Wound Management in the Patient with Inflammatory Bowel...

Wound Management in the Patient with Wound Management in the Patient with Inflammatory Bowel DiseaseInflammatory Bowel Disease

Nancy Tomaselli, RN, MSN, CRNP, CWOCN, LNC

President & CEO

Premier Health Solutions, LLC

www.PremierHealthSolutions.com

Pyoderma GranulosumPyoderma Granulosum

• Chronic neutrophilic inflammatory disease

• Can cause painful ulcerative lesions

• Associated with systemic diseases such as IBD (UC, regional enteritis, Crohn’s), arthritis, hematologic and immunologic abnormalities

• Pathophysiologic mechanism is unknown

• Extremely painful lesions

• Begin as a nodule, pustule or bullae

• Develop significant induration and erythema

• Progress to one or more chronic ulcers

• Course waxes and wanes

• Common characteristics

• Irregular wound edges that are elevated and violaceous

• Ulcers are deep, exudative and extremely tender

• Wound base is often filled with yellow slough and/or islands of necrosis

• Common characteristics

• Wound edges are undermined

• Band of erythema may extend from the wound edge, which defines the direction the ulcer may extend

• Healing present along one edge with enlargement along another edge

• Common characteristics• Ulcers heal slow and leave an atrophic,

irregular scar• Common sites: lower legs, buttocks,

abdomen, face, hands• Mechanism by which PG develops is

unknown• Pathergy (development of lesions in

areas of trauma) plays a role

Pyoderma GangrenosumPyoderma Gangrenosum

• Distinguishing features

• Ragged and boggy borders

• Elevated

• Dusky red, purple

• Edema halo

• Difficult to diagnose• Disease of exclusion• Misdiagnosed as venous, arterial,

neuropathic, vasculitic, or neoplastic wounds

• Dx based on clinical manifestations-no diagnostic test to confirm

• H&P, skin biopsy to exclude other causes, associated illness

• Treatment : cure does not exist• Systemic therapy with local wound

care• Corticosteroids: Prednisone 60-120

mg daily until reduction of pain and granulation tissue

• Dapsone used to control wound bioburden

• Treatment : cure does not exist

• Limited disease: topical or intralesional steroids

• Antibiotics with anti-inflammatory agents (cyclosporine)

• Infliximab

Pyoderma Granulosum:Pyoderma Granulosum:Topical TreatmentTopical Treatment

• Topical steroids (Orabase with Kenalog)

• Topical immunomodulators (tacrolimus & pimecrolimus)

• Nicotine patch

• Intralesional steroids

• Methylprednisolone

Pyoderma Granulosum:Pyoderma Granulosum:Systemic TreatmentSystemic Treatment

• Antineoplastics

• Chlorambucil

• Cyclophophamide

• Antibiotics

• Dapsone

• Minocycline

• Cyclosporine

• Clofazamine

• Anti-inflammatories

• Mesalamine

• Antimetabolites

• Methotrexate

• Corticosteroids

• Prednisone

• Monoclonal antibodies

• Infliximab

• Immunomodulatory agents

• Thalidonmide

• Immunosuppressents

• Azathioprine

• Mycophenolate mofetil

• IV immunoglobulin

• Plasmapheresis

• Treatment

• Topical wound management

• Exudate management

• Protection from trauma

• Moist wound environment

• Pain control

• Treatment

• Non-adhesive dressings d/t pain

• Debridement through autolysis and regression of disease process itself

• Antibacterial topical dressings warranted

• Use caution to prevent trauma

• Case study

• 52 year old female diagnosed with ulcerative colitis in 2005

• Colonoscopy revealed disease from rectum to mid transverse colon

• Medically managed without surgery

• Case study

• Medications

• Managed with Predisone until 2006

• Began Mesalamine in 2007

• Currently on Infliximab

• Case study• Hit leg on coffee table in October 2007• Treated in ED with antibiotics and

wound did not heal• Admitted to hospital 2 months later• Diagnosed as venous ulcer• Treated with Unna boot and

compression increased pathergy

• PG Venous Ulcer

• Case study

• Admitted to University of Chicago in February of 2008

• Biopsy of wound performed

• Started on Infliximab and lesions improved

• Treatment for wounds started in February 2008 and wounds were healed in March of 2008

• Case study

• Topical treatment included

• Alginate

• Alginate with silver

• Hydrogel

Pyoderma GangrenosumPyoderma GangrenosumFebruary 2008: Week 1February 2008: Week 1

Moist Wound HealingMoist Wound Healing

Pyoderma GangrenosumPyoderma GangrenosumMarch 2008: Week 1March 2008: Week 1

Hydrogel DressingHydrogel Dressing

Pyoderma GangrenosumPyoderma GangrenosumPeristomal lesionPeristomal lesion

ReferencesReferences

• Baranoski, S., & Ayello, E.A. (2004).Wound care essentials: Practice principles. Philadelphia: Lippincott, Williams & Wilkins.

• Bryant, R.A., & Nix, D.P. (2007). Acute and chronic wounds: Current management concepts (3rd ed). St. Louis: Mosby, Inc.

ReferencesReferences

• Burch, J., Jones, M., & Fellows, J. (2006). Pyoderma ganrenosum and leg ulcers associated with vasculitis. Journal of Wound, Ostomy and Continence Nursing, 33, 77-82.

• Colwell, J.C., Goldberg, M.T., & Carmel, J.E. (2004). Fecal & urinary diversions: Management principles. St. Louis: Mosby, Inc.

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