Treating Lower Extremity Wounds In The Face Of Systemic Disease

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Treating Lower Extremity Wounds In The Face Of Systemic Disease
The clinical appearance of this erythematous nodule is highly characteristic of a melanoma with a large central nodule, possibly arising within a congenital nevus. (Photo courtesy of James Q. Del Rosso, DO, FAOCD)
Clinical Editor: Lawrence Karlock, DPM

   A: Taking a biopsy is key to identifying a malignant wound, according to Drs. Miller and Schlanger. However, Dr. Miller notes the trick is knowing when to biopsy. One would biopsy a wound that continues to get worse despite appropriate therapy and also has a negative systemic workup, advises Dr. Miller. Dr. Schlanger says one should biopsy a wound that has not responded after 30 days of treatment. He adds that one should include the lesion and normal skin for a biopsy or else the pathologist is merely considering the inflamed cells of the wound.

   Dr. Karlock concurs. He says clinicians should have a higher index of suspicion for malignancy when dealing with wounds that have not responded to conventional therapy and wounds that have growing or spreading lesions with irregular borders.

   In addition, Dr. Miller notes a wound that recurs after apparent healing warrants a biopsy and a patient with a history of skin or soft tissue malignancies is at risk for recurrence. Recently, he treated a patient with multiple ulcerated lesions on her fingers and hands, and the patient had previously had a squamous cell carcinoma of the arm removed. Her biopsies showed these hand lesions were squamous cell carcinoma as well, according to Dr. Miller.

   Q: Do you have any special concerns or pearls for treating the renal failure patient with a chronic wound? What about treating rheumatoid arthritic patients with lower extremity wounds?

   A: Dr. Schlanger has experienced the most problems with his renal failure patients, saying he finds calciphylaxis very difficult to treat. In these cases, he says it is important to keep the lesion clean and avoid debridement unless it is necessary. Managing the calcium level in the wound will keep the lesion self-contained and facilitate eventual healing, according to Dr. Schlanger. He emphasizes control of edema and infection through effective dialysis and early recognition of cellulitis.

   When treating patients with renal failure, Dr. Miller has noted generalized pruritus, which he calls “severe and unrelenting.” He says this leads to multiple severe wounds and cellulitis due to scratching. If anti-pruritic medications do not work, Dr. Miller will order a systemic workup to rule out other causes. The goal of treatment, according to Dr. Miller, is minimizing the potential for more trauma while permitting the healing of the injured tissue. “In other words, the goal is to treat the cause which, in this case, is self-trauma,” he notes.

   Dr. Miller will use a zinc oxide impregnated gauze wrap (Unna’s Boot) to protect the injured skin from the traumatizing fingers. He applies multiple layers of the wrap and covers it with a cohesive bandage. Dr. Miller says he leaves the wrap on for a week and then reapplies it. When the ZnO2 layers fit snugly with the skin, Dr. Miller says the layers prevent patients from getting into the wraps, adding that even if they rub the outside of the wrap to scratch, the resultant trauma is still reduced. For these patients, Dr. Miller will also consider using topical steroids under the wraps and adjunctive use of anti-pruritic medications.

       “The end stage renal patient with diabetes is a notoriously poor candidate for lower extremity wound healing,” adds Dr. Karlock. “Even under the best of circumstances, these patients seem to poorly heal these wounds.”

   As for rheumatoid arthritis, Dr. Schlanger has found steroids and other chemotherapy agents work against wound healing. He splints the extremity, uses padding to prevent further breakdown and cautions that patients need to maintain nutrition to promote healing. “These patients are fragile and need to be handled very carefully,” advises Dr. Schlanger.

   Q:What systemic factors negatively affect wound healing?

   A: All three panelists cite diabetes as a negative factor with Dr. Schlanger noting that patients cannot heal until they have good glucose control. Drs. Karlock and Miller cite malnutrition and anemia for their affects on wound healing.

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