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?
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.