CPD: Skin Disinfection for Injectables

We are all well-aware of the risk of complications following injectable procedures such as dermal fillers and botulinum toxin. Skin disinfection is an important step towards preventing complications, such as infection, from occurring, and failing to employ adequate practice can put your patients at risk. This article will explore the importance of skin disinfection before injectable procedures, examining what is available and considerations for their use.

Why disinfect? Cutaneous microbiota (bacterial skin flora) play a role in both cutaneous health and disease, with some microorganisms having the potential to become pathogens.1 The diverse milieu of present microorganisms support the growth of commensal bacteria which, in turn, directly and indirectly protect the host from pathogenic bacteria. Resident organisms are mainly gram-positive, and include Staphylococcus, Micrococcus, and Corynebacterium sp., Staphylococcus aureus and Streptococcus pyogenes. Gramnegative organisms are not usually found or flourish on normal skin due to its dry environment. When skin’s normal environment and defence mechanisms are changed or breached (e.g. become moist/ occlusive), both commensal and pathogenic bacteria can grow.2 Thus, percutaneous procedures such as injection of botulinum toxin A and dermal fillers necessitates correct and optimal antimicrobial skin preparation.

Dermal filler Injection of foreign materials such as dermal fillers are, indeed, placement of an implant that will remain in place for some time. As such, these are associated with a risk of infection.3 Risk of adverse events and infection have been reported to be associated with skin bacteria including Staphylococcus epidermidis and Propionibacterium acne,4 stiffer gels and longer-lasting filler materials,5,6 injection technique and certain locations.7,8,9 Only a few microorganisms, stated above, are reported to be sufficient to contaminate the medical device during insertion/ placement via mucous membrane or skin.10,11 This can result in bacterial colonisation of the implanted hydrogels which, in time, builds resistance to antimicrobial actions with the onset of symptoms varying shortly or years post implantation.12-14 One study reported that in several dermal fillers, including polyacrylamide, hyaluronic acid and hydroxyapatite gels, pathogens such as Pseudomonas aeruginosa, Staphylococcus epidermidis, and Propionibacterium acnes form strong biofilms (Figure 1).15,16 Other authors have reported bacterial colonisation over the semi-permanent fillers used in their study and no bacterial growth or chemoattractant properties over permanent acrylic compounds.17 In regards to skin preparation and dermal fillers, Wang et al. used two in vitro models to explore this. They simulated and examined skin preparation and injection of dermal filler using pig skin (alcohol, chlorhexidine and povidone-iodine wipes reported similar efficacy) and silicone materials (to study transfer of viable bacteria). They used dermal filler simulant (a clear liquid with similar elastic properties). Increased bacteria transfer was reported with needle diameter (30 gauge, 25 gauge, 18 gauge), decreased transfer with increased injection depth from 1-3mm, similar transfer via serial puncture and linear threading techniques, and increased with fanning technique. They explained the ‘in vitro’ nature of their study was a limitation. Greater disinfection time, ‘multiple wipe steps’, and choice of correct technique were recommended to improve efficacy of skin preparation.18

De Boulle and Heydenrych report the following as related to major dermal filler complications:19 • Inappropriate patient selection • Sterility • Product placement • Volume • Injection technique The above contributing factors are also supported by ‘Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations’ published in 2018.20

Botulinum toxin In 2003, Hutin et al. published a paper, which was a bulletin of the World Health Organization, titled ‘Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections’. They recommended washing visibly soiled or dirty skin, however, reported that swabbing clean skin prior to injections is not necessary. When disinfecting the skin, they advised that single-use swabs should be

Figure 1: 360-degree spherical panorama view inside biofilm of antibiotic resistant bacteria. A biofilm is an aggregate of microorganisms (bacteria, protozoa, fungi, algae, yeast and other microorganisms) that are physically joined together.16

used to maintain product-specific recommended contact time to ensure optimal antibacterial activity.21 It should be noted that the advice was not specific to any particular medication/preparation and was only restricted to ‘infection control’. Studies have reported that local infections and complications (e.g. abscesses, sepsis) can be caused by intramuscular injections.22-24 A case report of mycobacterial (non-tuberculous mycobacteriosis) infection secondary to injection of botulinum toxin A was published in 2015, but the authors could not find the source of the contamination.25 To my knowledge, no other major cases of infection have been reported post injection of botulinum toxin. However, avoidance of injection close to areas of infection, adjacent to acne or inflamed skin is advised26 and use of optimal disinfection protocol is still important and recommended.

Prevention Contamination during injection/placement is the first step to the pathogenesis process, so prevention is key. In this regard, two important steps are to be considered; skin preparation prior to injectables and the injection technique.18

Skin preparation Patient preparation prior to skin disinfection should not be overlooked. Patients should firstly have their hair in a hairband or surgical cap and their hands washed and alcohol gelled in case they do attempt to touch treatment areas during or after the procedure. It is advisable for the patients to attend clinic without makeup. If they present wearing makeup, it should be removed, as well as skincare products, including sunscreen.27 It is best to clean the target area and the vicinity, as contaminants can interfere with the activity of the antiseptics, for example, reduce alcohol’s antimicrobial action.28 To prevent possible contamination and infection, accurate and optimal skin disinfection is obligatory.

Antiseptic agents There are various types of antiseptic agents that can be considered for injectable procedures.

Alcohol Variations: • Isopropyl alcohol 70% • Isopropyl alcohol (70%) plus povidone-iodine • Isopropyl alcohol (70%) plus chlorhexidine gluconate (2%) Alcohol is a fast-acting, broad-spectrum antimicrobial antiseptic. It induces antimicrobial activity against the following by causing protein and DNA damage:29-32 • Gram-positive and gram-negative bacteria • Multidrug-resistant pathogens including methicillin-resistant

Staphylococcus aureus (MRSA) and vancomycin-resistant

Enterococcus (VRE) • Mycobacterium tuberculosis • Fungi Its action is rapid (< 30 seconds) but does not have a persistent and cumulative activity. The persistent effect of the disinfectant used is important as it suppresses the regrowth of the remaining and residual skin flora. Alcohol-based solutions, including chlorhexidine and alcohol or povidone-iodine and alcohol, have greater antimicrobial activity in comparison to alcohol alone and, upon application, there is an immediate reduction of the microbial count, with sustained efficacy for a period of time. 33 Oral disinfection and injection Implantation of dermal fillers via oral mucosa and multiple injection sites are to be avoided.55 A chlorhexidine gluconatebased mouthwash can be used, and is recommended, prior to lip and perioral injections to decrease oral bacterial flora and therefore reduce the risk of contamination.19,56 Chlorhexidine gluconate has excellent bactericidal activity and substantivity (oral retentiveness). The 0.2% and 0.12% rinses have similar efficacy when used at correct doses and the time of the rinse should be 30-60 seconds.57 Non-chlorhexidine based mouthwashes may not have the same antimicrobial efficacy or longevity of the action.58 Sodium hypochlorite-based mouthwashes (diluted to low percentages such as 0.05%-0.25%) are broad-spectrum antimicrobial agents.44,59 Oral rinse with such mouthwashes is recommended19 and are particularly important when intraoral and extra-oral massage is employed by the practitioner.

Povidone-iodine Variations: Povidone-iodine (combination of molecular iodine + polyvinylpyrrolidone) Povidone-iodine has a broad spectrum antimicrobial activity, with proven efficacy and action against resistant microorganisms (e.g. methicillin-resistant Staphylococcus aureus).34 It takes three to five minutes for optimal effect. It has been reported that combination of ethyl or isopropyl alcohol and povidone-iodine are rapid acting, broad spectrum and more persistent than either of the agents used alone.35 Practitioners should consider contraindications before use.

Chlorhexidine Variations: Chlorhexidine gluconate Chlorhexidine gluconate (0.5-1%) based products (in alcohol) has broad spectrum activity, excellent efficacy and persistent action (48 hours).33A combination of the fast and immediate action of alcohol and persistent activity of chlorhexidine or iodine is optimal.36,37,38 Caution is advised when using chlorhexidine. It should be kept away from the eyes and ears (ototoxic) and practitioners should check for allergy prior to application.32,39

Sodium hypochlorite Sodium hypochlorite is an effective antiseptic agent. Its introduction for hand hygiene in the 19th century by Hungarian physician Dr Ignaz Semmelweis resulted in a steep reduction in morbidity and mortality.40 It is used effectively and safely in large scale industrial environments and at home. It is a strong bactericidal (gram-positive and gramnegative bacteria), sporocidal and fungicidal. Alvarez et al. examined the antiseptic action between 10% povidone-iodine and 10% sodium hypochlorite and reported no difference.41 In another study, the antiseptic activity of 10% sodium hypochlorite was examined versus 2% chlorhexidine gluconate in 70% isopropyl alcohol in 30 healthy volunteers. They reported equal efficacy, but only for procedures that do not require a long-acting agent. The same study reported the same efficacy for procedures that do not require a long-lasting action for chlorhexidine gluconate in isopropyl alcohol, sodium hypochlorite, and povidone-iodine.42 Topical use of sodium hypochlorite is reported to have a long safety record, and is not a mutagen, carcinogen or teratogen, however it is associated with redness and sensitivity.43,44,51 There is toxicity associated with sodium

Figure 2: Example of a disposable sterile pack. Pack should contain: 1x pair of examination gloves, 1x sterile sheet (water repellent/absorbent – patient), 1x white waste disposal polythene bag, 1x paper dressing towel (2 ply), 5x non-woven swabs (4 ply), 1x reduced static apron, 1x wound measure guide (10cm in length), 1x sterile sheet (water repellent/absorbent – outer use).

hypochlorite use; uses beyond topical use (inhalation, injection, ingestion, deposition into tissue/blood stream) can result in ‘significant morbidity and even mortality’, according to one study.45

Hypochlorous acid Hypochlorous acid also has a long history and wide applications ranging from hospital environment cleaning to wound care with reported ‘powerful microbicidal, antibiofilm, and wound-healing potency’.46-48 It is generated from sodium hypochlorite and hydrogen peroxide, although manufacturers claim that very little to no sodium hypochlorite is detected in the final solution49,50 because of its association with redness and sensitivity.51 Hypochlorous acid is non-cytotoxic, has a wide range of activity (bactericidal, fungicidal, virucidal, sporicidal), reported to be pH-neutral to both the skin and wound cells, and has antibiofilm activity.48,52,53 These properties make stable hypochlorous acid solution effective and optimal in medical aesthetic settings and for pre- and posttreatment application. Severing et al. studied the safety and efficacy profiles of different commercial sodium hypochlorite/ hypochlorous acid solutions, and concluded that efficacy and biocompatibility depends on their ‘specific formulation and physicochemical properties’.54

Injection practices For administration of dermal fillers, use of disposable sterile packs per patient is recommended (Figure 2). Sterile packs are inexpensive, easy to obtain and convenient to use. Sterile gloves can be used, but are not essential.14 Despite using sterile packs, needles and cannulae should not be placed on the working surface without their sheath or cover, touched with gloves or gauze. The dermal filler gels are sterile, however, I understand that the majority of the syringes in the market are not. The practitioners should ensure needle or cannulae are not contaminated during the procedure. To avoid risk of biofilm formation, injection through nasal or oral mucosa is not recommended.6,60 Correct application protocol for a chosen antiseptic should be employed. It is beyond the scope of this article to discuss clinical setting, clinician professional presentation, clinical attire and personal protective equipment (PPE) and such similar topics. However, these topics are also important, and all healthcare professionals should have training on this or seek it if they do not. Summary Skin disinfection is recommended prior to injectables. This is of particular importance when injections are short/long term implants, as the product remains for a period of time. Alcohol, chlorhexidine gluconate in isopropyl alcohol, sodium hypochlorite, povidone-iodine, and hypochlorous acid are all effective antiseptic agents. However, their mode of action, antimicrobial coverage, onset and longevity of effect varies. By taking these variables into consideration, the optimal agent can be chosen for various medical aesthetic procedures. The antiseptic of choice should be fast-acting, broad-spectrum and for more invasive procedures, suppress regrowth of microorganisms during and for a time after the procedure.

Dr Souphiyeh Samizadeh is a dental surgeon and clinical director of Revivify London clinic. She is the founder of the Great British Academy of Aesthetic Medicine, is an honorary clinical teacher at King’s College London and Queen Mary University of London and is the visiting associate professor for Shanghai Jiao Tong University. Dr Samizadeh has multiple published papers in peer reviewed journals and frequently presents at national and international conferences. She trains aesthetic doctors, dermatologists and surgeons worldwide.

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