What are the recommendations for tetanus (Td or Tdap) vaccination prior to Mohs surgery?

Tetanus Vaccination Recommendations for Mohs Surgery

Tetanus vaccination is not routinely required prior to Mohs surgery unless the patient has not received a tetanus booster within the past 10 years for clean minor wounds or within 5 years for contaminated wounds.

Wound Classification and Tetanus Risk

Mohs micrographic surgery creates clean, surgical wounds with an extremely low infection rate (0.7% overall) 1. These wounds are typically considered "clean, minor wounds" in the context of tetanus prophylaxis guidelines.

Tetanus Vaccination Guidelines Based on Wound Type:

• Clean, minor wounds (including typical Mohs surgery wounds):

  • Tetanus booster needed only if >10 years since last dose 2, 3
  • No Tetanus Immune Globulin (TIG) needed

• Contaminated wounds (dirt, feces, soil, saliva; puncture wounds; avulsions; crushing injuries):

  • Tetanus booster needed if >5 years since last dose 2, 3
  • TIG may be needed for patients with unknown/incomplete vaccination history

Vaccination Decision Algorithm

1. Determine patient's tetanus vaccination status:

   • Complete primary series (3+ doses) with documentation
   • Incomplete/unknown vaccination history

2. For patients with complete primary vaccination series:

   • If last tetanus vaccination was <10 years ago: No tetanus booster needed for Mohs surgery 2, 3, 4
   • If last tetanus vaccination was >10 years ago: Administer tetanus booster (Td or Tdap) 2

3. For patients with incomplete/unknown vaccination history:

   • Administer tetanus toxoid-containing vaccine (Tdap preferred for those who have not previously received it) 2
   • Consider completing the full primary series (3 doses total) after recovery 2

Vaccine Selection

• For patients aged ≥11 years who have never received Tdap: Use Tdap (preferred) 2
• For patients who have previously received Tdap: Use Td 2
• For pregnant women: Tdap is preferred regardless of prior Tdap history 2

Important Considerations

• Tetanus vaccination administered at the time of injury/surgery provides protection for future wounds, not the current wound 5
• The risk of infection following Mohs surgery is extremely low (0.7%), with most infections occurring on the nose (1.7%) and after flap reconstruction (2.4%) 1
• There is no urgency for tetanus toxoid administration in the acute setting of clean surgical procedures 5

Contraindications and Precautions

• Contraindications for Tdap/Td include:

  • History of serious allergic reaction to any vaccine component 2
  • History of encephalopathy within 7 days of previous pertussis vaccination (for Tdap only) 2

• Precautions/Deferrals:

  • Moderate or severe acute illness 2
  • History of Guillain-Barré syndrome within 6 weeks of previous tetanus vaccination 2
  • History of Arthus reaction to previous tetanus or diphtheria toxoid-containing vaccine (defer for at least 10 years) 2

Common Pitfalls to Avoid

1. Unnecessary vaccination: Administering tetanus boosters too frequently can increase the risk of adverse reactions, including Arthus reactions 2, 6

2. Failure to document: Ensure proper documentation of tetanus vaccination to prevent unnecessary future doses 2

3. Overestimating infection risk: Mohs surgery has an extremely low infection rate (0.7%), making routine antibiotic or tetanus prophylaxis unnecessary in most cases 1

4. Underestimating the importance of vaccination status assessment: Always attempt to determine the patient's complete vaccination history rather than just the time since last dose 2