Transcript Atypical Wound Care

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
atypical wound include inflammatory causes, infections,
vasculopathies, metabolic and genetic causes,
malignancies and 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 sarcoma
Araujo & Kirsner, 2004
• Vasculopathies
– Cryoglobulinemia
– Cryofibrinogenaemia
• External causes
– Bites
– Radiation
Araujo & Kirsner, 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
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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, 2005
• 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
result in even worse ulceration
• Avoidance of trauma at dressing removal
– disturbance can generate an even greater
inflammatory response and stimulate deterioration
Araujo, & Kirsner, 2004
• 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 !!