P. Kim Phillips

Antibiotic prophylaxis in dermatologic surgery: Advisory statement 2008

BACKGROUND Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. OBJECTIVE To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. METHODS A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. RESULTS For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. LIMITATIONS These recommendations are not based on multiple, large-scale, prospective trials. CONCLUSIONS There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.

An outbreak of Mycobacterium chelonae infections in tattoos

Nontuberculous mycobacteria infections may occur after cutaneous procedures. Review of the medical records of patients who developed a rash within a tattoo revealed 6 patients with skin infections caused by Mycobacterium chelonae after receiving tattoos by one artist at a single tattoo establishment. The interval between tattoo placement and the skin findings was 1 to 2 weeks. All patients received alternate diagnoses before mycobacterial infection was identified. Skin findings included pink, red, or purple papules; papules with scale; pustules; granulomatous papules; and lichenoid papules and plaques. Histopathologic examination revealed granuloma, lymphohistiocytic infiltrate, or mixed inflammation; acid-fast bacilli stains produced negative results. Diagnosis was made by culture in 3 patients, histopathology in two patients, and clinical/epidemiologic association in one patient. The M chelonae isolates were clarithromycin susceptible, and the infections responded to macrolide antibiotics. Physicians should consider mycobacterial infections in patients with skin findings within a new tattoo.

Incidence of and Risk Factors for Skin Cancer After Heart Transplant

OBJECTIVE To examine the incidence, tumor burden, and risk factors for nonmelanoma and other skin cancer types in this heart transplant cohort. DESIGN Retrospective review of patient medical records. SETTING Tertiary care center. Patients All heart transplant recipients at Mayo Clinic from 1988 to 2006. MAIN OUTCOME MEASURES Cumulative incidence of skin cancer and tumor burden, with Cox proportional hazards regression models used to evaluate risk factors for posttransplant primary and secondary nonmelanoma skin cancer. RESULTS In total, 312 heart transplant patients had 1395 new skin cancers in 2097 person-years (mean, 0.43 per year per patient) with a range of 0 to 306 for squamous cell carcinoma (SCC) and 0 to 17 for basal cell carcinoma (BCC). The cumulative incidence rates of any skin cancer were 20.4%, 37.5%, and 46.4% at 5, 10, and 15 years after heart transplant, respectively. Cumulative incidence of SCC after the first BCC was 98.1% within 7 years. Multivariate analysis showed that posttransplant nonskin cancer, increased age, and heart failure etiologic factors other than idiopathic disease were associated with increased risk of SCC. Posttransplant herpes simplex viral infection, increased age, and use of mycophenolate mofetil for immunosuppression were associated with increased risk of BCC. CONCLUSIONS With prolonged survival, many heart transplant patients have numerous skin cancers. Vigilant sun protection practices, skin cancer education, and regular skin examination are appropriate interventions in these high-risk patients.

More Than 2 Decades of Treating Atypical Fibroxanthoma at Mayo Clinic: What Have We Learned From 91 Patients?

BACKGROUND Atypical fibroxanthoma (AFX) typically occurs on the head and neck of elderly white men. Usually considered a malignancy, it is treated with wide local excision (WLE) or total margin control using Mohs micrographic surgery (MMS). OBJECTIVE To determine the most appropriate treatment for this tumor based on a review of cases treated at Mayo Clinic. METHODS We reviewed the medical records of patients with AFX treated at Mayo Clinic from 1980 to 2004. RESULTS We identified 91 patients with 93 tumors. Treatment information was available for 88 tumors (59 treated with MMS, 23 with WLE, and 6 by other means). There were no recurrences in the patients treated with MMS, with a median follow‐up of 4.5 years (range 1.0‐16.1 years). Two patients treated with WLE had single recurrences, with a median follow‐up of 8.7 years (range 1.5‐26.3 years). CONCLUSIONS Total microscopic margin control using MMS was the most effective means of treating AFX. The authors have indicated no significant interest with commercial supporters.

Cutaneous surgeons cannot predict blood-thinner status by intraoperative visual inspection.

&NA; Cutaneous surgeons cannot predict blood‐thinner status by intraoperative visual inspection. Many surgeons believe they can discern whether a patient is taking an anticoagulant or a platelet inhibitor (blood thinner) by visual inspection of intraoperative oozing. However, there is little objective evidence to support this strongly held belief. The authors’ objective was to determine whether visual inspection of intraoperative oozing during cutaneous surgery is accurate in identifying use of blood thinners. Blinded physician evaluators observed intraoperative oozing in 110 patients having cutaneous excisional surgery, rated the amount of oozing, and judged the likelihood that the patient was taking a blood‐thinning agent. On the basis of the impressions of the most senior evaluator, 43 patients having used aspirin in the past 14 days or warfarin or vitamin E in the past 2 days, seven were judged as definitely or probably taking blood‐thinning agents (sensitivity, 16.3 percent; 95 percent confidence interval, 6.8 to 30.7 percent). Of 67 patients who did not report recent use of a blood‐thinning agent, just 11 were judged as definitely or probably taking blood‐thinning agents (false‐positive rate, 16.4 percent; 95 percent confidence interval, 8.5 to 27.5 percent). The level of training of the physicians doing the judging did not affect diagnostic sensitivity. Only 10 of the 110 patients (9.1 percent) were assessed as exhibiting excessive oozing, and of those, only four (40 percent) were actually taking a blood thinner. Results were similar when only patients who were taking aspirin or warfarin were analyzed. Thus, contrary to a commonly and strongly held belief, visual inspection of intraoperative oozing during cutaneous excisional surgery correlates poorly with blood‐thinner use by patients. The data add further evidence that use of blood thinners does not have an objectively measurable adverse effect during cutaneous surgery.

Role of Multiple Scouting Biopsies before Mohs Micrographic Surgery for Extramammary Paget's Disease

Background Extramammary Pagets disease (EMPD) frequently extends subclinically, resulting in high recurrence rates after surgical excision. Mohs micrographic surgery (MMS) improves cure rates but may require time-consuming reexcision of subclinical extension. A mechanism to estimate the location and extent of subclinical extension would be helpful. Objective To describe and evaluate a technique for multiple scouting biopsies before MMS for EMPD. Method A retrospective review of patients at Mayo Clinic who had multiple scouting biopsies before MMS for EMPD without dermal invasion. Technique The clinical extent of EMPD is identified. The scouting biopsy sites are determined and documented with photographs. The scouting biopsy specimens are sent for permanent sections. The results of the scouting biopsies help guide the extent of the initial Mohs layer. The tumor is cleared with MMS. An additional 1 mm peripheral margin of tissue is usually submitted for permanent sections. Results Multiple scouting biopsies were done in five patients. Four of the five patients had at least one true-positive result. At least one true-negative result was obtained in all five patients. Two patients had at least one false-negative result. Conclusion Multiple scouting biopsies before MMS for EMPD without dermal invasion can be a beneficial adjuvant technique.

Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose.

BACKGROUND A large proportion of facial skin cancers occur on the nose, and defects after Mohs surgery in this location often present a reconstructive challenge. For intermediate‐sized defects, the choice of reconstruction is usually between skin flap and full‐thickness skin graft. Ongoing debate exists, and limited data are available to determine which of these methods is more satisfactory. OBJECTIVE To evaluate and compare the clinical appearance of wound healing after surgical repair with a skin graft versus a skin flap for Mohs defects on the nose. METHOD In this study, 43 flaps and 24 grafts were evaluated using a modified Hollander Wound Evaluation Scale and a visual analogue scale. RESULTS The mean visual analogue scale score was significantly better for flap repairs than for graft repairs. In addition, 100% of flaps had an acceptable overall cosmetic appearance on the basis of the Hollander Wound Evaluation Scale, compared with only 75% of skin grafts. CONCLUSIONS For defects on the nose where flap and graft repair may both be technically possible, a flap may be more likely to result in superior cosmetic outcome. The authors have indicated no significant interest with commercial supporters.