HPI: The patient is an otherwise healthy 80 yo man who underwent Mohs surgery on November 16, 2011 for a basal cell carcinoma of the mid-parietal area of the scalp. The large defect needed a complex closure. Within a few days there was some evidence of inflammation and a wound culture grew out staph aureus sensitive to methicillin but resistant to penicillin, clincamycin and erythromycin. He was treated with cephalexin and seemed to do well, but presented on January 19, 2012 with thick crusts along a portion of the scar (unfortunately not photographed). He feels well otherwise.
O/E: 1/19/2012. There were thick honey-colored crusts in a linear distribution over ~ 1/2 of the "S" closure. The crusts were lifted off with a number 15 blade and the base was covered with creamy pus which was cultured and cleansed. The base was glistening granulation tissue, in some areas eroded in others raised.
Clinical Photo after very gentle debridement
Culture Report: Pending
Diagnosis: Erosions secondary to subacute infection. Role of subcuticular sutures may be key. Possible erosive pustular dermatosis of the scalp secondary to inadequately treated infected Mohs wound.
Plan: At this time will wait for culture report and then treat with an appropriate antibiotic. I will debride the hypergranulation tissue and consider using a topical steroid as recommended for erosive pustular dermatosis of the scalp.
Your Comments will be appreciated.
2/22/12 Healed after Keflex 500 mg b.i.d. x 2 weeks and H2O2 cleansing
from Mary Maloney: I agree that you should not treat with antibiotics until a positive culture as there is no redness. I think there may be extruding buried sutures--most common with slowly dissolving (long acting) buried sutures. This may well have set up an erosive pustular dermatosis-type picture, so agree with topical steroids.
ReplyDeleteI looked at the photos from your patient. I'm not sure it was necessarily a bad thing to try to close the scalp wound with an O to Z flap. The upside would have been faster healing (had the patient not developed a wound infection) than secondary intention. Naturally the type of closure should be matched to what is reasonable for the patient to tolerate and the wishes of the patient. It is a big procedure for a PA - and he perhaps did not get good hemostasis. I do not have a surgical PA in my practice, but I doubt I would ever feel comfortable delegating flap design, incisions and placement of key deep sutures to a PA. I could see them doing linear closures and completing a flap, once key sutures placed. That's just my personal opinion and I know that many surgeons do employ surgical PA's. So many patients are on blood thinners now, so that could have played a role in hematoma formation as well. Any surgeon can get a wound infection - none of us are immune. My professors used to say: "If you don't want any surgical complications, don't do surgery". Your care of the patient is very appropriate - antibx to cover the meth resist staph infection and supportive care. The ulcerated areas, areas of delayed healing and dehiscence that resulted from the infection, will heal in with appropriate wound care. The hypertrophic granulation tissue can be cauterized with electrocautery or silver nitrate. If there are any obvious extruding sutures, you can grasp with forceps and clip knot to remove. Ultimately he will heal just fine. (From a Moh's surgeon)
ReplyDeleteI agree with your plan for debridement and appropriate wound care. You may try to compress the area with normal saline solution and apply hydrocolloid dressing to help with the healing.
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