Perioperative Management of Medications for Psoriasis and Psoriatic Arthritis: A Review for the Dermasurgeon

Abstract

This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

Dermatological complications and safety of anti-TNF treatments

“…These data, however, suffer from different definitions of inclusion criteria for surgeries, scheduling of treatments, and infections. Despite these conflicting conclusions, it is reasonable to withhold TNF agents perioperatively (for 1 week prior and for 1–2 weeks after surgery)32 given the lack of clinical trials, the increased incidence of infections during TNF treatment, and the considerable morbidity of SSIs verses transient increases in disease activity 33…”

Perioperative management of tumor necrosis factor antagonists in patients with psoriasis and other inflammatory disorders

“…With respect to the latter, even within a subspecialty, rates of postoperative complications vary tremendously among different types of surgery. For example, studies have shown that foot and ankle procedures carry a higher risk of postoperative infection than other types of orthopedic surgery (54). Most of the aforementioned studies included a wide range of surgeries, from same-day small procedures to major joint replacements; yet almost none of the studies addressed whether major and minor procedures were balanced across cohorts.…”

“…However, the slight trend towards increased frequency of infections and delayed wound healing in the setting of insufficiently powered studies has led most authors to advocate a more cautious approach. Most reviews of the rheumatologic literature recommend discontinuing any TNF antagonist for a week prior to surgery, with resumption of treatment 2-4 weeks after surgery (4,54,70). Until further studies are conducted in psoriasis and psoriatic arthritis, a reasonable approach would be to follow these rheumatologic recommendations.…”

Pain Management in Dermatologic Procedures: Before and After

“…It is the only NSAID that prolongs bleeding time because of its irreversible effect on platelets, which lasts for their entire lifespan of 10 to 14 days. Aspirin should be avoided at least 1 week before surgery unless its use is medically necessary . Patients reporting aspirin intolerance or an allergy to NSAIDs experience side effects due to high levels of leukotrienes as a result of the blockage of the COX pathway by these medications.…”

“…Nonselective NSAIDs weakly and reversibly bind to platelet COX‐1, which generates thromboxane A2, which is responsible for mediating platelet activation and aggregation. Drug elimination (4–5 half‐lives) before surgery should be adequate to prevent hemorrhagic complications . Preoperative use of NSAIDs has been demonstrated to decrease postoperative inflammation and pain, yet concerns regarding hemostasis will likely limit their use before surgery for pain control.…”