1. Atypical Wound Care LEE Wai-kuen Nurse Specialist Queen Mary Hospital

2. 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)

3. Potential etiologies Inflammatory causes –Vasculitis –Puoderma gangrenosum Infections –Atypical mycobacteria –Deep fungal infections Araujo & Kirsner, 2004

4. Metabolic and genetic causes –Calciphylaxis –Sickle cell anemia Malignancies –Squamous cell carcinoma –Basal cell carcinoma –Lymphoma –Kaposi’s sarcoma Araujo & Kirsner, 2004

5. Vasculopathies –Cryoglobulinemia –Cryofibrinogenaemia External causes –Bites –Radiation Araujo & Kirsner, 2004

6. Scleroderma A widespread connective tissue disease that involves changes in the skin, blood vessels, muscles, and internal organs.

7. Alternative Names CREST syndrome Progressive systemic sclerosis Systemic sclerosis Localized scleroderma

8. Affect 300,000 people in USA Female : Male = 4:1 Population –Infant elderly –Average age 22-55

9. 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

10. 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

11. Other organs involvement Bone, joint and muscle Digestive system Lung Kidney Gallbladder Heart Eye

12. Complications Heart failure Kidney failure Malabsorption Pulmonary fibrosis Pulmonary hypertension

13. Medication –Decrease activity of immune system Corticosteroids Immunosuppressants (Methotrexate, Cytoxan) Nonsteroidal anti-inflammatory drugs (NSAIDs) –Symptomatic control

14. 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.

15. 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

16. Epidermolysis Bullosa Epidermolysis simplex Junctional epidermolysis bullosa Dystrophic epidermolysis bullosa

17. 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

18. 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

19. 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

20. Lesions heal with scarring –result in strictures and contractures –limitation in mobility and eating Predispose to skin cancer

21. 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.

22. Aims of wound care Encourage wound healing Maintain daily activities Social acceptability

23. Dressing choice Wound contact layer dressing –eg. Mepitel, Urgotul Non adherent dressing –eg. Melolin, Tricose, Mepliex Alginate dressing

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

25. 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

26. Nutrition Dysphagia - gastrostomy feeding Constipation – soluble fibre supplement

27. Mobility Digital fusion –Results from repeated blistering and scarring Plastic surgery Splintage

28. 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

29. 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

30. 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

31. 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

32. Treatment Treat underlying disease Corticosteroid Immunosuppressant –Cyclosporine Systemic antibiotics Anaesthetic

33. 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

34. 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

35. The End !!