Atypical Wound Care

LEE Wai-kuen

Nurse Specialist

Queen Mary Hospital

Atypical Wound

• Wounds due to uncommon etiologies are called atypical

wounds.

• The most commonly encountered etiologies for an atypic

al wound include inflammatory causes, infections, vascul

opathies, metabolic and genetic causes, malignancies an

d external causes.

(Baranpski & Ayello, 2004)

Potential etiologies

• Inflammatory causes

– Vasculitis

– Puoderma gangrenosum

• Infections

– Atypical mycobacteria

– Deep fungal infections

Araujo & Kirsner, 2004

• Metabolic and genetic causes

– Calciphylaxis

– Sickle cell anemia

• Malignancies

– Squamous cell carcinoma

– Basal cell carcinoma

– Lymphoma

– Kaposi’s sarcomaAraujo & Kirsner, 2004

• Vasculopathies

– Cryoglobulinemia

– Cryofibrinogenaemia

• External causes

– Bites

– Radiation

Araujo & Kirsne

r, 2004

Scleroderma

• A widespread connective tissue disease that

involves changes in the skin, blood vessels,

muscles, and internal organs.

Alternative Names

• CREST syndrome

• Progressive systemic sclerosis

• Systemic sclerosis

• Localized scleroderma

• Affect 300,000 people in USA

• Female : Male = 4:1

• Population

– Infant elderly

– Average age 22-55

• Causes

– Unknown

– Not directly inherited

– Over production of collagen in the skin and

other organs

• Risk factors

– Occupational exposure to silica dust and

polyvinyl chloride

Skin symptoms

• Blueness or redness of fingers and toes in response to heat and cold

• Ulcerations on fingertips or toes

• Skin hardness / thickening

• Skin is abnormally dark or light

• Shiny hands and forearm

• Small white lumps beneath the skin

• Tight and mask-like facial skin

• Hair loss

Other organs involvement

• Bone, joint and muscle

• Digestive system

• Lung

• Kidney

• Gallbladder

• Heart

• Eye

Complications

• Heart failure

• Kidney failure

• Malabsorption

• Pulmonary fibrosis

• Pulmonary hypertension

• Medication

– Decrease activity of immune system

• Corticosteroids

• Immunosuppressants (Methotrexate, Cytoxan)

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

– Symptomatic control

Prognosis

• In most patients, the disease slowly gets worse.

• Death may occur from gastrointestinal, heart, kidney,

or lung involvement.

• Pulmonary sclerosis - most common cause of death.

Epidermolysis Bullosa (EB)

• A rare inherited disease

• The skin is very fragile and blisters formed in

response to friction and to every day trauma

• May also affect multiple systems of the body

Epidermolysis Bullosa

• Epidermolysis simplex

• Junctional epidermolysis bullosa

• Dystrophic epidermolysis bullosa

Epidermolysis simplex

• Largest group

• Dominantly inherited disorder

– One copy of the gene is faulty

• Not life threatening

• Blistering mainly limited to the hands, elbows, knees and

feet

• Reduce in severity as the child becomes older

Junctional epidermolysis bullosa

• Recessively inherited disease

– Both copies of the gene are faulty

• The most serious type of EB, infants usually die during

the first year of life

• Generalized lesions

• Affect mucous membrane

Dystrophic epidermolysis bullosa

• Can be either dominant or recessive

• Dominant – only mildly affected

• Recessive – severely affected

• Continuing blistering and ulceration of the skin follows

everyday trauma

• Lesions heal with scarring

– result in strictures and contractures

– limitation in mobility and eating

• Predispose to skin cancer

Handling of the children

• Small infants should never lift up under arms as

painful blisters may result.

• Older children should be encouraged to be

independent in his / her early age so as to avoid

trauma by others.

Aims of wound care

• Encourage wound healing

• Maintain daily activities

• Social acceptability

Dressing choice

• Wound contact layer dressing

– eg. Mepitel, Urgotul

• Non adherent dressing

– eg. Melolin, Tricose, Mepliex

• Alginate dressing

Clothing

• Fine material clothing• Can be worn inside out to avoid rough seams• Remove internal labels• Padded footwear

Oral care

• Affect mucous membrane

– eg. oral blistering, bleeding, oral submucous fibrosis, oesophageal strictures

• Dental decay

– Due to fragility of oral mucosa

– Fluoride supplement

– Oral hygiene

– ?? Tooth brushing

– ?? Dentures

Nutrition

• Dysphagia - gastrostomy feeding

• Constipation – soluble fibre supplement

Mobility

• Digital fusion

– Results from repeated blistering and scarring

• Plastic surgery

• Splintage

Pyoderma Gangrenosum (PG)

• An inflammatory process resulting in ulceration of unknown etiology.

• It was an immune-mediated inflammatory condition characterized by

ulcerative skin lesions.

• Affect about 5 percent of people with ulcerative colitis

Regueiro, et al, 2003

Papageprgiou, Mathew, Kaniorou-Larai, & Yiakoumetis, 2007

Systemic diseases associated with PG

• Associated with other conditions in up to 75% of patients.

– Inflammatory bowel disease

– Arthritis

– Hemotologic abnormalities

• Lymphoma

• Myeloma

• Leukemia

– Immunologic abnormalities

• SLE Araujo & Kirsner, 20

05

• Appear as a blister, red bump, or pustule

• Appear alone or in a group

• Pustules progress rapidly and develop into the ulcer

• Commonly found on the extremities

• More frequently on the legs than on the arms

Nkrumah, Addo, & Tachi, 2005

Papageprgiou, et al, 2007

Diagnosis

• No single diagnostic test available for PG

• It is a clinical diagnosis of exclusion

• Based on excluding other causes and evaluating the

patient for underlying systemic disease.

Trent & Kirsner, 2001

Treatment

• Treat underlying disease

• Corticosteroid

• Immunosuppressant

– Cyclosporine

• Systemic antibiotics

• Anaesthetic

Wound management

• Control pain

• Necrotic tissue

– surgical debridement is contraindicated as it may r

esult in even worse ulceration

• Avoidance of trauma at dressing removal

– disturbance can generate an even greater inflamm

atory response and stimulate deterioration

Araujo, & Kirsner, 20

04

• Negative pressure therapy

– may be used to assist debridement when the disease

is stable

• Debridement and skin grafting

– can be considered when condition is under controlled

– surgery may reactive the disease

Moffatt, Martin, Smithdale, 2007

The End !!