Watch for rare post-op infections

Chicago - When a post-operative infection in dermatologic surgery is suspected, the differential diagnosis should include bacterial, fungal, viral and atypical mycobacterial organisms, says Rebecca Tung, M.D., who presented data from a review of the literature at the American Academy of Dermatology's Academy '05.

"Often patients come to dermatologists with complications (from surgery) done by someone else. As other physicians and non-medical personnel have started to perform cosmetic procedures, we as dermatologists are starting to see more of these complications in our practices. Selecting a board-certified dermatologist who has extensive training in cosmetic procedures can help minimize a patient's risk of post-op infection," says Dr. Tung, who is a staff physician, department of dermatology, section of dermatologic surgery & cutaneous oncology, Cleveland Clinic Foundation, Cleveland.

"Sometimes the presentation is not straightforward. Symptoms are delayed. We need to be cognizant of the clinical manifestations of all postoperative infections, perform appropriate testing and get the patient back to health. Certain infections can be deadly without prompt treatment, and all infections have the potential to scar," she says.

Predisposing risk factors for postoperative infection include diabetes, extremes in age, tobacco usage, obesity and an impaired immune response. Other factors including large size of the post-op wound and location, such as on the ear, can also increase the risk of infections developing after dermatologic surgery regardless of the practitioner's skill, Dr. Tung says.

What to look for

Most post-op infections are caused by well-known pathogens, including Staphlococcus aureus, S. epidermidis, Pseudomonas aeruginosa and Candida. Usually infections are localized, but serious systemic conditions such as necrotizing fasciitis, toxic shock syndrome and endocarditis have also been reported.

Among the case reports Dr. Tung cited in her presentation was a case of necrotizing fasciitis, which occurred after a case of in-home liposuction performed by a practitioner. Other cases followed blepharoplasty, phlebectomy, suction lipectomy and botulinum toxin injection. Symptoms include erythema, bullae, purulence, necrosis and hypoesthesia. Streptococcus pyogenes or polymicrobial organisms are causative. Diagnosis is made by Gram's stain and culture.

Toxic Shock Syndrome (TSS) has been reported following laser resurfacing, chemical peels, lipectomy and excision. TSS results from S. Aureus toxin release. Symptoms include fever, erythroderma, mental confusion, organ failure and hypotension.

"With prompt diagnosis and treatment, there is a 95 percent survival rate," she tells Dermatology Times.

"While traditional ear piercing is within the realm of dermatologic practice, body piercing performed in non-medical settings is increasingly popular with younger patients but is not without risk," Dr. Tung says. Cases of endocarditis have been reported after piercing of the naval, nipple, tongue and nose.

Contaminated water or surgical supplies may lead to atypical mycobacterial infections in the skin and subcutaneous fat. Presentation includes erythema, abscesses, cellulitis, fistula tracts and chronic infection. Symptoms usually appear four to six weeks postoperatively. Special stains for acid-fast bacilli and culture may detect Mycobacteria abscessus, M. chelonae or M. fortuitum. Reports of these infections have been seen after facelifting, laser resurfacing, Mohs surgery, soft tissue augmentation, liposuction and punch biopsy.

Fungal infections are often caused by Candida but have also been reported from various molds like Aspergillus. Patients who are immunocompromised or have frequent occupational exposure to spores are most at risk. Patients on antibiotics or corticosteroids may also be at risk for fungal infections.

Viral infections, such as herpes simplex virus (HSV) and herpes zoster, have also been reported on rare occasions following laser resurfacing, dermabrasion, peels and liposuction. Patients with current HSV are most at risk. HSV can also occur despite prophylaxis.

Prophylaxis debate

Prophylactic antibiotics are commonly given if patients are considered high risk.