Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

AIM

To review the efficacy of perioperative antibiotics in reducing the risk of surgical-site infections (SSIs) following excision of ulcerated skin cancers.

SETTING AND DESIGN

Study selection, data extraction and analysis were carried out independently by four authors. Only randomized controlled trials (RCTs) reported in the English language were included.

INCLUDED STUDIES

RCTs in the English language in which patients received perioperative topical, intralesional or oral antibiotics for dermatological surgery, including Mohs micrographic surgery in general practice, dermatology or plastic surgery departments, were included.

OUTCOME

The proportion of participants developing SSI following excision of skin lesions.

RESULTS

Thirteen RCTs were identified from our literature search of PubMed and Embase, which evaluated SSI following use of topical (n = 5), oral (n = 3), intramuscular (n = 2), intravenous (n = 1) and intralesional antibiotics (n = 2) in dermatological surgery. Two RCTs specifically investigated SSIs in ulcerated skin cancer excisions; one RCT investigated the SSI rate following surgical treatment specifically for ulcerated skin cancers in individuals randomized to topical antibiotics vs. oral cephalexin; and one RCT compared intravenous cefazolin with no antibiotic, demonstrating significant reduction in SSI rates for ulcerated tumours (P = 0·04).

CONCLUSIONS

The heterogeneity of the RCTs included in this study makes it difficult to make a direct comparison of the outcomes measured. High-quality evidence demonstrating a beneficial effect of the use of perioperative antibiotics to prevent SSI following excision of ulcerated skin cancers is lacking. In the absence of an evidence base, we propose that a well-designed multicentre RCT could evaluate the effect of perioperative antibiotics following excision of ulcerated tumours, and potentially reduce inappropriate antibiotic prescription.

Are there sufficient numbers of low-risk basal cell carcinomas to justify general practitioners (family physicians) carrying out basal cell carcinoma surgery?

BACKGROUND

The incidence of basal cell carcinoma (BCC) is rising within the UK, and poses a significant workload on primary and secondary care services. Greater general practitioner (GP) involvement in the diagnosis and management of BCC has been suggested to reduce this burden. In 2010, the National Institute of Health and Care Excellence (NICE) produced guidelines on the management of low-risk BCCs by GP surgeons.

AIM

To assess what proportion of BCCs are suitable for excision by GP surgeons, and to determine the potential demand for GP-led BCC surgery.

METHODS

A retrospective analysis was undertaken of all BCCs excised over 32 months for a population of 795 000 from the West Midlands region, UK. The data collected were reviewed against NICE criteria to determine the number of BCCs suitable for excision by GP surgeons.

RESULTS

In total, 1743 BCCs were excised over 32 months, a BCC excision rate of 82 per 100 000 population per year. Taking into account body site, diameter, histological subtype and other criteria, 3.0% (2.5 per 100,000 per year) of BCCs were considered low-risk according to the national criteria from NICE.

CONCLUSION

Low-risk BCCs suitable for excision by GP surgeons are of low prevalence and it would be difficult for GPs to maintain competencies in BCC surgery. Dermatologists should continue to provide the lead in skin cancer diagnosis, treatment and management.

An unusual case of bilateral pyoderma gangrenosum with Achilles tendon rupture

Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory disease characterized by neutrophilic infiltration of the dermis and destruction of tissue. PG is a diagnostic challenge, which can lead to late diagnosis, delayed treatment and detrimental surgical interventions. We describe a presentation not previously reported, affecting deep muscle and tendon leading to tendon rupture. Furthermore, we show the multidisciplinary team approach to management of a patient with PG and the reconstructive surgical element. A 31-year-old woman presented with a rapid onset painful, tender, left calf and ankle, which was associated with a mild flare of ulcerative colitis. Investigations revealed a white cell count of 26 × 10(9) cells L(-1) , a C-reactive protein count of 226 mg L(-1) , no deep vein thrombosis on ultrasound, no bone or joint involvement on X-ray and no organisms on joint aspirate. Debridement was undertaken after the left ankle developed a foul-smelling discharging wound. Repeat debridement led to worsening of the condition (pathergy). Intraoperative tissue cultures and microscopy showed no evidence of fungi, bacteria or mycobacteria. Histology showed granulation, inflammatory infiltrate, abscess formation and focal necrotizing vasculitis. Dermatology opinion confirmed PG. Awareness of the diagnosis of PG, and early involvement of dermatology, in a rapidly progressing wound is essential to avoid delayed treatment and prevent worsening through pathergy.

Clinical triage of cutaneous squamous cell carcinoma and basal cell carcinoma to avoid treatment delay: value of an electronic booking system

BACKGROUND

Provisional clinical diagnosis is the first step in planning skin surgery. Different clinical priorities are given to basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM). Discriminating between SCC and BCC can be difficult. The rate of misdiagnosis of SCC as BCC is reported as 5.7-87.6%, and can cause treatment delay. We have developed a web-based surgery booking system that requires clinical commitment to a putative differential diagnosis category, rather than a single diagnosis, at the time of consultation. This includes a crucial overlap category of 'SCC or SCC/BCC'.

AIM

To assess whether our system helped avoid treatment delay to patients with SCC, and to measure the number needed to treat (NNT).

METHODS

This was a retrospective analysis from April 2012 to August 2013, comprising all patients undergoing booked excisional surgery in our unit. The clinical triaging category was compared with the histological diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), NNT and mean Breslow thickness were calculated.

RESULTS

In total, 1455 lesions were excised, identifying 789 (54.2%) invasive malignancies (86 MM, 115 SCC, 583 BCC, 5 other), 100 in situ lesions and 150 dysplastic lesions. The majority (83.2%) of malignancies were designated into the correct malignant category. Misdiagnosis of SCC as BCC was 5.2%. Sensitivity and NPV for SCC were 94.8% and 99.4%, respectively. NNT was 1.26, 4.12 and 3.19 for BCC, SCC and MM respectively, and 1.73 for all malignancies. Mean invasive Breslow thickness was 1.29 mm [0.78 mm including melanoma in situ (MMIS)], and the MM to MMIS was 1.6.

CONCLUSION

An overlap triage category of 'SCC or SCC/BCC' helps to prevent delay in the treatment for patients with SCC.