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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, January 26, 2022

In this post, I describe my background and journey to becoming the first nurse and woman to lead the World Union of Wound Healing Societies (WUWHS), as well as the lessons we have all learned from the COVID-19 pandemic and how they apply to the upcoming WUWHS Congress to be held in Abu Dhabi, United Arab Emirates (UAE), March 1 through 5, 2022.​

I strongly believe in the power of education, which I have used to connect my passion for service with knowledge and excellent patient care delivery. With profound interest and excitement, I began my wound care journey by enrolling and successfully graduating with high marks from the International Interprofessional Wound Care Course (IIWCC) in Iran in 2007. The theoretical background from the course solidified my knowledge about wound care but it was my passion for wound care education in UAE that changed my career. In 2010, the First Abu Dhabi Wound Care Conference was born under my chairmanship. Since then, the annual conference has been a premier event for wound care enthusiasts across the Middle East. The conference aims to present the latest evidence-based practices from around the globe. Subsequently, our team also began hosting the IIWCC in Abu Dhabi. Around 500 nurses, doctors, and allied health graduates have since begun to shape the landscape of the region in terms of wound care.

Alongside the other graduates of the IIWCC in Abu Dhabi, I created an association to uplift a common vision for wound care. I am the Founder and President of the International Interprofessional Wound Care Group (IIWCG), which is a registered association of the Dubai Association Center. Another initiative to strengthen wound care in Middle East was to focus on continuing education, which led me to be the Founder and Director of the Ostomy Care and Management, which started in Abu Dhabi 4 years ago. Aiming even higher, I submitted a bid to host the WUWHS Congress during their last conference in Florence, Italy in 2016. Of the five countries that applied, we successfully won the bid and I now currently serve as President of the WUWHS, the first nurse and woman to do so. Further, the UAE is the first country in the Middle East to host the Congress. The WUWHS conference was postponed from March 2020 because of COVID-19; a hybrid WUWHS Congress will take place in March 2022 instead.

As with any planned event, the WUWHS Congress was deeply affected by the pandemic. Immense organizations like the WUWHS change either because they want to or because they have to. The latter was the case with the global coronavirus pandemic.

The impact of COVID-19 is still felt globally in 2021, with powerful lessons learnt in a very short time. The virus taught us that clear voices and respectful messages have the power to significantly expand science and bridge cultural differences in real time. Regardless of profession or race, color, or creed, we healthcare professionals remained standing when many were brought low by the pandemic. We had to share skills and teach them to others fast, who in turn taught it to others and again to others. Skill acquisition and the rapid application of new skills to clinical practice became a priority as time suddenly became a prized commodity when patients started to overwhelm healthcare systems during the second and third waves of infection. Each profession was automatically granted a voice and a place on the team they served, in that manner to save lives through plans drafted sometimes on the spot. Suddenly the interprofessional team was not a far-fetched ideal, but a vital necessity.

In fact, we have realized that we are all members of a worldwide interprofessional team. The global impacts of COVID-19 taught us including the societies of all continents in the world on equal terms is feasible, and we have a lot to learn from each other. Challenges previously only experienced by some countries and societies are now global challenges for all. Successful strategies in overcoming those hurdles not only need to be shared, but should be preserved for the next generation of wound care professionals.

For me, it is of paramount importance that the WUWHS remain an organization where societies have the opportunity to share and showcase their wound-related initiatives and projects freely. In that manner, we can learn from each other without anyone reinventing the wheel. Our vision was and still is to position WUWHS as a flagship for wound care in the world by incorporating as many societies as possible, from all continents of the world under its banner. With compassion, respect, and transparency, the WUWHS is now moving toward inclusivity with minor adaptations and enhancements to existing processes, such as the hybrid conference model. Not only does this align our vision to wound care around the world, but it also serves as a powerful shared learning environment to be developed and made available to all. This vision was already partially achieved by the expansion of the WUWHS structure to include an International Affairs committee taking responsibility for shared governance of WUWHS. Each continent in the world is already represented in the teams of subcommittees of this branch. This International Affairs committee immediately embraced the wider horizon of shared responsibilities, positively impacting the position of WUWHS as the world class organization it is.

The aim of WUWHS' rebirth is to incorporate an inclusive perspective of the organization in a positive way that will empower others on their wound care journey. The future promises innovative platforms of ideas and solutions based on evidence, networking, teambuilding, education, research, and publication opportunities under this banner. Reverse innovation and creative solutions to complex problems are still the answer where resources are scarce. Incorporation of these lessons while still embracing complex advances to the science of wound care, remain the reason why WUWHS exists and will thrive in future. By empowering our supporting societies, the WUWHS in turn is empowered to enhance the Congress scheduled for Abu Dhabi, March 1-5, 2022.

During the Congress and beyond, we have the opportunity of a lifetime to bring wound prevention to the global forefront as a vital international priority. The preventive lessons and practical implementation of COVID-19 measures have taught the world that primary care and public health are of immense value, if consistently promoted. As a wound care fraternity, we have clearly received and lived that message, as many of us were on the frontlines of COVID-19, wielding a wide spectrum of skill sets that could be pooled and transferred into frontline duty. We realized that the same can be done in proactively preventing and addressing the chronic disease burdens and subsequent skin deterioration outcomes of our own patient populations, simply by pooling our resources. Prevention saves money, preserves dignity, and most of all, saves lives. As a worldwide society, we are perfectly positioned to meet this challenge right now and position wound prevention as the legacy of the WUWHS. Not only will it change lives, but provide lessons for those to come. 

Friday, September 25, 2020

Recently I was asked to see a woman in the hospital with a necrotic nodule on the back of her calf. Initially, the wound was thought to be caused by pressure from immobility, and the location of the wound did make this area vulnerable to ischemia secondary to pressure damage and resulting in skin necrosis. The area had well-demarcated lesions covered with strangely shaped black leathery eschar; most pressure injuries typically present in geometric shapes. On palpation, the area was indurated and lumpy, with an area of fluctuance. One of the most unusual symptoms was the intense pain over the injured area; even a light stroke was excruciating. Her medical history was complex, including diabetes mellitus, obesity, thyroid disease, hypertension, and renal failure that required hemodialysis for 8 years. 

Overall, her cutaneous lesion was inconsistent with pressure injury but seemed suggestive of calciphylaxis.  

Calciphylaxis most commonly occurs in patients with diabetes mellitus, obesity, autoimmune conditions such as systemic lupus erythematosus, hypercoagulable conditions, hepatitis, hypoalbuminemia, and end-stage renal disease, especially those who require hemodialysis. Although the exact pathogenesis is uncertain, calciphylaxis is an inflammatory disease of small- and medium-sized arteries characterized by vascular calcification, thromboembolism, and painful cutaneous ulcerations. Metabolic disturbances such as hyperglycemia, hyperphosphatemia, hypercholesterolemia, hypertension, and parathormone resistance are common. Evaluation of calciphylaxis starts with a careful medical history and clinical assessment and may require a skin biopsy for a definitive diagnosis. Evaluation may also include a panel of bloodwork including renal functions, mineral bone parameters, liver enzymes, and coagulation screen. Many patients with calciphylaxis could benefit from intravenous sodium thiosulfate, a chelating agent of calcium. Hyperbaric oxygen therapy may help to increase oxygen delivery to the affected parts of the body. Cinacalcet is considered to treat secondary hyperparathyroidism. Bisphosphonates have also been used to regulate serum calcium and phosphorous levels. Management will often involve an interprofessional and multiinterventional approach. 

For this patient, we made a local incision and drained approximately 300 cc of thick, purulent, and malodours fluid.  Because of her intense pain and inflammatory response, we decided to use collagenase to promote enzymatic debridement. The condition of the wound bed improved over the next few weeks, and the removal of nonviable unhealthy tissue exposed fragments of calcified tissue. Next, we used a silver dressing to reduce bacterial burden to control local infection. The patient continued to receive hemodialysis. 

Wednesday, August 12, 2020

In the latest guideline released by the CDC the use of face coverings or masks in public areas is highly recommended where social distancing is difficult.  The purpose of having people wear masks is to prevent dispersal of droplets while talking, sneezing, and coughing and therefore reduce the risk of transmitting the coronavirus.  Healthcare workers wear medical-grade facial protection including surgical masks, N95 respirators, and face shields for prolonged durations.  Long‐time mask wearing during the coronavirus disease 2019 (COVID-19) pandemic can have a significant impact on skin health, especially in hot, humid, and poorly ventilated conditions.  International wound care communities have published timely best practices on how to prevent personal protective equipment-related pressure injury on the face.  Little attention has been paid to other skin conditions with acne being one of the most common concerns.

Under the mask, a tightly sealed environment promotes high humidity and heat accumulation.  Increased sebaceous production and poral occlusion can disrupt the skin barrier, leading to bacterial microflora imbalance and precipitating acne eruption.  Facial movement while talking, laughing, and other facial expressions can displace the mask, causing friction as the mask material rubs against skin.  These are some of the potential reasons why people experience flare of acne, rosacea, and other dermatitis.  People with these facial dermatoses including acne, atopic dermatitis, or seborrhoeic dermatitis are more likely to experience itching leading to frequent touching of the mask and face.

To minimize acne, here are some useful tips:

  1. Clean your face with mild, pH balanced soap before wearing a mask
  2. Avoid using makeup under mask
  3. Use water-based emollient on face
  4. Avoid using oily occlusive ingredients: e.g., petrolatum, silicone
  5. Avoid alcohol-based astringent on face; they are too drying promoting more irritation
  6. Use medicated cream with benzoyl peroxide for active acne lesions
  7. Use oil absorbing powder or lotion on the T-zone of the face, which tends to be more oily
  8. Avoid over-exfoliation that can irritate the skin
  9. Shave in the direction of hair growth; waxing is not recommended

Wednesday, May 27, 2020

The current novel coronavirus 2019 (COVID-19) crisis is an unprecedented global event, and our most vulnerable population—older adults living with frailty—is at the highest risk for serious impacts from the disease. One of the central public health mitigation strategies has been the establishment of "physical distancing" measures, which include avoiding close contact with others and limiting activities outside the home. However, the impact of physical distancing on older individuals can be devastating, leading to social isolation, poor mental health, and disability, particularly among those who are very old, frail, or have multiple chronic conditions such as wounds.

Older adults in isolation may have difficulty securing food to meet nutrition needs, maintaining physical activity to prevent deconditioning, and engaging in socialization to cope with loneliness and depression. Mental health problems in adults over 65 years are common and stressors associated with the pandemic may cause an increase in these numbers. Finding effective ways for older individuals to remain socially connected through the use of technology, video chat, and messaging apps (eg, Zoom, Messenger, FaceTime, Google Duo) and other social network platforms may help to mitigate some of the potential negative consequences of physical distancing for this population.  

These mobile health (mHealth) technologies afford new avenues for individuals to connect with others through social media sites and applications to share information, ideas, experiences, as well as personal messages, images, and other content. Using the Internet allows users ready access to health information and the opportunity for active participation in self-care decisions for treatment including wound care. Accumulating evidence suggests that mHealth use is also associated with improved adherence to healthy lifestyle behaviors that are important to wound healing.

The innovative use of social media has the potential to overcome geographic boundaries and time constraints, widen access to health information, allow users to make decisions by engaging in active or passive interactions, and access hard-to-reach or isolated populations. Whether the benefits of mHealth technologies are transferrable to the older adult population is unknown. In the past, there has been concern around older adults' digital literacy, interest in social media, and accessibility because of poor vision, hearing impairment, or limited dexterity in manipulating small devices. Within this current context, there is an urgent need to investigate the full potential of mHealth and social media solutions to help older adults living with frailty maintain and manage their mental health in their own environment. 

Thursday, April 23, 2020

skin tear 1.jpg

George is a long-term care resident who developed a skin tear on his lower leg (Figure 1, above). A silicone dressing was used to cover the open area and left in place for 7 days (Figure 2, below). 

skin tear 2.jpg

What dressing the best option for the treatment of skin tears?

Wound healing is a dynamic process that requires a delicate balance of various host and local wound factors. One of the challenges in wound management is to maintain moisture balance to create an environment that is conducive to healing. Although a desiccated wound surface can slow down cellular migration, impairing wound healing, excessive moisture can damage wound edges and periwound skin. Recognizing the importance of moist wound healing, a plethora of dressings have been developed and are available in the marketplace for clinician use.  Scientific evidence for the treatment of skin tears is lacking but this clinician prefers to use atraumatic silicone dressings to prevent further periwound skin damage.

How should providers measure skin tears?

Wound measurements comprise the longest wound length and width dimensions that are perpendicular to each other to estimate wound surface areas. For type 1 or 2 skin tears, the measurement should include the flap (which is the damaged skin), not just the open/exposed dermal tissue.

Upon reassessment, how do we know the skin tear is healed?

  • Completely healed type 1 skin tears: when a dry, slightly firm healing ridge or new epithelium has formed along the edge when the flap meets the skin. The healing ridge is described as an area of swelling and hardness under the re-approximated skin edges indicating deposition of new collagen in the wound.
  • Completely healed type 2 or 3 skin tears: when the wound edges are bridged by new epithelium, including the establishment of a healing ridge. 
The following Table may also help: Skin Tear Predicted Healing Times and Signs and Symptoms of Healing
Outcome MeasureDays 1-4Days 5-9Days 10-14 (proliferative healing)Day 15  (remodeling)
Type 1 Skin Tears
Periwound olorRed edges approximatedRed, progressing to bright pink (all  skin tones)Bright pink (all skin tones)Pale pink, progressing to white or silver in light-skinned patients; pale pink, progressing to darker than normal skin color or may blanch to white in dark- skinned patients
Surrounding tissue inflammationSwelling, redness or skin discoloration, warmth, painNone presentNone presentNone present
Drainage typeSerosanguinous None presentNone presentNone present
Drainage amountModerate to minimalNone presentNone presentNone present
EpithelializationPresent by day 14Present along entire wound PresentNone present
Healing ridgeNone presentPresent along entire wound by day 9Present along entire woundPresent
Type 2 and 3 Skin Tears
Periwound colorRed edges not approximatedPeriwound skin red, progressing to bright pink (all  skin tones)Bright pink (all skin tones)Pale pink, progressing to white or silver in light-skinned patients; pale pink, progressing to darker than normal skin color or may blanch to white in dark- skinned patients
Surrounding tissue inflammationSwelling, redness or skin discoloration, warmth, painNone presentNone presentNone present
Drainage typeSerosanguinous SerosanguinousSerosanguinousNone present
Drainage amountModerate to minimalModerate to minimalMinimalNone present
EpithelializationNoneNone PresentNone present
Healing ridgeNone presentNone presentPresent along entire woundPresent

Table © 2020 Kim LeBlanc & Kevin Woo.