Variability in Wound Care Recommendations Following Dermatologic Procedures

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.

Inappropriate Topical Antibiotics Use in Clean Dermatological Procedures in South Korea in 2018: A Nationwide Population-Based Cross-Sectional Study

BACKGROUND

The use of topical antibiotics (TA) for prophylactic purposes after clean dermatologic procedures (CDP) is generally not recommended, and the prescription of TA needs to be individualized in consideration of each patient's situation and underlying disease. The aim of this study was to determine the proportion of patients who underwent CDP in outpatient settings and were prescribed TA inappropriately, as well as the factors that may affect the prescription of TA.

METHODS

Outpatient visits coded for CDP were selected using claims data from the Health Insurance Review and Assessment Service in 2018. Of these, patients receiving TA prescriptions were classified as having inappropriate TA use, and the proportion was estimated through technical analysis. A logistic regression analysis was used to identify factors influencing inappropriate prescriptions.

RESULTS

Data were analyzed using 423,651 visits, and TA was prescribed for approximately 1.9% of the visits. TA usage was higher among women (2.0%), 0-19 years of age (2.2%), medical aid (2.2%), clinic settings (2.4%), and metropolitan areas (2.0%). TA was prescribed more frequently in urology (8.6%), pediatrics (5.0%), and dermatology (4.2%) than in other specialties.

CONCLUSION

The prescription rate of TA after CDP was 1.9% using the 1.4 million patient sample from the national health insurance claims data in Korea, which is equally weighted to represent 50 million people. Although the proportion of inappropriate TA prescriptions in Korea is lower than that in other nations, it cannot be overlooked because of the large number of cases. Efforts to improve quality are required to reduce the number of inappropriate prescriptions.

Abortion Aftercare Instructions in the United States: A Content Analysis of Patient Handouts

BACKGROUND

At the clinical visit for abortion care, patients typically receive a handout with information about what to expect and how to care for themselves after the abortion. Published guidelines give little to no guidance regarding the content of postabortion instructions.

METHODS

We collected aftercare instruction handouts for first trimester procedural and medication abortion from abortion clinics throughout the United States. Instructions were coded and analyzed using conventional content analysis.

RESULTS

Of the 84 unique aftercare handouts we received, most included information about symptoms to expect (included in 98% of procedural handouts, 97% of medication handouts), how to manage symptoms (included in 100% of procedural handouts, 100% of medication handouts), and specific behaviors to avoid (included in 94% of procedural handouts, 66% of medication handouts). The most common behavioral avoidance instructions were "pelvic rest" (included in 90% of procedural handouts, 63% of medication handouts), avoiding strenuous activity (included in 61% of procedural handouts, 29% of medication handouts), and avoiding submersion in water (included in 41% of procedural handouts, 26% of medication handouts). Handouts varied with regard to the extent and duration of specific recommendations. They also varied in tone, word choice, and other characteristics.

CONCLUSIONS

There exists a wide range of abortion aftercare instructions throughout the United States. Inconsistency among instructions may reflect a lack of published, evidence-based clinical guidelines. Standardizing aftercare instruction handouts based on patient-oriented evidence could improve patient experience after abortion.

Hydrocolloid dressing versus conventional wound care after dermatologic surgery

Background

Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries.

Objective

To examine whether a one-time HCD application after dermatologic surgery results in greater patient satisfaction and improved postoperative outcomes compared with conventional daily dressings (CDD).

Methods

We examined patients who underwent Mohs or standard surgical excision with linear closure followed by HCD. The patients additionally had a history of excisional surgery with CDD in the past 5 years. A modified version of the validated Bluebelle Wound Healing Questionnaire was administered.

Results

The survey response rate was 74.4% (64/86). Compared with CDD, HCD rated higher in comfort, convenience, scar appearance, and simplicity of wound care instructions (P < .0001). Nearly all patients (96.8%) preferred HCD over CDD.

Limitations

Variability in time from prior dermatologic surgery may introduce recall bias. Prior surgeries involving CDD were sometimes performed by a different surgeon, which could introduce other confounding factors.

Conclusions

A simplified wound care regimen involving HCD can potentially lead to increased comfort, convenience, simplicity, and a subjective improvement in scar appearance, though additional studies are needed.

Re-thinking lactation-related nipple pain and damage

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple-areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple-areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Comparing the use of a novel antibiotic-free film-forming topical wound dressing versus a topical triple antibiotic in dermatologic surgical procedures including Mohs micrographic surgery

Background

There is no universally accepted protocol of topical wound care after cutaneous surgical procedures. The current practice is to use petrolatum‐based products, commonly containing topical antibiotics. The rise in antibiotic‐resistant bacteria and increased risk of allergic and contact dermatitis due to the use of topical antibiotics is well established.

Objective

To compare the prevalence of contact dermatitis, the infection rate and the subjective measures of healing of a novel, antibiotic‐free, film‐forming silicone‐based wound dressing to a topical triple antibiotic petrolatum‐based ointment in patients undergoing invasive dermatological interventions in two arms: (1) Mohs micrographic surgery (MMS) and (2) a combination of various routine dermatologic surgical procedures.

Design

The 231 patients were enrolled in this open‐label, randomized, single‐blinded study. Patients applied the products immediately after surgery and daily afterwards. Clinicians evaluated the surgical site for infection or contact dermatitis at all follow‐up visits. Acute wound healing progression was assessed using a rating scale against clinical experience and expected results from −4 (much worse) to +4 (much better).

Results

Contact dermatitis was significantly decreased in the wound dressing group compared to the topical antibiotic group (0 vs 15.9%, P < 0.001). There was no difference between the study arms (Mohs vs. non‐Mohs, P = 0.242). Infection rate was not significantly different between the groups (P > 0.05) and between the study arms (P > 0.05). Assessor‐rated secondary outcomes like healing time, healing quality, erythema and new tissue quality were significantly better in the wound dressing group, while comfort and perceived overall satisfaction were better in the antibiotic group. Patient‐rated outcomes did not show any difference between groups and between study arms.

Conclusion

The wound dressing used in this study is a topical silicone gel preparation and presents a viable alternative to topical antibiotics for postoperative wound care without enhancing the risk of infection.