Editor-in-Chief: Richard "Sal" Salcido, MD
ISSN: 1527-7941
Online ISSN: 1538-8654
Frequency: 12 issues per year
Ranking: Nursing 17/103
Impact Factor: 1.6

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Wound CSI: Can You Solve the Case?

Welcome to Wound Clinical Solutions Investigation (CSI). See if you can make the diagnosis.

Q.  A 71-year-old woman with history of bilateral venous leg ulcers below the medial malleoli for the previous 2 years presented to the wound clinic with a superficial ulcer on the left lateral ankle. The ulcer was closed after 3 months of compression therapy. Now, she notices a white scar-like lesion that is exquisitely painful. The ankle-brachial pressure index is 0.9 on both legs, indicating normal arterial circulation. The duplex scan reveals no signs of peripheral arterial disease.  

What is your diagnosis? 

  

 

 

 

A. This lesion is known as atrophie blanche (AB). Dilated dermal veins, often present as telangiectasia and reticular veins, around the ankle are usually the first sign of venous stasis disease. Increased venous pressure exacerbates capillary filtration and extravasation of blood particles into the tissues, causing hemosiderin (ferritin and ferric iron from red blood cells) deposits and hyperpigmentation of the skin. Accumulation of “trapped” white blood cells, growth factors, and fibrin deposits triggers an inflammatory response, promotes microthrombus formation, and increases the oxygen diffusion barrier. Clinically, venous microangiopathy changes are also responsible for venous eczema, lipodermatosclerosis (inflammation of the skin and fatty tissue causing woody changes of the skin), edema, and difficult to heal ulcers. Approximately 9% to 38% of venous leg patients develop AB or livedoid vasculopathy. Typically, AB appears as a smooth, pearly white, stellate scar with peripheral telangiectasia. It may be caused by microthrombi occlusion of dermal vessels and related to painful purpuric ulcers with reticular pattern of the lower extremities (remember with mnemonic: PURPLE).

The lesion related to AB eventually develops into a highly exudative ulcer. The ulcer was 8 cm in diameter and the surrounding skin showed prominent AB. The ulcer continues to cause intense burning pain, despite the regular use of acetaminophen.

Treatment involves the use of compression therapy and pentoxifylline—a xanthine derivative and a nonspecific inhibitor of cyclic adenosine monophosphate phosphodiesterase. The compound has been reported to increase flexibility of red blood cells and to decrease blood viscosity.

 

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Symposium Travels to New Orleans

Register now for the 30th annual Clinical Symposium on Advances in Skin & Wound Care! This year's conference will be held September 18-21, 2015, at the Hyatt Regency in New Orleans, Louisiana. Visit 1IsmAsW for complete registration and attendee information.

We'll see you in New Orleans!

Featured Video

Interview with Dr. Dimitri Beeckman

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CME Connection Now Live
ATTENTION PHYSICIANS: Do you need CME STAT? The Lippincott CME Connection website is now live, offering a variety of educational activities for physicians to receive continuing medical education credit. Articles on a variety of topics that have been published in 2014 are available. Visit http://cme.lww.com for immediate results, other CME activities, and your personalized CME planner tool.
Supplement Available

A supplement to the March 2014 issue, titled "Wound Bed Preparation Meets Dressing Form and Function: The Role of Hydrofera Blue and Endoform," is now available free of change. Read the full supplement articles.

 

Words on Wounds
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
A forum to discuss the latest news and ideas in skin and wound care.

Latest Entry: 7/9/2015 What is the best way to describe pressure ulcers?

HBO Nuggets of the Week
Frank L. Ross, MD, FACS
A forum to discuss interesting aspects of hyperbaric medicine.

Latest Entry: 6/26/2015 HBO Nugget 15

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WANTED: Online Exclusive Content!

Advances in Skin & Wound Care is going to offer authors the opportunity to have their article posted online only with free access to all readers. We are seeking a specific scope of article for this special section. Under the heading of “Wound Care around the World,” we’d like to invite articles that detail innovative and resourceful ways that clinicians are helping to heal patients’ wounds in all corners of the globe. Articles should have a “this is how we do it” approach, not present a research study. For example, an article might illustrate how clinicians fashion wound dressings in a remote region where current products and technology may be sparse or unavailable. Send your manuscript ideas to Kathleen Greaves, Senior Managing Editor, at Kathleen.Greaves@wolterskluwer.com. Articles invited for submission will go through the standard peer review and acceptance process. We hope to hear from you!

 

 

In the News

Ionic Fluid to Fight Biofilm

Biofilm-forming bacteria account for approximately 80% of total bacterial infections and the unique structure render bacteria inside biofilm resistant to antibiotics.  A research team from Los Alamos National Laboratory has identified a unique class of materials, known as ionic liquids (eg, choline-geranate) that are more effective than bleach in neutralizing biofilm-forming pathogens with minimal cytotoxicity effects on human cell.  The ionic liquids are able to penetrate through the skin and may also help the transdermal delivery of drugs.

 

Wound Healing Delayed by Neutrophil Extracellular Traps

Delayed wound healing is a common complication of people with diabetes.  According to scientists from the Boston Children’s Hospital’s Program in Cellular and Molecular Medicine, wound healing is impeded by excessive release of neutrophil extracellular traps (NETs) in diabetic mice.  Although NETs are produced by neutrophils as part of an inflammatory response during the healing process, the NETs form a dense, toxic mesh that could interfere with the migration of new skin cells to the wound base.  Mice treated with DNase 1 (an enzyme that breaks up DNA and disables NETs) displayed better healing by 20% compared with untreated animals.

 

Innovative Nitric Oxide Generating Wound Dressing for Diabetic Foot Ulcers

Diabetic foot ulcers are the leading cause of nontraumatic-related amputation and severe disability. EdixoMed Limited (Manchester, United Kingdom) had developed and launched an innovative nitric oxide-generating wound dressing (NOx).  Nitric oxide is a potent vasodilator and broad-spectrum antimicrobial agent and is released by the dressing in a controlled and sustained fashion that mimics the natural physiological production in normal skin. Nitric oxide may correct ischemia and infection.   A randomized controlled clinical study that involved 120 patients with chronic diabetic foot ulcers in the United Kingdom demonstrated promising clinical outcomes. Two-thirds of the patients treated with nitric oxide generating dressing (NOx) achieved wound area reduction by more than 90% compared with one-third of the patients who received standard care.

 

New Products with Dialkylcarbamoylchloride (DACC) Technology

BSN Medical (Hamburg, Germany) has introduced 3 new wound care products that incorporate products dialkylcarbamoylchloride (DACC) technology. DACC Technology attracts bacteria into the dressing material and inactivates them. These products include Cutimed sorbact hydroactive B dressing for wounds with low to moderate exudate levels, Cutimed siltec sorbact foam dressing with siltec foam structure for heavy exudative wounds, and Leukomed sorbact for surgical sites.

 

New Collagen Wound Dressings for Oral Wounds

NovaBone (Jacksonville, Florida) has received approval from the FDA to launch 2 new collagen wound dressings. NovaTape and NovaPlug are designed to manage oral wounds and sores, including dental sores, oral ulcers, periodontal surgical wounds, suture sites, burns, extraction sites, and surgical/traumatic wounds.