Postoperative Topical Antimicrobial Use

Vaneeta M. Sheth; Sarah Weitzul


Dermatitis. 2008;19(4):181-189. 

In This Article

Abstract and Introduction

Allergic contact dermatitis associated with topical antimicrobial agents is an increasing problem in the postoperative wound care period. We reviewed the topical antimicrobial agents most commonly used postoperatively in North America and Europe, examined the incidence of allergic contact dermatitis from each agent, and provided guidelines for the use of topical antimicrobials on closed and open wounds in the postoperative period. Neomycin was the most common cause of allergic contact dermatitis both in the general patch-tested population (11%) and in the postsurgical population. Bacitracin was also a common culprit, although at a lower rate (8%). There is a risk of co-reactivity between these two agents. Polymyxin B and mupirocin were not significant allergens. The rate of postoperative infectious complications in dermatologic surgery (1-2%) was similar to the rate of allergic contact dermatitis from topical antimicrobials (1.6-2.3%). We concluded that for closed wounds, the use of topical neomycin postoperatively should be avoided. White petrolatum is an efficacious and cost-effective alternative for closed wounds. For open wounds, topical antimicrobials that do not contain neomycin should be recommended.

Topical antimicrobials are among the most commonly purchased medications, used by the general public for everything from simple abrasions and cutaneous infections to routine wound care. It has been estimated that 25 million procedures are performed in dermatologists' offices yearly, and an average of 31.5% of dermatologic visits involve the excision or destruction of a skin lesion.[1,2] In addition, a random survey of dermatologic surgeons reported over 4.9 million procedures performed in 2005, 1.7 million of these being for skin cancers.[3] With the incidence of skin cancer (and thus surgical excisions) on the rise,[4] optimizing postoperative wound care is paramount. Most dressings used in the ambulatory surgery population involve the use of topical antimicrobial agents. However, it is important to remember that these frequently applied adjunctive medications are not without risk. One of the more common and easily observed adverse reactions is the development of an allergic contact dermatitis. The ease and convenience of patch testing makes it a readily available tool for investigating this phenomenon. Furthermore, one topical antimicrobial (neomycin) is part of the standard series of patch tests. This underscores the frequency of topical antimicrobials as allergens. The purpose of this review is to understand the benefits and risks of topical antimicrobial agents, specifically as used postoperatively, and to provide evidence-based guidelines for the judicious use of these agents.

A systematic review of the literature was performed by searching MEDLINE articles published in English from 1950 to the present, using the keywords "patch test," "allergy," "antibiotic," "surgery," "postoperative," and "wound." We searched for publications that discussed topical antibiotic use that resulted in (1) a cutaneous eruption, (2) further evaluation by patch testing, or (3) both a cutaneous eruption and further evaluation. We found more results with "antibiotic" than with "topical antibiotic" and more results with "allergy" than with "contact allergy." We used the term "antibiotic" synonymously with "antimicrobial" because topical antiviral and antifungal agents were not investigated. In evaluating the incidence of allergic contact dermatitis from the substance in question, the frequency of positive patch-test reactions was often used as a surrogate marker in the studies evaluated. We also evaluated the incidence of topical antimicrobial-related allergic contact dermatitis in postsurgical patient populations, using the keywords mentioned previously. Finally, to develop specific guidelines for the use of topical antimicrobials in postoperative wound care, we identified studies comparing the use of topical antibiotics and other topicals in this setting.