DERMATOLOGY FOR THE GPO Really Wound care for the GPO 2014 CAGPO Annual Meeting October 23, 2014 Tracey Brown-Maher, MD, FRCPC, IIWCC
Disclosure I have participated in advisory boards or received honoraria from the following: LeoPharma OrthoJanssen GlaxoSmithKline (GSK) Abbvie Sanofi-Aventis KCI None relevant to this talk May discuss off-label uses of products
Objectives To highlight interesting dermatology oncology cases GPOs might not see often To educate GPOs on basic wound care principles To illustrate wound care principles using cases To BRIEFLY overview dressings and antiseptics used in chronic wound care To briefly discuss some Iatrogenic complications of treatment in oncology patients that GPOs may/may not recognize To emphasize concerns specific to malignant wounds
DERMATOLOGY ONCOLOGY CASES To keep you awake before the wound care segment starts
55 YO male referred to me by GP Two month hx of asymptomatic nodules on trunk Occasional fever, chills, night sweats over last two weeks 0.5-2.0cm firm, rubbery blue nodules on back Labs negative
Diagnosis? Aleukemic leukemia cutis Presence of blasts in skin prior to appearance in peripheral blood or bone marrow Rare 7% of leukemia cutis cases Mean survival 3-30 months after cells infiltrate blood/bone marrow
44YO female, metastatic breast cancer, referred for strange rash Recently started proteinbound Paclitaxel Developed eruption after two cycles Did not come and go Worse with scratching Topical steroids provided no relief
Diagnosis? Flagellate hyperpigmentation Usually occurs with bleomycin?etiology: Chemo causes pruritus Scratching causes local skin accumulation Skin lacks inactivating enzyme Cystiene proteinase Direct toxic effect on melanocytes Self-limited usually
Rosacea fulminans
6YO female with Sclerodermoid GVHD BMT for SCID age 1 Sirolimus,tacrolimus, prednisone One year hx of recalcitrant foot ulcers Silver dressings, IV antibiotics Monthly extracorporeal photophoresis (ECP)
Five months later Platelet-derived growth factor gel Oxidized cellulose/collagen dressing and nonadherent foam Decreased pain at dressing changes No infections Off many immunosuppressants ECP decreased
WOUND CARE AND ONCOLOGY
Where do we start? Can the wound heal? Classify wounds as: Healable Non-healable Maintenance
What type of wound is it? Healable wound Can close with appropriate treatment and adherence Non-healable wound Will never close even with appropriate intervention and adherence Eg. Malignant wound Maintenance wound Has potential to close but patient factors prevent it Venous ulcer and non-adherence to compression
How do we optimize local wound care? Principles of Wound Care Wound Bed Preparation Paradigm Sibbald et al. Best practice recommendations for preparing the wound bed: update 2006. Wound Care Can 2006;4(1):15-29.
Sibbald et al. Wound Care Canada 2006;4(1):15-29 Principles of Wound Care: Wound Bed Preparation Paradigm Chronic Wound Treat Cause (Vascular, Venous) Local Wound Care (DIME) Patient Centred Concerns (Pain) Debridement Infection Inflammation Moisture Balance Edge Non-Healing
Patient Centred Concerns Pain At dressing changes Anticipatory pain Cost Quality of life
What do you do first? Document! Location Size and depth Describe the wound Edges, base, probe, exudate, erythema
What is next for wound care? DIME Debridement Inflammation/Infection Moisture Balance Edge Effect/Revaluate
Why do we need debridement? Removes nonviable tissue which impedes wound closure Nonviable tissue Masks/mimics infection Acts as source of nutrients for bacteria Impedes angiogenesis, granulation tissue Stimulates inflammatory cytokines & overproduces MMPs Stimulates inflammatory cascade for healing Specimen for culture/pathology Weir et al, Ch. 35, In: Chronic Wound Care: A Clinical Source Book for Health Professionals, 4 th ed. 2007:343-355.
Debridement Options Surgical Mechanical Autolytic Enzymatic Biologic Clinical Pearl: Do NOT debride if suspected arterial disease or known serious arterial disease unless wound infected
Infection/Inflammation Impairs growth factors and healing Can be difficult to distinguish between Infection also: Decreases oxygen content Increases exudate Leads to wound breakdown
All chronic wounds contain microorganisms Interact with chronic wounds at four levels: Contamination Colonization Critical Colonization Infection Rodeheaver and Ratliff, Ch. 34, In: Chronic Wound Care: A Clinical Source Book for Health Professionals, 4 th ed. 2007:331-342.
Infection: NERDS and STONES NERDS: Non-healing, Exudate increased, Red friable granulation, Debris, Smell Superficial infection STONES: Size increased, Temperature skin increased, probing or exposed, New/satellite areas breakdown, 3 E s (Erythema, Exudate, Edema), Smell Deep infection Sibbald et al. Adv Skin Wound Care. 2006;19(8):462-63.
Infection or Inflammation?
Actually Inflammation with critical colonization.
Vinegar/water sol. Cleanses, Enzymatic debridement, alginates steroid for contact dermatitis and radiation dermatitis
Moisture Balance: Is it too wet or too dry? Wounds heal better if kept moist Increase cell proliferation and activity by retention of wound exudate containing proteins and cytokines produced in response to injury Epithelize more quickly Promotes autolytic debridement Decreases pain Jones and Harding. Chapter 23. In: Chronic Wound Care: A Clinical Source Book for Health Professionals, 4 th ed. 2007: 199-200.
54 YO male recent excision of satellite melanoma metastases STSG one month ago paraffin gauze dressing applied with topical antibiotic ointment Not healing Came to my office for routine skin check Initially refused my suggestions Two weeks later called to say things worse and asked for suggestions
Too Wet! Hypergranulation present Lime green biofilm and exudate What did we do? Cleansed with ¼ vinegar and water solution Calcium alginate to wound and abdominal pad daily Closed in less than two weeks
Edge Effect/Revaluate If wound edge not advancing, revaluate Biopsy if no improvement after 12 weeks with appropriate treatment 2 yr hx of sore area Lost nail one year ago Referred for chronic wound
Diagnosis? Melanoma Metastases to elbow Died several months later with multiple metastases from melanoma and colon carcinoma
83 YO female Eight MO hx of nonhealing wound right groin 2.5cm x 2.0cm Every kind of dressing Worsening What is the plan?
What do you notice about the border?
The plan No improvement in wound after 8 months appropriate treatment alarm bells should be ringing! General rule is if no improvement after 3 months of appropriate treatment and adherence, should biopsy Rolled border suspicious! Did biopsy on first visit to rule out BCC Pathology confirmatory Referred to general surgery for excision
CLASSIFICATION OF DRESSINGS AND ANTISEPTICS
Classification of Dressings Wound Hydration Moisture Retentive Absorbent Topical Antimicrobials Compression Therapies will not discuss Biologic Therapies Will not discuss
WOUND HYDRATION Hydrocolloids Hydrogels
Provides moisture to wound: Not for draining wounds!
Wound Hydration Promote autolytic debridement Changed less often q2-3d Hydrocolloids may cause skin tears, contact dermatitis, maceration Good for ulcerated hemangioma, skin tear in non-fragile skin CI in infections
MOISTURE RETENTIVE: NOT TOO WET, NOT TOO DRY Non-adherents Transparents
Traps moisture already in wound
Non-Adherent=Wound contact layer Decreased pain at dressing change Transparent Conforms easily Allows some exudate to pass Silicone or plasticized
Transparents: Skin tears, IV site Not used in draining wounds Superficial only
ABSORBENT DRESSINGS: DRAINING WOUNDS Alginates Exudate Absorbers Foams Odor Specific
Too wet: Needs MORE absorbent dressing!
Alginates: Moderate-High Exudate Fibers from seaweed; Absorbs excess drainage Hemostatic Decreased dressing frequency q4d
Exudate Absorbers Hydrofiber (mild-moderate exudate) Fibrous sheet Applied dry, converts to gel Non-adhesive Change q1-4 days Hypertonic saline gauze (super soaker: high exudate) Decreases bulk in infected wounds Requires moisture retentive cover Sticks if minimal drainage
Hydrofiber Hypertonic saline gauze
Foams Polyurethane Non-adherent, flexible, cushion Promote granulation and epithelialization Moderate exudate Wear time 4-7 days Autolytic debridement
Foams
Odor Specific: for foul smelling wounds Charcoal Dressings Charcoal layered within product Variable absorption +/- silver +/- alginate Promotes clean wound bed Expensive Needs cover dressing
Charcoal Dressings
TOPICAL ANTIMICROBIALS: CRITICALLY COLONIZED MILD INFECTION Cadexomer Iodine/Iodine Silver Honey PHMB
Critically Colonized
Alavi et al. JAAD 201470(1):21.e17 Topical Antimicrobials: Cadexomer Iodine/Iodine impregnated gauze Short-term use Promotes autolytic debridement Minimal absorption Cadexomer iodine released slowly, less toxic Broad antimicrobial effect Gram positives more than negatives; MRSA Good penetration of biofilms Contraindications: iodine sensitivity nontoxic nodular goitre, Hashimoto s thyroiditis lithium pregnancy, breastfeeding
Cadexomer iodine good for debridement
Alavi et al. JAAD 2014;70(1);p.21.e17 Topical Antimicrobials: Silver-based Silver dressings, foams, alginates, hydrofibers, silver sulfadiazine cream Activated by moisture Silver nanoparticles enhance contact/antimicrobial activity E.coli, Klebsiella, Staph aureus, MRSA, antifungal, antiviral Antiinflammatory May adhere to wound, periwound staining/eschar High cost
Silver dressing and cadexomer iodine paste
Alavi et al. JAAD 2014;70(1):21.e17 Honey Medical grade, alginates, hydrogel, hydrocolloid Antibacterial, antifungal, antiviral Antiinflammatory High osmolar concentration aides antibacterial effect Can cause irritation Can develop contact allergy (propolis/fragrance)
PHMB Polyhexamethylene biguanide Antiseptic in chlorhexidine family Resists bacterial colonization, penetration Broad spectrum against gm positive, gm negative, fungi/yeast, including MRSA and VRE Available as gauze or strip Mild-moderate absorption
PHMB Put over granulation with biofilm, some drainage Moisture retentive over tendon to keep moist
ANTISEPTICS
Antiseptics Damage all cells upon contact and do not select out bacteria Kill bacteria on surface only as cannot penetrate tissue May cause damage to cells for wound repair Balance need for control of bacterial burden with risk of damage to tissue
TYPES OF ANTISEPTICS Povidone-iodine Chlorhexidine Mercurochrome Dakin s solution Acetic acid Hydrogen peroxide
Povidone-iodine Broad spectrum of activity Decreased in presence of exudate or pus Can dry out wound Caution in larger wounds or in long term use No RCT to support efficacy
Chlorhexidine 2% solution Rapid, bactericidal activity by damaging outer cell layers to allow leakage of cellular components Coagulation of intracellular constituents Active against S. aureus, Pseudomonas, but MRSA may be resistant Few toxic effects No RCTs
Mercurochrome Now mercury-free Different formulations Aqueous merbromin solution Chlorhexidine gluconate 0.05%, isopropyl alcohol and methylene blue Benzalkonium chloride Active against gm positives (and gram negatives if merbromin) Keeps wounds dry
Dakin s solution Sodium hypochlorite solution 0.5% No controlled studies Ability to dissolve necrotic tissue Technically acts as a chemical debrider Stop when necrotic tissue removed High ph can cause irritation Can select out gram negatives Basically bleach! Off label use!
Soapy tissue a good time to use Dakin s
Acetic acid 5% Physiologically unacceptable low ph Pseudomonas extremely sensitive to acidic environment Beneficial in uncontrolled trials May select out S. aureus Cleanses or soaks ¼ strength Dilute if patient cannot tolerate Definitely an off-label use of white table vinegar!
Critically colonized not infected vinegar/water solution
Hydrogen peroxide Very little antimicrobial activity Good chemical debriding agent Effective in dissolving blood clots Effervescence loosens debris and necrotic tissue Can form air emboli Increases risk of scar Not much use for chronic wounds
Apply Antiseptics and Dressing Categories to DIME Evaluate DIME Tailor antiseptics and dressings to patient and DIME problem(s) Change as DIME changes
IATROGENIC SKIN COMPLICATIONS/WOUNDS MALIGNANT WOUND CONCERNS
Iatrogenic Skin Complications/Wounds Radiation Induced Radiotherapy can cause endarteritis that can cause ulceration and impair wound healing Contact dermatitis Secondary Cancers or Inflammatory disorders due to radiation/immunosuppression Medications cause ulcers Hydroxyurea for myeloproliferative disorders can cause ulcers on lower legs, up to 15 years after start of treatment
42 YO male with palmar/plantar Mycosis fungoides after 2 nd treatment of localized radiation Had partial thickness burn this is one month later Very painful Was given Morphine?No dressings Wife a pharmacist Triple antibiotic therapy cream applied
What could have been done? Keep moist Hydrogel Hydrofiber +/- silver Silver sulfadiazine cream Petroleum jelly or other barrier cream Nonadherent dressing to prevent pain at dressing change
Contact Dermatitis and Radiation Ulcers 88 YO female SCC breast 1997 with excision, graft and radiation Necrosis and wound 2012 Reacted to silver sulfadiazine cream Then used hydrofiber with silver: too wet!
Recently seen some improvement Switched to ¼ vinegar/water sol. Barrier cream and alginate and abdominal pad daily Not as painful or wet More comfort May be nonhealable
Morphea Violaceous erythema with bound down skin and atrophy Can be painful, itchy, scars Turns brown when burnt out Idiopathic or secondary to radiation 62 YO lady had this in left axilla and on chest for over one year before being referred Could not wear bra for one year limited social interactions due to this!
This can occur after radiation, or in chronic lymphedema 78YO male Referred from orthopedics with seven week hx of nodule and severe left knee pain Orthopedics thought was pyoderma gangrenosum What was diagnosis? angiosarcoma
What would be the concerns for this patient with wound care?
Malignant Wound Concerns Drainage Bulk Odor Pain Cost Social Isolation
Drainage and Bulk Drainage can leak through to clothes Bulky dressings can be obvious through clothes or uncomfortable Embarrassment Use more absorbent dressings or change regularly Make it easy so caregivers or patient can do themselves
59 YO female hx breast ca 2013 Referred to me for furunculosis March 2014 By the way have a Lt breast wound since Aug. 2013 after surgery for benign breast growth 17 Rxs HBOT NPWT in past Draining, soaked through clothes often Hydrofiber packed daily
0.4cm diameter, 2cm depth; 30% fibrin, violaceous granulation
What is wrong with this? Violaceous granulation- hypergranulated Too red and too wet! Not packed far enough into tunnel Dressing inadequate for exudate Patient had to change cover dressing multiple times per day Inconvenient
What did we do? Chlorhexidine 0.5% solution cleanses Bridine soaked gauze wick packed gently into wound to dry it and dry dressing DAILY changes Decreased depth to 1cm in two weeks
Totally closed in one month
Odor
Odor Antiseptics can help; use to clean the wound Topical antimicrobials Charcoal based dressings Metronidazole Control odor and improve quality of life
Pain
Pain options Topical cream to cool area Silver sulfadiazine cream Magic cream HC 1% powder with 0.25% menthol and 0.25% camphor in a base emollient Pain medications before dressing changes Relaxing environment for dressing changes Nonadherent so no pain on removal Can soak dressing prior to removal Cover with foam with impregnated ibuprofen Topicals with pain medications (lidocaine/morphine/ketoprofen) Keep in place with surgilast so no adhesives
Cost A Big Issue Try to minimize cost but still provide effective treatment Community health provides dressings on formulary if patient referred Prescription antiseptics, topicals, pain relief a cost to patient Can use homemade products Tap water can be used to cleanse if boiled Homemade ¼ vinegar/water solution Homemade Dakin s solution Can use maxi pads, diapers, crib/mattress protectors for excessive drainage also
Social Isolation All of the previous issues lead to embarrassment and withdrawal from normal social contacts Leads to more stress, depression for patient and caregivers Consider this and try to pick choices for dressings that minimize the particular issues for the patient
Take Home Messages Dermatology and Oncology overlap at times Wound Care is complicated if you are not trained! Don t be overwhelmed! Remember Local wound care very important Always need to treat cause, patient concerns Wounds are dynamic - adapt based on DIME Malignant wounds have special concerns Multidisciplinary approach can improve outcomes and quality of life