Postoperative Care and Complications

Both occlusive and nonocclusive types of dressings are available. Occlusive dressings entail a covering that occludes the skin and may provide more postoperative comfort. These are typically left in place for 1-3 days before removal followed by soaking of the treated area. The patient may then continue wound care with an open dressing. The downside to this method is that the occlusion can mask an infection and may, in fact, promote infection by harboring bacteria in the occluded area (Christian 2000). Open dressings are usually petrolatum-based ointments that provide an occlusive-like effect and allow for easy visualization and monitoring of the healing skin. Frequent soaking with dilute acetic acid promotes healing and inhibits bacterial growth. A variety of petrolatum-based products have been used. Regular vegetable oil-based shortening is also an excellent choice. It is the product with the least likelihood of triggering a topical allergic or irritant dermatitis. Vegetable oil-based shortening is usually not the first line product, because of its lack of elegance. However, if an allergic or irritant reaction occurs while using another open dressing, it is our first choice substitute.

Complications of ablative resurfacing can include prolonged erythema, contact dermatitis, acne, infection, pigmentary changes, and scarring (Lewis and Alster 1996; Nanni and Alster 1998; Sriprachya-Anunt 1997). Postoperative erythema typically improves with time; it is most pronounced during the first week and steadily subsides over the next few weeks. Prolonged erythema and/or pruritus result from contact dermatitis, infection, or thermal damage. Allergic and irritant contact dermatitis occurs more commonly in newly resurfaced skin and likely relates to the increased density of Langerhans cells, which is noted in areas of perturbed epidermis. Thus, anything that comes into contact with the skin can trigger a reaction as the disrupted epidermis more readily attracts the dendritic cells to potential sites of antigen invasion. The most likely contactants are sources of perfumes or dyes such as those found in fabric softener dryer sheets or detergents. Patients should be forewarned to elimi nate these potential allergens. A reaction to a topical petrolatum-based dressing may occur during the first postoperative week and is best treated by switching to vegetable shortening. Oral antihistamines and topical steroids are invaluable for treating more severe reactions.

Acne can be activated by the occlusive effect of the dressings. It can take up to 6 weeks to clear. This acneform eruption usually responds to removal of the occlusive factor and a topical, or even oral, antibiotic may be needed in more severe cases. After a few weeks, comedolytics such as topical benzoyl peroxide, retinoids, and alpha- or beta-hydroxy acids may be added as needed.

Infection from either a viral, bacterial, or yeast/fungal source can also prolong erythema. Infections need to be treated promptly with a change in oral agents based on culture identification and sensitivity results or based on empiric observation. If herpes simplex viral infection (HSV) is suspected, the antiviral medication should be increased to a herpes zoster dose. Valcyclovir is the antiviral agent of choice, recommended for its ability to attain higher blood levels in comparison to other anti-HSV drugs (Data on file, GlaxoSmithKline). For suspected yeast infections, additional doses of fluconazole or spectazole are recommended.

Relative hypopigmentation can occur when removal of acquired sun damage has returned the skin to its normal nonsun-exposed color. A careful technique of feathering into the untreated, sun-damaged areas will minimize this demarcation. If it is still prominent, a touch up at the line of demarcation can help. Additionally, chemical peeling agents, hydroquinone preparations, or lasers which target melanin can be utilized to minimize the solar lentigines in the untreated area. Delayed hypopigmen-tation can arise in areas of significant erythema which may mask its earlier appearance. Although this hypopigmentation can be permanent, treatment with the excimer and other similar 308-nm light devices has been shown to improve this leukoderma (Friedman and Geronemus 2001)

Of greatest concern is scarring, which can be atrophic or hypertrophic in nature. Scars should be treated immediately, once they become apparent, as earlier treatment is more beneficial. Topical steroids should be applied and intralesional steroid injection is recommended for any hypertrophic scars. The pulsed dye laser can provide significant benefit but several treatments may be needed to obtain the desired result. The laser settings are similar to those used in other scar treatments and are generally performed at 3- to 6-week intervals, depending on severity, until the scarring process is abated.

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