Benzoyl Peroxide May Be Used as Infection-Prevention Antiseptic in Dermatologic Surgery

Benzoyl peroxide (BPO) may serve as an effective antiseptic in dermatologic surgery of sebaceous areas, with efficacy in preventing post-operative infections with a low risk of microbial resistance, according to a review published in the Journal of Clinical and Aesthetic Dermatology.¹

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Skin antiseptics aim to reduce microbial load on the skin before surgical procedures, thus minimizing the risk of post-operative infections. The Centers for Disease Control and World Health Organization recommend alcohol-based antiseptic solutions, with chlorhexidine gluconate (CHG) and povidone-iodine (PVI) being the most commonly used agents.²

Chlorhexidine Gluconate (CHG)

• Rapid onset and long-lasting.
• Effective against a broad range of microbes.
• Used in concentrations tailored to clinical needs.
• Potential adverse effects include irritation and rare severe allergic reactions.
• Not recommended for periocular or periauricular areas due to risks of keratitis and ototoxicity.

Povidone-Iodine (PVI)

• Rapid onset and broad-spectrum efficacy.
• Safe for use in periocular regions.
• Works as a strong oxidizing agent disrupting microbial cell membranes.
• Potential adverse effects include irritant contact dermatitis and possible cross-reactivity with other iodine-containing medications.

Isopropyl Alcohol

• Fast-acting but short-lived.
• Effective through membrane damage and protein denaturation.
• Optimal bactericidal concentration is 60% to 90%.
• Risks include irritant contact dermatitis and flammability concerns.

Research on the effects of antiseptics on the skin microbiome reveals that these agents cause a rapid but temporary reduction in microbial populations. Studies indicate that bacterial identity and location within the skin layers influence microbiota stability post-antiseptic application. For instance, Propionibacteriaceae may persist due to deeper skin residency or internal resistance mechanisms.³

A study by McNeil et al. identified chlorhexidine resistance in S. aureus isolates from pediatric patients, with resistance genes qacA/B and smr found in nearly 45 percent of isolates. These findings, although not consistently replicated, suggest a link between antiseptic use and increased antibiotic resistance.⁴

Dermatologic surgery, often conducted in outpatient settings, typically has a low incidence of surgical site infections, even without stringent sterile protocols. Prophylactic antibiotics are generally reserved for high-risk patients or procedures, with their use guided by the type and location of the surgery. Recent trends show a decline in routine antibiotic use, reflecting growing awareness of antibiotic resistance.

BPO, known for its effectiveness against gram-positive bacteria such as Staphylococcus, Streptococcus, and Cutibacterium acnes, exhibits a high resistance threshold and the ability to penetrate sebaceous glands. These factors make it a promising candidate for pre-surgical preparation, particularly in sebaceous areas, according to the review. Studies have shown its efficacy in reducing surgical site infections, suggesting its broader application in dermatologic surgery.

A limitation of the review, potentially impacting its generalizability, is a lack of high-quality powered research studies exploring antiseptic use, or BPO use, in dermatologic surgery.

Understanding the topographical distribution of skin microbes can inform more precise antimicrobial treatments, reducing resistance and improving outcomes, according to authors.

"The use of benzoyl peroxide in sebaceous areas makes use of the topographical heterogeneity of skin and narrows antimicrobial coverage," according to review authors Abdin et al. "Given the rising issue of antibiotic resistance and the importance of antibiotic, and possibly antiseptic, stewardship, benzoyl peroxide is a promising pre-surgical preparation agent in dermatologic surgery of sebaceous areas."

References

1. Abdin R, Kaiser M, Del Rosso JQ, Issa NT. Antiseptic and antibiotic stewardship in dermatologic surgery: Is benzoyl peroxide the solution? J Clin Aesthet Dermatol. 2024;17(5):24-28.
2. Global Guidelines for the Prevention of Surgical Site Infection. 2 ed. Geneva: World Health Organization. 2018.
3. SanMiguel AJ, Meisel JS, Horwinski J, et al. Antiseptic agents elicit short-term, personalized, and body site-specific shifts in resident skin bacterial communities. J Invest Dermatol. 2018;138; 2234—2243.
4. McNeil JC, Kok EY, Vallejo JG, et al. Clinical and molecular features of decreased chlorhexidine susceptibility among nosocomial Staphylococcus aureus isolates at Texas Children’s Hospital. Antimicrob Agents Chemother. 2016 Feb; 60(2): 1121—1128.