Skin Ulcers in the elderly

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Skin Ulcers in the elderly

• An introduction for IM residents

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Objectives

• At the end you will be able to
• identify the common causes of ulcers
• optimize the healing environment
• identify appropriate patients for the CCAC Ulcer
  team protocol
• choose a dressing appropriate to the wound

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Sorting out the differential

• Decubitus
• vascular
• venous
• arterial
• diabetic
• neuropathy
• vascular

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Sorting out the differential

• Trauma
• medications
• steroids, IV antibiotics
• malignancy
• infection
• surgical

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Buns of .
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A heel on Connell 3?
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Recognizing malignant ulcers
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A harder to miss one...
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Ulcers you dont see often
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What will make all of these causes worse?

• Edema
• anemia (Hb lt100 will NEVER heal)
• infection
• nutrition
• ?? Role of supplementation
• arterial insufficiency

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Defining an infected ulcer
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Looking at the more common causes

• Venous ulcers
• accounts for 75 of lower extremity ulcers
• occur on medial malleolus
• associated with eczema, edema, weeping
• lipodermatosclerosis in end-stage
• often remarkably painless

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Shame about the face
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The impact of being an biped
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Problems with the carbon-based biped
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Fitting the golden slipper
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More venous problems
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Dont try this at home
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What are local resources for this?

• Compression, compression, compression
• elevation
• education
• CCAC ulcer protocol
• Dr. Bayoumi

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Get the pressure off!

• Common in KGH and LTC
• common over bony prominences
• if found in unusual location, R/O other cause
• OT and Claire Westendorp are allies

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Where are they found?
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Yucky diabetic feet

• Autonomic chances
• foot shape change
• nail care footwear
• dry skin
• sensory changes
• PVD

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A classic diabetic ulcer
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Heres one to prevent
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Preventing diabetic ulcers
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How should you approach ulcers?

• DDx, staging and assessment of exacerbants
• get pressure off!
• adequate debridement
• moist wound healing
• appropriate dressing choice
• prevent injury to the healing wound

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Staging the wound

• I non-blanchable erythema lastinggt 30 min
• II partial thickness involving epidermis and/or
  dermis
• III full thickness involving down to fascia
• IV full thickness involving muscle, bone etc

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This is the bottom to remember
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Staging the wound

• Inflammatory early wound with lots of exudate
• Proliferative granulation, wound contraction,
  epithelialization
• Maturation tensile strength increases (50 by 3
  weeks, up to 75)

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Debriding the wound

• Caution with PVD, poor nutrition, low protein
• options include
• surgical
• mechanical
• chemical
• autolytic

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Choosing a dressing

• Clarify goal
• clarify stage and healing phase
• emphasize moist wound healing
• think of cost and equipment needs

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Looking at the ideal dressing
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What are the options?

• transparent film (Opsite , Tegaderm)
• Foam dressings (Allevyn, Curafoam)
• Hydrogels (Intrasite)
• Alginates (Algisite, Kaltostat)
• Saline dressings (wet to dry)
• Hypertonic Saline (Mesalt)
• Hydrocolloid (Duoderm, Tegasorb)

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Wheres the evidence?

• Refer to CCAC protocol
• Mostly B and C
• little RCT evidence for Vit C, E, Zinc
• do not use swabs for culture (C)

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Summary

• DDX and optimization of healing environment
• adequate debridement
• appropriate dressing for situation
• identify local expertise and resources