geller podiatry az - ulcer of pg tx by vac

8/14/2019 Geller Podiatry AZ - Ulcer of PG TX by VAC

1/4

Journal of the American Podiatric Medical Association Vol 95 No 2 March/April 2005 171

Pyoderma gangrenosum was first described by Brun-

sting et al1 in 1930. The term pyoderma gangreno-

sum is actually a misnomer, because the lesions arenot infectious or gangrenous.2 The typical lesion is a

vesicle, pustule, or papulopustular lesion that ulcer-

ates to form a wound with characteristic blue-to-pur-

ple undermined borders surrounded by erythema.2, 3

The lesions are usually painful and may appear any-

where on the body; however, they most often arise

on the lower extremities. They vary in that they may

have granular or necrotic wound beds with either

serous or purulent exudates.2-4

Diagnosis and Histopathology

Diagnosis of pyoderma gangrenosum is a diagnosis

of exclusion. There are documented characteristic

histologic findings associated with the disorder; how-

ever, the diagnosis is conferred only when other

pathologic processes such as infection, vasculitic

syndromes, and neoplasia have been ruled out.

Histologically, the lesions vary by site of biopsyfrom central wound polymorphonuclear leukocyte in-

filtration with scattered lymphocytes and epidermal

and papillary dermal necrosis to lymphocytic vasculi-

tis in the peripheral advancing wound margins.2

Thorough examination is required if pyoderma

gangrenosum is suspected, because the diagnosis is

associated with comorbidities in approximately 50%

of cases. The most common associated illness is in-

flammatory bowel disease, followed by rheumatoid

arthritis, seronegative arthropathies, malignancies,

and paraproteinemias.2

Treatment

The treatment of pyoderma gangrenosum is broad

but is primarily targeted at systemic control of the in-

flammatory process. Therapy includes high-dose cor-

ticosteroids or other systemic immunosuppressant

agents including, but not limited to, cyclosporine, cy-

clophosphamide, chlorambucil, and azathioprine.5

Ulceration of Pyoderma Gangrenosum Treated

with Negative Pressure Wound Therapy

Stephen M. Geller, DPM*

James A. Longton, DPM*

Pyoderma gangrenosum is a skin disease characterized by wounds with

blue-to-purple undermined borders surrounding purulent necrotic bases.

This article reports on a patient with a circumferential, full-thickness, and

partially necrotic lower-extremity ulceration of unknown etiology. Results

of laboratory tests and arterial and venous imaging studies were found to

be within normal limits. The diagnosis of pyoderma gangrenosum was

made on the basis of the histologic appearance of the wound tissue after

biopsy as a diagnosis of exclusion. Negative pressure wound therapy wasundertaken, which saved the patients leg from amputation. Although

negative pressure wound therapy has demonstrated efficacy in the treat-

ment of chronic wounds in a variety of circumstances, this is the first doc-

umented use of this technique to treat an ulceration secondary to pyo-

derma gangrenosum. (J Am Podiatr Med Assoc 95(2): 171-174, 2005)

CLINICALLY SPEAKING

*Podiatry Program, Phoenix Baptist Hospital, Phoenix, AZ.

Corresponding author: Stephen M. Geller, DPM, Podia-

try Program, Phoenix Baptist Hospital, 1728 W Glendale, Ste

103, Phoenix, AZ 85021.


2/4

172 March/April 2005 Vol 95 No 2 Journal of the American Podiatric Medical Association

Surgical debridement should be judicious, because

even minor trauma often causes an increase in the de-

structive process, a phenomenon known as pathergy.2-5

Negative Pressure Wound Therapy

Negative pressure wound therapy was first described

in 1997 by Argenta and Morykwas6 and Morykwas et

al7 in porcine animal models and human clinical ex-

perimental trials. The V.A.C., or Vacuum Assisted

Closure, wound therapy system (KCI, Inc, San Anto-

nio, Texas) is a subatmospheric pressure system that

uses foam fit by the applicator to the wound geome-

try. The foam comes in two varieties, Versafoam

(KCI, Inc), a white, hydrophilic, dense polyvinyl-alco-

hol foam that comes packaged in saline and is used

mainly on superficial or extremely painful ulcera-

tions, and a hydrophobic, black polyurethane foam

that has larger open cells that enhance exudate re-

moval. Noncollapsible suction tubing connected to a

vacuum pump is either embedded directly into a slit

cut into the foam by the practitioner or connected to

a TRAC pad (KCI, Inc) sitting on top of two layers of

foam, depending on the type of wound and the V.A.C.

model. The foam dressing and tubing are secured in

place by an adhesive drape to maintain an airtight

seal. Continuous or intermittent (5 min on, 2 min off)

subatmospheric pressure is distributed uniformly

across the wound bed through the open foam cells at

a manually adjusted pressure of 125 to 175 mm Hg

according to the amount of wound drainage. The

dressing offers a closed wound environment, which

requires less frequent dressing changes than tradition-

al wet-to-dry dressings but requires more skill in ap-plication, as the periwound area must be appropriate-

ly protected to avoid maceration from excess wound

fluids.

The physiologic effect of negative pressure wound

therapy on soft tissues is compared to the callus dis-

traction theory or the tension/stress effect on bones.

In vitro and limited in vivo studies have shown that

negative pressure wound therapy may increase local

tissue perfusion, increase the rate of granulation tis-

sue formation, and reduce wound bacterial load.7 It

has also been theorized that negative pressure wound

therapy causes changes in the wound microenviron-

ment by removing interstitial edema and wound exu-date containing substances that may impede wound

healing, including matrix metalloproteinases.8 These

effects are currently being studied to determine

whether they can be substantiated with a significant

number of patients in randomized controlled trials.

Negative pressure wound therapy is also being stud-

ied to determine its efficacy in venous stasis and neu-

ropathic ulcers. The significance of these studies has

not yet been determined.6, 9, 10 The therapy has shown

promise in other uses such as securing skin grafts

after transplantation and for reepithelialization of

donor sites.11, 12

Although negative pressure wound therapy is use-

ful in many clinical situations, it is contraindicated in

certain settings. It should not be used on necrotic tis-

sue with eschar present. Wounds with associated os-

teomyelitis must be treated with appropriate debride-

ment and antibiotic therapy. It is also not appropriate

in the presence of neoplasm because of its effect on

tissue proliferation. Other contraindications include

organ or body cavity fistulas and placement in prox-

imity to vessels.13

Case Report

An otherwise healthy 82-year-old woman presented

to the Wound Care and Hyperbaric Medicine Clinic

at Paradise Valley Hospital, Phoenix, Arizona, by re-

ferral after a 2-month history of a progressively en-

larging, painful ulceration on the posterior aspect of

her right lower extremity. The patient first noticed a

brownish discoloration in the area, which opened a

few days later with a moderate amount of yellowish,

watery exudate. The patient initially applied 1% hydro-

cortisone cream to the wound area, and the wound

grew larger and ulcerated. The patients primary-care

physician then performed a swab culture of the wound

and began administration of oral cephalexin. Local

wound care was managed with triple antibiotic oint-

ment and nonadherent dressing. After 6 weeks of

cephalexin therapy with no improvement, the patientwas referred to a vascular surgeon, who discontin-

ued the cephalexin and prescribed oral ciprofloxacin

and metronidazole. The patient was also prescribed

venous duplex ultrasound and referred to our clinic

for further evaluation.

The patients medical and social histories were

noncontributory, with no chronic illnesses or medi-

cations other than the ciprofloxacin and metronida-

zole. Review of systems revealed no history of de-

pendent edema of the lower extremities, varicose

veins, trauma, prior ulceration, or known insect bites.

The patient had no appreciable foot deformities or

burning, tingling, numbness, weakness, or crampingsensations.

Upon initial evaluation at our clinic, the patients

right lower leg was markedly edematous from the

knee to the toes. The wound was circumferential, ex-

tending from the inferior aspect of the gastrocnemius

muscle belly to just proximal to the malleoli and mea-

suring 15 cm at its greatest width (Fig. 1). There was


3/4


4/4

174 March/April 2005 Vol 95 No 2 Journal of the American Podiatric Medical Association

pletely epithelialized and the patient was fitted for

graduated compression stockings. However, the pa-

tient remains on a low dose of corticosteroids and

continues to be followed by the rheumatologist, who

is considering other immunosuppressive therapies.

Small serous fluidfilled vesicular lesions that contin-

ue to open and close are managed weekly in our clinic

with absorptive and compressive dressings.

Conclusion

Negative pressure wound therapy has demonstrated

efficacy in the treatment of chronic wounds in di-

verse circumstances. Appropriate indication and

contraindication criteria should be evaluated as withany wound treatment algorithm. In this case, a nearly

circumferential lower-extremity wound secondary to

pyoderma gangrenosum was treated successfully

with negative pressure wound therapy using white

polyvinyl-alcohol and then black polyurethane foam.

References

1. BRUNSTING LA, GOECKERMAN WH, OLEARY PA: Pyoderma

(ecthyma) gangrenosum: clinical and experimental ob-

servations in five cases occurring in adults. Arch Der-

matol 22: 655, 1930.

2. BENNETT ML, JACKSON JM, JORIZZO JL, ET AL: Pyoderma

gangrenosum: a comparison of typical and atypical forms

with an emphasis on time to remission: case review of

86 patients from 2 institutions. Medicine 79: 37, 2000.

3. POWELL FC, SCHROETERAL, SU WP, ET AL: Pyoderma gan-

grenosum: a review of 86 patients. Q J Med 55: 173, 1985.4. CALLEN JP: Pyoderma gangrenosum and related disor-

ders. Med Clin North Am 73: 1247, 1989.

5. HAFNER J, TRUEB RM: Management of vasculitic leg ul-

cers and pyoderma gangrenosum. Curr Probl Dermatol

27: 277, 1999.

6. ARGENTA LC, MORYKWAS MJ: Vacuum-assisted closure: a

new method for wound control and treatment: clinical

experience. Ann Plast Surg 38: 563, 1997.

7. MORYKWAS MJ, ARGENTA LC, SHELTON-BROWN EI, ET AL:

Vacuum-assisted closure: a new method for wound con-

trol and treatment: animal studies and basic foundation.

Ann Plast Surg 38: 553, 1997.

8. MORYKWAS MJ, ARGENTA LC: Nonsurgical modalities to

enhance healing and care of soft tissue wounds. J South

Orthop Assoc 6: 279, 1997.9. JOSEPH E, HAMORI CA, BERGMAN S, ET AL: A prospective

randomized trial of vacuum assisted closure versus stan-

dard therapy of chronic nonhealing wounds. Wounds

12: 60, 2000.

10. MCCALLON SK, KNIGHT CA, VALIULUS JP, ET AL: Vacuum-

assisted closure versus saline-moistened gauze in the

healing of postoperative diabetic foot wounds. Ostomy

Wound Management 46: 28, 2000.

11. SCHNEIDER AM, MORYKWAS MJ, ARGENTA LC: A new and

reliable method of securing skin grafts to the difficult

recipient bed. Plast Reconstr Surg 102: 1195, 1998.

12. GENECOV DG, SCHNEIDER AM, MORYKWAS MJ, ET AL: A

controlled subatmospheric pressure dressing increases

the rate of skin graft donor site reepithelialization. Ann

Plast Surg40:

219, 1998.13. MENDES-EASTMAN S: Negative pressure wound therapy.

Plast Surg Nurs 18: 27, 1998.

Figure 3. Appearance of wound 3 weeks after the startof negative pressure wound therapy. Note the emerg-ing skin islands and the absence of necrotic tissue.

Figure 4. Appearance of wound at 31 weeks.

geller podiatry az - ulcer of pg tx by vac

Documents