June 2018 - Volume 31 - Issue 6

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

Current Issue Highlights


Editorial


Commentary


Payment Strategies


Practice Points


Infolink



Clinical Management Extra


Original Investigations


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. 

 
Gingival Mesenchymal Stem Cells and Wound Healing​
The gingiva contains mesenchymal stem cells that allow mucosal tissues to heal twice as fast as skin and with reduced scar formation. A research team led by investigators from Penn Dental Medicine's Department of Anatomy and Cell Biology found that the gingival mesenchymal stem cells (GMSCs) contained more proteins overall, including the inflammation-dampening IL-1RA, which blocks a proinflammatory cytokine. In their study, the researchers found that GMSCs in mice with diabetes were less able to secrete IL-1RA, leading to delayed wound healing.

Hypothyroidism and Poor Wound Healing
Researchers at the University of Michigan have validated the relationship between low thyroid hormone levels and wound healing complications. A retrospective study included 182 patients with laryngeal squamous cell carcinoma who were first treated with radiation, but ultimately required a total laryngectomy. Forty to 50% of patients developed fistula, or a leak of saliva from the throat into the neck, leading to prolonged hospital stays. The investigators found was that patients with hypothyroidism had nearly 4 times the risk of fistula formation than those who had normal thyroid function. A prospective study is underway to determine if providing thyroid hormone supplement to patients would decrease their risk of developing fistula and improve their wound healing in the postoperative period. 

News about Hydrofera Blue
A few months ago, Hollister Incorporate announced the decision to divest portions of its wound care business. Tom Drury, one of the principle founders of Hydrofera, LLC, and a group of investors acquired the Hydrofera business. Mr. Drury originally brought Hydrofera Blue products to market and helped introduce the products to Hollister Incorporated. Hollister Incorporated will continue to provide customers with wound care products, including Hydrofera Blue, until Hydrofera, LLC begins distribution. It is a top priority to ensure that there will not be a disruption in service to customers. 
Insurance Coverage for Dermacell
Insurance provider Anthem now covers LifeNet Health's Dermacell for the treatment of both chronic diabetic foot ulcers (DFUs) and breast-reconstruction surgery. Approximately 40 million people insured by Anthem will have access to dermal grafts developed through LifeNet Health's innovations. Dermacell, an acellular human dermis, is treated as human tissue for transplantation under the FDA's human cells, tissues, and cellular and tissue-based products​ process. It is decellularized using Matracell, a patented technology that removes more than 97 percent of the donor's DNA without compromising the graft's biomechanical or biochemical properties and enables rapid cellular infiltration and re-vascularization. In a previous study of 168 patients with chronic DFUs, patients who received a single application of Dermacell experienced higher rates of wound-size reduction and wound closure compared to standard care, with 98 percent reaching closure by 12 weeks.