1.1 Definitions
Dorland’s Medical Dictionary defines ‘wound’
as “a disruption in the normal continuity of a body structure”. The term ‘wound’, as found in dictionaries and in the commonly accepted ter- minology, usually relates to an acute injury or an acute mechanical trauma, such as a gunshot wound, a stab wound, etc.
The accepted definition of ‘chronic wound’
relates to any wound that fails to heal within a reasonable period. There is no clear-cut defini-
Contents
1.1 Definitions 1
1.2 Three Aspects of Treatment in Wounds and Ulcers 2
1.2.1 Etiology 2
1.2.2 Clinical Appearance of the Ulcer 3 1.2.3 Adjuvant Therapy 3
1.3 Ulcer Depth 3
1.4 Comments on Current Treatments 4 References 4
T he treatment of leg ulcers is gener- ally looked upon as an inferior branch of practice, an unpleasant and unglorious task where much labor must be bestowed, and little honor gained.
(Edinb Med Surg, 1805)
’’
tion that points to the chronicity of a wound.
However, most physicians would agree that a wound that fails to heal within 3–4 months may be regarded as chronic. The estimated time for healing is not arbitrary but depends on factors such as the size of the wound, its cause, and the patient’s general clinical status.
In dermatology, the preferred term for ‘chron- ic wound’ is ‘chronic cutaneous ulcer’. An ulcer, in turn, is defined as a depressed lesion in which the epidermis and at least the upper der- mis have been destroyed [1] (Figs. 1.1, 1.2). An
‘erosion’, on the other hand, is a focal loss of the epidermis without involvement of the dermis (Fig. 1.3).
Note that a cutaneous ulcer is not a primary lesion. An ulcer does not develop de novo, from
Fig. 1.1.Schematic illustration of an ulcer. There is in- volvement of the epidermis and at least part of the der- mis
Basic Definitions and Introduction
1
intact normal skin. It is preceded by another in- itial pathologic lesion, such as a papule or a pustule, from which the ulcer evolves.
1.2 Three Aspects of Treatment in Wounds and Ulcers
In recent years, accumulating knowledge re- garding wound healing processes has led to the development of numerous therapies. A bewil- dering plethora of novel topical preparations, dressing materials, and advanced methods of debridement are now at the hands of physicians and medical personnel. In many cases, even those who specialize in the field of wound heal- ing, such as dermatologists or plastic surgeons, may find it difficult to choose the most appro- priate treatment.
This book places this flood of information and the many modes of therapy currently sug- gested into some order and offers a reasonable approach to the treatment of cutaneous ulcers.
The following chapters put forward a practical and algorithmic therapeutic approach, accord- ing to specific features of the ulcer.
As a rule, the treatment of a cutaneous ulcer is determined by three aspects:
5
Etiology
5
Clinical appearance of the ulcer
5Adjuvant therapy
1.2.1 Etiology
The treatment modality used is directed specifically to the pathologic process which caused the ulceration. For example:
5
Glucocorticoid therapy should be considered when the ulcer is attrib- uted to a vasculitic process or to a certain connective tissue disease. It is often advisable for pyoderma gangrenosum. However, since gluco- corticoids have an inhibitory effect on wound-healing processes, their use is not desirable for other kinds of cutaneous ulcers.
5
In an ulceration diagnosed as caused by leishmaniasis, one may consider applying a topical prepara- tion containing parmomycin. In cas- es of unresponsive or destructive ul- ceration, intravenous pentostam may be considered.
5
Splenectomy may be considered for recalcitrant ulcerations due to he- reditary spherocytosis.
Due to the vast array of diseases and patholog- ic processes characterized by the appearance of cutaneous ulcers, a comprehensive dermatolo-
Chapter 1 Basic Definitions and Introduction 2
1
Fig. 1.2.A cutaneous ulcer. Note that the destruction ex- tends deeper into the epidermis
Fig. 1.3.An erosion that developed following blister rup- ture
t
t
gy textbook would be needed to fully cover each issue. In this book we limit the discussion to the appropriate identification of an ulcer’s cause based on clinical features, histology, and laboratory tests (see Chaps. 5 and 6). A struc- tured diagnostic process is suggested as an al- gorithmic approach.
1.2.2 Clinical Appearance of the Ulcer
The currently accepted classification of cutane- ous ulcers is based on their clinical appearance [2–9]. A practical distinction is made between
‘yellow’, ‘black’, and ‘red’ ulcers. In most cases, the topical therapeutic method to be used de- pends on the ulcer’s clinical appearance.
In Chap. 20, a flow chart is presented for the treatment of cutaneous ulcers, when the ulcer’s clinical appearance is the major determinant regarding choice of topical treatment.
For the time being, there is no evidence that a certain dressing type or a certain method of debridement is more beneficial for a cutaneous ulcer of specific etiology (e.g., venous ulcers or diabetic ulcers).
1.2.3 Adjuvant Therapy
Modalities of adjuvant therapy are those in- tended to improve a patient’s general condition, thereby providing wounds with better healing conditions.
Improvement of a patient’s nutritional status and supplementation of certain nutritional in- gredients, as described in Chap. 19, is applicable here. The treatment of a patient’s other medical problems that can increase the severity of the ulcer can be included in this category. For ex- ample, treatment of congestive heart failure can reduce edema in the lower limbs, allowing en- hanced healing of leg ulcers.
Similarly, hyperbaric-oxygen therapy can be regarded as another mode of adjuvant therapy that may have a beneficial effect on the healing of a large spectrum of cutaneous ulcers. It should always be considered in cases of diffi- cult-to-heal cutaneous ulcers, in which ische- mia is involved in the pathogenesis.
1.3 Ulcer Depth
A further classification of ulcers refers to their depth. Definitions of ulcer staging, based on depth and severity, were originally used for pressure ulcers (Figs. 1.4–1.7). The staging
Fig. 1.4.A stage-I pressure ulcer
Fig. 1.5.A stage-II pressure ulcer
Fig. 1.6.A stage-III pressure ulcer
system was developed with the objective of creating better communication between medi- cal personnel. Obviously, these definitions can be implemented for any other sorts of cutane- ous ulcers as well.
A commonly accepted system was developed in 1987 in the USA by The National Pressure Ulcer Advisory Panel (NPUAP) [10], as fol- lows:
5
Stage I: Blanchable erythema of in- tact skin
5
Stage II: Partial-thickness skin loss involving the epidermis and dermis, presenting clinically as an abrasion
5Stage III: Full-thickness skin loss,
including the subcutaneous layer with extension down to (but not through) the underlying fascia
5Stage IV: Full-thickness skin loss
with involvement of muscle, bone, or other deep structures such as tendons or joint capsules
1.4 Comments on Current Treatments
Accepted modes of treatment are discussed in various chapters of this book, including dress- ing materials, methods of debridement, biolog- ical dressings and skin substitutes, and growth
factors. Other therapeutic measures have not been sufficiently established, thus they cannot be recommended as evidence-based methods in the treatment of cutaneous ulcers for the time being. These are mainly physical thera- peutic modalities such as infrared light, low-en- ergy laser irradiation, ultrasonography, and electrical stimulation. These modalities are not discussed in this book.
As a rule, it is difficult to accurately deter- mine the efficacy of various treatments for cu- taneous ulcers on the basis of current data. Re- searchers have indicated that in some studies, basic information such as history of previous ulceration, ulcer duration, or its appearance, has not been provided [11, 12]. Similarly, other studies have included too small a sample of pa- tients or have not been controlled. Neverthe- less, some idea of the efficacy of current treat- ments may be obtained, allowing a treatment approach to be suggested, as presented in sub- sequent chapters.
References
1. Stewart MI, Bernhard JD, Cropley, Fitzpatrick TB:
The structure of skin lesions and fundamentals of diagnosis. In: Freedberg IM, Eisen AZ, Wolff K, Aus- ten KF, Goldsmith LA, Katz SI (eds) Fitzpatrick’s Dermatology in General Medicine, 6th edn. New York: McGraw-Hill. 2003; pp 11–30
2. Hellgren L,Vincent J: Debridement: an essential step in wound healing. In: Westerhof W (ed) Leg Ulcers:
Diagnosis and Treatment. Amsterdam: Elsevier.
1993; pp 305–312
3. Hellgren L, Vincent J: A classification of dressings and preparations for the treatment of wounds by second intention based on stages in the healing pro- cess. Care Sci Pract 1986; 4 : 13–17
4. Stotts NA: Seeing red and yellow and black. The three- color concept of wound care. Nursing 1990; 20 : 59–61 5. Eriksson G: Local treatment of venous leg ulcers.Ac-
ta Chir Scand [Suppl] 1988; 544 : 47–52
6. Lorentzen HF, Holstein P, Gottrup F: Interobserver variation in the red-yellow-black wound classifica- tion system. Ugeskr Laeger 1999; 161 : 6045–6048.
7. Goldman RJ, Salcido R: More than one way to meas- ure a wound: An overview of tools and techniques.
Adv Skin Wound Care 2002; 15 : 236–243
8. Findlay D: Modern dressings: what to use. Aust Fam Phys 1994; 23 : 824–839
9. Romanelli M, Gaggio G, Piaggesi A, et al: Technolog- ical advances in wound bed measurements. Wounds 2002; 14 : 58–66
Chapter 1 Basic Definitions and Introduction 4
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Fig. 1.7.A stage-IV pressure ulcer. Note that the bone is exposed
t
10. Pressure ulcer prevalence, cost and risk assessment:
consensus development conference statement. The National Pressure Ulcer Advisory Panel. Decubitus 1989; 2 : 24–28
11. Nelson EA, Bradley MD: Dressing and topical agents for arterial leg ulcers (Cochrane Review). In: The
Cochrane Library, issue 1, 2003. Oxford: Update Soft- ware
12. Stephens P, Wall IB, Wilson MJ, et al: Anaerobic coc- ci populating the deep tissues of chronic wounds impair cellular wound healing responses in vitro. Br J Dermatol 2003; 148 : 456–466
