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IT’S NOT HEALING…WHAT NOW?AN INTRODUCTION TO THE CONCEPT OF ATYPICAL WOUNDS

Maria Lourdes M. Celis, MD, CCFP(COE), FCFP ,  Joanna Debosz, MD, CCFP 

Emily Kwan MD, FRCPC (Geriatric  Medicine)

Dr. Emily Kwan Disclosure

• Faculty: Department of Geriatric Medicine, University of Calgary

• Relationships with financial sponsors:‐ Grants/Research support: N/A

‐ Speakers Bureau/Honoraria: N/A

‐ Consulting Fees:N/A

‐ Patents:N/A

‐ Other:  The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

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Dr. Maria Celis Disclosure

• Faculty: Department of Family Medicine, Care of the Elderly Program

• Relationships with financial sponsors:‐ Grants/Research support: N/A

‐ Speakers Bureau/Honoraria: N/A

‐ Consulting Fees:N/A

‐ Patents:N/A

‐ Other:  The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

Dr. Joanna Debosz Disclosure

• Faculty: Department of Family Medicine

• Relationships with financial sponsors:‐ Grants/Research support: N/A

‐ Speakers Bureau/Honoraria: N/A

‐ Consulting Fees:N/A

‐ Patents:N/A

‐ Other:  The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

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IT’S NOT HEALING….WHAT NOW?

OBJECTIVES:

• IDENTIFY PRESENTATION OF ATYPICAL WOUNDS

• DESCRIBE HOW DIFFERENT WOUND DRESSING SHOULD BE USED IN PRACTICE

• USE NEW KNOWLEDGE IN WOUND ASSESSMENT TO PLAN FOR MANAGING ATYPICAL WOUNDS

Plast Aesthet Res 2015;2:250-6.

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TYPICAL CHRONIC ULCERS

• DIABETIC NEUROPATHIC ULCERS

• ARTERIAL ULCERS

• VENOUS INSUFFICIENCY ULCERS

• PRESSURE INJURY ULCERS

• TRAUMA

• SURGICAL

https://woundcareadvisor.com/wp‐content/uploads/2017/08/diabetic‐foot‐ulcer.jpg

https://www.nursingtimes.net/pictures/420x280/9/0/9/1205909_leg_ulcer.jpg

http://www.sierravein.com/images/leg_ulcer.jpg https://encrypted‐tbn0.gstatic.com/images?q=tbn:ANd9GcSopZ‐9LiTWxeS3G9azjMCIPTFJUenvejjUfKWED40pU5LWrlO5

ATYPICAL CHRONIC ULCERS 

• DEFINITION: WOUND OF UNKNOWN ETIOLOGY, CAUSED BY A DISEASE

OR CONDITION THAT DOES NOT TYPICALLY CAUSE A WOUND

• ABOUT 5% OF ALL WOUNDS

• CAUSES: MALIGNANCY, IMMUNOLOGIC, SYSTEMIC DISEASE, GENETIC

DISORDERS (SICKLE CELL), INFECTIONS (FUNGAL AND

MYCOBACTERIAL)

https://www.woundsource.com/

Acta Med Croatica. 2012 Oct;66 Suppl 1:5-

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WHAT TO CONSIDER

• ABCDE • Asymmetry• Border irregularity• Color• Diameter• Evolving size, shape or color

• HISTORY (PMX, MEDICATIONS)

• LOCATION

• RISK FACTORS

TYPICAL VS. ATYPICAL WOUNDS

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https://members.nursingquality.org/ndnqipressureulcertraining/Module2/OtherWoundTypes.aspx

TYPICAL OR ATYPICAL ?

https://www.dovepress.com/pyoderma‐gangrenosum‐challenges‐and‐solutions‐peer‐reviewed‐fulltext‐article‐CCID

TYPICAL OR ATYPICAL ?

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http://medtronicendovenous.com/content/uploads/2016/06/wound_DSC_0227_2.jpg

TYPICAL OR ATYPICAL ?

TYPICAL OR ATYPICAL ?

http://www.mohshawaii.com/most‐common‐types‐of‐skin‐cancer/basal‐cell‐carcinoma‐2/

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A 49 YEAR OLD WOMAN, HEALTHY • PRESENTED WITH A WOUND TO LOWER SHIN WHICH STARTED AS

A SMALL CUT FROM SHAVING

• CELLULITIS DEVELOPED, TREATED WITH ORAL AND THEN IV ANTIBIOTICS

• CELLULITIS RESOLVED BUT A MUCH LARGER ULCER, NOW VERY PAINFUL REMAINED - AT THAT POINT SHE WAS REFERRED TO WOUND CLINIC

PAST MEDICAL HISTORY• HISTORY OF FATIGUE, MUSCLE PAIN AND MALAISE, NO UNIFYING

DIAGNOSIS, SYMPTOMS PERSIST

• NO MEDICATION

FAMILY HISTORY• CROHN’S DISEASE

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PHYSICAL EXAMINATION

• NO CLINICAL INDICATIONS OF ARTERIAL OR VENOUS DISEASE

• CELLULITIS WAS RESOLVED

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• large shallow ulceration of the left lateral calf• base of the ulcer showed slough with some hemorrhage necrosis. • border of this lesion showed a classic purple‐greyish hued discoloration with evidence of incipient 

epidermal necrosis• no significant undermining, no evidence of infection

INVESTIGATIONS• PUNCH BIOPSY (2 SAMPLES ARE NEEDED: HISTOLOGY AND

TISSUE CULTURE)

• ROUTINE BLOOD WORK, CRP

• SPEP

• LUPUS PROFILE

• INFLAMMATORY BOWEL DISEASE PROFILE

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• PYODERMA GANGRENOSUM

Skin, Biopsy:

Neutrophil‐rich dermal infiltrate

If an infectious etiology has been excluded clinically, the histologic findings may be seen in a neutrophilic dermatosis such as pyoderma gangrenosum.  Clinical and pathologic  correlation, including correlation with final tissue culture results, is necessary for a definitive diagnosis.

DIAGNOSIS

• URGENT REFERRAL TO DERMATOLOGY

• INITIALLY STARTED ON ORAL PREDNISONE AND INTRALESIONAL KENALOG INJECTIONS

• DESPITE THAT, ULCER CONTINUED TO ENLARGE IN SIZE AND PAIN CONTINUED TO BE SEVERE

TREATMENT

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14.7 cm x 10cm

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• IN ADDITION TO ORAL PREDNISONE, CYCLOSPORINE WAS ADDED

• ONLY WHEN CYCLOSPORINE WAS ADDED, DID THE ULCER STOP EXPANDING

TREATMENT CONTINUED

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• FIVE MONTHS AFTER INITIAL TRAUMA, ULCER FULLY RESOLVED

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PYODERMA GANGRENOSUM

• RARE CUTANEOUS ULCERATIVE DISEASE WITH DISTINCTIVE MORPHOLOGICAL PRESENTATION 

• IDIOPATHIC IN 25‐50% OF PATIENTS 

• CAN BE ASSOCIATED WITH INFLAMMATORY CONDITIONS SUCH AS INFLAMMATORY BOWEL DISEASE, AUTOIMMUNE CONNECTIVE TISSUE DISEASES (MOSTLY LUPUS, RHEUMATOID ARTHRITIS),  MONOCLONAL GAMMOPATHIES AND OTHER HEMATOLOGIC DISORDERS 

SOURCE: UPTODATE

PYODERMA GANGRENOSUM

• DEFECTS IN CELL‐MEDIATED IMMUNITY, NEUTROPHIL AND MONOCYTE FUNCTION, AND HUMORAL IMMUNITY HAVE BEEN REPORTED ‐ HOWEVER NOT CONSISTENTLY ENOUGH 

• OFTEN STARTS AS MINOR TRAUMA AND CAN BE EXACERBATED BY SAME (PATHERGY)

• SKIN BIOPSY IS NECESSARY FOR DIAGNOSIS (MUST EXCLUDE INFECTION)

• TREATMENT INCLUDES SYSTEMIC CORTICOSTEROIDS AND ADDITIONAL AGENTS DEPENDING ON SEVERITY AND NUMBER OF LESIONS 

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KC 53 YEAR OLD MAN DIABETIC

• WITH DM NEPHROPATHY, CHARCOT ARTHROPATHIC ULCER,

NEUROPATHY, LEFT FOOT ULCER HEALING

• INCREASED SWELLING OF BOTH LEGS, QUITE TENDER WITH

INDURATION, COMPRESSION INCREASED TO TWO LAYERS.

• US FOR DVT IS NEGATIVE

• GFR 15 ML/MIN, HIGH PHOSPHATE, NORMAL

CALCIUM, NOT UREMIC

• SMALL BLISTERING PAINFUL ULCERS

DEVELOPED ON INDURATED AREAS

INCREASING NUMBER IN A WEEK

• URGENT NEPHROLOGY CONSULTATION FOR

POSSIBLE CALCIPHYLAXIS.

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• BONE SCAN SHOWED CALCIFICATIONS ON THE

RIGHT LEG, NO BIOPSY DONE

• URGENT DAILY DIALYSIS

• DEBRIDEMENT IN THE CLINIC WITH LOCAL

WOUND DRESSINGS TO CONTROL DRAINAGE

• COMPRESSION WRAPS FOR EDEMA

CALCIFIC UREMIC ARTERIOLOPATHY

• USUALLY SEEN IN PATIENTS WITH END STAGE RENAL DISEASE

• SXS: PAINFUL ISCHEMIC NECROTIC LESIONS OCCURRING IN

AREAS WITH GREAT ADIPOSITY ( BUTTOCK, ABDOMEN, LEGS)

• PAINFUL RED TO PURPLE LIVEDOID PLAQUES RAPIDLY

PROGRESSES TO NON HEALING NECROTIC ULCERS

• DIFF DX: DM WOUND, ARTERIAL, VENOUS, PRESSURE ULCER

Source:UptoDate

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Diagnosis 

• DX: BIOPSY- CAUTION

• RADIOGRAPHY- SOFT TISSUE, MAMMOGRAM TECHNIQUE,

SPIRAL CT, US, BONE SCAN

• LOOKING FOR ARTERIOLAR CALCIFICATIONS

• LABS: CALCIUM, PHOSPHOROUS, PTH, CREATININE

Source:UptoDate

CALCIFIC UREMIC ARTERIOLOPATHY

• TREATMENTS: NO EVIDENCE BASED GUIDELINES

• SYSTEMIC TREATMENT: DIALYSIS, PARTIAL

PARATHYROIDECTOMY

• WOUND CARE: DEBRIDEMENT, TOPICAL WOUND CARE, PAIN

MANAGEMENT

Source:UptoDate

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PROPERTIES OF A GOOD WOUND DRESSING

● COMFORTABLE

● CONFORMABLE

● LONGER WEAR TIME-MORE DRESSING CHANGES INCREASE THE PH OF THE

WOUND

● INSULATES

● MAINTAINS MOIST WOUND ENVIRONMENT

● BARRIER TO TRAUMA AND INFECTION

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GAUZES

• FIBRES OF COTTON, RAYON OR POLYESTER, PLAIN OR IMPREGNATED WITH PETROLEUM

JELLY OIL OR WATER EMULSION, GEL OR ANTI MIC

• VARIOUS SHAPES AND SIZES, CHEAP PRODUCT

• IND: LOW EXUDATE, FILL DEAD SPACE, DELIVER PRODUCT, CLEANS

• CI: NOT FOR HIGH EXUDATIVE WOUNDS

• DISADV: MACERATION, FREQUENT DRESSING CHANGES

Source: Wounds Canada

ACRYLICS /FILMS/MEMBRANES

• WATERPROOF FILM, IMPERMEABLE TO LIQUID AND BACTERIA

• MOISTURE VAPOUR TRANSMISSION RATES VARY

• ADV: EXTENDED WEAR TIME, WOUND MONITORING, SUPPORTS

AUTOLYTIC DEBRIDEMENT

• CI: MOD TO HIGH EXUD, INFECTED, DEEP CAVITIES,

• DIS: NOT FOR HIGH EXUD WOUNDS

Source: Wounds Canada

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CALCIUM ALGINATES

• FIBROUS ROPES OF GLUCURONIC ACID AND SODIUM CMC

• USED FOR MODERATELY TO HIGHLY EXUD WOUNDS, HEMOSTASIS,

FILLING WOUND DEAD SPACE

• ADV: CONFORMABLE, MOISTURE BALANCE

• DIS: : SECONDARY DRESSING NEEDED, MACERATION

• CI: DRY WOUND, DEEP SINUSES, HEAVY BLEEDING

Source: Wounds Canada

GELLING FIBRES

• SHEETS / STRIPS OF CMC, TURNS INTO GEL WHEN ACTIVATED

• IND: MOD TO HIGHLY EXUD WOUNDS , AUTOLYTIC DEBRIDEMENT

• CI: DRY WOUNDS, NARROW DEEP SINUSES

• ADVANTAGE: ABSORPTIVE, CONFORMABLE

• DISADVANTAGE: MACERATION, SECONDARY DRESSING

Source: Wounds Canada

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FOAMS

• POLYURETHANE, WITH VARIOUS MOISTURE VAPOUR

TRANSMISSION RATES

• OPTIONS: ANTIMICROBIAL, WITH BORDER, PAIN CONTROL

• ADV: CONFORMABLE, LOW TO MOD EXUDATE, WICKS EXUDATE

• DIS: MACERATION, DOES NOT REDUCE PLANTAR PRESSURE

Source: Wounds Canada

HYDROCOLLOIDS

• OCCLUSIVE SHEET DRESSING, POLYURETHANE

• MAY CONTAIN GELATIN, CMC, PECTIN

• USE: LOW LEVEL EXUDATE, AUTOLYTIC DEBRIDEMENT

• NOT USED: HIGH EXUDATING WOUNDS, INFECTED WOUNDS,

ARTERIAL WOUNDS, MAY MACERATE AND TEAR SKIN

Source: Wounds Canada

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CHARCOALS

• ACTIVATE CHARCOAL WITHIN A SLEEVE DRESSING

• SOME MAY HAVE SILVER

• IND: MALODOROUS WOUNDS, MILD TO MOD EXUDATE, CAVITY

WOUNDS

• CI: HIGHLY EXUDATING WOUNDS

Source: Wounds Canada

ANTIMICROBIAL AGENTS IN DRESSINGS 

• SILVER

• POLYHEXAMETHYLENE BIGUANIDE

• IODINE

• GENTIAN VIOLET/METHYLENE BLUE

• HONEY

Source: Wounds Canada

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QUICK REVIEW OF WOUND DRESSINGS

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What dressing would you use

What dressing would you use

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PEARLS

• IF A TYPICAL CHRONIC WOUND IS NOT HEALING IN SPITE OF

BEST WOUND PRACTICES, CONSIDER ATYPICAL CAUSE

• REVIEW MEDICAL HISTORY, FAMILY HISTORY, MEDICATIONS

• BIOPSY THE WOUND

• REFER TO THE WOUND CLINIC FOR INTERDISCIPLINARY CARE

WOUND CLINIC

• Sheldon Chumir Wound Clinic - Family Physicians, Dermatologists, Vascular Surgeon, Physiotherapist, RN’s with wound certification, LPN’s

• Different Wound Care Clinics associated with Home Care across the city

• Home Care would be able to follow/care for wounds at home

• Referrals can be faxed to Central Access at 403-943-1602

• More details at www.informalberta.ca

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ACKNOWLEDGEMENTS

• Dr Connie Zhang

• Cyrilene Lynch-Parker

• Teaching Materials provided by Sheldon Chumir Wound Clinic

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