1. Zalaudek I, Ferrara G, Argenziano G.

Dermoscopy insights into nevogenesis:

Abtropfung vs Hochsteigerung. Arch Dermatol. 2007;143(2):284.
2. Hofmann-Wellenhof R, Blum A, Wolf IH, et al. Dermoscopic classification of
atypical melanocytic nevi (Clark nevi). Arch Dermatol. 2001;137(12):15751580.
3. Rieger E, Kofler R, Borkenstein M, Schwingshandl J, Soyer HP, Kerl H. Melanotic macules following Blaschkos lines in McCune-Albright syndrome. Br J
Dermatol. 1994;130(2):215-220.
4. Quatresooz P, Hermanns JF, Hermanns-Le T, Pierard GE, Nizet JL. Laddering melanotic pattern of Langers lines in skin of colour. Eur J Dermatol. 2008;
18(5):575-578.
5. Langer K. On the anatomy and physiology of the skin, I: the cleavability of
the cutis. Br J Plast Surg. 1861;31(1):3-8.

A Comparison of High- and Low-Cost

Infection-Control Practices
in Dermatologic Surgery

hough several studies have examined infection

risk in dermatologic surgery, studies comparing costs of different infection control protocols are lacking. This study was undertaken to determine whether a low risk of infection could be maintained
with a low-cost infection-control protocol.

Methods. A prospective study of 573 consecutive patients with 670 tumors undergoing Mohs surgery with
same-day reconstruction or second-intention healing
evaluated whether a low rate of surgical site infection (SSI)
could be maintained with a low-cost infection-control protocol. Surgical site infections were tracked from January
through September 2010 in a single-surgeon academic
Mohs practice (termed low-cost group), and these were
compared with those from a previously published group
of 585 cases in which the infection rate had dropped from
2.5% (the practices initial infection rate) to 0.9% with
initiation of a more stringent but expensive infectioncontrol protocol (high-cost group). 1 The infectioncontrol protocols investigated are summarized in Table 1.
The study was approved by the Partners Human Research Office.

Infection was defined as any case in which antibiotic

therapy was used for suspected wound infection. Criteria for determining the presence of infection and initiating antibiotic therapy are summarized in the Figure.
Patients were seen for suture removal or for wound check
(in cases of second-intention healing) at postoperative
day 7 to 10. The presence or absence of infection was assessed at this visit. In addition, all patients were given
an instruction sheet on the day of surgery describing
symptoms of infection (redness, pain, swelling, fever, or
pus) with instructions to come to the office for evaluation if these symptoms occurred. Wounds were cultured before antibiotic therapy was begun in all cases.
Surgical skin preparation differed between groups because chloroxylenol, 3%, became commercially unavailable
during the study period. This likely had little impact on results because the efficacy of chloroxylenol and iodine skin

Erythema

Tenderness on light palpation

or movement
OR
Purulence (cloudy white or
yellow wound exudate)
OR
Fever 100 F in office or by
patient

Diagnosis of infection made

Edema
OR
No other signs/symptoms

No infection
Patient instructed to return if
signs or symptoms of
infection developed, if wound
looked worse to them, or if it
failed to heal

Wound culture obtained and

oral antibiotic therapy initiated

Figure. Criteria for a diagnosis of infection and initiation of antibiotic

therapy. The same criteria were used for both sutured wounds and those
healing by second intention.

Table 1. Infection-Control Protocols and Costs per Case

Surgical Requirement, Cost per Case

Characteristic
Jewelry restrictions
Surgical caps
Mohs excision
Staff hand wash
Gloves
Drape
Reconstruction
Staff hand wash
Gloves
Drape
Gowns
Total Cost per Case

Initial Protocol Used

in the Practice1
(2.5% Infection Rate)

High-Cost Protocol1
(0.9% Infection Rate)

Low-Cost Protocol
(0.7% Infection Rate)

None
None

Smooth wedding band only, no cost

Caps used, $0.03

Smooth wedding band only, no cost

Caps used, $0.03

Soap and water, negligible cost

Clean, negligible cost
None

CG-EA, $0.84
Sterile, $2.92
Sterile paper drape, $1.59

CG-EA, $0.84
Clean, negligible cost
Sterile paper drape, $1.59

CG-EA, $0.84
Sterile, $2.92
Sterile towels, a negligible cost

CG-EA, $0.84
Sterile, $2.92
Sterile half sheet, $1.06, and sterile
towels, a negligible cost
Sterile knee length, $4.42
$14.62 ($10.86 increase over initial
protocol)

CG-EA, $0.84
Sterile, $2.92
Sterile towels, a negligible cost

None (exposed arms), no cost

$3.76

Long-sleeved scrub tops, a negligible cost

$6.22 ($2.46 increase over initial protocol)

Abbreviation: CG-EA, chlorhexidine gluconate, 1%, and ethyl alcohol, 61%.

a From hospital linen supply.

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Table 2. Characteristics of Patients in the High- and Low-Cost Infection-Control Protocol Groups a
Infection-Control Protocol
Characteristic
Age, mean, y
Female
Tumor type
BCC
SCC
Other
Location
Head and neck
Trunk
Upper limbs
Lower limbs
Mohs stages, mean No.
Post-Mohs area, mean, cm2
Closure type
Primary
Flaps
Grafts
Secondary intention
Referral
Other
Prophylactic antibiotics
Before surgery
After surgery
Unknown
Current tobacco use
Diabetes
Immunosuppression

High Cost
(n = 585)

Low Cost
(n = 670)

P Value

67.3
260 (45)

67.4
324 (48)

NA
NA

NA
NA

347 (60)
184 (32)
54 (8)

433 (65)
215 (32)
22 (3)

NA
NA
NA

NA
NA
NA

525 (90)
15 (3)
21 (4)
24 (4)
1.3
2.26

549 (82)
35 (5)
32 (5)
54 (8)
1.3
2.94

.001
.01
NA
.004
NA
NA

15.41
6.06
NA
8.39
NA
NA

374 (64.5)
86 (15)
38 (7)
18 (3)
42 (7)
26 (4)

446 (67)
90 (13)
38 (6)
62 (9)
30 (4)
3 (0.5)

NA
NA
NA
.001
NA
NA

NA
NA
NA
19.97
NA
NA

43 (7)
0
1 (1)
22 (4)
47 (8)
59 (10)

29 (4)
0
0
48 (7)
56 (8)
34 (5)

.02
NA
NA
.01
NA
.001

5.27
NA
NA
6.87
NA
11.43

Abbreviations: NA, not applicable.

a Unless otherwise indicated, data are reported as number (percentage) of patients.

preparations are reportedly equivalent.2 There were no personnel changes, and resident participation was consistent
(approximately 20% of cases) between the groups.
Potential confounders that differed significantly on 2
test results between infection control protocol groups were
tested for association with the primary study outcome
(presence or absence of infection) via the Fisher exact
test. Statistical significance was set at P .05 (STATA 9;
StataCorp LP).
The cost of infection control per case was calculated
by tabulating the costs of infection-control protocols for
a 1-stage Mohs procedure and reconstruction performed by 1 surgeon and 1 assistant (Table 1). The cost
per infection prevented was calculated by dividing the
cost of infection control per case by the reduction in infection risk from the baseline risk of 2.5%.
Results. Patients in the low-cost group were statistically different from those in the high-cost group with regard to several variables (Table 2). However, none of
these variables was significantly associated with infection on Fisher exact testing (data not shown), indicating that there was no confounding of infection risk due
to these between-group differences.
Infection risk was the same between high-cost (n=5,
0.9%) and low-cost groups (n = 5, 0.7%). The cost of infection control per case was lowered from $14.62 in the
high-cost group to $6.22 in the low-cost group. Compared with the baseline cost of $3.76 and infection risk

of 2.5% previously published,1 the high-cost group had

a $10.86 cost increase per case and a 1.6% drop in infection risk, whereas the low-cost group had a $2.46 increase in cost and a 1.8% drop in infection risk. This corresponds to a cost per infection prevented of $678.75 for
the high-cost group and $136.67 for the low-cost group
($10.86/0.016 and $2.46/0.018, respectively).
Comment. This study indicates that low-cost infectioncontrol protocols can be implemented without impacting infection risk in office-based Mohs surgery. The cost
per infection prevented was reduced to $136.67, which
is likely cost-effective, since the costs associated with diagnosing and treating surgical site infections (including
physician time, patient time and discomfort, and costs
of wound cultures and antibiotic therapy) exceed this
amount.
Infection-control costs were reduced by eliminating
sterile gloves during Mohs stages, and sterile gowns and
half-sheet drapes during reconstruction. It may be possible to further reduce costs without altering infection
rate by using clean, nonsterile gloves during reconstruction as well.3,4 Since infection risks for Mohs and general dermatologic surgery are similarly low,5 the lowcost infection-control protocol described herein may be
applicable to all office-based dermatologic surgery.
The major limitation of this study is its singlesurgeon practice setting. There may be factors unique to
this study site or staff that are not generalizable to oth-

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ers. In addition, since the 3 changes in the low-cost protocol were made simultaneously, the impact of each individual change cannot be evaluated. However, infectioncontrol measures are frequently implemented and studied
as regimens involving several elements. A randomized, multicenter trial comparing infection regimens would eliminate the possibility of bias from use of historical controls
and enhance generalizability of results. Such studies are
needed to define optimally cost-effective infection-control
protocols in the dermatologic surgery patient population.
Evelyn Lilly, MD
Chrysalyne D. Schmults, MD, MSCE
Accepted for Publication: February 3, 2012.
Author Affiliations: Mohs and Dermatologic Surgery Center, Department of Dermatology, Brigham and Womens Hospital, Harvard Medical School, Boston, MA.
Correspondence: Dr Schmults, Mohs and Dermatologic Surgery Center, Department of Dermatology,
Brigham and Womens Hospital, 1153 Centre St, Ste 4349,
Jamaica Plain, MA 02130 (cschmults@partners.org).
Author Contributions: Both authors had full access to
all of the data in the study and take responsibility for the
integrity and the accuracy of the data analysis. Study concept and design: Schmults. Acquisition of data: Lilly. Analysis and interpretation of data: Lilly and Schmults. Drafting
of the manuscript: Lilly. Critical revision of the manuscript
for important intellectual content: Lilly and Schmults.
Statistical analysis: Schmults. Administrative, technical, and
material support: Lilly. Study supervision: Schmults.
Financial Disclosure: None reported.
1. Martin JE, Speyer LA, Schmults CD. Heightened infection-control practices
are associated with significantly lower infection rates in office-based Mohs
surgery. Dermatol Surg. 2010;36(10):1529-1536.
2. Aly R, Maibach HI. Comparative antibacterial efficacy of a 2-minute surgical
scrub with chlorhexidine gluconate, povidone-iodine, and chloroxylenol
sponge-brushes. Am J Infect Control. 1988;16(4):173-177.
3. Eisen DB. Surgeons garb and infection control: whats the evidence? J Am Acad
Dermatol. 2011;64(5):960.e1-960.e20.
4. Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay-Wiggan J, Eliezri YD.
Prospective study of wound infections in Mohs micrographic surgery using
clean surgical technique in the absence of prophylactic antibiotics. J Am Acad
Dermatol. 2010;63(5):842-851.
5. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective study of wound
infections in dermatologic surgery in the absence of prophylactic antibiotics.
Dermatol Surg. 2006;32(6):819-827.

ONLINE FIRST
Skin Cancer Screening Among Hispanic
Adults in the United States: Results From
the 2010 National Health Interview Survey

ompared with non-Hispanic whites, Hispanics

are more likely to be diagnosed as having melanoma at an earlier age, with thicker, more advanced lesions, and they are more likely to die from their
disease.1 Physician skin examination (PSE) may reduce
the incidence of thick melanomas that have a poor prognosis.2 Few studies have examined the rate of PSE among
US Hispanic adults. In the present study, we examine the
prevalence and correlates of PSE among US Hispanic
adults in a nationally representative sample.

Methods. The data were drawn from the 2010 National

Health Interview Survey (NHIS), which is an annual,
probability-based survey of US adults.3 Institutional
review board approval was obtained for the study. The
sample consisted of 4766 individuals who self-reported
Hispanic ethnicity, reported no personal history of
skin cancer, and provided data regarding their PSE
history.
Participants indicated whether they were born in the
United States and the language they generally use when
speaking, which are 2 commonly used proxy measures
of acculturation. They also reported their Hispanic origin, sex, age, level of education, region of residence, source
of routine preventive care, health care coverage, skin sensitivity to the sun, the number of sunburns they had in
the past year, and whether they had ever had a PSE (defined as having all of the skin from head to toe checked
for cancer by a dermatologist or other physician).
Using Sudaan 10.0 software and a statistical significance cutoff of P.05, we conducted a series of univariate logistic regression analyses, using ever having a PSE
as the dichotomous outcome variable and each of the other
variables as independent variables.
Results. As listed in the Table, 7.2% of participants reported ever having a PSE. Lower rates of PSE were found
among those born outside of the United States as well as
those who did not report speaking mostly or only in
English. The rate of PSE differed significantly according
to individuals Hispanic origin, with lower rates found
among those from Mexico and the Dominican Republic
and higher rates among those from Cuba and Puerto
Rico.
With regard to demographic factors, the rate of PSE
was lower among men, younger individuals, and those
with a lower education level, but the rate did not differ
across region of residence. The rate of PSE was lower
among individuals who had no source of preventive care
or who received preventive care somewhere other than
a physicians office or health maintenance organization.
Individuals lacking health care coverage also had lower
rates of PSE. Participants reporting less sun-sensitive skin
had lower rates of PSE than those with the most sensitive skin. The rate of PSE did not differ according to the
number of reported sunburns in the past year.
Comment. Only 1 in 14 US Hispanic adults in the present study reported ever having a PSE, which is lower than
the 1 in 4 rate (25.4%) among non-Hispanic white adults
in the 2010 NHIS. Based on their reported nativity and
language use, more-acculturated Hispanics had a higher
rate of PSE. Prior research has found mixed evidence regarding the association between acculturation among US
Hispanics and skin cancerrelated behaviors, with
more acculturated individuals having higher rates of
sunscreen use but lower rates of staying in the shade
and wearing sun-protective clothing.4 Differences in the
rate of PSE across individuals levels of acculturation
and Hispanic origin in the current study highlight the
need for future research to explore concomitant differences in skin cancer prevention knowledge, attitudes,
and beliefs.

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