Cosmeceutical Critique

Pre- and postprocedure skin care guide for your surgical patients

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Highlights:

Retinoids should be used 2-3 times prior to procedures to speed healing.

Retinoids should not be used after the procedure until reepithelization has occurred.

Vitamin C and zinc supplements taken post procedure might speed wound healing.


 

Whether patients are having a biopsy, surgical excision, or Mohs surgery, the outcome will be improved when the proper skin care is used before and after the procedure. This is a guide that you can use to educate your patients about pre- and postprocedure skin care needs.

Presurgery skin care and supplements

The goal is to speed healing and minimize infection, scarring, and hyperpigmentation. For 2 weeks prior to surgery, recommend products that have been shown to speed wound healing by increasing keratinization and/or collagen production. Ingredients that should be used prior to wounding include retinoids such as tretinoin and retinol. Several studies have convincingly shown that pretreatment with tretinoin speeds wound healing.1,2,3 Kligman and associates evaluated healing after punch biopsy and found the wounds on arms pretreated with tretinoin cream 0.05% to 0.1% were significantly smaller – by 35% to 37% – on days 1 and 4, and were 47% to 50% smaller on days 6, 8, and 11, compared with the untreated arms.4 Most studies suggest a 2- to 4-week tretinoin pretreatment regimen5 because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.6 This approach allows the skin to recover from any retinoid dermatitis prior to surgery. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.7

Although wound healing studies have not been conducted in this area, pretreating skin with topical ascorbic acid8 and hydroxyacids9 might help speed wound healing by increasing collagen synthesis.

Ingredients and activities to avoid presurgery

Patients should avoid using ingredients that could promote skin tumor growth. Although there are no studies evaluating the effects of growth factors on promoting the growth of skin cancer, caution is prudent. To reduce bruising, patients should avoid aspirin, ibuprofen, naproxen, St. John’s Wort, vitamin E, omega-3 fatty acids supplements, flax seed oil, ginseng, salmon, and alcohol. Most physicians agree that these should be avoided for 10 days prior to the procedure. Smoking should be avoided 4 weeks prior to the procedure.

Postsurgery skin care and supplements

Oral vitamin C and zinc supplements have been shown to speed wound healing in rats when taken immediately after a procedure.10 Oral Arnica tablets and tinctures are often used prior to and after surgery to reduce bruising and inflammation. There is much anecdotal support for the use of Arnica, but clinical trial evidence substantiating its efficacy to prevent bruising and reduce swelling is scant.

Dr. Leslie S. Baumann, a dermatologist, researcher, author, and entrepreneur who practices in Miami.

Dr. Leslie S. Baumann

Topical products used after surgery play an important role in healing. The combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in a gel pad was shown to reduce postoperative ecchymosis and edema after oculofacial surgery.11 Topical curcumin speeds wound healing in animals.12 Another study has demonstrated that an occlusive ointment containing a triad of antioxidants accelerated wound healing.13

A protein important in wound repair, defensin, is available in a topical formulation. Defensin14 has been shown to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5 and LGR6) stem cells. It speeds wound healing by increasing LGR stem cell migration into wound beds. Wounds should be covered to provide protection from sun exposure until reepithelialization occurs. Which occlusive ointments and wound repair products to use are beyond the scope of this article. Once epithelized, zinc oxide sunscreens can be used. These have been shown to be safe with minimal penetration into the skin.15

Ingredients to avoid post surgery

Topical retinoids should not be used post skin cancer surgery until epithelialization is complete. A study by Hung et al.16 in a porcine model used 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding demonstrated that use of tretinoin 10 days prior to wounding sped reepithelialization while use after the procedure slowed wound healing.

Acidic products will sting wounded skin. For this reason, benzoic acid, hydroxy acids, and ascorbic acid should be avoided until the skin has completely reepithelialized. Products with preservatives and fragrance should be avoided if possible.

Vitamin E derived from oral supplement capsules slowed healing after skin cancer surgery and had a high rate of contact dermatitis.17 Chemical sunscreens are more likely to cause an allergic contact dermatitis and should be avoided for 4 weeks after skin surgery. Organic products with essential oils and botanical ingredients may present a higher risk of contact dermatitis due to allergen exposure.

Conclusion

To ensure the best outcome from surgical treatments, patient education is a must! The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the outcomes will be. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners.

Encourage your patients to ask questions during their consultation and procedure and to get in touch with your office should they have any concerns when they leave. These steps help improve patient compliance and satisfaction, which will help you maintain a trusting relationship with established patients and attract new ones through word-of-mouth referrals.

Please email me at DrB@skintypesolutions.com if you have any other pre- and postprocedure skin care advice.

Dr. Leslie S. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

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2. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.

3. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.

4. Br J Dermatol. 1995 Jan;132(1):46-53.

5. J Am Acad Dermatol. 2004 Dec;51(6):940-6.

6. J Korean Med Sci. 1996 Aug;11(4):335-41.

7. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.

8. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.

9. Exp Dermatol. 2003;12 Suppl 2:57-63.

10. Surg Today. 2004;34(9):747-51.

11. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.

12. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.

13. Dermatol Surg. 1998 Jun;24(6):661-4.

14. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.

15. ACS Nano. 2016 Feb 23;10(2):1810-9.

16. Arch Dermatol. 1989 Jan;125(1):65-9.

17. Dermatol Surg. 1999 Apr;25(4):311-5.

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