Just say 'no': Drug interactions must be evaluated before dermatologic procedures

November 1, 2009

Elderly patients take numerous medications, requiring careful consideration before treatment.

Key Points

Beachwood, Ohio - Many elderly patients who take numerous medications, including anticoagulants such as Plavix (clopidogrel, Bristol-Myers Squibb/Sanofi), Coumadin (warfarin, Bristol-Myers Squibb) or aspirin, experience pre-, peri- and post-op surgical bruising. These patients also require careful consideration when it comes to treatment.

Although some dermatologic surgical procedures require the stoppage of these medicines, others do not, according to Jerome Litt, M.D., author of The Drug Eruption Reference Manual, which he has updated yearly for the past 15 years.

"Procedures such as excising a lesion, including basal cell carcinoma, large nevus or a large cyst in which sutures would be necessary, and cosmetic and plastic surgical procedures in which large areas are involved, or eyelid corrective surgery where the skin is very thin require detailed information.

"For these procedures, dermatologists will need to determine the patient's exact dosage of Coumadin or Plavix or aspirin," Dr. Litt says.

"If the patient is on a fairly large dose - say, 5 or 7.5 mg of Coumadin several times a week - I would be very cautious. There should be no anticoagulant for at least three days before surgery for this type of surgery and, probably in every case, only with the blessing of the patient's internist or general physician," Dr. Litt says.

He says the patient's age is also important, as are any concomitant medication(s) he/she might be taking.

Other therapies

Bruising in the geriatric population is a common occurrence. There have been anecdotal reports that homeopathic medicines, such as arnica, can be used pre-operatively to prevent bruising, or used to help heal post-surgical bruising. However, according to Dr. Litt, overall, most studies evaluating arnica for this use have not found significant benefit.

"The results of some trials do not suggest that homeopathic arnica has an advantage over placebo in reducing post-operative pain, bruising and swelling in patients undergoing elective surgery," he says.

Dr. Litt points out that some evidence exists that bromelain may reduce swelling, bruising, inflammation and pain after surgery. However, bromelain has been reported to cause adverse interactions with amoxicillin, tetracycline and other antibiotics and 5-fluorouracil and vincristine.

"There is no evidence that these products have any beneficial effect pre-, peri-, or post-operatively in treating patients who bruise easily," Dr. Litt says.

Drug interactions

Dr. Litt, who has also recently written the consumer book, Curious, Odd, Rare, and Abnormal Reactions to Medications (Barricade Books, 2009), advises that dermatologists keep a close watch on drug interactions when treating all patients, especially geriatric patients for surgical procedures, as well as all types of dermatological problems, including rashes, itching and blisters.

"For example, if a patient has diabetes and is taking insulin or some oral anti-diabetic medication, one has to be prudent in treating that patient with high doses of corticosteroids.

"People with epilepsy who take antiepileptic medication such as carbamazepine should never be given erythromycin or herbs like St. John's wort," he says.

Other issues can arise with Plavix, for example, which can cause a severe hazardous adverse reaction with Coumadin, atorvastatin (Lipitor, Pfizer), simvastatin (Zocor, Merck) and other medications, Dr. Litt says.