Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. ·...
Transcript of Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. ·...
![Page 1: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/1.jpg)
Evaluation and Management of Lower Extremity Ulcerations
Eric McBride, NP
![Page 2: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/2.jpg)
Wound Care Basics
• Principles of Wound Care
If it’s wet, dry it.
If it’s dry, wet it.
If it’s deep, fill it.
If it’s necrotic, debride it.
![Page 3: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/3.jpg)
Wound Care Basics
• Healthy wound bed.
• Beefy red granular tissue.
• Superficial wounds may have flat non-granular appearance.
• Moist wound bed
• Intact wound edges
• Serous or Serosanguinous drainage
• Minimal to no erythema on the surrounding skin
![Page 4: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/4.jpg)
Wound Care Basics
• Unhealthy wound bed
• Loose yellow tissue- (slough)
• Firm or leathery yellow tissue- (biofilm)
• Dry or wet gangrene -(black eschar)
• Green slough- (gram negative infection i.e. pseudomonas)
• Hypergranulation- wound bed above skin level.
• White/pale pink tissue- decreased arterial supply
![Page 5: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/5.jpg)
WOUND CLASSIFICATIONS
![Page 6: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/6.jpg)
Arterial Ulcers
![Page 7: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/7.jpg)
Arterial Ulcer
• Approximately 5% of all LE ulcerations in the U.S.
• Pathophysiology
• Caused by stenosis or occlusion of arterial supply
• Ischemia causes tissue necrosis
• Most common in diabetics and smokers
![Page 8: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/8.jpg)
Arterial Ulcer
• Clinical presentation
• Intermittent claudication
• Pain at rest with feet at level of heart or above.
• Decreased/absent peripheral pulses
• Cool skin temperature
• Shiny, thin skin.
• Absent hair on the extremity
• Prolonged cap refill
• Dependent rubor
![Page 9: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/9.jpg)
Arterial Ulcer
• Clinical presentation (cont.)
• Wounds are distal to area of blockage.
• Often between or on tips of toes, over phalangeal heads, or
around areas subject to trauma (malleolus)
• Edges are “punched out”
• Pale and dry wound base with no granulation
• Minimal drainage
• Dry or wet gangrene often present
![Page 10: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/10.jpg)
Arterial Ulcer
• By Jonathan Moore - Creating the Ideal Microcosm for Rapid Incorporation of Bioengineered Alternative Tissues Using An Advanced Hydrogel Impregnated Gauze Dressing: A Case Series. The Foot and Ankle Online Journal 1 (9): 2., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=6886430
![Page 11: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/11.jpg)
Arterial Ulcer• Work-up
• Arterial Duplex Ultrasound with ABI
• Wave forms show patency of arteries/arterioles
• Ankle-Brachial Index
• Normal is 0.9-1.3
• 0.8-0.9 is mild arterial disease
• 0.5-0.8 moderate arterial disease
• 0.5 or less is severe ischemia ***avoid compression***
• In office ABI can be done with US doppler/BP cuff
• Same side arm and leg using brachial and DP/PT pulse
• Inflate cuff on arm and ankle until no sound is heard
• Release pressure noting the first pulse sound
• Systolic ankle/Systolic brachial
![Page 12: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/12.jpg)
Arterial Ulcer• Work-up cont.
• CT Angiogram with run-off
• Dye injected into vasculature.
• CT images capture areas of blockage
• Magnetic Resonance Angiography
• Most accurate diagnostic
• With run-off for legs
• More expensive
• A study by Yucel et al found that MRA was more accurate in evaluating lower
extremity vessels when compared to conventional angiography.
![Page 13: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/13.jpg)
Arterial Ulcer
• Treatment
• Improve flow
• Stenting/Angioplasty
• Bypass surgery
• Anti-platelets
• Pentoxifylline
• Amputation (auto vs surgical)
• Lipid lowering agents
• Smoking cessation
• Improve A1C
• Analgesics
• Avoid pressure/injury!!!
• Keep stable eschar dry and clean
![Page 14: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/14.jpg)
Diabetic Foot Ulcers
![Page 15: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/15.jpg)
Diabetic/Neuropathic
• Pathophysiology
• Chronically elevated blood glucose levels cause
damage to nerves and capillaries
• This leads to a loss of sensation to the lower
extremities.
• No sensation = no pain.
• Pressure and trauma cause wounds.
• Shoes (callous)
• Nails, rocks, heating pads
• Charcot and other foot deformity (tendinopathy)
![Page 16: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/16.jpg)
Diabetic/Neuropathic Ulcers
By Penn State- Penn State Researchers Develop Topical Treatment for Diabetic Wound Healing https://invent.psu.edu/success-story/penn-state-researchers-develop-topical-treatment-for-diabetic-wound-healing
![Page 17: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/17.jpg)
Diabetic/Neuropathic
Classification Systems: Wagner Scale
• Grade 0 = pre-ulcer lesion, healed ulcer, presence of bony
deformity
• Grade 1 = superficial ulcer without subcutaneous involvement
• Grade 2 = penetration through the subcutaneous tissue
• May have exposed bone, tendon, ligament, or joint capsule
• Grade 3 = deep ulcer with abscess and/or osteomyelitis
• Grade 4 = ulcer that led to gangrene of the toes and/or
forefoot.
• Amputation likely
• Grade 5 = ulcer that has caused gangrene of the entire foot.
• Requires amputation
![Page 18: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/18.jpg)
Diabetic/Neuropathic
• Work-up
• Hgb A1C, CBC, CMP
• Arterial Duplex with ABI
• ABI may be falsely elevated due to calcification
• Monofilament test
• Wound tissue cultures
![Page 19: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/19.jpg)
Diabetic/Neuropathic• Treatment
• Improve glycemic control
• A1C greater than 8% significantly impacts healing
• Debridement
• Moisture control (sweat, shoes, gravity)
• Referral to podiatry
• Referral to prosthetist for orthotics/diabetic shoes
• Total Contact Casting
• Hyperbaric Oxygen Therapy (Wagner 3)
![Page 20: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/20.jpg)
Venous Stasis Ulcers
![Page 21: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/21.jpg)
Venous Stasis Ulcers
• Most common lower leg wound in the U.S. (70%)
• Pathophysiology
• Venous hypertension due to damage to veins and/or reduction in muscle pump
• Incompetent valves cause backflow (reflux)
• Often form a bulla before ulceration
Pooling of blood increased pressure capillary damage, altered lymphatics, inflammation tissue hypoxia ulceration
![Page 22: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/22.jpg)
Venous Stasis Ulcers
Risk Factors
• Obesity
• DVT
• Pregnancy
• Incompetent valves
• CHF
• Age
• Sedentary
• Trauma to leg
![Page 23: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/23.jpg)
Venous Stasis Ulcers
• Presentation
• Edema (may be pitting)
• Hemosiderin staining
• Wound tends to appear above medial malleolus (Gaiter area)
• Wound tends to be shallow with irregular borders
• Wound often has slough
• Wound edges are often either dry/crusted or macerated
• Easily infected. Frequent cause of cellulitis.
![Page 24: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/24.jpg)
Venous Stasis Ulcers
![Page 25: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/25.jpg)
Venous Stasis Ulcers
• Work-up
• Venous Insufficiency Doppler
• Evaluates waveforms
• Arterial Duplex
• Ankle Brachial Index
• Tissue cultures
![Page 26: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/26.jpg)
Venous Stasis Ulcers
Treatment
• Compression (garments or wraps)
• Elevation of feet
• Absorptive dressings (Alginates, foam, etc.)
• Pneumatic pumps
• Diuretics
• Endo-vascular closure
![Page 27: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/27.jpg)
Lymphedema
• Lymphedema
• localized edema due to lymph system failure
• Primary- hereditary or malformation
• Secondary- related to venous disease, trauma/infection, or surgery (cancer)
• Can cause elephantitis of an extremity
• Significant skin changes
• May only affect one limb
• Kaposi-Stemmer sign- inability to pinch a fold of skin at second toe
• Treatments are similar to venous stasis disease with the addition of manual lymph drainage.
![Page 28: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/28.jpg)
Lymphedema
![Page 29: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/29.jpg)
Peripheral Edema
• 0) None
• 1+
• 2mm pit
• 2+
• 4 mm pit
• 3+
• 6 mm pit
• 4+
• 8 mm pit
![Page 30: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/30.jpg)
Lymphedema/Venous Stasis Tx
Compression wrapping Pneumatic Pumps
![Page 31: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/31.jpg)
Skin changes with edema
![Page 32: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/32.jpg)
Skin changes with edemaHemosiderin Staining- iron deposition after RBC degradation
![Page 33: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/33.jpg)
Skin changes with edema Lipodermatosclerosis
![Page 34: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/34.jpg)
Skin changes with edema
• Hyperkeratosis- abnormal thickening of the stratum corneum (scaly/dry)
![Page 35: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/35.jpg)
Skin changes with edema
Papillomatosis- papillary surface elevation (cobblestone)
Taken from Wound Series Part 4: Lymphedema and Chronic wounds https://ceufast.com/imgs/wd-4-pic-3.jpg
![Page 36: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/36.jpg)
Skin changes with edema
• Lymphedema Rubra• NOT cellulitis
• Does not need antibiotics
![Page 37: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/37.jpg)
Atypical Wounds
![Page 38: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/38.jpg)
Pyoderma Gangrenosum
• Exact etiology is unknown. Dysregulation of immune system.
• Diagnosis of exclusion
• Internal organs may be involved, with lungs being the most
prevalent.
• Affects 1:100,000 people each year
• Most frequent in 40s and 50s
![Page 39: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/39.jpg)
Pyoderma Gangrenosum
• History
• Patient may describe the initial lesion as
• Insect/spider bite
• A red “bump” (papule)
• Pustule
• The lesion progressively gets worse and more painful
• The pain is often out of proportion to the wound
• May occur around stoma sites and be mistaken for irritation
![Page 40: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/40.jpg)
Pyoderma Gangrenosum
• History
• Over 50% of patients with PG have an auto-immune disease.
• Ulcerative colitis and Chron’s Disease most common
• Less common in RA, psoriatic arthritis, AS, and SLE
• May also be associated with leukemia and hepatitis
• Pathergy
• Minor trauma leads to development of ulceration
• Trauma to ulceration can cause the wound to grow
![Page 41: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/41.jpg)
Pyoderma Gangrenosum
• Presentation
• Usually in the legs or around a stoma
• Deep ulceration
• Violaceous border around the wound
• Purulent base is common
• Wound edges are often undermining
![Page 42: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/42.jpg)
Pyoderma Gangrenosum
Retrieved from diseasepictures.com
![Page 43: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/43.jpg)
Pyoderma Gangrenosum
![Page 44: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/44.jpg)
Pyoderma Gangrenosum
• Work-up
• Diagnosis of exclusion. No true diagnostic
• Biopsy, wound culture, CBC, CMP, LFT, hepatitis
panel
• Evaluate for auto-immune disease if not
previously diagnosed
• Vascular studies
![Page 45: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/45.jpg)
Pyoderma Gangrenosum
• Treatment
• Prednisone is first line medication
• Cyclosporine, TNF-alpha inhibitors (infliximab, adalimumab, etc) dapsone, tacrolimus, and other systemic therapies are second line.
• Super-potent topical steroids (cromolyn 2%, 5-aminosalicylic acid)
• Topical tacrolimus (less evidence)
• IV methylprednisone and immunoglobulin
• Hyperbaric Oxygen Therapy (limited evidence)
• GENTLE WOUND CARE- pathergy
• Methylene blue and crystalline violet dressings
• Silver sulfadiazine
• Avoid debridement or surgery unless on steroid therapy
![Page 46: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/46.jpg)
Calciphylaxis
• Poorly understood pathophysiology
• Most common in chronic renal failure(1-4% ESRD)
• Obesity, DM, hypercalcemia/phosphatemia
• Systemic inflammation is also believed to be a predisposing factor
• Chronic use of corticosteroids
• Vascular disease, with concurrent use of anticoagulation
• Lesions develop and progress rapidly
• Usually in lower extremities
• May develop on hands and torso
• In men, may have lesion on penis
• Intense pain
![Page 47: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/47.jpg)
Calciphylaxis
• Presentation
• Early lesions appear with violaceous mottling
• Become stellate purpuric lesions with central skin necrosis
• May have internal involvement
• GI bleeding
• Infarction
• Organ failure
• Work-up
• CBC CMP
• PTH
• Coags
• ANA ANCA to rule out vasculitis
• X-ray can show vascular calcification
• Incisional cutaneous biopsy
![Page 48: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/48.jpg)
Treatment
• Poor prognosis
• Ulceration is considered a late finding
• 1 year survival rate is 25%
• 5 year is 17%
• In acute disease, send to hospital
• Dialysis compliance
• Phosphate binders
• calcimimetics
• Parathyroidectomy
• Sodium thiosulfate (limited evidence/off-label)
• Amputation
• No consensus on debridement. Case by case
![Page 49: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/49.jpg)
Calciphylaxis
![Page 50: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/50.jpg)
Dressing Selection
![Page 51: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/51.jpg)
Dressing Selection
Bioburden/infection Silver dressings
Cadexomer iodine
Topical abx (bacitracin, bactroban, gentamicin, etc)
Betadine/Iodine/Dakin’s…DILUTED WITH NS!!!
Petrolatum impregnated gauze
Slough/Biofilm Debridement***
Santyl
Manuka Honey
Hydrocolloid (superficial wounds only)
![Page 52: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/52.jpg)
Dressing Selection
Heavily draining wounds Calcium Alginates, Hydrofibers, and specialty products
Moderately draining wounds
Same as above, foams
Minimal to no drainage
Foam, hydrocolloid, hydrogel, etc.
![Page 53: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/53.jpg)
Any Questions?
![Page 54: Evaluation and Management of Lower Extremity Ulcerations - Valley Health · 2019. 11. 5. · •Clinical presentation (cont.) •Wounds are distal to area of blockage. •Often between](https://reader033.fdocuments.net/reader033/viewer/2022053118/609eb199a517cd62b66cbeb5/html5/thumbnails/54.jpg)
References• Bjork, R. (2013). What’s causing your patient’s lower-extremity redness? Wound Care Advisor July/August 2013
2(4). Retrieved from http://woundcareadvisor.com/wp-content/uploads/2013/07/BP_LE_J-A13.pdf.
• Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier Mosby; 2012
• Chang, L. (2019). Bullous Pemphigoind. Medscape. Retrieved from https://emedicine.medscape.com/article/1062391-overview
• Chao, C., Yong-Ping, Z., Cheing, G. (2012) The Association Between Skin Blood Flow and Edema on Epidermal Thickness in the Diabetic Foot. Diabetes Technology and Therapeutics 14(7). doi: 10.1089/dia2011.0301
• Farrow, W. (2010) Phlebolymphedema–A Common Underdiagnosed and Undertreated Problem in the Wound Care Clinic. Journal of American Certified Wound Specialists, 2(1) 14-23. doi: https://dx.doi.org/10.1016%2Fj.jcws.2010.04.004
• Flugman S, Elston D. Stasis dermatitis medication. Retrieved from http://emedicine.medscape.com/article/1084813-medication#showall.
• Morton, L., Phillips, T. (2013). Venous Eczema and Lipoermatosclerosis. Seminry of Cutaneous Medicine and Surgery (32) 3. pp. 169-176. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24175404
• Nunley, J. (2018) Calciphylaxis. Retrieved from https://emedicine.medscape.com/article/1095481-overview#a4
• Vera. M., (2018) Atypical Wounds. Wound Source. Retrieved from https://www.woundsource.com/blog/atypical-wounds-causes-and-managemen
• Wound Educators. (2018). Wound Dressings. Retrieved from https://woundeducators.com/resources/wound-dressings/
• Wound Source. (2019). Arterial Ulcers. Retrieved from https://www.woundsource.com/patientcondition/arterial-ulcers