Wound care after
cutaneous surgery can play an integral role in wound healing.
Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood. Foremost is the improvement in wound healing achieved by keeping the
wound occluded and moist. This observation has led to an explosion of a whole new category of
occlusive dressings at the surgeon's disposal in healing postoperative
wounds. These dressings have numerous applications as discussed previously. Generally, for acute
surgical wounds,
occlusive dressings are most useful for split-thickness
wounds, such as graft donor sites and after
dermabrasion, chemical peel, or
laser treatment, and full-thickness
wounds allowed to heal by secondary intention.
Occlusive dressings may have greater benefit for the treatment of chronic
ulcers of varying etiologies. The different categories of dressings share the common disadvantage of being relatively expensive. For routine sutured
wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical
antibiotic ointment. Topical
antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery.
Povidone-iodine (
Betadine) and
chlorhexidine gluconate (
Hibiclens) have emerged as the two agents of choice. However,
antiseptics have been shown to be toxic to healing tissue, and should not be used on open
wounds. In contrast, topical
antibiotic ointments are safe to use on open
wounds, effective in preventing
wound infections, and promote wound healing by maintaining a moist
wound environment. The authors prefer the combination
antibiotic ointment Polysporin for routine postoperative
wound care.
Antibiotic prophylaxis in
dermatologic surgery to prevent
wound infection is appropriate in certain cases. Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of
antibiotics. Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from
antibiotic prophylaxis. The choice of
antibiotics should be based on the organism most likely to cause
wound infection at the particular surgical site. Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed. The risk of
bacterial endocarditis after
dermatologic surgery is not known.
Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin.
Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA). The
antibiotic chosen should again cover the organism most likely to cause
infection. One dose can be given 1 hour before surgery and repeated 6 hours postoperatively. Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office. Therefore,
wound care instructions should be clear, detailed, and provided in both oral and written form. Information should also be provided about what to expect as the
wound heals.