A comparison of postprocedural wound care treatments: do antibiotic-based ointments improve outcomes?

Postoperative Wound Care in Dermatologic Surgery: Update And Narrative Review

Dermatologic surgery is associated with a very low risk of complications. There is no widely accepted, evidence-based protocol with recommendations for postoperative wound care after dermatologic surgery. In this narrative review, we will be discussing the evidence on surgical wound care products and procedures. Overall, we found relatively few studies and, in many cases, a lack of statistically significant differences, possibly because of the low rate of complications. We'll be discussing the evidence on when we should initiate wound care procedures and their frequency, the type of ointment and antiseptics that should be applied, and the type of dressings that should be used. Despite the very few studies available on postoperative wound care following dermatologic surgery, there is sufficient evidence as to not recommend the use of prophylactic topical antibiotics. We also analyze the currently available evidence on surgical wound care in special situations, such as management of skin grafts, partial skin graft donor sites, xenografts/biomembranes, and surgical wounds to the legs.

Petroleum jelly: A comprehensive review of its history, uses, and safety

Petrolatum, also known as petroleum jelly, is a widely used topical agent, with a variety of uses in dermatology. Despite its popularity, many myths surround this ubiquitous dermatologic staple. This review details the history of petrolatum and how it is manufactured as well as how its biologic properties make it a great moisturizer. Additionally, data on its potential for flammability, allergenicity, and comedogenicity are detailed, dispelling misconceptions about petrolatum use around oxygen and as a cause of acne. The uses and benefits of petrolatum in dermatology are wide-ranging-a patch test instrument, a vehicle for medicated ointments, and a wound care essential. Given its ubiquitous presence, it is important for dermatologists to understand the history, safety profile, and myths surrounding this humble skincare staple.

Topical Antibiotic Prophylaxis for Preventing Surgical Site Infections of Clean Wounds: A Systematic Review and Meta-Analysis

Background: Topical antibiotic agents are not generally indicated for preventing of surgical site infections (SSIs) in clean incisions, and the drug concentrations that should be delivered to local incision sites remain uncertain. The aim of this study was to critically assess the efficacy of topical antibiotic agents in comparison with non-antibiotic agents for preventing SSIs in clean incisions by performing a systematic review and meta-analysis. Methods: We conducted a search of literature in PubMed, Embase, and Cochrane Databases and included randomized controlled trials (RCTs) on topical antibiotic use for patients with clean post-surgical incisions. The primary outcome was the incidence of SSI, presented as the event rate. Eleven RCTs were included. Results: Using random-effects modeling, the pooled risk ratio (RR) of developing a post-surgical incisions infection was 0.83 (95% confidence interval [CI], 0.61-1.16; I2, 0%). In subgroup analyses, no reductions in SSI were observed when topical antibiotic agents were used to treat incisions due to spinal (RR, 0.75; 95% CI, 0.40-1.38; I2, 0%), orthopedic (RR, 0.69; 95% CI, 0.37-1.29; I2, 0%), dermatologic (RR, 0.77; 95% CI, 0.39-1.55; I2, 65%), or cardiothoracic surgeries (RR, 1.31; 95% CI, 0.83-2.06; I2: 0%). The incidence of SSI across different operative phases did not differ for the application of topical antibiotic agents compared with non-antibiotic agents (RR, 0.80; 95% CI, 0.56-1.14; I2, 0%). Conclusions: The results of this meta-analysis show that topical antibiotic agents provide no clinical benefit for preventing SSI in clean incisions.

State of the Evidence for Facial Skin Cancer Reconstruction

This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

How to Promote Skin Repair? In-Depth Look at Pharmaceutical and Cosmetic Strategies

Skin repair encompasses epidermal barrier repair and wound healing which involves multiple cellular and molecular stages. Therefore, many skin repair strategies have been proposed. In order to characterize the usage frequency of skin repair ingredients in cosmetics, medicines, and medical devices, commercialized in Portuguese pharmacies and parapharmacies, a comprehensive analysis of the products' composition was performed. A total of 120 cosmetic products, collected from national pharmacies online platforms, 21 topical medicines, and 46 medical devices, collected from INFARMED database, were included in the study, revealing the top 10 most used skin repair ingredients in these categories. A critical review regarding the effectiveness of the top ingredients was performed and an in-depth analysis focused on the top three skin repair ingredients pursued. Results demonstrated that top three most used cosmetic ingredients were metal salts and oxides (78.3%), vitamin E and its derivatives (54.2%), and Centella asiatica (L.) Urb. extract and actives (35.8%). Regarding medicines, metal salts and oxides were also the most used (47.4%) followed by vitamin B5 and derivatives (23.8%), and vitamin A and derivatives (26.3%). Silicones and derivatives were the most common skin repair ingredients in medical devices (33%), followed by petrolatum and derivatives (22%) and alginate (15%). This work provides an overview of the most used skin repair ingredients, highlighting their different mechanisms of action, aiming to provide an up-to-date tool to support health professionals' decisions.

Biocompatible Triple-Helical Recombinant Collagen Dressings for Accelerated Wound Healing in Microneedle-Injured and Photodamaged Skin

Skin rejuvenation procedures such as microneedling and laser resurfacing have gained global popularity in medical cosmetology, leading to acute skin wounds with persistent pain, erythema, and edema. A variety of dressings have been explored to repair these postoperative skin injuries; however, their inadequate biocompatibility and bioactivity may raise concerns about undesirable efficacy and complications. Herein, we developed biocompatible and nonirritating triple-helical recombinant collagen (THRC) dressings for accelerated healing of microneedle-injured and photodamaged acute skin wounds. Circular dichroism (CD) measurements of THRC from various batches exhibited triple-helical structure characteristics of collagen. Cell experiments using L929 fibroblasts revealed that THRC dressings possess superior biocompatibility and bioactivity, significantly elevating the proliferation and adhesion of fibroblasts. In vivo, skin irritation tests of New Zealand rabbits demonstrated that the THRC dressings are gentle, safe, and non-irritating. Histological analysis of the animal model studies in photodamaged skin wounds using H&E and Masson’s trichrome staining revealed that 4 days of treatment with the THRC dressings effectively healed the damaged dermis by accelerating re-epithelialization and enhancing collagen deposition. In vivo studies of microneedle-injured rat defects showed that THRC dressings of varying concentrations exhibit the same rapid epithelialization rates at 48 h as commercial bovine collagen dressings. The highly biocompatible and bioactive recombinant collagen dressings may provide an advanced treatment of acute skin wounds, indicating attractive applications in postoperative care of facial rejuvenation.

Soft tissue infection and follow-up for an unsheltered patient: the role of Street Medicine providers in bridging gaps in care

Street Medicine is a volunteer-run initiative for low-resource healthcare settings. Formed to bridge gaps in care for persons experiencing homelessness, these organisations work to provide preventative medicine through maintenance care and follow-up. However, there are limits to what Street Medicine can accomplish given the geographical radius covered, lack of available transportation options and vulnerable sleeping locations night to night for the patients served. The subject of this case report is a middle-aged Spanish-speaking unsheltered man who began his care with a Street Medicine team. He was unable to attend medical appointments due to relocation, complicating his disease course and resulting in hospital intervention for cellulitis. Post-discharge, he stayed within radius and was treated by the street team. Increased emphasis on the effects of housing insecurity and addressing social determinants of health could prevent deterioration of manageable diseases and should be an area of active interest for Street Medicine team expansion.

Therapeutic delivery of nucleic acids for skin wound healing

Though wound care has advanced, treating chronic wounds remains a challenge and there are many clinical issues that must be addressed. Gene therapy is a recent approach to treating chronic wounds that remains in its developmental stage. The limited reports available describe the therapeutic applications of various forms of nucleic acid delivery for treating chronic wounds, including DNA, mRNA, siRNA, miRNA and so on. Though these bioactive molecules represent great therapeutic potential, sustaining their bioactivity in the wound bed is a challenge. To overcome this hurdle, delivery systems are also being widely investigated. In this review, nucleic acid-based therapy and its delivery for treating chronic wounds is discussed in detail.

Topical antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: a systematic review and meta-analysis

Background

Topical antibiotics are widely prescribed as prophylaxis for surgical site infection (SSI). Despite giving high drug concentrations at local wound sites, their efficacy remains controversial. This study is a systematic review and meta-analysis designed to compare the efficacy and safety of topical antibiotics with non-antibiotic agents in preventing SSI.

Methods

Randomized controlled trials (RCTs) comparing topical antibiotics in patients with clean and clean-contaminated postsurgical wounds were included. Relevant trials published before 30 September 2020, were searched in the PubMed, Embase, and Cochrane databases, without language restrictions. The primary outcome was the incidence of SSIs, presented as the event rate. The secondary outcome was the incidence of contact dermatitis (safety outcome). Data were synthesized using the random-effects model, with the results expressed as risk ratio (RR) with 95 per cent confidence intervals (c.i.).

Results

Thirteen RCTs were included. The incidence of SSIs and contact dermatitis showed no significant difference between topical antibiotics and non-antibiotic agents (RR 0.89, 95 per cent c.i. 0.59 to 1.32 (P = 0.56, I² = 48 per cent); and RR 2.79, 95 per cent c.i. 0.51 to 15.19 (P = 0.24, I² = 0 per cent), respectively). In the subgroup analyses, a reduction in SSIs was also not observed in dermatological (RR 0.77, 95 per cent c.i. 0.39 to 1.55; P = 0.46, I² = 65 per cent), ocular (RR 0.08, 95 per cent c.i. 0.00 to 1.52; P = 0.09), spinal (RR 1.34, 95 per cent c.i. 0.65 to 2.77; P = 0.43, I² = 0 per cent), orthopaedic (RR 0.69, 95 per cent c.i. 0.37 to 1.29; P = 0.25, I² = 0 per cent), or cardiothoracic surgeries (RR 1.60, 95 per cent c.i. 0.79 to 3.25; P = 0.19).

Conclusion

Given the current evidence, the routine application of topical antibiotics to surgical wounds did not reduce the incidence of SSI. Further trials are needed to assess their effectiveness in high-risk surgeries or in selected patient groups.

Bioactive antiinflammatory antibacterial hemostatic citrate-based dressing with macrophage polarization regulation for accelerating wound healing and hair follicle neogenesis

The efficient cutaneous wound healing accompanied with the enhanced skin appendage regeneration is still a challenge. The bacterial infection and excessive/prolonged inflammation inhibit wound healing process and result in the scar formation. Herein, we reported an anti-inflammatory polycitrate-polyethyleneimine-Ibuprofen (PCEI) and multifunctional PCEI-based F127-ε-polypeptide-alginic (FEA) dressing (FEA-PCEI) for accelerating wound healing and hair follicle neogenesis. PCEI showed the excellent anti-inflammation function through stimulating macrophage towards anti-inflammatory M2 subtype polarization. The FEA-PCEI dressing showed the temperature-response gelation, injectability, robust antibacterial activity, light-damage-resistant, homeostasis ability, and good cytocompatibility. The optimized dosage of FEA-PCEI dressing could significantly accelerate wound healing with anti-infection ability, reduce the scar formation, and promote the hair follicle neogenesis. This study provided a wound-repairing strategy through regulating the phenotype of immune cells by the designing bioactive multifunctional biomaterials.

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Anti-inflammation PCEI and multifunctional PCEI-based hydrogel was fabricated.

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PCEI and hydrogel dressing inhibited inflammation with increased M2 macrophages.

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PCEI-based hydrogel dressing showed antibacterial/anti-UV/hemostasis activity.

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PCEI-based hydrogel dressing promoted wound healing and hair follicle neogenesis.

The role of topical probiotics on wound healing: A review of animal and human studies

Pathogenic, opportunistic, and commensal bacterial coexist in the intestinal tract, and imbalances among these strains have been linked to systemic inflammation and a variety of disease states. Similarly, human skin plays an important role as an interface between the body and the environment with an estimated 1 billion microbes per square centimetres. Skin microbiome fluctuations that cause increases in pathologic bacteria, either because of individual and/or environmental factors, can lead to disease states at the skin level ranging from inflammatory conditions to infections. As wounds are inherently associated with perturbations in the local microflora due to injury and activation of the immune responses, the addition of topical probiotics could be a means to prevent infection, regulate inflammation, and potentially augment healing. The goal of this review is to analyse the impact the skin microbiome has on cutaneous wound healing with a focus on developing proposed treatment algorithms and support for their therapeutic potential.

Preoperative Considerations for the Prevention of Surgical Site Infection in Superficial Cutaneous Surgeries: A Systematic Review

Background: Surgical site infections (SSIs) pose challenges to the outcome of superficial cutaneous procedures. Objective: The objective of this study was to summarize published data regarding appropriate perioperative considerations to decrease SSI, including antiseptic use, topical decolonization, antibiotic prophylaxis, and clean versus sterile technique in superficial cutaneous procedures. A literature search was performed via PubMed and Cochrane Library by using relevant keywords. A total of 37 articles met the inclusion criteria. Strength of data was assessed according to the Oxford Centre criteria and a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: Chlorhexidine is the antiseptic of choice in clean or outpatient superficial cutaneous procedures. Decolonization of carriers of Staphylococcus aureus with mupirocin is warranted for all superficial cutaneous procedures. Minor procedure rooms may be considered for superficial cutaneous procedures that possess an inherently low risk of SSI. Surgeons may consider nonsterile gloves instead of sterile gloves for clean or outpatient superficial cutaneous procedures. Postoperative use of topical antibiotics may be discontinued, as there are risks of adverse effects and increasing bacterial resistance without a significant reduction in SSI. Conclusion and Relevance: This systematic review provides new and updated evidence for the prevention of SSI in superficial cutaneous procedures through antiseptic use, antibiotic use, topical agents, and the surgical environment. The overall quality of evidence is good, with most articles being original research or systematic reviews. However, there is a need for dermatologic- and plastic surgery-specific studies regarding the prevention of SSI.

Variability in Wound Care Recommendations Following Dermatologic Procedures

BACKGROUND

Dermatologists routinely perform office-based surgical procedures that result in cutaneous wounds. Wound care instructions are an important resource for postoperative patients. As there is no consensus on the ideal wound care regimen after dermatologic procedures, recommendations may vary.

OBJECTIVE

To evaluate the current recommendations for wound care following dermatologic procedures.

METHODS

The authors conducted a cross-sectional assessment of dermatology wound care handouts available online. The handouts were evaluated based on predefined parameters: topical agent recommendations for wound healing, caution against topical antibiotic use, and discussion of scarring, infection, bleeding, analgesia, and lifestyle considerations.

RESULTS

A total of 169 handouts were evaluated. The majority (84%) recommended the application of petrolatum-based products, specifically Vaseline (75%) and Aquaphor (43%). Nearly half (43%) recommended the use of topical antibiotics, whereas 24% advised patients to avoid antibiotic ointments. Handouts variably addressed scarring (36%), infection (72%), bleeding (69%), pain (66%), and lifestyle modifications (64%).

CONCLUSION

The instructions provided in dermatology patient handouts are highly variable, with various topical agents being recommended for wound healing. Topical antibiotics are not indicated for prophylaxis in clean dermatologic procedures but are still widely used. Greater efforts should be made to ensure that patients receive consistent and evidence-based wound care guidance.

The curative effects of the traditional Chinese herbal medicine "Jinchuang ointment" on excisional wounds

BACKGROUND

"Jinchuang ointment" is a traditional Chinese herbal medicine for external incised wounds. This herbal medicine has been successfully used to treat patients with diabetic foot ulcers and pressure sores in Taiwan for several decades. We previously examined its biological activities on cell-based in vitro assay platforms. Because some patients refused to use animal-derived ingredients ointment during our clinical practice, the efficacy of plant oil-based reconstituted "Jinchuang ointment" was also investigated.

METHODS

A porcine excisional wound model was established and used to evaluate its efficacy in vivo in this study. Besides, an unusual clinical case is also present.

RESULTS

As judged from the wound appearance of animal studies on day 14 and the results of blood flow flux at the wound sites on day 28, "Jinchuang ointment" accelerated wound closure significantly better than the control group.

CONCLUSIONS

The results from clinical treatment, histopathological evaluation, and the animal study showed that "Jinchung ointment" promotes wound healing significantly better than the control group. Also, sesame oil-reconstituted ointment can be a choice for patients who refuse to use lard-containing ointment.

Effect of Topical Garlic on Wound Healing and Scarring: A Clinical Trial

BACKGROUND

Historically, garlic containing compounds have been used on wounds to improve healing and ward off infection. Researchers have tested many of these ancient ointments, discovering that garlic is a common ingredient in those that are effective.

OBJECTIVE

To determine the efficacy of topical garlic on surgical wounds compared with Vaseline by analysis of visual analog scales and digital photograph analysis.

MATERIALS AND METHODS

Seventeen patients with 2 skin excisions applied a 30% garlic ointment to one surgical wound and Vaseline to the other surgical wound twice daily. They were followed up at 2 weeks and 4 weeks post-op. Digital photographs were taken of the sites, and wound visual analog scales were filled out by the patient and the physician.

RESULTS

Patients and the onsite physician stated the garlic site healed better in 59% and 65% of the wounds, respectively, at 2 weeks. At 4 weeks, the patients and the onsite physician stated the garlic site healed better in 76% and 88% of wounds, respectively. Digital photograph analysis revealed less erythema at the garlic sites (p-value = .02).

CONCLUSION

Surgical wounds treated with 30% garlic ointment healed with more cosmetically appealing scars than the Vaseline-treated sites.

Reduced Graphene-Oxide-Embedded Polymeric Nanofiber Mats: An "On-Demand" Photothermally Triggered Antibiotic Release Platform

The steady increase of antimicrobial resistance of different pathogens requires the development of alternative treatment strategies next to the oral delivery of antibiotics. A photothermally activated platform based on reduced graphene oxide (rGO)-embedded polymeric nanofiber mats for on-demand release of antibiotics upon irradiation in the near-infrared is fabricated. Cross-linked hydrophilic nanofibers, obtained by electrospinning a mixture of poly(acrylic acid) (PAA) and rGO, show excellent stability in aqueous media. Importantly, these PAA@ rGO nanofiber mats exhibit controlled photothermal heating upon irradiation at 980 nm. Nanofiber mats are efficiently loaded with antibiotics through simple immersion into corresponding antibiotics solutions. Whereas passive diffusion based release at room temperature is extremely low, photothermal activation results in increased release within few minutes, with release rates tunable through power density of the applied irradiation. The large difference over passive and active release, as well as the controlled turn-on of release allow regulation of the dosage of the antibiotics, as evidenced by the inhibition of planktonic bacteria growth. Treatment of superficial skin infections with the antibiotic-loaded nanofiber mats shows efficient wound healing of the infected site. Facile fabrication and implementation of these photothermally active nanofiber mats makes this novel platform adaptable for on-demand delivery of various therapeutic agents.

A systematic review and meta-analysis on the use of prophylactic topical antibiotics for the prevention of uncomplicated wound infections

Background

The prescription of topical antibiotics for the prevention of infections in uncomplicated wounds is common. However, the efficacy is not well reported. Therefore, the objective of the study was to conduct a systematic review and meta-analysis of the available evidence on prevention of uncomplicated wound infections by prophylactic topical antibiotics.

Materials and methods

The search included Pubmed, Google Scholar, SCOPUS, Embase, Cochrane, ClinicalTrials.gov, International Clinical Trials Registry Platform, National Technical Information Service, and the National Guidelines Clearinghouse.

Results

We identified eight randomized controlled trials and four quasi-randomized trials that met the criteria for the systematic review. Of these trials, 11 studies were pooled for meta-analysis to compare the effects of topical antibiotics versus placebo and 4 studies were pooled for comparison of effects of topical antibiotics versus topical antiseptics on uncomplicated wounds. Fewer wound infections occurred in the topical antibiotic arms compared to placebo (pooled risk ratio: 0.57 [95% CI: 0.37 to 0.86]; p=0.01 and pooled risk difference: −3.1% [95% CI: −5.8% to −0.34%]; p=0.03). Compared to antiseptics, topical antibiotics demonstrated statistically significant relative risk reduction (pooled risk ratio: 0.56 [95% CI: 0.23 to 0.91]; p=0.02), while there was no significant absolute risk reduction (pooled risk difference: −3.7% [95% CI: −7.9% to +0.6%]; p=0.09).

Conclusion

Topical antibiotics are effective in reducing wound infections after surgical procedures, but the absolute benefit is small. Given the global emergence of antimicrobial resistance, judicious use of antibiotics is encouraged and use of antiseptics should be considered as a reasonable alternative to topical antibiotics.

Pathophysiologic Mechanisms and Current Treatments for Cutaneous Sequelae of Burn Wounds

Burn injuries are a pervasive clinical problem. Extensive thermal trauma can be life-threatening or result in long-lasting complications, generating a significant impact on quality of life for patients as well as a cost burden to the healthcare system. The importance of addressing global or systemic issues such as resuscitation and management of inhalation injuries is not disputed but is beyond the scope of this review, which focuses on cutaneous pathophysiologic mechanisms for current treatments, both in the acute and long-term settings. Pathophysiological mechanisms of burn progression and wound healing are mediated by highly complex cascades of cellular and biochemical events, which become dysregulated in slow-healing wounds such as burns. Burns can result in fibroproliferative scarring, skin contractures, or chronic wounds that take weeks or months to heal. Burn injuries are highly individualized owing to wound-specific differences such as burn depth and surface area, in addition to patient-specific factors including genetics, immune competency, and age. Other extrinsic complications such as microbial infection can complicate wound healing, resulting in prolonged inflammation and delayed re-epithelialization. Although mortality is decreasing with advancements in burn care, morbidity from postburn deformities continues to be a challenge. Optimizing specialized acute care and late burn outcome intervention on a patient-by-patient basis is critical for successful management of burn wounds and the associated pathological scar outcome. Understanding the fundamentals of integument physiology and the cellular processes involved in wound healing is essential for designing effective treatment strategies for burn wound care as well as development of future therapies. Published 2018. Compr Physiol 8:371-405, 2018.

Laceration Management

BACKGROUND

Traumatic lacerations to the skin represent a fairly common reason for seeking emergency department care. Although the incidence of lacerations has decreased over the past decades, traumatic cutaneous lacerations remain a common reason for patients to seek emergency department care.

OBJECTIVE

Innovations in laceration management have the potential to improve patient experience with this common presentation.

DISCUSSION

Studies have confirmed that delays in wound closure rarely confer increased rates of infection, although comorbidities such as diabetes, chronic renal failure, obesity, human immunodeficiency virus, smoking, and cancer should be considered. Antibiotics should be reserved for high-risk wounds, such as those with comorbidities, gross contamination, involvement of deeper structures, stellate wounds, and selected bite wounds. Topical anesthetics, which are painless to apply, have a role in select populations. In most studies, absorbable sutures perform similarly to nonabsorbable sutures and do not require revisit for removal. Novel atraumatic closure devices and expanded use of tissue adhesives for wounds under tension further erode the primacy of regular sutures in wound closure. Maintaining a moist wound environment with occlusive dressings is more important than previously thought. Most topical wound agents are of limited benefit.

CONCLUSIONS

Recent innovations in wound closure are allowing emergency physicians to shift toward painless, atraumatic, and rapid closure of lacerations.

Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment

Importance

Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making.

Objective

To present the newest and best evidence to close common practice gaps in cutaneous surgery.

Evidence Review

We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed.

Findings

A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications.

Conclusions and Relevance

Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

Surgery-Related Contact Dermatitis: A Review of Potential Irritants and Allergens

Surgical procedures utilize an increasing number of medical products including antiseptics, anesthetics, gloves, suture materials, tissue adhesives, topical antibiotics, and bandages. Many of these products have irritant potential. Allergic contact dermatitis has also been reported. This review covers preoperative, operative, and postoperative exposures that may result in contact dermatitis. Testing with standard patch panels such as T.R.U.E. Test and the North American Contact Dermatitis Group 65 allergen series does not evaluate for all relevant contactants. A thorough understanding of potential exposures is vital to effectively evaluate a patient with surgery-related contact dermatitis. A systematic approach is needed to ensure that standard patch panels and supplementary patches adequately address each encountered contactant.

Chronic Wound Healing: A Review of Current Management and Treatments

Wound healing is a complex, highly regulated process that is critical in maintaining the barrier function of skin. With numerous disease processes, the cascade of events involved in wound healing can be affected, resulting in chronic, non-healing wounds that subject the patient to significant discomfort and distress while draining the medical system of an enormous amount of resources. The healing of a superficial wound requires many factors to work in concert, and wound dressings and treatments have evolved considerably to address possible barriers to wound healing, ranging from infection to hypoxia. Even optimally, wound tissue never reaches its pre-injured strength and multiple aberrant healing states can result in chronic non-healing wounds. This article will review wound healing physiology and discuss current approaches for treating a wound.

Topical antibiotics for preventing surgical site infection in wounds healing by primary intention

BACKGROUND

Surgical site infections (SSI) can delay wound healing, impair cosmetic outcome and increase healthcare costs. Topical antibiotics are sometimes used to reduce microbial contaminant exposure following surgical procedures, with the aim of reducing SSIs.

OBJECTIVES

The primary objective of this review was to determine whether the application of topical antibiotics to surgical wounds that are healing by primary intention reduces the incidence of SSI and whether it increases the incidence of adverse outcomes (allergic contact dermatitis, infections with patterns of antibiotic resistance and anaphylaxis).

SEARCH METHODS

In May 2015 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies, and bibliographies of relevant publications to identify further eligible trials. There was no restriction of language, date of study or setting. The search was repeated in May 2016 to ensure currency of included studies.

SELECTION CRITERIA

All randomized controlled trials (RCTs) and quasi-randomised trials that assessed the effects of topical antibiotics (any formulation, including impregnated dressings) in people with surgical wounds healing by primary intention were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and independently extracted data. Two authors then assessed the studies for risk of bias. Risk ratios were calculated for dichotomous variables, and when a sufficient number of comparable trials were available, trials were pooled in a meta-analysis.

MAIN RESULTS

A total of 10 RCTs and four quasi-randomised trials with 6466 participants met the inclusion criteria. Six studies involved minor procedures conducted in an outpatient or emergency department setting; eight studies involved major surgery conducted in theatre. Nine different topical antibiotics were included. We included two three-arm trials, two four-arm trials and 10 two-arm trials. The control groups comprised; an alternative topical antibiotic (two studies), topical antiseptic (six studies) and no topical antibiotic (10 studies), which comprised inert ointment (five studies) no treatment (four studies) and one study with one arm of each.The risk of bias of the 14 studies varied. Seven studies were at high risk of bias, five at unclear risk of bias and two at low risk of bias. Most risk of bias concerned risk of selection bias.Twelve of the studies (6259 participants) reported infection rates, although we could not extract the data for this outcome from one study. Four studies (3334 participants) measured allergic contact dermatitis as an outcome. Four studies measured positive wound swabs for patterns of antimicrobial resistance, for which there were no outcomes reported. No episodes of anaphylaxis were reported. Topical antibiotic versus no topical antibioticWe pooled the results of eight trials (5427 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with no topical antibiotic (RR 0.61, 95% CI 0.42 to 0.87; moderate-quality evidence downgraded once for risk of bias). This equates to 20 fewer SSIs per 1000 patients treated with topical antibiotics (95% CI 7 to 29) and a number needed to treat for one additional beneficial outcome (NNTB) (i.e. prevention of one SSI) of 50.We pooled the results of three trials (3012 participants) for the outcome of allergic contact dermatitis, however this comparison was underpowered, and it is unclear whether topical antibiotics affect the risk of allergic contact dermatitis (RR 3.94, 95% CI 0.46 to 34.00; very low-quality evidence, downgraded twice for risk of bias, once for imprecision). Topical antibiotic versus antiseptic We pooled the results of five trials (1299 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with using topical antiseptics (RR 0.49, 95% CI 0.30 to 0.80; moderate-quality evidence downgraded once for risk of bias). This equates to 43 fewer SSIs per 1000 patients treated with topical antibiotics instead of antiseptics (95% CI 17 to 59) and an NNTB of 24.We pooled the results of two trials (541 participants) for the outcome of allergic contact dermatitis; there was no clear difference in the risk of dermatitis between topical antibiotics and antiseptics, however this comparison was underpowered and a difference cannot be ruled out (RR 0.97, 95% CI 0.52 to 1.82; very low-quality evidence, downgraded twice for risk of bias and once for imprecision). Topical antibiotic versus topical antibioticOne study (99 participants) compared mupirocin ointment with a combination ointment of neomycin/polymyxin B/bacitracin zinc for the outcome of SSI. There was no clear difference in the risk of SSI, however this comparison was underpowered (very low-quality evidence downgraded twice for risk of bias, once for imprecision).A four-arm trial involved two antibiotic arms (neomycin sulfate/bacitracin zinc/polymyxin B sulphate combination ointment versus bacitracin zinc, 219 participants). There was no clear difference in risk of SSI between the combination ointment and the bacitracin zinc ointment. The quality of evidence for this outcome was low, downgraded once for risk of bias, and once for imprecision.

AUTHORS' CONCLUSIONS

Topical antibiotics applied to surgical wounds healing by primary intention probably reduce the risk of SSI relative to no antibiotic, and relative to topical antiseptics (moderate quality evidence). We are unable to draw conclusions regarding the effects of topical antibiotics on adverse outcomes such as allergic contact dermatitis due to lack of statistical power (small sample sizes). We are also unable to draw conclusions regarding the impact of increasing topical antibiotic use on antibiotic resistance. The relative effects of different topical antibiotics are unclear.

Wound healing and treating wounds: Chronic wound care and management

In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

OBJECT

The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.

METHODS

This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.

RESULTS

A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively).

CONCLUSIONS

This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

Complications associated with bacitracin powder in surgical wounds

OBJECT

There has been renewed interest in the application of concentrated antibiotic powder to surgical wounds as a method to decrease infection rates. While there is substantial medical literature describing the effectiveness and complications associated with vancomycin and gentamycin powders, very little has been reported regarding the safety and effectiveness of bacitracin powder in surgical wounds. In this paper the authors report their detailed analysis of potential bacitracin powder-related complications in a population of pediatric patients who underwent shunt surgery.

METHODS

A detailed retrospective analysis was completed of all CSF shunt surgeries performed by the corresponding author at a large children's hospital between 2001 and 2013. This cohort consisted of many patients who were the subject of a previous report that showed the use of bacitracin powder in shunt wounds potentially decreased infection rates. Data were collected regarding the most common known complications of bacitracin, i.e., anaphylaxis, wound healing difficulties, and renal dysfunction. Data were stratified by typical demographic, medical, and surgical variables, including whether bacitracin powder was applied to wounds prior to closure.

RESULTS

A total of 597 patients were reviewed in the analysis: 389 underwent surgery without bacitracin powder and 208 had concentrated bacitracin powder applied to the wounds prior to closure. The application of bacitracin powder was not associated with anaphylaxis (n = 0 both groups) or with an increase in wound breakdown (n = 5 in the control group, n = 0 in the bacitracin powder group) or renal dysfunction (creatinine/estimated glomerular filtration rate) using both comparative and multivariate analyses between the 2 groups. The sample size evaluating renal function was significantly lower (range 6-320) than that of anaphylaxis and wound breakdown analysis because only clinical values acquired during the routine care of these patients were available for analysis. The only significant difference in demographics was the more frequent use of intrathecal vancomycin and gentamycin in patients who received bacitracin powder (n = 1 for controls, n = 21 for bacitracin powder). In the multivariate analysis, only 1 factor, surgery performed on a premature infant within the first 3 months of life, was independently associated with a change in creatinine at 3 months (creatinine decreased by 0.18) compared with the level before surgery (p < 0.0001). Bacitracin powder was not a significant factor.

CONCLUSIONS

To the authors' knowledge, this is the first study to systematically analyze the potential complications of concentrated bacitracin powder applied to surgical wounds. The use of topical bacitracin powder in CSF shunt wounds was not associated with anaphylaxis, wound breakdown, or renal dysfunction. Further study using standardized protocols is necessary before widespread use can be recommended.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.

Dermatological postoperative patient information leaflets: is it time for more uniformity?

INTRODUCTION

Patient information leaflets (PILs) are an important source of information for patients postoperatively. There are currently no nationally agreed standards by dermatologists for postoperative advice following skin surgery.

AIM

To assess the common themes and areas of variation in advice given in PILs after skin surgery across all National Health Service (NHS) hospitals in England and Wales.

METHODS

All acute trusts in England (n = 159) and local health boards in Wales (n = 7) were requested to provide their postoperative dermatological PILs for general sutured wound care or excision biopsy. Eight preselected parameters were assessed: minimum dressing duration, duration of pressing on a bleeding wound, postoperative analgesia, explanation of infection signs, application of petroleum jelly, scarring, whom to contact if there is a problem, and the recommended postoperative time for abstaining from active exercise.

RESULTS

PILs were received from 137 different dermatology departments belonging to 127/166 (76.5%) organisations across England and Wales. Of these, 102 PILs gave a specific duration for dressings: 45/102 (44.1%) advised a minimum of 48 h, but 28/102 (27.5%) recommended leaving dressings in place until suture removal. Regarding duration of pressing on a bleeding wound, 117 PILs gave advice, with the most common recommendation being 15 min (30/117, 25.6%), followed closely by 10 min (26/117, 22.2%). Of the 137 PILs received, 125 gave advice regarding postoperative analgesia, with paracetamol alone being the most common recommendation (24/125, 19.2%). For the remaining parameters, 111/137 (81.0%) PILs described ≥ 2 signs of infection, 42/137 (30.7%) recommended the application of petroleum jelly, 65/137 (47.4%) mentioned scarring, 137/137 (100%) highlighted whom to contact if there were postoperative problems and 87/137 (63.5%) PILs gave advice regarding postoperative abstinence from active exercise.

CONCLUSIONS

The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.

Retrospective Clinical Trial of Fusidic Acid versus Petrolatum in the Postprocedure Care of Clean Dermatologic Procedures

BACKGROUND

Clean dermatologic procedures create wounds with a low risk of infection (usually up to 5%). Whether the use of topical antibiotics is advocated, with regard to its efficacy and safety issues such as antibiotic resistance and sensitizing potential, is controversial. Fusidic acid, a topical antibiotic against gram-positive bacteria, is a rare sensitizer and commonly used in postprocedure care in Korea.

OBJECTIVE

This is a retrospective study aimed at comparing the efficacy and safety between fusidic acid and petrolatum for the postprocedure care of clean dermatologic procedures.

METHODS

Patients were treated with either fusidic acid or petrolatum ointment, applied on the wound created during clean dermatologic procedures such as biopsy of the punch, incisional, excisional, and shave types. The efficacy, adverse events, and subjective level of satisfaction were retrieved from medical records.

RESULTS

A total of 414 patients with a total of 429 wounds were enrolled. The overall rate of adverse events was 0.9%, and the rates of adverse events in the fusidic acid group and the petrolatum group were 1.4% and 0.5%, respectively (p=0.370). There was no wound discharge, pain, tenderness, swelling, induration, or dehiscence in both groups. The patients' self-assessment of the wound was not significantly different between the two treatment groups.

CONCLUSION

Our findings support the hypothesis that the routine prophylactic use of topical antibiotics is not indicated for clean dermatologic procedures. We recommend the use of petrolatum in the postoperative care of clean dermatologic procedures because of its equivalent efficacy and superior safety profiles.

A pilot study to investigate the efficacy of tobramycin-dexamethasone ointment in promoting wound healing

INTRODUCTION

The standard postsurgical treatment of wounds after dermatologic procedures is currently limited. Topical corticosteroids have been used successfully in postoperative management of ophthalmologic surgeries that involve the skin of the eyelid. In particular, tobramycin 0.3%/dexamethasone 0.1% ophthalmic ointment is considered the "gold standard" of steroid-antibiotic fixed combinations and is marketed worldwide as an agent used to control postsurgical inflammation and prevent postsurgical infection. The purpose of this study is to evaluate both the efficacy and safety of tobramycin-dexamethasone ointment for the postsurgical management of Mohs or dermatologic surgery in comparison to white petrolatum.

METHODS

The authors employed a half-scar study in which patients who underwent skin cancer removal surgery were given tobramycin-dexamethasone ointment and white petrolatum to apply to each half of their wound for 2 weeks. The study was double blinded, and physicians and the patients independently evaluated the scars for cosmetic appearance at 2 and 6 weeks postoperatively. The evaluation criteria included judging which side of the wound looked better based on color, thickness, and discomfort.

RESULTS

Eighteen patients were enrolled, of which 13 patients completed the three phases of the study. After 6 weeks the wounds did not show a statistically significant difference in color, thickness, or discomfort on either side.

CONCLUSION

Results obtained to date suggest that the application of tobramycin-dexamethasone ointment to wounds after dermatologic surgery does not promote better wound healing than white petrolatum. These findings indicate that a topical steroid and antibiotic ointment may not be an effective intervention in improving postoperative outcomes in dermatologic surgeries.

Body piercing: complications and prevention of health risks

Body and earlobe piercing are common practices in the USA today. Minor complications including infection and bleeding occur frequently and, although rare, major complications have been reported. Healthcare professionals should be cognizant of the medical consequences of body piercing. Complications vary depending on the body-piercing site, materials used, experience of the practitioner, hygiene regimens, and aftercare by the recipient. Localized infections are common. Systemic infections such as viral hepatitis and toxic shock syndrome and distant infections such as endocarditis and brain abscesses have been reported. Other general complications include allergic contact dermatitis (e.g. from nickel or latex), bleeding, scarring and keloid formation, nerve damage, and interference with medical procedures such as intubation and blood/organ donation. Site-specific complications have been reported. Oral piercings may lead to difficulty speaking and eating, excessive salivation, and dental problems. Oral and nasal piercings may be aspirated or become embedded, requiring surgical removal. Piercing tracts in the ear, nipple, and navel are prone to tearing. Galactorrhea may be caused by stimulation from a nipple piercing. Genital piercings may lead to infertility secondary to infection, and obstruction of the urethra secondary to scar formation. In men, priapism and fistula formation may occur. Women who are pregnant or breastfeeding and have a piercing or are considering obtaining one need to be aware of the rare complications that may affect them or their child. Though not a 'complication' per se, many studies have reported body piercing as a marker for high-risk behavior, psychopathologic symptoms, and anti-social personality traits. When it comes to piercing complications, prevention is the key. Body piercers should take a complete medical and social history to identify conditions that may predispose an individual to complications, and candidates should choose a qualified practitioner to perform their piercing. As body piercing continues to be popular, understanding the risks of the procedures as well as the medical and psychosocial implications of wearing piercing jewelry is important for the medical practitioner.