Dermabrasion 

Updated: May 18, 2018
Author: Gaurav Bharti, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS 

Overview

Practice Essentials

Dermabrasion is a tried and true method for ablative facial resurfacing. Numerous laser resurfacing technologies are available in the marketplace and can be very costly devices with associated costly disposables for each use. Dermabrasion is highly cost effective and predictable when performed for the appropriately selected use.

Background

The face is arguably the most critical aesthetic unit of the human body. The art of facial rejuvenation has been practiced since ancient civilizations, and the interest in this subject continues to grow. Various options exist to perform skin resurfacing of the face, including dermabrasion, laser resurfacing, and chemical peels.[1, 2, 3, 4, 5] All skin-resurfacing modalities aim to remove damaged skin and stimulate normal wound healing. Dermabrasion is a simple, cost-effective means of skin resurfacing that can provide repeated and reliable results when used on the face or many other areas of the body.

The goal of dermabrasion is to remove a controlled thickness of damaged skin to stimulate normal wound healing and skin rejuvenation, while avoiding the complications of scarring and pigmentary changes.[6, 7] This controlled damage rapidly heals because of the abundance of a rich vascular and adnexal network along with the supply of macronutrients, which promotes tissue remodeling of the proteins and structures of the skin, yielding rejuvenated skin that is smoother and firmer than before.

Numerous studies have demonstrated that dermabrasion is a reliable and effective method for skin resurfacing and should be a part of a plastic and dermatologic surgeon's repertoire in resurfacing damaged skin and the aging and damaged face.[8] It has features that make it superior to chemical peels and lasers, including the ability to use it in focal segments of the face, the lower likelihood of injury to the pigment-containing melanocytes resulting in pigmentary changes, and the much lower cost compared with laser treatments. With experience, the risks of scarring and skin sloughing due to traction injuries are very low.

The development of antiviral medications, semipermeable dressings, tumescent anesthesia, and cryoanesthesia has advanced the technique of dermabrasion, as well as other resurfacing surgeries such as chemical peeling, ablative laser resurfacing (see Carbon Dioxide Cutaneous Laser Resurfacing and Erbium-YAG Cutaneous Laser Resurfacing), nonablative laser resurfacing, and microdermabrasion. A comprehensive understanding of the advantages and the disadvantages of each of these resurfacing procedures is necessary to achieve optimal surgical results in patients who undergo resurfacing surgery.

See the image below.

Technique and hand position for dermabrading raise Technique and hand position for dermabrading raised scars.

Anatomy

The most important element in dermabrasion is recognition of the appropriate depth of treatment. The skin is composed of 2 mutually dependent layers, the epidermis and the dermis, which rest on a fatty subcutaneous layer. The epidermis contains no blood vessels and protects the underlying dermis from the external elements. The epidermis is entirely dependent on the underlying dermis to deliver nutrients and to remove waste by means of diffusion across the dermoepidermal junction. An important function of the dermis is to sustain and support the epidermis. The dermis is divided into 2 layers: the relatively superficial papillary dermis and the relatively deep reticular dermis. Collagen, elastic tissue, and reticular fibers are present throughout both layers.

Epidermal appendages are intradermal epithelium-lined structures that can divide and differentiate. They develop as downgrowths of the epidermis into the dermis. They include sebaceous glands, sweat glands, apocrine glands, mammary glands, and hair follicles. Epidermal appendages serve an important role as a source of epithelial cells. These appendages are responsible for reepithelialization if the overlying epidermis is removed or destroyed in situations such as partial-thickness burns, chemical peeling, dermabrasion, traumatic abrasions, or harvesting of split-thickness skin grafts. See the image below.

Skin anatomy. Skin anatomy.

Controlled dermabrasion can be performed on the epidermis and on the upper layers of the dermis. The wound heals by means of reepithelialization from the remaining epidermal appendages, similar to the healing of partial-thickness burns. Reepithelialization begins within 24 hours of wounding and is usually complete after 7-10 days. Collagen remodeling continues for 3-6 months and results in dermal thickening and contraction, which further enhance the smoothing effect.

Areas of the body where the skin adheres closely and tightly to underlying structures are referred to as adherent or tight structures. Those areas where the skin can be very loose, such as the neck and upper and lower eyelids, are referred to as loose areas. Dermabrasion must be performed evenly across the entire area to be treated, and the leading edge needs to be as deep as the trailing edge of the abrader. This is very difficult to perform in areas that are very loose, even with cooling of the skin. Wherever possible, progression should go from fixed areas to looser areas rather than in the opposite direction. Areas of very loose skin can be caught within a mechanical dermabrader and sheared off completely, leaving a severe deficit, which can cause open wounds and scarring. Extremely loose areas should be approached with caution and only by an experienced dermabrasion specialist.

Pathophysiology

With aging, the skin undergoes atrophy. This process typically begins during the fourth decade of life. The outermost portion of the epidermis, the stratum corneum, becomes disorganized and less effective as a protective barrier to the external environment. A gradual decline also occurs in the number of melanocytes populating the basal layer of the epidermis. The dermoepidermal junction becomes flattened because fewer dermoepidermal papillae are present. The most significant changes occur in the dermis, where an overall loss of organization occurs as the dermis thins with age. The amount of ground substance decreases and elastic fibers degenerate, making the skin less resistant to deformational forces. Collagen is also lost, and the proportion of type I collagen relative to type III collagen is reduced.

Actinic damage also produces changes in the skin, resulting in skin that actually thickens. Actinic keratoses and lentigines form. Dermal elastosis results from accumulation of thickened degraded collagen and elastic fibers. Ground substance also increases, while mature forms of collagen decrease. Facial rhytides occur, probably as the result of a combination of aging, photodamage, gravity, and repeated use of the muscles of facial expression.

Prognosis

Dermabrasion is a well-established technique for skin resurfacing using mechanical abrasion of the skin. It can yield excellent results when a well-trained surgeon performs the procedure for the appropriate patient. The keys to performing dermabrasion are experience and understanding of its principles to provide sufficient resurfacing to the appropriate depth and minimize scar formation.[8] Careful patient screening is crucial to ensure realistic expectations.[8] With meticulous postoperative care, the results can be highly satisfying for patients.

With the armamentarium of resurfacing modalities increasing, mechanical dermabrasion remains an important dermatosurgical procedure, particularly for the improvement of cystic acne, postsurgical scars, partial-thickness Mohs defects, and the visual appearance of skin grafts.

Small areas may be easily and safely treated with proper technique, and these areas demonstrate rapid recovery. Although experience and skill are necessary in order to avoid serious complications with full-face dermabrasion, its efficacy for the treatment of acne scarring and deep rhytides currently remains unmatched for the patient who is willing to endure the resultant recovery period.

Close follow-up during the postoperative period is important in order to recognize and treat the most serious potential complications of infection and scarring at the earliest stages. While new technologies continue to emerge, mechanical resurfacing will likely remain an essential and unmatched modality for scar improvement.

Patient Education

Preoperative counseling is imperative to ensure realistic patient expectations. The patient's desired outcome must be clearly communicated and understood. Physicians may show patients preoperative and postoperative photos of patients treated with dermabrasion; complications should be included. In general, dermabrasion yields 35-50% subjective improvement of skin texture. Patients should not expect restoration of perfect skin, and dermabrasion does not affect skin redundancy or eliminate the possible need for rhytidectomy. Patients should be told that the greatest improvement is usually observed 6 months after surgery. Patients should be provided a reference list of alternative procedures and should be instructed that combining other procedures with dermabrasion is not uncommon.

Patients should avoid sun exposure before and after the procedure. Some surgeons prescribe antiviral prophylaxis to all patients, and patients with a history of herpes simplex should receive strong prophylactic doses of acyclovir 400 mg 3 times daily or valacyclovir 500 mg twice daily, beginning the day of, or even prior to, the procedure. The herpes virus requires viable epidermal cells to establish an infection. Therefore, antiviral therapy should continue for 10-14 days to allow complete reepithelialization to occur. Prophylactic antibiotics are usually not needed. However, patients with a history of impetigo, staphylococcal skin infection, or a compromised immune system may benefit from antibiotics.

After a patient is appropriately selected, the physician obtains informed consent for the procedure. This process includes a thorough discussion of possible complications. Select patients may require preoperative laboratory screening to include complete blood cell count and serum chemistries. In addition, at-risk individuals should be screened for HIV and infectious hepatitis

 

Presentation

History

The history should address bleeding disorders, prior herpes simplex infection, impetigo, keloidal or hypertrophic scarring, koebnerizing conditions, prior isotretinoin therapy, and immunosuppression.[9]

Patients should be questioned about previous exposure or any outbreaks of herpes simplex (ie, cold sores). For patients with a positive history of exposure or outbreaks, high-dose prophylactic antiviral medications are recommended. Prophylaxis with oral acyclovir 400 mg taken 3 times per day before and continued after the procedure can help reduce the risk of a herpetic outbreak. Dermabrasive surgery in patients with active herpetic lesions should be postponed.[10, 11]

The risk-to-benefit ratio of an iatrogenically induced wound is unfavorable in patients who are immunosuppressed, who have a history koebnerizing conditions such as lichen planus and psoriasis, or who demonstrate a propensity towards keloidal or hypertrophic scar formation.

A detailed drug history is important, specifically regarding isotretinoin, because recent isotretinoin exposure is a relative contraindication to dermabrasion. Shrunken sebaceous glands resulting from recent use of isotretinoin exposure can delay reepithelialization and increase the risk of hypertrophic scarring. To the authors' knowledge, no controlled studies have examined this problem; however, case reports have described delayed wound healing and keloid formation after treatment with dermabrasion.[12] Therefore, notable controversy remains regarding the use of isotretinoin in the setting of dermabrasion. In the current medicolegal climate, avoiding dermabrasion for at least 6 months after the completion of isotretinoin therapy is recommended; some authorsadvocateupto1 year.[13] .

The use of other medications, such as exogenous estrogens, oral contraceptives, or other photosensitizing drugs, may predispose patients to pigmentary changes after dermabrasion. The physician should ask about drug allergies, particularly allergies to topical petrolatum products or local anesthetics, to help prevent adverse reactions before and after the procedure. Use of medications that result in excessive bleeding (eg, aspirin, clopidogrel [Plavix], warfarin [Coumadin]) should also be noted.

When obtaining the patient history, physicians must determine if the patient may have infectious diseases that can be transferred by blood contact, such as HIV or hepatitis C. Dermabrasion causes a bloody field and aerosolization of blood. Even with the use of personal protective equipment such as goggles, masks, and scatter shields, the risk of viral transmission is not eliminated. Thus, dermabrasion is not recommended in patients who are HIV positive; other resurfacing options should be implemented.

Caution should also be exercised when planning to dermabrade patients who have recently undergone extensive procedures involving the area to be dermabraded, such as a facelift, because a robust blood supply is necessary for appropriate wound healing. Many surgeons prefer to wait 6 months after a facelift before subsequent dermabrasion.

Preexisting cardiac, hepatic, and renal disease may influence treatment decisions and choice of anesthetics. A history of a collagen disorder, cutis laxa, congenital ectodermal dysplasia, or scleroderma is a contraindication for dermabrasion because patients with these conditions often have abnormal adnexal structures and reepithelialize unpredictably.

Physical Examination

A detailed physical examination should be performed, including a determination of the patient’s motives for the procedure, preoperative photography, and skin type determination. The severity and depth of the patient’s condition needs to be assessed.

As part of the preoperative examination, meticulous attention should be given to the patient's skin type. Midrange skin types (III-IV) are more likely to become transiently hyperpigmented 4-8 weeks after surgery and hypopigmented 12-18 months after surgery. Lighter skin types (I-II) and the darkest skin type (VI) are less likely to heal with permanent discoloration.

Examine the patient's earlobes and sternum for areas of keloids or hypertrophic scarring. For patients with a history of keloid formation, a test spot is recommended prior to any full-face resurfacing or ablation of large nonfacial areas. Likewise, a history of koebnerizing or pathergic conditions, such as psoriasis, lichen planus, or pyoderma gangrenosum, may require test sites. Note the presence of facial telangiectasias and variation of pigment between the cosmetic units of the face. Finally, patients likely to be noncompliant or unable to avoid sun exposure because of occupation are unsuitable candidates for dermabrasion.

Patient motivation

Once the patient's skin and defects have been closely examined, an in-depth consultation should follow. The most important aspect of preoperative consultation is listening closely to the patient's specific motivation for undergoing dermabrasion.[14] Identifying this goal and establishing realistic outcome expectations is critical.

One of the most important components of the preoperative consultation is determining the patient’s specific motivation for resurfacing and establishing realistic expectations regarding the treatment outcome. The ultimate goal of any resurfacing treatment should be an improvement of the given defect rather than a complete eradication. Dermabrasion consistently achieves 30-50% improvement in the appearance of deep acne scars and rhytides, but the patient who seeks and expects the elimination of all scars and rhytides will rarely be satisfied.

Preoperative photography

Reviewing before-and-after photographs with the patient during consultation, particularly when considering full cosmetic unit or full-face dermabrasion, may foster realistic expectations for improvement.

Take a standardized set of preoperative photographs of each patient. These photographs can be taken directly in front of the patient at 45° angles (right and left sides) and at 90° angles (right and left sides). Close-up photographs of the defects are also helpful.

Skin type determination

The patient's skin type should be assessed using the Fitzpatrick classification and Glogau Scale (see Tables 1 and 2 below). The Fitzpatrick classification is used to categorize the skin according to its ability to tan or its likeliness to burn when it is exposed to ultraviolet (UV) light. The Glogau Scale is used to determine the overall amount of aging the face has undergone.

Table 1. Fitzpatrick Skin Classification [15] (Open Table in a new window)

Type

Skin Color

Characteristics

I

Very white

Always burns, never tans

II

White

Usually burns, tans with difficulty

III

White or light brown

Mildly burns, average ability to tan

IV

Brown

Rarely burns, tans easily

V

Dark brown

Very rarely burns, tans very easily

VI

Black

Never burns, darkly pigmented

In general, light skin types (types I-II) are most likely to heal without permanent color change, or dyschromia. Dark skin types are associated with increased rates of hypopigmentation and hyperpigmentation. Preexisting discolorations should be documented. Although dermabrasion produces some dyschromia in all patients, this effect can be minimized with appropriate patient selection.

Quantitative analysis of facial aging can be classified using the Glogau Scale of facial rhytides formation and photoaging.

Table 2. Glogau Scale of Facial Rhytides Formation and Photoaging (Open Table in a new window)

Skin Type

Age (y)

Clinical Findings

I (mild)

20-30

Early photoaging, fine wrinkling

II (moderate)

30-40

Early to moderate photoaging, present with motion, no keratoses

III (advanced)

50 and over

Advanced photoaging, wrinkles with rest, visible keratoses, noticeable discolorations

IV (severe)

60 and over

Severe photoaging, wrinkles throughout, dynamic and gravitational wrinkling, actinic keratoses

The Glogau scale is useful in evaluating the overall amount of aging the face has undergone and can be helpful in discussing potential results of facial cosmetic procedures with patients.

Complications

Postoperative spot bleeding, erythema, milia formation, hair avulsion, and flare-ups of acne are normal sequelae of dermabrasion and should be discussed with the patient preoperatively. A common effect is hyperpigmentation 4-6 weeks after the procedure, but this is usually transient and responds well to hydroquinone. Patients at increased risk include those taking oral contraceptives, exogenous estrogens, or other photosensitizing medications. When hyperpigmentation does not respond to topical treatment, nonablative laser therapy can be performed to diminish the pigment.

The skin typically is sensitive to the sun following dermabrasion, and this also may be a source of hyperpigmentation. Instruct patients to use sunscreen daily for 6-12 months following dermabrasion.

The most clinically significant complications are hypertrophic scarring and permanent hypopigmentation. The risk of prolonged erythema, scarring, and hypopigmentation is directly proportional to the depth of dermabrasion and to the delay of wound healing after the normal time for reepithelialization. Therefore, every effort should be made to control these factors.

Milia

Milia, or intraepidermal collections of keratinaceous debris, are commonly observed after dermabrasion. These collections appear as small white cysts. Treatment consists of abrasive soaps, electrodessication, unroofing, or lancing the cysts with a needle or scalpel.

Hypopigmentation

No reliably good treatment is available to manage the complication of hypopigmentation. This complication occurs to varying degrees in 20-30% of patients. Hypopigmentation is due to the destruction or inhibition of melanocytes. Because they originate from neural crest cells, melanocytes cannot regenerate or divide. Hypopigmentation is most noticeable in darkly pigmented patients and may be difficult to assess until erythema subsides; however, it may be permanent at that point. Pigmentary changes are less likely to occur with dermabrasion than with alternate techniques, such as chemical peeling or laser resurfacing. Camouflage methods are currently the best options to treat hypopigmentation, although certain lasers may be used to stimulate the melanocytes in some patients.

The 309-nm excimer laser has been shown to improve hypopigmented scars and vitiligo, and it also may be an option for improvement after dermabrasion.[16] True hypopigmentation should be differentiated from the pseudohypopigmentation seen when resurfaced skin without actinic damage simply appears lighter than the surrounding actinically damaged skin. Fulton et al reported successful blending of hypopigmentation using laser-assisted chemabrasion,[17] and Grimes et al reported success with topical photochemotherapy.[18]

Hypertropic scarring and keloid formation

Hypertrophic scarring and keloid formation are the most worrisome complications and can result from dermabrasion through the deep reticular dermis or an exaggerated inflammatory response. Therefore, any history of keloid formation in the patient's history should serve as a contraindication to dermabrasion.

Persistent erythema and delayed reepithelialization should alert the physician and patient that scarring is imminent. Erythema after dermabrasion typically lasts only 8-12 weeks, as opposed to 3-6 months of erythema after laser resurfacing. Wounds that demonstrate a lack of reepithelialization by day 14 are at risk for hypertrophic scarring. Early recognition and aggressive treatment are essential. Aggressive measures, such as the application of compressive silicone sheets, scar massage, topical or intralesional steroids, or pressure garments, may minimize the appearance of the scar. Mid- to high-potency topical steroid creams may be used. If induration is present, intralesional steroids (eg, triamcinolone acetonide [Kenalog]) may be given every 2-3 weeks. Pulsed-dye vascular lasers have been used with some success during the erythematous phase of hypertrophic scarring. Scar excision or further dermabrasion may be necessary if the results of these therapies are unsatisfactory.

Infectious complications

Infectious complications are unusual but must be recognized quickly to prevent undesirable scarring. Postoperative viral infections, especially those due to herpes simplex virus (HSV), may occur despite prophylaxis. If pain, erythema, or ulcerations appears 7-10 days after the procedure, viral infection should be suspected and full-strength antiviral therapy should be administered (valacyclovir 1 g 3 times a day for 7 days or famciclovir 500 mg 3 times a day for 7 days). Infections due to staphylococcal, streptococcal, and pseudomonal bacteria or candidal fungus may occur. If they do, wound cultures should be ordered and appropriate oral or topical antibiotics or antifungal treatment should be started.

Hair avulsion

Hair avulsion injury can be a dreaded complication of facial dermabrasion. Extreme care must be taken when performing this procedure on the face anywhere near hair. Areas of caution are near the side burns, temples, and forehead. The hair must be isolated away from the operative field. If hair is in contact with the dermabrader it can become entangled and large areas of hair can quickly become avulsed, leading to temporary alopecia.

 

Workup

Approach Considerations

Preoperative laboratory studies should include a hepatitis panel, HIV antibody screening with an informed consent, and a nasal swab for patients with a history of impetigo. Some patients may warrant a complete blood cell (CBC) count and chemistry profile.

 

Treatment

Treatment Overview

Dermabrasion is used for specific areas of the face more often than laser resurfacing or chemical peeling because it is less likely to cause pigmentary changes by injuring the pigment-containing melanocytes. When laser resurfacing and chemical peeling are applied to only a portion of the face, they often leave lines of demarcation between treated and untreated regions. Dermabrasion, however, can soften sharp edges of demarcated scars, making them inconspicuous. In addition, dermabrasion may be much less costly to the patient than laser resurfacing or chemical peeling.

The high concentration of pilosebaceous glands and the rich vascular network of the face aid in wound healing. This makes the face the most common and ideal site for dermabrasion, although other areas of the body can also undergo dermabrasion. The results of dermabrasion on areas other than the face are satisfactory but not as good, and scar formation is often increased.

Carbon dioxide resurfacing, Er:YAG resurfacing, and deep chemical peels may improve facial rhytides, but dermabrasion proves as efficacious or more efficacious at removal of both fine and moderate facial rhytides, with a slightly lower risk of permanent hypopigmentation.[19, 20, 21]

The major disadvantage of dermabrasion compared with other modalities is that it is much more operator dependent. Unlike laser and light devices, the depth of penetration is not preprogrammed. Successful treatment relies not only on the physician’s knowledge of the modality and application settings, but also on his or her skilled execution. In the novice’s hands, dermabrasion exhibits a narrower window or buffer between effective treatment depth and inappropriate scarring depth. However, this can be quickly overcome with experience.

Indications

Dermabrasion was initially developed to improve acne scars; this is the most common indication for its use. It can also be used to effectively treat traumatic or surgical scars, irregular scarring from skin grafts, photo-damage, some benign tumors, actinic keratoses, rhinophyma, and perioral rhytides.[8] Yarborough demonstrated that surgical and traumatic scars respond best to dermabrasion performed 6-8 weeks during the interval following incision or injury.[22]

Manual dermasanding has also been used in the treatment of periorbital wrinkles and fine lines.[23]

Dermabrasion has been used to manage superficial malignancies such as squamous cell carcinoma in situ and superficial basal cell carcinoma.[24] In addition, pigmentary changes due to melasma, tattoos, or postinflammatory hyperpigmentation can be lightened with dermabrasion. Dermabrasion can be comparable to laser resurfacing in the treatment of these conditions and may be used in conjunction with laser resurfacing for optimal results.[25]

Acne scars that are narrow, pitted, and sharply edged and cast shadows on the face are most amenable to dermabrasion. Some acne scars are deep and extend into the subcutaneous tissue. Dermabrasion of the epidermis, papillary dermis, and upper reticular dermis is possible. However, abrasion below these levels is prohibitive and results in scarring. Therefore, deep lesions are best managed by first excising them with punch biopsy with or without use of a full-thickness graft; after healing, these lesions can be treated with dermabrasion.

Dermabrasion can also be used to treat rhinophyma, a condition marked by swelling and redness of the nose caused by hyperplasia of the sebaceous glands and prominent vascularization of the skin.[26, 27] Thickening hyperplasia is often present, especially in the tip of the nose and in the alar regions. Dermabrasion allows the physician to substantially reduce this condition, and a full-thickness skin graft is rarely required. Reepithelialization is rapid, usually occurring within several days. Often, the surgeon can use electrofulguration and laser resurfacing of contractive tissue as an adjunct to dermabrasion.

Dermabrasion has also been used for the treatment of burn scars. It has been used as an adjunct for the treatment of deep dermal burn scars of the face with excellent results. It can be used for the treatment and management of acute burn injury to the face, as well as for the treatment of mature hypertrophic burn scars and the resurfacing of split-thickness skin grafts.

Dermabrasion has also proven to be a useful technique in the armamentarium of the Mohs surgeon (also see Mohs Micrographic Surgery). Thin carcinomas in cosmetically sensitive or high-risk areas can often be completely removed with a shallow Mohs layer to the level of the superficial reticular dermis. After clearance, these partial-thickness defects, particularly on the nose and scalp, may lend themselves to healing by secondary intention rather than primary closure, yet with slightly increased risk of an evident contour discrepancy or sharp pigmentary transition. Dermabrasion of the edges surrounding the partial-thickness Mohs defect greatly improves the final contour by replacing the steeply beveled wound edge with a more gradual slope. Additionally, dermabrading the remainder of an involved cosmetic subunit of the nose results in a less obvious scar by placing the pigmentary demarcation linesatthelessperceptiblesubunitboundaries.

Contraindications: Absolute and relative

Recent or ongoing use of isotretinoin was once thought to be an absolute contraindication to dermabrasion but is now regarded as a relative contraindication. Isotretinoin causes atrophy of pilosebaceous glands, which delays reepithelialization and increases the risk of hypertrophic scarring. No definitive study provides a clear-cut correlation between isotretinoin treatment and postdermabrasion scarring. Increased scarring in patients who were treated with isotretinoin has been reported; patients in whom no adverse outcomes occurred with dermabrasion and the use of isotretinoin have also been reported.[12] To avoid a possible adverse outcome, physicians should inform patients of potential risks and instruct them to stop using isotretinoin for a period of 6-12 months before dermabrasion.

Ablative resurfacing may exacerbate certain inflammatory conditions that impair reepithelialization and lead to scarring. Examples of such conditions are scleroderma, cutis laxa, psoriasis, congenital ectodermal dysplasia, and collagen disorders due to abnormal adnexal structures.

Dermabrasion is contraindicated if recent surgery (eg, rhytidectomy) has involved undermining the skin that is slated to undergo dermabrasion. Dermabrasion should be postponed for at least 6 months to allow the underlying vascular bed to heal. The risks of necrosis and delayed wound healing are increased because of the compromised blood supply.

Previous radiation therapy leading to radiodermatitis is a relative contraindication because the skin is thinned in irradiated areas. Therefore, the risk of delayed healing with excessively deep dermabrasion is increased.

Bleeding disorders, immunosuppression, and diabetes mellitus may also delay healing and increase the risk of surgical infection. Therefore, these conditions are relative contraindications.

Dermabrasion should be avoided over small areas in patients with freckled skin because the freckles may disappear in those areas (but not elsewhere).

Although deep rhytides and excessive facial skin are not definitive contraindications, these conditions may not be significantly improved with dermabrasion. Patients with these findings are likely best served with traditional face-lift procedures.

Dermabrasion is also contraindicated in patients with active herpetic lesions and in women who are pregnant or nursing.

Dermabrasion should be avoided in patients who develop atypical scars such as keloids.

Dermabrasion should be avoided in patients who are HIV positive or with hepatitis C because of the risk of the aerosolization of viral particles.

Medical Prophylaxis

All patients should receive antiviral prophylaxis. Patients with very recent or frequent herpetic infections and those patients with postoperative breakthrough herpes simplex virus (HSV) infections may require a greater prophylactic dosage (ie, valacyclovir at 500-1000 mg/day for 10-14 days or famciclovir at 500-1000 mg/day for 10-14 days). Because the herpes virus requires viable epidermal cells to establish an infection, antiviral prophylaxis is continued for 10-14 days, which is longer than the time required for reepithelialization to occur.

While most patients do not require antibiotic prophylaxis, patients who are immunosuppressed, patients with a history of impetigo, or carriers of Staphylococcus species may benefit from prophylactic antibiotics (ie, cephalexin at 1000-2000 mg/day for 10-14 days or ciprofloxacin at 500-1000 mg/day for 10-14 days). If prophylactic antibiotics are administered, fluconazole at 200 mg/day for 10 days prevents secondary yeast infections. Also see The Role of Antibiotics in Cutaneous Surgery.

Sleep deprivation can be prevented with sedating medications (flurazepam at 15-30 mg administered the night before surgery and each night following surgery while patients are sleeping in a full face mask). Thirty to 60 minutes prior to surgery, the following is administered: 5-10 mg of diazepam sublingually, 50-75 mg of meperidine intramuscularly, and 25 mg of hydroxyzine intramuscularly. Regional nerve blocks of the mental, infraorbital, supraorbital, and supratrochlear nerves are achieved with 1% lidocaine and epinephrine (1:100,000 concentration of epinephrine).

Skin Preconditioning

Trans -retinoic acid (Retin-A, Renova), a topical exfoliative agent, is believed to increase the rate of epidermal turnover. This turnover promotes rapid reepithelialization after dermabrasion. Trans -retinoic acid may be applied every night or every other night for several weeks before dermabrasion, depending on the degree of skin irritation and the patient's tolerance.

An alternative product relatively new to the market is Kinerase (Valeant Pharmaceuticals North America; Costa Mesa, Calif.), which is reported to be less irritating and less sensitizing to sunlight than trans -retinoic acid.

Tretinoin cream applied for 2-3 weeks prior to dermabrasion has been shown to decrease the time for reepithelialization.[28]

Some surgeons report that the use of topical hydroquinone for several weeks prior to surgery decreases the incidence of postoperative hyperpigmentation.

In addition, patients should be instructed to clean the face and avoid using moisturizers or makeup the morning prior to dermabrasion.

Equipment

Dermabrasion is typically performed in an office-based setting, generally not requiring inpatient hospitalization or general anesthesia.[14] Appropriate lighting is critical, and the operator and assistant must wear surgical gowns, gloves, and masks with eye protection. Because of the high rate of rotation, the surgical field should be cleared of sponges, towels, and other equipment that may become entangled and injure the physician, assistant, or patient.

The dermabrader consists of an electric hand engine with a high-speed rotary motor and an interchangeable abrading end piece. The surgeon may control the speed with a foot pedal or handheld device. Pressure exerted on the handpiece and the revolutions per minute of the handpiece are the most important variables in technique. Avoiding excessive pressure on the handpiece is important because excessive pressure can result in gouging. Suggested rotational speeds of 12,000-15,000 revolutions per minute (rpm) for the abrading heads result in controlled, gradual planing of the treated surface.

The most commonly used end pieces are diamond fraises, wire brushes, or serrated wheels. Diamond fraises are available in many shapes, sizes, degrees of coarseness, and levels of quality. Small devices are used in confined spaces, such as around the nose or eyelids. Experienced surgeons tend to use the coarse or extra-coarse fraises. Large wheels are used on broad flat surfaces, such as the forehead and cheeks. Diamond fraises can be used without a spray refrigerant, whereas wire brushes require cooling. The wire brush produces microlacerations in the skin but causes little thermal injury and is often preferred by experienced surgeons over the diamond fraise. The diamond fraise is easiest to learn to use, but it can increase thermal injury because deep resurfacing requires several passes applied with pressure. The wire brush is recommended for deeper scars, and the diamond fraise is recommended for more superficial scars.

Use of sandpaper wrapped around a digit or cylinder (eg, a test tube) is the simplest means to perform dermabrasion.[29, 30] It has been demonstrated to provide excellent outcomes and is extremely cost-effective. This technique is less likely to cause injury, but it is difficult to perform finer and deeper areas of resurfacing with this technique.

Preparation

The physician's preference determines the type of anesthesia needed. Patients should be given preoperative anesthetic medication prior to beginning the procedure. Patients may also be given an anxiolytic medication if needed. Dermabrasion may be performed with general anesthesia, a regional block, or local anesthesia with or without conscious sedation. The skin may be pretreated for 20-30 minutes with an ice pack. Refrigerant sprays (eg, fluoroethyl, freon-114) used prior to dermabrasion can produce topical anesthesia, decrease bleeding by means of vasoconstriction, and stiffen the surface of the skin. Care must be taken with refrigerant agents to prevent freezing too deeply and causing cell damage from cryonecrosis. When using sedation or general anesthesia, the patient’s heart rate, blood pressure, and oxygen saturation must be monitored.

The areas to be treated are marked in sections and then prepared and draped in a sterile fashion. The patient’s skin should be held taut by using both of the surgical assistant's hands and the surgeon's nondominant hand. The surgeon and staff should practice strict exposure precautions, including the wearing of protective face shields, to avoid contact with aerosolized matter and blood-borne pathogens. In addition, the assistant should wear cotton gloves on top of rubber gloves to prevent injury, as the rotating handpiece can catch rubber gloves very quickly. Gentian violet staining of the treated area can be used to determine the degree of abrasion.

Technique Overview

The abrading instrument is correctly held by placing the forefingers around the body of the instrument with the thumb outstretched on the shaft for stability and control. See the image below. The direction of rotation of the abrading end piece can be clockwise or counterclockwise. For right-handed surgeons, counterclockwise rotation directs the momentum of rotation toward the thumb in a stabilizing fashion. Make passes with archiform horizontal strokes perpendicular to the direction of the rotating brush or fraise.

Technique and hand position for dermabrading raise Technique and hand position for dermabrading raised scars.

Irregular or imperfect facial surfaces are abraded to yield a smooth and even surface. See the images below.

Dermabrasion of a raised scar. Dermabrasion of a raised scar.
Technique of dermabrasion for a depressed scar. Technique of dermabrasion for a depressed scar.

The results of dermabrasion depend on the coarseness of the abrading tip, the length of time the tip is applied to the skin, and the pressure used to apply the tip. The abrasion should begin in dependent areas, such as along the sides of the face, working toward the center. This approach prevents bleeding from obscuring the skin to be abraded. In critical areas of the face, abrade cosmetic units as a whole to decrease the risk of noticeable pigmentary changes.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best. This method allows blood from a previously abraded area to flow in an inferior, gravitational direction away from the next area to be abraded. With this approach, the nose, the mid upper lip, and the mid forehead are the last areas to be abraded in a full-face procedure.

The key to successful dermabrasion is controlling the wound created. The rotating head should be kept parallel to the skin surface, and the handpiece should be in motion at all times. The motion should be deliberate, firm, steady, and with even pressure. Planing the epidermis down to the dermal junction begins the abrasion. No bleeding occurs during dermabrasion through the epidermis because of a lack of blood vessels in this layer. Decreased pigmentation is encountered when the process continues through the epidermis. The dermoepidermal junction is reached next, followed by the papillary layer of the dermis. Uniform bleeding from punctate sites over a smooth, shiny surface marks this layer. The deep papillary dermal layer is encountered when the surface becomes rough and when bleeding points increase.

Although each site bleeds only minimally, the multitude of bleeding sites can result in considerable blood loss. As the depth of abrasion increases, the superficial reticular dermis is reached, and bleeding becomes brisk and confluent. This layer is rougher than the deep papillary dermis and represents exposed dermal collagen. This surface has a whitish-yellow appearance. Dermabrasion should not be performed below the superficial reticular dermis. Below this level, yellow fat globules are encountered, and clinically significant scarring would result if dermabrasion were continued here.

At the periphery of the abraded area, the borders are lightly feathered by decreasing the pressure and the number of strokes to yield a uniform appearance. Caution should be exercised over bony prominences, where excessively deep dermabrasion commonly occurs.

As the skin warms, increased bleeding may occur. Saline-moistened gauze or nonadherent dressings (Telfa) soaked in dilute epinephrine solution with or without lidocaine can be applied to the treated area for 5-10 minutes to decrease pain and provide hemostasis.

Standard Technique

Treating surgical scars, rhinophyma, and partial-thickness Mohs defects provides an excellent point of entry into the practice of dermabrasion prior to practicing advanced techniques such as full-face dermabrasion. If the treatment area is limited in size, local anesthesia (1% lidocaine with epinephrine 1:100,000) or tumescent technique is adequate. When treating the entire nose, a ring block also may achieve an appropriate degree of anesthesia. Prior to abrasion, the area to be treated is cleansed with a 4% chlorhexidine solution.

The body of the hand engine is grasped in the palm of the dominant hand with 4 fingers, allowing the thumb to project along the neck for stabilization (see image below). Finger position is similar to a "thumbs-up" sign or to that seen when gripping a golf club, yet the hand and instrument are pronated, with the palm facing downward.

To hold the hand engine properly, the forefingers To hold the hand engine properly, the forefingers grasp the body of the hand engine while the thumb stabilizes the neck.

Freon-114 refrigerant spray (Frigiderm; see image below) is applied to the treatment area in an amount necessary to achieve a 5- to 10-second thaw time, during which time abrasion is performed on the frozen area. Refrigerant spray accomplishes 2 important functions: decreasing pain by cryoanesthesia and a providing a firm substrate upon which to achieve recontouring.[31, 32] Refrigerants containing Freon-12 have a freezing point of -30°C to -60°C, which is too cold and can produce hypertrophic scarring.

Frigiderm is an effective spray refrigerant used i Frigiderm is an effective spray refrigerant used in wire brush and diamond fraise dermabrasion.

Immediately after freezing, 3-point retraction is obtained by the 2 hands of the surgical assistant and the nondominant hand of the surgeon. The frozen skin is thus stabilized by retraction, and the lesion is recontoured with the wire brush rotating in a counterclockwise direction (with the angle of the radiating bristles) as determined from the point of view of the body of the hand engine. The wire brush is passed over the treatment area in an arciform motion with the long axis perpendicular to the rotating handpiece (parallel to the body of the hand engine). See video below.

Freeze defects and rhytides in their relaxed state without stretching or distorting so that they may be sculpted and recontoured.

Counterclockwise rotation of the wire brush offers a less aggressive technique of wire-brush surgery, which is especially well-suited for spot dermabrasion of Mohs defects or surgical scars without cryoanesthesia. With counterclockwise rotation, the radiating bristles are less prone to gouge unfrozen skin. This counterclockwise direction of rotation is also useful when dermabrading free margins of the face such as the lips and nasal alae, in order to prevent the inadvertent "grabbing" of tissue by the rotating wire brush when dermabrading from the right side with the dominant right hand.

Regular pinpoints of bleeding signal abrasion to the level of the papillary dermis. As depth increases to the reticular dermis, the bleeding foci become larger, and frayed collagen bundles become apparent. Surgical scars frequently disintegrate upon abrasion, which is a desirable endpoint. Contouring should often include feathering, or graduating zones of treatment around the central scar, to provide a smooth transition between different planes and improved pigment transition. Alternatively, the treatment zone may be stopped at the border of a cosmetic unit or carried to an inconspicuous endpoint, such as 1 cm beyond the mandible.

Advanced Technique

While local or tumescent anesthesia may be adequate for scar or spot dermabrasion, full-face abrasion of acne scarring or rhytides is best accomplished with a combination of oral or intramuscular light sedation, nerve blocks, and cryoanesthesia. A standard regimen consists of meperidine at 50-75 mg intramuscularly, hydroxyzine at 25 mg intramuscularly, and diazepam at 50 mg orally or sublingually 30-60 minutes prior to the start of the procedure. After preparation with chlorhexidine, nerve blocks to the supratrochlear, supraorbital, infraorbital, and mental nerves may also be performed.

In contrast to the counterclockwise rotation typically used for less aggressive dermabrasion, more experienced practitioners may opt to use a clockwise rotation of the abrasive wire brush. Rotation in a clockwise direction occurs against the angle of the radiating wire bristles and causes the tip to pull away from the thumb rather than driving toward it. Deeper planing and recontouring are possible with clockwise rotation, but this direction is much less forgiving. Additionally, clockwise rotation used by a dominant right hand increases the risk that free margins of the face, such as lips and nasal alae, will be grabbed by the rotating bristles rather than brushed away, resulting in unintentional, deeper abrasion in these areas.

When performing full-face dermabrasion, beginning at the periphery of the cheek or mandible and working toward the center of the face allows the practitioner to avoid gravity-dependent bleeding as the procedure progresses (see video below). A surgical towel, surgical cap, or petrolatum may also be used to help prevent entanglement of hair at the periphery of the treatment area. Surgical towels are also preferable to cotton gauze as sponges on the surgical field because gauze becomes more easily entangled in the wire brush and hand engine.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best.

Postoperative Details

Postoperative care is aimed at providing an ideal environment for moist wound healing to prevent dehydration and promote epithelial cell migration. After the procedure, a topical petroleum product should be applied to all treated areas. Scented or mentholated antibiotic ointments should be avoided because of their potential to cause hypersensitivity reactions.

An open or closed wound care regimen may be followed. In a typical open wound care regimen, compresses moistened with saline solution or 25% vinegar are applied 4-5 times per day to cleanse the area, followed by the petroleum ointment mentioned above. Reepithelialization requires 10-14 days. A closed wound care regimen may decrease the time for complete reepithelialization by 50% to only 5-7 days. Semipermeable dressings, such as petroleum-impregnated gauze, are applied directly to the skin and covered with nonstick dressings, gauze, and net dressing. Patients undergo dressing changes every 24 hours, and the patient is then serially evaluated to monitor progression.

Another closed-technique, layered bandage is composed of a semipermeable hydrogel dressing (Vigilon, Second Skin) in contact with the wound, a nonadherent dressing (Telfa) above, and paper tape or surgical netting to secure the bandage in place. Semipermeable hydrogel dressings may provide 2 important advantages over other types of dressings: decreased patient discomfort in the postoperative period and decreased time to reepithelialization by up to 40%. The dressing should be changed daily for 3-5 days. See dressing in the image below.

Dressing for full-face dermabrasion is shown. Dressing for full-face dermabrasion is shown.

Patients may be given prescription medications for pain relief, a course of systemic antibiotics (often cephalexin), or a short course of oral steroids with a quick taper to reduce instances of inflammation. If the patient has a history of herpes virus outbreaks, antiviral medications such as acyclovir or valacyclovir should be prescribed.

Instruct patients to reapply the bland topical petroleum product throughout the day any time the face feels tight or dry. The patient is allowed to shower and gently wash the face with nonresidue soap using fingertips only. After showering, the face should be patted dry and a new coating of ointment applied. Instruct patients not to pick at their wounds during the recovery period. The patient should understand the process of reepithelialization and the importance of compliance with the prescribed posttreatment regimen.

Long-Term Monitoring

In the early stages of wound healing, the patient should be reexamined early and repeatedly, generally within 48 hours and again every several days. Any buildup of fibrinous exudate or significant eschar should be removed to prevent infection, delayed healing, and possible scarring.

If full-face dermabrasion has been performed, the most convenient plan is to have the patient return to the office for dressing changes during this period. For smaller areas, the patient may change the bandage at home. After 3-5 days, the patient begins an open wound care technique at home. Acetic acid (0.25%) soaks (1 tablespoon white vinegar into 1 pint of warm water) are followed by topical petrolatum ointment until reepithelialization is complete, usually 7-10 days after the procedure. Strict adherence to this regimen reduces the risks of secondary infection and scarring.

If full-face dermabrasion is performed, a short course of oral or intramuscular steroids may also be given immediately after the procedure to help reduce facial swelling. Swelling is an anticipated consequence of full-face dermabrasion and may be expected to resolve over several weeks to a few months.

After reepithelialization is complete, the new skin may be bright pink or red, with deeply abraded areas appearing most erythematous. This coloration typically fades within 8-12 weeks. Patients may use makeup to camouflage the appearance, although they should be instructed not to apply makeup, trans -retinoic acid, or skin care products until the face is healed to the satisfaction of the treating physician.

Some practitioners have used topical agents that contain platelet products or growth factors after dermabrasion. Although these products have been shown to improve wound healing in clinical situations other than dermabrasion, the present authors know of no data from randomized controlled clinical trials that support their use in this setting. Further research continues in this area.

Patients must use sunblock to protect the new sensitive skin after it reepithelializes to prevent burning and dyschromia. Patients should use sunscreen every day for 6-12 months after dermabrasion. Some patients have transient hyperpigmentation for 4-6 weeks after surgery. Bleaching creams, such as hydroquinone, may be used 3 weeks after surgery to help prevent this effect.

All previously prescribed antivirals and antibacterials should be instituted or continued, and patients should be given a prognosis and expected recovery timeframe. Postoperative edema continues to improve for 3 months. As the edema resolves, deep rhytides and acne scars may initially appear to be persistent. Collagen remodeling continues for another 3-6 months, and new collagen fills deep defects. Patients should be told that the greatest improvement is usually observed 6 months after surgery.

 

Medication

Medication Summary

Antiviral prophylaxis is instituted in all patients. Patients with very recent or frequent herpetic infections and those patients with postoperative breakthrough herpes simplex virus (HSV) infections may require a greater prophylactic dosage (ie, valacyclovir at 500-1000 mg/day for 10-14 days or famciclovir at 500-1000 mg/day for 10-14 days).

Most patients do not require antibiotic prophylaxis. However, immunosuppressed patients, those with a history of impetigo, or carriers of Staphylococcus species may benefit from prophylactic antibiotics (ie, cephalexin at 1000-2000 mg/day for 10-14 days or ciprofloxacin at 500-1000 mg/day d for 10-14 days). If prophylactic antibiotics are administered, fluconazole at 200 mg/day for 10 days prevents secondary yeast infections

Sedating medications preprocedure and for anesthesia include flurazepam, diazepam, meperidine, and hydroxyzine.

Skin conditioning medications can include trans -retinoic acid, tretinoin cream, topical hydroquinone (for postoperative hyperpigmentation).

Antiviral Agent, Other

Class Summary

These agents are inhibitors of DNA polymerase in herpes simplex virus (HSV)–1 and HSV-2 strains, inhibiting viral replication.

Famciclovir (Famvir)

Famciclovir is a prodrug that when biotransformed into its active metabolite penciclovir, may inhibit viral DNA synthesis/replication.

Acyclovir (Zovirax)

Acyclovir has an affinity for viral thymidine kinase and, once phosphorylated, causes DNA chain termination when acted upon by DNA polymerase. The drug, which requires 5 daily doses, can be associated with compliance problems.

Valacyclovir (Valtrex)

Valacyclovir is a prodrug that is rapidly converted to the active drug acyclovir. It is more expensive than acyclovir, but its dosing regimen is more convenient.

Antibiotics, Other

Class Summary

For patients who do not respond to standard antimicrobial treatments, therapy should be guided by culture sensitivity.

Ciprofloxacin (Cipro)

Ciprofloxacin inhibits DNA gyrase and topoisomerase IV for bactericidal activity. Use it as an alternative for methicillin-resistant Staphylococcus aureus (MRSA) infection.

Cephalexin (Keflex)

Cephalexin is a first-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell-wall synthesis. It is bactericidal and effective against rapidly growing organisms, forming cell walls. Resistance occurs through alteration of penicillin-binding proteins.

Cephalexin is effective for the treatment of infections caused by streptococci or staphylococci, including penicillinase-producing staphylococci; it may be used to initiate therapy when such infections are suspected. Its primary activity is against skin flora. It is used for treatment of skin infections or for prophylaxis in minor procedures.

Antifungal Agents

Class Summary

These agents are used to treat secondary yeast infections.

Fluconazole (Diflucan)

Fluconazole is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.

Anxiolytics, Benzodiazepines

Class Summary

These agents treat presurgery-associated anxiety. By binding to a specific receptor site, these agents appear to potentiate the effects of gamma-aminobenzoic acid (GABA) and to facilitate inhibitory GABA neurotransmission and other inhibitory neurotransmitters.

Diazepam (Valium, Diastat, Diastat AcuDial)

Diazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA. Diazepam diminishes or terminates seizures. Individualize the dosage and increase cautiously to avoid adverse effects.

Flurazepam

Flurazepam is frequently chosen as a short-term treatment of insomnia. It enhances the inhibitory effects of the GABA neurotransmitter on neuronal excitability that results by increased neuronal permeability to chloride ions. The shift in chloride ions results in hyperpolarization and stabilization of the neuronal membrane.

Antihistamines, 1st Generation

Class Summary

H1 receptor antagonists act by competitive inhibition of histamine at the H1 receptor. Agents in this class have sedating properties.

Hydroxyzine (Vistaril)

Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in the subcortical region of the CNS.

Analgesics, Opioid

Class Summary

Analgesics ensure patient comfort, promote pulmonary toilet, and possess sedating properties, which are beneficial for patients having surgery. These agents are used for comfort and sedation and to blunt the discomfort of surgical incisions.

Meperidine (Demerol, Meperitab)

Meperidine is an analgesic with multiple actions, similar to those of morphine; it may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. Meperidine may be used in combination with promethazine to provide a synergistic effect.

Anesthetics

Class Summary

Anesthetics may be used for regional nerve blocks of the mental, infraorbital, supraorbital, and supratrochlear nerves.

Lidocaine anesthetic (Xylocaine, Zingo)

Lidocaine is an amide local anesthetic used in 1-2% concentration. The 1% preparation contains 10 mg of lidocaine for each 1 mL of solution; the 2% preparation contains 20 mg of lidocaine for each 1 mL of solution. Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. Adding epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Retinoid-like Agents

Class Summary

Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes and may reduce the potential for malignant degeneration. They also modulate keratinocyte differentiation.

Tretinoin topical (Retin-A, Renova, Atralin, Tretin X)

Tretinoin inhibits microcomedo formation and eliminates lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove.

Depigmenting Agents

Class Summary

These agents are used for gradual bleaching of hyperpigmented skin.

Hydroquinone (Alphaquin HP, Eldopaque Forte, Nuquin HP)

Hydroquinone is a 1,4-benzenediol that suppresses melanocyte metabolic processes, especially enzymatic oxidation of tyrosine to 3,4-dihydroxyphenylamine. Exposure to sun reverses the effects and causes repigmentation.

Antiseptics

Class Summary

These agents inhibit growth of gram-positive and gram-negative bacteria.

Chlorhexidine gluconate (Hibiclens, Avagard, Betasept Surgical Scrub, Hibistat)

Chlorhexidine binds to negatively charged bacterial cell walls and extramicrobial complexes. It has bacteriostatic and bactericidal effects.