Sound Evidence - April 2008 - (Page 64) well. In the current case, a patient with lcSSc and an infected, painful digital ulcer averted a fourth fingertip amputation arising from digital ulceration. This outcome, achieved with 10 weeks of APWT added to the conventional hydrocolloid occlusive dressing, stands in contrast to the outcomes of this patient’s three previous digital ulcers, which resulted in fingertip amputation (patient records from treating facility not available). In this patient, APWT was able to remove extensive, firmly adherent fibrin slough from an MRSA-infected wound where surgical Figure 1. Healing progression of a digital vasculopathy ulcer over 10 weeks debridement could not be tolerated due to intense pain. (July 26 – October 4) of acoustic pressure wound therapy. The absence of pain associated with APWT is likely attributable to the fact that acoustic pressure delivered via a fine saline mist use of extra-thin hydrocolloid dressings over calcidoes not produce palpable mechanical pressure on um alginate with silver was continued. After 4 weeks the wound bed. The possibility that this acoustic of APWT (August 25), the dressing was changed to energy may even provide a palliative benefit has a collagen matrix with silver (Promogran Prisma been documented only in a very small retrospective Matrix®, Johnson & Johnson) under the hydrocolstudy7 and requires additional prospective investiloid occlusive dressing. 2 Wound area decreased from 11.1 cm at APWT gation. Similarly, the preliminary evidence of bactericidal effects with APWT9 warrants expanded laboinitiation to complete closure (see Figure 1) after 31 APWT treatments over 10 weeks (July 26 to ratory and clinical investigation. October 4). Four weeks into APWT (August 25), The results of a small case series10 suggest that wound pain had diminished from a patient-reportrhythmic external compression of the limbs (20 1ed rating of 10 out of 10 on the visual analog scale hour sessions) also may help heal digital ulcers in (VAS) to 6 out of 10. At week 5, the patient’s pain SSc patients. Additionally, a case report 11 has score was 4 out of 10 and, by week 6, the patient was described successful treatment with hyperbaric oxypain-free and no longer required narcotic pain gen therapy (30 treatments) in a non-healing, SScmedication. associated digital ulcer. In addition to wound-specific care, pharmacologic agents for managing Raynaud’s phenomenon and maintaining vascular Discussion integrity may assist in healing digital ulcers. Digital ulcers and underlying digital vasculopathy Vasodilating agents used to manage Raynaud’s phein SSc patients are associated with serious complicanomenon have shown some benefit in healing digitions, including functional disability, gangrene and tal ulcers, but intolerable side effects often preclude critical ischemia, and the need for digital sympathecthe use of therapeutic doses.4 In a randomized, doutomy or digital amputation.5 Currently, no clear “best practice” is proliferated for the care of these challengble-blind, placebo-controlled trial2 of 122 patients, ing wounds that are complicated by substantial underthe endothelin-receptor antagonist, bosentan, was lying vascular and autoimmune disease. shown to reduce the rate of new ulcer development The use of a hydrocolloid occlusive dressing for in patients with lcSSc, but did not improve healing. digital ulcers is supported by a prospective, randomSeveral prostacyclin agents have been reported in ized trial6; however, debridement is often necessary as clinical trials4 to either prevent (oral epoprostenol 64 OstomyWound Management
Table of Contents Feed for the Digital Edition of Sound Evidence - April 2008 Sound Evidence - April 2008 Sound Evidence - April 2008 - (Page 62) Sound Evidence - April 2008 - (Page 63) Sound Evidence - April 2008 - (Page 64) Sound Evidence - April 2008 - (Page 65)
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.