Sound Evidence - April 2008 - (Page 63) contribute to cutaneous digital ulcer formation.2,4 Slow healing of digital ulcers in patients with underlying SSc is common and can be attributed to poor blood flow and tissue oxygenation, epidermal thinning in patients with longstanding disease, and skin tightly stretched over joints.2 The slow healing process renders these ulcers particularly vulnerable to infection.4 Digital ulcers in patients with SSc are associated with pain (often extreme), scarring and digital resorption, and severe impairment of finger and hand function.2,4 Ulcer infection, which can lead to osteomyelitis or other serious soft tissue infection, may require either oral or parenteral antibiotics. 5 The current standard of care for patients with SSc includes pharmacologic therapies to manage the SSc conditions that contribute to digital ulceration. These include vasodilators to treat Raynaud’s phenomenon and pulmonary arterial hypertension (PAH), endothelin-receptor antagonists for PAH and prevention of digital ulceration, and various antiplatelet, anticoagulant, and antithrombotic agents to maintain vascular integrity and manage PAH.4 From a wound care perspective, the optimal therapy for these challenging ulcers has not been established.2 Hydrocolloid membrane occlusive dressings have been shown to speed healing of SSc-associated digital ulcers and reduce associated pain when compared with control treatment.6 However, surgical or chemical debridement of necrotic tissue often is required and can be very painful. It is generally accepted that acoustic pressure wound therapy (APWT), a noncontact, low-frequency, nonthermal ultrasound therapy to accelerate healing, cleanse, and débride, is not associated with treatment-related pain. On the contrary, results of a small retrospective study7 suggest that APWT may even provide a palliative benefit in painful wounds. Acoustic pressure wound therapy delivers acoustic energy to the wound bed via a fine, sterile, saline mist. The potential cellular effects of APWT on the wound healing process and the clinical studies demonstrating improved wound healing compared with conventional wound care have been described previously.8 Additionally, Kavros et al 9 observed the destruction of bacterial cell walls in vitro after APWT administration. Case Report In June 2006, a 68-year-old man with lcSSc, including peripheral bilateral hand vasculopathy, developed a painful ulcer on the lateral aspect of the second knuckle on the left second finger. His medical history includes three prior fingertip amputations secondary to digital vasculopathy, coronary artery stent placement, hernia repair, cervical laminectomy, cholecystectomy, and the following concomitant medications: minocycline 100 mg twice daily, aspirin, and diltiazem as needed. He was initially treated at a large hospital wound care center but when sharp debridement proved too painful the wound was wrapped in saline-soaked hydrofiber dressing with silver and covered with petroleum gauze, roll gauze, and finger netting. The patient was instructed to change the dressing daily and return to the clinic in 4 months. On July 14, the patient became concerned about the slow progression of healing and sought treatment at the author’s center. Conservative surgical debridement of eschar (one treatment) was performed, but the patient’s extreme pain in response to debridement prevented removal of the firmly adherent fibrin and yellow slough. At this time, the wound culture was positive for communityacquired methicillin-resistant Staphylococcus aureus (MRSA), which was treated with tetracycline 250 mg twice daily. The wound was dressed with antimicrobial alginate (SILVERCEL®, Johnson & Johnson, Somerville, NJ) and extra-thin hydrocolloid occlusive dressing (DuoDERM® Extra Thin, ConvaTec, Princeton, NJ) to promote autolytic slough debridement. On July 16, wound area measured 8.14 cm2; sodium chloride dressings also were used at this time. Oxycodone (one to two tablets every 4 hours when needed) and extended-release morphine sulphate (15 mg twice daily) were required for pain management. On July 26, wound area had increased to 11.1 cm2 and APWT treatment (MIST Therapy® System, Celleration, Inc., Eden Prairie, Minn) was initiated three times weekly for 5 minutes per session. The April 2008 Vol. 54 Issue 4 63
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