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Nanotherapies make inroads in wound regeneration
DENVER – Move over, gauze, bandages, and moist wound-healing techniques. Nanomaterials are making significant inroads in wound regeneration.
Dr. Adam Friedman, director of dermatologic research at the Montefiore-Einstein College of Medicine, New York, highlighted four nanotherapies in the field of wound care.
• Antimicrobial nano-based dressings. The antibacterial properties of silver have been documented since 1000 B.C., said Dr. Friedman of the departments of dermatology and of physiology and biophysics at the medical school. Silver ions are believed to directly disrupt pathogen cell walls/membranes and suppress respiratory enzymes and electron transport components. Silver has been used commercially for decades, with demonstrated antimicrobial effects (Crede’s 1% silver nitrate eyedrops were used to prevent mother to child transmission of gonococcal eye infection); anti-inflammatory properties (silver nitrate is used in pleurodesis); and infection protection (silver nanoparticle–impregnated wound dressings prevent infection and enhance wound healing).
Silver nanoparticles have an "increased likelihood of directly interacting with the target bacteria or virus," Dr. Friedman said in an interview in advance of the annual meeting of the American Academy of Dermatology. "They bind to and/or disturb bacterial cell membrane activity as well as release silver ions much more readily then their bulk counterparts." Silver dressings currently on the market include Silvercel, Aquacel, and Acticoat.
Similarly to nanometals, the biological activity of curcumin (a water-insoluble polyphenolic compound derived from tumeric) can be used in the nanoform and has been shown to both effectively clear methicillin-resistant Staphylococcus aureus in burn wound infections and accelerate the healing of thermal burn wounds.
• Immunomodulating antimicrobial nanoparticles. One of the most promising immunomodulators in wound healing is the gaseous molecule nitric oxide (NO). This potential has yet to be realized, Dr. Friedman said, as NO is highly unstable and its site of action is often microns from its source of generation. Nanotechnology can allow for controlled and sustained release of this evasive biomolecule and make therapeutic translation a reality. "At Einstein, we are utilizing NO-generating nanoparticles to accelerate wound healing and eradicate multidrug resistant pathogens," he said. "But, because NO is integral to so many biological processes, it can do so much more. This technology is also being studied for the treatment of cardiovascular disease and even the topical treatment of erectile dysfunction."
• Gene modifying/silencing technologies. RNA interference is an endogenous mechanism to control gene expression in a variety of organisms. "We can take advantage of this process using siRNA (small interfering RNA) to manipulate limitless biological processes," Dr. Friedman explained. "While a hot area, translation to the bedside has been difficult as siRNA are very unstable and have a difficult time reaching their targets inside cells. Nanoparticles have been shown to overcome these limitations." Dr. Friedman noted how siRNA encapsulate nanoparticles targeting fidgetin-like 2 (an ATPase that cleaves microtubules), can knock down this gene in vivo, resulting in accelerated epithelial cell migration and hastened wound closure in both excisional and burn wound mouse models.
• Growth factor–releasing nanoparticles. Growth factors have been found to speed the healing of acute and chronic wounds in humans, including Regranex, a analogue of platelet-derived growth factor that is FDA-approved for treating leg and foot ulcers in diabetic patients, epidermal growth factor (donor-site wounds), fibroblast growth factor (burn wounds), and growth hormone (donor sites in burned children). "Nanomaterials offer many advantages here, from allowing for temporal release depending on the wound environment to delivering multiple factors at the same or different times, to even serving as a structural foundation for wound healing while releasing factors simultaneously," Dr. Friedman said. "The possibilities are limitless."
Dr. Friedman characterized nanomedicine as "a newborn branch of science. These promising and innovative tools should help us overcome limitations of traditional wound care, improve direct intervention on phases of wound healing, and provide better solutions for wound dressing that induce favorable wound healing environments. More work – and funding – is needed."
Dr. Friedman disclosed that he is a consultant and/or a member of the scientific advisory board for SanovaWorks, Prodigy, Oakstone Institute, Liquidia Technologies, L’Oréal, Amgen, Onset, Aveeno, GSK, MicroCures, and Nano Bio-Med. He is also a speaker for Onset and Amgen.
This article was updated March 24, 2014.
DENVER – Move over, gauze, bandages, and moist wound-healing techniques. Nanomaterials are making significant inroads in wound regeneration.
Dr. Adam Friedman, director of dermatologic research at the Montefiore-Einstein College of Medicine, New York, highlighted four nanotherapies in the field of wound care.
• Antimicrobial nano-based dressings. The antibacterial properties of silver have been documented since 1000 B.C., said Dr. Friedman of the departments of dermatology and of physiology and biophysics at the medical school. Silver ions are believed to directly disrupt pathogen cell walls/membranes and suppress respiratory enzymes and electron transport components. Silver has been used commercially for decades, with demonstrated antimicrobial effects (Crede’s 1% silver nitrate eyedrops were used to prevent mother to child transmission of gonococcal eye infection); anti-inflammatory properties (silver nitrate is used in pleurodesis); and infection protection (silver nanoparticle–impregnated wound dressings prevent infection and enhance wound healing).
Silver nanoparticles have an "increased likelihood of directly interacting with the target bacteria or virus," Dr. Friedman said in an interview in advance of the annual meeting of the American Academy of Dermatology. "They bind to and/or disturb bacterial cell membrane activity as well as release silver ions much more readily then their bulk counterparts." Silver dressings currently on the market include Silvercel, Aquacel, and Acticoat.
Similarly to nanometals, the biological activity of curcumin (a water-insoluble polyphenolic compound derived from tumeric) can be used in the nanoform and has been shown to both effectively clear methicillin-resistant Staphylococcus aureus in burn wound infections and accelerate the healing of thermal burn wounds.
• Immunomodulating antimicrobial nanoparticles. One of the most promising immunomodulators in wound healing is the gaseous molecule nitric oxide (NO). This potential has yet to be realized, Dr. Friedman said, as NO is highly unstable and its site of action is often microns from its source of generation. Nanotechnology can allow for controlled and sustained release of this evasive biomolecule and make therapeutic translation a reality. "At Einstein, we are utilizing NO-generating nanoparticles to accelerate wound healing and eradicate multidrug resistant pathogens," he said. "But, because NO is integral to so many biological processes, it can do so much more. This technology is also being studied for the treatment of cardiovascular disease and even the topical treatment of erectile dysfunction."
• Gene modifying/silencing technologies. RNA interference is an endogenous mechanism to control gene expression in a variety of organisms. "We can take advantage of this process using siRNA (small interfering RNA) to manipulate limitless biological processes," Dr. Friedman explained. "While a hot area, translation to the bedside has been difficult as siRNA are very unstable and have a difficult time reaching their targets inside cells. Nanoparticles have been shown to overcome these limitations." Dr. Friedman noted how siRNA encapsulate nanoparticles targeting fidgetin-like 2 (an ATPase that cleaves microtubules), can knock down this gene in vivo, resulting in accelerated epithelial cell migration and hastened wound closure in both excisional and burn wound mouse models.
• Growth factor–releasing nanoparticles. Growth factors have been found to speed the healing of acute and chronic wounds in humans, including Regranex, a analogue of platelet-derived growth factor that is FDA-approved for treating leg and foot ulcers in diabetic patients, epidermal growth factor (donor-site wounds), fibroblast growth factor (burn wounds), and growth hormone (donor sites in burned children). "Nanomaterials offer many advantages here, from allowing for temporal release depending on the wound environment to delivering multiple factors at the same or different times, to even serving as a structural foundation for wound healing while releasing factors simultaneously," Dr. Friedman said. "The possibilities are limitless."
Dr. Friedman characterized nanomedicine as "a newborn branch of science. These promising and innovative tools should help us overcome limitations of traditional wound care, improve direct intervention on phases of wound healing, and provide better solutions for wound dressing that induce favorable wound healing environments. More work – and funding – is needed."
Dr. Friedman disclosed that he is a consultant and/or a member of the scientific advisory board for SanovaWorks, Prodigy, Oakstone Institute, Liquidia Technologies, L’Oréal, Amgen, Onset, Aveeno, GSK, MicroCures, and Nano Bio-Med. He is also a speaker for Onset and Amgen.
This article was updated March 24, 2014.
DENVER – Move over, gauze, bandages, and moist wound-healing techniques. Nanomaterials are making significant inroads in wound regeneration.
Dr. Adam Friedman, director of dermatologic research at the Montefiore-Einstein College of Medicine, New York, highlighted four nanotherapies in the field of wound care.
• Antimicrobial nano-based dressings. The antibacterial properties of silver have been documented since 1000 B.C., said Dr. Friedman of the departments of dermatology and of physiology and biophysics at the medical school. Silver ions are believed to directly disrupt pathogen cell walls/membranes and suppress respiratory enzymes and electron transport components. Silver has been used commercially for decades, with demonstrated antimicrobial effects (Crede’s 1% silver nitrate eyedrops were used to prevent mother to child transmission of gonococcal eye infection); anti-inflammatory properties (silver nitrate is used in pleurodesis); and infection protection (silver nanoparticle–impregnated wound dressings prevent infection and enhance wound healing).
Silver nanoparticles have an "increased likelihood of directly interacting with the target bacteria or virus," Dr. Friedman said in an interview in advance of the annual meeting of the American Academy of Dermatology. "They bind to and/or disturb bacterial cell membrane activity as well as release silver ions much more readily then their bulk counterparts." Silver dressings currently on the market include Silvercel, Aquacel, and Acticoat.
Similarly to nanometals, the biological activity of curcumin (a water-insoluble polyphenolic compound derived from tumeric) can be used in the nanoform and has been shown to both effectively clear methicillin-resistant Staphylococcus aureus in burn wound infections and accelerate the healing of thermal burn wounds.
• Immunomodulating antimicrobial nanoparticles. One of the most promising immunomodulators in wound healing is the gaseous molecule nitric oxide (NO). This potential has yet to be realized, Dr. Friedman said, as NO is highly unstable and its site of action is often microns from its source of generation. Nanotechnology can allow for controlled and sustained release of this evasive biomolecule and make therapeutic translation a reality. "At Einstein, we are utilizing NO-generating nanoparticles to accelerate wound healing and eradicate multidrug resistant pathogens," he said. "But, because NO is integral to so many biological processes, it can do so much more. This technology is also being studied for the treatment of cardiovascular disease and even the topical treatment of erectile dysfunction."
• Gene modifying/silencing technologies. RNA interference is an endogenous mechanism to control gene expression in a variety of organisms. "We can take advantage of this process using siRNA (small interfering RNA) to manipulate limitless biological processes," Dr. Friedman explained. "While a hot area, translation to the bedside has been difficult as siRNA are very unstable and have a difficult time reaching their targets inside cells. Nanoparticles have been shown to overcome these limitations." Dr. Friedman noted how siRNA encapsulate nanoparticles targeting fidgetin-like 2 (an ATPase that cleaves microtubules), can knock down this gene in vivo, resulting in accelerated epithelial cell migration and hastened wound closure in both excisional and burn wound mouse models.
• Growth factor–releasing nanoparticles. Growth factors have been found to speed the healing of acute and chronic wounds in humans, including Regranex, a analogue of platelet-derived growth factor that is FDA-approved for treating leg and foot ulcers in diabetic patients, epidermal growth factor (donor-site wounds), fibroblast growth factor (burn wounds), and growth hormone (donor sites in burned children). "Nanomaterials offer many advantages here, from allowing for temporal release depending on the wound environment to delivering multiple factors at the same or different times, to even serving as a structural foundation for wound healing while releasing factors simultaneously," Dr. Friedman said. "The possibilities are limitless."
Dr. Friedman characterized nanomedicine as "a newborn branch of science. These promising and innovative tools should help us overcome limitations of traditional wound care, improve direct intervention on phases of wound healing, and provide better solutions for wound dressing that induce favorable wound healing environments. More work – and funding – is needed."
Dr. Friedman disclosed that he is a consultant and/or a member of the scientific advisory board for SanovaWorks, Prodigy, Oakstone Institute, Liquidia Technologies, L’Oréal, Amgen, Onset, Aveeno, GSK, MicroCures, and Nano Bio-Med. He is also a speaker for Onset and Amgen.
This article was updated March 24, 2014.
AT THE AAD ANNUAL MEETING
VIDEO: Try ‘restaurant menu’ approach to laser treatment of scars
CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.
CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.
CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.
EXPERT ANALYSIS FROM THE ODAC CONFERENCE
Practice Question Answers: Closure Materials
1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?
a. memory
b. plasticity
c. pliability
d. size
e. stretching
2. Which of the following has the highest memory?
a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel
3. The most worrisome consequence of capillarity is:
a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength
4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?
a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)
5. Knot security is thought to be most directly related to which property of suture:
a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength
1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?
a. memory
b. plasticity
c. pliability
d. size
e. stretching
2. Which of the following has the highest memory?
a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel
3. The most worrisome consequence of capillarity is:
a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength
4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?
a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)
5. Knot security is thought to be most directly related to which property of suture:
a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength
1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?
a. memory
b. plasticity
c. pliability
d. size
e. stretching
2. Which of the following has the highest memory?
a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel
3. The most worrisome consequence of capillarity is:
a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength
4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?
a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)
5. Knot security is thought to be most directly related to which property of suture:
a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength
Closure Materials
State-of-the-Art Wound Healing: Skin Substitutes for Chronic Wounds
Cosmetic Corner: Dermatologists Weigh in on Scar Treatments
To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:
Valeant Consumer Products, a division of Valeant Pharmaceuticals North America LLC
“Biafine Topical Emulsion has a very nice effect on scars and erthema.”—Jeffrey M. Weinberg, MD, New York, New York
• BioCorneum HC
Enaltus, LLC
“I like Biocorneum HC for hypertrophic scars. It is a silicone gel scar cream with sunscreen and low-potency steroid. It is a good combination product and patients like it.”—Amy J. Derick, MD, Barrington, Illinois
Enaltus, LLC
Recommended by Anthony M. Rossi, MD, New York, New York
Mertz Pharmaceuticals, LLC
Recommended by Kenneth Beer, MD, Miami, Florida
Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:
Valeant Consumer Products, a division of Valeant Pharmaceuticals North America LLC
“Biafine Topical Emulsion has a very nice effect on scars and erthema.”—Jeffrey M. Weinberg, MD, New York, New York
• BioCorneum HC
Enaltus, LLC
“I like Biocorneum HC for hypertrophic scars. It is a silicone gel scar cream with sunscreen and low-potency steroid. It is a good combination product and patients like it.”—Amy J. Derick, MD, Barrington, Illinois
Enaltus, LLC
Recommended by Anthony M. Rossi, MD, New York, New York
Mertz Pharmaceuticals, LLC
Recommended by Kenneth Beer, MD, Miami, Florida
Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:
Valeant Consumer Products, a division of Valeant Pharmaceuticals North America LLC
“Biafine Topical Emulsion has a very nice effect on scars and erthema.”—Jeffrey M. Weinberg, MD, New York, New York
• BioCorneum HC
Enaltus, LLC
“I like Biocorneum HC for hypertrophic scars. It is a silicone gel scar cream with sunscreen and low-potency steroid. It is a good combination product and patients like it.”—Amy J. Derick, MD, Barrington, Illinois
Enaltus, LLC
Recommended by Anthony M. Rossi, MD, New York, New York
Mertz Pharmaceuticals, LLC
Recommended by Kenneth Beer, MD, Miami, Florida
Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
Mohs surgery site, not type, predicts risk of suture contamination
CHICAGO – Bacterial contamination of sutures is surprisingly common, and periorificial sites have a suture contamination rate of nearly 100%, according to a study of sutures collected during Mohs micrographic surgeries in 182 patients.
There’s no direct correlation between suture contamination and surgery site infection, said Dr. Jeremy Sunseri of Brown University, Providence, R.I., who presented the unpublished study at the annual meeting of the American Society of Dermatologic Surgery. However, knowing the risk factors for suture contamination can help reduce the risk of infections and potential antibiotic overuse, he noted.
"For instance, the use of antibiotic-coated sutures in high-risk contamination sites, or variations on draping techniques in these areas, may prove beneficial," Dr. Sunseri noted.
The investigators removed 338 sutures directly from their sterile surgery sites, and placed them in Petri dishes with a growth medium used for the isolation of gram-positive organisms.
They further classified the sutures based on anatomic locations (17), type of surgical closure (5), and suture type (7).
More than 57% of all sutures had bacterial growth, and almost all of those collected from the nose, mouth/lip, eye/orbit were contaminated.
Sutures collected from the scalp, neck, trunk, and upper and lower extremities had significantly lower risk of contamination, ranging from 0% to 20%, with the exception of the groin, which showed a 100% contamination rate.
Sutures from flap repairs were the most frequently contaminated (71%). Sutures collected from complex closures also had a relatively high rate of contamination (68%).
Sutures from intermediate repairs had a contamination rate of 47%, while grafts, purse string closures, and incomplete closures had a 44% rate.
Staphylococci were the most commonly identified bacteria, notably isolates of of Propionibacterium acnes, Corynebacterium sp., and Rothia dentocariosa.
There were no significant differences in the contamination rates of the seven different types of sutures studied.
"The take-home message is that the suture is long and patients are dirty, so be careful where you put that suture," Dr. Sunseri said during his presentation.
Dr. Sunseri had no financial conflicts to disclose.
On Twitter @NaseemSMiller
CHICAGO – Bacterial contamination of sutures is surprisingly common, and periorificial sites have a suture contamination rate of nearly 100%, according to a study of sutures collected during Mohs micrographic surgeries in 182 patients.
There’s no direct correlation between suture contamination and surgery site infection, said Dr. Jeremy Sunseri of Brown University, Providence, R.I., who presented the unpublished study at the annual meeting of the American Society of Dermatologic Surgery. However, knowing the risk factors for suture contamination can help reduce the risk of infections and potential antibiotic overuse, he noted.
"For instance, the use of antibiotic-coated sutures in high-risk contamination sites, or variations on draping techniques in these areas, may prove beneficial," Dr. Sunseri noted.
The investigators removed 338 sutures directly from their sterile surgery sites, and placed them in Petri dishes with a growth medium used for the isolation of gram-positive organisms.
They further classified the sutures based on anatomic locations (17), type of surgical closure (5), and suture type (7).
More than 57% of all sutures had bacterial growth, and almost all of those collected from the nose, mouth/lip, eye/orbit were contaminated.
Sutures collected from the scalp, neck, trunk, and upper and lower extremities had significantly lower risk of contamination, ranging from 0% to 20%, with the exception of the groin, which showed a 100% contamination rate.
Sutures from flap repairs were the most frequently contaminated (71%). Sutures collected from complex closures also had a relatively high rate of contamination (68%).
Sutures from intermediate repairs had a contamination rate of 47%, while grafts, purse string closures, and incomplete closures had a 44% rate.
Staphylococci were the most commonly identified bacteria, notably isolates of of Propionibacterium acnes, Corynebacterium sp., and Rothia dentocariosa.
There were no significant differences in the contamination rates of the seven different types of sutures studied.
"The take-home message is that the suture is long and patients are dirty, so be careful where you put that suture," Dr. Sunseri said during his presentation.
Dr. Sunseri had no financial conflicts to disclose.
On Twitter @NaseemSMiller
CHICAGO – Bacterial contamination of sutures is surprisingly common, and periorificial sites have a suture contamination rate of nearly 100%, according to a study of sutures collected during Mohs micrographic surgeries in 182 patients.
There’s no direct correlation between suture contamination and surgery site infection, said Dr. Jeremy Sunseri of Brown University, Providence, R.I., who presented the unpublished study at the annual meeting of the American Society of Dermatologic Surgery. However, knowing the risk factors for suture contamination can help reduce the risk of infections and potential antibiotic overuse, he noted.
"For instance, the use of antibiotic-coated sutures in high-risk contamination sites, or variations on draping techniques in these areas, may prove beneficial," Dr. Sunseri noted.
The investigators removed 338 sutures directly from their sterile surgery sites, and placed them in Petri dishes with a growth medium used for the isolation of gram-positive organisms.
They further classified the sutures based on anatomic locations (17), type of surgical closure (5), and suture type (7).
More than 57% of all sutures had bacterial growth, and almost all of those collected from the nose, mouth/lip, eye/orbit were contaminated.
Sutures collected from the scalp, neck, trunk, and upper and lower extremities had significantly lower risk of contamination, ranging from 0% to 20%, with the exception of the groin, which showed a 100% contamination rate.
Sutures from flap repairs were the most frequently contaminated (71%). Sutures collected from complex closures also had a relatively high rate of contamination (68%).
Sutures from intermediate repairs had a contamination rate of 47%, while grafts, purse string closures, and incomplete closures had a 44% rate.
Staphylococci were the most commonly identified bacteria, notably isolates of of Propionibacterium acnes, Corynebacterium sp., and Rothia dentocariosa.
There were no significant differences in the contamination rates of the seven different types of sutures studied.
"The take-home message is that the suture is long and patients are dirty, so be careful where you put that suture," Dr. Sunseri said during his presentation.
Dr. Sunseri had no financial conflicts to disclose.
On Twitter @NaseemSMiller
AT THE ASDS ANNUAL MEETING
Major finding: Nearly 100% of sutures removed from periorificial surfaces showed bacterial contamination.
Data source: Analysis of bacterial growth from 338 sutures removed directly from the sterile surgery site in 182 patients.
Disclosures: Dr. Sunseri had no financial conflicts to disclose.
Creams and patches can replace narcotics for skin pain
LAS VEGAS – A topical mixture of amitriptyline and ketamine controls pain in a variety of skin conditions, even when more traditional options fail, according to Dr. Mark Davis, chair of the division of clinical dermatology at the Mayo Clinic in Rochester, Minn.
"We are getting patients off systemic narcotics with these mixtures," he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Lidocaine patches are allowing leg ulcer patients to drop narcotics, too, and are greatly helping those with erythromelalgia, an often-misdiagnosed condition involving intermittent and excruciating, burning pain in the feet, hands, and sometimes ears. "To have something topical [for such pain] is terrific," Dr. Davis said.
The Mayo Clinic uses topical amitriptyline and ketamine for brachioradial pruritus, erythromelalgia, rectogenital and perineal pain, and other localized skin pain recalcitrant to oral medications and other standard approaches. Dr. Davis and his colleagues recently published several reviews and retrospective studies on the use of topical pain relievers, including a recent article showing that more than half the patients who used topical amitriptyline-ketamine for pain reported substantial or complete relief (Pain Physician 2012;15:485-8).
Pharmaceutical companies are working to bring the combination to market, but it’s not yet available commercially, so Mayo Clinic dermatologists have their pharmacists compound it in two strengths – 2% amitriptyline and either 0.5% or 5% ketamine – using Lipoderm cream as the base, according to Dr. Davis. Patients apply the mixture three times daily. Why it works isn’t clear; the drugs have different and perhaps synergistic effects on skin pain.
"I try to get people to use it [the product] on small parts of the body, such as the hands and feet, and, in patients with brachioradial pruritus, both arms," said Dr. Davis. "I’ve never used it any more extensively than that; I am afraid patients would absorb too much ketamine," he said.
Of more than 1,000 Mayo Clinic patients who have tried the combination, "I’d say less than 1% has told me that they’ve ever had a side effect," he said. "I’ve had just two or three patients tell me they’ve gotten nightmares," a known effect of ketamine. "This is a product that has great promise," he noted.
Meanwhile, some erythromelalgia patients at the Mayo Clinic have been able to walk again after applying lidocaine patches to their feet, and the clinicians there consider the patches first-line treatment for the condition. "Many patients are well controlled just by using [the patches], and I don’t think I’ve come across any side effects in the hundreds of patients I’ve treated," Dr. Davis said. In the inherited form of the disease, which accounts for perhaps 5% of cases, erythromelalgia is caused by a genetic sodium channel glitch that keeps nerves in the skin firing once they are stimulated.
Lidocaine patches also are "really useful for patients with bad, painful ulcers; I use [them] over whatever wound care I am using," Dr. Davis noted. Sometimes these patients can discontinue, or at least reduce, their use of narcotics, he said.
Lidocaine helps with debridement, too. "For leg ulcers, our nurses take 4 x 4-inch gauze and soak it in lidocaine 4% solution, and leave it on the ulcer for about 20 minutes. We are usually able to debride those ulcers [after that] even if they were very painful to start," he said.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – A topical mixture of amitriptyline and ketamine controls pain in a variety of skin conditions, even when more traditional options fail, according to Dr. Mark Davis, chair of the division of clinical dermatology at the Mayo Clinic in Rochester, Minn.
"We are getting patients off systemic narcotics with these mixtures," he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Lidocaine patches are allowing leg ulcer patients to drop narcotics, too, and are greatly helping those with erythromelalgia, an often-misdiagnosed condition involving intermittent and excruciating, burning pain in the feet, hands, and sometimes ears. "To have something topical [for such pain] is terrific," Dr. Davis said.
The Mayo Clinic uses topical amitriptyline and ketamine for brachioradial pruritus, erythromelalgia, rectogenital and perineal pain, and other localized skin pain recalcitrant to oral medications and other standard approaches. Dr. Davis and his colleagues recently published several reviews and retrospective studies on the use of topical pain relievers, including a recent article showing that more than half the patients who used topical amitriptyline-ketamine for pain reported substantial or complete relief (Pain Physician 2012;15:485-8).
Pharmaceutical companies are working to bring the combination to market, but it’s not yet available commercially, so Mayo Clinic dermatologists have their pharmacists compound it in two strengths – 2% amitriptyline and either 0.5% or 5% ketamine – using Lipoderm cream as the base, according to Dr. Davis. Patients apply the mixture three times daily. Why it works isn’t clear; the drugs have different and perhaps synergistic effects on skin pain.
"I try to get people to use it [the product] on small parts of the body, such as the hands and feet, and, in patients with brachioradial pruritus, both arms," said Dr. Davis. "I’ve never used it any more extensively than that; I am afraid patients would absorb too much ketamine," he said.
Of more than 1,000 Mayo Clinic patients who have tried the combination, "I’d say less than 1% has told me that they’ve ever had a side effect," he said. "I’ve had just two or three patients tell me they’ve gotten nightmares," a known effect of ketamine. "This is a product that has great promise," he noted.
Meanwhile, some erythromelalgia patients at the Mayo Clinic have been able to walk again after applying lidocaine patches to their feet, and the clinicians there consider the patches first-line treatment for the condition. "Many patients are well controlled just by using [the patches], and I don’t think I’ve come across any side effects in the hundreds of patients I’ve treated," Dr. Davis said. In the inherited form of the disease, which accounts for perhaps 5% of cases, erythromelalgia is caused by a genetic sodium channel glitch that keeps nerves in the skin firing once they are stimulated.
Lidocaine patches also are "really useful for patients with bad, painful ulcers; I use [them] over whatever wound care I am using," Dr. Davis noted. Sometimes these patients can discontinue, or at least reduce, their use of narcotics, he said.
Lidocaine helps with debridement, too. "For leg ulcers, our nurses take 4 x 4-inch gauze and soak it in lidocaine 4% solution, and leave it on the ulcer for about 20 minutes. We are usually able to debride those ulcers [after that] even if they were very painful to start," he said.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – A topical mixture of amitriptyline and ketamine controls pain in a variety of skin conditions, even when more traditional options fail, according to Dr. Mark Davis, chair of the division of clinical dermatology at the Mayo Clinic in Rochester, Minn.
"We are getting patients off systemic narcotics with these mixtures," he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Lidocaine patches are allowing leg ulcer patients to drop narcotics, too, and are greatly helping those with erythromelalgia, an often-misdiagnosed condition involving intermittent and excruciating, burning pain in the feet, hands, and sometimes ears. "To have something topical [for such pain] is terrific," Dr. Davis said.
The Mayo Clinic uses topical amitriptyline and ketamine for brachioradial pruritus, erythromelalgia, rectogenital and perineal pain, and other localized skin pain recalcitrant to oral medications and other standard approaches. Dr. Davis and his colleagues recently published several reviews and retrospective studies on the use of topical pain relievers, including a recent article showing that more than half the patients who used topical amitriptyline-ketamine for pain reported substantial or complete relief (Pain Physician 2012;15:485-8).
Pharmaceutical companies are working to bring the combination to market, but it’s not yet available commercially, so Mayo Clinic dermatologists have their pharmacists compound it in two strengths – 2% amitriptyline and either 0.5% or 5% ketamine – using Lipoderm cream as the base, according to Dr. Davis. Patients apply the mixture three times daily. Why it works isn’t clear; the drugs have different and perhaps synergistic effects on skin pain.
"I try to get people to use it [the product] on small parts of the body, such as the hands and feet, and, in patients with brachioradial pruritus, both arms," said Dr. Davis. "I’ve never used it any more extensively than that; I am afraid patients would absorb too much ketamine," he said.
Of more than 1,000 Mayo Clinic patients who have tried the combination, "I’d say less than 1% has told me that they’ve ever had a side effect," he said. "I’ve had just two or three patients tell me they’ve gotten nightmares," a known effect of ketamine. "This is a product that has great promise," he noted.
Meanwhile, some erythromelalgia patients at the Mayo Clinic have been able to walk again after applying lidocaine patches to their feet, and the clinicians there consider the patches first-line treatment for the condition. "Many patients are well controlled just by using [the patches], and I don’t think I’ve come across any side effects in the hundreds of patients I’ve treated," Dr. Davis said. In the inherited form of the disease, which accounts for perhaps 5% of cases, erythromelalgia is caused by a genetic sodium channel glitch that keeps nerves in the skin firing once they are stimulated.
Lidocaine patches also are "really useful for patients with bad, painful ulcers; I use [them] over whatever wound care I am using," Dr. Davis noted. Sometimes these patients can discontinue, or at least reduce, their use of narcotics, he said.
Lidocaine helps with debridement, too. "For leg ulcers, our nurses take 4 x 4-inch gauze and soak it in lidocaine 4% solution, and leave it on the ulcer for about 20 minutes. We are usually able to debride those ulcers [after that] even if they were very painful to start," he said.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
EXPERT ANALYSIS FROM THE SDEF LAS VEGAS DERMATOLOGY SEMINAR
When wounds won’t heal, try these strategies
SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:
• Have you diagnosed the wound correctly?
• What systemic conditions are keeping the wound from healing?
• Have you tailored your treatment to the wound correctly?
Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.
"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.
Ulcer types
The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.
Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.
Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.
A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.
Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."
Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.
Systemic conditions
Wound healing can be inhibited by things that doctors do, and by things that patients do.
Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.
Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.
When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.
Tailor therapy appropriately
Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.
Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.
Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.
For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.
When to refer
Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.
If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.
Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.
Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.
Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.
On Twitter @sherryboschert
SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:
• Have you diagnosed the wound correctly?
• What systemic conditions are keeping the wound from healing?
• Have you tailored your treatment to the wound correctly?
Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.
"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.
Ulcer types
The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.
Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.
Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.
A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.
Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."
Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.
Systemic conditions
Wound healing can be inhibited by things that doctors do, and by things that patients do.
Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.
Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.
When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.
Tailor therapy appropriately
Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.
Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.
Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.
For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.
When to refer
Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.
If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.
Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.
Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.
Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.
On Twitter @sherryboschert
SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:
• Have you diagnosed the wound correctly?
• What systemic conditions are keeping the wound from healing?
• Have you tailored your treatment to the wound correctly?
Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.
"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.
Ulcer types
The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.
Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.
Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.
A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.
Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."
Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.
Systemic conditions
Wound healing can be inhibited by things that doctors do, and by things that patients do.
Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.
Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.
When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.
Tailor therapy appropriately
Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.
Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.
Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.
For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.
When to refer
Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.
If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.
Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.
Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.
Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.
On Twitter @sherryboschert
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE PACIFIC DERMATOLOGIC ASSOCIATION
Mystery leg lesions and low vitamin C? Think scurvy
When repeated dermatologic treatments for skin lesions on a patient's lower extremities didn't lead to resolution, Dr. Richard C. Glogau decided to check the patient's vitamin C levels. What he found was "a big shock": The cause of the lesions was a scourge that once plagued sailors throughout history: scurvy. Dr. Glogau has since discovered more cases masquerading as hard-to-treat skin disorders.
When repeated dermatologic treatments for skin lesions on a patient's lower extremities didn't lead to resolution, Dr. Richard C. Glogau decided to check the patient's vitamin C levels. What he found was "a big shock": The cause of the lesions was a scourge that once plagued sailors throughout history: scurvy. Dr. Glogau has since discovered more cases masquerading as hard-to-treat skin disorders.
When repeated dermatologic treatments for skin lesions on a patient's lower extremities didn't lead to resolution, Dr. Richard C. Glogau decided to check the patient's vitamin C levels. What he found was "a big shock": The cause of the lesions was a scourge that once plagued sailors throughout history: scurvy. Dr. Glogau has since discovered more cases masquerading as hard-to-treat skin disorders.
