March 2018 - Volume 31 - Issue 3

  • Richard "Sal" Salcido, MD
  • 1527-7941
  • 1538-8654
  • 12 issues per year
  • 1.088

Current Issue Highlights


Editorial


Payment Strategies


Commentary


Practice Points



Clinical Management Extra


Original Investigation


Case Series


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

Q.  Mr. M presented to the clinic with recurring wounds on his calves. Examination revealed several relatively shallow wounds dispersed bilaterally around his lower legs. Wounds were painful and produced a moderate amount of malodourous drainage; there was no local erythema or increase in skin temperature. What’s the diagnosis?

 CSI 1-9-18_2.jpg   CSI 1-9-18_1.jpg

A. The patient has a body mass index of 43, and comorbidities included heart failure, diabetes, chronic respiratory disease, and osteoporosis. Mr. M has had chronic edema for a number of years, leading to progressive skin changes including hyperpigmentation, hyperkeratosis (build-up of skin scales and plaques), and lipodermatosclerosis (woody fibrosis). Closer examination of the lower extremities also revealed positive Stemmer’s sign (the skin was not pinchable at the base of the second toe). 

Taken together, the ulcers were likely related to lymphedema and chronic venous insufficiency. Short stretch bandages were prescribed to promote venous return. A silver alginate dressing was selected for the treatment of local infection. Extra padding was applied under compression bandages to avoid potential damage in areas where significant indentation was created by the edges of the compression system. The dressings and bandages were changed 2 times per week. There was some improvement; providers noted a reduction in drainage and smell in the first 2 weeks, but healing stalled and new shallow lesions developed in adjacent areas. 

A new treatment plan was developed that involved meticulous skin hygiene including:
Washing the legs with gentle soap and water at each dressing change: Harsh detergents were avoided to optimize the skin barrier function.
Removing hyperkeratotic areas: According to expert opinions, sub-optimal treatment of hyperkeratosis can introduce an environment conducive for bacterial and fungal proliferation. In addition, the cracks between the hyperkeratotic scales allow pathogens to enter the deeper layers of the skin, precipitating cellulitis. 
Removing thickened skin and scales carefully without causing any bleeding to expose underlying healthy skin.
Applying cadexomer iodine powder to the entire area under compression: Cadexomer iodine contains water-soluble modified starch polymer containing 0.9% iodine. While an iodine-based ointment was available, the powder was more desirable because it promoted better moisture control and allowed providers to disperse the agent to a large area, including the denuded and intact skin.
Covering open areas with absorbent dressings.
Controlling edema with short stretch compression.

After 2 weeks, the wounds were closed and the iodine powder was discontinued. To prevent recurrence, providers applied an emollient to moisturize the skin after each cleansing.

Skin hygiene is a vital component to address wound infection but it is often undervalued. 

 
Elastic Surgical Glue Quickly Seals Wounds

Collaboration between researchers from the University of Sydney and Boston's Northeastern University has developed a surgical glue, called MeTro, that could seal wounds or incisions without the need for sutures and staples. MeTro is derived from natural elastic protein technologies and is ideal for internal, hard-to-reach wounds and in body tissues that continually expand and relax (such as lungs, hearts and arteries) at high risk for re-opening. The agent solidifies into a gel on tissue surfaces and it is stabilized with a short light-mediated crosslinking treatment. This allows the sealant to be accurately placed and to tightly bond and interlock with structures on the tissue surface. The technology has a built-in degrading enzyme that can be tailored to determine how long the sealant lasts, from hours to months.

Topical Antihypertensive Agent for Wound Healing 

Wound healing is regulated by the skin's renin-angiotensin system (RAS), which is involved in the inflammatory response, collagen deposition, and signaling. Researchers from Johns Hopkins have showed that topical formulations of angiotensin II receptor antagonists or blockers would potentially increase wound blood flow to promote faster healing. In a porcine model, the research team demonstrated that wounds received 1% valsartan healed faster and achieved complete closure compared with the placebo-treated wounds. Pigs treated with valsartan had a thicker epidermal and dermal collagen layer, as well as a more organized collagen fiber arrangement, resulting in stronger healing skin. The drug acts locally on the tissues where it's absorbed, rather than affecting the entire body.

Smart Wound Dressing Delivers Individualized Medications

Researchers from the University of Nebraska-Lincoln, Harvard Medical School, and MIT have designed a smart dressing that can accommodate individualized doses and delivery schedule of multiple medications based on the needs of specific types of wound. The smart wound dressing is no larger than a postage stamp, and is activated by a smartphone or other wireless device that sends small amounts of voltage through a chosen fiber. That voltage heats the fiber and its hydrogel, releasing antibiotics, tissue-regenerating growth factors, painkillers, or other medications. The researchers applied a smart dressing loaded with growth factor to wounded mice. When compared with a dry bandage, the treated animals regrew three times as much of the blood-rich tissue critical to the healing process.

FDA Approved First Shock Wave Device to Treat Diabetic Foot Ulcers

The Dermapace System is an external (extracorporeal) shock wave system that uses pulses of energy, similar to sound waves, to mechanically stimulate the wound. The system is intended to treat chronic, full-thickness diabetic foot ulcers with wound areas measuring no larger than 16 cm2 that extend through the epidermis, dermis, tendon, or capsule, but without bone exposure. Evidence was available from 2 multicenter, randomized, double-blind studies with a total of 336 diabetic patients receiving either standard of care plus the Dermapace System shock wave therapy or standard of care plus sham shock wave therapy. Patients who had between 1 and 7 treatments with the Dermapace System showed an increase in wound healing at 24 weeks with a 44% wound closure rate. Those patients treated with the sham shock wave therapy showed a 30% wound closure rate during the same time period. The most common side effects observed were pain during application of the device, local bruising and numbness, migraines, nausea, fainting, wound infection, infection beyond the wound (cellulitis, osteomyelitis), and fever.

Copper as a Potential Target for Wound Healing

Normal copper is essential for angiogenesis. Scientists from the Vascular Biology Center at the Medical College of Georgia at Augusta University have evidence that in inflammatory diseases such as diabetes, copper levels within cells become excessive, impeding angiogenesis. Blood vessel walls are less flexible, leak more, and are more prone to accumulate plaque deposits and scars that impede good blood flow. Impaired angiogenesis contributes to a host of problems from heart attacks to nerve death to loss of limbs to poor wound healing. Treatments that target ATP7A, a copper transporter that normally helps ensure healthy copper levels for a wide variety of functions in our body, may one day help patients with diabetes recover the innate ability to make healthy new blood vessels. ​