In patients on anticoagulant treatment (ACT), anticoagulation should not be discontinued if preoperative HR is low (provided the ACT is not above the target therapeutic range).18,19 This applies to all procedures performed immediately in outpatient consultation settings and, to a variable extent, also to some procedures scheduled for the operating room. In cases of moderate-to-high HR, discontinuation of ACT should be considered. In such circumstances, the duration of discontinuation and the need for bridging therapy will depend on the anticoagulant drug and the TER. In patients on direct oral anticoagulants (DOACs), it may even be decided not to discontinue the drug; however, if interruption is necessary, it should be performed according to creatinine clearance (CrCl), without the need for monitoring or bridging therapy.7,9,10,19 Conversely, patients on classic vitamin K antagonist (VKA) anticoagulants should discontinue the drug according to their INR (Table 3).10,25 The need for bridging therapy in patients on VKAs should be restricted to those with high TER (Table 2).6,7,9,11,19 Reintroduction of anticoagulation, in cases of adequate hemostasis and low postoperative bleeding risk, should occur 8h after surgery in the case of DOACs or 24h after surgery in the case of VKAs, although this should be delayed until 48–72h in cases of incomplete hemostasis or high bleeding risk.9,16,17

When bridging therapy has been initiated due to persistent high TER in patients chronically treated with VKAs, this should be performed using low-molecular-weight heparin (LMWH) or, alternatively, unfractionated heparin (UFH) in patients with CrCl<30mL/min. It should be initiated 36–48h after the last anticoagulant dose—once the INR has fallen below the patient's target threshold (usually between 2 and 3.5 depending on the underlying condition indicating anticoagulation). Heparin should be administered, adjusted according to body weight and CrCl, at prophylactic doses if ACT is indicated for primary or secondary prevention, but at therapeutic doses if the patient's regular ACT is considered active treatment and surgery cannot be delayed until its completion (Table 4). Whenever possible, if the patient's usual ACT is therapeutic rather than preventive due to one of the high-TER scenarios (Table 2), surgery should be postponed if the TER is transient, depending on the urgency of the dermatologic intervention. The last dose of heparin used as bridging therapy should be administered 4–6h before surgery in the case of UFH, 12h before surgery if LMWH is administered at prophylactic doses (usually every 24h), or 24h before surgery if LMWH is administered at therapeutic doses (every 12 or 24h). These intervals may, depending on the case, be doubled if CrCl<30mL/min.23,26 If monitoring is required, LMWH should be monitored using activated anti-factor Xa levels, whereas UFH is monitored using activated partial thromboplastin time (aPTT).23,27,28 Protamine sulfate is the antidote for both types of heparin, although it is more effective in the case of UFH.29,30 After surgery, heparin administration should be resumed using the same regimen as before surgery once 12h have passed after the procedure, overlapping with the patient's regular VKA treatment starting at 24h or 48–72h depending on postoperative bleeding risk, as previously established.31 Both treatments should be administered concomitantly until the target INR is reached on subsequent monitoring, at which point heparin may be discontinued.

For patients on antiplatelet therapy, it is necessary to distinguish whether the prescription is for primary or secondary prevention. In cases of primary prevention, the antiplatelet agent may be discontinued and resumed up to 1 week after surgery. As in the case of anticoagulants, this will not be necessary for most routinely performed minor procedures, but it should be considered in patients whose surgery will be performed as MAS or in the operating room under sedation or general anesthesia.

If administration is for secondary prevention, treatment with acetylsalicylic acid (ASA) at a dose of 100mg/day should be maintained throughout the perioperative period.16 Higher doses of ASA or other drugs such as thienopyridines and P2Y12 inhibitors (P2Y12i) (clopidogrel, prasugrel, and ticagrelor) should be discontinued in the days prior to surgery and replaced with ASA 100mg/day (Table 3).21–23,25,31 The use of heparin as bridging therapy in cases of antiplatelet discontinuation is not recommended. Only in cases of secondary prevention with moderate or high TER and low HR may continuation of P2Y12i therapy be considered.16,18 Similarly, in cases of dual antiplatelet therapy during early secondary prevention of cerebrovascular and cardiovascular events, the possibility of postponing surgery until the critical risk period has passed should be evaluated (e.g., 6 weeks after implantation of a bare-metal stent or 6 months after placement of a drug-eluting stent) due to the increased HR associated with dual therapy. If dermatologic surgery cannot be postponed or TER is not transient, it is recommended to assess HR and maintain both antiplatelet agents only in cases of low HR, while considering changes to the antiplatelet regimen in other cases (discontinuation of the P2Y12i while maintaining ASA at 100mg/day).6,16,18 After surgery, regular antiplatelet therapy should be resumed 12–24h after surgery in the presence of low postoperative bleeding risk, or 48–72h later if postoperative bleeding risk is high.31

Regarding patient medication, patients on simultaneous anticoagulant and antiplatelet therapy have a higher bleeding risk. They should be independently evaluated for each medication according to the recommendations previously described. In any case, if continuation of both therapies is decided (e.g., ASA and VKA), INR should be confirmed to be <3.5 in the days prior to surgery.16 Anticoagulant drugs that potentiate antithrombin III (UFH, LMWH, heparinoids such as danaparoid, and oligosaccharides such as fondaparinux) are rare as chronic drugs in patients undergoing dermatologic surgery. In the case of UFH and LMWH, they are more frequently used as bridging therapy in patients on VKAs. In cases of primary treatment with any of these agents, it is important to consider their necessity and potential impact if emergency surgery is required, as they are generally prescribed transiently and may eventually transition permanently to VKAs. A similar situation applies to intravenous thrombin inhibitors such as bivalirudin and lepirudin. Less commonly used antiplatelet agents acting through the ADP pathway, including phosphodiesterase inhibitors (dipyridamole), thienopyridines (ticlopidine), and glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide), also require special precautions and should be individually evaluated together with the prescribing physician. Bruton tyrosine kinase inhibitors (BTKi) such as ibrutinib and acalabrutinib, used for chronic hematologic disorders including chronic lymphocytic leukemia, have been associated with bleeding episodes following dermatologic surgery. Any decision regarding temporary discontinuation of these inhibitors should be made jointly with the prescribing physician, particularly because prolonged interruption of these medications may result in progression of the underlying disease.16 Finally, several dietary supplements have been associated with increased bleeding risk, including vitamin E, fish oil, feverfew, garlic, ginger, ginkgo, ginseng, and glucosamine. Discontinuation of supplements associated with increased bleeding risk before surgery may be considered.16

Similarly, comorbidities such as hypertension (HTN) may condition increased HR and hinder adequate intra- and postoperative hemostasis. Proper control of HTN before and during surgery is necessary, and numerous pharmacologic alternatives exist that should be individualized according to the patient's comorbidities and the urgency of blood pressure control depending on hemodynamic stability.32–34

Regarding surgical characteristics, although every procedure is unique, in surgical procedures with high HR and risk of postoperative hematoma formation, placement of a capillary drain (Penrose) or vacuum drain (Redon) may be considered (e.g., surgical procedures involving extensive undermining or generating spaces that cannot be completely obliterated). Similarly, compressive dressing of the operated area plays an essential role in controlling postoperative bleeding risk or hematoma formation. This is routinely recommended in most dermatologic surgeries, although there are anatomical areas that are more difficult to compress (folds, abdomen, etc.) and therefore carry higher postoperative risk.35–37 Finally, factors such as potential complications during the procedure, type of anesthesia used (with or without vasoconstrictor), and type of hemostasis performed (e.g., ligation or electrocautery) should be considered when assessing postoperative bleeding risk.