with AIDS and SOTR, immune reconstitution alone may be curative [28]. A switch from cyclosporine to sirolimus in a SOTR resulted in clinical regression in one case report. Additional approaches for localized disease include: cryotherapy, laser surgery, radiation, intralesional chemotherapy, imiquimod, topical retinoids, and excision. Patients with systemic disease may require chemotherapy if immune reconstitution is ineffective or not feasible.

Summary: Special Surgical Considerations in the

Organ Transplant Patient

•Solid organ transplant recipients are more likely to develop high-risk and recurrent neoplasms. Mohs is considered the standard of care for treating these tumors, and frequent follow-up is necessary. The following list summarizes the key elements to managing these patients:

Preoperative Evaluation

•Type of transplantation

•History of skin cancer including size, location, and histology

•Relevant medications (may impact wound healing)

Surgical Management

•SCC (lowand high-risk subtypes) – Treatment recommendations by clinical and histologic criteria (Fig. 9.1)

•Merkel cell, Melanoma, and BCC management similar to immunocompetent patients.

Postoperative

•Notify primary transplant team for consideration of immunosuppressant regimen alteration

•3–6-month follow-up with regional lymph node evaluations

important when assessing the immunosuppressed patients. Special emphasis should be placed on the size, location, and histology of each skin cancer to determine the appropriate treatment modality. Patient medications should be closely evaluated, as several immunosuppressant agents (corticosteroids, sirolimus, and everolimus) have been associated with delayed or poor wound healing [62]. SOTR do not appear to be at an increased risk for scar formation, but history of keloid formation or hypertrophic scarring after transplantation should be noted. The current status of the patient’s transplant should be determined, and any special precautions, such as need for antibiotic prophylaxis, be discussed.

9.5.2Antibiotic Prophylaxis

Large scale, randomized studies examining the role of antibiotic prophylaxis in organ transplant patients undergoing dermatologic surgery do not currently exist, so consensus statements have been developed to help guide the Mohs surgeon in choosing when prophylaxis is required. The statements are to be used as guidelines but may not apply to all situations.

Although immunocompromised patients have an increased incidence of many skin and systemic infections, they are not considered at extremely high risk for surgical site infections, and prophylaxis is not routinely indicated when performing cryotherapy or electrodessication and curettage. For larger procedures, such as excision or Mohs surgery, surgical site prophylaxis should be considered utilizing the same criteria as in nonimmunosuppressed population.

Organ transplantation does not routinely require preoperative antibiotics to prevent graft infection with cutaneous procedures. The American Heart Association does recommend prophylaxis when dermatologic surgery is performed on cardiac transplant patients with valvulopathy, if performed on infected

9.5.1Preoperative Evaluation

The preoperative evaluation is an important screening tool for the dermatologic surgeon when evaluating prospective surgical candidates and is especially

mendations for prophylactic antibiotics parallel use in the immunocompetent population and SOTR and HIV patients are also advised to have prophylactic antibiotics if they have had joint replacement in the past 2 years in order to minimize the risk of hematogenous joint infection [64].