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INTRODUCTION

Topical agents are important in procedural dermatology. They can prevent infection, improve the skin barrier, minimize pain, create an environment for wound healing, decrease scarring, and enhance skin appearance. The most basic of topical agents important for skin health are cleansers designed to maintain a healthy biofilm key to the prevention of wound infection. A specialized subset of cleansers are hand sanitizers used by physicians and patients alike, as the most accessible source of pathogens for wound infection is the hands. Moisturizers are sometimes required due to the overly aggressive effects of cleansers and are useful in improving postprocedural skin appearance and creating an environment for barrier repair and healing. Many scar creams are specialized moisturizers with an important subset considered as FDA 510(k) cleared prescription products. Some contain interesting new ingredients, such as stem cell extracts and peptides, engineered to promote healing with market crossover into the anti-aging market. This chapter discusses these technologies and their relevance to procedural dermatology.

THE SKIN BIOFILM

The skin biofilm assumes great importance in procedural dermatology because it can become a source of organisms resulting in postprocedural complications. The biofilm covers every inch of the skin and is composed of sebum, eccrine and apocrine secretions, environmental dirt, cosmetics, skin care products, bacteria, yeast, and fungal organisms. It can be diminished, but not eliminated. Even after aggressive skin cleansing, the biofilm begins to reappear almost immediately. This begs the question as to whether the biofilm is an asset or hindrance to the success of dermatologic procedures. A healthy biofilm can be an asset to procedural dermatology because there is a limit to how many bacterial and fungal organisms can live in a square centimeter of skin. Colonization with nonpathogenic organisms, such as Malassezia furfur and Staphylococcus epidermidis, can limit the ability of pathogenic organisms, such as Candida albicans and methicillin-resistant Staphylococcus aureus (MRSA), to grow. On the other hand, it has been suggested that inadvertent injection of biofilm organisms into the skin with fillers has resulted in sterile granuloma formation. Nevertheless, the biofilm must be controlled to prevent postprocedural infections.

The main method of controlling the biofilm is through cleansing. Cleansing temporarily removes the biofilm, but recolonization occurs rapidly in a contaminated world. It is thought that the pH of healthy skin is 5, but this is really the pH of the biofilm. The slightly acidic biofilm pH limits the growth of organisms and must be maintained. For this reason, it is important to understand the role of skin cleansing in procedural dermatology.

SKIN CLEANSING

Skin cleansing is an important mechanism for procedural infection prevention, and represents a complex interaction between the skin surface, physical rubbing, and the chemistry of the cleanser. Even though cleansing is a routine skin hygiene event, it is technologically profound. The invention of soap ranks along with clean water and public sewers as ...

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