Why the next skin prep fad will hurt body piercing

I must admit that the day the FDA issued their press release regarding Care-Tech Labs, stating that "...Care-Tech violated numerous provisions of the FDA’s current good manufacturing practice (cGMP) regulations that direct how antimicrobial drugs are made ... the FDA recommends that Care-Tech’s customers seek alternative products”[1], effectively pulling bottles of Techni-Care® off the shelves, I felt no small amount of schadenfreude. I could not say “I told you so” enough. Why?

Techni-Care® violated both the “if it ain't broke don't fix it” and the "if it is marketed specifically at body piercers, it's probably bad” rules. As an industry, we believed and perpetuated the myth of povidone-iodine allergies[2]. We completely ignored the efficacy and appropriateness of isopropyl alcohol[3]. Piercers quickly became fond of lauding Techni-Care®'s 30-second kill time (but were typically remiss in acknowledging the instruction that called for a 2-minute swab)[4]. I was frequently told how much better it was than the alternatives, but could not find any convincing studies to indicate that Chloroxylenol (PCMX) works at all, much less any better than what doctors and nurses use on an everyday basis[5][6]. In short, we bought the marketing and skipped the analysis. The lack of critical thinking could not be more evident than when piercers started paying top dollar for expired bottles of the recalled* product on eBay®. Downright Jonestownian Kool-Aid® drinking.

Eventually, some product, maybe even a newly FDA-approved Techni-Care®, will vie to be the new darling of the body piercing industry, and when that happens my suggestion is this: Think Critically. Specifically consider the following:

1) Is "Product X" widely used by doctors, surgeons, or nurses for skin prep?

Answer: It won't be. Talk to any doctor, and ask them what they use to prep skin for outpatient procedures similar to a body piercing (something like an injection, biopsy, or blood sample). It will nearly always be isopropyl alcohol or povidone-iodine, with the occasional chlorhexidine gluconate or even “injections don't really need skin prep”[3]. Think about what this means: The stakes are much higher for the medical industry. Doctors are far-better educated than nearly every body piercer, and they are the ones who research, test, and evaluate new products. Sure, that process takes time, and this is a good thing.

2) Is "Product X" in a sterile, single use pouch (like an alcohol or iodine swab)?

Answer: It (probably) won't be. If Techni-Care® is the model, it definitely won't be. The bottle out of which you dispense “Product X” can be contaminated, whereas sterile single use alcohol or iodine swabs are far less likely to be mishandled. In either case, there are examples of the manufacturer contaminating their own product, but, in the piercing shop, bottle dispensers are not as good as sterile, single-use supplies of any product we use on a client.

3) What advantage is there in using "Product X," a skin prep product that is brand new, and has not stood the test of time?

Answer: Street cred. That's all. Your ego might get the benefit of jumping on the bandwagon, but in truth you are gambling with your client's safety. Choose to follow a preponderance of evidence, particularly research-based evidence. Large, properly-conducted studies with peer reviewed papers should be the requirement before we, as an industry, even consider adopting new skin prep chemicals.

There are a few facts we need to acknowledge: We are not doctors. We are rarely scientists. Collectively, we have egg on our faces for widely endorsing Techni-Care® with nearly no data to back it up. We need to see Techni-Care® for the very big mistake it was, not the (unfulfilled) promises it made. Techni-Care® should be held up as a “Never Forget (that we aren't as smart as we think we are.)”

Where do we go from here? My suggestion: in lockstep with the medical industry. If we are going to be proven wrong (ahem, again), we should be proven wrong at the exact moment every doctor, nurse, phlebotomist, researcher, etc. is proven wrong. What does lockstep with the medical industry mean? It depends on how you choose to categorize body piercing: Surgical skin prep or injection skin prep.

I hate the meme “body piercing is a small surgical procedure.” It conceptually biases our perspective to an inaccurate extreme. However, if you believe that piercing falls nearer to “surgery” than “injection”, povidone-iodine or clorhexidine gluconate (though, keep CHG away from mucous membranes) and isopropyl alcohol is the way to go. If you prefer to consider a body piercing on par with injection or blood draw, the medical community nigh universally chooses 70% isopropyl alcohol. At present, you make this decision, but either perspective and practice is a safer bet than blindly adopting whatever new "Product X" is around the corner.

[1] http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm181654.htm

“Care-Tech Laboratories Agrees to Stop Making, Selling and Distributing Unapproved Antimicrobial Products”

[2] http://www.ncbi.nlm.nih.gov/pubmed/2302848

- "Sensitization to povidone-iodine."

[3] http://www.clinicaladvisor.com/improved-pre-injection-skin-prep/article/166068/

quote: “No controlled studies exist, but the standard of care is to use an alcohol-based solution to cleanse the skin before intramuscular, intradermal, or subcutaneous injection, as well as before venipuncture for nonsterile specimens. An iodine-based solution should be used before injecting a joint space or obtaining blood for culture.—Reuben W. Zimmerman, PA-C (137-1)

[4] http://www.caretechlabs.com/ctl-reference.html#prep

quote: "Swab site for 2 minutes insuring coverage inside sterile field." from the article "Skin Prep".


quote: “Studies of parachlorometaxylenol (PCMX) have produced contradictory results and therefore, further studies are required in order to determine the efficacy of the agent with other agents (Soulsby, Barnett, & Maddox, 1986).” from “Recommended Standards of Practice for Skin Prep of the Surgical Patient” - Association of Surgical Technologists

[6] http://web.archive.org/web/20100526060618/http://www.chloraprep.com/study-27


quote: “The positive culture rate associated with the hallux site in the ChloraPrep group was significantly lower than that in the DuraPrep™ group, which was significantly lower than that in the Techni-Care® group” from “Efficacy of Surgical Preparation Solutions in Foot and Ankle Surgery
Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980–985”.

*I have been corrected on referring to Techni-Care as having been "recalled". Technically, "shut down by the FDA" is more accurate, as Care-Tech never initiated a recall.

This blog post was written by Jef Saunders, owner of
Rockstar Body Piercing
, Instructor at the
Fakir Intensives
and Member of the
Association of Professional Piercers

Creative Commons License
Why the next skin prep fad will hurt body piercing by Jef Saunders is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.