A. Shai H. I. Maibach
Wound Healing and Ulcers of the Skin Diagnosis and Therapy –
The Practical Approach
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A. Shai
H. I. Maibach
Wound Healing and Ulcers
of the Skin
Diagnosis and Therapy – The Practical Approach
With 115 Figures and 25 Tables
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Dr. Avi Shai
Department of Dermatology Soroka University Medical Center Faculty of Health Sciences
Ben-Gurion University of the Negev Beer-Sheva 84105
Israel
Professor Howard I. Maibach Department of Dermatology University of California
San Francisco School of Medicine Box 0989
San Francisco, CA 94143-0989 USA
Library of Congress Control Number: 2004104389 ISBN 3-540-21275-2 Springer Berlin Heidelberg New York
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcast- ing, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this pub- lication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law.
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In recent years, the amount of knowledge surrounding the processes of wound heal- ing has significantly increased, resulting in a vast array of therapeutic options. The assortment of preparations currently available may become somewhat perplexing to physicians and medical personnel.
We have become aware of the difficulty involved in selecting the most appropri- ate therapy for a specific type of wound. Our main purpose in writing this book, therefore, is to present a step-by-step algorithmic approach to the treatment of chronic wounds.
The caring of wounds has always been the realm of the various branches of sur- gery. Dermatology, on the other hand, being the medical science that specializes in skin and cutaneous physiology, deals with the essential and fundamental aspects of wound healing. Due to its very nature, wound healing overlaps into the many disci- plines of medicine in general. Internists, diabetologists, and geriatricians are be- coming increasingly involved in the field of wound care. General practitioners and family physicians are frequently required to treat acute and chronic wounds.
In this book, we introduce the dermatologic perspective of wound healing which applies to the diagnosis of cutaneous ulcers, based on history, physical examination, biopsy, and laboratory tests. We also present a therapeutic approach to ulcers ac- cording to their appearance.
We believe that this guidebook will assist physicians in the treatment of chronic wounds, and that it will ultimately serve to reduce the immense suffering of those af- flicted.
Note to the Reader.Neither the authors nor the publishers are liable for any con- sequences arising from the use of information presented in this book. The readers are advised to check for up-dated information provided by the manufacturers, including dosage and safety regulations, for each of the products described in this book. Ultimate responsibility rests with the treating physician.
Some of the chapters include lists of commercial names of preparations used in the healing of chronic ulcers. This is by no means intended as a commercial recom- mendation. It is simply intended to provide the readers with a guide to the range of brand names in use for a certain biologic substance. We have done our best to pro- vide up-dated and accurate lists. However, this area is subject to frequent changes, and the readers are advised to gather information from other currently available sources.
Preface
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Acknowledgements
The authors wish to thank the following for providing this book with illustrations and pictures: Dr. Emanuela Cagnano for Figs. 12.1 (modified by Inanit Ashtamker as Fig. 1.1), 2.2, 6.1, 6.3, and 6.6; Dr. Oren Lapid for Figs. 12.3 and 12.4; Dr. David Vigoda for Fig. 12.5; Dr. Tidhar Steiner and the Semmelweis Museum of the History of Med- icine for Figs. 3.5 and 3.6; Dr. Alex Zvulunov for Fig. 4.2; Dr. Kosta Mumcuoglu for Figs. 9.6–9.8; Professor Sima Halevy for Figs. 14.1–14.7; Audra J. Gera and Novartis for Figs. 2.6 and 3.9, from Dermatology: A Medical Artist’s Interpretation, copyright 1990 by Sandoz Pharma LTD; The Wellcome Library, London, for Figs. 3.1–3.4, 3.7, and 8.8; Taylor & Francis Publishing House for Fig. 8.6, reprinted from Jacobsson et al: A new principle for the cleansing of infected wounds. Scandinavian Journal of Plastic & Reconsructive Surgery, 10 : 65–72, 1976; Taylor & Francis Publishing House for Fig. 20.2, reproduced from Handbook of Cosmetic Skin Care, published by Mar- tin Dunitz, 2001. Figure 18.1 is reprinted from T.J. Ryan: Wound healing and current dermatologic dressings. Clinics in Dermatology 8 : 21–29, copyright 1990, with per- mission from Elsevier Science; Fig. 2.5 is reprinted from Germain et al: Human wound healing fibroblasts have greater contractile properties than dermal fibro- blasts. Journal of Surgical Research 57 : 268–273, copyright 1994, with permission from Elsevier Science; Fig. 18.2 is reprinted from Dermatologic Therapy in General Practice, by M. Sulzberger and J. Wolf, (p 116), published by The Year-Book Publish- ers, copyright 1943, with permission from Elsevier Science; Fig. 6.2 is reprinted from Falanga et al: The cutaneous manifestations of cholesterol crystal embolization, Archives of Dermatology 122 : 1194–1198, copyright 1986, with permission from the American Medical Association; Fig. 4.4 is reprinted from S.W. Graeca et al: A painful precursor for necrosis. Postgraduate Medicine 106 : 249–250, copyright 1999, with permission from Postgraduate Medicine (photographed by Scott Dornbaser).
Fig. 6.4 is reprinted from J. Lima-Maribona et al: Self-assessment examination. The American Academy of Dermatology Journal 29 : 803, 1993, with permission from Mosby-Year Book, Inc.; part of Fig. 2.1 is reprinted from CIBA Clinical Symposia on common bleeding disorders, vol 35, no 3, p 8, copyright 1983, with permission from Novartis; part of Fig. 2.1 is taken from Dermatology: A Medical Artist’s Interpreta- tion, copyright 1990 by Sandoz Pharma LTD.
Many thanks are due to the following for their assistance in the preparation of the text and for their valuable comments: Dr. Gary Zentner; Professor Ilana Harman- Bohem; Professor Pablo Yagupsky; Dr. Batya Davidovici; Dr. Marcelo H. Grunwald;
Dr. Dafna Hallel-Halevy; and Dr. Emmilia Hodak. Our particular thanks go to all the reviewers of the chapters in this book for their efforts and assistance (see below); to Professor Sima Halevy, for advancing the field of wound healing in Soroka Uni- versity Medical Center and for actively supporting the production of this book; to Mrs. Rina Ben-Zeev for her assistance in the preparation of the Appendix section of the book and for constructive collaboration at the Chronic Wound Clinic; to Dr.Alex
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Zvulunov and Mr. Naftali Oron for their most valuable ongoing advice stemming from sheer wisdom and clear reason. We would like to especially thank Miss Kristina Hawthorne for contributing her vast experience in the production of books, for her creative ideas, and for her indispensable support and assistance throughout the whole course of this project.
Acknowledgements VIII
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Contents
1 Basic Definitions and Introduction . . . 1
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
2 Natural Course of Wound Repair Versus Impaired Healing in Chronic Skin Ulcers . . . 7
2.1 Overview . . . 7
2.2 Inflammation Phase . . . 8
2.2.1 Vasoconstriction and Hemostasis . . . 8
2.2.2 Vasodilatation and Increased Permeability . . . 9
2.2.3 Chemotactic Growth Factors and Phagocytosis . . . 9
2.3 Tissue Formation Phase . . . . 9
2.3.1 Angiogenesis and Granulation Tissue Formation . . . 9
2.3.2 Extracellular Matrix Formation . . . 10
2.3.3 Re-epithelialization . . . 11
2.3.4 Wound Contraction . . . 11
2.3.5 Role of Nitric Oxide in Wound Healing . . . 12
2.4 Tissue Remodeling Phase . . . 12
2.5 Types of Repair . . . 13
2.6 Chronic Ulcers and Protracted Inflammation . . . . 13
2.6.1 Increased Enzymatic Activity of Matrix Proteases . . . 13
2.6.2 Reduced Responsiveness to Growth Factors . . . 13
2.6.3 Cell Senescence . . . 14
2.7 Concluding Remarks . . . 15
References . . . 15
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Contents X
3 Milestones in the History of Wound Healing . . . 19
3.1 Overview . . . 19
3.2 The Ancient World . . . 19
3.2.1 Medicine in Mesopotamia . . . 20
3.2.2 Ancient Egypt . . . 20
3.3 Inflammation, Infection and the Attitude to Appearance of Purulent Discharge in the Past . . . 21
3.4 Renaissance Era . . . 22
3.5 Antiseptics, Identification of Bacteria and the Use of Antibiotics . . . 23
3.5.1 Ignatz Phillip Semmelweis . . . 23
3.5.2 Joseph Lister . . . 23
3.5.3 Other Researchers . . . 25
3.5.4 Antibiotics . . . 26
3.6 Investigation of Wound Healing Processes . . . 26
3.7 The Significance of a Moist Wound Environment . . . . 26
3.8 Keratinocyte Cultures and Advanced Skin Substitutes . . . 27
3.9 Recent Developments . . . 27
3.10 Future Directions in Wound Healing . . . 27
References . . . 28
4 Etiology and Mechanisms of Cutaneous Ulcer Formation . . . 31
4.1 Overview: Etiologies of Cutaneous Ulcers . . . 31
4.2 Mechanisms of Ulcer Formation . . . 31
4.3 Mechanisms of Formation of Specific Types of Cutaneous Ulcers . . . 36
4.3.1 Ulceration Following Injury/External Damage to the Skin . . . 36
4.3.2 Infections . . . 37
4.3.3 Vascular Disease . . . 41
4.3.4 Leukocytoclastic Vasculitis . . . 44
4.3.5 Connective Tissue and Multisystem Diseases . . . 44
4.3.6 Hypercoagulable States . . . 44
4.3.7 Metabolic Disorders: Diabetes Mellitus . . . 45
4.3.8 Hematologic Abnormalities . . . 47
4.3.9 Nutritional Disorders . . . 48
4.3.10 Other Causes . . . 48
References . . . 48
5 Determining Etiology: History and Physical Examination . . . 53
5.1 Diagnostic Approach: Overview . . . 53
5.2 Incidence by Age: Common Causes of Ulcers in Adults and Children 54 5.2.1 Adults . . . 54
5.2.2 Children . . . 54
5.3 Typical Location of Various Cutaneous Ulcers . . . 56
5.3.1 Lower Legs . . . 56
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Contents XI
5.3.2 Fingers and Toes . . . 59
5.3.3 Soles . . . 59
5.3.4 Facial Ulcers . . . 59
5.3.5 Genital Ulcers . . . 60
5.4 The Ulcer’s Appearance and Its Surroundings . . . 61
5.4.1 The Ulcer’s Margin . . . 61
5.4.2 The Skin that Surrounds the Ulcer . . . 62
5.5 The Primary Lesion from Which the Ulcer Originates . . . . 63
5.5.1 Ulcers Originating from a Plaque or a Nodule . . . 63
5.5.2 Ulcers that May Originate from a Vesicle or a Pustule . . . 63
5.5.3 Erythematous Area that Gradually Darkens . . . 63
5.6 Infectious Ulcers in Various Geographical Areas . . . 64
5.7 Additional Points . . . 65
5.8 Addendum: Details Regarding Venous and Arterial Ulcers . . . 66
5.8.1 Venous Ulcers . . . 66
5.8.2 Arterial Ulcers . . . 67
References . . . 67
6 Determining Etiology: Biopsy and Laboratory Investigation . . . 71
6.1 Overview . . . 71
6.2 A Cutaneous Ulcer in Which the Clinical Diagnosis Is Not Established . . . . 72
6.2.1 Possibilities of Histologic Picture . . . 72
6.2.2 Intravascular Occlusion . . . 72
6.2.3 Vasculitis . . . 76
6.2.4 Other Histologic Patterns . . . 79
6.2.5 Insufficient Histologic Data . . . 80
6.3 A Non-Healing Ulcer . . . 80
6.3.1 The Various Histologic Patterns . . . 80
6.3.2 Histologic Characteristics of Venous Ulcers . . . 80
6.3.3 Histologic Characteristics of Ischemic Ulcers . . . 82
6.3.4 ‘Unexpected’ Histologic Findings in Certain Types of Cutaneous Ulcers . . . 82
6.4 Suspected Malignancy . . . 82
6.4.1 When Should Malignancy Be Suspected? . . . 82
6.4.2 Epithelioma as a Primary Lesion . . . 83
6.4.3 Epithelioma Developing in a Long-Standing Cutaneous Ulcer . . . 83
6.5 An Ulcerated Nodule or Plaque . . . . 84
6.5.1 Ulcers Developing Within a Nodule or a Plaque . . . 84
6.5.2 Granulomatous Histologic Pattern . . . 84
6.5.3 Seeking an Infectious Cause . . . 84
6.6 Pyoderma Gangrenosum . . . 85
References . . . 86
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Contents XII
7 Ulcer Measurement and Patient Assessment . . . 89
7.1 Introduction . . . 89
7.2 Ulcer/Wound Measurements . . . 90
7.2.1 Precise Anatomic Site . . . 90
7.2.2 Measurement of the Ulcer Area . . . 91
7.2.3 Assessment of Depth . . . 93
7.2.4 Undermining . . . 94
7.2.5 Measurement in Cases of Infection or Suspected Infection . . . 94
7.2.6 Appearance of the Ulcer Surface and Spectrophotometry . . . 95
7.3 Patient Assessment . . . . 95
7.3.1 General . . . 95
7.3.2 Nutritional Deficits . . . 96
7.3.3 Drugs . . . 96
7.3.4 Edema . . . 96
7.3.5 Other Factors to Be Considered . . . 98
7.4 Summary Tables . . . 100
References . . . 100
8 Dressing Materials . . . 103
8.1 Overview . . . 103
8.2 Traditional Dressings: Non-Resorbable Gauze/Sponge Dressings . . . 103
8.3 Development of Advanced Dressing Modalities . . . 104
8.4 Features of Dressings . . . 104
8.4.1 Transparency . . . 104
8.4.2 Adhesiveness . . . 105
8.4.3 Form of Dressing . . . 105
8.4.4 Absorptive Capacity . . . 105
8.4.5 Permeability/Occlusiveness . . . 105
8.4.6 Antimicrobial Effect . . . 106
8.5 Advanced Dressing Modalities . . . 106
8.5.1 Occlusive Dressings: Films, Hydrocolloids, Foams . . . 106
8.5.2 Hydrogels . . . 110
8.5.3 Hydrophilic/Absorptive Dressings . . . 111
8.6 Other Types of Dressings . . . 114
8.6.1 Dressings Combining Two of the Above Groups . . . 114
8.6.2 Interactive Dressings . . . 114
8.6.3 Dressings with Unique Features . . . 115
8.6.4 Biological Dressings . . . 115
8.7 Summary . . . 115
References . . . 116
9 Debridement . . . 119
9.1 Definition of Debridement . . . 119
9.2 Appearance of Necrotic Material on an Ulcer’s Surface . . . 119
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Contents XIII
9.3 Why Should Ulcers Be Debrided? . . . 120
9.4 Methods of Debridement . . . 121
9.4.1 Surgical Debridement . . . 122
9.4.2 Mechanical Debridement . . . 125
9.4.3 A Variant of Mechanical Debridement: Absorptive Debridement . . . . 126
9.4.4 Chemical Debridement . . . 127
9.4.5 Autolytic Debridement . . . 129
9.4.6 Maggot Therapy . . . 129
9.5 Disadvantages of and Contraindications to Debridement: Final Comments . . . 131
9.6 Summary . . . 131
References . . . 132
10 Antibiotics, Antiseptics, and Cutaneous Ulcers . . . 136
10.1 Overview: Detrimental Effects of Bacteria on Wound Healing . . . 136
10.2 Antibiotics and Antiseptics: Definitions and Properties . . . 136
10.3 Infected Ulcers, Clean Ulcers, and Non-Healing ‘Unclean’ Ulcers . . . . 137
10.3.1 Infected Ulcers . . . 137
10.3.2 Clean Ulcers . . . 138
10.3.3 The Broad Spectrum Between Clean Ulcers and Infected Ulcers . . . 138
10.3.4 Non-Healing ‘Unclean’ Ulcers . . . 139
10.4 Systemic Antibiotics for Cutaneous Ulcers . . . 139
10.4.1 General . . . 139
10.4.2 Clinical Studies . . . 140
10.4.3 Arguments Against the Use of Systemic Antibiotics for Non-Healing ‘Unclean’ Cutaneous Ulcers . . . 140
10.4.4 Arguments Supporting the Use of Systemic Antibiotics for Non-Healing ‘Unclean’ Cutaneous Ulcers . . . 141
10.5 Topical Preparations for Infected Cutaneous Ulcers and ‘Unclean’ Ulcers . . . 141
10.5.1 Topical Antibiotics . . . 142
10.5.2 Topical Antiseptics . . . 142
10.5.3 Allergic Reactions to Topical Antibiotics and Antiseptics . . . 143
10.5.4 When to Consider the Use of Antiseptics or Topical Antibiotic Preparations . . . 143
10.6 Guidelines for the Use of Topical Antibiotics and Antiseptic Preparations in the Management of Cutaneous Ulcers 144 10.6.1 Avoid Toxic Antiseptics . . . 144
10.6.2 Base Selection of Antibiotics on Clinical Grounds . . . 144
10.6.3 Consider Carefully the Type of Antibiotic Preparation . . . 144
10.6.4 Take a Careful History Regarding Allergic Reactions . . . 145
10.6.5 Avoid Spreading Infection . . . 145
10.6.6 Cleanse and Debride the Ulcer . . . 145
10.6.7 Final Comment . . . 145
10.7 Addendum A: Collection and Identification of Pathogenic Bacteria . 145 10.7.1 Swabbing . . . 145
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Contents XIV
10.7.2 Deep-Tissue Biopsy . . . 146
10.7.3 Needle Aspiration . . . 146
10.7.4 Curettage . . . 146
10.7.5 Conclusion . . . 146
10.8 Addendum B: Biofilms . . . 147
References . . . 147
11 Topical Antibacterial Agents . . . 151
11.1 Overview . . . 151
11.2 Oxidizing Agents . . . 151
11.2.1 Hydrogen Peroxide . . . 151
11.2.2 Potassium Permanganate . . . 152
11.3 Iodines . . . 152
11.3.1 Povidone-Iodine . . . 152
11.3.2 Other Iodine Compounds . . . 153
11.4 Chlorines . . . 153
11.5 Silver . . . 154
11.5.1 General Comments . . . 154
11.5.2 Silver Sulfadiazine . . . 154
11.6 Other Antiseptics . . . 155
11.6.1 Antiseptic Dyes . . . 155
11.6.2 Burow’s Solution . . . 156
11.7 Conclusion . . . 156
References . . . 156
12 Skin Grafting . . . 159
12.1 Introduction . . . 159
12.2 Split-Thickness Skin Graft and Full-Thickness Skin Graft . . . 160
12.3 Preparing a Cutaneous Ulcer for Grafting . . . 160
12.4 Forms of Autologous Grafting . . . 161
12.5 Conclusion . . . 162
References . . . 163
13 Skin Substitutes and Tissue-Engineered Skin Equivalents . . . 165
13.1 Overview . . . 165
13.2 ‘Non-Living’ Skin Substitutes . . . 165
13.2.1 General Functions . . . 165
13.2.2 Allogeneic Cadaver Skin . . . 165
13.2.3 Xenografts . . . 166
13.2.4 Naturally Occurring Collagen Matrix and Collagen-Containing Dressings . . . 166
13.2.5 Conclusion . . . 168
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Contents XV
13.3 ‘Living’ Skin Substitutes . . . 168
13.3.1 General . . . 168
13.3.2 Epidermal: Keratinocyte Grafts . . . 169
13.3.3 Dermal Grafting . . . 172
13.3.4 Composite Grafts . . . 172
13.4 Summary . . . 173
References . . . 174
14 Human Skin Equivalents: When and How to Use . . . 177
14.1 General Structure and Mechanism of Action . . . 177
14.2 Product Description . . . 178
14.2.1 Apligraf . . . 178
14.2.2 OrCel . . . 178
14.3 Indications . . . 178
14.4 Instructions for Use . . . 179
14.4.1 Preparing the Ulcer Bed . . . 179
14.4.2 Steps to Take Prior to Applying the Product to the Ulcer Bed . . . 179
14.4.3 Grafting Procedure . . . 180
14.4.4 Dressing the HSE Layer . . . 180
14.4.5 Following Grafting . . . 180
14.5 Contraindications . . . 181
14.6 Efficacy . . . 181
14.7 Concluding Remark . . . 181
References . . . 183
15 Growth Factors . . . 185
15.1 Overview . . . 185
15.2 What Are Growth Factors? . . . 185
15.3 Beneficial Effects of Growth Factors on Acute Wounds and Chronic Cutaneous Ulcers . . . 186
15.4 Recombinant Human Platelet-Derived Growth Factor: rhPDGF (Becaplermin) . . . 186
15.5 Research Studies Using Recombinant Human PDGF . . . 187
15.6 PDGF: Indications and Contraindications . . . 187
15.7 Mode of Using PDGF Gel Preparation . . . 188
15.8 Topical Use of Other Growth Factors . . . 188
15.8.1 Granulocyte-Macrophage Colony-Stimulating Factor . . . 189
15.8.2 Epidermal Growth Factor . . . 189
15.9 Anti-Infective Effects of Growth Factors . . . 190
15.10 Summary and Future Research . . . 190
References . . . 190
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Contents XVI
16 Drugs, Wound Healing and Cutaneous Ulcers . . . 193
16.1 Overview . . . 193
16.2 Ulceration at the Injection Site . . . 194
16.2.1 Injections for Therapeutic Purposes – Subcutaneous or Intramuscular . . . 194
16.2.2 Injection for Therapeutic Purposes – Extravasation . . . 196
16.2.3 Accidental Injections . . . 196
16.2.4 Drug Abuse . . . 196
16.2.5 Self-Inflicted Ulcers . . . 197
16.3 Direct Cutaneous Exposure . . . 198
16.4 Systemic Drugs that Directly Induce Ulceration . . . 198
16.4.1 Causing or Aggravating Certain Diseases . . . 198
16.4.2 Induction of Vasculitis . . . 199
16.4.3 Vasospasm . . . 199
16.4.4 Drugs Affecting Coagulability . . . 199
16.4.5 Drugs Causing Bullae . . . 200
16.4.6 Unidentified Mechanisms . . . 200
16.5 Interference with Normal Mechanisms of Wound Healing . . . 200
16.5.1 Glucocorticoids . . . 201
16.5.2 Non-Steroidal Anti-Inflammatory Drugs . . . 202
16.5.3 Anti-Neoplastic and Immunosuppressive Drugs . . . 202
16.5.4 Other Drugs that Interfere with Healing . . . 202
16.6 Drugs that Adversely Affect Skin Quality . . . 202
16.6.1 Leg Edema . . . 202
16.6.2 Skin Atrophy or Scleroderma-Like Reactions . . . 203
References . . . 203
17 Alternative Topical Preparations . . . 209
17.1 Overview . . . 209
17.2 Herbal and Traditional Home Remedies . . . 210
17.2.1 Aloe Vera . . . 211
17.2.2 Calendula . . . 211
17.2.3 Other Herbal Extracts . . . 211
17.2.4 Balsam of Peru . . . 212
17.2.5 Clay . . . 212
17.3 Honey . . . 212
17.3.1 General . . . 212
17.3.2 Mode of Action: Why Does Honey Have a Beneficial Effect? . . . 212
17.3.3 Research . . . 213
17.3.4 Mode of Use . . . 214
17.3.5 Summary . . . 214
17.4 Conclusion . . . 214
References . . . 214
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Contents XVII
18 Additional Topical Preparations . . . 217
18.1 Overview . . . 217
18.2 Vitamins and Trace Elements . . . 217
18.2.1 Topical Vitamin A and Derivatives . . . 217
18.2.2 Topical Zinc . . . 218
18.3 Scarlet Red . . . 219
18.4 Hyaluronic Acid Derivatives . . . 220
18.5 Biafine® . . . 220
References . . . 221
19 Nutrition and Cutaneous Ulcers . . . 223
19.1 Overview . . . 223
19.2 Malnutrition . . . 223
19.2.1 Assessment of Nutritional Status . . . 224
19.2.2 Protein Depletion . . . 224
19.2.3 Supplementation of Amino Acids . . . 225
19.2.4 Caloric- and Lipid-Deficient States . . . 225
19.2.5 Practical Conclusions . . . 226
19.2.6 Maintaining Appropriate Hydration . . . 226
19.2.7 Specific Types of Ulcers Directly Associated with Malnutrition . . . 226
19.3 Vitamins . . . 226
19.3.1 Vitamin A . . . 228
19.3.2 Vitamin C . . . 230
19.3.3 Vitamin E . . . 231
19.4 Trace Elements . . . 231
19.4.1 Zinc . . . 231
19.4.2 Iron . . . 233
19.4.3 Other Vitamins and Trace Elements . . . 233
19.4.4 Vitamin and Trace Element Supplementation in Patients with Cutaneous Ulcers . . . 234
19.5 Summary . . . 234
References . . . 235
20 Therapeutic Approach to Cutaneous Ulcers According to Appearance . . . 241
20.1 Overview . . . 241
20.2 Secreting ‘Yellow’ Ulcers . . . 242
20.2.1 Ulcers with Profuse and/or Purulent Secretion . . . 242
20.2.2 Ulcers with Mild to Moderate Secretion . . . 242
20.2.3 Additional Comments . . . 244
20.3 Dry ‘Black’ Ulcers . . . 244
20.4 ‘Sloughy’ Ulcers . . . 245
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Contents XVIII
20.5 Clean ‘Red’ Ulcers . . . 247
20.5.1 Ulcers Advancing Towards Healing . . . 248
20.5.2 ‘Stagnant’ Ulcer . . . 248
20.6 ‘Unresponsive’ Ulcers . . . 249
20.7 ‘Mixed’ Ulcers . . . 250
20.8 Additional Comments . . . 250
20.9 Treating Hypergranulation Tissue . . . 250
20.10 Addendum: Dressings that Apply Topical Negative Pressure . . . 251
References . . . 252
21 Appendix: Guidelines for Patients and Medical Staff . . . 255
21.1 General Patient Guidelines for Treatment of Ulcers or Wounds at Home . . . 255
21.2 Patient Guidelines for the Management of Skin Ulcers Caused by Venous Insufficiency . . . 256
21.3 Patient Guidelines for the Management of Skin Ulcers Caused by Diabetes or Peripheral Arterial Disease . . . 256
21.4 Treatment of Edema . . . 257
References . . . 257
21.5 Guidelines for Nurses: Outpatient Management of Cutaneous Ulcers 258 References . . . 259
Subject Index . . . 261
List of Products . . . 269
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List of Reviewers
Natural Course of Wound Repair versus Impaired Healing in Chronic Cutaneous Ulcers
Theodora Mauro, MD
Associate Professor in Residence and Vice-Chairman Department of Dermatology
University of California, San Francisco Service Chief, Dermatology
San Francisco Veteran’s Hospital San Francisco, California USA
Milestones in the History of Wound Healing David T. Rovee, PhD
Cambridge, MA USA
Etiology and Mechanisms of Cutaneous Ulcer Formation Jürg Hafner, MD, PD
Dermatology, Vascular Medicine, Phlebology, Dermatologic Surgery Senior Staff Member
Department of Dermatology University Hospital of Zürich Zürich
Switzerland
Determining Etiology: History and Physical Examination Irwin M. Braverman, MD
Professor of Dermatology Department of Dermatology Yale Medical School
New Haven, CT USA
Determining Etiology: Biopsy and Laboratory Investigation Robert S. Kirsner, MD
Department of Dermatology and Cutaneous Surgery Department of Epidemiology and Public Health University of Miami School of Medicine Veterans Administration Medical Center Miami, Florida
USA
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List of Reviewers XX
Ulcer Measurement and Patient Assessment Marco Romanelli, MD, PhD
Consultant Dermatologist Department of Dermatology University of Pisa
Pisa Italy
Dressing Materials Marketa Limova, MD Associate Clinical Professor Wound and Ulcer Clinic
University of California, San Francisco San Francisco, CA
USA
Debridement
William H. Eaglstein, MD Harvey Blank Professor
Department of Dermatology and Cutaneous Surgery University of Miami School of Medicine
Miami, FL USA
Antibiotics, Antiseptics and Cutaneous Ulcers Keith G. Harding, MD MB ChB MRCGP FRCS
Professor of Rehabilitation Medicine (Wound Healing) Head of Department of Surgery
Wound Healing Research Unit
University of Wales College of Medicine Cardiff
UK
Topical Antibacterial Agents Raza Aly, PhD
Professor of Dermatology and Microbiology Department of Dermatology
University of California San Francisco, CA USA
Skin Grafting I. Kelman Cohen, MD Emeritus Professor
Plastic and Reconstructive Surgery Virginia Commonwealth University Health Science Center
Richmond, Virginia USA
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List of Reviewers XXI
Skin Substitutes and Tissue-Engineered Skin Equivalents Tania J. Phillips, MD FRCPC
Professor of Dermatology
Boston University School of Medicine Department of Dermatology
Boston, MA USA
Growth Factors Martin C. Robson, MD Emeritus Professor of Surgery Department of Surgery
University of South Florida, Tampa Florida
USA
Drugs, Wound Healing and Cutaneous Ulcers Sima Halevy, MD
Professor of Dermatology Ben-Gurion University
Chairman, Department of Dermatology Soroka University Medical Center Beer Sheva
Israel
Nutrition and Cutaneous Ulcers Nancy Collins, PhD, RD, LD/N Nutrition Guidance Center Pembroke Pines
Florida USA
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