Utilizing Topical Compounded Medications To Modulate Wound Healing

Author(s): 
Allen Jacobs, DPM, FACFAS

Compounding topical medications can help tailor the treatment of wounds to individual patient needs and may offer wound healing effects that are not otherwise available. This author explores how compounded topical medication can reduce pain, stimulate new tissue healing, increase vascular perfusion and decrease bioburden.

Ulceration is a pathologic condition that not infrequently confronts podiatric physicians. Common causes of ulceration in podiatry practices include ulceration secondary to venous insufficiency; decubitus ulceration, particularly on the posterior heel; ulceration associated with arterial insufficiency; mixed arteriovenous ulceration; and neuropathic ulcerations in patients with diabetes. Less commonly, ulceration is associated with malignancy, connective tissue disorder, hypertension or sickle cell anemia.

   Since ulcerations may differ in their etiology, addressing the evaluation and specific treatment of ulceration does require consideration of etiologic factors that may be unique to the development of the ulceration. For example, venous ulceration, which typically occurs in the area of the medial malleolus, results from poor venous function with increased venous pressure. Treatment options include compression therapy, the use of skin grafts or skin graft substitutes, open or endovascular management of incompetent venous structures, sclerosis of the veins and, of course, wound care for management of the ulceration.

   Constant unrelieved pressure causes decubitus ulcerations, resulting in a loss of blood supply and ischemia. We most often encounter this on the posterior aspect of the heel. The treatment of decubitus ulcerations frequently requires debridement and wound care as well as local flaps and grafts.

   Arterial insufficiency ulceration results from a lack of perfusion with subsequent necrosis of tissue. These are more common on the lateral aspect of the ankle joint, are typically painful and are associated with the clinical signs and symptoms of peripheral arterial disease (PAD). The treatment of arterial ulcers typically includes restoration of the vascular supply, debridement and wound care, and often amputation.

   Arteriovenous ulceration arises secondary to venous insufficiency in combination with PAD.

   Neuropathic diabetic foot ulceration is associated with areas of increased pressure or injury unperceived by the patient with diabetes secondary to sensory neuropathy. Such ulcers are also associated with an increased incidence of vascular disease. The treatment of such ulcers includes removal of pressure and offloading, improvement in vascular supply, reduction of bioburden, debridement and local wound care.

   Extemporaneous compounding helps physicians individualize the treatment required for patient specific needs and create topical preparations that are not otherwise commercially available.1 Topical compounded medications for ulcer management are adjunctive and work in conjunction with other principles of good wound care such as pressure relief, debridement, revascularization or hyperbaric oxygen therapy in order to enhance healing.

   Due to the varying etiologies of ulceration and the specific clinical presentation of each patient, the clinician must assess the unique needs of each patient and the particular clinical scenario. One would utilize compounded medications in the treatment of ulcerations when premade medications are insufficient or not available to meet those specific needs. Ultimately, the goal is the enhancement of wound healing.

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