In a patient with a documented chlorhexidine allergy who just received a fresh skin graft that hasn't revascularized yet, can I apply povidone‑iodine (Betadine) to the graft?

Povidone-Iodine Use on Fresh Skin Grafts in Chlorhexidine-Allergic Patients

Yes, you can safely apply povidone-iodine (Betadine) to a fresh, non-revascularized skin graft in a patient with documented chlorhexidine allergy—povidone-iodine is the recommended first-line alternative antiseptic when chlorhexidine is contraindicated. 1, 2

Primary Recommendation

Povidone-iodine solution (preferably with alcohol) is the standard alternative antiseptic for patients with chlorhexidine sensitivity or allergy across all wound care and catheter-related applications. 1, 2 This recommendation comes from the KDOQI 2019 guidelines and is reinforced by CDC guidelines for intravascular catheter care. 1

Evidence Supporting Povidone-Iodine on Skin Grafts

Direct Clinical Experience

• Povidone-iodine gel has been specifically recommended for use with tie-over dressings on skin grafts to ensure graft success. 3 This Japanese study from plastic surgery practice demonstrates that povidone-iodine gel applied directly to grafts under tie-over dressings reduces complications and improves outcomes. 3

• For split-thickness skin grafts requiring coverage, a combination of tulle gras with gauze soaked in 1:10 diluted Betadine solution is an established protocol. 4 This approach has been used successfully in dermatological surgery without cytostatic effects or delayed healing. 4

Antimicrobial Efficacy on Transplanted Tissue

• Povidone-iodine effectively reduces bacterial contamination on transplantable allograft skin, demonstrating safety for use on grafted tissue. 5 While chlorhexidine shows superior bacterial reduction (82% reduction in gram-positive contamination), povidone-iodine alone still achieves 86.3% bacterial-free donor skin. 5

Application Protocol for Fresh Grafts

Proper Technique

• Allow povidone-iodine to remain on the graft site for at least 2 minutes and let it air dry completely before applying dressings. 1, 6 This contact time is essential for achieving full bacteriostatic action. 6

• Apply using gentle technique to avoid mechanical disruption of the non-revascularized graft. 3 Consider using povidone-iodine gel formulation rather than solution for better adherence and less mechanical trauma. 3

Concentration and Formulation

• Use alcoholic povidone-iodine formulations when available, as they demonstrate superior efficacy compared to aqueous preparations. 2 However, for direct graft application where alcohol may cause irritation, standard 10% povidone-iodine solution diluted 1:10 or povidone-iodine gel are acceptable alternatives. 4

Critical Considerations for Non-Revascularized Grafts

Wound Environment Protection

• Protect the graft site from wet and dirty environments, particularly when the graft has not yet fully healed or revascularized. 1 This principle from catheter exit site care applies equally to fresh grafts. 1

• Use sterile gauze dressings rather than transparent semi-permeable dressings if the graft site is bleeding or oozing. 1 Fresh grafts typically have some exudate, making gauze the preferred choice. 1

Avoiding Common Pitfalls

• Do not use organic solvents (acetone, ether) on or near the graft site. 1 These agents can damage tissue and impair healing. 1

• Ensure adequate contact time—do not rush the application. 6 Insufficient contact time (less than 2 minutes) reduces antimicrobial effectiveness. 6

• Document the chlorhexidine allergy prominently to prevent inadvertent exposure to chlorhexidine-impregnated dressings or chlorhexidine-coated materials. 2 This is particularly important in the perioperative setting where multiple products may contain chlorhexidine. 2

Alternative Antiseptic Options (If Povidone-Iodine Contraindicated)

Secondary Alternatives

• If povidone-iodine is also contraindicated or unavailable, 70% isopropyl alcohol alone can serve as an alternative antiseptic. 2 However, alcohol may cause more irritation on open graft sites. 2

• Tincture of iodine (iodine in alcohol solution) is another acceptable option. 2 This provides iodine-based antisepsis with alcohol's additional antimicrobial properties. 2

Monitoring and Follow-Up

Signs of Complications

• Monitor for signs of graft failure, infection, or allergic reaction to povidone-iodine itself (though rare). 4 In a large dermatological surgery series with epicutaneous patch testing, no sensitization to povidone-iodine was observed. 4

• Maintain aseptic technique during all dressing changes to prevent introducing organisms to the non-revascularized graft. 1 Hand hygiene before and after graft care is essential. 1