TOPICS

Management of Acute Skin Infections

J Clin Aesthet Dermatol. 2017 Feb; 10(2): E5–E7.

By Emma Davies, RN, NIP and Martyn King, MD


Definition

For the purpose of these guidelines, an acute skin infection is the invasion and multiplication of microorganisms in body tissues, especially those causing local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response.

Introduction

Acute skin infections can occur following any procedure where the normal integrity of the skin is breached. Typically, this is following an intradermal injection, such as performance of dermal fillers, botulinum toxin treatments, micro-needling, or sclerotherapy. However, it is also possible with nonpenetrating treatments, such as chemical damage following skin peels or thermal damage caused by laser or intense pulsed light.

Incidence

Although specific data on infection rates following aesthetic procedures is not readily available, most experts would agree that infections are uncommon following dermal filler treatment. The risk of infection depends on multiple factors relating to the patient, the practitioner, the procedure, the technique, and the amount of skin trauma.

Minimizing the Risks

(A) Patient. Prior to any treatment, a full medical history should be taken along with relevant examination of the patient. There are contraindications for all procedures, although any condition that impairs immunity is a risk factor for skin infections. Relative contraindications include diabetes mellitus, immunosuppression (acquired or drug-induced), obesity, venous insufficiency, edema or lymphoedema, dental infection or poor oral hygiene, and intravenous drug use. Treatments should not be carried out in an area with a pre-existing infection or if the patient has a systemic infection.

Patients should be informed of the risk of infection as part of the consent process and given written aftercare advice on what to look for and what to do if symptoms develop.

(B) Practitioner. The practitioner should have knowledge and understanding of infection control and the etiological factors involved. Infection control training must be in-line with professional standards and their code of conduct (NMC, GMC, GDC).

(C) Environment. The environment should be suitable for carrying out aesthetic treatments and in compliance with infection control standards. At bare minimum the environment needs to be clean and hygienic with appropriate surfaces. Hand washing needs to be available. Sterile packs and drapes should be utilized where needed. Good infection control procedure protocols should be in line with national standards (NICE 2012).

(D) Product. Use only legitimate products in which the source can be identified. Products need to be used within their expiry date or discarded appropriately. Do not administer products from a single syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items. Do not administer products from single-dose syringes or ampoules to multiple patients or combine leftover contents for later use.

Reconstitute using aseptic technique as per manufacturer guidelines and discard any unused product. If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile and the cap disinfected prior to penetration. Multi-dose vials should be discarded within 28 days unless manufacturer advises otherwise.

(E) Technique. Ensure good skin preparation; all make-up or other potential contaminants should be removed with facial wash and followed with antiseptic skin preparation of the treatment area such as 2% chlorhexidine and isopropyl alcohol 70%, if the patient has no history of sensitivity. Skin disinfection should be undertaken after make-up removal and after any application of ice.

Skin disinfectant solution should be applied using gentle friction repeated up and down, back and forth for 30 seconds to reduce the number of resident bacteria present at the insertion site which could serve as a source of infection. The solution should be allowed to fully air dry.

An aseptic technique, including hand hygiene, should be adopted where necessary. Sterile field and gloves are recommended for deep tissue augmentation with dermal fillers.

Ensure the needle or cannula is not contaminated during injection procedures and do not let the needle or cannula touch the skin except during actual injection. Do not wipe excess product from the needle tip with gauze as residual amounts can be flicked off.

Ensure accurate documentation of your treatment protocol.

(F) Aftercare. Patients should be advised to avoid touching the area for four hours and to refrain from applying make-up for 12 hours. For patients who are observed to unconsciously and habitually touch their face, it may be appropriate to apply alcohol gel to their hands on completion of the treatment session.

Treatment

As part of the consent process, patients should be informed of the risk and symptoms of infection and advised to report to the practitioner for immediate assessment if they develop any erythema, heat, tenderness, and swelling that is not settling within the first 48 hours or is worsening. If their practitioner is unobtainable, the patient should be advised to seek the attention of a medical practitioner.

Nonprescribing practitioners should refer immediately to their prescribing aesthetic practitioner for diagnosis and treatment. The general practitioner should be notified in accordance with professional standards and good medical practice with the consent of the patient.

Medical history should be reviewed with particular attention to allergy/sensitivity or interactions with concomitant prescribed medicines.

First line treatment is for seven days, although if treatment response is slow, continue for a further seven days.

First Line Treatment:11

Flucloxacillin 500mg QDS PO

If Penicillin allergic, Clarithromycin 500mg BD PO

Second Line Treatment:11

Consider the addition of Penicillin, Amoxicillin or Co-amoxiclav

If Penicllin allergic, Clindamycin 300mg QDS PO

Consult your local formulary for first- and second-line treatments for acute skin infections as local variations are common. If there is no response at 48 to 72 hours, a change in antibiotic regime should be considered and swab for microbiology, culture, and sensitivity if available.

If gram negative bacteria or anaerobes are suspected, use broad spectrum antibiotics. Consider specialist local microbiologist advice for resistant infections.

If abscess formation occurs and the infection is fluctuant with systemic symptoms, incision and drainage is necessary.12 The patient may need to be referred if the practitioner is unable to do this.

Paracetamol and/or ibuprofen may be required for pain management and control of fever. Wound management may also be needed dependent on the skin trauma and infection and careful debridement or dressing care could be required if there has been associated necrosis.

Areas of Caution

Periorbital cellulitis should be considered an emergency as there is a risk of orbital spread and subsequent blindness, consider immediate specialist referral.

Follow-up

Having prescribed oral antibiotics, the patient should be reviewed according to clinical need until the infection has resolved. It is suggested that initial follow-up after prescribing antibiotics should be within 48 hours. Photographic documentation should be kept and the practitioner should keep a log of infection rates for audit purposes. Good follow up and client support and full explanations to the patient is the best approach to stop a complication from turning into a claim.

References

2. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008;34:S92–S99. 
3. Clinical Resource Efficiency Support Team (CREST) Guidelines on the Management of Cellulitis in Adults. Belfast: CREST; 2005. 
4. NHS Choices. Map of Medicine, Cellulitis and erysipelas—Suspected. http://healthguides.mapofmedicine.com/choices/map/cellulitis_and_erysipelas1
5. Ozturk CN, Li Y, Tung R, et al. Complications following injection of soft-tissue fillers. Aesthet Surg J. 2013;33(6):862–877. 
6. NICE. Prevention and control of healthcare-associated infections in primary and community care. The Royal College of Physicians; London, United Kingdom: 2012. March.
7. Safe Injection Practices Coalition. The Joint Commission Multi-Dose Vials. 2009.
8. Toy BR, Frank PJ. Outbreak of mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg. 2003;29:971–973. 
9. Royal College of Nursing. Wipe it out: one chance to get it right. London, United Kingdom: 2012. 
10. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295–316. 
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