January 2017 - Volume 30 - Issue 1

  • Richard "Sal" Salcido, MD
  • 1527-7941
  • 1538-8654
  • 12 issues per year
  • 1.337
Current Issue Highlights


Needs Assessment

Payment Strategies

Practice Points

Original Investigations

Clinical Management Extra

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

Q.  A 64-year-old resident in a long-term care facility presented with the following discoloration on the gluteal area.  What is the correct diagnosis?

 CSI DTI 11-30-16.jpg


A. The male resident is incontinent of stool and urine, and is totally immobile.  He is unable to swallow and is reliant on enteral feeding to maintain adequate nutritional and fluid intake.  He is placed in an upright position for most of the day to prevent aspiration.  Given the resident's history and risks for pressure injury, one would presume that deep tissue injury (DTI) is the most likely diagnosis.

According to the most recent National Pressure Ulcer Advisory Panel guidelines, DTI refers to an area that exhibits persistent, nonblanchable, deep red, maroon, or purple discoloration.  A DTI may also manifest itself as a darkened wound bed or blood filled blister.  There are 2 possible outcomes; a DTI may evolve rapidly to a wound revealing the actual extent of tissue injury, or it may resolve without tissue loss.  This purple discoloration on the skin has existed for more than 12 months. Would this injury fit into the definition of DTI?

There are other differential diagnoses that should be considered.  Since there is no consensus on the direct and accurate determination of DTI, it is important to rule out other conditions that may mimic this condition.  The person is incontinent; thus, moisture-associated skin damage, incontinent dermatitis, or contact irritant dermatitis should be considered as an alternative diagnosis.  In the literature, people who are immobile may also develop venous congestion in the sacral area.  Venous congestion may promote local inflammation and skin changes similar to those documented for venous leg disease.  Other conditions may include post-inflammatory pigmentation, scarring, ecchymosis, infection, and inflammatory skin diseases, such as psoriasis.  

As the name DTI implies, what is evident on the skin surface or wound bed indicates that the injury has likely occurred from the inside out—from deep tissue. When a darkened wound bed is caused by dressing material, it is confusing whether DTI is the appropriate diagnosis.  If the injury is caused from the "outside-in," it may only involve superficial tissue.  There is a need to clarify this important concept that is evidence based.  Further dialogue will help move this issue forward to achieve a better consensus.







Decreasing Multidrug-Resistant Bacteria Levels

Burn injuries are associated with high mortality associated with infections, especially those who suffer extensive burns that cover 40% or more of the body. Pseudomonas aeruginosa is one of the most lethal pathogens, found in approximately 33% of all burn cases and in 59% of extensive burns. Researchers from the Southwestern Medical Center in San Antonio showed that topical application of an engineered adhesion inhibitor molecule, Multivalent Adhesion Molecule 7, substantially decreased the multidrug-resistant Pseudomonas aeruginosa levels in wounds in the first 24 hours after administration. The molecules also prevented the spread of the infection to adjacent tissue for 3 days and aided wound healing by maintaining normal inflammatory responses. The new approach targets the microbes' ability to bind, or stick, to cells in an early and crucial step in causing infection.

FDA Approves PolyPlex Wound Dressing

Global Health Solutions has secured 510(k) clearance from the FDA for its PolyPlex wound dressing.  PolyPlex is a petrolatum-based topical gel that features the company's PermaFusion delivery system to provide protection against bacteria, fungi, and yeasts without irritation to fragile and healing tissue.  It is indicated for acute and chronic wound management. Petrolatum base may promote moist wound healing with minimal risk of causing maceration wounds like hydrogels.  PermaFusion delivery system is also used in the firm's other wound dressing product, CurX antimicrobial gel.

Evaluating Pain Management with Topical Analgesics

Clarity, an international scientific research company based in Austin, Texas, has released the results of a study titled, "Optimizing Patient Experience and Response to Topical Analgesics".  The study was intended to evaluate patient perceptions of pain treatment with the use of FDA-approved topical/transdermal formulations alone or in combination with neuropathic supplements.  The latest analysis of more than 1000 patients ranging in age from 18 to 64 indicates the efficacy of topical analgesic in reducing 45% of opioid usage and a significant reduction of nonopioid drugs to treat chronic pain. Most patients found the topical analgesics convenient and easy to use with minimal reported side effects.

SkinGun Technology Receives Patent Extension

RenovaCare has developed an autologous (self-donated) stem cell therapy for the regeneration of human organs and the US Patent and Trademark Office has granted an additional 30-month extension for the patent, providing protection beyond the year 2035.  The SkinGun technology is designed to isolate and spray a liquid suspension of a patient's stem cells onto burns and wounds for rapid self-healing. Independent studies have demonstrated that human skin stem cells sprayed with the SkinGun maintained 97.3% viability. The device and related systems are under development and have not received FDA approval.