Complications of laser resurfacing include infections, scarring, hyperpigmentation, hypopigmentation, and delayed healing. Postoperative infections cause pain, prolonged healing, and can result in scarring. Ablative laser techniques cause partial- or full-thickness wounds, whereas so-called "nonablative procedures" may cause "spotty" epidermal wounds. Antibiotic prophylaxis is necessary when the risk for postoperative infection is significant or when the risk of infection is moderate but the consequences of infection are significant. Prophylactic antibiotic agents should have a broad spectrum of activity, be well-tolerated and be safe. The most appropriate choice is a broad-spectrum agent such as cefdinir, even for patients allergic to penicillin. Additionally, all patients should be treated prospectively with antivirals to prevent activation and dissemination of herpes simplex virus type I. Treatment of infections in patients who have and have not received prophylactic antibiotics requires identification of the causative factor and appropriate treatment. Nonablative treatments such as photodynamic therapy do not usually require antibiotic prophylaxis, although a few patients treated for acne may acquire a secondary bacterial infection that should be treated.
As people age, they accumulate significant exposure to ultraviolet light, leading to sun damage, wrinkles, and skin cancer. To meet the demands of our patients to "turn back the clock," we continue to improve the effectiveness and safety of our cosmetic surgical techniques.
For each patient, our general approach is to (1) evaluate the degree of photoaging, expectations for improvement, downtime, risks (eg, infections), and need for anesthesia; (2) consider treatment options; and (3) educate the patient on the efficacy and safety of various treatment modalities. Although improvement in deep wrinkles and scars is greatest with ablative procedures, nonablative procedures minimize downtime and the risks of infection and scarring. For these reasons nonablative procedures have been applied to skin diseases, especially those with cosmetic overlap--rosacea, melasma, acne, and actinic damage. Current treatments for cosmetic enhancement are shown in Table 1.
Complications of laser resurfacing, the most common ablative procedure, can include infections, scarring, hyperpigmentation, hypopigmentation and delayed healing syndromes. Healing problems may lead to permanent scarring 8 to 10 months after resurfacing. (1-3) Postoperative infections cause pain, prolong healing, and can result in scarring. (4) Most laser surgeons choose antibiotic and antiviral prophylaxis in laser resurfacing although to some the use remains controversial.
An algorithm for the treatment of uncomplicated skin and skin structure infections has been prepared for use by primary care physicians. (5) This algorithm is being revised to more closely fit the medical and surgical practices of dermatologists. The new algorithm will include the appropriate use of antibiotics (eg, prophylaxis) in dermatologic and laser surgery. An initial draft of the new algorithm appears in Figure 1.
This report discusses the current use of antibiotic and antiviral agents to prevent and treat postoperative infections in patients treated with both ablative and nonablative laser procedures.
Any wound can become infected, even when a procedure is performed by the most skilled professional. Ablative laser techniques cause partial- or full-thickness wounds (epidermal and dermal), whereas newer nonablative procedures may cause "spotty" epidermal wounds. Regarding infection, physicians must decide whether to prescribe antibiotics or antiviral agents as a prophylactic measure or to prescribe these agents only when an infection actually occurs.
Postoperative infection with ablative (C[O.sub.2]) laser resurfacing (discussed below) is well documented. (6-10) Occluded wounds are more likely to become infected than open wounds. (11) The risk of postoperative cutaneous colonization, infection, or both--which may cause scarring--may be higher in patients with preoperative staphylococcal colonies in their anterior nares. (6) Methicillin-resistant Staphylococcus aureus, (6,12) Mycobacterium fortuitum, (8) herpes simplex virus (HSV), (7,12,13-15) fungal, (12,13) and yeast (15) infections have been associated with C[O.sub.2] laser resurfacing.
In surgery, antibiotic prophylaxis is the use of antimicrobial agents in surgical patients with no established infection. (16) Antibiotic prophylaxis is considered necessary when the risk for postoperative infection is significant (as in diabetic or immunosuppressed patients) and when the risk of infection is moderate but the consequences of infection are significant. Prophylactic antibiotic agents should have a broad spectrum of activity, be well-tolerated, and be safe.
Anti-HSV prophylaxis has been recommended (17) with C[O.sub.2] laser resurfacing, even in patients with no history of HSV. (12-15) In a 500-patient study, postoperative infection with HSV occurred in 14 patients (7.4%), half without history of perioral "fever blisters" or "cold sores." (15)
Antiviral prophylaxis is necessary when the risk for reactivation of HSV is significant and when the risk for reactivation is moderate but the consequences of reactivation are significant (eg, simple outbreak vs. an open wound). HSV can be reactivated by trauma (15) and proliferates in an open wound. Immunosuppression, tolerability, and safety are primary considerations in selecting a prophylactic antiviral agent.
Antibiotic agents, antiviral agents, or both are indicated when wounds become clinically infected or de novo infection (eg, HSV) occurs and requires evaluation and treatment. Early signs of infection include increasing redness, increasing pain, and new ulcerations that emerge as a wound heals. (18) Empiric therapy with antivirals and broad-spectrum antibiotics is initiated and, when culture results become available, the initial therapy may be modified. When patients fail broad-spectrum antibiotics and experience a chronic unyielding course, HSV, a fungal infection, or atypical bacteria may be present. (8)
Ablative Laser Resurfacing
With proper technique, patient selection, and care (preoperative and postoperative), ablative resurfacing with C[O.sub.2] and erbium: yttrium-aluminum-garnet (Er:YAG) laser devices can be safe and effective. (19,20) Significant complications can be minimized when they are recognized and treated quickly. Ablative resurfacing procedures may be used alone or in combination with nonablative procedures. (21)
Classically, the high-energy, short-pulsed, C[O.sub.2] laser device has been the standard in ablative resurfacing because its rapid pulsing and computer-controlled scanning permit consistent levels of ablative damage to the skin (21) The UltraPulse C[O.sub.2] laser (Lumenis, Santa Clara, CA) (22) and the Silk and Feather Touch scanned lasers (Lumenis) (23) are examples of devices with these technologies. While results are certainly impressive, the use of these devices can be associated with significant side effects and complications. Virtually all patients treated with the C[O.sub.2] laser device have an open wound for 1 week and erythema that lasts at least 8 to 12 weeks. Complications can include infections, scarring, hyperpigmentation, hypopigmentation, and delayed healing. Because of these drawbacks, the number of C[O.sub.2] procedures performed has dropped dramatically.
Introduced in the late 1990s, the gentler Er:YAG laser device can achieve similar results with reduced healing times, duration of erythema, and adverse effects. (24) Long-pulsed Er:YAG laser devices offer homeostasis and improved tightening of the skin. Complications (including infection) still occur, however, and physicians must still exercise care in technique, patient selection, and preoperative and postoperative care.
When treating patients with the Er:YAG laser device, most physicians prescribe both oral antibiotics and oral antiviral agents for prophylactic reasons, and some also believe that topical retinoids and bleaching creams improve healing attributes of the skin as well as enhance the final result.
Prophylaxis or Not?
The use of antibiotic prophylaxis in full-face C[O.sub.2] laser resurfacing has been debated. In a prospective study, (25) Ross and colleagues found that infection with S. aureus occurred in 2 of 4 consecutive patients who had not received antibiotics before full-face treatment with a C[O.sub.2] laser device. The next 4 consecutive patients were given oral antibiotic for Grampositive organisms 2 days before the same laser treatment. Culture of these 4 patients showed no staphylococcus colonies or infection after 2 days. Culture of another non-study patient receiving the same pretreatment (plus an antiviral agent) showed only Gram-negative organisms after laser treatment. The authors concluded that narrow-spectrum, Gram-positive oral antibiotic prophylaxis was appropriate for patients receiving full-face and regional laser resurfacing.
In a retrospective study, (26) 133 consecutive patients who had received cutaneous C[O.sub.2] laser resurfacing were placed into 4 categories: (1) no antibiotic prophylaxis, (2) single-dose intraoperative cephalexin given intravenously, (3) postoperative oral azithromycin, and (4) intraoperative intravenous cephalexin with postoperative oral azithromycin. The authors found a significantly higher infection rate in patients of categories 2 and 4 and Gram-negative organisms in patients with antibiotic prophylaxis.
The authors concluded that antibiotic prophylaxis appears to be unnecessary in class 1 clean wounds (wounds made in uncontaminated skin with sterile surgical technique and an infection rate less than 5% (27)), given that patients receive appropriate postoperative care, for which two methods exist: open techniques, which use topical emollients, and closed techniques, which use artificial dressing materials. Open techniques require patients to apply emollient multiple times daily and provide more visibility while the wound heals. Closed techniques, though they may require less of patients, appear to be associated with a high risk of infection. Leaving closed bandages in place for no longer than 48 hours may minimize the risk of infection with closed techniques. (18,28)
Despite these opposing views, most laser surgeons feel that antibiotic prophylaxis is necessary and the most appropriate choice for antibiotic infection prophylaxis is a broad-spectrum agent effective against Gram-positive pathogens (eg, S. aureus and Streptococcus pyogenes) and, to some degree, Gram-negative pathogens. An excellent choice would be an extended spectrum cephalosporin such as cefdinir which provides coverage of Gram-positive bacteria and appropriate coverage of Gram-negative bacteria. In addition, since cefdinir does not cross react with penicillin, it can be used in patients allergic to penicillin. Another option is to start with a broad-spectrum antibiotic and add a complementary agent. Patients preparing for ablative cutaneous C[O.sub.2] surgery should start the antibiotic during the evening before the procedure or on the morning just before the procedure. They should continue therapy until reepithelialization is complete. (12)
As for antiviral infection prophylaxis, patients should take the antiviral twice daily beginning 2 days before laser surgery and continue the treatment until reepithelialization is complete (10 days). Susceptible patients should take moderate doses of the antivirals. When infection occurs during prophylaxis, a culture should be performed to guide therapy. A patient who received deep Er:YAG laser resurfacing with prophylaxis is shown in Figure 2.
In addition to infection, ablative laser resurfacing may result in hyperpigmentation, hypopigmentation, and scarring. A small number of patients have significant difficulty in healing after laser resurfacing. (29) These patients are generally of skin type I or II and are treated by closed-dressing type procedures. Although the etiology of this complication is unclear, a combination of infection and autoimmunity phenomena are thought to impede reepithelialization. The most success in treating this rare complication has been with (1) combinations of oral antibiotics, antivirals, and gentle topical treatment; (2) open-dressing type procedures; and (3) judicious use of topical corticosteroids (eg, betamethasone dipropionate ointment). Healing may require up to 10 months and result in scarring. (21)
Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) has been used to treat actinic damage, acne, and non-melanoma skin cancers. In this relatively new nonablative technique, topical ALA, a precursor in the biosynthesis of heme, is selectively taken up by rapidly proliferating cells and converted to protoporphyrin IX (PpIX), a potent photosensitizer. (30) Exposure to intense light of the appropriate wavelength activates PpIX, leading to the formation of singlet oxygen and ultimate cell death. Depending on the indication, PpIX may be activated by lasers, pulsed light, or continuous light (blue, red). (31,32)
In the author's experience, secondary bacterial infections have not occurred in more than 500 patients treated for actinic damage, rosacea, or photorejuvenation by ALA PDT. Antibiotic prophylaxis is therefore unnecessary, although antiviral prophylaxis may be appropriate in some patients.
Since ALA also penetrates sebaceous glands, ALA PDT has been applied to the treatment of popular, pustular, and severe cystic acne. PpIX activation leads to the destruction of sebaceous glands and, by other mechanisms, Propionibacterium acnes. Three of the author's patients have acquired secondary bacterial infections (Gram-negative enteric) with this treatment, so antibiotic prophylaxis may be necessary at times in this patient population.
In general, prophylaxis with antibiotics and antivirals is unnecessary with nonablative procedures. Aggressive treatments can cause superficial wounds lasting 2 to 7 days and judicious use of broad-spectrum antibiotics (eg, cefdinir) may be indicated in these cases. Antiviral prophylaxis should be considered in susceptible patients. When infections occur in patients not on prophylactic antibiotics or receiving prophylaxis treatment, culture and appropriate antibiotic or antiviral regimens are required to guide therapy. Guidelines for antibiotic and antiviral prophylaxis are shown in Table 2.
Summary and Conclusions
Ablative laser resurfacing continues to have significant clinical benefits in patients with deep wrinkles and scars. When prophylaxis is indicated, patients should be treated with broad-spectrum antibiotics (eg, cefdinir) and antivirals. Nonablative treatments such as ALA PDT do not usually require antibiotic prophylaxis, although a few patients treated for acne may acquire a secondary bacterial infection that should be treated.
[FIGURE 2 OMITTED]
Dr. Nestor is a member of the Speakers Bureau of Abbott Laboratories.
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Address for Correspondence
Mark S. Nestor MD PhD
Center for Cosmetic Enhancement
2925 Aventura Blvd, Ste. 205
Aventura, FL 33180-3108
Mark S. Nestor MD PhD
Center for Cosmetic Enhancement, Aventura, FL
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