Sections

Mohs Surgery

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Class Summary

Prophylactic antibiotics are recommended when the surgical site is considered high risk for surgical infection, including the oral mucosa, genitalia, and lower extremities below the knee.

Dicloxacillin

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Dicloxacillin is used for the treatment of infections caused by penicillinase-producing staphylococci. It may be used to initiate therapy when staphylococcal infection is suspected.

Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. Its primary activity is against skin flora, and it is used for skin infections or prophylaxis in minor procedures.

Clindamycin (Cleocin)

Clindamycin is a lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest.

Doxycycline (Adoxa, Doryx, Vibramycin, Monodox)

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Doxycycline is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. The adult dosage is 100 mg orally twice daily. Severe hepatic dysfunction is a contraindication.

Azithromycin (Zithromax, Zmax)

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Azithromycin t is used to treat mild-to-moderate microbial infections. In adults, it is given in a single dose of 1 g orally. Azithromycin acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. It concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra DS)

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Trimethoprim/sulfamethoxazole inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. The antibacterial activity of trimethoprim/sulfamethoxazole includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Ciprofloxacin (Cipro)

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Ciprofloxacin is a fluoroquinolone with activity against most gram-negative organisms but no activity against anaerobes. It inhibits bacterial DNA synthesis and consequently growth.

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Media Gallery

Mohs surgery is generally indicated for the treatment of tumors in areas where a high risk of recurrence exists and cosmetic results are critical.
The conventional bread-loaf technique for checking tissue margins by using vertical sections. Less than 1% of the margin is evaluated, as compared with almost 100% of the margin with the Mohs surgical technique. As illustrated here, residual tumor may not be found and may recur.
A Mohs surgery specimen is carefully separated into 4 quadrants.
Each quadrant of a specimen undergoing Mohs surgery is marked with 2 different colored dyes.
Marked tissue undergoing Mohs surgical technique is embedded into a chuck for the cryostat.
A Mohs surgery tissue specimen is cut into thin sections.
Mohs surgery sections are stained with hematoxylin and eosin and placed on slides.
Mohs surgery sections are stained with hematoxylin and eosin and placed on slides.
Residual tumors are marked on a map.
An illustrated example of the Mohs surgical technique.

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Author

Shang I Brian Jiang, MD Clinical Professor of Medicine and Dermatology, Director, Dermatologic and Mohs Micrographic Surgery, Program Director, UCSD Dermatologic and Mohs Surgery Fellowship, University of California School of Medicine, San Diego

Shang I Brian Jiang, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery, Association of Professors of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Silvia Soohyun Song University of California San Diego School of Medicine

Disclosure: Nothing to disclose.

Maureen A Mooney, MD, FAAD, FACMS Partner, Cascade Eye and Skin Centers; Clinical Instructor, Division of Dermatology, University of Washington School of Medicine; Clinical Instructor, Pacific Northwest University of Health Sciences

Maureen A Mooney, MD, FAAD, FACMS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery, Washington State Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Acknowledgements

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Mary Farley, MD Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center

Disclosure: Nothing to disclose.

Maureen Ann Mooney, MD Partner, Cascade Eye and Skin Centers; Clinical Staff, Division of Dermatology, University of Washington School of Medicine

Maureen Ann Mooney, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, Washington State Medical Association, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Edward Parry, MD Fellowship Director, Clinical Professor, Department of Dermatology, Louisiana State University Medical School

Edward Parry, MD is a member of the following medical societies: American Academy of Dermatology and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Désirée Ratner, MD Director, Comprehensive Skin Cancer Center, Continuum Cancer Centers of New York, Director of Dermatologic Surgery, Beth Israel Medical Center and St. Luke's and Roosevelt Hospitals, Professor of Clinical Dermatology, College of Physicians and Surgeons of Columbia University

Désirée Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Clark A Rosen, MD Director, University of Pittsburgh Voice Center; Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine

Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society

Disclosure: Merz Aesthetic Inc Consulting fee Consulting; Merz Aesthetic Inc Consulting fee Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Feature of Tumor	Mohs Surgery	Excision, Electrodesiccation and Curettage, Cryosurgery, and Radiation Therapy
Primary or recurrent	Recurrent or incompletely excised	Primary
Location	High risk; on ear, digits, genitalia, or central part of face	Low risk; on trunk and extremities
Histologic finding	Aggressive growth pattern: morpheaform, infiltrating, keratotic, perineural or perivascular invasion	Nodular, superficial
Size	>0.6-1 cm on face, >2 cm elsewhere	< 0.6-1 cm on face, < 2 cm elsewhere
Clinical nature	Ill-defined borders, multicentric, radiation, genetic syndrome with multiple tumors	Well-defined borders

Treatment	Primary Tumor, %	Recurrent Tumor, %
Mohs surgery	1.0	5.6
Surgical excision	10.1	17.4
Radiotherapy	8.7	9.8
Cryosurgery	7.5	13.0^*
Electrodesiccation and curettage	7.7	40.0
^* Less than 5 years; no statistics for 5-year follow-up.

Mohs Surgery Medication

Medication Summary

Antibiotics