Expert Insights On Wound Care Products

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This woman has rheumatoid vasculitic ulcers on both of her legs. Dr. Karlock says he has used growth factors with success on vasculitic ulcers.
As you can see, this heel has pressure induced neuropathic heel ulcerations with buds of granulation.
This patient’s toe shows a macerated neuropathic ulcer.
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The array of wound care products can be quite astounding. Choosing the right product(s) for your patient can be difficult. With this in mind, our panelists, strongly emphasizing case-by-case management, share their experiences, success stories and caveats with certain wound care products. Read on for what five expert panelists had to say about treating neuropathic ulcers, when to use growth factors and the role of wet-to-dry dressings.
Q: What wound care products do you use on the diabetic neuropathic ulcer?
A:
All of the panelists agree that appropriate product selection is done on a case-by-case basis. Edwin Blitch, IV, DPM, adds that he considers several factors before prescribing a particular wound care regimen. These factors include: type and duration of the ulcer; anatomic location; patient compliance; comorbid conditions; and affordability.
In treating diabetic neuropathic ulcers, Jason Hanft, DPM, looks for products that provide a moist wound healing environment, bandages that maintain moist wound healing and other products that are easy for the patient to use. To that end, Dr. Hanft says he uses topical hydrogels, topical antibiotics and topical antibiotic bandages (i.e. Acticoat and Iodoflex).

For stable, dry and granulating wounds, Jordan Grossman, DPM, says he uses either normal saline moist to dry dressing changes or hydrogel for patients who are only compliant enough for once-a-day dressing changes. Dr. Blitch adds that many of the hydrogel products are quite effective in promoting re-epithelialization of chronic wounds that have a healthy base of granulation tissue.
For the macerated, neuropathic ulceration, Lawrence Karlock, DPM, emphasizes once-a-day application of Iodosorb gel with a dry, sterile dressing. Once the ulcer becomes more beefy with less hyperkeratotic tissue, Dr. Karlock will switch to one of the hydrogel dressings or even Bactroban cream on a daily basis.
Dr. Grossman also uses Bactroban, as well as silver-based products or acetic acid, to treat colonized or superficially infected wounds. When you see wounds with extensive infection, he says performing an I&D is essential for controlling the infectious process.
Barry Rosenblum, DPM, notes that he is a “firm believer” that the most important aspect of wound care is offloading. “In addition to an adequate debridement, (offloading) is probably more conducive to wound healing than any one particular product,” emphasizes Dr. Rosenblum.

Q: What is your favorite wound debridement agent?
A:
Drs. Hanft and Rosenblum say their favorite debridement agent is a scalpel. More specifically, Dr. Hanft recommends sharp debridement of vascularized lower extremity wounds in order to initiate an acute wound healing phase, remove nonviable tissue and decrease bacterial count. Dr. Grossman also primarily relies upon sharp debridements for removing necrotic tissue.
Dr. Hanft says the only time he will use a debriding agent (enzymatic or topical) is when patients are dysvascular and cannot undergo debridement, and are non-bypassable.

Dr. Rosenblum adds that he has used Panafil in the past with some success, but only on certain wounds. While Dr. Grossman doesn’t use a lot of enzymatic debriding agents, when he does go that route, he uses Accuzyme. Dr. Karlock employs Accuzyme when performing aggressive debridement of a less necrotic ulcer with less eschar. Dr. Blitch also believes Accuzyme is a good option in the right situation.
“This product has assisted surgical debridements beyond that of any other product I have ever utilized in the past,” explains Dr. Blitch. “I have not found it uncomfortable for my patients after daily application. In fact, Accuzyme allows efficient enzymatic debridement on patients who are unable to tolerate excision of necrotic eschar with a surgical instrument.”
Dr. Karlock notes that he also uses Santyl and Polysporin powder, as “these agents seem not to be irritating to the ulcer itself and the surrounding skin.”

Q: Do you use growth factors? If so, when do you use them?
A:
Dr. Blitch cautions that growth factor products tend to be cost-prohibitive for many patients. All of the panelists agree that you should reserve the use of growth factors for recalcitrant wounds that have failed conserative treatments. Dr. Grossman also uses growth factors on patients who have marginal blood supply.

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