Dermatology

PCP submission

68 yo Female, PMHx Heart Failure, HTN, HLD, PAD who is currently wheelchair dependent. She currently has a pressure ulcer of the sacral region, stage 3. She does have a home health aide who assists her with ADLs and dressing changes. Dressings currently utilized include: Medihoney and zinc oxide as well as antibiotic ointment, all applied three times weekly (MWF) with dressing changes in next 1-2 weeks then two times weekly.

Photo attached in eConsult submission.

Can you please evaluate and treat for wound care given the patient’s current condition?

Specialist response

You present a 68 yr old female patient with a stage 3 sacral pressure wound. Recommendations and discussion: The history and location indeed strongly suggest a pressure wound or decubitus ulcer. This is a challenging problem for patients in this setting. We are often asked what to put on these wounds in terms of topical treatment, salves, antibiotics, bandages, and the like. Many years ago I was taught that what really matters is what we do NOT put on the wound, which is the weight of the patient. Choice of topical treatment is less important. These wounds characteristically occur over bony prominences such as heels, greater trochanter, sacrum, coccyx, ischium. The wounds commonly develop in the context of immobility, lack of sensation, and related comorbid conditions. Pressure wounds on the heels are often associated with underlying ischemia. In the case of a pressure wound on the heel it is crucial to verify that there is adequate circulation. This begins with a careful examination of pulses at dorsal pedal and posterior tibial positions. When healthy pulses are not present referral to vascular surgery is a high priority in this setting. The primary treatment is to get the pressure off the wound rigorously and consistently. This requires repositioning the patient regularly, rolling from side to side, using specialty support surfaces such as air mattresses designed for the purpose. Specialized gel cushions in chairs are needed, chair “push-ups” are recommended, limiting sitting to 30 minutes at a time is needed. Debridement of necrotic material is a very important step in care. Debrided tissue is cultured; this is far better than a swab culture which captures primarily contaminants on the surface. Appropriate antibiotics directed by culture are used if needed (and avoided if not needed to prevent overgrowth of resistant strains such as MRSA, VRE, pseudomonas, candida, etc). Healing of these wounds can be limited by nutritional problems. Protein supplements, Vit C supplements, and Zinc are often prescribed. A large number of topical treatments are available for use on these ulcers. There is, in certain instances, some support in wound care literature for some of these dressings. The wound care literature is confusing, largely uncontrolled, offers limited help in guiding choice between topical agents. It is almost entirely industry funded, and designed to gain FDA approval for marketing new products rather than to compare outcomes and allow an evidence-based choice between available topical agents. The environment on the wound surface is best kept moist. A partial thickness wound (stage 2) can often be dressed with xeroform. There is an advantage to keeping tape off the surrounding skin, as this too can lead to skin damage as it is removed. Hydrocolloid (“Duoderm”) is another product that is commonly used. It can stay in place for 2-3 days at a time, and is relatively nontraumatic on its removal. It provides some help with debridement of necrotic material. Another simple wound dressing to keep the wound moist is Hydrogel, covered with a simple gauze dressing. There are countless other dressing options available. It is very difficult to find comparative controlled data to distinguish between outcomes with different dressings. This reinforces the point that what is most important is “un-weighting” or “off-loading” the wound area. (This is also the hardest thing to achieve). Wound Vacs can be helpful after a wound is cleanly debrided. The location of the wound can make them tough to maintain. Biological dressings, sometimes referred to inaccurately as “skin substitutes” are also employed in some cases. The problem is that strict off-loading has to be maintained for healing, regardless of use of biologicals or a wound vac. Surgical flaps have a place in management of these wounds in selected patients. Reconstructive plastic surgery is the appropriate specialty. I believe the qualifications include a patient who is motivated and able to maintain really strict unweighting/off-loading for weeks after the procedure so that the healing flap is not damaged by pressure. I hope these thoughts help. Intense focus and effort is needed to maintain off-loading, and other efforts are often not helpful unless unweighting is rigorously maintained. It is the simplest principle, but also the hardest measure to achieve. (These thoughts are based on information that has been shared by the individual caring for a patient, without benefit of a comprehensive personal evaluation including history and/or physical examination. These thoughts are offered for the benefit of the patient’s provider and represent general comments regarding questions or concerns brought forward by the treating provider or providers. These thoughts do not constitute direct patient care as there is no personal professional contact with a patient.) Recommendations for Immediate Next Step ( ) Condition can be managed within primary care: Recommendations provided for current scope of condition can be completed within primary care setting ( ) Options exist to maximize care within the primary care setting. These include frequent, rigorous positioning to “off-load” pressure from the wound, meticulous hygiene, debridement of necrotic material, culture of debrided tissue when infection is suspected, and dressings selected based on need for absorption of fluid (alginates), moistening a dry or desiccated wound (hydrogel, medihoney) or debriding non viable material (Santyl, hydrocolloid). Referral to general surgery, plastic surgery, or wound care is recommended when there are stage 4 wounds, or for wounds refractory to basic wound care measures as outlined.