbo
TABLE SIDE REACTIONS
FOLLOWING
-
THE
USE
III
OF A
PRESURGICAL
-
DEPILATORY
CREAM
Type of Side Reactions *No. of Applications
Operative Procedure or Site of Surgery
ExpIoratory Iaparotomy. ........ InguinaI herniorrhaphy. ......... Genital procedures (women1 ) ..... Rectal procedures ............... Abdominal procedures ........... Head, neck and face ............. GenitaI procedures (men). ....... Amputations and open reduction o i fractures ..................... Breast .........................
ChoIecystectomy................ Thoracic procedures ............. Appendectomy
..................
Gastrectomy................... Lumbar region and back ......... Abdominal-PerineaI. ............
Prostatectomy.................. Tendon Transplant (hand). Skin grafting ...................
No. of Patients with Side Reactions
Burning Sensation
6 4 4 4 3 I
72 71 26 30 49 24
Stinging Erythema
36 30 23 29 30 13 2
-
SIight
3 2
2
2
I
2
4
I I
Severe
3 2
I I
2
I
I I
21
61
Rash
Prllritis
I
I
I
I
I I
I
I
I
I
I I
I
I
I
I
I
I
3 I
......
5 *526
TotaI ........................
_37
25
I4
-
IO
-
* 513 patients, some had more than one application. t Includes ten patients who had perinea1 preparation
SIDE
Urticaria
9
7
5
4
-
before debvery.
ever, if the patient reported the subjective reaction as painfuI or if there was objective evidence, such as erythema or rash, the cream was immediately removed and the preparation of the operative site was completed by shaving. The incidence of side effects, whether minor or severe, is recorded in TabIe III for comparison with the number of applications; the operative site was identified by the body area or the type of surgica1 procedure. The depiIatory cream was empIoyed for preoperative preparation 526 times in 515 patients. Thirtyseven reported side effects, of which the most frequent were burning or stinging or transitory erythema. These accounted for more than 60 per cent of the undesirabIe manifestations. Erythema, urticaria, pruritis, burning and stinging generaIIy disappeared within a matter of minutes after remova of the cream. In a few instances some discomfort persisted for two hours. In nine patients in whom a rash
REACTIONS
As previousIy noted, patients with histories of aIIergy were tested prior to the preoperative use of the cream. Three of the five patients whose reported aIIergies were manifested mainIy by dermatitis or eczema, had positive reactions to the patch test, and were not considered good candidates for further use of the depiIatory cream. It was our opinion that the innocuous character of the cream demonstrated in the patch test justified its routine use in the preparation of a11 surgica1 patients,‘with the exception of those cited above. AI1 patients were carefuIIy observed for immediate or deIayed reactions attributabIe to the depiIatory. CompIaints of minor discomfort, such as transitory stinging or burning were disregarded, provided the sensations, operative site remained free of erythema. How904
EvaIuation
of a ChemicaI
DepiIatory
developed, this followed the usual course contact dermatitis, lasting from three days Ihur patients, to two weeks in one patient.
of in
An analysis of the side effects associated with preoperative hair removal with the depilatory cream discloses that some complaints were caused by factors other than the chemical compound itself. The following case reports are
illustrative: A twenty-one year old woman (L. R., Hospital No. oz-o6og) was hospitalized for a right inguinai hernia. On April 8, 1962, in preparation for surgery, the depilatory cream was applied to remove hair from the pubic and inguinal region. The nurses’ aide performing this procedure inadvertently placed some of the cream on the labia minor and the resultant burning sensation necessitated the immediate removal of the depilatory. Hair removal was completed by shaving. In this patient, inexpert application undoubtedIy the cause of the side reaction the unsuccessful chemical remova of the
was and hair.
A forty-seven year old man (M. K., HospitaI No. 61-8735) was admitted with a tender anal lesion. On June 6, 1961, he was prepared for biopsy, the perineal hair was removed with the depilatory cream. The patient did not complain of discomfort during this procedure nor was there any evidence of local reaction. The biopsy of anal tissue revealed squamous cell carcinoma, and an abdominal perineal operation with dissection of the inguinal nodes was contemplated. On July 3rd, in preparation for surgery, a blood transfusion was given, immediately followed by chills, fever, generalized erythema and edema. The patient responded satisfactorily to antihistamine therapy for the transfusion reaction. The next day the hair over the operative site was removed with the depilatory cream, the second such appIication this patient had received, and localized erythema, edema and dermatitis developed. This reaction was not attended by discomfort, and the subsequent surgical procedure was without incident. To check on the possibIe allergenicity of the cream, a skin test was performed during the patient’s postoperative phase. A small amount of the cream was placed on his arm and left undisturbed for an hour. No reaction, either subjective or objective was observed. In view
cluded
that
of this
negative rest&, it was conthe Iocal side effects folIowing the
for Preoperative
Preparation
second preoperative use of the depilatory were related to the temporary extreme sensitivity of the patient from the transfusion reaction. The last case for which a special review is of interest, is that of a patient who had four applications of the depiIatory cream. Twice it was applied to the right chest with no allergic manifestation. The third time, it was applied to the head with the subsequent development of a dermatitis on the left side of the head. On the fourth occasion, the cream was again applied to the chest with the reaction of a mild, temporary erythema. A woman (J. McG., Hospital No. 61-15o5o) forty-seven years of age was admitted to Harlem Hospital on September 4, rg6r, with a bronchopleural fistula and a right empyema cavity. On October 3, the right chest was prepared for closed thoracotomy, and the cream was used for hair removal, with satisfactory results. On October 17, a right thoracoplasty was performed. Since there had been no significant regrowth in the interval, the depilatory was not employed before the procedure On November g, the patient had a convulsion and subsequent weakness of the extremities on the left side. She was aphasic and disoriented. These developments, considered with her prolonged systemic infection, led to a diagnosis of brain abscess, and the patient’s head was prepared for surgery on November IO. The depilatory was applied over the proposed operative site with no complaint from the patient. However, when the nurse removed the cream by wiping and then washing the area, it was noted that the left side of the scalp was blanched and excoriation rapidly developed. The operation was postponed and the patient received interim antibiotic therapy. Her general condition improved and the localized scalp dermatitis subsided. Skin tests were subsequently conducted in which small amounts of the cream were left on the body and the right side of the head for prolonged periods. No untoward reaction occurred. In view of the prior successful use of the cream and the negative skin tests, as well as the limitation of the adverse reaction to the left side of the head, it was concluded that the nurse empIoyed in the solution with which the cream was washed off, a substance which gave rise to a Iocal irritation. The patient remained in the hospital and on February 6, 1962, and again on the thirteenth of that month, revisions of the thoracotomy wound were performed. On each occasion the depiIatory was used for preoperative preparation with only a slight erythema which did not inconvenience the patient nor interfere with surgery.
Prigot,
Garnes
and Nwagbo reactions and emphasize precautions in the topica appIication of any chemica1 substance.
These subsequent applications of the cream without significant aIIergic manifestations confirm our impression that some other factor precipitated the episode of IocaI irritation which had occurred the previous November. As previously noted, in eight instances it was necessary to remove the depiIatory cream immediateIy when severe IocaI reactions occurred, and the preoperative preparation of these patients was compIeted by shaving. In two other patients, the surgicaI procedures were postponed temporarily because of late aIIergic manifestations.
CONCLUSION
This cream is superior to shaving technics in depiIation of operative sites and resuIted in surgica1 fields free of hair, celIuIar debris and derma1 excoriation. With precautions to avoid contact with mucous membranes or use in highly alIergic individuaIs, we recommend it as a useful adjunct and an advance in the management of the surgica1 patient. REFERENCES
I.
SUMMARY
Physician as patient. Ann. Int. Med., 55: 1039,
1961. 2. YUST, W. EncycIopediaBritannica, 14th ed., voI. 16, p. 33. Chicago, 1949. 3. EBELL, B. (Translator): The Papyrus Ebers, Levin & Munksgaard, Copenhagen, H. MiIford, London, 1937. 63: 76: 80. 4. CHAPLET, H. Epilatories. Par&m Moderne, 24: 427,
A hair removing cream was empIoyed in the preoperative preparation of 515 patients. The necessitated depilation surgical procedures which involved a11 regions of the body. The superiority of the cream over shaving technics was established in 470 of 526 applications, the body surfaces were Ieft cIean and smooth with no scratching nor excoriation of the skin. In appearance and odor the cream is acceptable to patients. Nurses report that its consistency and ease of appIication and remova facihtated the preparation of surgica1 patients, hair was removed from body crevices, infIamed or sensitive areas, and around Iacerations with rapidity and without discomfort. AIthough the bacteria1 inhibitory properties are Iimited, the compound is steriIe. In animal studies, it effectively removed hair and ceIIuIar debris, was nonirritating and nontoxic and did not interfere with the heaIing of experimenta wounds. HistoIogic comparison of dermaI sections from the same patient, one operative site shaved and the other prepared with the depiIatory, revealed no tissue reaction to the chemical compound. In pIastic surgery and autografts of the skin, there was no interference with the “take” of the graft. A low order of alIergenicity was found in patch tests in IOO patients. Side reactions in preoperative hair removal are reported thirtyseven times in 526 appIications. The majority of these manifestations were miId in character and of short duration. Three case histories detaiI other factors accountabIe for adverse
709, 779. 835, ‘930. and present. 5. DOWNING, J. G. Cosmetics-past J. A. M. A., 102: 2089, 1934. 6. FRIEDMANN, M. Zur Geschicte der Engernung ungewuenschter Haare. Dermat. Wocbenscbr., 90: 45’. 1930. 7. PIESSE, G. The Art of Perfumery, 3rd ed., p. 313. London, 1892. Longmans, Green. 8. VOLK, R. and WINTER, F. Lexikon der kosmetschen Praxis. p. 107. Wien, 1936. J. Springer. 9. MOORE, E. K. and KOPPENHOEFER,R. Studies on the chemistry of Iiming. VI. The inffuence of various suIfides on unhairing with calcium hydroxide suspensions. J. Am. Leatber Cbem. Assn., 28: 206, 1933. IO. JANISTYNE, H. Modern depiIatories. Soap, Perfumery @ Cosmetics, I I : 419, 1938. _ II. FRUTON. J. S. and CLARK. H. T. Chemical reactivity’ of cystine and its derivatives. J. Biol. Cbem.. 106: 667, 1934. _-. 12. MERCE;, E. H. Some experiments in the orientation and hardening of keratin in the hair foIIicle. Biocbim. et Biopb;. acta, 3: 161, 1949. studies of keratin 13. STOVES, J. L. HistochemicaI fibres. Proc. Roy. Sot., London s.B., 626: 132, 1945. 14. STOVES, J. L. The roIe of disulfides and mercaptans in hair chemistry. J. Sot. Cosmet. Cbem., 3: 17% 1952. 15. ROSENTHAL, N. A. and OSTER, G. Recent progress in the chemistry of disuIfides. J. Sot. Cosmet. Cbem., 5: 286, 1;54. 16. VESTAL. P. W. Preooerative Dreoaration of the skin with a depiIatory cream and a detergent. Am. J. Surg., 3: 398, 1952. I
906
I