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					Find us on the web:                                                          No. 70
www.sawma.org.au                                                          January 2010




                                  Wound Wisdom
                                        Newsletter of the
                      South Australian Wound Management
                                Association Inc.
                                Box 1144 Blackwood, SA 5051
                                  Telephone: 0406 440 813


          EDUCATION MEETING
       WEDNESDAY 17 FEBRUARY 2010
                   World Wide Wounds
                           &
                  Annual General Meeting
  Wound Management & Cultural Diversity, including guest speaker Carmen George

                          Trade display & supper 1845
               Annual General Meeting commences 1930
                               ALL WELCOME
                      Non members $5.00 Members & students free
                        SAWMA is a multidisciplinary association and is
                        non-partisan in its approach to wound products




   CAMPAIGN FOR ACCESS TO SUBSIDISED DRESSING PRODUCTS
 Sign the petition at www.elephantintheroom.com.au to support subsidisation of
dressing products across Australia in all care settings. Don’t be an elephant and
   ignore the problem. SAWMA strongly encourages its members to sign.
               Encourage your colleagues and patients to sign too!

             EDUCATION NIGHT VENUE: ANF BUILDING
 NEW                         191 Torrens Road, Ridleyton SA
VENUE!                         Just before South Road (City Side)
                        Off Street Parking available behind the venue
www.sawma.org.au                                             Newsletter 70 October 2010

g
                     PRESIDENT'S REPORT

President’s report
SAWMA newsletter
January 2010

Welcome to 2010! As the next decade starts it is a good time to reflect on where SAWMA
and wound management has been and where we are going.
The noughties saw the phenomenon of silver-containing dressings, a focus on infection
and a framework for wound bed preparation. We learnt about bacteria, found out what a
biofilm is and discovered that it is not just specific to old ham and unbrushed teeth! We
have seen new products come onto the market, including a significant expansion of the
Topical Negative Pressure Therapy technologies. There has been increasing use of
‘natural’ therapies, including honey and larval therapy. Wound assessment tools have
improved significantly, with an increase in access to, affordability of and quality of digital
photography. Tools that calculate wound surface area and changes to wound surface area
have become available, making accurate, standardised wound assessment easier and
more reliable.
The international world of wound management has become much closer. We have seen
the birth of the World Union of Wound Healing Societies and the release of several
international position documents. The internet has allowed clinicians, educators and
researchers throughout the world to readily access and share high quality, contemporary
information. Email has facilitated local, national and international communication on an
almost instant basis. Never before have we been able to access so much information so
readily. We can now discuss wound issues with our colleagues throughout the country or
overseas or, contact wound management practitioners we might have only previously
heard of via journals or books. No longer do we take slides or overhead transparencies
with us for presentations. Electronic presentations using digital images, videos and internet
links have revolutionised the quality and scope of information-sharing. Even our computer
technology has advanced incredibly, allowing us to store and transport huge amounts of
data. We have gone from floppy disks to compact discs to tiny USB sticks with more
memory on them than an entire computer system had only a few years ago.
AWMA has had a very successful decade. AWMA held several conferences, taking us on a
national wound management journey. The Australian Standards for Wound Management
and the first Clinical Practice Guidelines (for the Prediction and Prevention of Pressure
Ulcers) were released. Work was commenced on the Clinical Practice Guidelines for
Venous Leg Ulcers and revision of the Standards for Wound Management. AWMA
developed its first Position Document (on bacteria in wounds) and first Position Statement
(on wound and skin products and devices). Development of the Australian Pressure Ulcer
Advisory Panel was commenced. The journal has continued to expand and evolve,
including a change of name and introduction of a regular newsletter. The website has
grown and, more recently been significantly updated with a new look and functions. A
national Wound Awareness campaign has been run to raise awareness of wounds and
lobby for increased support for the forgotten and ‘un-sexy’ issue of wounds.
SAWMA too has had a busy and very productive decade. We have also seen significant
growth to meet the ever-changing area of wound management. Our website has
undergone expansion and revision. I am proud of the scope and quality of unrestricted
information SAWMA offers. We have continued to hold regular education evenings on
many topics, with a variety of well renowned speakers. Our biennial seminars have been
www.sawma.org.au                                             Newsletter 70 October 2010

very successful, with some seminars attracting national attention and attendance. The
SAWMA newsletter has been re-named, re-vamped and expanded. The SAWMA
Constitution has been revised – a mammoth but necessary task. Interestingly, the previous
Constitution was typed on a typewriter! We continue to offer research grants – and have
supported several significant projects. More recently we have introduced an education
grant. SAWMA continues to have links with the trade, who support our endeavours and
provide a valuable resource for members.
If you are like me, you will have found that the last decade seemed to fly by. I’m sure this
next decade will be no different. Whilst we are not yet driving flying cars, nor do we have
robots to do the housework (damn!!) we have seen enormous advances in wound
management, and I’m sure we will continue to do so. I look forward to this next decade with
anticipation and excitement at what we can achieve for our members, our clients and our
colleagues. The next ten years are sure to bring advances we cannot yet imagine and
bring benefits to our practice and client outcomes not currently possible. I hope you will join
SAWMA on this journey into the future of wound management – together we can make a
difference and improve the lives of persons with a wound.
Happy wound management and Happy 2010!




Ms Sue Templeton
SAWMA President




WOUND WORDS CROSSWORD SOLUTION
www.sawma.org.au                                           Newsletter 70 January 2010


       SAWMA FEATURE ARTICLE
    “BURSTING THE BUBBLE’ FLINDERS
                STYLE!

   Author: Awen Griifiths RN, Treatment Room Coordinator, Surgical Specialties
                               Outpatient Dept. FMC


Establishment of a Nurse Led Seroma Drainage Clinic at Flinders Medical Centre,
Adelaide SA 2009
At the Plastic Surgery Outpatient’s Department Flinders Medical Centre we see
approximately 80 post operative plastic surgery patients per week. A small percentage of
these patients develop a seroma post operatively.


Background
A seroma is a collection of lymph and serous fluid that occur beneath the skin flaps after
breast surgery. Seroma formation is the most common complication following breast
cancer surgery [Keogh et al,1998]. Reported incidence is between 24.6% and 69% in
patients undergoing mastectomy [Aitken et al,1984].Many of these seromas are
troublesome to the patient causing pain, discomfort and reduced arm mobility. Some
seromas are small and will subside without treatment, but occasionally drainage is
necessary. More seriously, seroma formation can lead to infection, delayed wound healing
and flap necrosis.
Prior to the commencement of the project, patients requiring aspiration of seroma were
treated in the Treatment Room, Outpatient Department and were randomly allocated a 5
minute time slot. This caused clinic time delays, as nurses were required to wait for a
Medical Officer to aspirate the seroma. This caused increased anxiety for our patients,
delays for doctors who were allocated afternoon theatre sessions and delays for ongoing
Treatment Room activity.
As Coordinator of the Treatment Room, I felt we were lacking a service to these patients
who had developed seromas post operatively. The aspiration was often rushed, in a noisy
environment with little privacy and little time to explain the procedure thoroughly.


Project Implementation
In early 2009 in discussion with Andrea Smallman CSC and Dr Nicola Dean, Consultant
Plastic Surgery, an evidence based protocol to implement a Nurse Led Seroma Drainage
Service within the Outpatient Department was initiated.
Consultation was made with the Breast Care Nurses at Flinders Medical Centre and with
Gemma Sacco [Nurse Unit Manager, Breast Service, Southern Health, Moorabin, VIC].
Research concerning Nurse Led clinics in England, United Kingdom was also performed.
www.sawma.org.au                                              Newsletter 70 January 2010

In conjunction with Dr Dean an education programme for the experienced staff who work
within the Treatment Area was developed. A competency and accreditation programme
was developed which the nursing staff completed. Full competency was based on
achievement of the following:


   •   Attended a lecture by Dr Dean
   •   Observed aspiration of a seroma performed by a doctor
   •   Participated in aspiration of a seroma with a prosthesis
   •   Performed aspiration under the supervision and guidance of Dr N Dean.


Once staff were accredited a protocol was devised and made available on the hospital
intranet and a Patient Information leaflet was written. This leaflet is provided to the patient
once the seroma is diagnosed. Currently the Nurse Led Clinic sees approximately 3
patients a week. The patient is allocated a 30 minute time slot on a different day which
enables the seroma to be aspirated in a much quieter, calmer environment. More time is
available to reassure the patient and more time can be taken to explain the procedure and
answer any questions the patient may have. The nurses are all aware of their scope of
practice and the medical team is contacted if any assistance is required.
This newly developed clinic, which is still in its infancy, provides an improved service by
offering patients more flexible appointment times, more appropriate time allocation and
continuity of care.
For the patients who have been treated by the Nurse Led Seroma Drainage Clinic a patient
satisfaction survey is in progress. Anecdotal feedback from patients has been very positive
and encouraging.


Reference List.
Aitken , D.R, Hunsacker ,R., James ,A.G [1984] ‘Prevention of seromas following
mastectomy and axillary dissection’ .Surgery, Gynaecology and Obstetrics,158,327-333
Keogh ,G.W., Dalty , J.C, Mccardle , C.F.M., Cook, T.G [1998] ‘Seroma formation related
to electrocautery in breast surgery’ Breast,7:39-41




Awen Griffiths RN
Coordinator
Treatment Room
Outpatient Department
Surgical & Speciality Services
Flinders Medical Centre
Bedford Park
SA 5047
awengriffiths@health.sa.gov.au
www.sawma.org.au                                            Newsletter 70 January 2010

                SAWMA SEMINAR REVIEW:
                   YOUR FEEDBACK

              “BACKTO THE FUTURE; WOUND BASICS AND BEYOND”

For those who missed the SAWMA Biannual Seminar, October 23rd turned out to be a
warm pleasant day, further lending to the lush setting provided by the Belair Park Country
Club. A total of 122 delegates attended the seminar, a great turn out, especially
considering the change from the traditional Saturday time spot to a Friday.

As per the Seminar title, the theme of all presentations and workshops was that of basic
wound management skills and knowledge. The day kicked off with Damian Williams (CNC,
Prince Charles Hospital, QLD) providing a well structured overview of a systematic
approach to Wound Assessment, while Pam Morey (NP, Sir Charles Gardiner Hospital,
WA) reminded us about the important aspects of Documentation in wound management,
including professional responsibility, communication and legal requirements. Margie
Moncrieff (NP, Flinders Medical Centre, SA) shared her knowledge on how to manage
Cavity Wounds, after which delegates then had a choice of attending two of three
concurrently run workshops covering Dressings, Basic Debridement and Pressure
Redistribution, Mapping and Offloading.
The day was rounded off with AWMA President A/Professor Michael Woodward’s
presentation on ‘Why Wounds Won’t Heal’.

Feedback from a Survey of attending delegates, revealed above average levels of
satisfaction for all of the presentations and workshops, with the Dressings, Managing
Cavity Wounds and Wound Assessment sessions being listed as favourites. General
feedback was extremely positive, with many people praising the quality of the speakers
and welcoming the chance to validate their basic wound management practice through
access to experts and specialists.

Criticisms about the seminar focused mainly around workshop time management, with
many people feeling that there was insufficient time for questions at the end of each
session. Seating for the main presentations was another issue raised, with people feeling
that this could have been better arranged. This feedback has been noted by the SAWMA
committee, who will endeavour to take this into consideration for our next seminar planned
for 2012.

In summary, it would certainly seem that there remains a significant hunger for basic
wound management knowledge and skills. It is interesting that despite the wide variety in
wound management skills and knowledge held amongst the various attendants, all were
satisfied with the opportunity to be exposed to new knowledge or to consolidate existing
knowledge and skills, regardless of the ‘basic’ nature of the information presented. In
today’s landscape of constantly changing dressing products, physiological knowledge and
management trends it is nice, as a clinician, to be told that what you are doing, have been
doing or plan to be doing is correct and inline with contemporary practice and research. I
feel that the 2009 SAWMA seminar provided an excellent opportunity to do all of the
above.
                               IMPORTANT DATES 2010
March 24-27 2010 Australian Wound Management Association National Conference 2010
‘Journey into New Frontiers’, Perth Australia’s biennial wound management conference
www.awma.com.au for more details

May 26-28 2010 European Wound Management Association ‘Get the timing right’ The 20th
Annual Scientific meeting of the EWMA, being held in Geneva, Switzerland in conjunction with the
Swiss Association of Wound Care, see http://ewma.org/english/ewma-conferences.html for more
details

South Australian Orthopaedic Nurses, AGM 8th Feb 2010 ; Members Meetings 3rd May and 13th
of August. Topics yet to be announced. www.saon.org for more information

Australian Association of Stomal Therapy Nurses, Branch Meetings 4th Wednesday of every
month. www.stomaltherapy.com for more information

September 2-7 2012, 4th Congress of the World Union of Wound Healing Societies, Yokohama
Japan, see http://wuwhs2012.com for more information

   This newsletter aims to share information about contemporary issues in wound management. We welcome
                              your contributions, resources, tips, case studies etc.
                                       Submit contributions to the editor
                      Frank Guerriero Ph 8222 5771 or frank.guerriero@health.sa.gov.au


SAWMA COMMITTEE MEMBERS
Office Bearers                                                                                               Web address
                                                                                                              Visit us at:
Ms Sue Templeton                       1300 364 264            President & AWMA rep                        www.sawma.org.au
Mr Frank Guerriero                     8222 2996               Vice President & Editor
Ms Andrea Smallman                     8204 4311               Secretary
Ms Bec Daebeler                        8204 4884               Treasurer
Mr Michael Arthur                      8355 3500               Membership Secretary

General Committee Members
Ms Margi Moncrieff                     8204 5511                                     Committee members can
Ms Lindsey Brooks                      0437 771 605                                  be contacted via e-mail,
Mr Tim Garfield                        8823 0286                                      the mailing address or
Ms Helen Pecanek                       0419 845 619                                   through a message left
Mr Paul Philcox                        8222 1690                                     on the SAWMA phone:
                                                                                          0406 440 813
Ms Elizabeth Keen                      8222 4000
Ms Awen Griffiths
All phone numbers are work contact numbers


All expressions of opinion and all other statements in this newsletter and any attachments are published on the authority of the writer/s over
whose signature they appear and are not to be regarded as expressing the views of the South Australian Wound Management Association. Where
clinical information is provided readers are encouraged to verify this independently. Whilst every effort is made to ensure the accuracy of
information no responsibility is taken by SAWMA for any inaccuracies or omissions
www.sawma.org.au                                                Newsletter 70 January 2010


     South Australian Wound Management Association
                       Incorporated
              Annual General Meeting 2010
              Committee Nomination Form
In 2010 vacancies on the SAWMA Committee will occur at the Annual General Meeting to be
held 17th February 2010. Committee terms are for two (2) years.
 Persons nominating must be financial members of
                      SAWMA.
A copy of the Constitution is available from the Membership Officer, Michael Arthur through the
SAWMA mobile phone: 0406 440 813
Nominations in accordance with the SAWMA Inc. Constitution (1995) are now required for the
positions of:

       Membership Officer
       Secretary
       Committee Position x 2
  To nominate for a committee position please complete
      the form below and post to SAWMA, PO Box 1144
                   Blackwood, SA 5051.
Postal nominations must reach SAWMA by 5pm Friday 12 February 2010. Alternatively, the
nomination form can be placed in the box at the AGM Wednesday 17 February 2010.
This nomination form can be photocopied if required.


Position nominated for: …………………………………...…

Nominee (name): ………………………………….………...…

Signature: ………………………………………….…………...

Proposed by (print name): …………………………………….

Seconded by (print name): ……………………………………
Only financial members of SAWMA are eligible to hold office, propose or second nominations.

      SAWMA welcomes new members to its committee
 The committee is a dynamic, fun, working group who work hard for SAWMA members
 and wound management in South Australia.
 Committee members assist SAWMA in meeting its objectives through commitment
 and active participation.
 The SAWMA committee meets from 6.00pm on the second Wednesday of the month
 at the Tap Inn., Rundle Road, Kent Town
 Some out of committee meeting activities may also be required by members.
      South Australian Wound Management Association
         (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”
Calcific Uremic Arteriolopathy (the disease formerly known as Calciphylaxis)
Mr Frank Guerriero
RN, Hyperbaric Unit, Royal Adelaide Hospital

Clinical presentation
•      Wounds which typically start out as a localised abnormal and unpleasant sensation in the
       affected tissue
•      Progression to livedo reticularis which follows on to frank ulceration
•      Ulceration may affect:
       o      Dermis
       o      Subcutaneous tissue
       o      Adipose tissue
       o      Fascia
•      Pain from the ulceration is extreme
•      The surrounding peri-wound area is often erythematous
•      Deposits of subcutaneous calcium may be palpable
•      Ulcers are characterised by thick leathery black eschar

Location
•     Predominately affects distal limbs (legs)
•     Cases affecting abdominal wall and penis have been reported
•     Rarely affects face or upper extremities

Associated conditions
•    CHRONIC KIDNEY DISEASE (highest prevalence)
•    Malnutrition
•    Obesity
•    Female
•    Diabetic
•    Hypertension

Known associations
•   Hyperparathyroidism
•   Elevated serum phosphate

Pathophysiology
•    Tissue necrosis resulting from calcification of small vasculature
•    Related to chronically elevated serum calcium and phosphate
     o    Typical of End Stage Renal Disease (ESRD)
•    Understanding of aetiology and pathogenesis is incomplete

Diagnosis
•    Biopsy (histology)
•    Clinical appearance
       o   In context of ESRD
   •   Transcutaneous oximetry (peri-wound hypoxia)

Treatment
•     Wound management
•     Eschar debridement
•     Autolytic
•     Sharp (once wet)
•     Manage secondary infections (topical antimicrobials if indicated)
•     Moisture balance (wide variances in exudate)

Novel therapies
•     Hyperbaric Oxygen Therapy
•     Sodium thiosulphate infusion

Case Study
•     62 y.o. male
•     PMHx
      o     Single Kidney Transplant
      o     Chronic Renal Failure
      o     Chronic Wounds (CUA)
      o     MRSA Infection
      o     Severe pain
•     Non-healing lesion left lateral calf
•     Suspected reoccurrence of CUA (virtually unheard of)

Assessment
•     Transcutaneous oximetry
     o    revealed peri-wound hypoxia

Treatment
•     Hyperbaric oxygen therapy (30 treatments)
•     Wound Management
      o    Debridement
      o    Moisture balance
•     Pain Management

References
Rogers N, Tuebner D & Coates P (2007) ‘Calcific Uremic Arteriolopathy: Advances in Pathogenesis
and Treatment’ Seminars in Dialysis, vol.20 (2) pp. 150-157

Rogers N, Chang S, Tuebner D & Coates P (2008) ‘Hyperbaric oxygen as effective adjuvant therapy
in the treatment of distal calcific uraemic arteriolopathy’ Nephrology Dialysis Transplantation Plus, vol.
4, pp.244-249

Rogers N & Coates P (2008) ‘Calcific uraemic arteriolopathy: an update’ Current opinion in nephrology
and hypertension, Nov 17 (6), pp. 629-634
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”

Toxic Epidermal Necrolysis
Ms Margi Moncrieff
Nurse Practitioner, Flinders Medical Centre

Patient profile
• 76 year old married woman admitted with a rapidly spreading, flat, red rash
• Febrile, rigors and generalized body aches
• Affected face, mucous membranes and trunk, with a few blisters erupting initially
• Admitted to the ward but deteriorated rapidly and was transferred to CCMU
• Diagnosed with Toxic Epidermal Necrolysis (TEN) also known as Stevens-Johnson Syndrome
    (SJS)

Clinical presentation and aetiology
• TEN & SJS are two forms of the same life threatening skin disorder that cause rash, skin peeling
    and sores on the mucous membranes
• Usually caused by reaction to drugs, bacterial infection or unknown cause
    o Known drugs include; antibiotics (sulphonamides), anticonvulsants, non-steroidal anti-
       inflammatory agents, Allopurinol, anti-virals and corticosteroids
• SJS causes blistering of mucous membranes including the mouth, eyes and vagina and patchy
    areas of rash
• TEN causes all of the above and peeling of the entire top layer of the skin in sheets from large
    areas of the body (>30%)

Toxic epidermal necrolysis
• Diagnosed by clinical presentation and biopsy
• Rapid deterioration from rash to epidermal detachment
• Exposure to inciting agent causes an immune complex mediated phenomenon
• High risk of infection/death with a mortality rate of 30-40%
• Death is caused by wound infection and sepsis or respiratory distress

Treatment (General)
• Withdrawal of the culprit drug
• Management in a burn unit or intensive care unit in isolation
• Intravenous fluid and electrolyte replacements
• Antibiotics
• Analgesia
• Nutritional support
• Meticulous wound management
• 2nd line Treatment: IV Immunoglobulin to prevent further immune damage to the skin and
    progression of blistering
Wound management (Case study)
• Skin loss was similar to a severe burn
  o RAH Burns Unit consulted
• Pressure relief mattress
• Acticoat to wounds, covered with large Melolite and Hypafix to hold together
• Full dressing change every three days with daily wetting of Acticoat
• Reverse barrier nursing
• Each dressing change took four hours
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”

Squamous cell carcinoma
Ms Sue Templeton
Wound Specialist Nurse

Presentation
• 78 year old lady
• Long standing right lower leg venous ulcer
• Treated with compression with success
• During treatment developed a new ulcer on her left lower leg
• Similar appearance to right leg ulcer
• Left leg ulcer treated with compression but did not improve

Management
• After several months with no improvement to left leg ulcer - referred by GP to plastic surgeon
• Biopsy performed: Squamous Cell Carcinoma (SCC)
• Excision of lesion and split skin graft
• Healed uneventfully
• Right lower leg ulcer went on to heal with compression

Skin cancers
• Basal cell carcinoma
• Squamous cell carcinoma
• Malignant melanoma

Getting the diagnosis
• Skin cancers on the lower limb are often mistaken for ulcers of circulatory insufficiency
• May have months of dressings or other treatments (eg compression)
• However they may:
    o Not heal despite best practice management
    o Be hypergranulated or look unusual
    o Have non viable tissue and malodour
• Biopsy is recommended for any lower limb wound that does not significantly improve in 3 months
   of best practice management

Basal cell carcinoma (BCC)
• Also known as a ‘rodent ulcer’
• Usually due to sun damage to skin
• Arise in skin of normal appearance
• Grow slowly over months or years
• Several various forms
   o Nodular
   o Superficial
   o Morphoeic
   o Pigmented
    o   Basisquamous – mixed BCC & SCC

Appearance
• Often have a shiny, nodular or plaque-like appearance
• May have a central ulcer with raised, rolled edges

Treatment options
• Superficial curettage and cautery
• Excision and local flap or skin graft
• Photodynamic therapy (PDT)
• Imiquimod cream
• Radiotherapy
• Cryotherapy

Squamous cell carcinoma (SCC)

Intra-epidermal SCC (Bowen’s disease)
• SCC insitu

Presentation
• Irregular, flat, scaly, red patches
• Most common on sun exposed areas – face, hands, ears, lower legs

Treatment
• Cryosurgery
• Shave, curettage & cautery
• 5-Fluorouracil cream
• Imiquimod cream
• Photodynamic therapy (PDT)

Invasive SCC
• Slow growing, tender, scaly, crusty lumps
• May develop into ulcers that fail to heal
• Common on sun exposed sites – face, lips, hands, forearms, ears, lower legs
• Approx 5% of SCCs metastasize

Treatment
• Surgical excision and flap or skin graft
• Radiotherapy
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”
Pyoderma Gangrenosum
Mr Frank Guerriero
RN, Hyperbaric Unit, Royal Adelaide Hospital

Clinical presentation
• Described as a non-infectious neutrophilic dermatosis
• Clinically manifests as pustules which rapidly progress into ulcers
• Ulcers vary in size and depth, often with undermined violaceous edges
• Associated wound pain is excessive and disproportionate to wound size
• Ulceration/necrosis of tissues
    o Dermis
    o Subcutaneous Tissue
    o Fascia
    o Muscle (rarely)

Location
• Case series most commonly report ulcers affecting LEGS
• Have also been known to affect
   o Peri-stomal area
   o Mucous membranes
   o Genitals
   o Some case reports of head/neck
   o Anywhere?

Associated conditions
• More common in women than men
• Peak incidence occurring between ages of 20 to 50
• Some association with the following diseases
   o Rheumatoid arthritis
   o Chron’s Disease
   o Irritable Bowel Disease
   o Ulcerative Colitis
   o Hepatitis C
   o White blood cell disorders (lymphoproliferative)
• Also known to arise post administration of Granulocyte-macrophage Colony Stimulating Factor
   (GM-CSF)
          • A medication used to stimulate white cell growth post chemotherapy

Pathophysiology
• Aetiology is poorly understood 1,2
• Current theories
    o Cross reacting antigens (bowel and skin)
    o Excessive neutrophil extravasation stimulated by T-lymphocytes
    o Mast cell activation (When your immune system turns to evil instead of good!)
Diagnosis
• NO specific blood test or histological marker exists
• Clinical presentation (wound edges, pain)
• Presence of associated conditions
• Biopsy of wound edge
    o Dense neutrophilic infiltrate
    o Deep suppurative folliculitis
• Hypoxia?

Treatment
• Systemic treatment with immunosuppressant agents has greatest reported success
• Corticosteroids (prednisolone, methylprednisolone)
• Cyclosporin (T-lymphocyte inhibitor)
• TIME Wound dressing princples
    o Manage exudate
    o Balance moisture
    o Treat secondary infection (topical anti-microbial dressings)
• PAIN MANAGEMENT!!!

Case Study
• 72 y.o female
• PMHx
   o Cardiac disease (stents)
   o Hypertension
   o Bilateral hip replacements
   o Peripheral arterial disease
• Presented with 3 month history of non-healing ulcer (anterior left leg)
   o Extremely painful
   o Treated with extensive regime of IV antibiotics

Assessment
• Transcutaneous oximetry
   o Revealed mild peri-wound hypoxia

Treatment
• Hyperbaric oxygen therapy (30 treatments)
• Wound management
    o Moisture donation – hypergel / hydrocolloid
    o Only able to tolerate hydrogel and simple dressings

Outcome
• Approximately half way through hyperbaric treatment we convinced the ‘managing clinician’ to
   refer to a dermatologist for skin biopsy
• Commenced prednisolone 50mg daily
• Later switched to cyclosporin (variable dose)
• Dressings made minimal impact on wound healing

References
Blitz N & Rudikoff D (2001) ‘Pyoderma Gangrenosum’ The Mount Sinai Journal of Medicine, vol. 68
no.4&5 pp. 287-297

Wollina U (2007) ‘Pyoderma gangrenosum – a review’ Orphanet Journal of Rare Diseases, 2:19
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”

Necrobiosis Lipoidica
Ms Sue Templeton
Wound Specialist Nurse

Presentation
• 23 year old woman
• Type 1 diabetes mellitus
    o Average – poor control
• Smoker
• No other significant health history
• Presented with wounds on the anterior aspect of the right lower leg
• Present for several months
• No known cause & failing to heal

Diagnosis
• Necrobiosis lipoidica
    o Also known as: necrobiosis lipoidica diabeticorum
• Rare skin condition commonly seen in persons with type 1 diabetes but can occur in people
   without diabetes
• Usually occurs on the lower leg
• Develop as tender yellowish-brown patches that may become shiny, pale and atrophic plaques
   with telangiectasia
• Can ulcerate

Pathophysiology
• Disorder of collagen degeneration
• Granulomatous response, blood vessel wall thickening and fat deposition
• Unknown cause
• Three times more common in women

Management
• Biopsy confirms diagnosis
   o An inflammatory reaction around destroyed collagen
• Treatment is difficult as cause is unknown

Treatment
• Topical or systemic steroids
• Intra-lesion steroid injections
• Asprin & Dipyridamole
• Oxypentifylline
• Cyclosporin
• Photochemotherapy

Outcome
• Managed primarily with better blood sugar control in this client
• Dressings chosen for wound conditions and comfort
• Healed, but with significant scarring
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”
Livedoid Vasculopathy
Mr Frank Guerriero
RN, Hyperbaric Unit, Royal Adelaide Hospital

Clinical presentation
• Characterised by localised haemorrhagic injury to the skin
    o Purpura
    o Petechiae (pinpoint spots caused by intradermal bleeding)
• Recurrent purpura progress to painful leg ulcers, irregular and asymmetrical in shape
• Livedo reticularis affecting the peri-wound area and general surrounding skin

Location
• Cases report condition only found in the feet or legs

Associated conditions
• Cases have been associated with
• Hypercoagulable states
   o Genetic mutations and disorders
   o Weird blood leads to weird wounds?
• Inflammatory diseases
   o Rhematoid arthritis, systemic lupus erythematosis, scleroderma
• Cancers (solid organ) or haematological malignancies

Pathophysiology
• Dermal blood vessel occlusion leading to haemorrhage and tissue necrosis
   o ? Caused by hypercoagulable states
   o ? Autoimmune disease
• Pathogenesis is poorly understood

Diagnosis
• Full blood work-up including immune markers
   o C-Reactive protein
   o Activated partial thromboplastin time
   o Anti-DNA antibody
   o Anti-neutrophilic cytoplasmic antibody (ANCA)
   o Rheumatoid factor
   o Lupus anticoagulant
   o (to name a few)
• Venous Doppler ultrasound (to exclude chronic venous stasis)
• Histology (biopsy)
• Transcutaneous oximetry (we have found peri-wound hypoxia in all referred cases)
• A history of leg ulcers with atrophie blanche
Treatment
• TIME wound management principles
• Pain Management (++++)
• Hyperbaric Oxygen Therapy
   o Anecdotal, however 3 cases and 3 successful outcomes
   o 1 published study demonstrates favourable results4
• Pharmacological treatment
   o Low dose aspirin
   o Oxpentifylline (Trental)
   o Dipyridamole
   o Anabolic steroids
   o Warfarin
   o Heparin / enoxaparin
Note: in general these are directed therapies and dependant on presence of related comorbidities

Case Study
• 51 year old male
• 9 month history of non-healing superficial ulcerations on right medial foot
• Paradoxically no immunological abnormalities
• Excessive pain
• Assessment
   o Biopsy (vascular changes consistent with LV)
   o Transcutaneous oximetry

Treatment
• Hyperbaric oxygen therapy (27 treatments total)
• Wound dressings
    o Hydrocolloid initially
    o Silicone foam once moisture balanced
• Pain management review

Outcome
•   100% epithelialisation by 27th treatment
•   Significant decrease in pain
•   Returned to work 2 months post completion of hyperbaric therapy

References
Callen J (2006) ‘Livedoid Vasculopathy What It Is and How the Patient Should Be Evaluated and
Treated’ Archives of Dermatology, Vol. 142 pp. 1481-1482

Hairston B, Davis M, Pittelkow M & Ahmed I (2006) ‘Livedoid Vasculopathy Further Evidence for
Procoagulant Pathogenesis’ Archives of Dermatology, vol. 142 pp. 1413-1418

Khenifer S, Thomas L, Balme B & Dalle S (2009) ‘Livedoid vasculopathy: thrombotic or inflammatory
disease’ Clincal and Experimental Dermatology, [accessed online 11th November 2009 pre publication
release]
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”
Verrucous Hyperplasia
Mr Christopher Wiebelt
Senior Podiatrist, The Queen Elizabeth Hospital

Definition
• Verrucous hyperplasia is a warty-appearing or cauliflower like mass with raised or papulonodular
    structures and has a keratotic top layer of tissue
• Also has been called Lymphatic or Stasis Papillomatosis

Presentation
• Very vascular and bleeds easily
• The tissue is erythematous
• There is tissue hypertrophy
• Slow to heal and can ulcerate
• The tissue often weeps and is macerated
• Malodour
• The area can become easily infected
• Rapid growth of poor quality tissue which readily breaks down again

Causes
• Neuropathy
• Friction/irritation over prolonged periods
• Oedema
• Severe stasis dermatitis
• Bacterial infection
• Amputation

Location
• Verrucous hyperplasia has been documented to occur in dental and oral surgery, with dentures
• It has been identified as a problem with prosthesis of the lower limb, due to poor fit or friction
• It is a increasing problem in forefoot or trans-metatarsal amputations of the foot

Patho-mechanics
• Following trans-metatarsal amputation there is a pressure gradient between the proximal tissue
    and the distal stump
• This results in oedema of the amputation site
• This results in tissue growth and hypertrophy of tissue
• The tissue is not as robust and resilient to normal loads and forces
• Abnormal friction and irritation , further damaging the tissue
Management
• Initially silver nitrate may be used to reduce the tissue hypertrophy
• Combined with regular debridement and conservative care
  o As well as silver nitrate
• Compression and some cushioning at the amputation site may also be required with good long
   term results
  o Reducing oedema of the tissue at the amputation site
• We have had good results with a Silopos® stump stock
  o Provides low grade compression on the amputation site has silicone liner inside the sock.

References
M.A.Rosales, DPM, B.RMartin. DPM, D.G.Armstrong,DPM,MSc,Phd, B.P.Nixon,DPM, HR Hall, DPM
Verrucous hyperplasia, A common and problematic finding in the high risk diabetic foot. Journal of the
American Podiatric Association July/August Vol 96 no 4

P.Sbano MD, C. Miracco MD, M. Risulo MD, M. Fimiani MD. Acrodermatitis (pseudo-karposi sarcoma)
associated with verrucous hyperplasia induced by suction-socket lower limb prosthesis. Journal of
Cutaneous Pathology

M. Ichimiya, Y. Teramoto, Y. Yoshikawa, Y. Hamamoto. Verrucous hyperplasia is associated with
neuropathy? The American Society for Dermatologic Surgery, Inc
      South Australian Wound Management Association
        (SAWMA) Education Evening November 2009
“Weird Wounds & Odd Aetiologies”

Ichythosis
Ms Sue Templeton
Wound Specialist Nurse

Presentation
• 75 year old man
• Long term ulcer on left medial malleolus
• Venous insufficiency
• Managed with appropriate compression
• Developed a fixed ankle and loss of calf muscle
• Despite many months of compression and various dressings the ulcer failed to heal

Presentation
• Very unusual skin surrounding the ulcer
• Lower leg covered in thick, brownish plaque-like scales
• On questioning client revealed he had Ichthyosis
• Likely that the combination of venous disease and Ichthyosis contributed to the ulcer failing to
    heal

Pathophysiology
• Ichthyosis – ‘fish scale’ disease
• At least 20 forms of the disease
• Most common (95% of cases) is Ichthyosis Vulgaris
• Most Ichthyosis is mild
• Genetic condition – autosomal dominant
• Usually becomes apparent within 12 months of birth

Pathophysiology
• Occurs in 1:250 persons
• Can affect all races of people
• An abnormality occurs in the skin
• The skin reproduces at a faster rate that it can be shed
• Dead skin cells collect on the skin as thick flakes resembling fish scales
• Often associated with allergies, eczema or asthma

Symptoms
• Polygonal shaped scales
• Darker on the extremities
• Face and flexural areas usually spared
• Markings on palms & soles accentuated
Symptoms
• Symptoms are often worse in cold weather and improve or resolve in warm or humid weather
• Symptoms can include:
   o Itchiness
   o Overheating – reduced ability to sweat
   o Limited movement and pain
   o Secondary infection – due to skin cracks and splits
   o Impaired eyesight & healing – due to skin building up over the eyes & ears

Management
• No cure – management is aimed at control
• Daily exfoliation of skin to prevent scaling
   o Pumice stone on wet skin
• Daily moisturising
   o Apply moisturiser to wet skin
   o Products containing lanolin, urea, lactic acid and other alpha hydroxy acids may help
• Hair brushing to remove scalp scales

				
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