Drug management in skin surgery

Managing pain associated with dermatologic procedures

Dermatologists are faced with an aging population, accompanied by an increase in the incidence of skin cancer, especially nonmelanoma skin cancer. With this increase in cutaneous malignancy comes an increase in the number of dermatologic procedures being performed. A common concern of dermatologists and dermatology patients is the attenuation and management of pain associated with dermatologic procedures. Fortunately, there are several techniques that may be used in the preoperative, intraoperative, and postoperative periods to manage patient anxiety, minimize injection pain, and safely and effectively treat postoperative pain.

Robust surgical approach for cutaneous neurofibroma in neurofibromatosis type 1

BACKGROUND

Cutaneous neurofibromas (cNF) are physically disfiguring, painful, and cause extensive psychologic harm in patients with neurofibromatosis type 1 (NF1). There is currently no effective medical treatment and surgical procedures are inaccessible to most NF1 patients globally.

OBJECTIVE

While research is underway to find an effective medical treatment for cNF, there is an urgent need to develop surgical approach that is accessible to all NF1 patients in the world with the skill set and equipment found in most general medical office settings. Here, we present a robust surgical approach to remove cNF that does not require sterile surgical field, utilizes accessible clinical equipment, and can be performed by any health care providers including family practitioners, and physician assistants.

METHODS

In a prospective case-series, patients with NF1 underwent this surgical procedure which removes multiple cutaneous neurofibromas. The Dermatology Life Quality Index was given to subjects before and after the procedure as surrogate for patient satisfaction.

RESULTS

83 tumors were removed throughout the body from twelve individuals. Examination at follow-up visits revealed well-healed scars without infection or adverse events including aberrant scarring. Patient satisfaction with the procedure was high with significant improvements in symptoms, daily activities, leisure, personal relationships, and treatment experience (P = 0.00062).

CONCLUSION

This study demonstrates a robust surgical approach to management cutaneous neurofibromas which can be accessed world-wide to individuals with NF1 and performed by a wide-variety of medical specialists with high clinical efficacy and patient satisfaction.

Evaluation of the risk of post-operative bleeding complications in skin cancer surgery without interruption of anticoagulant/antithrombotic medication: A prospective cohort study

BACKGROUND

Previous reports showed lack of consensus concerning interruption of anticoagulant/antithrombotic (AC/AT) treatment before skin cancer surgery.

AIM

The aim of this study was to evaluate the risk of postoperative bleeding in patients on AC/AT treatment undergoing skin cancer surgery without interruption of this treatment.

METHOD

This prospective cohort study included 271 consecutive patients divided into two groups - patients without and patients with AC/AT therapy. Inclusion criteria were skin cancer (basal-cell carcinoma, squamous-cell carcinoma, or malignant melanoma). Exclusion criteria were patients undergoing regional lymph node dissection or sentinel lymph node biopsy. Postoperative bleeding complications taken into consideration were those evaluated as moderate or severe and requiring some form of surgical or non-surgical hemostasis on an outpatient or inpatient basis.

RESULTS

There were 47 patients in the AC/AT group and 224 in the control group (mean age = 76.6 and 68 years, respectively), with almost equal distribution of tumours in both groups. There were 34.1% of patients on AT, 55% on AC treatment, and 10.6% on mixed treatment (AC+AT or AT+AT). Postoperative bleeding complications did not show a statistically significant difference between the two groups (p = 0.063).

CONCLUSION

Skin cancer surgery can be safely performed without discontinuation of AC/AT treatment, since the risk of postoperative bleeding is statistically insignificant.

Using cold air for reducing needle-injection pain

BACKGROUND

Pain is associated with skin injections. Reducing injection-associated pain is important especially when multiple injections are needed in difficult areas, such as the palms. We present a new safe application for cold air used in laser therapy.

OBJECTIVE

The main objectives of this study are to see whether cold air can reduce needle-injection pain and to evaluate the safety of this new application.

MATERIALS AND METHODS

Patients undergoing skin injection (n=40) were included. Assessment of pain level using visual analog scale (VAS) was done using cold air and again without cold air in the same patient. Comparison of pain scores was performed.

RESULTS

Thirty-three patients had lower VAS scores using cold air. Five patients had worse VAS scores, and two patients did not have any change in their pain score. In the group of patients where injections were made to the palms (n=5), there was even more reduction in VAS scores. There were no significant immediate or delayed side effects.

CONCLUSIONS

Cold air seems to be useful in reducing needle-injection pain in the majority of patients, especially in the palms. This procedure is safe, apart from immediate tolerable discomfort when used around the nose.

Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy

BACKGROUND

The aim was to identify risk factors for postoperative bleeding following skin cancer surgery.

METHODS

This was a prospective study of 5950 skin lesions excised in 2394 patients. No patient stopped taking aspirin or warfarin unless the international normalized ratio (INR) exceeded 3.0.

RESULTS

The rate of postoperative bleeding was 0.7 per cent overall and 2.5 per cent in the 320 patients taking warfarin. The rate of bleeding was 1.0 per cent for skin flap repairs, 0.4 per cent for simple excision and closure, and 5.0 per cent for skin grafts. Diabetic patients and smokers were not at increased risk of bleeding. There were four independent factors for bleeding: age 67 years or older (odds ratio (OR) 4.7 (95 per cent confidence interval 1.8 to 12.2); P = 0.002), warfarin therapy (OR 2.9 (1.4 to 6.3); P = 0.006), surgery on or around the ear (OR 2.6 (1.2 to 5.7); P = 0.012) and closure with a skin flap or graft (OR 2.7 (1.4 to 5.3); P = 0.004). Aspirin therapy was not an independent risk factor for bleeding.

CONCLUSION

Most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin. There was no case for discontinuing aspirin before skin surgery, but the INR should be monitored in patients taking warfarin.

Pregnancy and Dermatologic Surgery

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

Doctors' confusion over ratios and percentages in drug solutions: the case for standard labelling

The different ways of expressing concentrations of drugs in solution, as ratios or percentages or mass per unit volume, are a potential cause of confusion that may contribute to dose errors. To assess doctors' understanding of what they signify, all active subscribers to doctors.net.uk, an online community exclusively for UK doctors, were invited to complete a brief web-based multiple-choice questionnaire that explored their familiarity with solutions of adrenaline (expressed as a ratio), lidocaine (expressed as a percentage) and atropine (expressed in mg per mL), and their ability to calculate the correct volume to administer in clinical scenarios relevant to all specialties. 2974 (24.6%) replied. The mean score achieved was 4.80 out of 6 (SD 1.38). Only 85.2% and 65.8% correctly identified the mass of drug in the adrenaline and lidocaine solutions, respectively, whilst 93.1% identified the correct concentration of atropine. More would have administered the correct volume of adrenaline and lidocaine in clinical scenarios (89.4% and 81.0%, respectively) but only 65.5% identified the correct volume of atropine. The labelling of drug solutions as ratios or percentages is antiquated and confusing. Labelling should be standardized to mass per unit volume.

Doctors’ Confusion over Ratios and Percentages in Drug Solutions: The Case for Standard Labelling

The different ways of expressing concentrations of drugs in solution, as ratios or percentages or mass per unit volume, are a potential cause of confusion that may contribute to dose errors. To assess doctors’ understanding of what they signify, all active subscribers to doctors.net.uk , an online community exclusively for UK doctors, were invited to complete a brief web-based multiple-choice questionnaire that explored their familiarity with solutions of adrenaline (expressed as a ratio), lidocaine (expressed as a percentage) and atropine (expressed in mg per mL), and their ability to calculate the correct volume to administer in clinical scenarios relevant to all specialties.

2974 (24.6%) replied. The mean score achieved was 4.80 out of 6 (SD 1.38). Only 85.2% and 65.8% correctly identified the mass of drug in the adrenaline and lidocaine solutions, respectively, whilst 93.1% identified the correct concentration of atropine. More would have administered the correct volume of adrenaline and lidocaine in clinical scenarios (89.4% and 81.0%, respectively) but only 65.5% identified the correct volume of atropine.

The labelling of drug solutions as ratios or percentages is antiquated and confusing. Labelling should be standardized to mass per unit volume.

Local anesthesia. Topical application, local infiltration, and field block

Local anesthetics are warranted whenever a clinical procedure causes pain that could be eliminated by their use. Their effectiveness is influenced by many factors, particularly the choice of agent and the technique of administration. The authors discuss the clinical uses and advantages of common local anesthetics and describe three techniques used in the primary care setting: topical application, local infiltration, and field block.

The simple excision

Elliptical excisional surgery offers several advantages over other cutaneous surgical techniques (i.e., shave excision, saucerization) which require healing by second intention. In general, an elliptical excision exhibits faster healing, better cosmesis, and yields a specimen for histologic exam and review of margins, and with proper attention to the details of cutaneous anatomy, familiarity with instrumentation, local anesthetics, suture materials, and observance of meticulous surgical technique, is performed with relative ease in the dermatology outpatient office setting.