Perioperative management of and recommendations for antithrombotic medications in dermatological surgery

With the ever-increasing number of patients on anticoagulant or antiplatelet medications presenting for a dermatological surgical procedure, dermatological surgeons are facing the challenge of managing these drugs in order to balance the bleeding complications against the risk of thromboembolic events. The difficulty arises from the scarce available recommendations, the data in the literature that is in part contradictory and the rate of emergence of newer agents that have not been thoroughly studied and widely used. Although the common approach in the past was to stop any antithrombotic medications, including warfarin and aspirin, several days prior to cutaneous surgery, recent data suggest that this practice should be changed as the relatively low risk of bleeding does not justify the life-threatening nature of a likely thrombosis. For patients on warfarin, surgery should be avoided if the international normalized ratio is > 3·5; aspirin should not be stopped prior to dermatological surgery and in most other circumstances patients taking long-term antithrombotic medication should not stop this prior to dermatological surgery. In more complicated cases liaison with the prescriber is indispensable even when the therapy should be discontinued for a short period of time. This review studies the available data and presents the dermatological surgeon with up-to-date information about all studies concerning the old and new antithrombotic agents in the setting of dermatological surgery procedures. Our aim is to propose our recommendations based on the most recent evidence and our experience and provide a comprehensive approach to the dermatological surgeon without excluding the need for individual assessment of each case.