Safety and efficacy of benzoyl peroxide, blue light and chlorhexidine in Cutibacterium prophylaxis

 Efficacy of Combinational Therapy Using Blue Light and Benzoyl Peroxide in Reducing Cutibacterium Acnes Bioburden at the Deltopectoral Interval: A Randomized Controlled Trial

These authors compared the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) prep in eradicating Cutibacterium on the skin surface at the deltopectoral interval measured by positive, quantitative cultures.

Adult male volunteers were randomized to one of three treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. For BLT group, a single 23- minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure 55.2 J/cm2).

 For BPO+BLT group, volunteers received both treatments. After treatment with either BPO, BLT, or both, a single swab culture was taken from the skin of the treatment shoulder. Next, control and treatment shoulders were prepped with CHX, and cultures were taken from each shoulder. 

Sixty male volunteers, 20 per group. Prior to CHX administration, 56 of the 60 samples grew Cutibacterium. 

The  BPO group and BPO+BLT group had significantly less growth of Cutibacterium than the BLT group after treatment but prior to CHX. 

Following CHX administration, BPO and BPO+BLT groups had significantly fewer positive cultures  and less quantity of growth compared to their control arms. This was not seen in BLT group. 

For quantitative between group analysis, no significant synergistic effects were seen in the BPO+BLT group compared to BPO only. 

The authors concluded that blue light therapy alone did not demonstrate effective antimicrobial properties against Cutibacterium. 

Comment: 

(1) An important lesson from this study is that a substantial percentage of subjects receiving prophylaxis experienced side effects (itching, burning, dryness, peeling, flaking, erythema) that would create a concern about making a skin incision for shoulder arthroplasty through the treated area. Six out of the 20 subjects in each group reported at least 1 side effect within 1 week of treatment. These treatments may not be benign. 

(2) The skin surface cultures were obtained soon after the application of CHX. Prior studies have shown that the prophylactic effect of CHX subsides rapidly after application.

(3) This study does not examine the effectiveness of prophylaxis on the levels of Cutibacterium in the dermis. It is the dermal levels that are of concern in that the pilosebaceous units are the reservoir for Cutibacterium; the dermal incision at arthroplasty releases Cutibacterium into the wound.

See the study below:Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients

These authors point out that home chlorhexidine washes prior to shoulder surgery are commonly used in an attempt to reduce the skin bacterial load. However, recent studies have suggested that this agent is relatively ineffective against Cutibacterium acne.

Benzoyl peroxide (BPO) soap is a treatment for acne, but evidence regarding its effectiveness as prophylaxis in shoulder surgery is lacking. 

The objective of their study was to compare the effectiveness of home chlorhexidine washes with benzoyl peroxide soap in patients undergoing shoulder arthroplasty surgery in reducing Cutibacterium levels on the skin surface and in the dermis. 

50 male patients planning to undergo shoulder arthroplasty were consented to be randomized into treatment with 4% chlorhexidine solution (CHG) or 10% benzoyl peroxide soap (BPO) used to wash the operative shoulder the night prior and morning of surgery. 

Skin swabs prior to incision and swabs of the dermis incised after standard skin preparation and preoperative IV antibiotics were obtained, and the bacterial load was reported in a semiquantitative manner as the Specimen Cutibacterium Value (SpCuV). 

Skin surface swabs were positive in 100% of patients using CHG and 100% of patients using BPO soap. 

The Cutibacterium load (SpCuV) on the skin surface was similar between the two groups (CHG 1.6 ± 1.1 vs. BPO 1.5 ± 1.4, p = 0.681). 

The percentages of dermal cultures that were positive were not significantly different between the two groups (CHG 61% vs BPO 46%, p = 0.369). 

The Cutibacterium load (SpCuV) on the incised dermal edge was similar between the two groups (CHG 0.8 ± 1.0 vs. BPO 0.8 ± 1.4, p = 0.991). 

The authors concluded that neither BPO soap nor chlorhexidine washes prior to shoulder surgery were effective in eliminating Cutibacterium from the skin surface or the incised dermal edge. 

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).