Ideal Dressing for STSG Donor Site – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

In the 2009 review (2nd reference below),  Voineskos and colleagues did a literature review of skin graft donor-site dressings.  They noted that although there is no clear evidence that moist dressings are any better overall when compared with dry dressings,  there is evidence that moist dressings tend to be less painful than dry dressings.

Donor sites take an average of 7 to 21 days to heal, depending on their size, location, and the patient's health status. 

This latest study (first article referenced below) compared Aquacel and a modified (perforated) polyurethane dressing modified (MPD).  The study is a prospective randomized double-blind clinical trial which included 50 adult patients. 
The authors state (bold emphasis is mine):

The ideal dressing should protect the wound from desiccation and at the same time permit gas exchange to accelerate reepithelialization. It should be impermeable to exogenous microorganisms, comfortable for the patient and the ward staff and associated with only minimal labor input. Moreover, the dressing should be flexible and pliable to permit conformation to irregular wound surfaces. Resistance to linear and shear stress are required as well as good tensile strength to resist fragmentation and retention of membrane fragments when removed. It should, furthermore, be adaptable to the varying dimensions of donor sites and, in spite of everything; it should also be of low cost. Existing dressing materials meet some of these criteria but fail to fulfill all of them, especially in larger donor sites.

Dornseifer and colleagues had previously (4th reference) noted that the “single disadvantage of polyurethane film dressings is an uncontrolled leakage” which they solved by modifying it by perforating the polyurethane film.  This  permits a controlled leakage into a secondary absorbent dressing.

They chose to compare this MPD to Aquacel ® (ConvaTec, Skillman, NJ, USA), a sodium carboxy-methylcellulose hydrocolloid polymer that is claimed to have a high fluid-absorptive capacity and was also described to be a new preferred donor site dressing. (5th reference)

Half of the skin graft donor sites were dressed with an application of Aquacel(R) and half with MPD.  The dressings were kept unchanged for ten days at which time they were removed and the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day, as well as during dressing removal.

In this small study, MPD was found to best Aquacel ®.  More MPD donor sites completely reepithelialized by 10 days than the Aquacel ® sites (86.4% vs 54.5%).

MPD was significantly less painful until and during removal of the dressing (p < 0.001).

Pain at the donor site during the postoperative period was consistently low after wound coverage with both materials, considering that 90% of the values assessed by the six-items pain scale were equal to or less than 1 (minimal intermittent pain) at both sites.
However, when patients were asked to compare both sites, a significantly higher percentage of MPD sites were rated superior to the Aquacel® sites

Dornseifer and colleagues note the costs of the Aquacel® dressing turned out to be about four times more expensive, relating to a donor site of 8 x 20 cm2 and depending on the
respective price level.

Scarring was inconspicuous in both groups 60 days following surgery and no significant differences were detected between the MPD and Aquacel® treated donor sites.

REFERENCES

1.  The ideal split-thickness skin graft donor site dressing: a clinical comparative trial of a modified polyurethane dressing and Aquacel(R); Dornseifer, Ulf; Lonic, Daniel; Ivo Gerstung, Tristan; Herter, Frank; Max Fichter, Andreas; Holm, Charlotte; Schuster, Tibor; Ninkovic, Milomir; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 June 2011; doi: 10.1097/PRS.0b013e3182268c02

2.  Systematic Review of Skin Graft Donor-Site Dressings; Voineskos, Sophocles H.; Ayeni, Olubimpe A.; McKnight, Leslie; Thoma, Achilleas; Plastic & Reconstructive Surgery. 124(1):298-306, July 2009; doi: 10.1097/PRS.0b013e3181a8072f

3.  The theoretically ideal donor site; Birdsell, D. C., Hein, K. S., Lindsay, R. L.; dressing. Ann Plast Surg 2: 535-537, 1979.

4.   The ideal split-thickness skin graft donor site dressing: rediscovery of polyurethane film;  Dornseifer, U., Fichter, A. M., Herter, F., et al.; Ann Plast Surg 63: 198-200, 2009.

5.  Clinical comparative study of aquacel and paraffin gauze dressing for split-skin donor site treatment; Barnea, Y., Amir, A., Leshem, D., et al.;   Ann Plast Surg 53: 132-136, 2004.

Does Negative Pressure Promote Wound Healing? -- article review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

There was a recent EurekAlert which caught my attention:  No healing in a vacuum. 

Negative-pressure wound therapy probably does not promote healing. This is the conclusion of Frank Peinemann and Stefan Sauerland's meta-analysis in the current edition of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[22]: 381-9).

The press release actually contained a link to a pdf file of the article (full reference and link below).

Negative-pressure wound therapy (NPWT), also known as vacuum assisted closure,  involves covering the wound with an an airtight film and an adjustable negative pressure is applied using an electronically controlled pump.  The vacuum or negative pressure drains wound exudate.   NPWT is used for chronic persistent wounds and complicated wounds.

The article by Peinemann and Sauerland is a systematic review of the literature (English and German), aimed at  evaluating wound healing and adverse events following NPWT in comparison to conventional treatment in patients with acute or chronic wounds.  From the beginning summary:

We found reports of 9 RCTs in addition to the 12 covered by earlier IQWiG reviews of this topic. Five of the 9 new trials involved NPWT systems that are not on the market. The frequency of complete wound closure is stated in only 5 of the 9 new reports; a statistically significant effect in favor of NPWT was found in only two trials.The results of 8 of the 9 new trials are hard to interpret, both because of apparent bias and because diverse types of wounds were treated.

Data analysis used complete wound closure as the primary endpoint.  This was based on the U.S. Food and Drug Administration’s (FDA) 2006 Guidance for Industry definition for complete wound closure as “skin closure without drainage or dressing requirements.”

The following dependent variables were used as secondary endpoints:
● Adverse events, such as death, secondary amputations, fistula formation, and wound infection
● Time to complete wound closure
● Reduction in wound size
● Health-related quality of life.

In the discussion section of the article, some key summaries:

Regarding the primary endpoint of “wound closure” – results were not homogenous.  The authors notes it is currently impossible to be sure that NPWT performs better than control treatments.

Regarding the secondary endpoints

– Most articles reported “time to wound closure”  occurred quicker in NPWT groups.  The authors note “However, there were considerable differences between trials in terms of the methods used to measure and evaluate wound closure; particularly problematic is the fact that no blinding was used when this endpoint was measured.”  So for now, as with the  primary endpoint, it remains undecided.

--  The results on adverse events were not homogenous and varied depending on the specific complications.   For a number of other adverse events no statistically significant difference was detected.

The authors note that most trials of NPWT were conducted in hospitals.  They make this point in regard to the FDA report (3rd reference below):

The FDA recently issued a report on six deaths and 77 other complications that were reported within a two year period in connection with NPWT . All the deaths were caused by acute hemorrhages, and known contraindications for NPWT (e.g. a large blood vessel
exposed) had clearly been overlooked. Many of the deaths occurred in outpatient care or care homes, which highlights the need to monitor therapy.

The authors conclusion:

Although NPWT may have a positive effect on wound
healing, there is no proof that it is either superior or inferior to conventional wound treatment. Further RCTs of good methodological quality are required.

REFERENCES

Peinemann F, Sauerland S: Negative pressure wound therapy—systematic review of randomized controlled trials; Dtsch Arztebl Int 2011; 108(22): 381–9; DOI: 10.3238/arztebl.2011.0381

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds (Last updated: May 2001)

FDA: Serious complications associated with negative pressure; 2009 (last updated 02/24/2011)

Caring for Horse and Donkey Bite Wounds

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active.

Earlier this week this tweet from @prsjournal caught my eye

Most Popular: Management of Horse and Donkey Bite Wounds: A Series of 24 Cases: No abstract available http://bit.ly/lgNkCS

I missed this article when it came out in the June 2010 issue of the Plastic and Reconstructive Surgery Journal.  As I have covered fire ant bites, cat bites, and snake bites.  Fellow blogger Bongi has written about hippo bites.  It’s time to cover horse and donkey bites. 

Dr. Köse, Department of Plastic and Reconstructive Surgery, Harran University Hospital, Turkey and colleagues presented a retrospective evaluation of 24 patients treated for animal bites (19 horse and five donkey bites) from 2003 to 2009.  The head and neck were the most frequent bite sites (14 cases), followed by the extremities (8 cases) and the trunk (2 cases).

The article is very short, representing their personal viewpoint and experience. 

Our experience shows the safety of primary closure for horse and donkey bite wounds, provided that careful debridement and good cleansing with antibiotic prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary repair and reconstructive procedures.

Dr. Köse note that horse and donkey bites often result in tissue loss wounds.  Their review of the literature (not sure how extensive) found one reported case of anaphylaxis after a horse bite and one case of a deep crush injury with hematoma, fat necrosis, and muscle rupture without an external wound in a woman bitten on her thigh by a horse.

As I shared in my post Assessing and Managing Mammal Bites – an Article Review

• Thoroughly examine patients with bites.  Especially with children, check the entire body to identify additional injuries.
  
• Examine the wound itself meticulously. It’s easy to miss things.
• Be alert for injuries to the vasculature, nerves, tendons, bones, and joints.
• Bites from large mammals can damage and even fracture bone.  Plain radiographs should be viewed after the exam.
• Large mammals who bite and shake can dislocate joints. Have patients perform active range-of-motion with joints that are near bite wounds.
• Use plain radiography to assess for retained foreign bodies and skeletal injuries. Computed tomography and magnetic resonance imaging have increased sensitivity for foreign bodies and subtle fractures.

As with all wounds, standard wound care applies.  This means copiously irrigate and debride as needed.  Bites are tetanus-prone wounds. Review the patient’s immunization records.  Give updates, etc as needed.

REFERENCE

Management of Horse and Donkey Bite Wounds: A Series of 24 Cases; Köse, Rüstü; Sögüt, Özgür; Mordeniz, Cengiz; Plastic & Reconstructive Surgery. 125(6):251e-252e, June 2010; doi: 10.1097/PRS.0b013e3181d515dd

Topical Treatment of Hypertensive Leg Ulcers – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

An interesting little article in the April issue of the Archives of Dermatology (full reference below) by Senet and colleagues on the treatment of hypertensive leg ulcers with platelet-derived growth factor-BB.  Interesting, in that, it reported a negative outcome or lack of superiority for one treatment over another.

First, what is a hypertensive leg ulcer (HLR)?

According to the Graves and colleagues (second article referenced below), Martorell, a Spanish cardiologist (1906-1984) first noticed the relationship between hypertension and alterations in arterioles and leg ulcers in 1945.  Martorell called these ulcers hypertonic or hypertensive ulcers of the legs and published the first 4 cases. 

Originally, Martorell described the following diagnostic criteria:

a) Ulcer located anterolaterally on the lower legs,

b) arterial diastolic hypertension of the lower legs,

c) hyperpulsatility of the arteries of the lower legs,

d) absence of arterial calcification,

e) absence of CVI (chronic venous insufficiency),

f) symmetric lesions (either ulceration at the same time or as a result of previous ulceration of the opposite leg),

g) increased pain in horizontal position, and

h) female sex.

Graves also noted that soon after Martorell reported his 4 cases, 11 other cases were published by Hines and Farber confirming the existence of these ulcers -- thus, the ulcer is also called the "hypertensive ulcer of Hines-Farber."

Senet and colleagues note, “Hypertensive leg ulcers (HLUs), first described in the 1940s, were renamed Martorell HLUs or necrotic angiodermatitis by American and European dermatologists.”

So HLU’s are also known as “hypertensive ulcer of Hines-Farber” and as necrotic angiodermatititis.

……

Whatever it is called, HLR’s are extremely painful, superficial, rapidly spreading, necrotic wounds on the dorsolateral part of the leg which have red purpuric margins.  The pathophysiologic characteristics of HLUs include dermal and subdermal vessel arteriosclerosis, inappropriate local vasoconstriction, but no significant involvement of the large deeper vessels.

Senet and colleagues note the medical management of HLU is currently symptomatic: controlling hypertension and diabetes, wound debridement, and application of the usual dressings.  Surgical management is often skin grafts.

Senet and colleagues conduced a multicenter, randomized controlled trial from March 2004 to June 2009 to determine the effect of topical becaplermin gel on HLU healing.

Eligible participants (n=59) were randomly assigned to receive either topical becaplermin gel-BB, 0.01% (Regranex gel) or hydrogel (Duoderm Hydrogel).

For both groups, treatment began 1 week after randomization, during the second visit (week 0), and all patients received the same daily local care: wound irrigation with normal saline, application of a continuous thin layer of gel on the wound, covering with a moist saline gauze and a bandage.

Each reference wound surface was estimated on treatment day 1 by measuring wound length and width to determine the appropriate becaplermin gel or hydrogel volume to apply that was maintained throughout the study [a single 15-g tube is enough to treat a 5-cm² wound for 6 weeks (1 cm of gel/cm²/d)].

The patient or his/her caregiver was instructed on proper wound care, gel application, and wound dressing, which was continued until complete healing or for a maximum of 8 weeks.   All patients were observed through week 12.

Topical becaplermin, compared with hydrogel dressing, did not improve the complete wound closure rate (primary outcome measure) after treatment week 8 and had no significant effect on quality of life, pain, or median wound area.

Complete wound closure rates for becaplermin and hydrogel, respectively, were 18% (5 of 28 patients) and 10% (3 of 31 patients), respectively, at week 8 (an 8 percentage-point difference; 95% confidence interval [CI], –10.3 to 26.0) and 36% (10 of 28 patients) and 26% (8 of 31 patients) at week 12 (10 percentage-point difference; 95% CI, –13.6 to 33.4).

REFERENCES

1.  Topical Treatment of Hypertensive Leg Ulcers With Platelet-Derived Growth Factor-BB: A Randomized Controlled Trial; Patricia Senet; Eric Vicaut; Nathalie Beneton; Clelia Debure; Catherine Lok; Olivier Chosidow; Arch Dermatol. 2011;0(2011):archdermatol.2011.84. 

2.  Martorell Hypertensive Leg Ulcer:  Case Report and Concise Review of the Literature; Graves JW, Morris JC, Sheps SG. J Human Hypertension. 2001;15:279-283. (pdf file)

3.  Las ulcers supramalleolares por arteriolitis de las grandes hipertensas; Martorell F.;  Actas del Instituto Policlinico de Barcelona. 1945;1:6-9. (not read by me)

4.  Ulcer of the leg due to arteriosclerosis and ischemia occurring in the presence of hypertensive disease; Hines EA Jr, Farber EM.; Mayo Clin Proc. 1946;21:337-346.  (not read by me)

Reimbursement for Surgical Dressings

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

I opted out of Medicare many years ago, so I could skip articles like the one referenced below.  I don’t.  

Kathleen Schaum writes a very informative article on the ins & outs of reimbursement for surgical dressings.  She gives a self-test to help you and your team assess your knowledge:

….If you pass the LCD/Article self-test, congratulate yourself for a job well done. If you do not pass the self-test, you should immediately take steps to become compliant. Let's start the self-test now.

* Do you know how to find the LCD for Surgical Dressings and the Surgical Dressing Policy Article that is pertinent to the geography that you serve?

If yes, have you printed both documents, read them, and shared them with your entire wound care team? If no, the Web sites in Table 1 will connect you with each of the DME MACs' LCDs and Articles. Remember that your wound care patients are counting on you to understand and implement a process that will meet all the LCD/Article guidelines.

* Can you correctly answer these frequently asked questions?

Unfortunately, the LCD for Surgical Dressings and its attached Article have been either forgotten by or not introduced to some modern-day wound care professionals. ……...

Q: Why do medical suppliers tell my patients with skin tears that Medicare does not cover the dressings that I order?

A. Wound dressings are covered by Medicare when they are used on a surgical wound, partial-, or full-thickness skin wound, or partial- or full-thickness burn. Dressings are not covered for skin tears, abrasions, Stage I ulcers, first-degree burns, or cutaneous fistulas unrelated to a surgical procedure.

…….

The helpful web sites given in Table 1 of the article:
CIGNA Government Services (CIGNA) – http://www.cignagovernmentservices.com
National Government Services (NGS) – http://www.ngsservices.com
National Heritage Insurance company (NHIC) – http://www.medicarehic.com
Noridian Administrative Services (Noridian) – https://www.noridianmedicare.com




REFERENCES
Can You Pass the Surgical Dressing Ordering and Documentation Test?; Schaum, Kathleen D.; Advances in Skin & Wound Care. 24(3):112-117, March 2011; doi: 10.1097/01.ASW.0000395044.66516.02

Factitious Disorder?

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Have you ever seen a case of factitious disorder?  Ever had a patient who’s wound just wouldn’t heal in spite of all the good care you gave them, all the blood work you checked (ie nutrition, infection, etc)?  Ever wondered if perhaps this nice patient was doing something to themselves?

This recent case report in the December issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery prompted me to look up the diagnosis of “factitious disorder.”  Here is the abstract summary (full reference below):

This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.

I don’t have access to the full article, but what I found when I looked up factitious disorder makes me wonder
The Cleveland Clinic has a nice overview of factitious disorder aka Ganser Syndrome aka Munchausen Syndrome (bold emphasis is mine).

Factitious disorders are mental disorders in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created his or her symptoms. (The name factitious comes from the Latin word for "artificial.")

People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways.

The Cleveland Clinic website list the possible warning signs of factitious disorders include the following:

• Dramatic but inconsistent medical history
• Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
• Predictable relapses following improvement in the condition
• Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
• Presence of many surgical scars
• Appearance of new or additional symptoms following negative test results
• Presence of symptoms only when the patient is alone or not being observed
• Willingness or eagerness to have medical tests, operations, or other procedures
• History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
• Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care provider

I’ll pick on myself here.  In fact that is exactly why a small area in my left eyebrow has failed to heal as quickly as it should.  I keep picking at it, picking off the scab before it’s ready to fall off.  I don’t do it to create or exaggerate the problem.  It’s a nervous tick.  I’ve always been a scab picker (and, yes, I tell my patients not to pick at theirs).  It’s a trait that comes in handy as a surgeon who gets to debride wounds.

Don’t forget that some patients are simply like me.  Don’t forget that some may have a issue like this (Trigeminal Trophic Syndrome).  All these other possibilities must be ruled out before giving the patient the diagnosis of factitious disorder.

REFERENCE

Factitious Disorder as a differential diagnosis for recurrent skin graft failure; D.M. Seoighe, M. Dempsey, C. Lawlor, A.M. O’Dwyer;  
Journal of Plastic, Reconstructive & Aesthetic Surgery - 27 December 2010 (10.1016/j.bjps.2010.11.004)

Factitious Disorder; eMedicine Article, October 22, 2009; Todd S Elwyn, MD and Iqbal Ahmed, MBBS

Foreign Bodies in the Skin

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I recently read a nice review article on the topic:  Diagnosis and Management of Foreign Bodies in the Skin.   Most humans at one time or another will have an experience with a foreign body – splinters, thorns, broken glass, etc.

Physicians see the worst ones.  The ones that aren’t easily removed or only partially removed.

The history of the injury is always the starting place.   It is important to know when (recent, days or weeks ago), where (home, farmyard, ocean, etc), how (sharp object, fist to mouth, blunt object), and if known the possible foreign body (splinter, fish spine, teeth, glass).

Remember fragments of the foreign body can be left in the wound even if you or the patient think it was removed.  Check to make sure the “needle” is complete, etc.

It is also important to remember with blunt penetration other materials may be embedded along with the offending agent.

If a nail penetrates both the shoe and the sock, it may also force leather, rubber, or sock material into the foot. A blunt object may push a plug of epidermis deep into the dermis. This traumatic implantation results in an epidermal inclusion cyst.

When assessing the patient remember 4 P's: pain, pulselessness, paresthesia, and pallor.

Pain to palpation over an embedded foreign body can help you locate it, especially when located under the skin but above the muscle layer as is the focus of this article.

Pulselessness and pallor can indicate a vascular injury.  Paresthesia can indicate a nerve injury.

The article has a nice section on radiologic evaluation of foreign bodies under the skin which can be very important in localization of the object.  Especially important when it’s an old injury with healed skin (visualization impossible), infected wound (patient won’t allow adequate palpation exam), foreign body deeper than 5 mm, etc.

Diagnostic tests used to determine the location of a foreign body in the skin, include x-ray, computed tomography (CT) scan, ultrasonography, and magnetic resonance imaging (MRI).

X-ray -- A plain film should be ordered first if a suspected foreign body is not visible to the eye during the initial exam.

Metal, aluminum, bone, some types of fish spines, teeth, graphite (from pencils), some types of plastics, glass, gravel, stone, wood, and sand are visible on plain x-ray.

Multiple projections can also be used to help estimate the location of the foreign body after placement of radiopaque skin markers, such as paper clips, on the skin at the wound site.

CT Scan may be more sensitive than plain-film x-ray, but they also cost more and have an increased radiation dose. 
Ultrasonography  is a great tool to use to locate foreign bodies made of wood, plastic, and radiolucent materials that are larger than 4 to 5 mm.

Ultrasonography has a sensitivity of 50% to 90% and may be used to estimate the depth and size of a foreign body, as well as determine its relationship to surrounding anatomic structures.

Magnetic Resonance Imaging  should not be used on foreign bodies suspected to be gravel or metal-containing.  As with CT scans, this choice can be more expensive and has a higher radiation dose than plain x-rays.

One of, if not the most important thing, to remember in removing foreign bodies is to inspect the removed object and try to assess whether is has been removed entirely rather than leaving part of it.

Otherwise, it’s good basic wound care – clean, irrigate, closure, tetanus status, antibiotics or not, etc.

REFERENCES
Diagnosis and Management of Foreign Bodies in the Skin; Winland-Brown, Jill E., Allen, Sandra; Advances in Skin & Wound Care. 23(10):471-476, October 2010; doi:  10.1097/01.ASW.0000383220.72147.e2

Pyoderma Gangrenosum of the Breast

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I was prompted to delve into this topic not because I had a patient with the problem, but because of a MDLink to an article (the first one listed below, subscription required). 

The eMedicine article states:

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition of uncertain etiology. Pyoderma gangrenosum was first described in 1930. It is associated with systemic diseases in at least 50% of patients who are affected. The diagnosis is made by excluding other causes of similar appearing cutaneous ulcerations, including infection, malignancy, vasculitis, collagen vascular diseases, diabetes, and trauma. Ulcerations of pyoderma gangrenosum may occur after trauma or injury to the skin in 30% of patients; this process is termed pathergy.

The 2 primary variants of pyoderma gangrenosum are the classic ulcerative form, usually observed on the legs, and a more superficial variant known as atypical pyoderma gangrenosum that tends to occur on the hands.

Pyoderma gangrenosum (PG) is not common.   It occurs in about 1 person per 100,000 people each year in the United States.   Basically, PG is a noninfectious neutrophilic dermatosis.

Patients with PG may have involvement of other organ system, most commonly the heart, the central nervous system, the GI tract, the eyes, the liver, the spleen, bones, and lymph nodes.

It is characterized by the presence of 1 or more ulcerations that are typically violaceous with an undermined border. Diagnosis is clinical and dependent on the exclusion of other causes of cutaneous ulceration. No specific pathologic or laboratory findings exist. Concurrent systemic disease occurs in 50% of affected patients. Commonly associated conditions include inflammatory bowel disease, arthritis, and hematologic malignancy. The remaining cases are considered autoimmune or idiopathic

The 5th reference article is open access.   The article is a case presentation of PG localized on the breast (photo credit) in a 51-year-old woman who presented with a large, moderately painful ulceration on her right breast which began 12 days prior to presentation with no history of  injury or trauma. 

Along with the case presentation, the authors notes that in a literature review only 31 cases of PG had been reported (article published in (January 2010).

In most of these cases the lesions were related to previous surgical interventions, probably as the result of a pathergy phenomenon. The main differential diagnoses were skin and soft tissue infections including necrotizing fasciitis, and malignant neoplasms. Negative initial wound cultures and the relative sparing of nipple/areola complex helped to eliminate these disorders.

PG doesn’t respond to antibiotic therapy or the usual wound care.  This is a often the first tipoff.  The recommended therapy involves steroids not antibiotics.

Topical therapies include gentle local wound care and dressings, superpotent topical corticosteroids, cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid. The new topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients.

Systemic therapies include corticosteroids, cyclosporine,  mycophenolate mofetil, azathioprine,  dapsone, tacrolimus, cyclophosphamide, chlorambucil, thalidomide, tumor necrosis factor-alpha (TNF-alpha) inhibitors, and nicotine.

Intravenous therapies include pulsed methylprednisolone, pulsed cyclophosphamide, infliximab,  and intravenous immune globulin.

Other therapy includes hyperbaric oxygen.

Surgery should be avoided, if possible, because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement. In some patients, grafting has resulted in the development of pyoderma gangrenosum at the harvest site. In the cases in which surgery is required, the best plan, if possible, is to have the patient on therapy in order to prevent pathergy.

REFERENCES

1.  Pyoderma gangrenosum of the breast: A diagnosis not to be missed; A. Duval, N. Boissel, J.M. Servant, C. Santini, A. Petit, M.D. Vignon-Pennamen; Journal of Plastic, Reconstructive & Aesthetic Surgery - 20 September 2010 (10.1016/j.bjps.2010.07.022)

2.  Pyoderma Gangrenosum; eMedicine article, March 23, 2010; J Mark Jackson, MD, Jeffrey P Callen, MD

3.  Pyoderma gangrenosum; Orphanet Encyclopedia, September 2003; Wollina U.

4.  Atypical Pyoderma Gangrenosum After Breast Reduction;  Karoly Gulyas, FrankW. Kimble; Aesthetic Plastic Surgery Vol 27, No 4, 328-331, DOI: 10.1007/s00266-003-3017-y

5.  Pyoderma gangrenosum on the breast: A case presentation and review of the published work; Ayşe Tülin Mansur, Deniz Balaban,  Fatih GÖKTAY, Sezen Takmaz, The Journal of Dermatology, Special Issue: Systemic Sclerosis (pages 1-84) Volume 37, Issue 1, pages 107–110, January 2010; DOI: 10.1111/j.1346-8138.2009.00756.x

Local Wound Care for Malignant and Palliative Wounds – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Wounds in palliative care patients may be related to their underlying malignancy or to skin breakdown (poor nutrition, advanced age, poor perfusion, etc).  Wounds and associated skin changes that develop in palliative patients are generally considered as nonhealable. 

Therefore, the goal is refocused in an attempt to reduce emotional distress to patients and their families as well as reduction of  local physical wound issues.  The article defines these issues using the mnemonic HOPES:    Hemorrhage, Odor, Pain, Exudate, and Superficial infection.

The article reminds us that malignant wounds (due to cutaneous mets) have been estimated to affect 5% to 19% of patients with metastatic disease.  The chest, breasts, and the head and neck, followed by the abdomen, are the most common sites for these metastatic malignant wounds.

Regardless of the cause, if the wound has been determined to be a non-healable wound, then the goals remain as above—reduce the patients emotional distress and address the “HOPES.”

H: Hemorrhage (or bleeding)
May be due to granulation tissue or to tumor erosion into a blood vessel. 

For minor bleeding, agents such as calcium alginates are readily available as a wound dressing. Calcium, as part of the alginate, is released into the wound in exchange for sodium, potentially triggering the coagulation cascade. The sodium alginate then converts the fiber to a hydrogel, promoting local comfort and protection. In severe cases, suturing a proximal vessel, intravascular embolization, laser treatment, cryotherapy, radiotherapy, and electrical cauterization may be necessary.

O: Odor

Unpleasant odor and putrid discharge are associated with increased bacterial burden, particularly involving anaerobic and certain Gram-negative (eg, Pseudomonas) organisms.  

Topical application of metronidazole is readily available as a gel and cream. ….. Some patients derive the greatest benefit if the metronidazole is administered orally.

Activated charcoal dressing has been used to control odor with some success. To ensure optimal performance of charcoal dressing, edges should be sealed, and the contact layer should be kept dry.

If topical treatment is not successful or practical, putting odor-absorbing agents such as kitty litter or baking soda (not charcoal; only works as a filter) beneath the bed may reduce odor.

P: Pain

Pain is frequently experienced during dressing changes. 

Careful selection of dressings with atraumatic and nonadherent interfaces, such as silicone, has been documented to limit skin damage/trauma with dressing removal and minimize pain at dressing changes.

In addition to the choices of dressing supplies, when possible the frequency of dressings can be reduced.  Gentle technique can also reduce the pain of dressing changes.

For severe pain, clinicians may need to consider oral agents combining long-acting narcotics (oral, patch), as outlined in the World Health Organization Pain Ladder, with adjunctive agents for the neuropathic component and short-acting agents for breakthrough. In resistant cases, clinicians may consider using general anaesthesia, local neural blockade, spinal analgesia, or general anesthesia or using mixed nitrous oxide and oxygen

E: Exudate

Exudation is promoted by inflammation that may be associated with infection. Excessive moisture creates an ideal wound environment for bacteria to proliferate, especially when the host defense is compromised.

Moisture is contraindicated in nonhealable wounds; hydrating gels and moisture-retentive dressings (hydrocolloids) should be avoided. 

To contain and remove excess exudate from the wound, a plethora of absorbent dressings has been developed. Major categories of dressings include foams, alginates, and hydrofibers, along with superabsorbent products based on diaper technology

S:  Superficial infection

All chronic wounds contain bacteria:  contamination or colonization.   Preventing infections is important for palliative care patients.

Debridement is a crucial step to remove devitalized tissue, such as firm eschar or sloughy material, which serves as growth media for bacteria. …….

Topical antimicrobial products are available, but no one product is indicated or suitable for all patients…….

In nonhealable wounds where bacterial burden was more of a concern than tissue toxicity, antiseptics including povidone-iodine, chlorhexidine, and their derivatives are propitious treatment options (Table 5).

Other topical antimicrobial agents are summarized in Table 6. If the infection is promulgated systemically, systemic agents must be administered. Prophylactic use of antibiotics has not been demonstrated to facilitate wound healing.

REFERENCE
Local Wound Care for Malignant and Palliative Wounds; Woo, Kevin Y., Sibbald, R.Gary; Advances in Skin & Wound Care. 23(9):417-428, September 2010

When and How to Perform a Biopsy on a Chronic Wound – an Article Review

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Super nice article on in the March 2010 issue of Advances in Skin & Wound Care (full reference below) on a very important topic. Most of us may know when a biopsy should be done of a chronic wound, but most of us are not trained in how to do one. Different areas of the chronic wound are best biopsied depending on the suspected diagnosis.

The article clearly lists the indications and contraindications for a wound biopsy.

This is probably the most important question for healthcare professionals dealing with wound care. Benefits of biopsy in a wound can be divided into 3 groups that reflect the 3 main causes of wounds in general:
1. to diagnose the etiology of a wound (wound edge),
2. to rule out malignancy (wound edge), and
3. to obtain tissue for bacterial quantitative culture or to identify an infecting organism.

The next question to consider is: Are there any contraindications to wound biopsy?
There are 2 relative contraindications to wound biopsy11:
1. blood dyscrasia with the risk of uncontrollable bleeding
2. venous congestion and extremely vascular wounds (arterial insufficiency) in a setting that access to care is limited or the biopsy wound is unlikely to heal.

There is an extensive table listing the preferred biopsy site for different suspected pathologies. Some of those listed include:

• Basal cell carcinoma (superficial) -- It is best to do a shave or curette biopsy of the rolled margin.
• Basal cell carcinoma (other variants) – It is best to do a deep punch or excisional biopsy of the base or wound edge.
• Squamous cell carcinoma -- It is best to do a punch or excisional biopsy of the deep wound base.
• Pyoderma gangrenosum -- It is best to do a punch or deep wedge biopsy of the wound ulcer border and center. The biopsy should include cultures to rule out infection.
• Vasculitis (large vessel) – It is best to do a deep incisional wedge biopsy of the center of the lesion. DIF (direct immunofluorescence) should be considered.

The article gives clear instructions on how to perform three different types of wound biopsies: shave, punch, and elliptical deep excisional.

I recommend this article to anyone (family physicians, dermatologists, plastic surgeons, etc) who take care of chronic wounds.

REFERENCE

When and How to Perform a Biopsy on a Chronic Wound; Advances in Skin & Wound Care 23(3):132-140, March 2010; Alavi, Afsaneh; Niakosari, Firouzeh; Sibbald, R. Gary; doi: 10.1097/01.ASW.0000363515.09394.66

Peristomal Skin Complications and Management -- an Article Review

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

There is a very nice review article in the “throw away” journal Advances in Skin & Wound Care (full reference below) which discusses the causes and management of peristomal skin complications.  The photo (credit) to the right shows normal, healthy skin around a stoma.

Peristomal complications are one of the most challenging aspects of living with ostomies.  The purpose of this review article was stated to be “to illustrate practical approaches to prevent and treat common peristomal skin conditions.”

The authors propose the use of the mnemonic MINDS to help clinicians remember and be mindful of the potential
causes of peristomal skin problems:

M:  Mechanical trauma from the ostomy equipment and skin stripping
I:     Infection (bacterial and fungal)
N:  Noxious chemical and irritants including strong alkaline, feces, or urine
D:   Diseases of the skin that are common in persons with ostomies, such as pyoderma gangrenosum, psoriasis, and so on
S:    Skin allergens

The article then proceeds to address each of those with suggestions for each.

There is a nice table of sealants/protectants which can be used to minimize skin stripping (mechanical) due to loss of epithelial cells with repeated application and removal of adhesive tapes and appliances.  The photo (credit) to the right show a severe case of contact dermatitis surrounding a stoma.

Silicones are polymers that include silicone together with carbon, hydrogen, oxygen.  These are applied to the peristomal skin.
Zinc oxide powder is an inorganic compound that is insoluble in water.  It is applied generously to skin.  It ma interfere with activity of ionic silver.
Acrylates form a protective interface on skin attachment sites.  They are sprayed or wiped on skin sparingly.  Allergy is uncommon.
Hydrocolloid wafers consists of a backing with carboxymethylcellulose as the filler, water-absorptive components, such as gelatin and pectin (commercial gelatin desserts), and an adhesive.  Window frame the stoma to prevent recurrent stripping of skin.  Allergies have been reported from some colophony-related adhesives that are associated with some hydrocolloid dressings

The article addresses another mechanical issue, urostomy encrustations, which affect about 20% of people with a urostomy.  These encrustations are precipitation or crystals of phosphates and uric acid caused by accumulation (stagnation) of urine, alkaline urine, and infection.

These reddish-brown and gritty deposits produce a localized inflammatory change that resembles the wart virus clinically and is referred to as false wartlike lesions (pseudoverrucous lesions [Figure 2]) or
pseudoepitheliomatous hyperplasia.

Other signs and symptoms may include localized pain, erythema, or a loss of the superficial epidermis, with the remaining epidermis forming the base (erosion).

This condition is mainly caused by improper skin barrier/pouch with an opening that is too large for the stoma, leading to urine leakage around the peristomal
skin.

Treatment is directed at the specific problem as outlined in Table 3. Other strategies may entail the use of a urostomy pouch that has a 1-way valve to prevent retrograde flow of urine, a convex pouching system for uneven peristomal skin or recessed stomas, and proper sizing of skin barrier and pouch, so peristomal skin is not chronically overexposed to effluent.

If you take care of patients with osteomies, then check out the article for their discussion of the other causes.  An osteomy expert may not find it informative, but for the rest of us its is.  The article includes some nice photos which illustrate the different problems.

For all you general surgery residents, check out this  video of a preoperative stoma marking done by Sterile Eye.  Proper placement of a stoma can alleviate a lot of problems.

REFERENCE

Peristomal Skin Complications and Management; Advances in Skin & Wound Care. 22(11):522-532, November 2009 [doi: 10.1097/01.ASW.0000305497.15768.cb]; Woo, Kevin Y.; Sibbald, R. Gary; Ayello, Elizabeth A.; Coutts, Patricia M.; Garde, Dianne E. 

Preventing and Treating Skin Tears

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

If you work with elderly patients, then you have probably seen “skin tears.”  There is a nice basic article (see full reference below) on the topic that recently crossed my desk.  I’d like to share some of the information with you. (photo credit)

In considering the mechanism of skin tears, I love the way Dr Salcido (2nd reference below) puts it.  His paper explanation could be useful in explaining the problem to patients.

I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions:  pathomechanical & pathophysiological.

The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears.

To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will.

Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.

The main article has a nice list of risk factors for “skin tears” that should be considered when dealing with patients:

• Advanced age (>85 years of age)
• Sex (female)
• Race (white)
• Immobility (chair or bed bound)
• Inadequate nutritional intake
• Long-term corticosteroid use
• History of previous skin tears; presence of ecchymoses
• Altered sensory status or cognitive impairment
• Stiffness and spasticity
• Using assistive devices; Visual impairment
• Applying and removing stockings
• History of vascular, cardiac, and/or pulmonary problems

Many of the prevention strategies shared are common sense and focus on fall prevention – ie adequate lighting, removing clutter from a pathway, avoiding scatter rugs, making the bathroom safe for bathing.  Other strategies focus on removing sources of skin trauma – ie padding edges of furniture and equipment, avoiding adhesive products on frail skin, keeping fingernails and toenails cut short. 

Lift patients, do not drag them across sheets or surfaces.  Reduce moisture from incontinence or other sources.

Improved nutrition and hydration are important in prevention, as well as being gentle with the skin.

Once a skin tear has occurred, the same principles used to manage other wounds should be used.    First, the wound has to be assessed.  They suggest using the Payne-Martin classification of the skin tear.   However, the STAR consensus does not

Once again, the STAR consensus was to simplify the parameters of assessment and

a category 1a or 1b skin tear is one ‘where the edges can be realigned to the normal anatomical position
(without undue stretching)’.

A category 2a or 2b skin tear presents ‘where the edges cannot be realigned to the normal anatomical position (without undue stretching)’.

Whichever classification you use, remember these are acute wounds and have the potential to close by primary intention.

 Next,  the wound has to be cleaned -- removing bacteria and necrotic tissue.  When thinking about repair, it is usually best to avoid staples and sutures as the fragile tissue won’t hold.  So go straight to the next step – the dressing.

Most skin tears tend to achieve wound closure within 7 to 10 days using the following treatment plan:

• Category 1a or b skin tears can be treated with adhesive strips anchor or Dermabond to the re-approximated edges
• Category 2a or b skin tears can be treated with soft silicone or low tact foam dressing. 

All can be treated by using a  transparent film dressing (ie POLYSKIN* II) if there is minimal moisture.  The longer the dressing can be left unchanged, the better for the fragile skin.  It will often need changed every 3-7 days, but if the wound looks fine underneath consider leaving it another day or so.  If fluid develops under the transparent film dressing, then it will need to be changed promptly.

REFERENCES

Prevention and Management of Skin Tears; Advances in Skin & Wound Care, 22 (7):  325-332, July 2009; LeBlanc, Kim BScN, RN, ET, MN; Baranoski, Sharon MSN, RN, CWOCN, APN, DAPWCA, FAAN

Deconstructing Skin Tears; Advances in Skin & Wound Care,  22(7):294-295,July2009;  Salcido, Richard MD

STAR: a consensus for skin tear classification; Primary Intention Vol. 15 N o. 1 FEBRUARY 2007; Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P

Maggot Therapy

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Recently read a new article (the sixth one in the references below) on “maggot therapy” and couldn’t resist updating the one I first did in October 2007.

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization.

W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy.

A drawing of the life cycle of this fly appears below.

One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons.

It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day.

They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus).

Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Maggots must be disposed of as infectious waste in a biohazard bag when finished.  It is best to double-bag and seal the removed maggots.

From the sixth reference article regarding use of maggots in the United States:

Maggots are available only by prescription.

The Food and Drug Administration regulates the use of medical maggots, as not all species are therapeutic or safe.

Approved use currently exists for the debridement of non-healing necrotic skin and soft tissue wounds that include pressure ulcers, venous ulcers, neuropathic foot ulcers, and non-healing traumatic or postsurgical wounds.

In the United States, the supplier of Medical Maggots is Monarch Labs in Irvine, California. A vial of 250 to 500 larvae costs approximately $88 plus shipping and handling.  The number of vials needed will be determined by the wound size and duration of therapy. Many wounds require only 1 to 2 applications over a 3- to 7-day period.

REFERENCES

1.  Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

2.  From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

3.  Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

4.  Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

5.  Maggot Therapy for Wound Management; Advances in Skin & Wound Care:Vol 22(1),Jan 2009, pp 25-27; Hunter, Susan RN, MSN; Langemo, Diane PhD, RN, FAAN; Thompson, Patricia RN, MS; Hanson, Darlene RN, MS; Anderson, Julie PhD, RN, CCRC

7.  Maggots Are Enough to Gag Superbugs; Wall Street Journal Article August 8, 2008;  by Scott Hensley (Don’t watch the video in the article if you are squeamish.)

My Old Blog Posts
Maggot Therapy, October 31, 2007
Maggot Therapy Revisited, August 11, 2008

Occlusive vs Gauze Dressings–an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

We all have our favorite dressings for wounds. As the cost of healthcare continues to be an issue, it is good to look at the effectiveness AND cost of dressings. This recent article (full reference below) in the Archives of Surgery attempts to look at both.

They compared the gauze dressings

gauze mostly has been used in local wound care, mainly because of its low price and simplicity. The rationale behind this conventional wound management is to absorb exudation from the wound to keep it dry and clean enough to avoid bacterial contamination (also known as the wet-to-dry approach).

and occlusive dressings

Around the 1950s, a new concept of wound management was introduced. This method aimed at occluding the wound to protect against bacteria while keeping it moist to supply growth factors and prevent crust formation, which would impede wound healing.

The study was limited to wounds in adult surgical patients who were admitted to the hospital and had open wounds that required local wound care. The patients were then randomly placed into the occlusive (141 patients) or gauze-based (136 patients) local wound care.

Excluded were patients with burn wounds or ulcerating malignancies, surgically closed wounds, wounds treated with vacuum-assisted closure devices, ostomies or drain openings, and pin holes from external fracture fixation materials and patients receiving chemotherapy or local irradiation therapy or with a life expectancy less than 6 months.

Pain, costs, and healing were all accessed. In their study, few patients in either group need analgesics for dressing changes. Pain in both groups were similar. The number of dressing changes per day was, of course, lower for the occlusive than the gauze dressing group by almost half. The median time needed for each dressing application was nearly the same (4.8 min for occlusive and 5.0 min for gauze).

All dressings used and materials needed for redressing the wounds were counted. Commercial prices of dressing materials and wages of nurses (nurse assistant, 7.00 [US $10.98] per hour; trainee, 11.25 [$17.65] per hour; registered and senior, 19.15 [US $30.05] per hour) in the various working shifts as of January 1, 2005, were used to calculate material costs.

Daily costs of occlusive dressing materials were significantly higher. Nursing time costs per day were higher when gauze was used. However, the total costs were higher for the occlusive dressing group. The number of days spent in the hospital was longer for the occlusive group than the gauze dressing group.

occlusive, 6.43 [US $9.95] vs gauze, 1.85 [US $2.90]; P < .001)
nursing time costs per day (occlusive, 1.28 [US $2.01] vs gauze, 2.41 [US $3.78]; P < .001)

total costs per patient per day of hospital stay (7.48 [US $11.74]) when occlusive wound management was applied than for the gauze-based treatment (3.98 [US $6.25]; P = .002).

Median duration of hospitalization was 18 days (IQR, 8-36 days) in the occlusive dressings group, which was slightly but significantly (P = .02) higher than the 13 days (IQR, 6-27 days) in the gauze dressings group.

There was no significant difference in wound healing time found between the two groups. The authors conclusions would support using gauze dressings over occlusive ones.

The occlusive, moist-environment dressing principle in the clinical surgical setting does not lead to quicker wound healing or less pain than gauze dressings. The lower costs of less frequent dressing changes do not balance the higher costs of occlusive materials.

REFERENCE

Occlusive vs Gauze Dressings for Local Wound Care in Surgical Patients: A Randomized Clinical Trial; Arch Surg. 2008;143(10):950-955; Dirk T. Ubbink; Hester Vermeulen; Astrid Goossens; Raoul B. Kelner; Sanne M. Schreuder; Maarten J. Lubbers

Treatment of Pressure Ulcers – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

In the United States,  pressure ulcers are now classified as “never events”.    So if we ever reach that goal, then perhaps all this information will be moot.  Until then, we need to continue to look for the best treatments possible to treat the ones that do occur. 

The first article in the reference below attempted to do just that – see if there is a best treatment.  The authors of the article noted that even though many treatments for pressure ulcers are used and  promoted, the relative efficacy of these treatments remain unclear.  They stated their objective as:

To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers.

Using a database search of  MEDLINE, EMBASE, and CINAHL, all relevant randomized controlled trails (RCT’s) in English language, published from inception through August 23, 2008 were reviewed by three of the investigators.

A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings.

Then these were categorized into 3 groups to mirror the way wound specialist approach pressure ulcer management:

• RCT investigated the management of underlying contributing factors (first:  reduce or eliminate underlying contributing factors – support surfaces and nutritional supplementation)
• RCT investigated the effects of local wound care (second: provide local wound care – wound dressings and biological agents)
• RCT investigated adjunctive therapies (third: consider adjunctive therapies – ie vacuum therapy, surgery)

Here are their conclusions:

Relatively few RCTs evaluating pressure ulcer treatments follow standard criteria for reporting non-pharmacological interventions.

High-quality studies are needed to establish the efficacy and safety of many commonly used treatments.

There is little evidence from RCTs to justify the use of 1 support surface or dressing over alternatives.

Similarly, there is little evidence to justify the routine use of nutritional supplements, biological agents, and adjunctive therapies compared with standard care.

Clinicians should make decisions regarding pressure ulcer therapy based on fundamental wound care principles, cost, ease of use, and patient preference.

Even though there does not seem to be evidence to justify the one support surface or dressings over the others, here are some other references you may find helpful in understanding the care of pressure ulcers should one occur.

REFERENCE

Treatment of Pressure Ulcers: A Systematic Review; JAMA. 2008;300(22):2647-2662; Madhuri Reddy; Sudeep S. Gill; Sunila R. Kalkar; Wei Wu; Peter J. Anderson; Paula A. Rochon

Guidelines for the treatment of pressure ulcers; Wound Repair Regen. 2006;14(6):663-679; Whitney J, Phillips L, Aslam R; et al. (PubMed)

European Pressure Ulcer Advisory Panel; European guidelines for pressure ulcer treatment; Published in 1998.

Pressure Ulcers, Surgical Treatment and Principles; eMedicine Article, Aug 5, 2008; Brandon J Wilhelmi MD and Michael Neumeister MD

Pressure Ulcers and Wound Care; eMedicine Article, Aug 10, 2006; Richard Salcido MD and Adrian Popescu MD

Pressure Ulcers, Nonsurgical Treatment and Principles; eMedicine Article, Jul 8, 2008; Christian N Kirman MD and Joseph A Molnar MD