Iodine Allergy and Skin Prep: 3 Tips to Help You Choose the Safest Solution

When a patient has a known sensitivity or allergy to iodine-based skin prep, switching to an alternative isn’t just a box to check—it’s a clinical decision that must prioritize both infection prevention and patient safety.

But choosing the right alternative isn’t always straightforward.

Just ask Laila Bailey, DNP, RN, CNS, CNOR, ACNS-BC, service line leader for Urology, Cystoscopy, and Pediatric Surgery at Inova Fairfax Hospital in Falls Church, Virginia. A longtime perioperative leader and expert on iodine reactions, Dr. Bailey helps teams navigate the complexities of safe skin antisepsis when iodine is off the table.

While questions about allergies to skin prep products containing povidone or povacrylex iodine come up frequently in patient care, they also present opportunities for nurses to deepen their knowledge of available prep solutions and make the right call for their patients.

Here are Dr. Bailey’s top tips to tackle this practice question with evidence.

1. Understanding Iodine Allergies and Skin Prep Reactions

Be well informed about the difference between a povidone-iodine reaction and a true allergy—these are not the same, Dr. Bailey says. “Hypersensitivity reactions due to some chemical in the solution, such as povidone, can happen, but this is a reaction, not necessarily an allergy.”

The first step when a patient is flagged for an iodine allergy is to understand their history and ask questions to confirm their past reaction. “Many electronic health records may flag the patient as allergic to povidone-iodine due to a reaction to another iodine-containing substance,” Dr. Bailey said.

She says the best way to confirm what the patient is actually allergic to is to ask: “Have you ever had a reaction to a solution on your skin?” This can help determine whether the patient has had a reaction to a povidone-iodine skin prep solution.

“Make sure to ask questions about prior reactions without using the word ‘iodine,’ as this will help to elicit a great deal of information about the true nature of the prior reaction,” she said.

Many patients end up with the “iodine allergy” label because of a shellfish or iodinated contrast reaction, which are much more common than a povidone-iodine reaction.

“Remember that it is not iodine that patients need to avoid. Even if two items have iodine, they are not inherently related. Since this myth is so pervasive, making sure the correct information is in the patient’s chart is key,” Dr. Bailey said. “Once a nurse establishes the correct allergies, then planning for care in the perioperative area can be done based on evidence.”

2. Choosing Alternative Skin Prep for Patients with Iodine Reactions

If a patient has had a prior reaction to povidone-iodine—whether a true allergy or hypersensitivity reaction—selecting an appropriate alternative prep solution is the next step. Both baby shampoo and CHG 4 percent scrub have been considered as substitutes, but Dr. Bailey notes that evidence shows mixed results for each.

According to AORN’s Guideline for Preoperative Patient Skin Antisepsis, the perioperative team should weigh the potential benefits and harms of available options to determine the safest and most effective solution for the individual patient.

3. Patient Education on Iodine Allergy Myths and Skin Prep Safety

Dr. Bailey acknowledges “there is still a great deal of misinformation concerning iodine-containing products” and cautions that “overcoming the iodine allergy myth will take time.” The most common misconception is that if a patient is allergic to one iodine-containing product, they must avoid all iodine-containing products—not true.

Here are key facts about iodine allergies relevant to preoperative skin antisepsis she suggests sharing with patients:

• If you have had a shellfish reaction, you are no more likely than any other patient to have a reaction to povidone-iodine, povacrylex iodine, iodinated contrast, or other iodine-containing products.
• A previous reaction to iodinated contrast is a hypersensitivity reaction and doesn’t create antibodies that can then trigger an allergic response. Having reacted to contrast will not put you at risk of reacting to povidone-iodine prep or any other iodine-containing substance.
• Perioperative care providers evaluate each iodine-containing product separately because, even though they contain iodine, they are not related. Knowing this helps the team determine the best skin prep alternative. For example, if you have a history of reaction to iodinated contrast, you can still receive an IV infusion of indocyanine green, since the two are not related in any way.

Relevant Resources on Skin Antisepsis Reactions and Iodine Alternatives

Dr. Bailey suggests perioperative nurses seeking more information on skin antisepsis reaction and alternatives explore these research articles:

• Clarifying Misconceptions About Iodine “Allergies” for Perioperative Patient Care
• Preoperative vaginal preparation with baby shampoo compared with povidone-iodine before gynecologic procedures
• A Randomized Trial of Vaginal Antiseptic Preparation Solutions to Reduce Bacteria Colony Counts in Patients Undergoing Vaginal Surgery

AORN Education Solutions for Patient Skin Antisepsis

• Periop 101: A Core Curriculum^TM: Each of the three available onboarding learning plans—OR, ASC, and Cesarean Section—includes a module on patient skin antisepsis to help your novice nurses build strong, evidence-based habits from the start. To ensure consistency and refresh knowledge among more experienced nurses, the program also offers Periop Mastery 2.0—an assessment-based course, which also covers this important clinical topic.
• eGuidelines Plus: Provide facility-wide digital access to a comprehensive, one-stop perioperative resource with a vast number of tools to support learners, perioperative teams, and ancillary departments in day-to-day practice. Refer to the latest AORN Guideline for Preoperative Patient Skin Antisepsis and review quick guides to best practices on aseptic technique.
• AORN CineMed Video Library: Help both novice and tenured perioperative staff solidify best practices with over 40 mobile-friendly, video-based courses on patient and worker safety within the AORN CineMed Video Library. Assign the Patient Skin Antisepsis course to the entire team. Nurture learners with Contact Hours and verify competency via posttests.

Our team is here to help you find the right mix of education solutions to meet your team’s needs—while also helping you take advantage of cost savings through volume pricing. Learn more: aorn.org/trio.