Wounds

A. Paul Kelly, MD

Keloids are scars, unique to humans, that grow beyond the boundaries of a cutaneous injury, inflammation, burn, or surgical incision. Although benign, keloids are often aesthetically malignant. The etiology of keloids is uncertain. However, we do know that they occur more often in African-American and Asian than Caucasian patients. There is no one therapeutic modality that either prevents the formation of keloids or treats active or inactive lesions. Consequently, there are many therapeutic options. In this review, an approach to medical and surgical management of keloids is provided, as well as a review of experimental therapeutic modalities.

*For a PDF of the full article, click on the link to the left of this introduction.

A. Paul Kelly, MD

Keloids are scars, unique to humans, that grow beyond the boundaries of a cutaneous injury, inflammation, burn, or surgical incision. Although benign, keloids are often aesthetically malignant. The etiology of keloids is uncertain. However, we do know that they occur more often in African-American and Asian than Caucasian patients. There is no one therapeutic modality that either prevents the formation of keloids or treats active or inactive lesions. Consequently, there are many therapeutic options. In this review, an approach to medical and surgical management of keloids is provided, as well as a review of experimental therapeutic modalities.

*For a PDF of the full article, click on the link to the left of this introduction.

A. Paul Kelly, MD

Keloids are scars, unique to humans, that grow beyond the boundaries of a cutaneous injury, inflammation, burn, or surgical incision. Although benign, keloids are often aesthetically malignant. The etiology of keloids is uncertain. However, we do know that they occur more often in African-American and Asian than Caucasian patients. There is no one therapeutic modality that either prevents the formation of keloids or treats active or inactive lesions. Consequently, there are many therapeutic options. In this review, an approach to medical and surgical management of keloids is provided, as well as a review of experimental therapeutic modalities.

*For a PDF of the full article, click on the link to the left of this introduction.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.

ARLINGTON, VA. — It may not be the first tool that physicians think of, but nutrition can be a powerful one against pressure ulcers, dietitian Mary Ellen Posthauer told a meeting of the National Pressure Ulcer Advisory Panel.

“Please involve dietitians early on if you see people with pressure ulcers or those who are at high risk of developing pressure ulcers,” said Ms. Posthauer of the company Supreme Care West in Evansville, Ill.

People with pressure ulcers are in a hypermetabolic condition, she explained. A small person with a pressure ulcer is probably pulling protein from his or her lean body tissue.

More research is needed on the impact of nutrition on wound healing in obese patients, Ms. Posthauer said. Patients with stage III or IV pressure ulcers should not be on restricted diets. Patients with pressure ulcers need to eat 30-35 kilocalories per kilogram of body weight a day, she said. “If the person doesn't eat the food, you aren't going to get wound healing.”

Ms. Posthauer offered several tips for how to provide enough calories:

▸ Consider the individual's favorite foods and cultural preferences. The goal is to serve “foods that they are actually going to eat, not give to their tablemates.”

▸ Offer variety. A chocolate milkshake is less attractive than usual when a person gets three a day.

▸ Use fortified foods, such as high-density cereal and pudding, or follow recipes for high-calorie, high-protein foods.

▸ Offer high-calorie, high-protein supplements, using trial and error to determine which one the patient prefers. Research has shown that offering a nutritional supplement between meals improves the acceptance of the supplement and mealtime food.

“There needs to be a team effort in following up to see that the food is being consumed,” Ms. Posthauer emphasized. “Dietitians are great at developing menus and sending out food, but if nobody is eating it, we haven't achieved much.”

Studies have shown that increased protein intake is associated with better healing of pressure ulcers, with a recommended daily intake of 1.25 to 1.5 g/kg of body weight. But it's important to monitor both healing rates and renal function in a person getting supplements and to adjust intake as needed, Ms. Posthauer said. “Monitor the healing, and if you aren't seeing results, try increasing the amount of protein.”

Enteral nutrition is an option for some individuals, but only if it is monitored carefully, Ms. Posthauer said. When considering enteral nutrition, ask the individual and family members whether they understand the risks and benefits associated with this more invasive form of feeding. If individuals receive tube feeding, then the formula for the liquid being administered should be evaluated periodically to make sure that it is providing enough calories and protein to improve wound healing.

Research does not support the use of mega doses of vitamin C to enhance wound healing, but some evidence supports the use of zinc supplements if a deficiency exists in that mineral. Strive for a balanced diet and confirm a deficiency before adding any vitamin supplement, said Ms. Posthauer. Remember that many liquid calorie supplements meet the daily recommendations for most vitamins and minerals, so further additions may be unnecessary, she added.

Relatives may know which foods older kin prefer and may offer strategies to help elders get the calories they need for optimal wound healing.

Ms. Posthauer disclosed no financial conflicts relevant to her presentation.

ARLINGTON, VA. — It may not be the first tool that physicians think of, but nutrition can be a powerful one against pressure ulcers, dietitian Mary Ellen Posthauer told a meeting of the National Pressure Ulcer Advisory Panel.

“Please involve dietitians early on if you see people with pressure ulcers or those who are at high risk of developing pressure ulcers,” said Ms. Posthauer of the company Supreme Care West in Evansville, Ill.

People with pressure ulcers are in a hypermetabolic condition, she explained. A small person with a pressure ulcer is probably pulling protein from his or her lean body tissue.

More research is needed on the impact of nutrition on wound healing in obese patients, Ms. Posthauer said. Patients with stage III or IV pressure ulcers should not be on restricted diets. Patients with pressure ulcers need to eat 30-35 kilocalories per kilogram of body weight a day, she said. “If the person doesn't eat the food, you aren't going to get wound healing.”

Ms. Posthauer offered several tips for how to provide enough calories:

▸ Consider the individual's favorite foods and cultural preferences. The goal is to serve “foods that they are actually going to eat, not give to their tablemates.”

▸ Offer variety. A chocolate milkshake is less attractive than usual when a person gets three a day.

▸ Use fortified foods, such as high-density cereal and pudding, or follow recipes for high-calorie, high-protein foods.

▸ Offer high-calorie, high-protein supplements, using trial and error to determine which one the patient prefers. Research has shown that offering a nutritional supplement between meals improves the acceptance of the supplement and mealtime food.

“There needs to be a team effort in following up to see that the food is being consumed,” Ms. Posthauer emphasized. “Dietitians are great at developing menus and sending out food, but if nobody is eating it, we haven't achieved much.”

Studies have shown that increased protein intake is associated with better healing of pressure ulcers, with a recommended daily intake of 1.25 to 1.5 g/kg of body weight. But it's important to monitor both healing rates and renal function in a person getting supplements and to adjust intake as needed, Ms. Posthauer said. “Monitor the healing, and if you aren't seeing results, try increasing the amount of protein.”

Enteral nutrition is an option for some individuals, but only if it is monitored carefully, Ms. Posthauer said. When considering enteral nutrition, ask the individual and family members whether they understand the risks and benefits associated with this more invasive form of feeding. If individuals receive tube feeding, then the formula for the liquid being administered should be evaluated periodically to make sure that it is providing enough calories and protein to improve wound healing.

Research does not support the use of mega doses of vitamin C to enhance wound healing, but some evidence supports the use of zinc supplements if a deficiency exists in that mineral. Strive for a balanced diet and confirm a deficiency before adding any vitamin supplement, said Ms. Posthauer. Remember that many liquid calorie supplements meet the daily recommendations for most vitamins and minerals, so further additions may be unnecessary, she added.

Relatives may know which foods older kin prefer and may offer strategies to help elders get the calories they need for optimal wound healing.

Ms. Posthauer disclosed no financial conflicts relevant to her presentation.

ARLINGTON, VA. — It may not be the first tool that physicians think of, but nutrition can be a powerful one against pressure ulcers, dietitian Mary Ellen Posthauer told a meeting of the National Pressure Ulcer Advisory Panel.

“Please involve dietitians early on if you see people with pressure ulcers or those who are at high risk of developing pressure ulcers,” said Ms. Posthauer of the company Supreme Care West in Evansville, Ill.

People with pressure ulcers are in a hypermetabolic condition, she explained. A small person with a pressure ulcer is probably pulling protein from his or her lean body tissue.

More research is needed on the impact of nutrition on wound healing in obese patients, Ms. Posthauer said. Patients with stage III or IV pressure ulcers should not be on restricted diets. Patients with pressure ulcers need to eat 30-35 kilocalories per kilogram of body weight a day, she said. “If the person doesn't eat the food, you aren't going to get wound healing.”

Ms. Posthauer offered several tips for how to provide enough calories:

▸ Consider the individual's favorite foods and cultural preferences. The goal is to serve “foods that they are actually going to eat, not give to their tablemates.”

▸ Offer variety. A chocolate milkshake is less attractive than usual when a person gets three a day.

▸ Use fortified foods, such as high-density cereal and pudding, or follow recipes for high-calorie, high-protein foods.

▸ Offer high-calorie, high-protein supplements, using trial and error to determine which one the patient prefers. Research has shown that offering a nutritional supplement between meals improves the acceptance of the supplement and mealtime food.

“There needs to be a team effort in following up to see that the food is being consumed,” Ms. Posthauer emphasized. “Dietitians are great at developing menus and sending out food, but if nobody is eating it, we haven't achieved much.”

Studies have shown that increased protein intake is associated with better healing of pressure ulcers, with a recommended daily intake of 1.25 to 1.5 g/kg of body weight. But it's important to monitor both healing rates and renal function in a person getting supplements and to adjust intake as needed, Ms. Posthauer said. “Monitor the healing, and if you aren't seeing results, try increasing the amount of protein.”

Enteral nutrition is an option for some individuals, but only if it is monitored carefully, Ms. Posthauer said. When considering enteral nutrition, ask the individual and family members whether they understand the risks and benefits associated with this more invasive form of feeding. If individuals receive tube feeding, then the formula for the liquid being administered should be evaluated periodically to make sure that it is providing enough calories and protein to improve wound healing.

Research does not support the use of mega doses of vitamin C to enhance wound healing, but some evidence supports the use of zinc supplements if a deficiency exists in that mineral. Strive for a balanced diet and confirm a deficiency before adding any vitamin supplement, said Ms. Posthauer. Remember that many liquid calorie supplements meet the daily recommendations for most vitamins and minerals, so further additions may be unnecessary, she added.

Relatives may know which foods older kin prefer and may offer strategies to help elders get the calories they need for optimal wound healing.

Ms. Posthauer disclosed no financial conflicts relevant to her presentation.

SAN FRANCISCO — Maggot debridement therapy helped clear necrotic tissue from purpura fulminans in a 9-month-old boy who was not responding to standard wound care, according to Dr. Xuan Nguyen.

Reports of maggot debridement therapy in children are scarce. This appears to be the first case of using the therapy in a child with purpura fulminans, Dr. Nguyen said at a meeting of the Society for Pediatric Dermatology.

Maggot debridement therapy—also called biosurgery—was used in the United States in the 1930s and 1940s and reintroduced into medical practice in the 1980s and 1990s. In 2004, the Food and Drug Administration approved the production and marketing of medical maggots for debridement of nonhealing necrotic skin and soft tissue wounds, pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and nonhealing traumatic or postsurgical wounds.

Although purpura fulminans is not a specific indication, it is a chronic wound infection that seems amenable to maggot debridement therapy, she said.

The previously healthy boy presented to the Phoenix Children's Hospital with mottled skin 24 hours after receiving immunizations. He developed Staphylococcus aureus septicemia that led to extensive purpura fulminans, a diffuse necrosis of the skin and subcutaneous tissue secondary to microvascular thrombosis from transient protein C deficiency. All four extremities and some other areas became necrotic.

Conventional wound management using Dakin's solution, Vaseline petroleum gauze dressing over the ecchymotic wounds, Kerlix wraps, and daily wound dressing changes was applied as some of the wounds and mummified regions started to demarcate. Wounds on the face healed relatively well, but the lower extremities of the patient, in particular, had trouble healing. One patella was exposed after the rotting lower leg slid off, said Dr. Nguyen, a pediatric dermatologist at the hospital.

Dr. Nguyen and her associates applied five rounds (lasting 4-5 days each) of maggot debridement therapy combined with adjunctive daily whirlpool baths to which bleach was added. After five rounds of maggot treatment, whirlpool baths were scheduled three times per week as maintenance.

Maggot therapy serves three functions: It debrides necrotic tissue, acts as an antimicrobial therapy, and stimulates wound healing. Maggots like a moist environment and are relatively contraindicated in dry wounds. “We try not to use them in open wounds of body cavities, because the maggots get lost” when it is time to remove them, she said.

The maggots, which are larvae of the greenbottle blowfly (Lucilia sericata), are applied when 1-2 mm in size and grow to 10 mm after 4-5 days, when they are removed from the wound. The maggots ingest nothing but necrotic tissue, and 200 maggots can consume up to 15 g/day. Mouth hooks on their front ends rake in decaying flesh, making them remarkable eating machines.

The maggots secrete proteolytic enzymes including collagenase, trypsinlike enzymes, and chymotrypsinlike enzymes that facilitate wound healing. Their activity disrupts tissue planes only minimally, and some of their secretions inhibit gram-positive and gram-negative bacteria.

Sterile maggots on gauze were tied over the boy's leg wounds and covered with a Kerlix wrap, netting, and a stocking to keep the maggots in the wound. The boy is healing after amputation of his hands and feet, maggot debridement therapy, and use of maintenance baths, Dr. Nguyen said.

Information about conflicts of interest could not be obtained by press time.

SAN FRANCISCO — Maggot debridement therapy helped clear necrotic tissue from purpura fulminans in a 9-month-old boy who was not responding to standard wound care, according to Dr. Xuan Nguyen.

Reports of maggot debridement therapy in children are scarce. This appears to be the first case of using the therapy in a child with purpura fulminans, Dr. Nguyen said at a meeting of the Society for Pediatric Dermatology.

Maggot debridement therapy—also called biosurgery—was used in the United States in the 1930s and 1940s and reintroduced into medical practice in the 1980s and 1990s. In 2004, the Food and Drug Administration approved the production and marketing of medical maggots for debridement of nonhealing necrotic skin and soft tissue wounds, pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and nonhealing traumatic or postsurgical wounds.

Although purpura fulminans is not a specific indication, it is a chronic wound infection that seems amenable to maggot debridement therapy, she said.

The previously healthy boy presented to the Phoenix Children's Hospital with mottled skin 24 hours after receiving immunizations. He developed Staphylococcus aureus septicemia that led to extensive purpura fulminans, a diffuse necrosis of the skin and subcutaneous tissue secondary to microvascular thrombosis from transient protein C deficiency. All four extremities and some other areas became necrotic.

Conventional wound management using Dakin's solution, Vaseline petroleum gauze dressing over the ecchymotic wounds, Kerlix wraps, and daily wound dressing changes was applied as some of the wounds and mummified regions started to demarcate. Wounds on the face healed relatively well, but the lower extremities of the patient, in particular, had trouble healing. One patella was exposed after the rotting lower leg slid off, said Dr. Nguyen, a pediatric dermatologist at the hospital.

Dr. Nguyen and her associates applied five rounds (lasting 4-5 days each) of maggot debridement therapy combined with adjunctive daily whirlpool baths to which bleach was added. After five rounds of maggot treatment, whirlpool baths were scheduled three times per week as maintenance.

Maggot therapy serves three functions: It debrides necrotic tissue, acts as an antimicrobial therapy, and stimulates wound healing. Maggots like a moist environment and are relatively contraindicated in dry wounds. “We try not to use them in open wounds of body cavities, because the maggots get lost” when it is time to remove them, she said.

The maggots, which are larvae of the greenbottle blowfly (Lucilia sericata), are applied when 1-2 mm in size and grow to 10 mm after 4-5 days, when they are removed from the wound. The maggots ingest nothing but necrotic tissue, and 200 maggots can consume up to 15 g/day. Mouth hooks on their front ends rake in decaying flesh, making them remarkable eating machines.

The maggots secrete proteolytic enzymes including collagenase, trypsinlike enzymes, and chymotrypsinlike enzymes that facilitate wound healing. Their activity disrupts tissue planes only minimally, and some of their secretions inhibit gram-positive and gram-negative bacteria.

Sterile maggots on gauze were tied over the boy's leg wounds and covered with a Kerlix wrap, netting, and a stocking to keep the maggots in the wound. The boy is healing after amputation of his hands and feet, maggot debridement therapy, and use of maintenance baths, Dr. Nguyen said.

Information about conflicts of interest could not be obtained by press time.

SAN FRANCISCO — Maggot debridement therapy helped clear necrotic tissue from purpura fulminans in a 9-month-old boy who was not responding to standard wound care, according to Dr. Xuan Nguyen.

Reports of maggot debridement therapy in children are scarce. This appears to be the first case of using the therapy in a child with purpura fulminans, Dr. Nguyen said at a meeting of the Society for Pediatric Dermatology.

Maggot debridement therapy—also called biosurgery—was used in the United States in the 1930s and 1940s and reintroduced into medical practice in the 1980s and 1990s. In 2004, the Food and Drug Administration approved the production and marketing of medical maggots for debridement of nonhealing necrotic skin and soft tissue wounds, pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and nonhealing traumatic or postsurgical wounds.

Although purpura fulminans is not a specific indication, it is a chronic wound infection that seems amenable to maggot debridement therapy, she said.

The previously healthy boy presented to the Phoenix Children's Hospital with mottled skin 24 hours after receiving immunizations. He developed Staphylococcus aureus septicemia that led to extensive purpura fulminans, a diffuse necrosis of the skin and subcutaneous tissue secondary to microvascular thrombosis from transient protein C deficiency. All four extremities and some other areas became necrotic.

Conventional wound management using Dakin's solution, Vaseline petroleum gauze dressing over the ecchymotic wounds, Kerlix wraps, and daily wound dressing changes was applied as some of the wounds and mummified regions started to demarcate. Wounds on the face healed relatively well, but the lower extremities of the patient, in particular, had trouble healing. One patella was exposed after the rotting lower leg slid off, said Dr. Nguyen, a pediatric dermatologist at the hospital.

Dr. Nguyen and her associates applied five rounds (lasting 4-5 days each) of maggot debridement therapy combined with adjunctive daily whirlpool baths to which bleach was added. After five rounds of maggot treatment, whirlpool baths were scheduled three times per week as maintenance.

Maggot therapy serves three functions: It debrides necrotic tissue, acts as an antimicrobial therapy, and stimulates wound healing. Maggots like a moist environment and are relatively contraindicated in dry wounds. “We try not to use them in open wounds of body cavities, because the maggots get lost” when it is time to remove them, she said.

The maggots, which are larvae of the greenbottle blowfly (Lucilia sericata), are applied when 1-2 mm in size and grow to 10 mm after 4-5 days, when they are removed from the wound. The maggots ingest nothing but necrotic tissue, and 200 maggots can consume up to 15 g/day. Mouth hooks on their front ends rake in decaying flesh, making them remarkable eating machines.

The maggots secrete proteolytic enzymes including collagenase, trypsinlike enzymes, and chymotrypsinlike enzymes that facilitate wound healing. Their activity disrupts tissue planes only minimally, and some of their secretions inhibit gram-positive and gram-negative bacteria.

Sterile maggots on gauze were tied over the boy's leg wounds and covered with a Kerlix wrap, netting, and a stocking to keep the maggots in the wound. The boy is healing after amputation of his hands and feet, maggot debridement therapy, and use of maintenance baths, Dr. Nguyen said.

Information about conflicts of interest could not be obtained by press time.

LAS VEGAS — An evolving understanding of the pathogenesis of calciphylaxis in hospitalized patients may lead to antithrombotic treatment strategies focused on vascular occlusion as well as dialysis- and parathyroid-specific interventions.

“Calciphylaxis is a therapeutic conundrum and also a nightmare,” said Dr. Mark D.P. Davis, professor of dermatology at the Mayo Clinic, Rochester, Minn.

“We urgently need better treatment and preventive strategies,” he stressed at a dermatology seminar sponsored by Skin Disease Education Foundation.

The condition's name, calciphylaxis, reflects an early belief that the introduction of a certain agent (likely during dialysis) induced calcification of vessels, a notion now disputed since the disease occurs in patients without renal insufficiency.

A more accurate name, first proposed by Dr. Patrick Dahl and associates, is the vascular calcification-cutaneous necrosis syndrome (J. Am. Acad. Dermatol. 1995;33:53–8), which better characterizes calciphylaxis as “akin to a myocardial infarction,” Dr. Davis said.

Calcifications in the walls of small arterioles supplying the skin are the first evidence of the disorder. The resultant clots then trigger skin infarctions, just as a blockage of a vessel leads to a myocardial infarction.

Treatment strategies at Mayo focus on vascular occlusion, along with management of hypercalcemia (with low calcium dialysate and sodium thiosulfate in dialysis patients), hyperphosphatemia (with phosphate binding agents), hyperparathyroidism (with cinacalcet and bisphosphonates), and pain.

“We … feel it's very important to treat vascular occlusions and eliminate these luminal thromboses causing this cutaneous infarct,” he said. “One way to treat an existing clot is to use thrombolytic agents.”

Several Mayo Clinic patients have been treated in this fashion with infused tissue plasminogen activator (tPA) at doses 1/10 of those used to treat a myocardial infarction. Because of concern over bleeding, patients are admitted for the 2-week procedure, he said.

“We have had some success and are presently reviewing our experience with this approach,” Dr. Davis said.

Anticoagulant medications, including heparin, low-molecular-weight heparin, and warfarin, are also used in calciphylaxis patients “so they don't further clot.”

Dr. M.R. (Pete) Hayden, a calciphylaxis researcher who has published several studies on sodium thiosulfate as a possible treatment for calciphylaxis, said in an e-mail message that he is “looking forward excitedly to future papers” on the anticoagulant approach from Dr. Davis and Mayo researchers.

“Indeed, thrombolytic agents may be an important adjunctive intervention along with calcium-chelating agents and phosphate binding agents in appropriate patients because there are so many precipitating variables important to the development of calciphylaxis,” wrote Dr. Hayden, research professor of internal medicine in the division of endocrinology, diabetes, and metabolism at the University of Missouri, Camdenton campus.

Other interventions have not fared as well. A comprehensive review of 64 patients treated at the Mayo Clinic failed to find any survival benefit for parathyroidectomy, despite case studies and series suggesting the surgery is beneficial (J. Am. Acad. Dermatol. 2007;57:365–6).

Debridement was associated with a 1-year survival rate of 62%, compared with 27% survival rates in patients who failed to undergo the procedure. Because surgical and mechanical debridement are difficult to perform in patients with this “excruciatingly painful” disease, painless debridement using maggots and ultrasound is being utilized at Mayo to good effect, Dr. Davis said.

A population-based study conducted in the Rochester, Minn., area found an incidence of 4.5 cases per million people, per year. About 1% of patients with chronic renal failure and 4% of dialysis patients reportedly have the disease.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS — An evolving understanding of the pathogenesis of calciphylaxis in hospitalized patients may lead to antithrombotic treatment strategies focused on vascular occlusion as well as dialysis- and parathyroid-specific interventions.

“Calciphylaxis is a therapeutic conundrum and also a nightmare,” said Dr. Mark D.P. Davis, professor of dermatology at the Mayo Clinic, Rochester, Minn.

“We urgently need better treatment and preventive strategies,” he stressed at a dermatology seminar sponsored by Skin Disease Education Foundation.

The condition's name, calciphylaxis, reflects an early belief that the introduction of a certain agent (likely during dialysis) induced calcification of vessels, a notion now disputed since the disease occurs in patients without renal insufficiency.

A more accurate name, first proposed by Dr. Patrick Dahl and associates, is the vascular calcification-cutaneous necrosis syndrome (J. Am. Acad. Dermatol. 1995;33:53–8), which better characterizes calciphylaxis as “akin to a myocardial infarction,” Dr. Davis said.

Calcifications in the walls of small arterioles supplying the skin are the first evidence of the disorder. The resultant clots then trigger skin infarctions, just as a blockage of a vessel leads to a myocardial infarction.

Treatment strategies at Mayo focus on vascular occlusion, along with management of hypercalcemia (with low calcium dialysate and sodium thiosulfate in dialysis patients), hyperphosphatemia (with phosphate binding agents), hyperparathyroidism (with cinacalcet and bisphosphonates), and pain.

“We … feel it's very important to treat vascular occlusions and eliminate these luminal thromboses causing this cutaneous infarct,” he said. “One way to treat an existing clot is to use thrombolytic agents.”

Several Mayo Clinic patients have been treated in this fashion with infused tissue plasminogen activator (tPA) at doses 1/10 of those used to treat a myocardial infarction. Because of concern over bleeding, patients are admitted for the 2-week procedure, he said.

“We have had some success and are presently reviewing our experience with this approach,” Dr. Davis said.

Anticoagulant medications, including heparin, low-molecular-weight heparin, and warfarin, are also used in calciphylaxis patients “so they don't further clot.”

Dr. M.R. (Pete) Hayden, a calciphylaxis researcher who has published several studies on sodium thiosulfate as a possible treatment for calciphylaxis, said in an e-mail message that he is “looking forward excitedly to future papers” on the anticoagulant approach from Dr. Davis and Mayo researchers.

“Indeed, thrombolytic agents may be an important adjunctive intervention along with calcium-chelating agents and phosphate binding agents in appropriate patients because there are so many precipitating variables important to the development of calciphylaxis,” wrote Dr. Hayden, research professor of internal medicine in the division of endocrinology, diabetes, and metabolism at the University of Missouri, Camdenton campus.

Other interventions have not fared as well. A comprehensive review of 64 patients treated at the Mayo Clinic failed to find any survival benefit for parathyroidectomy, despite case studies and series suggesting the surgery is beneficial (J. Am. Acad. Dermatol. 2007;57:365–6).

Debridement was associated with a 1-year survival rate of 62%, compared with 27% survival rates in patients who failed to undergo the procedure. Because surgical and mechanical debridement are difficult to perform in patients with this “excruciatingly painful” disease, painless debridement using maggots and ultrasound is being utilized at Mayo to good effect, Dr. Davis said.

A population-based study conducted in the Rochester, Minn., area found an incidence of 4.5 cases per million people, per year. About 1% of patients with chronic renal failure and 4% of dialysis patients reportedly have the disease.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS — An evolving understanding of the pathogenesis of calciphylaxis in hospitalized patients may lead to antithrombotic treatment strategies focused on vascular occlusion as well as dialysis- and parathyroid-specific interventions.

“Calciphylaxis is a therapeutic conundrum and also a nightmare,” said Dr. Mark D.P. Davis, professor of dermatology at the Mayo Clinic, Rochester, Minn.

“We urgently need better treatment and preventive strategies,” he stressed at a dermatology seminar sponsored by Skin Disease Education Foundation.

The condition's name, calciphylaxis, reflects an early belief that the introduction of a certain agent (likely during dialysis) induced calcification of vessels, a notion now disputed since the disease occurs in patients without renal insufficiency.

A more accurate name, first proposed by Dr. Patrick Dahl and associates, is the vascular calcification-cutaneous necrosis syndrome (J. Am. Acad. Dermatol. 1995;33:53–8), which better characterizes calciphylaxis as “akin to a myocardial infarction,” Dr. Davis said.

Calcifications in the walls of small arterioles supplying the skin are the first evidence of the disorder. The resultant clots then trigger skin infarctions, just as a blockage of a vessel leads to a myocardial infarction.

Treatment strategies at Mayo focus on vascular occlusion, along with management of hypercalcemia (with low calcium dialysate and sodium thiosulfate in dialysis patients), hyperphosphatemia (with phosphate binding agents), hyperparathyroidism (with cinacalcet and bisphosphonates), and pain.

“We … feel it's very important to treat vascular occlusions and eliminate these luminal thromboses causing this cutaneous infarct,” he said. “One way to treat an existing clot is to use thrombolytic agents.”

Several Mayo Clinic patients have been treated in this fashion with infused tissue plasminogen activator (tPA) at doses 1/10 of those used to treat a myocardial infarction. Because of concern over bleeding, patients are admitted for the 2-week procedure, he said.

“We have had some success and are presently reviewing our experience with this approach,” Dr. Davis said.

Anticoagulant medications, including heparin, low-molecular-weight heparin, and warfarin, are also used in calciphylaxis patients “so they don't further clot.”

Dr. M.R. (Pete) Hayden, a calciphylaxis researcher who has published several studies on sodium thiosulfate as a possible treatment for calciphylaxis, said in an e-mail message that he is “looking forward excitedly to future papers” on the anticoagulant approach from Dr. Davis and Mayo researchers.

“Indeed, thrombolytic agents may be an important adjunctive intervention along with calcium-chelating agents and phosphate binding agents in appropriate patients because there are so many precipitating variables important to the development of calciphylaxis,” wrote Dr. Hayden, research professor of internal medicine in the division of endocrinology, diabetes, and metabolism at the University of Missouri, Camdenton campus.

Other interventions have not fared as well. A comprehensive review of 64 patients treated at the Mayo Clinic failed to find any survival benefit for parathyroidectomy, despite case studies and series suggesting the surgery is beneficial (J. Am. Acad. Dermatol. 2007;57:365–6).

Debridement was associated with a 1-year survival rate of 62%, compared with 27% survival rates in patients who failed to undergo the procedure. Because surgical and mechanical debridement are difficult to perform in patients with this “excruciatingly painful” disease, painless debridement using maggots and ultrasound is being utilized at Mayo to good effect, Dr. Davis said.

A population-based study conducted in the Rochester, Minn., area found an incidence of 4.5 cases per million people, per year. About 1% of patients with chronic renal failure and 4% of dialysis patients reportedly have the disease.

SDEF and this news organization are owned by Elsevier.

A simple protocol can assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.

The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J. M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.

The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.

Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.

Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:

▸ Vibration with 128-Hz tuning fork.

▸ Pinprick sensation.

▸ Ankle reflexes.

▸ Vibration perception threshold testing.

Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).

Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.

Subsequent therapy and follow-up care should be provided according to the category: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.

A simple protocol can assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.

The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J. M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.

The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.

Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.

Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:

▸ Vibration with 128-Hz tuning fork.

▸ Pinprick sensation.

▸ Ankle reflexes.

▸ Vibration perception threshold testing.

Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).

Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.

Subsequent therapy and follow-up care should be provided according to the category: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.

A simple protocol can assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.

The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J. M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.

The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.

Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.

Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:

▸ Vibration with 128-Hz tuning fork.

▸ Pinprick sensation.

▸ Ankle reflexes.

▸ Vibration perception threshold testing.

Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).

Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.

Subsequent therapy and follow-up care should be provided according to the category: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.

An initially successful healing rate in patients who were hospitalized with diabetic foot ulcers did not lead to comparable long-term outcomes in a prospective study of 94 consecutive patients.

The presence of nephropathy was found to be an important predictor of poorer outcomes, whereas age was an independent predictor of global therapeutic success (GTS), according to a report presented in Diabetes Care.

Of 94 consecutive diabetic patients hospitalized for diabetic foot ulcers between January 1998 and December 2000, 89 (63 men) were successfully followed up for an average of nearly 80 months. The mean age of the patients was nearly 64 years.

Researchers calculated the rates of primary healing, new ulcers, amputations, mortality, and disability, and evaluated the GTS of foot care management (defined as primary healing without recurrence or disability at the end of follow-up). To their knowledge, this was the first time that disability and dependency, which were measured using Katz's index of activities of daily living, were considered as end points of a prospective diabetic foot study, according to Dr. Edouard Ghanassia and colleagues from the Centre Hospitalier Universitaire Montpellier (France).

Primary healing without major amputation occurred in 69 patients (nearly 78%). Amputations were performed in 39 patients (44%), with 30 minor and 9 major amputations; of the minor amputations, 24 occurred in the primary healing group. Ulcers recurred in nearly 61% of patients. Ultimately, 46 patients (nearly 52%) died, including 23 from cardiovascular events.

At the end of the follow-up period, 25 patients (28%) were dependent and 40 patients (nearly 45%) had achieved GTS.

Using multivariate analysis, the researchers found that smoking and renal impairment were independent predictors of healing failure; an age older than 70 years was the only independent predictor of GTS. There were no independent predictors of disability.

Insulin treatment prior to admission was the only predictor of ulcer recurrence, and diabetic nephropathy was the only independent predictor of first amputation. The only independent predictors of cardiovascular mortality were insulin therapy before admittance and renal impairment.

Diabetic nephropathy was also seen to be an important marker of other factors in long-term prognosis, with impaired renal function being an independent predictor of healing failure and all-cause mortality; in conjunction with albuminuria, it was associated with amputations. Using univariate analysis, popliteal stenosis (diagnosed by Doppler ultrasound) was found to be an independent predictor of amputation, "confirming that vascular involvement in diabetic patients with foot ulcers is particularly important," the authors stated (Diabetes Care 2008;31:1288–92).

One limitation of the study, according to the authors, was that interview follow-up was conducted by telephone rather than in person.

An initially successful healing rate in patients who were hospitalized with diabetic foot ulcers did not lead to comparable long-term outcomes in a prospective study of 94 consecutive patients.

The presence of nephropathy was found to be an important predictor of poorer outcomes, whereas age was an independent predictor of global therapeutic success (GTS), according to a report presented in Diabetes Care.

Of 94 consecutive diabetic patients hospitalized for diabetic foot ulcers between January 1998 and December 2000, 89 (63 men) were successfully followed up for an average of nearly 80 months. The mean age of the patients was nearly 64 years.

Researchers calculated the rates of primary healing, new ulcers, amputations, mortality, and disability, and evaluated the GTS of foot care management (defined as primary healing without recurrence or disability at the end of follow-up). To their knowledge, this was the first time that disability and dependency, which were measured using Katz's index of activities of daily living, were considered as end points of a prospective diabetic foot study, according to Dr. Edouard Ghanassia and colleagues from the Centre Hospitalier Universitaire Montpellier (France).

Primary healing without major amputation occurred in 69 patients (nearly 78%). Amputations were performed in 39 patients (44%), with 30 minor and 9 major amputations; of the minor amputations, 24 occurred in the primary healing group. Ulcers recurred in nearly 61% of patients. Ultimately, 46 patients (nearly 52%) died, including 23 from cardiovascular events.

At the end of the follow-up period, 25 patients (28%) were dependent and 40 patients (nearly 45%) had achieved GTS.

Using multivariate analysis, the researchers found that smoking and renal impairment were independent predictors of healing failure; an age older than 70 years was the only independent predictor of GTS. There were no independent predictors of disability.

Insulin treatment prior to admission was the only predictor of ulcer recurrence, and diabetic nephropathy was the only independent predictor of first amputation. The only independent predictors of cardiovascular mortality were insulin therapy before admittance and renal impairment.

Diabetic nephropathy was also seen to be an important marker of other factors in long-term prognosis, with impaired renal function being an independent predictor of healing failure and all-cause mortality; in conjunction with albuminuria, it was associated with amputations. Using univariate analysis, popliteal stenosis (diagnosed by Doppler ultrasound) was found to be an independent predictor of amputation, "confirming that vascular involvement in diabetic patients with foot ulcers is particularly important," the authors stated (Diabetes Care 2008;31:1288–92).

One limitation of the study, according to the authors, was that interview follow-up was conducted by telephone rather than in person.

An initially successful healing rate in patients who were hospitalized with diabetic foot ulcers did not lead to comparable long-term outcomes in a prospective study of 94 consecutive patients.

The presence of nephropathy was found to be an important predictor of poorer outcomes, whereas age was an independent predictor of global therapeutic success (GTS), according to a report presented in Diabetes Care.

Of 94 consecutive diabetic patients hospitalized for diabetic foot ulcers between January 1998 and December 2000, 89 (63 men) were successfully followed up for an average of nearly 80 months. The mean age of the patients was nearly 64 years.

Researchers calculated the rates of primary healing, new ulcers, amputations, mortality, and disability, and evaluated the GTS of foot care management (defined as primary healing without recurrence or disability at the end of follow-up). To their knowledge, this was the first time that disability and dependency, which were measured using Katz's index of activities of daily living, were considered as end points of a prospective diabetic foot study, according to Dr. Edouard Ghanassia and colleagues from the Centre Hospitalier Universitaire Montpellier (France).

Primary healing without major amputation occurred in 69 patients (nearly 78%). Amputations were performed in 39 patients (44%), with 30 minor and 9 major amputations; of the minor amputations, 24 occurred in the primary healing group. Ulcers recurred in nearly 61% of patients. Ultimately, 46 patients (nearly 52%) died, including 23 from cardiovascular events.

At the end of the follow-up period, 25 patients (28%) were dependent and 40 patients (nearly 45%) had achieved GTS.

Using multivariate analysis, the researchers found that smoking and renal impairment were independent predictors of healing failure; an age older than 70 years was the only independent predictor of GTS. There were no independent predictors of disability.

Insulin treatment prior to admission was the only predictor of ulcer recurrence, and diabetic nephropathy was the only independent predictor of first amputation. The only independent predictors of cardiovascular mortality were insulin therapy before admittance and renal impairment.

Diabetic nephropathy was also seen to be an important marker of other factors in long-term prognosis, with impaired renal function being an independent predictor of healing failure and all-cause mortality; in conjunction with albuminuria, it was associated with amputations. Using univariate analysis, popliteal stenosis (diagnosed by Doppler ultrasound) was found to be an independent predictor of amputation, "confirming that vascular involvement in diabetic patients with foot ulcers is particularly important," the authors stated (Diabetes Care 2008;31:1288–92).

One limitation of the study, according to the authors, was that interview follow-up was conducted by telephone rather than in person.

CHICAGO — The novel skin substitutes Suprathel and Matriderm resulted in complete healing and excellent functionality in patients with deep burns in two studies.

By using Suprathel, complete epithelialization was achieved in 14–20 days for 38 of 40 patients with deep dermal burns. Regrafting was necessary in only two patients, said Dr. David Lumenta, who presented the results on behalf of Dr. Lars-Peter Kamolz at the annual meeting of the American Burn Association. Both are with the division of plastic and reconstructive surgery at the Medical University of Vienna.

Average total body surface area burned (TBSA) was 35%, although the team has used Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany) in patients with burns up to 90% TBSA.

Suprathel is a resorbable skin substitute produced from a fully synthetic copolymer with a porous membrane, based largely (greater than 70%) on poly-DL-lactide. It is available in various pore and surface sizes and is indicated mainly for use on donor sites and partial-thickness burns.

Its main advantages are reduced pain, accelerated epithelialization, and employment in functionally stressed regions and joints. It is more easily handled than other biologic dressings, and there is no biological risk, Dr. Lumenta said. No signs of local or systemic allergic reaction were observed in the 40 patients.

In a poster at the same meeting, Dr. Kamolz reported their experience with Matriderm in 10 patients with severe hand burns.

Matriderm (Dr. Suwelack Skin & Health Care AG, Billerbeck, Germany) is a thin, porous membrane consisting of a native bovine type I, II, and V collagen-fiber template coated with elastin hydrolysate, which is converted into native host collagen within weeks of application, Dr. Kamolz said in an interview.

The matrix serves as a support structure for new cell growth while the collagen improves the stability and elasticity of the regenerating tissue. As healing progresses, fibroblasts produce their own extracellular matrix and Matriderm is resorbed. The main indications for this matrix are full-thickness burns in functionally and aesthetically important regions, he said.

A two-step repair is recommended for Matriderm sheets 2 mm or greater in thickness, with a 7-day interval between matrix application and transplantation of split-thickness skin grafts to allow for vascularization of the matrix. A single operation is feasible in the acute phase after burn trauma using a 1-mm-thick sheet.

The take-rate using Matriderm does not differ significantly, compared with traditional split-thickness skin grafts, and the quality of the resulting scar has been superior, Dr. Kamolz said.

The take-rate was 97% at 3 months' follow-up among 10 patients, mean age 45 years, with severe, full-thickness hand burns (TBSA 23%) who underwent early debridement and immediate grafting with Matriderm and an unmeshed skin graft in a single operation.

The pliability of the grafted area was excellent, with a mean Vancouver Scar Scale score of 3.2. Full range of motion was achieved in all hands, he said.

No blisters and no unstable or hypertrophic scars were observed. In comparison with conventional skin grafts, the color of the skin grafts over the matrix appeared pale during the first few days, but no difference was observed after 2 weeks.

"These good functional and aesthetic results remain stable, even 12 months postoperatively," he reported.

The study was supported by the Medical University of Vienna. The investigators disclosed no relevant conflicts of interest. Neither product has been approved for use in the United States.

A patient whose severe hand burns (left) were treated with Matriderm grafting showed free range of motion and good function at 1 year. Photos courtesy Dr. Lars-Peter Kamolz

CHICAGO — The novel skin substitutes Suprathel and Matriderm resulted in complete healing and excellent functionality in patients with deep burns in two studies.

By using Suprathel, complete epithelialization was achieved in 14–20 days for 38 of 40 patients with deep dermal burns. Regrafting was necessary in only two patients, said Dr. David Lumenta, who presented the results on behalf of Dr. Lars-Peter Kamolz at the annual meeting of the American Burn Association. Both are with the division of plastic and reconstructive surgery at the Medical University of Vienna.

Average total body surface area burned (TBSA) was 35%, although the team has used Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany) in patients with burns up to 90% TBSA.

Suprathel is a resorbable skin substitute produced from a fully synthetic copolymer with a porous membrane, based largely (greater than 70%) on poly-DL-lactide. It is available in various pore and surface sizes and is indicated mainly for use on donor sites and partial-thickness burns.

Its main advantages are reduced pain, accelerated epithelialization, and employment in functionally stressed regions and joints. It is more easily handled than other biologic dressings, and there is no biological risk, Dr. Lumenta said. No signs of local or systemic allergic reaction were observed in the 40 patients.

In a poster at the same meeting, Dr. Kamolz reported their experience with Matriderm in 10 patients with severe hand burns.

Matriderm (Dr. Suwelack Skin & Health Care AG, Billerbeck, Germany) is a thin, porous membrane consisting of a native bovine type I, II, and V collagen-fiber template coated with elastin hydrolysate, which is converted into native host collagen within weeks of application, Dr. Kamolz said in an interview.

The matrix serves as a support structure for new cell growth while the collagen improves the stability and elasticity of the regenerating tissue. As healing progresses, fibroblasts produce their own extracellular matrix and Matriderm is resorbed. The main indications for this matrix are full-thickness burns in functionally and aesthetically important regions, he said.

A two-step repair is recommended for Matriderm sheets 2 mm or greater in thickness, with a 7-day interval between matrix application and transplantation of split-thickness skin grafts to allow for vascularization of the matrix. A single operation is feasible in the acute phase after burn trauma using a 1-mm-thick sheet.

The take-rate using Matriderm does not differ significantly, compared with traditional split-thickness skin grafts, and the quality of the resulting scar has been superior, Dr. Kamolz said.

The take-rate was 97% at 3 months' follow-up among 10 patients, mean age 45 years, with severe, full-thickness hand burns (TBSA 23%) who underwent early debridement and immediate grafting with Matriderm and an unmeshed skin graft in a single operation.

The pliability of the grafted area was excellent, with a mean Vancouver Scar Scale score of 3.2. Full range of motion was achieved in all hands, he said.

No blisters and no unstable or hypertrophic scars were observed. In comparison with conventional skin grafts, the color of the skin grafts over the matrix appeared pale during the first few days, but no difference was observed after 2 weeks.

"These good functional and aesthetic results remain stable, even 12 months postoperatively," he reported.

The study was supported by the Medical University of Vienna. The investigators disclosed no relevant conflicts of interest. Neither product has been approved for use in the United States.

A patient whose severe hand burns (left) were treated with Matriderm grafting showed free range of motion and good function at 1 year. Photos courtesy Dr. Lars-Peter Kamolz

CHICAGO — The novel skin substitutes Suprathel and Matriderm resulted in complete healing and excellent functionality in patients with deep burns in two studies.

By using Suprathel, complete epithelialization was achieved in 14–20 days for 38 of 40 patients with deep dermal burns. Regrafting was necessary in only two patients, said Dr. David Lumenta, who presented the results on behalf of Dr. Lars-Peter Kamolz at the annual meeting of the American Burn Association. Both are with the division of plastic and reconstructive surgery at the Medical University of Vienna.

Average total body surface area burned (TBSA) was 35%, although the team has used Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany) in patients with burns up to 90% TBSA.

Suprathel is a resorbable skin substitute produced from a fully synthetic copolymer with a porous membrane, based largely (greater than 70%) on poly-DL-lactide. It is available in various pore and surface sizes and is indicated mainly for use on donor sites and partial-thickness burns.

Its main advantages are reduced pain, accelerated epithelialization, and employment in functionally stressed regions and joints. It is more easily handled than other biologic dressings, and there is no biological risk, Dr. Lumenta said. No signs of local or systemic allergic reaction were observed in the 40 patients.

In a poster at the same meeting, Dr. Kamolz reported their experience with Matriderm in 10 patients with severe hand burns.

Matriderm (Dr. Suwelack Skin & Health Care AG, Billerbeck, Germany) is a thin, porous membrane consisting of a native bovine type I, II, and V collagen-fiber template coated with elastin hydrolysate, which is converted into native host collagen within weeks of application, Dr. Kamolz said in an interview.

The matrix serves as a support structure for new cell growth while the collagen improves the stability and elasticity of the regenerating tissue. As healing progresses, fibroblasts produce their own extracellular matrix and Matriderm is resorbed. The main indications for this matrix are full-thickness burns in functionally and aesthetically important regions, he said.

A two-step repair is recommended for Matriderm sheets 2 mm or greater in thickness, with a 7-day interval between matrix application and transplantation of split-thickness skin grafts to allow for vascularization of the matrix. A single operation is feasible in the acute phase after burn trauma using a 1-mm-thick sheet.

The take-rate using Matriderm does not differ significantly, compared with traditional split-thickness skin grafts, and the quality of the resulting scar has been superior, Dr. Kamolz said.

The take-rate was 97% at 3 months' follow-up among 10 patients, mean age 45 years, with severe, full-thickness hand burns (TBSA 23%) who underwent early debridement and immediate grafting with Matriderm and an unmeshed skin graft in a single operation.

The pliability of the grafted area was excellent, with a mean Vancouver Scar Scale score of 3.2. Full range of motion was achieved in all hands, he said.

No blisters and no unstable or hypertrophic scars were observed. In comparison with conventional skin grafts, the color of the skin grafts over the matrix appeared pale during the first few days, but no difference was observed after 2 weeks.

"These good functional and aesthetic results remain stable, even 12 months postoperatively," he reported.

The study was supported by the Medical University of Vienna. The investigators disclosed no relevant conflicts of interest. Neither product has been approved for use in the United States.

A patient whose severe hand burns (left) were treated with Matriderm grafting showed free range of motion and good function at 1 year. Photos courtesy Dr. Lars-Peter Kamolz

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng