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Five pearls target wound healing
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
EXPERT ANALYSIS FROM ODAC 2018
VIDEO: Light-based scar treatments improve more than just cosmetic appearance
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
VIDEO: Treating vascular lesions in children
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Nail biopsies made simple
CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”
The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”
Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.
In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.
In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.
For dorsal pigmentation, the proximal nail matrix should be biopsied.
“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.
The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.
Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.
Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.
For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.
For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.
“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.
A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.
In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.
After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.
Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.
With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.
Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.
Dr. Skelsey reported that she had no conflicts of interest.
[email protected]
On Twitter @karioakes
CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”
The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”
Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.
In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.
In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.
For dorsal pigmentation, the proximal nail matrix should be biopsied.
“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.
The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.
Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.
Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.
For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.
For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.
“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.
A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.
In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.
After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.
Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.
With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.
Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.
Dr. Skelsey reported that she had no conflicts of interest.
[email protected]
On Twitter @karioakes
CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”
The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”
Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.
In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.
In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.
For dorsal pigmentation, the proximal nail matrix should be biopsied.
“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.
The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.
Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.
Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.
For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.
For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.
“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.
A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.
In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.
After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.
Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.
With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.
Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.
Dr. Skelsey reported that she had no conflicts of interest.
[email protected]
On Twitter @karioakes
AT THE 2017 AAD SUMMER MEETING
Pregnancy not a barrier to providing cutaneous surgery
NEW YORK – For some dermatologists, surgical care of the pregnant patient represents an area of uncertainty. But with few exceptions, dermatologists can continue with business as usual for their pregnant patients, according to Keith Harrigill, MD.
Dr. Harrigill, a dermatologist who previously was a practicing obstetrician-gynecologist, delineated the safe zones of dermatologic surgery in these patients at the summer meeting of the American Academy of Dermatology.
About 2% of pregnant women will require nonobstetric surgery and about 75,000 pregnant women in the United States will have surgery annually, he said. Appendectomies and other emergent abdominal surgery account for a large proportion of these cases; dermatologic surgeries are not included in these figures, and cutaneous procedures in pregnant women are not usually tracked. The literature on dermatologic treatments during pregnancy is “scant,” said Dr. Harrigill, a dermatologist in private practice in Birmingham, Ala.
However, it’s known that one-third of women with melanoma are of childbearing age, and melanoma accounts for 8% of the malignancies diagnosed during pregnancy, with a rate estimated at 0.14 to 2.8 per 1,000 live births, he said.
Since some women will have to address potentially serious skin issues during pregnancy, what’s safe, and what isn’t? Dr. Harrigill said that the American College of Obstetrics and Gynecology has provided guidance with an April 2017 opinion, prepared in conjunction with the American Society for Anesthesia, on nonobstetric surgery during pregnancy (Obstet Gynecol. 2017;129:777-8).
The opinion primarily focuses on major surgery. “What we do – cutaneous surgeries – they consider to be minor surgery,” he said. But even with major procedures, the good news is that “there’s no increase in birth defects in fetal exposure to anesthesia at any age,” he noted.
Dr. Harrigill’s approach, which conforms to the general guidance provided by the opinion, is to think of dermatologic procedures in three categories: urgent, nonurgent, and elective. Urgent procedures might include biopsying and treating a lesion suspicious for melanoma or an aggressive nonmelanoma skin cancer, or controlling a friable, bleeding pyogenic granuloma. “Do these right away,” he said.
Nonurgent procedures, such as treatment of a nodular basal cell carcinoma, should be done during the second trimester, when possible. Elective procedures, such as a scar excision, should be deferred until after delivery.
Dermatologists can almost always achieve adequate pain control with local anesthesia alone, said Dr. Harrigill, pointing out that local anesthesia is “the safest known way to give anesthesia during pregnancy.”
However, when thinking about even a remote risk of teratogenesis, it’s important to understand that fetal organogenesis occurs from day 15 to day 56, and that before 15 days, adverse events are limited to spontaneous abortion. So it’s particularly important to avoid teratogenic medications during the first 2 months of gestation, Dr. Harrigill said.
Part of the concern, he noted, is that it’s ethically problematic to perform large randomized trials in pregnant women, so the guidelines regarding surgery and medication safety are drawn from retrospective studies, registries, meta-analyses, and expert consensus.
Still, according to the ACOG guidelines, “a pregnant woman should never be denied indicated surgery, regardless of trimester.”
There’s no reason to risk delaying a diagnosis of malignancy in a pregnant patient, Dr. Harrigill said. “My dermatologic surgery approach is to biopsy anything that is clinically suspicious for malignancy, at any gestational age.”
When performing biopsies in pregnant patients, he uses the same protocol as he uses with any other patient. Skin preparation can be done with either isopropyl alcohol or chlorhexidine. Some practitioners avoid using povidone iodine because of a theoretical risk of fetal hypothyroidism.
For anesthesia, Dr. Harrigill noted that lidocaine is generally considered safe in pregnancy. He is also comfortable using epinephrine, despite the theoretical concern of uterine artery spasm, for which “studies are lacking.” The relatively minute amount of epinephrine used in dermatologic anesthesia, he said, is not likely to have an impact on such a large vessel.
Prilocaine is generally safe, and combination creams with prilocaine are fine to use, he said. Diphenhydramine is also safe to use. However, he advised avoiding long-acting anesthetic agents, such as mepivacaine and bupivacaine.
His advice regarding sedation? “Don’t do it.” Dr. Harrigill said he doesn’t use sedation in the office for his nonpregnant patients, either.
Before about 20 weeks of pregnancy, Dr. Harrigill said not to worry about how the patient is positioned. But after that, the lateral decubitus position is best because it keeps the gravid uterus from compressing the great vessels.
“Pregnant women are prone to fainting due to progesterone-mediated vasodilation,” he said. Dermatologists can work with their office staff to keep these patients well hydrated, and make sure they get in and out of chairs and off exam tables slowly.
No changes are needed in excision or suturing techniques. Because cicatrization is delayed in pregnant women, Dr. Harrigill uses longer-lasting absorbable sutures with high tensile strength, especially when performing procedures on the trunk or abdomen. This means that his closures will use delayed-absorption epidermal sutures with running nylon pull-through subcuticular sutures as well. He will leave these in for 5-7 days longer than usual.
Pregnant women are not at a higher risk of infection than the general population, so he follows the standard procedures here as well. If an antibiotic is indicated, penicillin, a cephalosporin, azithromycin, and erythromycin base are all logical choices.
To be avoided are sulfamethoxazole/trimethoprim, which carries a risk of feta hyperbilirubinemia, especially when given in the second trimester; doxycycline and tetracycline, which can cause permanent brown discoloration of the teeth; and fluoroquinolones, which have been associated with cartilage defects.
For analgesia, acetaminophen is an option. Ibuprofen and salicylates should be avoided, especially at the end of pregnancy when their administration is associated with premature closure of the ductus arteriosus, and, possibly, placental abruption, Dr. Harrigill noted.
However, short-term use of opioids is generally considered safe for the fetus. If larger doses are given just before delivery, the neonate may experience respiratory depression. This scenario is unlikely to be faced by the dermatologist, noted Dr. Harrigill. “I use these without reservation” in terms of fetal risk, he said.
Collaboration is key when caring for pregnant patients, said Dr. Harrigill, who recommends consulting the obstetrician of record for any procedures other than a simple biopsy or shave removal.
Dr. Harrigill reported that he had no conflicts of interest.
[email protected]
On Twitter @karioakes
NEW YORK – For some dermatologists, surgical care of the pregnant patient represents an area of uncertainty. But with few exceptions, dermatologists can continue with business as usual for their pregnant patients, according to Keith Harrigill, MD.
Dr. Harrigill, a dermatologist who previously was a practicing obstetrician-gynecologist, delineated the safe zones of dermatologic surgery in these patients at the summer meeting of the American Academy of Dermatology.
About 2% of pregnant women will require nonobstetric surgery and about 75,000 pregnant women in the United States will have surgery annually, he said. Appendectomies and other emergent abdominal surgery account for a large proportion of these cases; dermatologic surgeries are not included in these figures, and cutaneous procedures in pregnant women are not usually tracked. The literature on dermatologic treatments during pregnancy is “scant,” said Dr. Harrigill, a dermatologist in private practice in Birmingham, Ala.
However, it’s known that one-third of women with melanoma are of childbearing age, and melanoma accounts for 8% of the malignancies diagnosed during pregnancy, with a rate estimated at 0.14 to 2.8 per 1,000 live births, he said.
Since some women will have to address potentially serious skin issues during pregnancy, what’s safe, and what isn’t? Dr. Harrigill said that the American College of Obstetrics and Gynecology has provided guidance with an April 2017 opinion, prepared in conjunction with the American Society for Anesthesia, on nonobstetric surgery during pregnancy (Obstet Gynecol. 2017;129:777-8).
The opinion primarily focuses on major surgery. “What we do – cutaneous surgeries – they consider to be minor surgery,” he said. But even with major procedures, the good news is that “there’s no increase in birth defects in fetal exposure to anesthesia at any age,” he noted.
Dr. Harrigill’s approach, which conforms to the general guidance provided by the opinion, is to think of dermatologic procedures in three categories: urgent, nonurgent, and elective. Urgent procedures might include biopsying and treating a lesion suspicious for melanoma or an aggressive nonmelanoma skin cancer, or controlling a friable, bleeding pyogenic granuloma. “Do these right away,” he said.
Nonurgent procedures, such as treatment of a nodular basal cell carcinoma, should be done during the second trimester, when possible. Elective procedures, such as a scar excision, should be deferred until after delivery.
Dermatologists can almost always achieve adequate pain control with local anesthesia alone, said Dr. Harrigill, pointing out that local anesthesia is “the safest known way to give anesthesia during pregnancy.”
However, when thinking about even a remote risk of teratogenesis, it’s important to understand that fetal organogenesis occurs from day 15 to day 56, and that before 15 days, adverse events are limited to spontaneous abortion. So it’s particularly important to avoid teratogenic medications during the first 2 months of gestation, Dr. Harrigill said.
Part of the concern, he noted, is that it’s ethically problematic to perform large randomized trials in pregnant women, so the guidelines regarding surgery and medication safety are drawn from retrospective studies, registries, meta-analyses, and expert consensus.
Still, according to the ACOG guidelines, “a pregnant woman should never be denied indicated surgery, regardless of trimester.”
There’s no reason to risk delaying a diagnosis of malignancy in a pregnant patient, Dr. Harrigill said. “My dermatologic surgery approach is to biopsy anything that is clinically suspicious for malignancy, at any gestational age.”
When performing biopsies in pregnant patients, he uses the same protocol as he uses with any other patient. Skin preparation can be done with either isopropyl alcohol or chlorhexidine. Some practitioners avoid using povidone iodine because of a theoretical risk of fetal hypothyroidism.
For anesthesia, Dr. Harrigill noted that lidocaine is generally considered safe in pregnancy. He is also comfortable using epinephrine, despite the theoretical concern of uterine artery spasm, for which “studies are lacking.” The relatively minute amount of epinephrine used in dermatologic anesthesia, he said, is not likely to have an impact on such a large vessel.
Prilocaine is generally safe, and combination creams with prilocaine are fine to use, he said. Diphenhydramine is also safe to use. However, he advised avoiding long-acting anesthetic agents, such as mepivacaine and bupivacaine.
His advice regarding sedation? “Don’t do it.” Dr. Harrigill said he doesn’t use sedation in the office for his nonpregnant patients, either.
Before about 20 weeks of pregnancy, Dr. Harrigill said not to worry about how the patient is positioned. But after that, the lateral decubitus position is best because it keeps the gravid uterus from compressing the great vessels.
“Pregnant women are prone to fainting due to progesterone-mediated vasodilation,” he said. Dermatologists can work with their office staff to keep these patients well hydrated, and make sure they get in and out of chairs and off exam tables slowly.
No changes are needed in excision or suturing techniques. Because cicatrization is delayed in pregnant women, Dr. Harrigill uses longer-lasting absorbable sutures with high tensile strength, especially when performing procedures on the trunk or abdomen. This means that his closures will use delayed-absorption epidermal sutures with running nylon pull-through subcuticular sutures as well. He will leave these in for 5-7 days longer than usual.
Pregnant women are not at a higher risk of infection than the general population, so he follows the standard procedures here as well. If an antibiotic is indicated, penicillin, a cephalosporin, azithromycin, and erythromycin base are all logical choices.
To be avoided are sulfamethoxazole/trimethoprim, which carries a risk of feta hyperbilirubinemia, especially when given in the second trimester; doxycycline and tetracycline, which can cause permanent brown discoloration of the teeth; and fluoroquinolones, which have been associated with cartilage defects.
For analgesia, acetaminophen is an option. Ibuprofen and salicylates should be avoided, especially at the end of pregnancy when their administration is associated with premature closure of the ductus arteriosus, and, possibly, placental abruption, Dr. Harrigill noted.
However, short-term use of opioids is generally considered safe for the fetus. If larger doses are given just before delivery, the neonate may experience respiratory depression. This scenario is unlikely to be faced by the dermatologist, noted Dr. Harrigill. “I use these without reservation” in terms of fetal risk, he said.
Collaboration is key when caring for pregnant patients, said Dr. Harrigill, who recommends consulting the obstetrician of record for any procedures other than a simple biopsy or shave removal.
Dr. Harrigill reported that he had no conflicts of interest.
[email protected]
On Twitter @karioakes
NEW YORK – For some dermatologists, surgical care of the pregnant patient represents an area of uncertainty. But with few exceptions, dermatologists can continue with business as usual for their pregnant patients, according to Keith Harrigill, MD.
Dr. Harrigill, a dermatologist who previously was a practicing obstetrician-gynecologist, delineated the safe zones of dermatologic surgery in these patients at the summer meeting of the American Academy of Dermatology.
About 2% of pregnant women will require nonobstetric surgery and about 75,000 pregnant women in the United States will have surgery annually, he said. Appendectomies and other emergent abdominal surgery account for a large proportion of these cases; dermatologic surgeries are not included in these figures, and cutaneous procedures in pregnant women are not usually tracked. The literature on dermatologic treatments during pregnancy is “scant,” said Dr. Harrigill, a dermatologist in private practice in Birmingham, Ala.
However, it’s known that one-third of women with melanoma are of childbearing age, and melanoma accounts for 8% of the malignancies diagnosed during pregnancy, with a rate estimated at 0.14 to 2.8 per 1,000 live births, he said.
Since some women will have to address potentially serious skin issues during pregnancy, what’s safe, and what isn’t? Dr. Harrigill said that the American College of Obstetrics and Gynecology has provided guidance with an April 2017 opinion, prepared in conjunction with the American Society for Anesthesia, on nonobstetric surgery during pregnancy (Obstet Gynecol. 2017;129:777-8).
The opinion primarily focuses on major surgery. “What we do – cutaneous surgeries – they consider to be minor surgery,” he said. But even with major procedures, the good news is that “there’s no increase in birth defects in fetal exposure to anesthesia at any age,” he noted.
Dr. Harrigill’s approach, which conforms to the general guidance provided by the opinion, is to think of dermatologic procedures in three categories: urgent, nonurgent, and elective. Urgent procedures might include biopsying and treating a lesion suspicious for melanoma or an aggressive nonmelanoma skin cancer, or controlling a friable, bleeding pyogenic granuloma. “Do these right away,” he said.
Nonurgent procedures, such as treatment of a nodular basal cell carcinoma, should be done during the second trimester, when possible. Elective procedures, such as a scar excision, should be deferred until after delivery.
Dermatologists can almost always achieve adequate pain control with local anesthesia alone, said Dr. Harrigill, pointing out that local anesthesia is “the safest known way to give anesthesia during pregnancy.”
However, when thinking about even a remote risk of teratogenesis, it’s important to understand that fetal organogenesis occurs from day 15 to day 56, and that before 15 days, adverse events are limited to spontaneous abortion. So it’s particularly important to avoid teratogenic medications during the first 2 months of gestation, Dr. Harrigill said.
Part of the concern, he noted, is that it’s ethically problematic to perform large randomized trials in pregnant women, so the guidelines regarding surgery and medication safety are drawn from retrospective studies, registries, meta-analyses, and expert consensus.
Still, according to the ACOG guidelines, “a pregnant woman should never be denied indicated surgery, regardless of trimester.”
There’s no reason to risk delaying a diagnosis of malignancy in a pregnant patient, Dr. Harrigill said. “My dermatologic surgery approach is to biopsy anything that is clinically suspicious for malignancy, at any gestational age.”
When performing biopsies in pregnant patients, he uses the same protocol as he uses with any other patient. Skin preparation can be done with either isopropyl alcohol or chlorhexidine. Some practitioners avoid using povidone iodine because of a theoretical risk of fetal hypothyroidism.
For anesthesia, Dr. Harrigill noted that lidocaine is generally considered safe in pregnancy. He is also comfortable using epinephrine, despite the theoretical concern of uterine artery spasm, for which “studies are lacking.” The relatively minute amount of epinephrine used in dermatologic anesthesia, he said, is not likely to have an impact on such a large vessel.
Prilocaine is generally safe, and combination creams with prilocaine are fine to use, he said. Diphenhydramine is also safe to use. However, he advised avoiding long-acting anesthetic agents, such as mepivacaine and bupivacaine.
His advice regarding sedation? “Don’t do it.” Dr. Harrigill said he doesn’t use sedation in the office for his nonpregnant patients, either.
Before about 20 weeks of pregnancy, Dr. Harrigill said not to worry about how the patient is positioned. But after that, the lateral decubitus position is best because it keeps the gravid uterus from compressing the great vessels.
“Pregnant women are prone to fainting due to progesterone-mediated vasodilation,” he said. Dermatologists can work with their office staff to keep these patients well hydrated, and make sure they get in and out of chairs and off exam tables slowly.
No changes are needed in excision or suturing techniques. Because cicatrization is delayed in pregnant women, Dr. Harrigill uses longer-lasting absorbable sutures with high tensile strength, especially when performing procedures on the trunk or abdomen. This means that his closures will use delayed-absorption epidermal sutures with running nylon pull-through subcuticular sutures as well. He will leave these in for 5-7 days longer than usual.
Pregnant women are not at a higher risk of infection than the general population, so he follows the standard procedures here as well. If an antibiotic is indicated, penicillin, a cephalosporin, azithromycin, and erythromycin base are all logical choices.
To be avoided are sulfamethoxazole/trimethoprim, which carries a risk of feta hyperbilirubinemia, especially when given in the second trimester; doxycycline and tetracycline, which can cause permanent brown discoloration of the teeth; and fluoroquinolones, which have been associated with cartilage defects.
For analgesia, acetaminophen is an option. Ibuprofen and salicylates should be avoided, especially at the end of pregnancy when their administration is associated with premature closure of the ductus arteriosus, and, possibly, placental abruption, Dr. Harrigill noted.
However, short-term use of opioids is generally considered safe for the fetus. If larger doses are given just before delivery, the neonate may experience respiratory depression. This scenario is unlikely to be faced by the dermatologist, noted Dr. Harrigill. “I use these without reservation” in terms of fetal risk, he said.
Collaboration is key when caring for pregnant patients, said Dr. Harrigill, who recommends consulting the obstetrician of record for any procedures other than a simple biopsy or shave removal.
Dr. Harrigill reported that he had no conflicts of interest.
[email protected]
On Twitter @karioakes
EXPERT ANALYSIS FROM THE 2017 AAD SUMMER MEETING
When – and how – to do a full-thickness graft repair
NEW YORK – Though flap reconstruction can provide elegant solutions with very good cosmesis after Mohs surgery and other excisional procedures, skin grafts provide another set of options.
Both split and full thickness grafts have a place in the dermatologist’s repertoire, but some tips and tricks can make a full thickness graft an attractive option in many instances, according to Marc Brown, MD, professor of dermatology and oncology at the University of Rochester (N.Y.).
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Brown said that retrospective studies have shown that patients are highly satisfied with the cosmesis of full thickness skin grafting for reconstruction post Mohs surgery – if they’re asked after enough time has passed for the graft to mature and the dermatologist to perform some of the tweaks that are occasionally necessary. “It takes time to get to that point, but the overall satisfaction improves over time,” he said.
Full thickness skin grafts may be a good option when flap coverage is suboptimal or infeasible, he said. Some other pros of opting for a full thickness graft are that better cosmesis can be achieved in certain cases, and the donor site can be sutured, allowing for quicker healing with less downtime. However, a full thickness graft is a thicker graft, with resulting high metabolic demand. To ensure good “take,” dermatologists must be mindful that the graft site has a good vascular supply. Also, he added, full thickness grafts often need thinning, and physicians shouldn’t be afraid of being aggressive.
Both to reduce unwanted bulk and to help with better graft take, subcutaneous fat should be stripped completely from the graft, Dr. Brown noted. “You should see nothing that looks yellow,” he said. Fine serrated scissors are an excellent defatting tool, and while expensive, “they’re worth the cost,” he added.
Areas to be considered for full thickness grafts include the nasal ala, the medial canthus of the eye, the upper eyelid, fingers, and the ear. Larger defects on the scalp or forehead may also be good candidates, and full thickness grafts can work well on the lower leg.
For smaller grafts – those less than 1 or 2 cm diameter – Dr. Brown said that the preauricular area can work well as a donor site for facial grafts, since there’s often extra tissue with little tension there. Patients who are worried about donor site cosmesis may prefer the postauricular area, though the result is usually very good in either case, he said. Other potential donor sites are the glabella, nasolabial area, and the eyelid.
When grafts of more than 2 cm diameter are needed, Dr. Brown said the lateral neck, the supraclavicular area, or the lateral chest area can provide a good match in color and texture to facial skin.
Other tips for surgical technique are to use an appropriately-sized nonadherent gauze pad as a template for exact graft sizing. Precision counts, said Dr. Brown: “Measure twice, cut once.”
A central basting suture can be used to hold the graft in place while getting started, and Dr. Brown often uses a bolster for grafts of less than 1 cm. “Bolsters are helpful to prevent bleeding and improve contact in larger grafts,” he added.
Sutures should be placed graft to skin – “up and under,” Dr. Brown noted. He uses rapid-absorbing chromic suture material, with silk on the outside for the tie-over bolster. It’s also important to avoid tension on the wound edge, and he advised always using a pressure bandage for 48-72 hours.
If there’s concern about blood supply when grafting over cartilage, Dr. Brown advises making a few 2-mm punch defects in the cartilage to boost blood supply and help with engraftment.
For larger grafts where hematoma formation might result in graft failure, he will place a few parallel incisions through the graft as a means of escape should there be significant bleeding. At about 1 week post procedure, the graft should be purplish-pink in color, and patients should be counseled about the appearance of the graft as healing progresses, he said.
Physicians can manage patient expectations by letting them know not to expect the best cosmesis right away. However, said Dr. Brown, if the graft remains thickened, there are lots of options. Intralesional triamcinolone injections can help with thinning, and can be used beginning about 3 months after the graft. Dermabrasion is another good option, but he likes to wait 4-6 months before performing this procedure.
With appropriate site selection, meticulous technique, and good patient communication, dermatologists can keep full thickness skin grafting in the repertoire of viable options for excellent cosmesis, and a valuable tool in their own right. “Skin grafts are not a failure of reconstruction,” Dr. Brown said.
Dr. Brown had no conflicts to disclose.
[email protected]
On Twitter @karioakes
NEW YORK – Though flap reconstruction can provide elegant solutions with very good cosmesis after Mohs surgery and other excisional procedures, skin grafts provide another set of options.
Both split and full thickness grafts have a place in the dermatologist’s repertoire, but some tips and tricks can make a full thickness graft an attractive option in many instances, according to Marc Brown, MD, professor of dermatology and oncology at the University of Rochester (N.Y.).
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Brown said that retrospective studies have shown that patients are highly satisfied with the cosmesis of full thickness skin grafting for reconstruction post Mohs surgery – if they’re asked after enough time has passed for the graft to mature and the dermatologist to perform some of the tweaks that are occasionally necessary. “It takes time to get to that point, but the overall satisfaction improves over time,” he said.
Full thickness skin grafts may be a good option when flap coverage is suboptimal or infeasible, he said. Some other pros of opting for a full thickness graft are that better cosmesis can be achieved in certain cases, and the donor site can be sutured, allowing for quicker healing with less downtime. However, a full thickness graft is a thicker graft, with resulting high metabolic demand. To ensure good “take,” dermatologists must be mindful that the graft site has a good vascular supply. Also, he added, full thickness grafts often need thinning, and physicians shouldn’t be afraid of being aggressive.
Both to reduce unwanted bulk and to help with better graft take, subcutaneous fat should be stripped completely from the graft, Dr. Brown noted. “You should see nothing that looks yellow,” he said. Fine serrated scissors are an excellent defatting tool, and while expensive, “they’re worth the cost,” he added.
Areas to be considered for full thickness grafts include the nasal ala, the medial canthus of the eye, the upper eyelid, fingers, and the ear. Larger defects on the scalp or forehead may also be good candidates, and full thickness grafts can work well on the lower leg.
For smaller grafts – those less than 1 or 2 cm diameter – Dr. Brown said that the preauricular area can work well as a donor site for facial grafts, since there’s often extra tissue with little tension there. Patients who are worried about donor site cosmesis may prefer the postauricular area, though the result is usually very good in either case, he said. Other potential donor sites are the glabella, nasolabial area, and the eyelid.
When grafts of more than 2 cm diameter are needed, Dr. Brown said the lateral neck, the supraclavicular area, or the lateral chest area can provide a good match in color and texture to facial skin.
Other tips for surgical technique are to use an appropriately-sized nonadherent gauze pad as a template for exact graft sizing. Precision counts, said Dr. Brown: “Measure twice, cut once.”
A central basting suture can be used to hold the graft in place while getting started, and Dr. Brown often uses a bolster for grafts of less than 1 cm. “Bolsters are helpful to prevent bleeding and improve contact in larger grafts,” he added.
Sutures should be placed graft to skin – “up and under,” Dr. Brown noted. He uses rapid-absorbing chromic suture material, with silk on the outside for the tie-over bolster. It’s also important to avoid tension on the wound edge, and he advised always using a pressure bandage for 48-72 hours.
If there’s concern about blood supply when grafting over cartilage, Dr. Brown advises making a few 2-mm punch defects in the cartilage to boost blood supply and help with engraftment.
For larger grafts where hematoma formation might result in graft failure, he will place a few parallel incisions through the graft as a means of escape should there be significant bleeding. At about 1 week post procedure, the graft should be purplish-pink in color, and patients should be counseled about the appearance of the graft as healing progresses, he said.
Physicians can manage patient expectations by letting them know not to expect the best cosmesis right away. However, said Dr. Brown, if the graft remains thickened, there are lots of options. Intralesional triamcinolone injections can help with thinning, and can be used beginning about 3 months after the graft. Dermabrasion is another good option, but he likes to wait 4-6 months before performing this procedure.
With appropriate site selection, meticulous technique, and good patient communication, dermatologists can keep full thickness skin grafting in the repertoire of viable options for excellent cosmesis, and a valuable tool in their own right. “Skin grafts are not a failure of reconstruction,” Dr. Brown said.
Dr. Brown had no conflicts to disclose.
[email protected]
On Twitter @karioakes
NEW YORK – Though flap reconstruction can provide elegant solutions with very good cosmesis after Mohs surgery and other excisional procedures, skin grafts provide another set of options.
Both split and full thickness grafts have a place in the dermatologist’s repertoire, but some tips and tricks can make a full thickness graft an attractive option in many instances, according to Marc Brown, MD, professor of dermatology and oncology at the University of Rochester (N.Y.).
Speaking at the summer meeting of the American Academy of Dermatology, Dr. Brown said that retrospective studies have shown that patients are highly satisfied with the cosmesis of full thickness skin grafting for reconstruction post Mohs surgery – if they’re asked after enough time has passed for the graft to mature and the dermatologist to perform some of the tweaks that are occasionally necessary. “It takes time to get to that point, but the overall satisfaction improves over time,” he said.
Full thickness skin grafts may be a good option when flap coverage is suboptimal or infeasible, he said. Some other pros of opting for a full thickness graft are that better cosmesis can be achieved in certain cases, and the donor site can be sutured, allowing for quicker healing with less downtime. However, a full thickness graft is a thicker graft, with resulting high metabolic demand. To ensure good “take,” dermatologists must be mindful that the graft site has a good vascular supply. Also, he added, full thickness grafts often need thinning, and physicians shouldn’t be afraid of being aggressive.
Both to reduce unwanted bulk and to help with better graft take, subcutaneous fat should be stripped completely from the graft, Dr. Brown noted. “You should see nothing that looks yellow,” he said. Fine serrated scissors are an excellent defatting tool, and while expensive, “they’re worth the cost,” he added.
Areas to be considered for full thickness grafts include the nasal ala, the medial canthus of the eye, the upper eyelid, fingers, and the ear. Larger defects on the scalp or forehead may also be good candidates, and full thickness grafts can work well on the lower leg.
For smaller grafts – those less than 1 or 2 cm diameter – Dr. Brown said that the preauricular area can work well as a donor site for facial grafts, since there’s often extra tissue with little tension there. Patients who are worried about donor site cosmesis may prefer the postauricular area, though the result is usually very good in either case, he said. Other potential donor sites are the glabella, nasolabial area, and the eyelid.
When grafts of more than 2 cm diameter are needed, Dr. Brown said the lateral neck, the supraclavicular area, or the lateral chest area can provide a good match in color and texture to facial skin.
Other tips for surgical technique are to use an appropriately-sized nonadherent gauze pad as a template for exact graft sizing. Precision counts, said Dr. Brown: “Measure twice, cut once.”
A central basting suture can be used to hold the graft in place while getting started, and Dr. Brown often uses a bolster for grafts of less than 1 cm. “Bolsters are helpful to prevent bleeding and improve contact in larger grafts,” he added.
Sutures should be placed graft to skin – “up and under,” Dr. Brown noted. He uses rapid-absorbing chromic suture material, with silk on the outside for the tie-over bolster. It’s also important to avoid tension on the wound edge, and he advised always using a pressure bandage for 48-72 hours.
If there’s concern about blood supply when grafting over cartilage, Dr. Brown advises making a few 2-mm punch defects in the cartilage to boost blood supply and help with engraftment.
For larger grafts where hematoma formation might result in graft failure, he will place a few parallel incisions through the graft as a means of escape should there be significant bleeding. At about 1 week post procedure, the graft should be purplish-pink in color, and patients should be counseled about the appearance of the graft as healing progresses, he said.
Physicians can manage patient expectations by letting them know not to expect the best cosmesis right away. However, said Dr. Brown, if the graft remains thickened, there are lots of options. Intralesional triamcinolone injections can help with thinning, and can be used beginning about 3 months after the graft. Dermabrasion is another good option, but he likes to wait 4-6 months before performing this procedure.
With appropriate site selection, meticulous technique, and good patient communication, dermatologists can keep full thickness skin grafting in the repertoire of viable options for excellent cosmesis, and a valuable tool in their own right. “Skin grafts are not a failure of reconstruction,” Dr. Brown said.
Dr. Brown had no conflicts to disclose.
[email protected]
On Twitter @karioakes
EXPERT ANALYSIS FROM the 2017 AAD SUMMER MEETING
Tips for managing dermatology procedures in kids
CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.
“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.
The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”
Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”
One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”
Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.
In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.
During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”
Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”
Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”
The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”
Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.
Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.
Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”
Dr. Price reported having no financial disclosures.
[email protected]
CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.
“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.
The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”
Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”
One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”
Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.
In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.
During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”
Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”
Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”
The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”
Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.
Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.
Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”
Dr. Price reported having no financial disclosures.
[email protected]
CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.
“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.
The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”
Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”
One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”
Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.
In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.
During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”
Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”
Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”
The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”
Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.
Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.
Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”
Dr. Price reported having no financial disclosures.
[email protected]
AT WCPD 2017
Ibrutinib and bleeding complications in Mohs surgery
Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.
On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.
“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”
The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.
Find the full summary here.
Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.
On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.
“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”
The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.
Find the full summary here.
Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.
On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.
“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”
The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.
Find the full summary here.
FROM JAMA DERMATOLOGY
Time for dermatologists in nine states to start submitting CPT code 99024
The Centers for Medicare & Medicaid Services survey period is upon us, and it’s time for dermatologists in nine test states to act.
In my April column, I discussed the CMS survey, which is intended to gather data on when follow-up visits for surgical procedures take place. Reporting started July 1st and will continue for several months, at least, possibly for a year.
All of you in these nine test states recently received a two-page letter from CMS telling you that, if you are in a practice with fewer than 10 dermatologists, you don’t have to report. That’s correct – you don’t have to – but is not reporting in the best interest of dermatology? I contend it is not; you can and must report!
Simply put, you need to generate and append code 99024 to your claims whenever possible. The 99024 code is a “no charge” code that informs CMS you did some follow-up work, either in person or on the phone.
That’s right, generate a 99024 after every visit when you or your staff do not bill for an evaluation and management code – and whenever you, or your physician assistant, nurse practitioner, nurse, medical assistant, or receptionist even speak to a patient on the phone. Yes, phone contacts count for a 99024.
So, when you or a member of your staff call back biopsy or lab results after a procedure, or call to schedule or change a postop appointment, speak to a relative, give instructions to the visiting nurse, or provide reassurance after a procedure, you or your staff member should generate a very brief note in the chart, plug in the working diagnosis, put that 99024 in there, and make sure the billing company posts it. Some of your billing systems may require that a physician finalize the receptionist note or that you charge a penny to get the software to cooperate, but you should still put in 99024.
(And I tell you what, I am personally good to cover all the 1-cent charges that get generated and you don’t want to write off. Just have the patients send the bill to good ole “Hotsteel” here in Cincinnati!)
Some of you may say, “Hey, a skin biopsy is a 0-day global, so why report a follow-up? Here’s why. How often do you do a skin biopsy using a shave code, or without freezing an actinic keratosis? Reporting the 99024 when you call back with the biopsy results correctly documents the actinic keratosis and shave-embedded follow-up visit, so you should do it.
When you see that patient back to remove her sutures after an excision, submit the 99024.
When you see him to inject a hypertrophic scar from an electrodessication, submit the 99024.
I know we see our patients at follow-up visits and communicate with them by phone – sometimes for years after a procedure, at no charge. I hope to see hundreds of thousands of 99024 codes generated from small groups and solo dermatologists. You need to make sure these services are acknowledged and that dermatologists get credit when credit is due. The future of our specialty depends on your doing so.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
The Centers for Medicare & Medicaid Services survey period is upon us, and it’s time for dermatologists in nine test states to act.
In my April column, I discussed the CMS survey, which is intended to gather data on when follow-up visits for surgical procedures take place. Reporting started July 1st and will continue for several months, at least, possibly for a year.
All of you in these nine test states recently received a two-page letter from CMS telling you that, if you are in a practice with fewer than 10 dermatologists, you don’t have to report. That’s correct – you don’t have to – but is not reporting in the best interest of dermatology? I contend it is not; you can and must report!
Simply put, you need to generate and append code 99024 to your claims whenever possible. The 99024 code is a “no charge” code that informs CMS you did some follow-up work, either in person or on the phone.
That’s right, generate a 99024 after every visit when you or your staff do not bill for an evaluation and management code – and whenever you, or your physician assistant, nurse practitioner, nurse, medical assistant, or receptionist even speak to a patient on the phone. Yes, phone contacts count for a 99024.
So, when you or a member of your staff call back biopsy or lab results after a procedure, or call to schedule or change a postop appointment, speak to a relative, give instructions to the visiting nurse, or provide reassurance after a procedure, you or your staff member should generate a very brief note in the chart, plug in the working diagnosis, put that 99024 in there, and make sure the billing company posts it. Some of your billing systems may require that a physician finalize the receptionist note or that you charge a penny to get the software to cooperate, but you should still put in 99024.
(And I tell you what, I am personally good to cover all the 1-cent charges that get generated and you don’t want to write off. Just have the patients send the bill to good ole “Hotsteel” here in Cincinnati!)
Some of you may say, “Hey, a skin biopsy is a 0-day global, so why report a follow-up? Here’s why. How often do you do a skin biopsy using a shave code, or without freezing an actinic keratosis? Reporting the 99024 when you call back with the biopsy results correctly documents the actinic keratosis and shave-embedded follow-up visit, so you should do it.
When you see that patient back to remove her sutures after an excision, submit the 99024.
When you see him to inject a hypertrophic scar from an electrodessication, submit the 99024.
I know we see our patients at follow-up visits and communicate with them by phone – sometimes for years after a procedure, at no charge. I hope to see hundreds of thousands of 99024 codes generated from small groups and solo dermatologists. You need to make sure these services are acknowledged and that dermatologists get credit when credit is due. The future of our specialty depends on your doing so.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
The Centers for Medicare & Medicaid Services survey period is upon us, and it’s time for dermatologists in nine test states to act.
In my April column, I discussed the CMS survey, which is intended to gather data on when follow-up visits for surgical procedures take place. Reporting started July 1st and will continue for several months, at least, possibly for a year.
All of you in these nine test states recently received a two-page letter from CMS telling you that, if you are in a practice with fewer than 10 dermatologists, you don’t have to report. That’s correct – you don’t have to – but is not reporting in the best interest of dermatology? I contend it is not; you can and must report!
Simply put, you need to generate and append code 99024 to your claims whenever possible. The 99024 code is a “no charge” code that informs CMS you did some follow-up work, either in person or on the phone.
That’s right, generate a 99024 after every visit when you or your staff do not bill for an evaluation and management code – and whenever you, or your physician assistant, nurse practitioner, nurse, medical assistant, or receptionist even speak to a patient on the phone. Yes, phone contacts count for a 99024.
So, when you or a member of your staff call back biopsy or lab results after a procedure, or call to schedule or change a postop appointment, speak to a relative, give instructions to the visiting nurse, or provide reassurance after a procedure, you or your staff member should generate a very brief note in the chart, plug in the working diagnosis, put that 99024 in there, and make sure the billing company posts it. Some of your billing systems may require that a physician finalize the receptionist note or that you charge a penny to get the software to cooperate, but you should still put in 99024.
(And I tell you what, I am personally good to cover all the 1-cent charges that get generated and you don’t want to write off. Just have the patients send the bill to good ole “Hotsteel” here in Cincinnati!)
Some of you may say, “Hey, a skin biopsy is a 0-day global, so why report a follow-up? Here’s why. How often do you do a skin biopsy using a shave code, or without freezing an actinic keratosis? Reporting the 99024 when you call back with the biopsy results correctly documents the actinic keratosis and shave-embedded follow-up visit, so you should do it.
When you see that patient back to remove her sutures after an excision, submit the 99024.
When you see him to inject a hypertrophic scar from an electrodessication, submit the 99024.
I know we see our patients at follow-up visits and communicate with them by phone – sometimes for years after a procedure, at no charge. I hope to see hundreds of thousands of 99024 codes generated from small groups and solo dermatologists. You need to make sure these services are acknowledged and that dermatologists get credit when credit is due. The future of our specialty depends on your doing so.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Isotretinoin patients need not postpone skin surgery
Skin procedures including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures can be performed safely on patients who have recently been or are currently being treated with isotretinoin, according to new recommendations from a consensus panel.
The recommendations were published online in JAMA Dermatology.
Postponing surgical procedures in patients taking isotretinoin because of the potential for keloid formation and delayed wound healing “has persisted despite increasing reports to the contrary,” wrote Leah K. Spring, DO, of Naval Hospital Camp Lejeune, Camp Lejeune, N.C., and her colleagues (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2017.2077).
This protocol is based on 11 patients with delayed healing and keloids, the researchers noted. “In our consensus-based assessment, these initial cases presented a hypothesis to be tested, rather than the foundation for medical dogma on which more than 30 years of clinical practice was built,” they wrote.
To establish the current level of evidence for delaying procedures in isotretinoin patients and to make recommendations, an expert panel reviewed data from 32 publications and more than 1,485 procedures. The literature was divided into five areas: dermabrasion, chemical peels, cutaneous surgery, laser hair removal, and ablative/nonablative laser treatments.
The researchers determined that evidence does not support the safety of mechanical dermabrasion or fully ablative laser surgeries for current or recent isotretinoin users. Manual dermabrasion and microdermabrasion were deemed safe for isotretinoin patients based on the latest evidence, however, as were fractional ablative and fractional nonablative procedures.
In addition, the evidence did not support refraining from chemical peels, laser hair removal, or cutaneous surgery for current and recent isotretinoin patients, although the panel recommended additional prospective, controlled clinical trials in these areas.
In the area of cutaneous surgery, the consensus panel also noted the need for “a rigorous evaluation of the aforementioned specific warning that muscle flap insertion should be delayed until the patient displays normal [creatine phosphokinase (CPK)] levels or, at least, CPK levels below twofold of normal.”
The recommendations can be a resource for discussions with patients about the risks of procedures concurrent with isotretinoin, Dr. Spring and her associates emphasized. “For some patients and some conditions, an informed decision may lead to earlier and potentially more effective interventions.”
Lead author Dr. Spring had no relevant financial conflicts to disclose. Several members of the consensus group disclosed relationships with multiple companies including Allergan, Merz, Leo, Promius, Lumenis, Cynosure, and Valeant.
Skin procedures including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures can be performed safely on patients who have recently been or are currently being treated with isotretinoin, according to new recommendations from a consensus panel.
The recommendations were published online in JAMA Dermatology.
Postponing surgical procedures in patients taking isotretinoin because of the potential for keloid formation and delayed wound healing “has persisted despite increasing reports to the contrary,” wrote Leah K. Spring, DO, of Naval Hospital Camp Lejeune, Camp Lejeune, N.C., and her colleagues (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2017.2077).
This protocol is based on 11 patients with delayed healing and keloids, the researchers noted. “In our consensus-based assessment, these initial cases presented a hypothesis to be tested, rather than the foundation for medical dogma on which more than 30 years of clinical practice was built,” they wrote.
To establish the current level of evidence for delaying procedures in isotretinoin patients and to make recommendations, an expert panel reviewed data from 32 publications and more than 1,485 procedures. The literature was divided into five areas: dermabrasion, chemical peels, cutaneous surgery, laser hair removal, and ablative/nonablative laser treatments.
The researchers determined that evidence does not support the safety of mechanical dermabrasion or fully ablative laser surgeries for current or recent isotretinoin users. Manual dermabrasion and microdermabrasion were deemed safe for isotretinoin patients based on the latest evidence, however, as were fractional ablative and fractional nonablative procedures.
In addition, the evidence did not support refraining from chemical peels, laser hair removal, or cutaneous surgery for current and recent isotretinoin patients, although the panel recommended additional prospective, controlled clinical trials in these areas.
In the area of cutaneous surgery, the consensus panel also noted the need for “a rigorous evaluation of the aforementioned specific warning that muscle flap insertion should be delayed until the patient displays normal [creatine phosphokinase (CPK)] levels or, at least, CPK levels below twofold of normal.”
The recommendations can be a resource for discussions with patients about the risks of procedures concurrent with isotretinoin, Dr. Spring and her associates emphasized. “For some patients and some conditions, an informed decision may lead to earlier and potentially more effective interventions.”
Lead author Dr. Spring had no relevant financial conflicts to disclose. Several members of the consensus group disclosed relationships with multiple companies including Allergan, Merz, Leo, Promius, Lumenis, Cynosure, and Valeant.
Skin procedures including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures can be performed safely on patients who have recently been or are currently being treated with isotretinoin, according to new recommendations from a consensus panel.
The recommendations were published online in JAMA Dermatology.
Postponing surgical procedures in patients taking isotretinoin because of the potential for keloid formation and delayed wound healing “has persisted despite increasing reports to the contrary,” wrote Leah K. Spring, DO, of Naval Hospital Camp Lejeune, Camp Lejeune, N.C., and her colleagues (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2017.2077).
This protocol is based on 11 patients with delayed healing and keloids, the researchers noted. “In our consensus-based assessment, these initial cases presented a hypothesis to be tested, rather than the foundation for medical dogma on which more than 30 years of clinical practice was built,” they wrote.
To establish the current level of evidence for delaying procedures in isotretinoin patients and to make recommendations, an expert panel reviewed data from 32 publications and more than 1,485 procedures. The literature was divided into five areas: dermabrasion, chemical peels, cutaneous surgery, laser hair removal, and ablative/nonablative laser treatments.
The researchers determined that evidence does not support the safety of mechanical dermabrasion or fully ablative laser surgeries for current or recent isotretinoin users. Manual dermabrasion and microdermabrasion were deemed safe for isotretinoin patients based on the latest evidence, however, as were fractional ablative and fractional nonablative procedures.
In addition, the evidence did not support refraining from chemical peels, laser hair removal, or cutaneous surgery for current and recent isotretinoin patients, although the panel recommended additional prospective, controlled clinical trials in these areas.
In the area of cutaneous surgery, the consensus panel also noted the need for “a rigorous evaluation of the aforementioned specific warning that muscle flap insertion should be delayed until the patient displays normal [creatine phosphokinase (CPK)] levels or, at least, CPK levels below twofold of normal.”
The recommendations can be a resource for discussions with patients about the risks of procedures concurrent with isotretinoin, Dr. Spring and her associates emphasized. “For some patients and some conditions, an informed decision may lead to earlier and potentially more effective interventions.”
Lead author Dr. Spring had no relevant financial conflicts to disclose. Several members of the consensus group disclosed relationships with multiple companies including Allergan, Merz, Leo, Promius, Lumenis, Cynosure, and Valeant.
FROM JAMA DERMATOLOGY
Key clinical point:
Major finding: Experts found insufficient evidence to postpone manual dermabrasion, superficial chemical peels, fractional ablative or nonablative laser resurfacing, laser hair removal, or cutaneous surgery in patients taking isotretinoin or those who have taken it within the past 6 to 12 months.
Data source: The data come from 32 clinical publications and a total of 1,485 procedures.
Disclosures: Lead author Dr. Spring had no relevant financial conflicts to disclose. Several members of the consensus group disclosed relationships with multiple companies, including Allergan, Merz, Leo, Promius, Lumenis, Cynosure, and Valeant.