medical comorbidities and their impact on wound healing

MEDICAL COMORBIDITIES
AND THEIR
IMPACT ON WOUND HEALING
Lee C. Ruotsi, MD, CWS, UHM
Wound Care is Only
Part of the Story…
Success Depends on How
You Manage the Rest of the
Patient’s Problems
2
HEMOSTASIS
INFLAMMATION
PROLIFERATION
REMODELING
Damaged vessels
constrict to slow
blood flow. Platelets
aggregate to stop
bleeding.
Leukocytes
migrate into tissue
to initiate
inflammatory
process.
3
Neutrophils
secrete chemicals
Fibroblasts proliferate
to kill bacteria.
In the wound and
Macrophages
Secrete glycoproteins
engulf and digest
and collagen. Epidermal
foreign particles and
Cells migrate from the
necrotic debris.
wound edge.
Macrophages
Granulation tissue is
release angiogenic
formed from
substances
macrophages,
to stimulate capillary
fibroblasts and new
growth and
capillaries.
granulation tissue.
Fibroblasts secrete
collagen to
strengthen wound.
Wound
remodeling occurs to
reorganize
fibers. Wound
contracts increasing
tissue integrity.
Epidermal cells grow
over connective
tissue to close
wound.
Hemostasis
4
Inflammatory
5
Proliferative
6
Remodeling
7
Abnormal Wound Healing

Failure to progress through normal orderly
stages of wound healing in a timely fashion

Chronicity has been defined by failure to
progress to closure over a 90 day period.

Chronicity may also be defined by wound
characteristics
Mustoe TA, O'Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current
treatment strategies: a unifying hypothesis. J Plast Reconstr Surg. 2006;117:35-41
8
The Chronic Wound

Has failed to proceed through and orderly and
timely process to produce anatomical and
functional integrity, or proceeded through the
repair process without establishing a sustained
anatomic and functional result.
Robson MC, Barbul A. Guidelines for the best care of chronic wounds.
Wound Repair and Regeneration. Volume 14, Issue 6, pp 647 – 648, Nov 2006
9
The Chronic Wound



10
Out of control inflammatory response that is self-sustaining
Equilibrium between synthesis and degradation has been
shifted
Visually: inadequate granulation, persistent or excessive
exudate, deficient wound contraction and/or absence of
neo-epithelialization
Menke N, Ward K, Witten T, Bonchev D, Diegelman R. Impaired Wound Healing Clinics in Dermatology (2007) 25:19-25
“A chronic wound is an acute wound
with an impediment”
T.K Hunt, M.D.
“The impediment may be the treating
physician”
Harriett Hopf, M.D.
11
12
Systemic Co-morbidities

13
Vasculitis
Rheumatoid disease
Lupus (SLE)
Scleroderma
Wegener’s
Granulomatosis
Polyarteritis Nodosa






Diabetes
Polycythemia Vera
Renal failure
Chemotherapy
Radiation
Pyoderma
Gangrenosum
Good H&P




HPI – Wounding
PMH
PSH
Past wounding hx
Etiology
Location
Treatment
Response
14




Meds
Family hx
ROS
Thorough exam
Skin
Wounding
Vascular supply
Infection
General Appearance

Cushingoid (puffy) appearance

Rheumatoid joints

Cachexia

Scleroderma skin
General Appearance

Abnormal affect and behavior

Focal neurologic deficit

Tobacco
Diabetes
Cell
Membrane
Tissue
Compliance
A.G.E.’s
DIABETES
WBC
Function
Neuropathy
Angiogenesis
17
Ischemia
18
Motor Neuropathy

Anterior tibial weakness

Pedal muscle atrophy

Fat pad atrophy

Increased peak pressures

Ulcerations over deformities
19
Khan K, Derksen T, Steinberg J in Wound Care Practice 2nd Ed. Sheffield P, Fife C (eds) Volume 1, pp. 407-424
Sensory Neuropathy





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Diabetic sensory
polyneuropathy
Peri-nerve edema
Increased wounding risk
due to L.O.P.S.
Unable to feel pressure
or pain
Ulcerations develop without
knowledge
Khan K, Derksen T, Steinberg J in Wound Care Practice 2nd Ed.
Sheffield P, Fife C (eds) Volume 1, pp. 407-424
Autonomic Neuropathy

Faulty sweat gland activity

Dry, fissured skin leads to
infection and ulceration

Uncontrolled vasodilatation
due to decreased arteriolar
tone
21
Autoimmune Disorders







22
Rheumatoid Arthritis
Crohns Disease
Pernicious Anemia
Ulcerative Colitis
Antiphospholipid Syn.
Graves Disease
Wegener’s
Granulomatosis







Psoriasis
Systemic Lupus
Polymyositis
Dermatomyositis
Ankylosing
Spondylitis
Sjogren’s Syndrome
Autoimmune
Hemolytic anemia
Autoimmune Mechanism




23
Protective component of immune system mounts
attack on normal structures
75% women of childbearing age
Auto-antibodies generated against normal body
structures or abnormal materials deposited on
normal structures
Auto-antibodies may be continuously, intermittently
or transiently produced, determining temporal
nature of process
Smith AP. Etiology of the problem wound. In: Sheffield PJ, Fife CE. (eds) Wound Care Practice 2nd edition,
Volume 1. Best Publishing Co. 3 - 50
Rheumatoid Disease

Systemic autoimmune disorder of unknown etiology

Leg ulcerations in 8 – 9% of patients

Ulcer is smooth, irregularly shaped and painful

Felty’s Syndrome; Combination of RA,
splenomegaly, granulocytopenia and leg ulcers
24
JB Shah. Approach to Commonly Misdiagnosed Wounds and Unusual Leg Ulcers.
In: Sheffield PJ, Fife CE (eds) Wound Care Practice 2nd Edition Volume 1. Best Publishing Co. Pp. 581 - 601
Rheumatoid Disease

Systemic Treatment: High dose steroids,
cyclophosphamide, Dapsone, disease
modifying agents

Wound treatment: Standard wound care,
bioengineered skin, growth factors
25
Rheumatoid Leg Ulcers
26
Systemic Lupus (SLE)






27
Systemic autoimmune disease of unknown etiology
Well defined margins with purulent wound bed and
varying granulation
Surrounding skin normal or erythematous with atrophie
blanche
Leg ulcer prevalence approx. 2%
Commonly in pre-tibial areas and painful
Treatment challenging – systemic and intra-lesional
steroids and topical retinoic acid
JB Shah. Approach to Commonly Misdiagnosed Wounds and Unusual Leg Ulcers.
In: Sheffield PJ, Fife CE (eds) Wound Care Practice 2nd Edition Volume 1. Best Publishing Co. Pp. 581 - 601
Lupus Related Leg Ulcer
28
Scleroderma (C.R.E.S.T.)




29
Autoimmune disorder of
unknown etiology
Ulcers usually over digits,
pre-tibial area and bony
prominences
Subcutaneous calcification
makes epithelialization
difficult
Occlusive dressings and
moist wound care
JB Shah. Approach to Commonly Misdiagnosed Wounds and Unusual Leg Ulcers.
In: Sheffield PJ, Fife CE (eds) Wound Care Practice 2nd Edition Volume 1. Best Publishing Co. Pp. 581 - 601
Polycythemia Vera

Increased production of
RBC’s by bone marrow

Genetic mutation –
men > women

Treatment:
Phlebotomy
Hydroxyurea (problem)
30
www.mayoclinic.org/diseases-conditions/polycythemia-vera
Wegener’s Granulomatosis




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Rare disease of uncertain
cause
Inflammatory process
primarily affecting upper
resp. tract and kidneys
Can cause vasculitis
leading to wound healing
problems
Suspicion = testing
(ANCA)
www.medicinenet.com/wegeners_granulomatosis/article.htm
Cryoglobulinemia




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Abnormal proteins in
blood which thicken when
exposed to cold
Types I, II, III (mixed)
Protein antibodies thicken
and occlude capillaries
leading to skin wounding
and necrosis
II and III associated with
other autoimmune
conditions
www.vasculitisfoundation.org/education/forms/cryoglobulinemia/
Raynaud’s






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Intermittent, severe ischemia of
fingers/toes
Sympathetic vasoconstriction
Soft-tissue atrophy and
ulceration
Precipitated by cold or localized
trauma
Vasodilators, anti-platelet
agents, rheologics, PD-5
inhibitors. (Nifedipine)
Moist wound care
Goundry B, Diagnosis and Management of Raynauds Phenomenon.
BMJ 2012 : 344:e289
Vasculitis




34
Inflammation of blood
vessels of unknown
etiology
Thrombosis of capillaries
leading to local tissue
hypoxia
Prevalent in elderly
Male = female
American College of Rheumatology
www.rheumatology.org
Vasculitis





Flat, red nodules
macules or purpura
Lesions frequently
ulcerate and are difficult
to heal
Biopsy for diagnosis
Moist wound care
Anti-platelet agents and
steroids
35
Factor V Leiden Mutation





36
Protein C resistance
Increased risk of
thrombosis, venous >
arterial
Progressive thrombotic
occlusion leads to poor
venous outflow
Venous ulcers as result
Multilayer compression
and moist wound care
Lee P, Prasad K in International journal of Lower Extremity Wounds,
Mani R, Ed. Pp 4 - 12
Sickle Cell Disease




37
RBC’s sickle or crescent
shaped rather than
spherical
Capillary occlusion leads
to skin hypoxia and
ulceration
Autosomal recessive leads to trait or disease
Characterized by painful
crises
Armstrong DG, Meyr AJ. Wound Healing and Risk Factors for Non-healing
Up-To-Date 2014
Renal Failure






Calciphylaxis rare and life-threatening
Annual incidence is 1% in ESRD patients
Female 3:1
Microvascular calcification, thrombosis and
occlusion lead to necrosis and gangrene
Parathyroidectomy of some benefit but
prognosis remains poor and mortality high
HBO may be of benefit
Budisavijevic M, et al. Calciphylaxis in Chronic renal Failure. J. Am.
Soc. Nephrology 1996; 7: 978-982
38
Protein Energy Malnutrition


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



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39
Insidious onset. May be rapid.
Elderly and lower socioeconomic groups at risk
Good food is more expensive than bad food
Hyperglycemia delays wound healing
Multiple supplements and interventions
Early diagnosis important
Prealbumin and Transferrin good markers
Nutrition/dietary consultation
Possinger C. Nutrition & Wound Care – From Treatment to Prevention.
Catholic Medical Partners (CMP) IPA April, 2014
ABC’s of Nutrition Assessment
40
A. Anthropometrics:
Height, weight, skinfolds
B. Biochemical:
alb, pre-alb, transferrin, TLC,
minerals, BUN/Cr, hgb, hct
C. Clinical Signs:
Skin – pale, dry, scaly, swollen
Hair – thin, dull, changed texture
Eyes – sunken, scleral yellowing
Mouth – cheilosis, tongue color,
missing teeth,
gums
D. Dietary:
Calorie counts, % of consumption
Knox TA, et al. Clin Inf ect Dis. (2003) 36 (supplement 2) pp. 63 - 68
Protein & Energy Stores
41
Demling RH, Nutrition, Anabolism and the Wound Healing Process
An overview. ePlasty; 2009-9
Loss of
Lean Mass
10% loss
20% loss
30% loss
Muscle
Wound
42
Barbul and Kavalukas. Nutrition and Wound Healing, an Update
Plast. Reconstr. Surg. 2011; 127
Aging




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43
↑ Life expectancy
Skin is largest organ we have
Thinning of dermis and basement membrane
↓ density of vascularity and nerves
↓ amount of collagen and ability to produce
collagen
Multiple comorbidities
Cheung C, Older Adults and Ulcers. Chronic Wounds in the Geriatric Population
Advances in Skin and Wound Care. January 2010, Vol. 23, No. 1 pp 39-44
Aging







44
↓ Growth factors
↓ Epithelialization
↓ Angiogenic activity
↑ Multiple meds
↓ mobility and ↑ falls
↑ in mood disorders
↓ percentage of closed
wounds in elderly by 25%
as compared to younger
population
Cheung C, Older Adults and Ulcers. Chronic Wounds in the Geriatric Population
Advances in Skin and Wound Care. January 2010, Vol. 23, No. 1 pp 39-44
3/28/13
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8/26/13
Medications
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Systemic Steroids
NSAIDS
Methotrexate
Heparin
Hydroxyurea
Amlodipline/Nifedipine
Warfarin
Select chemotherapeutics
Povidone
Smith RG. Podiatry Management August 2008
www.podiatrym.com
Chemotherapy


47
Bevacizumab Monoclonal antibody
against VEGF inhibits
angiogenesis in tumor
and healthy tissue alike.
BIG impediment to
wound healing
Feldmeier JJ, Crotty MJ, Godley SP. Problem Wounds: The Impact of Radiation therapy and Chemotherapy
In: Wound Care Practice 2nd edition. Vol 1 Sheffield PJ, Fife CE (eds) Volume 1, pp 513 - 539
Radiation Therapy





Impairs vascularity
and depletes cell lines
Impacts all phases of
wound healing
Progressive over time
Good response to
HBOT
Radiation Proctitis
Hypoxic
Hypovascular
Clark, Cone et al, 2008
48
Feldmeier JJ. Hyperbaric Oxygen Therapy Committee Report
Undersea and Hyperbaric Medical Society Gesell LB Ed.
Hypocellular
Radiation Related Wounds
49
Pyoderma Gangrenosum




50
Painful ulcers of varying
depth and size
Purulent wound bed
and blue-black edge
Most commonly
associated with
underlying autoimmune
or malignant disease
Pathergy!
Factitious Disorder





51
Accompanies various
psychiatric disorders
Lesions in various
stages of healing
Well circumscribed
borders
Areas accessible and
reachable with hands
Usually sparing back
ETOH Induced High-Velocity
Pavement Wound
52
Smoking
Impedes healing by:







53
Local vasoconstriction and
hypoxia
↑ CO delivery to wound
Endothelial and vasomotor
dysfunction
Accelerated atherosclerosis
↑ platelet activation
↓ collagen synthesis
↑ risk of post-op wound
infection and rupture
Sorensen, et al. Smoking as a risk factor for wound healing and infection
in breast cancer surgery. Eur J Surg Oncol 2002 Dec; 28(8): 815-820
54
Summary







55
Careful H&P
History of prior wounding
Lifestyle and mobility questions
Nutritional assessment
Wound characteristics
Prior treatment; successes and failures
Pay attention: When all else fails – take a
history!
Thank you !
56
Lee C. Ruotsi, MD, CWS, UHM
[email protected]