User login
Recommendations for Empiric Antibiotic Therapy in Hidradenitis Suppurativa
Recommendations for Empiric Antibiotic Therapy in Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic scarring inflammatory skin condition of the follicular epithelium that impacts 1% to 4% of the general population (eFigure).1-3 This statistic likely is an underrepresentation of the affected population due to missed and delayed diagnoses.1 Hidradenitis suppurativa has been identified as having one of the strongest negative impacts on patients’ lives based on studied skin diseases.4 Its recurrent nature can negatively impact both the patient’s physical and mental state.3 Due to the debilitating effects of HS, we aimed to create updated recommendations for empiric antibotics based on affected anatomic locations in an effort to improve patient quality of life.
Methods
An institutional review board–approved retrospective medical chart review of 485 patients diagnosed with HS and evaluated at the University of Texas Medical Branch in Galveston from January 2006 to December 2021 was conducted. Males and females of all ages (including pregnant and pediatric patients) were included. Only patients for whom anatomic locations of HS lesions or culture sites were not documented were excluded from the analysis. Locations of cultures were categorized into 5 groups: axilla; groin; buttocks; inframammary; and multiple sites of involvement, which included any combination of 2 or more sites. Types of bacteria collected from cultures and recorded included Escherichia coli, Enterococcus species, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci (CoNS), and other Gram-negative species. Sensitivity profiles also were analyzed for the most commonly cultured bacteria to create recommendations on antibiotic use based on the anatomic location of the lesions. Data analysis was conducted using descriptive statistics and bivariate analysis.
Results
The analysis included 485 patients comprising 600 visits. Seventy-five percent (363/485) of the study population was female. The axilla was the most common anatomic location for HS lesions followed by multiple sites of involvement. In total, 283 cultures were performed; males were 1.1 times more likely than females to be cultured. While cultures were most frequently obtained in patients with axillary lesions only (93/262 [35%]) or from multiple sites of involvement (83/179 [46%]) as this was the most common presentation of HS in our patient population, cultures were more likely to be obtained when patients presented with only buttock (32/38 [84%]) and inframammary (20/25 [80%]) lesions (Table).
Staphylococcus aureus was the most commonly cultured bacteria in general (53/283 [19%]) as well as for HS located the axilla (24/56 [43%]) and in multiple sites (16/51 [31%]). Proteus mirabilis (29/283 [10%]) was the second most commonly cultured bacteria overall and was cultured most often in the axilla (15/56 [27%]) and inframammary region (6/14 [43%]). These were followed by beta-hemolytic Streptococcus species (26/283 [9%]) and Enterococcus species (21/283 [7%]), which was second to P mirabilis as the most commonly cultured bacteria in the inframammary region (6/14 [43%])(eTable 1).
eTable 2 shows the sensitivity profiles for the most commonly cultured bacteria: S aureus, P mirabilis, and Enterococcus species. Staphylococcus aureus located in the axilla, buttocks, and groin was most sensitive to rifampin (41/44 [93%]), TMP/SMX (41/44 [93%]), and tetracycline (39/44 [89%]) and most resistant to erythromycin (26/44 [59%]) and oxacillin (24/44 [55%]). Proteus mirabilis in the inframammary region was most sensitive to ampicillin (27/27 [100%]), gentamicin (27/27 [100%]), levofloxacin (27/27 [100%]), and TMP/SMX (26/27 [96%]). Enterococcus species were most sensitive to vancomycin (20/20 [100%]) and ampicillin (19/20 [95%]) and most resistant to gentamicin (5/20 [25%]).
Comment
To treat HS, it is important to understand the cause of the condition. Although the pathogenesis of HS has many unknowns, bacterial colonization and biofilms are thought to play a role. Lipopolysaccharides found in the outer membrane of Gram-negative bacteria are pathogen-associated molecular patterns that present to the toll-like receptors of the human immune system. Once the toll-like receptors recognize the pathogen-associated molecular patterns, macrophages and keratinocytes are activated and release proinflammatory and anti-inflammatory cytokines and chemokines. Persistent presentation of bacteria to the immune system increases immune-cell recruitment and worsens chronic inflammation in patients with HS. Evidence has revealed that bacteria initiate and sustain the inflammation seen in patients with HS; therefore, reducing the amount of bacteria could alleviate some of the symptoms of HS.5 It is important to continue learning about the pathophysiology of this disease as well as formulating tailored treatments to minimize patient discomfort and improve quality of life.
Based on the findings of the current study and the safety profile of the medication, tetracyclines may be considered for first-line empiric therapy in patients with HS involving the axilla only, buttocks only, or multiple sites. For additional coverage of P mirabilis in the axilla or inframammary region, TMP/SMX monotherapy or tetracycline plus ampicillin may be considered. For inframammary lesions only, empiric treatment with ampicillin or TMP/ SMX is recommended. For HS lesions in the groin area, coverage of Enterococcus species with ampicillin should be considered. Patients with multiple sites of involvement that include the inframammary or groin regions similarly should receive empiric antibiotics that cover both S aureus and Gram-negative bacteria, such as TMP/SMX or tetracycline and ampicillin, respectively; if the multiple sites do not include the inframammary or groin regions, Gram-negative coverage may not be indicated. Based on our findings, standardization of treatment for patients with HS can allow for earlier and potentially more effective treatment.
In a similar study conducted in 2016, bacteria species were isolated from the axilla, groin, and gluteus/perineum in patients with HS.5 In that study, the most prominent bacteria in the axilla was CoNS; in the groin, P mirabilis and E coli; and in the gluteus/perineum, E coli and CoNS. These results differed from ours, which found S aureus as the abundant bacteria in these areas. In the 2016 study, the highest rates of resistance were found for penicillin G, erythromycin, clindamycin, and ampicillin.5 In contrast, the current study found high sensitivities for clindamycin and ampicillin, but our results support the finding of high resistance for erythromycin. These differences could be accounted for by the lower sample size of patients in the 2016 study: 68 patients were analyzed for sensitivity results, and 171 patients were analyzed for frequency of bacterial species in patients with HS.5
Our study is limited by its relatively small sample size. Additionally, all patients were seen at 1 of 2 clinic sites, located in League City and Galveston, Texas, and the data from this geographic area may not be applicable to patients seen in different climates.
Conclusion
Outcomes for patients with HS improve with early intervention; however, HS treatment may be delayed by selection of ineffective antibiotic therapy. Our study provides clinicians with recommendations for empiric antibiotic treatment based on anatomic location of HS lesions and culture sensitivity profiles. Utilizing tailored antibiotic therapy on initial clinical evaluation may increase early disease control and improve morbidity and disease outcomes, thereby increasing patient quality of life.
- Vinkel C, Thomsen SF. Hidradenitis suppurativa: causes, features, and current treatments. J Clin Aesthet Dermatol. 2018;11:17-23.
- Lee EY, Alhusayen R, Lansang P, et al. What is hidradenitis suppurativa? Can Fam Physician. 2017;63:114-120.
- Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60:539-561; quiz 562-563.
- Yazdanyar S, Jemec GBE. Hidradenitis suppurativa: a review of cause and treatment. Curr Opin Infect Dis. 2011;24:118-123.
- Hessam S, Sand M, Georgas D, et al. Microbial profile and antimicrobial susceptibility of bacteria found in inflammatory hidradenitis suppurativa lesions. Skin Pharmacol Physiol. 2016; 29:161-167.
Hidradenitis suppurativa (HS) is a chronic scarring inflammatory skin condition of the follicular epithelium that impacts 1% to 4% of the general population (eFigure).1-3 This statistic likely is an underrepresentation of the affected population due to missed and delayed diagnoses.1 Hidradenitis suppurativa has been identified as having one of the strongest negative impacts on patients’ lives based on studied skin diseases.4 Its recurrent nature can negatively impact both the patient’s physical and mental state.3 Due to the debilitating effects of HS, we aimed to create updated recommendations for empiric antibotics based on affected anatomic locations in an effort to improve patient quality of life.
Methods
An institutional review board–approved retrospective medical chart review of 485 patients diagnosed with HS and evaluated at the University of Texas Medical Branch in Galveston from January 2006 to December 2021 was conducted. Males and females of all ages (including pregnant and pediatric patients) were included. Only patients for whom anatomic locations of HS lesions or culture sites were not documented were excluded from the analysis. Locations of cultures were categorized into 5 groups: axilla; groin; buttocks; inframammary; and multiple sites of involvement, which included any combination of 2 or more sites. Types of bacteria collected from cultures and recorded included Escherichia coli, Enterococcus species, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci (CoNS), and other Gram-negative species. Sensitivity profiles also were analyzed for the most commonly cultured bacteria to create recommendations on antibiotic use based on the anatomic location of the lesions. Data analysis was conducted using descriptive statistics and bivariate analysis.
Results
The analysis included 485 patients comprising 600 visits. Seventy-five percent (363/485) of the study population was female. The axilla was the most common anatomic location for HS lesions followed by multiple sites of involvement. In total, 283 cultures were performed; males were 1.1 times more likely than females to be cultured. While cultures were most frequently obtained in patients with axillary lesions only (93/262 [35%]) or from multiple sites of involvement (83/179 [46%]) as this was the most common presentation of HS in our patient population, cultures were more likely to be obtained when patients presented with only buttock (32/38 [84%]) and inframammary (20/25 [80%]) lesions (Table).
Staphylococcus aureus was the most commonly cultured bacteria in general (53/283 [19%]) as well as for HS located the axilla (24/56 [43%]) and in multiple sites (16/51 [31%]). Proteus mirabilis (29/283 [10%]) was the second most commonly cultured bacteria overall and was cultured most often in the axilla (15/56 [27%]) and inframammary region (6/14 [43%]). These were followed by beta-hemolytic Streptococcus species (26/283 [9%]) and Enterococcus species (21/283 [7%]), which was second to P mirabilis as the most commonly cultured bacteria in the inframammary region (6/14 [43%])(eTable 1).
eTable 2 shows the sensitivity profiles for the most commonly cultured bacteria: S aureus, P mirabilis, and Enterococcus species. Staphylococcus aureus located in the axilla, buttocks, and groin was most sensitive to rifampin (41/44 [93%]), TMP/SMX (41/44 [93%]), and tetracycline (39/44 [89%]) and most resistant to erythromycin (26/44 [59%]) and oxacillin (24/44 [55%]). Proteus mirabilis in the inframammary region was most sensitive to ampicillin (27/27 [100%]), gentamicin (27/27 [100%]), levofloxacin (27/27 [100%]), and TMP/SMX (26/27 [96%]). Enterococcus species were most sensitive to vancomycin (20/20 [100%]) and ampicillin (19/20 [95%]) and most resistant to gentamicin (5/20 [25%]).
Comment
To treat HS, it is important to understand the cause of the condition. Although the pathogenesis of HS has many unknowns, bacterial colonization and biofilms are thought to play a role. Lipopolysaccharides found in the outer membrane of Gram-negative bacteria are pathogen-associated molecular patterns that present to the toll-like receptors of the human immune system. Once the toll-like receptors recognize the pathogen-associated molecular patterns, macrophages and keratinocytes are activated and release proinflammatory and anti-inflammatory cytokines and chemokines. Persistent presentation of bacteria to the immune system increases immune-cell recruitment and worsens chronic inflammation in patients with HS. Evidence has revealed that bacteria initiate and sustain the inflammation seen in patients with HS; therefore, reducing the amount of bacteria could alleviate some of the symptoms of HS.5 It is important to continue learning about the pathophysiology of this disease as well as formulating tailored treatments to minimize patient discomfort and improve quality of life.
Based on the findings of the current study and the safety profile of the medication, tetracyclines may be considered for first-line empiric therapy in patients with HS involving the axilla only, buttocks only, or multiple sites. For additional coverage of P mirabilis in the axilla or inframammary region, TMP/SMX monotherapy or tetracycline plus ampicillin may be considered. For inframammary lesions only, empiric treatment with ampicillin or TMP/ SMX is recommended. For HS lesions in the groin area, coverage of Enterococcus species with ampicillin should be considered. Patients with multiple sites of involvement that include the inframammary or groin regions similarly should receive empiric antibiotics that cover both S aureus and Gram-negative bacteria, such as TMP/SMX or tetracycline and ampicillin, respectively; if the multiple sites do not include the inframammary or groin regions, Gram-negative coverage may not be indicated. Based on our findings, standardization of treatment for patients with HS can allow for earlier and potentially more effective treatment.
In a similar study conducted in 2016, bacteria species were isolated from the axilla, groin, and gluteus/perineum in patients with HS.5 In that study, the most prominent bacteria in the axilla was CoNS; in the groin, P mirabilis and E coli; and in the gluteus/perineum, E coli and CoNS. These results differed from ours, which found S aureus as the abundant bacteria in these areas. In the 2016 study, the highest rates of resistance were found for penicillin G, erythromycin, clindamycin, and ampicillin.5 In contrast, the current study found high sensitivities for clindamycin and ampicillin, but our results support the finding of high resistance for erythromycin. These differences could be accounted for by the lower sample size of patients in the 2016 study: 68 patients were analyzed for sensitivity results, and 171 patients were analyzed for frequency of bacterial species in patients with HS.5
Our study is limited by its relatively small sample size. Additionally, all patients were seen at 1 of 2 clinic sites, located in League City and Galveston, Texas, and the data from this geographic area may not be applicable to patients seen in different climates.
Conclusion
Outcomes for patients with HS improve with early intervention; however, HS treatment may be delayed by selection of ineffective antibiotic therapy. Our study provides clinicians with recommendations for empiric antibiotic treatment based on anatomic location of HS lesions and culture sensitivity profiles. Utilizing tailored antibiotic therapy on initial clinical evaluation may increase early disease control and improve morbidity and disease outcomes, thereby increasing patient quality of life.
Hidradenitis suppurativa (HS) is a chronic scarring inflammatory skin condition of the follicular epithelium that impacts 1% to 4% of the general population (eFigure).1-3 This statistic likely is an underrepresentation of the affected population due to missed and delayed diagnoses.1 Hidradenitis suppurativa has been identified as having one of the strongest negative impacts on patients’ lives based on studied skin diseases.4 Its recurrent nature can negatively impact both the patient’s physical and mental state.3 Due to the debilitating effects of HS, we aimed to create updated recommendations for empiric antibotics based on affected anatomic locations in an effort to improve patient quality of life.
Methods
An institutional review board–approved retrospective medical chart review of 485 patients diagnosed with HS and evaluated at the University of Texas Medical Branch in Galveston from January 2006 to December 2021 was conducted. Males and females of all ages (including pregnant and pediatric patients) were included. Only patients for whom anatomic locations of HS lesions or culture sites were not documented were excluded from the analysis. Locations of cultures were categorized into 5 groups: axilla; groin; buttocks; inframammary; and multiple sites of involvement, which included any combination of 2 or more sites. Types of bacteria collected from cultures and recorded included Escherichia coli, Enterococcus species, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci (CoNS), and other Gram-negative species. Sensitivity profiles also were analyzed for the most commonly cultured bacteria to create recommendations on antibiotic use based on the anatomic location of the lesions. Data analysis was conducted using descriptive statistics and bivariate analysis.
Results
The analysis included 485 patients comprising 600 visits. Seventy-five percent (363/485) of the study population was female. The axilla was the most common anatomic location for HS lesions followed by multiple sites of involvement. In total, 283 cultures were performed; males were 1.1 times more likely than females to be cultured. While cultures were most frequently obtained in patients with axillary lesions only (93/262 [35%]) or from multiple sites of involvement (83/179 [46%]) as this was the most common presentation of HS in our patient population, cultures were more likely to be obtained when patients presented with only buttock (32/38 [84%]) and inframammary (20/25 [80%]) lesions (Table).
Staphylococcus aureus was the most commonly cultured bacteria in general (53/283 [19%]) as well as for HS located the axilla (24/56 [43%]) and in multiple sites (16/51 [31%]). Proteus mirabilis (29/283 [10%]) was the second most commonly cultured bacteria overall and was cultured most often in the axilla (15/56 [27%]) and inframammary region (6/14 [43%]). These were followed by beta-hemolytic Streptococcus species (26/283 [9%]) and Enterococcus species (21/283 [7%]), which was second to P mirabilis as the most commonly cultured bacteria in the inframammary region (6/14 [43%])(eTable 1).
eTable 2 shows the sensitivity profiles for the most commonly cultured bacteria: S aureus, P mirabilis, and Enterococcus species. Staphylococcus aureus located in the axilla, buttocks, and groin was most sensitive to rifampin (41/44 [93%]), TMP/SMX (41/44 [93%]), and tetracycline (39/44 [89%]) and most resistant to erythromycin (26/44 [59%]) and oxacillin (24/44 [55%]). Proteus mirabilis in the inframammary region was most sensitive to ampicillin (27/27 [100%]), gentamicin (27/27 [100%]), levofloxacin (27/27 [100%]), and TMP/SMX (26/27 [96%]). Enterococcus species were most sensitive to vancomycin (20/20 [100%]) and ampicillin (19/20 [95%]) and most resistant to gentamicin (5/20 [25%]).
Comment
To treat HS, it is important to understand the cause of the condition. Although the pathogenesis of HS has many unknowns, bacterial colonization and biofilms are thought to play a role. Lipopolysaccharides found in the outer membrane of Gram-negative bacteria are pathogen-associated molecular patterns that present to the toll-like receptors of the human immune system. Once the toll-like receptors recognize the pathogen-associated molecular patterns, macrophages and keratinocytes are activated and release proinflammatory and anti-inflammatory cytokines and chemokines. Persistent presentation of bacteria to the immune system increases immune-cell recruitment and worsens chronic inflammation in patients with HS. Evidence has revealed that bacteria initiate and sustain the inflammation seen in patients with HS; therefore, reducing the amount of bacteria could alleviate some of the symptoms of HS.5 It is important to continue learning about the pathophysiology of this disease as well as formulating tailored treatments to minimize patient discomfort and improve quality of life.
Based on the findings of the current study and the safety profile of the medication, tetracyclines may be considered for first-line empiric therapy in patients with HS involving the axilla only, buttocks only, or multiple sites. For additional coverage of P mirabilis in the axilla or inframammary region, TMP/SMX monotherapy or tetracycline plus ampicillin may be considered. For inframammary lesions only, empiric treatment with ampicillin or TMP/ SMX is recommended. For HS lesions in the groin area, coverage of Enterococcus species with ampicillin should be considered. Patients with multiple sites of involvement that include the inframammary or groin regions similarly should receive empiric antibiotics that cover both S aureus and Gram-negative bacteria, such as TMP/SMX or tetracycline and ampicillin, respectively; if the multiple sites do not include the inframammary or groin regions, Gram-negative coverage may not be indicated. Based on our findings, standardization of treatment for patients with HS can allow for earlier and potentially more effective treatment.
In a similar study conducted in 2016, bacteria species were isolated from the axilla, groin, and gluteus/perineum in patients with HS.5 In that study, the most prominent bacteria in the axilla was CoNS; in the groin, P mirabilis and E coli; and in the gluteus/perineum, E coli and CoNS. These results differed from ours, which found S aureus as the abundant bacteria in these areas. In the 2016 study, the highest rates of resistance were found for penicillin G, erythromycin, clindamycin, and ampicillin.5 In contrast, the current study found high sensitivities for clindamycin and ampicillin, but our results support the finding of high resistance for erythromycin. These differences could be accounted for by the lower sample size of patients in the 2016 study: 68 patients were analyzed for sensitivity results, and 171 patients were analyzed for frequency of bacterial species in patients with HS.5
Our study is limited by its relatively small sample size. Additionally, all patients were seen at 1 of 2 clinic sites, located in League City and Galveston, Texas, and the data from this geographic area may not be applicable to patients seen in different climates.
Conclusion
Outcomes for patients with HS improve with early intervention; however, HS treatment may be delayed by selection of ineffective antibiotic therapy. Our study provides clinicians with recommendations for empiric antibiotic treatment based on anatomic location of HS lesions and culture sensitivity profiles. Utilizing tailored antibiotic therapy on initial clinical evaluation may increase early disease control and improve morbidity and disease outcomes, thereby increasing patient quality of life.
- Vinkel C, Thomsen SF. Hidradenitis suppurativa: causes, features, and current treatments. J Clin Aesthet Dermatol. 2018;11:17-23.
- Lee EY, Alhusayen R, Lansang P, et al. What is hidradenitis suppurativa? Can Fam Physician. 2017;63:114-120.
- Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60:539-561; quiz 562-563.
- Yazdanyar S, Jemec GBE. Hidradenitis suppurativa: a review of cause and treatment. Curr Opin Infect Dis. 2011;24:118-123.
- Hessam S, Sand M, Georgas D, et al. Microbial profile and antimicrobial susceptibility of bacteria found in inflammatory hidradenitis suppurativa lesions. Skin Pharmacol Physiol. 2016; 29:161-167.
- Vinkel C, Thomsen SF. Hidradenitis suppurativa: causes, features, and current treatments. J Clin Aesthet Dermatol. 2018;11:17-23.
- Lee EY, Alhusayen R, Lansang P, et al. What is hidradenitis suppurativa? Can Fam Physician. 2017;63:114-120.
- Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60:539-561; quiz 562-563.
- Yazdanyar S, Jemec GBE. Hidradenitis suppurativa: a review of cause and treatment. Curr Opin Infect Dis. 2011;24:118-123.
- Hessam S, Sand M, Georgas D, et al. Microbial profile and antimicrobial susceptibility of bacteria found in inflammatory hidradenitis suppurativa lesions. Skin Pharmacol Physiol. 2016; 29:161-167.
Recommendations for Empiric Antibiotic Therapy in Hidradenitis Suppurativa
Recommendations for Empiric Antibiotic Therapy in Hidradenitis Suppurativa
PRACTICE POINTS
- The inflammation seen in patients with hidradenitis suppurativa (HS) is initiated and sustained by bacteria; therefore, reducing the number of bacteria may alleviate some of the symptoms of HS.
- For HS involving the axillae or buttocks, tetracyclines should be recommended as first-line empiric therapy.
- Patients with HS with multiple sites affected that include the inframammary or groin regions should receive empiric antibiotics that cover both Staphylococcus aureus and Gram-negative bacteria, such as trimethoprim-sulfamethoxazole or tetracycline plus ampicillin.
How to Optimize Epidermal Approximation During Wound Suturing Using a Smartphone Camera
Practice Gap
Precise wound approximation during cutaneous suturing is of vital importance for optimal closure and long-term scar outcomes. Although buried dermal sutures achieve wound-edge approximation and eversion, meticulous placement of epidermal sutures allows for fine-tuning of the wound edges through epidermal approximation, eversion, and the correction of minor height discrepancies (step-offs).
Several percutaneous suture techniques and materials are available to dermatologic surgeons. However, precise, gap- and tension-free approximation of the wound edges is desired for prompt re-epithelialization and a barely visible scar.1,2
Epidermal sutures should be placed under minimal tension to align the papillary dermis and epidermis precisely. The dermatologic surgeon can evaluate the effectiveness of their suturing technique by carefully examining the closure for visibility of the bilateral wound edges, which should show equally if approximation is precise; small gaps between the wound edges (undesired); or dermal bleeding, which is a manifestation of inaccurate approximation.
Advances in smartphone camera technology have led to high-quality photography in a variety of settings. Although smartphone photography often is used for documentation purposes in health care, we recommend incorporating it as a quality-control checkpoint for objective evaluation, allowing the dermatologic surgeon to scrutinize the wound edges and refine their surgical technique to improve scar outcomes.
The Technique
After suturing the wound closed, we routinely use a 12-megapixel smartphone camera (up to 2× optical zoom) to photograph the closed wound at 1× or 2× magnification to capture more details and use the zoom function to further evaluate the wound edges close-up (Figure). In any area where inadequate epidermal approximation is noted on the photograph, an additional stitch can be placed. Photography can be repeated until ideal reapproximation occurs.
Practice Implications
Most smartphones released in recent years have a 12-megapixel camera, making them more easily accessible than surgical loupes. Additionally, surgical loupes are expensive, come with a learning curve, and can be intimidating to new or inexperienced surgeons or dermatology residents. Because virtually every dermatologic surgeon has access to a smartphone and snapping an image takes no more than a few seconds, we believe this technique is a valuable new self-assessment tool for dermatologic surgeons. It may be particularly valuable to dermatology residents and new/inexperienced surgeons looking to improve their techniques and scar outcomes.
- Perry AW, McShane RH. Fine-tuning of the skin edges in the closure of surgical wounds. Controlling inversion and eversion with the path of the needle—the right stitch at the right time. J Dermatol Surg Oncol. 1981;7:471-476. doi:10.1111/j.1524-4725.1981.tb00680.x
- Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402. doi:10.1016/j.jaad.2014.08.006
Practice Gap
Precise wound approximation during cutaneous suturing is of vital importance for optimal closure and long-term scar outcomes. Although buried dermal sutures achieve wound-edge approximation and eversion, meticulous placement of epidermal sutures allows for fine-tuning of the wound edges through epidermal approximation, eversion, and the correction of minor height discrepancies (step-offs).
Several percutaneous suture techniques and materials are available to dermatologic surgeons. However, precise, gap- and tension-free approximation of the wound edges is desired for prompt re-epithelialization and a barely visible scar.1,2
Epidermal sutures should be placed under minimal tension to align the papillary dermis and epidermis precisely. The dermatologic surgeon can evaluate the effectiveness of their suturing technique by carefully examining the closure for visibility of the bilateral wound edges, which should show equally if approximation is precise; small gaps between the wound edges (undesired); or dermal bleeding, which is a manifestation of inaccurate approximation.
Advances in smartphone camera technology have led to high-quality photography in a variety of settings. Although smartphone photography often is used for documentation purposes in health care, we recommend incorporating it as a quality-control checkpoint for objective evaluation, allowing the dermatologic surgeon to scrutinize the wound edges and refine their surgical technique to improve scar outcomes.
The Technique
After suturing the wound closed, we routinely use a 12-megapixel smartphone camera (up to 2× optical zoom) to photograph the closed wound at 1× or 2× magnification to capture more details and use the zoom function to further evaluate the wound edges close-up (Figure). In any area where inadequate epidermal approximation is noted on the photograph, an additional stitch can be placed. Photography can be repeated until ideal reapproximation occurs.
Practice Implications
Most smartphones released in recent years have a 12-megapixel camera, making them more easily accessible than surgical loupes. Additionally, surgical loupes are expensive, come with a learning curve, and can be intimidating to new or inexperienced surgeons or dermatology residents. Because virtually every dermatologic surgeon has access to a smartphone and snapping an image takes no more than a few seconds, we believe this technique is a valuable new self-assessment tool for dermatologic surgeons. It may be particularly valuable to dermatology residents and new/inexperienced surgeons looking to improve their techniques and scar outcomes.
Practice Gap
Precise wound approximation during cutaneous suturing is of vital importance for optimal closure and long-term scar outcomes. Although buried dermal sutures achieve wound-edge approximation and eversion, meticulous placement of epidermal sutures allows for fine-tuning of the wound edges through epidermal approximation, eversion, and the correction of minor height discrepancies (step-offs).
Several percutaneous suture techniques and materials are available to dermatologic surgeons. However, precise, gap- and tension-free approximation of the wound edges is desired for prompt re-epithelialization and a barely visible scar.1,2
Epidermal sutures should be placed under minimal tension to align the papillary dermis and epidermis precisely. The dermatologic surgeon can evaluate the effectiveness of their suturing technique by carefully examining the closure for visibility of the bilateral wound edges, which should show equally if approximation is precise; small gaps between the wound edges (undesired); or dermal bleeding, which is a manifestation of inaccurate approximation.
Advances in smartphone camera technology have led to high-quality photography in a variety of settings. Although smartphone photography often is used for documentation purposes in health care, we recommend incorporating it as a quality-control checkpoint for objective evaluation, allowing the dermatologic surgeon to scrutinize the wound edges and refine their surgical technique to improve scar outcomes.
The Technique
After suturing the wound closed, we routinely use a 12-megapixel smartphone camera (up to 2× optical zoom) to photograph the closed wound at 1× or 2× magnification to capture more details and use the zoom function to further evaluate the wound edges close-up (Figure). In any area where inadequate epidermal approximation is noted on the photograph, an additional stitch can be placed. Photography can be repeated until ideal reapproximation occurs.
Practice Implications
Most smartphones released in recent years have a 12-megapixel camera, making them more easily accessible than surgical loupes. Additionally, surgical loupes are expensive, come with a learning curve, and can be intimidating to new or inexperienced surgeons or dermatology residents. Because virtually every dermatologic surgeon has access to a smartphone and snapping an image takes no more than a few seconds, we believe this technique is a valuable new self-assessment tool for dermatologic surgeons. It may be particularly valuable to dermatology residents and new/inexperienced surgeons looking to improve their techniques and scar outcomes.
- Perry AW, McShane RH. Fine-tuning of the skin edges in the closure of surgical wounds. Controlling inversion and eversion with the path of the needle—the right stitch at the right time. J Dermatol Surg Oncol. 1981;7:471-476. doi:10.1111/j.1524-4725.1981.tb00680.x
- Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402. doi:10.1016/j.jaad.2014.08.006
- Perry AW, McShane RH. Fine-tuning of the skin edges in the closure of surgical wounds. Controlling inversion and eversion with the path of the needle—the right stitch at the right time. J Dermatol Surg Oncol. 1981;7:471-476. doi:10.1111/j.1524-4725.1981.tb00680.x
- Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402. doi:10.1016/j.jaad.2014.08.006
