Cutaneous Lymphoma How to heal your wounds

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1 Cutaneous Lymphoma How to heal your wounds William G. Tsiaras, MD, PhD Instructor, Harvard Medical School Director, Angiogenesis and Wound Healing Center Brigham and Women s Hospital

2 Introduction Wounds are relatively common in patients with cutaneous lymphoma and can have a significant impact on quality of life and risk of infection

3 Outline Fundamentals of modern wound care Moist wound healing Debridement Antimicrobials

4 What is a wound? An alteration in the skin s integrity May be caused by: Injury Disease Surgery Environmental Assault Acute versus chronic wounds

5 History Interest in wound care is not new Sumerian clay tablet from 2200 BC: The three healing gestures -- washing the wounds, making the plasters, and bandaging the wound. Plasters: mixtures of either mud, clay, plants, herbs, oil, milk, or beer Sumerians brewed at least 19 different types of beer for use in wound care Yardley, PA A Brief History of Wound Healing. 1998

6 History Egyptian papyruses from 1650 BC describe how to wash wounds, prepare and apply plaster, and cover with bandages Egyptians made plasters out of grease, honey, and vegetable fiber. Also used green copper based paint on wounds (antibacterial) Egyptians were first to use adhesive bandages Shah JB The History of Wound Care. 2011

7 History Ancient Greeks stressed cleanliness Wash wounds with clean (boiled) water, vinegar solution, or wine For ~2000 years no advance in wound dressings Shah JB The History of Wound Care. 2011

8 Moist Wound Healing In the mid-1900s, state-of-the-art in wound dressings was dry gauze Encouraging wounds to dehydrate and form scab to protect from infection Change to dry healing concept came in 1960 s with studies on moist wound healing

9 Moist Wound Healing Wound Care Education Institute 2009

10 Modern Wound Care Concept of moist wound healing eventually caught on Number of wound care products went from essentially 1 to over 5000 in the last 50 years Advanced wound dressings are associated with increased healing rates, improved cosmesis, reduced pain, reduced infection, and reduced overall costs. Ovington LG Advances in Wound Dressings. 2007

11 Basic Approach to Wound Care Foundation is concept of moist wound healing and dressings that optimize moisture balance Start with wound assessment Goal is using the right product on the right wound at the right time If wound is dry, add moisture. If the wound has drainage, absorb it. If necrotic tissue, debride it.

12 Wound Assessment Necrotic Tissue Necrotic tissue, slough, eschar, scab This material needs to be removed debridement Sharp/surgical Autolytic Enzymatic Hydrotherapy/pulsed lavage Maggot larvae (green bottle fly Lucillia sericata) Mechanical (wet-to-dry)

13 Wound Assessment Moisture Dry wound bed Minimal exudate Moderate to heavy exudate

14 Wound Assessment Moisture Dry wound bed need to add moisture Hydrogel gels, sheets, strips, and gauze forms Water or glycerin based polymer (80-99% water) Hydrates wound, reduces pain, non-adherent

15 Wound Assessment Moisture Minimal exudate need to maintain existing moisture Transparent film dressing Polyurethane or polymer membrane with adhesive Barrier, waterproof, promotes autolytic debridement

16 Wound Assessment Moisture Minimal exudate need to maintain existing moisture Hydrocolloid dressing Mixture of adhesive, absorbent polymers, pectin gelling agents, and sodium carboxymethylcellulose React with exudate to form soft gel over wound Barrier, promotes autolytic debridement, comfort

17 Wound Assessment Moisture Moderately exudative absorb/maintain moisture Hydrofiber Dressings Sodium carboxymethyl cellulose fibers Highly absorbent but interacts with exudate to form gel Promotes autolytic debridement Conforms to wound surface, reduces pain

18 Wound Assessment Moisture Highly exudative wounds need to absorb moisture Foam Dressings Polyurethane foam, highly absorbent, gas permeable Protection for bony surfaces and fragile skin Not for dry wounds

19 Wound Assessment Moisture Highly exudative wounds need to absorb moisture Calcium Alginate Dressings Non-woven fibers of calcium and sodium alginate, a cellulose-like polysaccharide made from seaweed Forms soft gel in contact with wound exudate Can absorb 20 times their weight; autolytic debridement

20 Wound Assessment Infection Patients with cutaneous lymphoma have a unique predisposition to infection Disruption of normal protective skin barrier Immunosuppression secondary to lymphoma and/or local and systemic therapies Axelrod et al, JAMA 1992; Thursky et al, BJH 2005

21 Wound Assessment Infection Bacterial colonization versus true infection? Antimicrobials Antiseptic soaks, cleansers, etc. Topical antibiotics, sliver or iodine based topicals Silver or iodine containing dressings

22 Antiseptics Chlorhexidine Povidone-Iodine Hydrogen peroxide Alcohol - Effective antiseptics - Cytotoxic: impair wound healing

23 Antiseptics Bleach baths - Dilute sodium hypochlorite solution - Effective against fungi, viruses, bacteria - 1 teaspoon household bleach per gallon of water - 1/4-1/2 cup bleach for full bath tub - Soak trunk and extremities for 15 minutes then rinse off Sodium hypochlorite is cytotoxic and impairs wound healing

24 Antiseptics Vinegar soaks - Dilute acetic acid solution - Effective against bacteria (Pseudomonas aeruginosa) - Distilled white vinegar (5-8% acetic acid) - Acetic acid concentrations of 1-5% have been shown to be effective for treatment of chronic wounds infected or colonized with Pseudomonas at acetic acid concentrations of 1-5% - Stinging sensation at higher concentrations, otherwise safe

25 Silver Broad Spectrum Antimicrobial Silver ions kill most pathogenic organisms Effective agent against fungi, viruses, bacteria Silver salts silver sulfadiazine, silver nitrate Can impair wound healing Nanocrystalline silver most modern silver dressings Minimal inhibition of healing

26 Iodine Broad Spectrum Antimicrobial Effective at killing many pathogenic microbes High concentration of free iodine impair wound healing Dressings with slow release of iodine are effective and less toxic to wound healing

27 Wound Thank You Odor Odor is a common concern in patients with wounds Causes Necrotic tissue - remove when possible Bacteria - topical metronidazole 0.75% gel or crushed tablets - silver or iodine based dressings - medical-grade honey based dressings Exudate absorbent dressings - charcoal dressings - foam, alginates, hydrofiber dressings

28 Thank You

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