Scrub in or rub in?

New thoughts on hand asepsis

Dr. John Smith is getting ready for his first surgery of the day.

He puts on his cap and mask, adjusts them methodically, and starts to rigorously prepare his hands for surgery. He grabs a brush soaked with chlorhexidine scrub and goes to work, as if it were a ritual: First his fingers, then the palm of each hand, then the back, then his wrists, then his forearms, for a full five minutes, just like he has been doing for the past 15 years as a surgeon.

Sounds perfectly acceptable, doesn’t it?

What Dr. Smith doesn’t know is that his surgical scrub routine is actually detrimental to the health of his hands, increases the likelihood of contamination, and puts him at risk of developing occupational dermatitis.

Meanwhile, Dr. Denis Verwilghen of Copenhagen, Denmark, is getting ready for his first surgery of the day.

He puts on his cap and mask, adjusts them methodically, and starts to rigorously prepare his hands for surgery. He first gently washes his hands with a mild, non-medicated soap, dries them with a non-sterile paper towel, and then meticulously rubs a hydroalcoholic solution on his hands and arms for a couple of minutes — until they are dry.


Something new

For decades, veterinary colleges and practices have been teaching a very similar protocol for hand asepsis. But new evidence suggests that better methods are available.

In a 2011 article published in Veterinary Surgery, Dr. Verwilghen illustrates the superior effects of hydroalcoholic solutions on bacterial control and hand skin health.

Dr. Verwilghen’s article outlines multiple reasons that using a brush and chlorhexidine or povidone iodine scrub is detrimental to hand skin health. First, washing hands multiple times throughout the day results in loss of the natural barriers of the skin.“The hands of surgical staff have higher bacterial counts and more pathogenic organisms than the hands of others,” he writes. “One reason for this is the increased contact with infected wounds, but far more important is the effect of the products used for skin disinfection during pre-surgical hand preparation on skin integrity and skin-resident flora.”

“Each hand wash detrimentally alters the water lipid layer of the superficial skin, creating a loss of protective agents such as amino acids and natural antimicrobial factors.”

His next point addresses the length of time spent scrubbing hands before a procedure. This process has become something like a ritual for many colleagues and surgeons.

Chlorhexidine or povidone iodine scrubs require about five minutes of contact to be effective. “Prolonged or repeated washing leads to damaged barrier function of the stratum corneum, resulting in the skin becoming more permeable for toxic agents and bacteria.”

The third point informs the reader about the damage being done by the scrub brushes themselves. The current misconception is that by aggressively scrubbing the surface of the skin, more bacteria will be destroyed than if the antiseptic were simply rubbed in. In fact, “Scrubbing causes small excoriations and thus damages the skin, also increasing the risk of colonization of the skin by pathogenic species.”

In a recent survey performed among surgeons where hand health scores were evaluated, colleagues using chlorhexidine scrubs for hand preparation reported significantly lower hand health scores, particularly on moisture content and intactness, than did users of hydroalcoholic solutions. These findings corroborate reports from human literature and underline the detrimental effects of “regular” scrubbing products on our skin.


Rubbing over scrubbing?

There has been no reported resistance to commercially available alcohol-based rubs, in contrast to increasing reports on acquired chlorhexidine resistance. There are also fewer cases of contact dermatitis with alcohol-based rubs as compared to chlorhexidine or povidone iodine.

Because alcohol-based rubs evaporate and do not require copious rinsing, unlike traditional scrubs, there are a number of other benefits. Water usage is greatly decreased, as well as potential recontamination caused by faucets. Multiple species of Pseudomonas and other Gram-negative bacteria have been cultured from spigots.

Alcohol-based rubs perform as well or better than their scrub counterparts. Chlorhexidine scrubs have very good initial effect on bacteria but raise some concerns over their effect on methicillin-resistant Staph. aureus (MRSA) as well as certain species of enterococci.

Although povidone iodine has been shown to have good effects on MRSA micro-organisms, activity is variable against the more common strains of bacteria, especially in the presence of organic debris. Add to that the high likelihood for skin irritation and inevitable staining of cloth drapes, clothing and patient skin, and povidone-iodine scrubs seem to be the least popular method of presurgical prep.

Hydro alcoholic-based rubs perform as well as chlorhexidine scrubs initially but have a greater sustained effect over time. Unless hands become visibly soiled again, this suggests that after the first hand preparation of the day, application of the rub alone would satisfy hand asepsis protocols suggested by the World Health Organization.

The recommendations in Dr. Verwilghen’s article suggest that hydro-alcoholic rub solutions are superior to the more traditional chlorhexidine and povidone-iodine scrubs. Our colleague shared his findings at the last symposium of the American College of Veterinary Surgeons in San Antonio in October and created quite a stir.

I am among the many colleagues who are making the Big Switch.


Dr. Phil Zeltzman is a mobile, board-certified surgeon in Allentown, Pa. His website is He is the co-author of “Walk a Hound, Lose a Pound” (

Katie Kegerise, a certified veterinary technician in Reading, Pa., contributed to this article.


1. D. Verwilghen et al. “Presurgical hand antisepsis: concepts and current habits of veterinary surgeons.” Vet Surg. 2011, Vol 40, N 5, p. 515-521.
2. D. Verwilghen et al. Surgical hand antisepsis in veterinary practice: evaluation of soap scrubs and alcohol based rub techniques. Veterinary Journal. 2011, 190, 372-377.
3. D. Verwilghen. Presurgical hand asepsis in veterinary medicine: what is holding us back? 2013 Annual meeting of the ACVS, San Antonia, Texas.

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