He says it is superior to traditional sharp debridement, noting that it is quicker, stimulates wound healing and is easy to use. For outpatients, Dr. Armstrong will use ultrasound units for debridement. He has found success with Misonix and Soring devices, saying the results remind him of the results he has with maggot debridement therapy. Q: What topical antimicrobials do you employ for lower extremity wounds? A:
Dr. Kravitz cites the use of various silver, cadexomer iodine and biguanide products, all of which are broad spectrum and treat resistant bacteria such as methicillin resistant Staph aureus
(MRSA) and vancomycin resistant Enterococcus
(VRE). He touts SilvaSorb Gel (Medline Industries), an ionic silver that delivers a sustained release. Dr. Kravitz says SilvaSorb Gel is cost effective because when one applies it with any non-adherent, the silver dressing it forms is often less expensive than many packaged dressings. For patients who have severe dermatosclerosis with deep skin fissures and skin creases, he notes the gel permits direct contact with these patients’ irregular skin surfaces. Dr. Armstrong has had promising results with silver-based antimicrobials. However, he notes every wound healing company has its own silver products. He says the silver arena has become so saturated that only the advent of meaningful clinical trials can help differentiate between the different silver modalities. Such studies are starting to emerge but Dr. Armstrong notes their scope is less than impressive. In addition, Dr. Kravitz uses the broad-spectrum XCell®
Cellulose Dressings Antimicrobial with 0.3% polyhexamethylene biguanide (PHMB) (Medline Industries). He says patients with very sensitive ulcers tolerate this dressing well. Dr. Kravitz says the dressing hydrates a dry portion of a wound and absorbs exudate from another area of the same wound. For most wounds, Dr. Karlock uses mupirocin (Bactroban 2% Cream, Glaxo SmithKline) for moist wound healing, saying it does not seem to macerate as many hydrogels do. For a macerated neuropathic foot wound, he initially employs Iodosorb Gel™
(Smith & Nephew) as a topical agent. Dr. Armstrong and his group, the Center for Lower Extremity Ambulatory Research (CLEAR), are currently looking at topical and regionally-delivered antimicrobials that are “a few generations beyond silver.” Peptide-based antimicrobials and bacteriophage technologies are becoming more viable for use, according to Dr. Armstrong, who notes this month’s International Diabetic Foot Conference (www.dfcon.com
) will have a symposium about these technologies. Dr. Armstrong is a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine in Chicago. He is the founder and Director of CLEAR, and is an immediate past member of the National Board of Directors of the American Diabetes Association. Dr. Kravitz is a Fellow of the American College of Foot and Ankle Surgeons, and the American Professional Wound Care Association. He is an Assistant Professor in the Department of Orthopedics and is on the clinical faculty for the Advanced Wound Healing Center at the Temple University School of Podiatric Medicine. Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.
References 1. Nelson J. An evaluation of the efficacy of the Circulator Boot™ altering hemodynamics of the ischemic lower extremity and foot. 2. Vela A, Carlson LA, Blier B, Felty C, Kuiper JD and Rooke TW. Circulator boot therapy alters the natural history of ischemic limb ulceration. Vascular Medicine 5:21-25, 2000. 3. Armstrong D, Lavery L. Negative pressure wound therapy after partial diabetic foot amputation: a multicenter, randomized controlled trial. Lancet 366:1704-1710, 2005.