Management of difficult wounds, ulcers

Treating leg and foot ulcers irrespective of the etiology has always been a mountain to climb for physicians and patients alike.

Positive resolutions of these wounds are sometimes difficult to achieve. O. Fred Miller III M.D., emeritus director of the department of dermatology at Geisinger Medical Center in Danville, Pa., will offer some pearls in the treatment and management of these sometimes very stubborn and frustrating lower extremity wounds today in FRM508 from noon to 2 p.m.

He said that there are four main issues in ulcer therapy that the physician must address at the start of therapy.First, the edema that strangulates the tissues surrounding the open wound must be treated, as it significantly impedes the expedition of the healing process. Second, the pressure and/or friction on and around the wound must be eliminated. Third, thorough and repeated debridement of necrotic tissues must be undertaken. The dead tissue further impedes the healing process. Fourth, the tissue surrounding the wound must be respected and handled with "silk gloves."

He said that diuretics are ineffective for nonpitting edema, but the use of an Unna boot does very well. The all-important debridement can be carried out mechanically or through the application of hydrocolloids (e.g. Duoderm), or by applying proteolytics to the wound.Topical steroids can be used for skin care of the surrounding tissues.

He said that moist to moist saline gauze, not wet to dry saline gauze, is very beneficial for wound maintenance and healing. Dr. Miller stresses that wound cleansing should be done with saline, and that physicians should avoid using betadine, hydrogen peroxide and hexachlorophine.

In the case of diabetic ulcers, it is of paramount importance that the physician assesses the permeability of the vasculature and if compromised, the patient should be referred to a vascular surgeon. Here, it is also important that debridement of devitalized tissues be carried out and that external pressures and friction to the ulcer be removed. Lastly, Dr. Miller says that a baseline extra should be taken to assess the bone and soft tissue.

He stresses that if the blood perfusion is adequate, all diabetic foot ulcers should heal without amputation, and that the wary and diligent physician will be able to save many feet from a bad end. DT