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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 • • • • 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 !!