Introduction to Wound Care and the first session is Wound Bed Preparation. My name is Afsaneh Alabi. I'm a dermatologist at Mayo Clinic Rochester, Minnesota. Here are my disclosures. It is a great pleasure to start the first session of a series of co-curriculum talks on wound care for dermatologists. We have an amazing group of faculty speaking about different topics with focus on them from atypical ulcers by Dr. Mark Davis, speaking about histopathology of wounds by Dr. Carolyn Wannatt. Dr. Eisen is going to talk about surgical wound care, a vascular surgeon with experience in this area, Dr. Marston, discuss the vascular studies for dermatologists, and we have two experienced nurses in wound care, Barbara Delmore and Dr. Weir, discussing the compression therapy, the dressings, and what is available. Dr. Hadal Leftov speaks about skin substitutes, and Dr. Robert Kerstner about advanced therapy other than skin substitutes. Dr. David Armstrong is a podiatrist and a key opinion leader. He will talk about offloading for diabetic foot, Dr. Scott Ehrman speaking about inpatient dermatology related to wounds, and Dr. Catherine Sewell is going to talk about approach to pediatric wounds. For the wound bed preparation paradigm, the objective are to highlight the importance of wound bed preparation for dermatologists, to review the different type of the treatment, and to formulate an approach to local wound care in patients with wounds. With rising aging population, more and more survivor of cancers, more and more emerging of new therapies, we are seeing more patients with chronic wounds, and dermatologists are also involved in management of wounds, either part of a big interdisciplinary care, or we see many of wounds as a presentation to dermatology clinics. But in wound care, wound care education in dermatology curriculums is not adequate compared to what we need in our practice. Chronic wounds create a major problem, not only for patients, but also for healthcare systems are very costly, and the incidence of wounds are rising, and more even looking at only the venous leg ulcers, 1% of population in United States are suffering from this condition. Wound healing involves a complex but overlapping sequential series of events, starting from coagulation, going to inflammation, to proliferation and remodeling. Many cell types, like platelets, microphages, neutrophils, and cytokines are involved in this process. But it's not going always through this stage on a smooth and regular base, and sometimes wounds stall in inflammatory stage or other stages of the wound and become chronic. Approach to chronic wounds is, I like this algorithm because it makes it easy, and also it says that the first step in approaching every wound is to have the right diagnosis, which I believe in many cases dermatologists play a major role. But first, we have to know what we are treating. And the second patient-centered approach, because what is the best for this wound in the context of everything around him, from the affordability, accessibility, family and circle of care, and after that, going to decide on local wound care based on the information that we have, information about the diagnosis and information about patient-centered concept. And I like this mnemonic of time, or time, that we look at first step, tissue debridement or debridement, control of infection and inflammation, moisture balance, which address dressings, not too wet, not too dry, choosing a dressing that create a balance for the wound bed and then going to edge effect or when the edge is installed, we need to use advanced therapies such as negative pressure wound therapy, such as skin substitute. Almost most wounds heal a timely manner, but the proportion don't. And for this group, it is very important to do, to look at, for all of these, all of wounds, it's important to look at medical history, physical exam and do investigation. One of the investigation is wound biopsy. It's sometimes, because it's, many occasions we have non-specific changes in the wound, it's so important where to do the biopsy and also sometimes needed to do multiple biopsies, sequential biopsy, and I encourage you to listen to Dr. Rana talk on this topic. Vascular studies are important in a large portion of wounds that are actually from vascular abnormalities, venous, arterial, and we need to know what test to order and then who needs to be referred to vascular surgery and other tests based on the cases of the wound. Local wound care is what I'm going to expand on to, as an important part of wound bed preparation. Debridement, play a key role in tissue preparation by removing non-viable tissue and pathogenic bacteria and biofilms. There are multiple technologies for debridement and from surgical, using a curette, to using mechanical, enzymatic, and autolytic debridement. Wound cleansing is one step prior to debridement, is the initial step for this process, and the reduction of bioburden through removal of loose material on the surface wound edge by rinsing, irrigating, wiping, and you can use that cleaning of the wound with water, still water, or with other cleansers like antiseptics, and depending on chlorhexidine, surfactants, to use as a help for cleaning the base of the wound prior to the drug. We discussed that one of the role of debridement is to remove biofilms. Biofilms are encased and it's our protected bacteria, then antibiotic does not penetrate to the bacteria that are pathogens that are encased by biofilms, then debridement would be a great help for fighting with that group of microbes, and it's important to know that wound biofilm is not visible with naked eye, and this is something that not obviously see it all. There are various types of debridement. We mentioned autolytic, biologic, enzymatic, mechanical, sharp, surgical, and technical debridement, that you decide based on the type of the wound which debridement would be the best option. A sharp or surgical debridement is one of the fastest and more selective and probably easy for us in dermatology to perform it. You can use scissor, scalpel, or curette to do a sharp debridement, but at the same time, sharp debridement is expensive because the time that needs the compensation of time by the specialist, either surgeon, dermatologist, to perform that, sometimes it's painful and need special skills, and it's contraindicated in ischemic tissue and when there is bleeding disorder that you are concerned that you cannot control the bleeding after that. But, and also it's the best type of debridement when there is no risk of pathology, when there is risk of pathology, you don't want to use sharp debridement. This picture, I took this picture when I was in Miami and Dr. Rob Kirsner is doing this debridement, and you see that you, when in a diabetic foot, that removing the whole callus from this area. Control infection and inflammation, that's important because all wounds are colonized, but not every wound is infected and needs oral antibiotics. Wounds that are critically colonized, the large volume of bacteria there, they need topical antiseptics, but not every wound needs topical antiseptic. Then wounds move from a stage of contamination colonization to critical colonization, which is a superficial infection that impair healing, but it's not systemic infection. That's where antiseptics work. It's the better terminology is critical colonization and then infection. Infection when we have deep and surrounding tissue infection, when patient needs antibiotic and when we have symptoms of infection and the healing of the wound is impaired. But if you do a swab at the stage of very clean wound here, still the swab would be positive, but that's contamination. That doesn't mean that antibiotic is or antiseptic is needed. The main antiseptic classes that are used in dressing, just an example of some of them, polyhexyl methylene by guanid, which is a derivative of chlorhexidine, ionized silver, slow release iodine, methylene blue and gentian violet, honey and surfactant based solutions. But what we need to avoid is using topical antibiotics for different reasons. Topical antibiotics has potential risk for allergic contact dermatitis more than antiseptics. And also there is a risk of bacterial resistance. Then it's better to avoid topical antibiotics and instead use topical antiseptics. Moisture balance, what dressing we need to use. The choice of dressing, one of the main things that guide dressing would be based on absorbency, the simplest thing. That if a wound is dry, you want to add moisture. A very dry wound, you give hydrogen that adds moisture. If a wound is not dry, but you want to just maintain the moisture and no drainage or minimal drainage, you use dressing that maintain the moisture. But the wounds that have exudate and draining depends on the amount of drainage you use absorbent dressing. I want to encourage you to listen to the talk by Dr. Vir and Dr. Barbara Delmore on dressings and compression therapies to get more information on this area. Let's go through some of the examples, how we choose a type of the treatment. This is an 83 year old gentleman, diabetic hypertensive and returns for follow-up of right lower leg extremity. Also for the past six months, which is growing larger. As you see here, what is most likely diagnosed? Is this a PG? Is this arterial ulcer? Let's go back. You see here is a necrotic ulcer with some mild levidoid pattern around it. Is this calciflaxis, vasculitis, cocaine use, levomazole induced vasculitis or levidoid vasculopathy? This is martyred hypertensive ischemic leg ulcer that some people believe it's similar or the same entity as non-uremic calciflaxis. This was described and more well recognized in Europe is as a result of almost skin infarction, as a result of calcium deposition in the blood vessels. And it's not common. A location usually lower leg over a Achilles tendon or back posterior calf. There is no macrovascular disease. If you do ankle brachial index, it's not, it doesn't show or it doesn't show large vessel involvement or abnormality. Ankle brachial index could be normal and they have extreme pain, disproportionately painful. And they have long standing history of high blood pressure but the blood pressure might be controlled but that's how it was defined by Dr. Martorelli who was a Spanish cardiologist. The risk factor are arterial hypertension, diabetes, secondly, hyperparathyroidism and taking oral anticoagulant. What this patient was referred to plastic surgery was biopsy, biopsy confirmed the diagnosis of Martorelli and usually for biopsy, we do an elliptical biopsy because conch biopsy might not show exactly the diagnosis and you see calcification in the blood vessels. And a patient was referred to surgery with diagnosis of Martorelli and received a sharp debridement, surgical debridement. This is after the debridement and slowly over time patient lesion completely healed. This is this patient after a couple of months and remain healed. And it's a possibility for recurrence and recurrence is common in this patient because the underlying cause is there even though we stop anticoagulant but some other causes then, but this patient was doing great. This is a couple of months after the debridement. This is a paper that I had the pleasure of working with Dr. Hafner and a group of colleagues looking at Martorelli hypertensive ischemic leg ulcer. And as you see here, the debridement is one of the treatment options and probably one of the best. Autolytic debridement is another type of debridement is using endogenous enzyme with moisture-retentive dressings. It has low speed, low selectivity. It's costly because you use dressing. It's contraindicated in infected wounds and we usually don't use it if bone or tendon exposed. And what we do is use hydrochlorate, hydrogel or alginate dressing on the wound that has drainage to have some autolytic debridement using their own wound exudate to dissolve the necrotic tissue. Look at this example. This is a 50 year old gentleman with extremely painful ulcer. He was referred from rheumatology for wound management. They already had the diagnosis of cryoglobulinemic vasculitis. The same patient because extremely painful and they wanted to have a management for wound. You see how necrotic and patient couldn't tolerate compression, didn't want to touch the wound but we thought this patient cannot handle a sharp debridement. Then probably autolytic debridement is the best step to go. What dressing you choose, what compression you choose, that's what you decide. We thought that at this stage we cannot discuss compression with the patient and we went with hydrogel covering with a dressing to create an autolytic debridement. Hydrogel needs to be changed on daily basis but we try to bring patient back after two weeks and this is him after two weeks. The wound is clean and now we have his trust to discuss the compression therapy. In the next step, we discuss the compression therapy and we change our dressing to another dressing, just an absorptive foam dressing, no need for hydrogel anymore because the autolytic debridement was done. Enzymatic debridement is another type of debridement. It has low pain, medium cost and again, low selectivity. Some patients are allergic to this and could be potentially allergic to this enzyme preparation. What is in the market is collagenase, is the only one that FDA approved in the United States or brand name Santol, a selective debriding agent derived from bacterial strain of clostridium histolyticum and the enzyme degrade the necrotic tissue and it can be used on yellow slough or black eschar that we see. The next type of debridement is biologic debridement using larva therapy. It has a long history, even though some people don't like it because just the sense of having larva on the wound, it's not in most cases now, the larva is in a teabag and the dressing is made in a way that the larva is not freely on the wound, it's in a teabag and you put the teabag that contain larva on the wound and then when you remove it, it's heavy and has done the debridement. It's high speed, but medium pain, high cost, contraindicated if there are tunnels and if there is risk of bleeding and a potential treatment for biofilm for chronic wounds. Here in this case report, they combined using larva and then after cleaning the wound, put the graft and showed efficacy of that. Overall, some of the debridements are non-invasive and some invasive. Example of non-invasive, autolytic debridement, osmotic, oxidative, enzymatic debridement and this is a document that just very recently was published and these are the less invasive one are methods that may need adjunct other treatments, but the ones that can be used stand alone. One is this larva therapy that we mentioned, mechanical debridement using gauze, which is not recommended, wet to dry gauze because it's not selective at all and it may remove granulation tissue. Technical that are more common now, using hydroid surgery, using ultrasound, like mist therapy or other names and negative pressure wound therapy installation, not regular negative pressure wound therapy, using negative pressure wound therapy installation for debridement and short debridement with scalpel, scissor and curette. We discussed that less invasive debridement. An example of using ultrasound is this debridement that's using low intensity, low frequency ultrasound for treatment of wound. Let's practically look at this last case of 73 year old gentleman with previous history of venous disease, abnormal venous study. Had intervention and recently was diagnosed with antiphospholipid antibody, negative test for lupus anticoagulant that showed highly positive test for IgM anti-beta-2 glycoprotein-1 antibody and positive testing for antiphospholipid and IgM antibody. Okay, was referred to dermatology, what needs to be done for this wound? What type of debridement you choose? You may decide to go to autolytic debridement with this case. If there was loose tissue, you may go with short debridement just removing the loose tissue. What antiseptic? Do you need antiseptic? What I see here, I don't see any evidence of critical colonization on this wound. From observation here, there is no need for antiseptic. I wouldn't do swab this wound because if swab come positive, what I want to do? What dressing do you choose? You go with absorptive dressing and because if it was heavily exudating, I go with super absorbent dressing. But if it's mild to moderate, I would go with a foam dressing. What compression? You can discuss it with the patient and try to use lighter compressions first if you want to use briscoe paste, sorry, zinc oxide paste with, or what is called duc boot first, or you can use a compression therapy wrap with milder pressure, the light one first till patient be able to touch. That's what we look at for wound care plan for every patient. Then the key message is debridement choice is important dependent on the wound. Do you need to address infection and inflammation? Is there a systemic infection needs antibiotic and your dressing choice to keep the moisture balanced? Thank you so much for the opportunity.

wound care

debridement

chronic wounds

patient-centered

infection assessment

antibiotic resistance