January 25, 2019

Dermatologists should consider the higher risk for complications among immunosuppressed patients undergoing MMS when counseling them and managing their care.

According to a study conducted at the Dermatologic and Mohs Surgery Center of the University of California, San Diego, ,immunosuppression — in particular immunosuppression after solid organ transplant and the use of immunosuppressive therapy — in patients undergoing Mohs micrographic surgery (MMS) is linked to a higher risk for postoperative complications, including surgical site infection and wound dehiscence. The results of a retrospective, cross-sectional chart review of patient characteristics, clinical characteristics, and complications in immunosuppressed patients undergoing MMS for basal cell carcinoma or squamous cell carcinoma during a 4-year period were published in the Journal of the American Academy of Dermatology.

The investigators sought to establish the incidence and nature of postsurgical complications among immunosuppressed patients undergoing MMS. All patients who underwent MMS between July 2011 and June 2015 were evaluated, with data obtained via review of electronic medical records. Complications were defined as an adverse event (AE) that occurred within 2 weeks after MMS that was directly related to the procedure and was evaluated by the medical staff at a follow-up visit. Possible AEs included a clinical diagnosis of wound bleeding, dehiscence, tissue necrosis, and surgical site infection (including a combination of purulence, erythema, tenderness, and/or warmth at the site of the lesion, with or without fever).

The overall rate of complications among all those who participated in the analysis was 5.0%. Complications were significantly more likely to occur in older than in younger patients (70.7 vs 67.8 years of age; P =.005). No significant differences according to gender were reported. Surgical site infection (2.5%) and wound dehiscence (0.51%) were more prevalent among those who were immunosuppressed, with an overall complication rate of 5.4% in this population.

Per univariable analysis, in a comparison of immunocompetent and immunosuppressed individuals, immunosuppression was associated with a 9.6-fold greater likelihood of the development of a postoperative complication (P =.003). Solid organ transplant was associated with an 8.824-fold greater likelihood of a postsurgical complication (P =.006), whereas immunosuppressive therapy was associated with a 5.775-fold greater likelihood of a postsurgical complication (P =.021).

The investigators concluded that dermatologists should consider the higher risk for complications among immunosuppressed patients undergoing MMS when counseling them and managing their care. Administering the lowest possible dose of immunosuppressive therapy to facilitate transplant tolerance yet not promote cutaneous surgical complications is a key clinical consideration that warrants additional study.

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Reference

Basu P, Goldenberg A, Cowan N, et al. A four-year retrospective assessment of post-operative complications in immunosuppressed patients following Mohs micrographic surgery [published online November 28, 2018]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2018.11.032