about wound care for the inpatient dermatology consult service. In my role at the University of Miami, I share responsibilities covering our inpatient service and our consult service, but I also work as a medical director of inpatient wound care, and so I come to you today with this expertise. That is me. All right, so really today we're going to be talking about wound care basics. My lecture is part of a large series that the AAD is putting on, and many of the basics that we will talk about will have already been discussed in greater detail by other faculty presenters. The purpose of the early part of my talk is for you to think about what's important to consider when thinking about wounds in the inpatient setting. The most important thing to begin with when you're thinking about a wound is characterizing the wound, and to characterize the wound, I think an initial framework is characterizing whether or not the wound is acute versus chronic. Acute wounds are wounds that generally heal within a few weeks, but they can become chronic. These are often surgical, traumatic, some infectious, and some inflammatory processes. Chronic wounds are ones that usually do not heal by normal repair processes, and these may take weeks to even months to heal. These include venous leg ulcerations, arterial ulcers, pressure ulcers, diabetic foot ulcers, the list goes on. Important considerations for you managing an inpatient wound is the following. The presence or absence of granulation tissue is really important to figure out how healthy the tissue is. You also have to take into account the presence or absence of necrotic tissue, whether this be slough or eschar, which will inform your decision of whether or not any form of debridement is needed. I think it's helpful to look for and assess the presence of undermining or tunneling. This may help you when you think about treating the wound, but also thinking about the etiology of the wound. We also have to control for the exudate and odor, and this can be achieved with many dressings and some topical medicines. These will have already been discussed. It's also important to consider the condition of the peri-wound. The skin around the wound is often forgotten, and so it's important to think about the presence of any infection in this area, the health of this tissue, because your need to treat that surrounding tissue is important in terms of healing the wound. And lastly, as I just mentioned, the presence of infection is an important thing to consider because unless treated appropriately, it's going to make your wound care and your wound healing much more difficult. When we think about dressing selection within our hospitalized patients, it's important to think about the condition of the wound bed. We have to think about the amount of exudate. Again, we're going to choose different dressings depending on how moist or how exudative a wound is. We're going to want something more absorptive if there's a lot of exudate, and we're going to want to change it frequently, or maybe not. Maybe we'll choose something that we need to change infrequently as well. And again, our goal is to manage drainage while also promoting and maintaining a moist wound healing environment, which is an important consideration in terms of healing wounds. And we also have to manage and think about bio-burden, bacterial buildup, biofilms, etc. that may exist within the wound that may impede our ability to heal it. The most important thing when thinking about dressings, at least in my opinion, is that wound healing is a dynamic process. Dressing choices should and may change over time. In the outpatient setting, we may think about reassessing the appropriateness of a dressing every few days, even a couple of weeks. Whereas in the inpatient setting, we really have the benefit of being able to see a wound on a daily basis and to make changes based on the characteristics of that wound in real time to optimize wound healing. Now in the hospital, the other considerations that are important to consider are the following. A patient's nutrition is paramount. Better nutritional status, better protein in the diet will allow for better wound healing. The circulation is also really important. The better the circulation, the more that we can enhance that, the better our wound healing is going to be. As a corollary, edema is something that we really need to control. And minimizing edema and controlling and compressing will help with wound care and also reduce times of wound healing. The last thing within the hospital setting, or at least an important point, is glucose control. With elevated sugars, we know that wound healing is impaired, and so adequately controlling glucose in our hospitalized patients is important to ensuring appropriate and easy wound healing, if that can be achieved. Now in the inpatient setting, one of the things that is really important is determining the wound etiology. We talked about acute versus chronic wounds, and while some of these may be obvious, traumatic or surgical, if we're thinking about more of our inflammatory or infectious processes, this is really where us as dermatologists can use clues from the physical exam, from the patient, et cetera, to figure out what's going on. And if we can control for and manage any underlying infections, inflammatory dermatoses, et cetera, this will also help to optimize our wound healing because we have to control that underlying process before we can heal the wound. The other important thing within our hospitalized patients is managing pressure injuries. Pressure injuries may be truly from being bedbound, but also pressure injuries may happen from medical devices, and it's important for us to recognize that this may be the case if we ever see something that looks like it could be somewhat geometric or from a device. It's important to know. So let's move on to common inpatient dermatoses that present with wounds. The list of patients who we're going to see, this is all from my own collection. This is not meant to be exhaustive, but it's just a good representation of what you might be seeing in your hospitalized patients. So HSV is probably one of the most commonly encountered infections that we'll see in our hospitalized patients. As many wise mentors have told me, if you ever see a wound, we should swab it and we should swab it for herpes because it is just so common. This was a patient who I had seen recently who had been bedbound for quite some time, somewhat immunosuppressed, being treated for an underlying malignancy and had this wound in the inguinal area that was just treated with hydrocortisone and ketoconazole or nystatin, something like that, until finally it wasn't getting better. It was expanding and it was painful and a team astutely said we should have dermatology come and take a look. And this is a beautiful picture of HSV. Here you can see punched out erosions. This ulcer or large erosion has scalloped borders, suggestive of HSV. And the other thing about HSV that I think is characteristic here is that you often get kissing lesions, so lesions on opposing tissues that may be coming into contact, let's say at a fold. So this is classic for HSV and without controlling for the underlying viral infection, this wound is not going to heal. Other commonly encountered dermatoses that we'll see in hospitalized patients are our neutrophilic dermatoses. Neutrophilic dermatoses include the spectrum of conditions such as pyodermic angrenosum and sweet syndrome or acute febrile neutrophilic dermatosis. Some people view these as very separate entities. Some people view them as on a spectrum. I am more of a lumper than a splitter so I kind of fit there, but to each their own. Here I'm going to point out a couple of common wounds that we'll see. So in this first patient we see almost a violaceous border around this ulcer that is around a patient's ostomy. This is peristomal pyodermic angrenosum. You can even appreciate almost some cribriform nature within this lesion. Pretty common, pretty classic. Important for us to treat this appropriately with anti-inflammatories before this is going to heal. Now managing peristomal pyodermic angrenosum can be challenging because choosing the appropriate dressing can be challenging here and getting something to stick and so that is just of note. Here's another picture of what I would say looks like classic pyodermic angrenosum under a patient's breast. This looks like it has already been present for quite some time. You can see a little bit of an active rim around this with some violaceous erythema, but you can already see a scarring process happening within the center, almost a cribriform nature, again fairly suggestive of pyodermic angrenosum. And always I like pointing out cases that are like this. So this was a patient after a total hip arthroplasty. The patient was febrile, had a profound neutrophilia, kept going back to the operating room for washouts and procedures, and ultimately, you know, infectious disease said maybe this isn't an infection, let's have dermatology take a look. And this was ultimately, you know, something on this neutrophilic dermatosis spectrum, call it sweets, call it pyodermic angrenosum. Either way, this was something that wasn't going to heal appropriately without appropriate treatment, which for both of these conditions, you know, the main state of treatment is prednisone or systemic corticosteroids. So with that, we can see that this wound has calmed down, exudate has decreased, and this ultimately was allowed to heal. So again, in an atypical case where you're seeing something that doesn't quite fit or antibiotics don't seem to be the answer, you know, that's often when I think about neutrophilic dermatosis. Other things that we might encounter within the hospital, this was a patient with an ANCA-associated pyoderma or antineutrophilic cytoplasmic antibody-associated pyoderma. These historically were called pyoderma maligna in the literature many decades ago. These may present on the body, they may present on the face. They're somewhat atypical wounds that mimic PG, but in the presence of ANCA-associated antibodies. Again, it's important to recognize this because treatment is with wound care, of course, but without systemic anti-inflammatories in this case, prednisone, this is not going to heal appropriately. This was after three days of prednisone. You can see how much of the wound has improved. There's less exudate, there's less slough, and it's looking much better. So again, without managing the underlying condition, this isn't going to get better. One of the most commonly encountered wounds that I find, at least in my practice here at the University of Miami, in the hospital setting is hydradenitis operativa. Now, HS is obviously a condition that we as dermatologists feel comfortable managing, diagnosing, and I think that, you know, this is an easy diagnosis for us to make. You see this axilla with what seems to be fairly at least moderate disease, maybe even severe disease with inflammatory nodules, tunnels, fistulas, etc. And so, yes, we can manage a wound here, but we have to manage all the considerations that fall into this wound before treating the wound itself. We have to think about underlying infection, managing bioburden and biofilms here. We have to think about anti-inflammatories, etc. This isn't going to heal just with wound dressings alone. Other conditions that often present into the hospital, especially in our patients who are with end-stage renal disease, although you don't need that for this diagnosis, this is calciflaxis. These are two patients, both with pretty classic retiform or net-like purpura presenting with central eschar or necrotic tissue. Anytime I see this, you know, the areas over fattier tissues with this type of net-like eschar calciflaxis is high on my differential, especially in the right patient group, those on dialysis, etc. Again, we can manage the wound in this condition, but if we're not managing underlying calcium and phosphate balance, if we're not managing the underlying condition, if we're not switching the appropriate anticoagulation away from warfarin, you know, we're not going to see these wounds get better. Of course, this is a disease with a pretty high morbidity and mortality, so an important one for us to recognize and to manage. Some of the morbidity and mortality comes from infections here, so managing these wounds is really important as a dermatologist. Other wounds that we might see in our hospitalized patients are wounds as a result of blistering disorders. The patient on the left and the right are both patients with bullous pemphigoid. The patient on the left seems to have irritation around a tunneled catheter, which is not an uncommon presentation, or you can see that in bullous pemphigoid. The patient in the center has pretty severe pemphigus vulgaris. Again, we can come up with wound care plans for all of these wounds, but unless we're managing the underlying dermatosis, we're not going to see improvement in these wounds necessarily. No talk about wounds in the inpatient setting would be complete without mentioning toxic epidermal necrolysis, TEN, or SJS in mild forms. This is something where, again, we recognize that these patients are covered in wounds, quote-unquote. They have total loss of their epidermis with epidermal necrosis, and of course wound care is so important in these patients, and we won't talk about treatments for this. The jury's still out on many treatments, but the one thing that we do know is if we're seeing something like this, of course we can think about managing the wounds, but we have to be doing a really good medication history and withdrawing any potential agents that may be propagating this. So that was just a flavor of some of the inflammatory and infectious dermatoses that we'll see within our hospitalized patients presenting as wounds. The last part of today's talk, which we'll focus on, is something that maybe as dermatologists we're familiar with, maybe not. That's the whole point of these talks. We're gonna talk about pressure injuries. Now, pressure injuries are a hot topic, especially for those of you working in the hospital setting and seeing patients in the hospital, because hospital-acquired wounds are something that we really try to avoid. We really try to identify and minimize, and so this is one of the places where we as dermatologists can add value to our institutions if we decide to partake in and help with these endeavors. So it's important to think about pressure injuries as what they are. They are localized injury to skin and soft tissue, often over bony prominences, and it's from sustained external pressure, again, very commonly seen in our hospitalized patients who are critically ill. Obviously, there are ways that we can help minimize these, such as frequent turning and repositioning, but it's important to note that these are of a significant morbidity, mortality, and cost. These pressure injuries happen as a result of the sustained pressure over these bony prominences. It reduces blood flow to the tissue. We get tissue ischemia and necrosis, and they can be staged in various ways. We'll talk about the staging, but just good for us to be familiar with and to be refreshed on. Now, pressure injuries are common. We see them in vulnerable populations. I put on some of this in the last slide, but we see it in those who are more elderly. We also see it in those with limited mobility. We can also see it in patients with neurologic issues who may have suffered contractures or be in certain positions that may lead to the propensity of having certain tissues in one position for a long time. As I mentioned before, there's a significant morbidity, mortality, and cost to this, so it's important to identify them, and again, as much as we can to work to preventing them, we all benefit. Now, when we think about pressure ulcer staging, this is something that I think about on a daily basis, but it might be a while that many of you have thought about this. So stage one wounds are intact skin with non-blanchable redness of a localized area, usually over a bony prominence, in darkly pigmented skin. The blanching may be difficult to assess, but the colors may be different from the surrounding area. That's often your clue, and often there could be other symptoms associated with this. These may be painful. They have different textures to them, often compared to the surrounding skin, and often different temperatures, and again, as I've mentioned before, it may be difficult to detect these in darker skin tones, so you have to have a higher index of suspicion, as we do, again, in many of our inflammatory conditions where redness is just more difficult to be perceived. In stage two wounds, this is where we start to lose some tissue, so these are partial thickness loss of the dermis presenting as a shallow open wound, often with a pink to red wound bed, and often without slough. You might see ruptured or fluid-filled bisters in stage two wounds, and again, I think it's important to note, and we'll talk about this a little bit later, that here in stage two wounds, we're really excluding other forms of injuries that aren't pressure-related, so skin tears, issues from tape, incontinence-associated dermatitis, maceration and excloration, like these should not be included in our staging of pressure injuries. In stage three wounds, this is where we have full thickness tissue loss. The dermis is often lost, and subcutaneous fat may be visible, but usually we haven't gone through the subcutaneous fat layer. We're not seeing bone, tendon, or muscle. You may have slough here, and there may be undermining or tunneling. The depth of a pressure injury, a stage three one, may vary by the anatomical location, so in certain areas where there's not a lot of subcutaneous tissue, they may be very shallow, but still a stage three. Oops, I've advanced too much here, but that's okay. A stage four injury is where we have full thickness tissue loss with an exposed bone, tendon, or muscle. Slough or eschar may be present at some parts of the wound bed, and then again, the depth may vary here depending on the different anatomical locations. Now, here we have listed as unstageable. Unstageable wounds are areas where there's full thickness tissue loss, but you can't perceive how deep it goes because the wound is covered with slough or eschar. Until those things are removed, we can't know the true depth, and so these are called unstageable. Now lastly, an entity that is recognized by the National Pressure Injury Advisory Panel and many hospitals are things called deep tissue injuries or deep tissue pressure injuries, DTPIs. These are often purple or maroon areas that are discolored over intact skin or blisters that may be preceded by symptoms, pain, bogginess, different temperatures, and then these often progress to various stages of wounds. So these are kind of like an intermediate step. It's almost like it's telling you that there's a pressure injury on its way developing into often a later stage wound, but not always. Sometimes DTPIs resolve on their own. So it's a concept to be familiar with because they are used within our hospital system and within the Pressure Injury Advisory Panel. It's part of their nomenclature and classification. I mentioned this before and it's important, again, to highlight that pressure ulcers are really caused from pressure. These should not include moisture-associated skin damage, so things from incontinence, incontinence-associated dermatitis, intertrigenous dermatitis or intertrigo for us, medical adhesive-related skin injuries or traumatic wounds. So again, these are not falling into our pressure-related wounds, but they all have their own nomenclature and a little bit of different etiologies that cause them. And again, the DTPI, that last bucket that I talked about, these should not be used to describe vascular traumatic neuropathic or other dermatologic conditions. One of the ways where I find that I add value to my hospital system and my consult service is that I'm often asked to figure out whether or not there is an underlying dermatosis that could be mimicking as one of these pressure injuries or a DTPI. And if we can identify an alternative etiology, again, everyone's happy and we can come up with an actionable plan to help address the underlying condition. Now, something else to be familiar with is what I've listed here, which are medical device-related pressure injuries. I mentioned this a little bit earlier, but these are injuries from devices that typically conform to the shape, injuries that show you almost like a geometric pattern that conform to the shape of the device. And just an important note is that if you have injury to the mucosa, which sometimes we see, especially with nasogastric tube, sometimes with nasal cannula, these can't be staged. And so all of these together are called MDRPIs or medical device-related pressure injuries. On the next slide, we'll see some examples of different devices that may commonly cause MDRPIs as well as staging just based on a photo. So here we go. Here's examples from endotracheal tubes, from trach sites, from oxygen probes, from CPAPs, from oxygen tubing. Again, just important for you to be aware of all the lines and tubes and drains that could be available to a patient, obviously for important treatments, but may also be a risk to the surrounding skin. Now, one of the ways that we are able to help distinguish between some of these pressure-related wounds versus other mimickers or perhaps just skin discoloration that might not suggest an underlying wound is this long-wave infrared thermography or thermal imaging for short. We know that before skin changes occur that are visual or able to be visualized by hospital teams or dermatologists, often patients will experience pain. Now, sometimes hospital patients are unable to tell us about pain, so something objective is helpful. And this is where temperature changes can actually be helpful. So often, temperatures that are at risk for progressing into pressure injuries will be cooler than the surrounding skin. And so these thermal imaging devices are able to detect temperature differences that are statistically meaningful between at-risk skin and surrounding skin. So this might demonstrate pressure injuries, and the hope is that if we identify pressure injuries before they've opened up, we might be able to identify strategies and solutions to prevent that from happening. So when we think about pressure injuries and management, again, it's important to realize that skin care should be optimized. Of course, this is obvious to us, and I think it is obvious to many inpatient teams who care for patients, but we want to limit excessive dryness or moisture. We're really looking for that sweet spot between the two. Skin is very fragile, especially on our older patients and those who are vulnerable and very ill, so we have to work to minimize friction, shear, and pressure. Managing incontinence is very important. Of course, there are many devices that help us with that in our hospitalized patients, but it's important that this is identified in those who are at risk to help prevent wounds from these. As mentioned before, one of our most important things that we can help with patients in the hospital is their nutrition. So optimizing nutrition status will often help with pressure injury prevention management and other wound management. Some of the patients with the most difficult to control or manage pressure-related injuries are those who are malnourished and lack the ability to regain that nutrition. Lastly, an important thing that can't go unrecognized is that appropriate pain control is of the utmost importance. Pain control may improve patient cooperation in repositioning and dressing changes, and we know that it's these things, it's repositioning frequently, maybe getting different beds, having appropriate dressing changes will help to improve wound care and wound healing in these patients. So the more that they're able to comply and cooperate, the better. With that, these are just some references for you to look at if you're interested. I hope this was a good 100,000-foot view of inpatient wounds. Hopefully this was helpful for you to think about how to manage, how to consider wounds in the hospital setting, perhaps identifying some mimickers and some common inflammatory and infectious conditions that may present as wounds, as well as a basic overview over pressure-related injuries in our hospitalized patients and why preventing them and managing them is important. So with that, I thank you for your time and your attention.

wound management

chronic wounds

inpatient dermatology

pressure ulcers

wound healing

infection control