Today's Wound Clinic - Winter 2008 - (Page 36) inperspective Figure 1: Example of friable, discolored, pocketed wound bed with increased exudate evidenced by the macerated edges. Figure 2: Patient presenting with atypical ulcer in “typical” site and appearance. Biopsy diagnosed vasculitis. IDENTIFICATION OF ATYPICAL ULCERS Everyone has evaluated patients whose lower extremity ulcer “was just there one day” or developed when they “hit their leg,” or “scratched their leg in the night.” Often, legs presenting this way have evidence of varicose veins, hemosiderin staining, and edema. Such ulcers that are “dressed up” like a venous ulcer; indeed, the ulcer may be in part related to venous disease. In his many lectures on atypical ulcers, Dr. Robert Kirsner teaches, If it is in an atypical location, with an atypical appearance, an atypical history, and it doesn’t respond in reasonable time to standard treatments, biopsy. A vasculitis and a vasculopathy patient are shown in Figures 2 and 3, respectively. Figure 2 shows a leg with brawny edema, hemosiderin staining, and an ulcer located on the medial aspect of the patient’s ankle. A few additional suspicious ulcers were located on the dorsum of her foot.The ulcer shown in Figure 3, with purpura evident is clearly not typical but not all atypical ulcers are so easy to spot. Clinicians must be vigilant for vasculitis, pyoderma, and cancer, among other conditions. Doing a biopsy is easy, relatively painless, net a wealth of information, and save a great deal of time spent treating an ulcer topically that may need medical or surgical management. Note: the clinician must be aware of the presence of co-existing ischemic disease and arteriovascular status. limited as to the number of visits than the type of products to use. The clinic initiates use of products such as Oxidized Regenerated Cellulose (ORC)/collagen, ORC collagen with silver, extracellular wound matrix, topical Platelet Derived Growth Factor (PDGF), bilayered living cell therapy, and negative pressure wound therapy (and combinations of these) much earlier than other facilities. Can product use be justified? When consideration is given to the long duration of many wounds at the time of presentation and that many patients are compromised by diabetes, scleroderma, radiation, and steroid use, among other factors. aggressive care can be cost effective care. Figure 3: Pt with lower extremity ulcer with very atypical location and appearance, and diffuse purpura indicating need to biopsy for definitive diagnosis. All eligible patients have a vascular consult for potential intervention with modalities such as endovenous laser ablation of incompetent perforators or ultrasoundguided sclerotherapy.After years of “revolving door” venous ulcer treatment, the availability of these interventions has made it possible not only to heal patients,but also to keep them healed, hopefully for life. CONCLUSION Is it possible to get rid of the “frustrating 15%”? Not all venous patients may heal because not all circumstances are within our control. However, the job of the wound care practitioner is to identify those factors that can be controlled. ■ CLOSURE VERSUS HEALING Most patients eventually heal. Based on outcome data, the author’s clinic has an 85% healing rate at 12 weeks.At 24 weeks, that number jumps to 93%. However, this database documents wounds that are “resolved.” It is important to differentiate between ulcers that have closed versus healed. In most cases, achieving venous ulcers closure is not nearly has challenging as maintaining durable healing. Keeping patients with venous ulcers healed used to present a dilemma. Maintenance strategies include compression stockings, compression pumps (occasionally), and educating patients on the need for life-long management of their edema but these efforts may be insufficient. A huge step forward for our clinic was the arrival of a vascular surgeon with whom we can partner to help many of our patients achieve long-term healing through venous interventions. These procedures not only aid in healing, but also more importantly may prevent recurrence. REFERENCES 1. Doughty DB, Holbrook R. Lower-extremity ulcers of vascular etiology. In: Bryant RA, Nix DP (eds). Acute and Chronic Wounds: Current Management Concepts, 3rd edition. St. Louis, Mo: Mosby Elsevier;2007. 2. Myers BA. Venous insufficiency ulcers. In: Myers BA (ed). Wound Management Principles and Practice. Upper Saddle River, NJ: Pearson Education Inc;2004. 3. Kalra M, Gloviczki P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. In: Steed, DL (ed) Surg Clin N Am, 83 (2003)671–705. WB Saunders Company. 4. Serena T, Robson MC, Cooper DM, Ingatius J. Lack of reliability of clinical/visual assessment of chronic wound infection: the incidence of biopsy-proven infection in venous leg ulcers. WOUNDS. 2006;18(7):197–202. 5. Gardner SE, Frantz, RA, Doebbeling BN. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen. 2001; 9(3): 178–186. USE OF ADVANCED TREATMENTS As a clinician in a center and hospital with a great deal of managed care where advanced and active products are readily available and early use of these modalities is encouraged, this author is often more 36 Winter 2008 Today’s Wound Clinic
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