Topical Approaches to Improve Surgical Outcomes and Wound Healing: A Review of Efficacy and Safety
March 2017 | Volume 16 | Issue 3 | Original Article | 209 | Copyright © 2017
Kristin Totoraitis BS,a Joel L. Cohen MD,b and Adam Friedman MDc
aOakland University William Beaumont School of Medicine, Rochester, MI bAboutSkin Dermatology and DermSurgery, Englewood, CO cThe George Washington School of Medicine and Health Sciences, Washington, DC
Surgical procedures are an important piece of a dermatologist’s daily practice. Therefore, the optimization of post-surgical wound healing is an area of utmost importance and interest. Although low risk, one notable barrier to proper wound healing is surgical site infection.
In an attempt to mitigate this risk and improve surgical outcomes, multiple topical products continue to be used both pre- and postprocedure. Traditionally, this includes both topical antibiotics and antiseptics. However, these products are not without consequence.
The overuse of topical antibiotics as prophylaxis for infection has contributed to increased bacterial resistance, and in fact is no longer recommended by the American Academy of Dermatology in clean post surgical wounds. Topical antiseptics, including chlorhexidine and povidone-iodine, can have a cytotoxic effect on keratinocytes and may actually impede wound healing as a result. In addition, chlorhexidine in particular can produce both otologic and ocular toxic effects when used on the face. Emerging products, such as hypochlorous acid, may be a potential alternative to the more commonly used agents, as it has effective antimicrobial actions and minimal adverse effects. Therefore, the purpose of this review is to highlight several topical products used to optimize post-surgical wound healing and discuss both their efficacy and safety.
J Drugs Dermatol. 2017;16(3):209-212.
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Surgical procedures are an essential piece of a dermatologist’s practice. In fact, it has been reported that dermatologists perform over 25 million minor surgical procedures annually.1,2 A major focus of these procedures is to restore the integrity of the skin while minimizing scarring and potential complications. With dermatologic surgeries being so numerous, there is much discussion about how to optimize post-surgical wound care while decreasing potential barriers to healing. While relatively low risk, one well-known wound healing impediment that is important to recognize is wound infection. Therefore, proper wound care entails measures to both prevent infection and subsequently manage it if need be. Yet, to develop a consensus regarding how to optimize post surgical wound healing is difficult given that recent evidence suggests there is a gap in wound care education within dermatology.3 A survey of dermatology residents published by Stamell Ruiz et al found that the majority of respondents did not feel prepared to manage both acute and chronic wounds.3 Furthermore, over 75% of respondents felt that more education was needed in the area of wound care during residency training.3 The purpose of this review is to highlight several topical approaches used to improve post surgical healing as a means to address elements of this educational gap. It is uniformly accepted that sterile or sterile-like “clean” technique should be used to minimize the risk of post surgical infection. Many topical preparations are used as adjuvants to sterile technique to help decrease this risk. Historically, topical antibiotic ointments have been used in dermatology for a variety of disease states including the management of acne, bacterial skin infections, and most notable to this article, the prevention of wound infection.2 According to data collected in 2003, dermatologists prescribe between three to four million topical antibiotics annually.4 Both bactericidal and bacteriostatic antimicrobials including neomycin, gentamycin, mupirocin, retapamulin, bacitracin, and polymyxin B, have been reportedly used for wound care purposes.2 Unfortunately, the overuse and in many cases blanket misuse of antibiotics overall has led to an increase in bacterial resistance.2 In fact, up to 50% of antibiotics prescribed in both outpatient and inpatient settings have been found to be unnecessary.5 Dermatologic wound care is not an exception to this trend. Methicillin resistant Staphlococcus aureus (MRSA) is just one example of the resistant bacteria that now commonly challenge physicians. Illustrating this fact, one study found that the proportion of MRSA isolates collected with high level mupirocin resistance increased from 1.6% between 1995 and 1999 to 7.0% between 2000 and 2004.6 With this in mind, it’s therefore necessary to question the benefit that topical antibiotics have in wound care. In fact, there is a lack of evidence indicating that the prophylactic use of topical antimicrobials actually work to prevent infection.1,2,7 A randomized, double-blind prospective trial performed by Smack and