MIAMI BEACH Consider whether antimicrobial prophylaxis is needed for cosmetic procedures by evaluating the nature and extent of any wound that may result, as well as the patient's history of herpes simplex infection, Dr. Mark S. Nestor said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.
Prophylaxis is a must for ablative procedures such as CO2 and erbium laser resurfacing, but clinical judgment is needed for other procedures. More aggressive nonablative procedures such as Fraxel laser treatment can cause superficial wounds that last 27 days; judicious use of antibiotics may be indicated, he said.
For photodynamic therapy and Thermage, antibiotic prophylaxis is generally not needed unless the patient has risk factors such as diabetes or immune suppression or is malnourished, he said.
The antibiotic used for prophylaxis should be sufficiently broad spectrum to cover not only gram-positive streptococcal and staphylococcal infections, but also the important gram-negative pathogens. A useful choice is cefdinir (Omnicef), which has excellent skin penetration and can be used even in penicillin-allergic patients, he said.
"You are going to get calls from the pharmacist about using a cephalosporin in penicillin-allergic patients, but there is no problem with this whatsoever," he said. The reason for this lies in the structure of the drug: Cefdinir's side chains are different from those of penicillin or ampicillin.
Antiviral prophylaxis should be considered for susceptible patients. "For patients who get frequent cold sores, there really is no reason not to give these drugs because they are safe and easily tolerated," he said. Either famciclovir or valacyclovir can be used.
Prophylaxis is not required with the use of injectable fillers, but antiviral treatment may be needed if the lips are the site of injection and the trauma results in reactivation, said Dr. Nestor, who is in private practice in Aventura, Fla.
Antiviral prophylaxis can begin 2 days before the procedure, while antibiotic prophylaxis should begin the night before or the morning of the procedure. Both should continue for about 10 days, until the patient is fully reepithelialized, he said.
Prophylaxis can prevent many, but not all, infections. Early signs of bacterial infection include increasing redness, pain, and new formation of ulcerations. Cultures and a change of antibiotic are often necessary, and vigilance is needed because scarring can occur, he said.
If a viral infection occurs while the patient is on an antiviral drug, the dosage can be increased. "If the patient is on 250 mg of famciclovir twice a day, I will double it or even give 500 mg three times a day," he said.
Certain patients Dr. Nestor has seen over the years have experienced what he refers to as a nonhealing syndrome. They initially have an infection, but it is followed by an autoimmune phenomenon that prevents the wound from healing. "If you culture them, you will grow out everything. They can be treated with everything in the book but don't get better," he said. The approach he has used is to give them a judicious course of antibiotic treatment along with a short course of betamethasone dipropionate ointment. "We have had some amazing results because this cuts down the autoimmune response," he said.
Dr. Nestor disclosed that he is a member of the speakers' bureau for Abbott Laboratories, manufacturer of cefdinir.
Prophylaxis should continue for about 10 days, until the patient is fully reepithelialized. DR. NESTOR