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Words on Wounds

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

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.

Tuesday, April 14, 2020

WHO report.jpg

2020 is the International Year of the Nurse and the Midwife. This year, the World Health Organization (WHO) and other health organizations are paying special tribute to the work of nurses- and the value of nurses is more evident than ever during the current COVID-19 pandemic. 

The WHO recently released a report titled The State of the World's Nursing 2020: Investing in Education, Jobs, and Leadership, highlighting the strengths, threats, and opportunities for nurses and nursing. In the report, the WHO underscores the need to invest in nursing as a pivotal part of the global agenda to achieving universal health coverage and quality care for all. 

Although nurses represent almost two thirds of health professionals, their functions vary, and their roles include a broad spectrum of activities that may vary across countries and jurisdictions. In general, nurses are involved in the planning, delivering, and evaluation of care to people of all ages and settings with the key objective to promote health and safety, prevent illness, and optimize care. Nurses play an essential role in ensuring patient safety by monitoring patient response to treatment and detecting errors to ensure high-quality care. Evidence links 'good' nursing care to pressure injury reduction and other critical wound care outcomes. However, in order to fully articulate the contribution of nursing and effectively navigate health services priorities, there is a need to develop internationally standardized definitions that will help support nursing functions.

Nonetheless, nursing practice is rapidly evolving, producing nurse specialists, nurse practitioners, and advanced practice roles. Globally, many nurses are certified specialists in wound management.  Advanced practice nurses have been shown to enhance access to care for underserved and remote populations, reduce health disparities, and improve patient satisfaction with care. The WHO panelists lend support for the establishment of nurse-led clinics and to expand nurses' prescribing authority. Our goal should be to optimize nurses' productivity in providing patient care or leadership and management with other members of the interprofessional team.

To strengthen nursing in the future, the WHO report identified several priorities:

  1. Nursing remains a highly gendered profession, with associated biases in the workplace. Efforts must be made to address gender-based discrimination in the work environment, including working hours and conditions, minimum wage, and social protection.
  2. Nursing is a scientific discipline. Nurses prepared at the master's and doctorate levels are needed to strengthen capacity for a vibrant research milieu and scholarship. The shortage of nursing faculty can have a direct impact on nurses' competence to generate high-quality evidence that help inform practice and policy making, and to assume leadership roles in academic and health care sectors.
  3. Nursing curricula should be re-designed and modernized to prepare new graduate nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology.  
  4. Senior nurses in government are expected to lead the policy dialogue that results in health policy decisions germane to nursing governance and stewardship. The WHO recommends leadership programs be developed to nurture leadership development in young nurses.
  5. Practice, policy development, and investment decisions should be informed by research. Nursing data can be compiled and analyzed in collaboration with key stakeholders such as regulatory councils, nursing education institutions, health service providers, and professional associations. 
As always, thank you to the hardworking nurses the world over for your contributions to global healthcare, including safe and evidence-based skin and wound care.