Do antibiotic-based ointments improve outcomes in wound healing?

Air boat tour outside New Orleans . (Dr. Noorali Bharwani)
Air boat tour outside New Orleans . (Dr. Noorali Bharwani)

After surgery, patients always ask, “Doctor, do I need to use antibiotics to prevent infection?”

Surgical incisions are usually closed by fixing the edges together with stitches, staples or steri-strips. This process helps the cut edges heal together and is called ‘healing by primary intention’. This has a very low potential for infection.

Minority of surgical wounds are not closed in this way. This happens when there is a high risk of infection. The wounds may be left open to heal by the growth of new tissue rather than by primary closure. This is known as ‘healing by secondary intention’.

There is a risk of infection in open wounds, which may impact on wound healing, and antiseptic or antibiotic treatments may be used to prevent infections.

We don’t have to use any topical antibiotics (like Polysporin or Neosporin) for surgical wounds which are clean. Yet we continue to promote its use for clean surgical incisions.

A clean surgical procedure requires a clean dressing that protects incisions from bacteria and keeps it clean and dry. Dressings should be changed daily or according to your doctor’s orders.

In a recent article (Five Things Clinicians and Patients Should Question) written under the leadership of the Canadian Dermatology Association in Choosing Wisely Canada (March 2019), the association advises Canadians not to routinely use topical antibiotics (like Polysporin) on a clean surgical wound.

This review article says that for wounds closed with stitches, the potential harms (like allergic contact dermatitis to topical ingredients and antibiotic resistance) outweigh the marginal reduced risk of postoperative infection achieved by use of antibiotics applied to the skin.

Only wounds that show symptoms of infection (pus, swelling, spreading redness, wound breakdown and systemic symptoms) should receive appropriate antibiotic treatment.

In another study published in 2015 (J Dermatolog Treat) the authors compared topical antibiotic prophylaxis for prevention of surgical wound infections and found no statistically significant difference in incidence of postsurgical wound infections between topical antibiotics (like Polysporin) and petroleum jelly.

The authors of the article recommend use of Petrolatum (petroleum jelly) instead of topical antibiotics as a prophylactic measure to prevent postsurgical wound infections in the outpatient dermatologic setting.

Other studies have shown with repeated usage, about 10 per cent of people will develop an allergy to local use of antibiotic ointment. These same studies have shown that white petrolatum jelly (Vaseline) is the preferred wound care agent after skin procedures. All you need is gentle daily soap/water cleansing, and applications of Vaseline.

What is petroleum jelly? Petroleum jelly (also called petrolatum) is a mixture of mineral oils and waxes, which form a semi-solid jelly-like substance. This product hasn’t changed much since Robert Augustus Chesebrough discovered it in 1859. Petroleum helps seal your skin with a water-protective barrier. This helps your skin heal and retain moisture.

What is Polysporin? Polysporin consists of two antibiotics, bacitracin and polymyxin B.

What is Neosporin? Neosporin consists of three different antibiotics, neomycin sulfate, polymyxin B sulfate and bacitracin.

There are many studies which encourage use of petroleum jelly for routine care of superficial wounds, because it is as effective for wound healing as over-the-counter antibiotic preparations and does not contribute to antibiotic resistance or allergic contact dermatitis.

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Is PSA test a public health disaster?

Sand art on the beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)
Sand art on the beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)

Dr. Richard J. Ablin, PhD, DSc (Hon), first discovered prostate-specific antigen (PSA) in 1970. At the time, Ablin and colleagues were trying to identify an antigen that was specific to prostate cancer.

PSA test was introduced in the United States around 1990 for early detection of prostate cancer.

In 2010, Ablin called the PSA test a public health disaster. So, what went wrong? Why do we still order PSA test?

Let us start from the begining.

All men have a prostate gland. The gland produces some of the ingredients of semen. It sits just in front of the rectum and below the bladder. It can be felt on a rectal examination. It weighs about 30 grams. It is vital for the proper functioning of the male reproductive system.

One of the enzymes in prostatic fluid is prostate-specific antigen (PSA). After ejaculation, PSA makes thickened semen runnier, helping sperm travel through it more easily. Thus, increasing their likelihood of successfully fertilizing an egg.

Why PSA test can do more harm than good?

Reviewing some literature, I found Ablin, who is now a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research, has said, “in approving the procedure (PSA test), the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 per cent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.” Was that a wise decision?

PSA test is costing health care system billions of dollars. It is estimated that each year, some 30 million men undergo PSA testing in the US, at a cost of $30 billion. Ablin has said the test is hardly more effective than a coin toss. The PSA test cannot distinguish between the two types of prostate cancer – the one that will kill you and the one that won’t.

The American Cancer Society now urges more caution in using the test and the American College of Preventive Medicine has concluded that there was insufficient evidence to recommend routine screening. Then why do we still use it?

“Many doctors have distorted perceptions of the value of medical tests,” says Dr. Miriam Shuchman in the Canadian Medical Association Journal (CMAJ February 04, 2019). And patients have the same distorted perceptions.

In 2014, the Canadian Task Force on Preventive Health Care recommended against using the PSA test to screen for prostate cancer in healthy men, concluding that it results in substantial harms via biopsies and surgeries that can lead to infections, impotence or urinary incontinence, and does not save men’s lives.

Canadian and American task forces recommend that any man considering screening for prostate cancer should have a chance to first discuss the pros and cons with a doctor. The CMAJ article says that if men knew what the risks were associated with PSA testing and how slim to nonexistent the benefits are, no man in his right mind would get tested.

Considering PSA screening results in only a 0.1 per cent reduction in death from prostate cancer, the harms associated with screening outweigh the benefits for most people.

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Sun safety and prevention of skin cancer starts in childhood.

Dubai Desert Safari. (Dr. Noorali Bharwani)
Dubai Desert Safari. (Dr. Noorali Bharwani)

Snow has melted and summer is around the corner. It is about time to get some sun exposure and vitamin D. But we have to be careful. We have to find a right balance. Too much sun exposure allows ultraviolet (UV) rays to reach your inner skin layers that gives you sunburn. Sunburn kills your skin cells and cause cancer. You don’t want that.

UV rays are invisible, and are produced by the sun and tanning lamps. Most often, skin cancer is the result of overexposure to sun. Good news is most cases of skin cancer can be prevented.

There are three types of skin cancers. Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma. The first two are common and have good prognosis but can disfigure your face. Melanoma can be lethal if not treated early. Melanoma is the least common, but most serious type of skin cancer.

Who gets melanoma?

The rate of melanoma has tripled in the last 50 years. Melanoma is the deadliest skin cancer. It accounts for only about one per cent of all cases of skin cancer, but is responsible for the vast majority of skin cancer deaths.

In men, melanoma is most commonly found on the back and other places on the trunk (from the shoulders to the hips) or the head and neck. The most common sites in women are the arms and the legs. People with fair skin, such as those with Scandinavian ancestry, are more prone to sun damage than people with darker skin.

Approximately two per cent of melanomas occur in patients under the age of 20 years, and about 0.4 per cent of melanomas occur in prepubertal children. Children spend more time outdoors than adults. It is known that high exposure to sunlight during childhood sets the scene for higher rates of melanomas as an adult. Your risk of skin cancer increases with level of total cumulative exposure to the sun and number of sunburns. Melanoma loves overexposed and burnt skin.

What happens after diagnosis?

Your doctor will investigate if the melanoma is at an early stage or advanced stage. Early-stage means the cancer hasn’t grown much and hasn’t spread. Treatment is more likely to be successful.

Advanced-stage melanoma usually means the cancer is bigger and has probably spread. It’s important to know the stage of a cancer. It helps decide on your treatment.

Most early melanomas can be treated with wide surgical excision. But prognosis drops dramatically when the tumor has spread. There is no curative treatment available for advanced melanoma.

While we are waiting for scientific breakthrough in many areas of melanoma, we can try and prevent melanoma by protecting against sun exposure and sun burn. Natural protection (shade) is considered the best protection. And sunscreen (SPF 15 or higher) should be adjunct to natural protection.

Wear sun protective clothing (tightly woven). Wear wide brim hats. And use eyeglasses that block both UVA and UVB light.

Skin is the largest organ in the body. It is a very precious and important organ. It has many important functions. It is important for our survival. Let us protect it well starting from childhood. There is no doubt melanoma risk rises rapidly with increasing exposure to ultraviolet light in childhood. That is where the prevention should start and then continued into adult life.

Have a wonderful safe summer.

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Aging gracefully after retirement is a challenge we all face.

Space Needle in Seattle. (Dr. Noorali Bharwani)
Space Needle in Seattle. (Dr. Noorali Bharwani)

Today, people are living longer than they did 60 years ago. Now we have extra 15 to 20 years. Barring any unfortunate incidence most people will live to 80 years. Women will live longer.

The question is: how to grow older in good health so that we can actually enjoy those extra years? A Consumer Reports survey of 2,066 Americans age 50 and older revealed that we are eager to maintain our quality of life into retirement and far, far beyond.

As we get older our health changes. This happens even if we don’t like it. These changes can be due to normal aging process or age-related diseases. Most of our activities in life depend on our health and how mobile we are. Our retirement goals, such as travel, choice of home, sports and a broad range of other activities depend on our health.

Financial independence is also very important. Have you saved enough to get the help you need in case you are dependent on others?

What kind of health issues we should be worried about in our retirement?

Here is a list of health issues you have to be prepared for as you get older:

Are you capable of driving? If your vision is not good and you have difficulty with concentration then you cannot drive. Make sure you see your eye doctor on a regular basis.

How mobile are you? Arthritis, stroke, feet problems, and other health issues affecting your mobility will create frustration and anger. Joint deterioration can compromise your ability to stay active or climb stairs. Some of these problems come with the aging process. Be active and keep your muscles strong to mitigate the effects of these problems.

Are you able to hear your friends and family talk? Are you able to enjoy listening to music and watch television? Hearing loss can interfere with your relationships and lead to isolation. Don’t be shy to wear a hearing aid. Be proactive. Do not wait till you are completely hard of hearing.

Do you have cognitive deterioration? That means you have difficulty thinking and making decisions that affect your everyday life. This is feared by all. Alzheimer’s in old age makes it difficult to interact socially. You become dependent on others. Maintaining an active social network for yourself and being a lifelong learner are the best ways to reduce the risk of cognitive decline.

How can we take a proactive approach to prepare ourselves to make a smooth life transition?

Unfortunately, there is no magic solutions to the problems mentioned earlier. The basic principles are to prepare for what is to come. Be proactive and prepare yourself when you are young and healthy. Understand the importance of exercise, healthy diet and good health habits like no smoking.

If you are living in a big house then think about downsizing. Do it early when you are still in good health and in sound mind. Do not depend on your family to do it when you have lost control of your life. If you want to have choice, control and independence throughout your life, you need to think about these things early.

Not able to drive can cause severe frustration and anxiety. You should plan carefully where to live. Your social life will rely on whether you can get around. People do not realise how so many elements of their retirement plans are dependent on transportation. The problem gets worse if your friends are of the same age and cannot drive.

It all comes down to keeping control of your life and anticipating and planning for lifestyle changes as we age.

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