Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

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Everyday Agents You Can Use For Wound Care

Serous drainage/weeping dermatitis: 0.9% NaCl, wet-to-dry dressings
Green-ish colonization (Pseudomonas): 3% boric acid, wet-to-dry dressings
Yellow fibrous base: 10% benzoyl peroxide occlusion
Verrucous change/keratin plaques: Ammonium lactate 12% bid
Xerosis: Lactic acid 10% cream, vitamin E 3,500 units bid
Dermatitis: Topical steroids, hydrocortisone derivatives

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Author(s): 
Molly Judge, DPM, FACFAS

   In contrast, chronic wounds often result from systemic etiologies such as peripheral vascular disease (PVD), impaired venous return (chronic venous stasis and venous hypertension), diabetes, autoimmune disease, obesity, poor nutrition and illicit drug use, just to name a few key conditions. Documented cases of spider bites or other wounds that involve venom retention and tissue necrosis are particularly troublesome and can complicate the health of patients with diabetes suffering from neuropathy as they often lack sufficient protective sensation to feel the bite or sting of the insect. These conditions result in wounds that are slow to heal and the clinical course of healing is often unpredictable.

   Mechanical wounds, which are often associated with peripheral neuropathy and foot deformity, can be either acute or chronic depending on the time to discovery and how promptly the patient reported the wound to a physician. In either case, acute or chronic, wounds that have exposed subcutaneous tissues are at higher risk for bacterial colonization and infection in contrast to the more superficial wounds. Be certain to categorize the etiology of the wound and consistently document that with each successive note.

When Bacterial Colonization And Infection Impede Wound Healing

Bacterial colonization or infection can slow if not halt wound healing, especially in the patient with diabetes. If malodor or discoloration of the wound and surrounding skin are present, be suspicious that bacteria or fungal elements may be working against healing the wound bed. A biopsy of the tissue is the best way to determine whether there is bacteria or fungus affecting the wound. A tissue culture will allow differentiation between colonization and infection as the microbiology lab can quantify organisms within tissues. From an academic standpoint, researchers suspect the density of microorganisms is the critical factor in determining whether a wound is likely to heal.3-7

   Since it is common to find that bacterial colonization and infection are polymicrobial, one can argue that the specific pathogens are of primary importance when wound healing appears to be blunted.8-13

   While it is intuitive that the specific organism and the numbers of those organisms that are present in a wound are important to determine when attempting to optimize wound healing, there are other researchers who put more credence in the type of material one places over the wound bed.14-20

   In fact, there has been a study to explore the potential benefits of using a topical bacteriophage solution to aid in reducing bacterial load and enhancing the wound healing process.21 This study used an animal model and based upon histologic findings, researchers demonstrated that topically applied bacteriophage treatment effectively decreased bacterial colony counts and improved wound healing. The study notes the treatment was the most effective in Staphylococcus aureus and Pseudomonas aeruginosa infections but the results were not as promising with the organism Acinetobacter baumannii.

   These results suggest that topically administered bacteriophage treatment may be effective in resolving chronic infections, especially when one applies them in conjunction with wound debridement. From these findings, I extrapolated that this treatment can be effective and safe when treating chronic infections in diabetic populations.

Understanding The Dynamics Of Common Diabetic Dermatopathology

The nature and extent of diabetic dermopathy oftentimes interferes with the wound healing process. Unfortunately, while diabetic dermopathy is often obvious clinically, it is not often diagnosed, much less treated.

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