A two-part continuing education review synthesises the evidence on perioperative antibiotics for excisional dermatological surgery — standard excisions, Mohs micrographic surgery and the reconstructive techniques that follow. Its starting point is that these are clean procedures with a low baseline infection rate, and its conclusion is a risk-stratified approach rather than a routine.

The practical content is mostly subtractive. Systemic prophylaxis is not indicated for routine dermatological procedures. Topical antibiotics are not required on clean wounds, where plain petrolatum is described as safe and effective — which makes the reflex prescription of a topical antibiotic ointment after an excision an avoidable contribution to resistance and to contact sensitisation. Where risk genuinely is raised, the review sets out that decisions should turn on procedural, anatomical and patient factors together, names prosthetic joints, high-risk cardiac conditions and immunosuppression including transplant recipients as the populations needing specific consideration, and identifies localised intra-incisional antibiotics as an alternative to an oral course in higher-risk cases.

It does not follow that a patient with a prosthetic joint or a replaced valve automatically receives prophylaxis for a skin excision — the review's own framing is risk-stratified, and the current cardiology and orthopaedic guidance on prophylaxis for cutaneous procedures has not changed. Check the specific recommendation for the specific patient rather than defaulting either way.

In India the default runs the other way: a post-excision oral antibiotic course and a topical antibiotic are close to routine in many settings, and antimicrobial stewardship pressure is greater here than almost anywhere. This is the desk's clearest opportunity to stop doing something.

Do not prescribe systemic prophylaxis for a routine clean excision or Mohs procedure
Use plain petrolatum rather than a topical antibiotic on a clean surgical wound
Stratify by procedure, anatomical site and patient factors together — no single factor decides it
Identify prosthetic joints, high-risk cardiac conditions and immunosuppression as the situations needing a specific decision, not an automatic prescription
Consider intra-incisional antibiotic as an alternative to an oral course where risk genuinely is raised

Why it matters

The post-excision antibiotic is one of the commonest prescriptions in dermatology and one of the least often indicated.

Don't overread it

This is a review of existing guidance rather than new evidence, and it does not change what cardiology or orthopaedic guidance says for any individual patient.