Wound care in the dermatology office: Where are we in 2011? James Q. Del Rosso, DO Las Vegas, Nevada Dermatologists perform several minor surgical procedures in their offices on a daily basis that result in superficial cutaneous wounds. Conventionally, the approach to postoperative care for these superficial wounds has been the application of a topical antibiotic ointment. In reality, this practice is based more on perception and habit, and not on sound scientific evidence, especially regarding reduction in postoperative infection rates and risk of adverse reactions. In addition, the routine use of a topical antibiotic in this scenario may contribute to the emergence of antibiotic-resistant bacterial strains, and has been shown to increase the risk of allergic contact dermatitis. With few new antibiotics in development and several worldwide initiatives to curb the increase in antibiotic resistance in progress, it is important that clinicians reevaluate the standard postoperative wound care that is used after superficial office-based dermatologic procedures. ( J Am Acad Dermatol 2011;64:S1-7.) Key words: allergic contact dermatitis; antibiotic resistance; cutaneous infections; history of wound care; postoperative wound care; superficial wounds; topical antibiotic; wound healing. t has been estimated that 50 million elective The care of superficial wounds created by health surgical incisions are made each year in the care providers under aseptic conditions has typically I 1 4,5 United States. Dermatologists perform in excess involved the use of a topical antibiotic. In fact, the of 25 million minor surgical procedures annually, routine use of topical antibiotics after a superficial with this number increasing every year.2,3 Commonly dermatologic procedure is thought to be both unnec- performed dermatologic procedures, including cu- essary and not recommended, based on more recent rettage, shave or saucerization procedures, biopsies, evidence that takes into account the vast number of and cryosurgery are performed multiple times each superficial dermatologic procedures performed in day in essentially all dermatology offices. Many ambulatory practice, the very low risk of postopera- dermatology practices regularly incorporate cos- tive infection, the lack of evidence demonstrating metic procedures such as laser resurfacing and skin prevention of infection, and the relatively common peels. All of these procedures create superficial occurrence of allergic contact dermatitis with the use cutaneous wounds, which require rational postop- of bacitracin and neomycin.6-9 Resistance to topical erative care to ensure a satisfactory outcome for the antibiotics is a continually emerging issue in the patient (Table I). dermatology community.10 Despite growing con- cerns regarding the increase in antibiotic resistance, current wound care practices used by many practi- tioners are based on habit rather than evidence-based From the University of Nevada School of Medicine, Touro Univer- sity College of Osteopathic Medicine, and Valley Hospital medicine. Given this, it may be time we step back and Medical Center. review how we got to our current standard of care, Publication of this article was supported by Beiersdorf Inc. and examine more closely why and how we should Disclosure: Dr Del Rosso has served as a consultant, been a modify our approach to topical wound care. speaker or a member of a speaker’s bureau, and received grants for clinical research from Allergan Inc, CORIA Labo- ratories Ltd, Galderma Laboratories LP, Intendis Inc, Medicis ORIGINS OF WOUND CARE Pharmaceutical Corp, Graceway Pharmaceuticals LLC, Ortho- The care of wounds has evolved over the centu- Neutrogena, Onset Therapeutics, Ranbaxy Laboratories Ltd, Stiefel Laboratories Inc, Triax Pharmaceuticals, Unilever, Phar- ries as new discoveries have been made. These maDerm, and Warner Chilcott. include advances in the understanding of the mech- Accepted for publication October 21, 2010. anisms of wound repair and the causes of wound Reprint requests: James Q. Del Rosso, DO, 4488 S Pecos Rd, Las complications and the development of new treat- Vegas, NV 89121. E-mail: [email protected]. ments and procedures for wound care. Published online January 19, 2011. 0190-9622/$36.00 During the Renaissance, wound care was pre- ª 2010 by the American Academy of Dermatology, Inc. dominantly left to the ‘‘barber-surgeons,’’ considered doi:10.1016/j.jaad.2010.10.038 lower-class practitioners compared with physicians S1 S2 Del Rosso JAM ACAD DERMATOL MARCH 2011 and surgeons. Wound care practices were frequently in length, created during predominantly clean, based on superstition, anecdotal advice, and elective surgery. Using a pressurized powder spray personal experience.11 Advances in wound manage- of neomycin-bacitracin-polymyxin sprayed period- ment came predominantly from the treatment of ically into the wound during the course of surgery, battlefield wounds. The standard of care at the time infection rates were reduced from 5% to 10% down was to treat gunshot wounds with boiling oil, thought to an average of 3.3%, with annual infection rates to cure the patient of the alleged poison contained in continuing to decrease, and reaching just 1.8% in gunpowder. Because of a dwindling supply of oil in the final year of the investigation.18 In 1969, one battlefield ‘‘hospital,’’ Ambroise Pare, often con- Heisterkamp et al19 compared tetracycline spray, sidered one of the fathers of surgery, used an ancient neomycin-bacitracin-polymyxin spray, and vehicle Roman remedy containing turpentine, egg yolks, and for the treatment of 255 wounds in a war zone oil of roses to treat firearm wounds. The mixture both where conditions prevented wound debridement. relieved the pain and sealed the wounds, with the Antibiotic treatment significantly reduced the inci- turpentine providing antiseptic properties, whereas dence of infections compared with vehicle (16% vs those treated with boiling oil remained in agony. 39%, respectively). During the 1970s, several groups Realizing that the boiling oil not only was of no reported a similar reduction in infections of surgical benefit, but was actually harmful, Pare put an end to wounds treated with various antimicrobial this tortuous practice.11 sprays.20,21 The findings from these studies led to Before the mid-19th century, surgical wounds the adoption of prophylactic topical antibiotics as frequently became infected, resulting in sepsis and part of the standard of care for surgical procedures. often death.12 Over the years, the relationship A relatively recent advance in the care of wounds between micro-organisms and infections was eluci- was the finding that keeping the wound moist dated and various measures were introduced to promotes re-epithelialization and accelerates heal- reduce the risk of infection. In the 19th century, ing.22,23 When applied to superficial wounds, Ignaz Philipp Semmelweiss developed the first ster- moisture-retentive dressings and ointments have ile surgical techniques, observing that infectious been shown to heal an average of 3 to 4 days faster diseases could be passed between patients through than wounds that were either exposed to air22,23 or contaminations on the physicians’ hands, and wash- dressed with conventional gauze.24 The use of ing them in chlorinated lime could dramatically occlusive dressings has also been shown to speed reduce death rates.13 Although micro-organisms re-epithelialization in superficial wounds such as were first visualized under a microscope during the those caused by shave biopsies.25 Renaissance period, they were not linked to the Today, the principles of topical wound therapy cause of infections and disease until the time of Louis involve elimination of necrotic tissue, control of Pasteur and Robert Koch whose work convinced the bacterial loads, management of wound exudate, medical community of the credibility of the germ maintenance of open proliferative wound edges, theory.14 Joseph Lister took the findings of both and provision of a moist and protected wound Pasteur and Semmelweiss and pioneered the aseptic surface (Table II).26,27 In the dermatology office, techniques used in surgery today. These techniques the standard of care for the vast majority of minor included sterilizing equipment, surgical instruments, superficial wounds resulting from removal of benign and the operating room; wearing gloves; and wash- neoplasms includes cleaning the wound with either ing hands before and after surgery.15,16 a cleanser or irrigation, applying a topical antibiotic The mechanism of wound healing was further ointment, and covering the wound with a elucidated in 1910 when the Nobel Prize winner dressing.4,28 Alexis Carrel divided acute wound healing into 4 There are a few procedures such as laser resur- sequential, yet overlapping, phases: (1) hemostatic, facing for which there is no well-established stan- (2) inflammatory, (3) proliferative, and (4) remodel- dard of care for the treatment of wounds,29 and ing.1 Once it was realized that infection impairs the treatment is directed by individual circumstances. normal mechanism of wound healing, prophylactic For example, occlusive dressings might be used antibiotics were introduced as part of normal wound for ablative resurfacing procedures, whereas for care.17 nonablative procedures, open wound care with an Several experiments conducted in the 1960s and occlusive topical agent is far more convenient and 1970s investigated the use of topical antibiotics at appears to