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Dr. Todd Yip MSc MD FRCPC Dine and Learn Event Victoria Division of Family Practice January 28, 2014 Slide 2 Declaration One Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic Slide 3 Foot and Leg Ulcer Clinic RJH Memorial Pavilion 40-50 new referrals per month Nurses, Pedorthist, Orthotist, Physician, Surgeon Not open Mondays, some Friday PM Referrals must be via Central Intake Recommend fax copy of referral to FLUC Slide 4 Dr. Todd YipMSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014 Slide 5 Edema Lower limb edema control is vital to heal wounds and to prevent recurrent ulceration. How much compression would be reasonable? What is a reasonable to compression management? Slide 6 PVD Work-up Arterial **Renal function (eGFR >60) **Resting arterial doppler U/S (includes ABI) ABI (with doppler study **CTA Abdo Aorta + runoff (preferred) Conventional unilateral angiogram MR Angiography **key items Venous Reflux (valve competence) Deep veins, Superficial veins, perforators Slide 7 Ankle Brachial Index/Doppler Ultrasound Index 1.3Poorly compressible vessels Age and diabetes main confounders Doppler Waveform (flattens with disease) Triphasic Normal BiphasicMild disease Monophasic Severe disease Localizes occlusive disease Eg. Monophasic popliteal, dorsalis pedis, posterior tibial = above knee stenosis Toe pressure >30 mmHg Predicts healing in non-diabetic >50 mmHg Predicts healing in diabetic Slide 8 Ankle Brachial Index Sensitivity: 70-90% Lower in elderly or diabetics Specificity: 65-95% Khan TH et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews, 2008, 4, 101-106 Slide 9 ABI/Toe Pressure Slide 10 Slide 11 Approach to Compression Avoid compression (generally) Severe PAD; ABI 0.5 Pure venous + leg edema +/- significant drainage Needs dressing, not socks Mixed PVD Medium compression (15-20 mmHg) Mixed PVD, if edema control reasonable If tolerating low compression Try adding low compression sock to low compression dressing to graduate Slide 12 Approach to Compression High compression At least 20-30 mmHg compression Strong, palpable pulses, normal ABI; No risk factors Pure venous disease, mild edema ?Local dressing + compression sock vs. compression dressing Depends on clinical picture/practical options Trial and (hopefully not) error approach If dressings, change 2 to 3 x per week Slide 13 Practical Considerations The application of compression dressings (or complex dressing) is highly variable Socks must be hand-washed and hung to dry Socks must be less than 6-8 months old (of total daily use) Socks on in the AM, off in the PM, unless patient sleeps in chair Dressing and sock costs are often not covered in community Slide 14 Some Compression Dressings Modified Unnas boot +/- tensor Less than 10mmHg Light options: local dressing + tubifast (blue- or yellow-line, or tubigrip) Coban 2 lite 20-30 mmHg Coban 2 30-40 mmHg Slide 15 Some Compression Options If no ulcer or nearly healed, then compression stockings: 8-15 mmHg (e.g. Diabetic sensifoot) 15-20 mmHg intermediate 20-30 mmHg venous insufficiency, some PAD 30-40 mmHg lymphedema 40-50 mmHg young venous insufficiency Some patients can use remarkably high compression safely Slide 16 Compression Stocking Practical Tips Layered lower level compression stockings for increased compliance/ease of management and cost savings 10 mmHg stocking liner 10 mmHg ankle-high socklet Open-toed or zippered socks Sock donning gadgets Home supports as required for dressing Slide 17 Dr. Todd YipMSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014 Slide 18 Work-up - Foot X-ray +/- x-ray in 3 weeks CBC, CRP, renal function Bone scan (debatable role non-specific) add infection label if + WBC label if 3/12 Indicate duration of ulcer and if patient on antibiotics on requisition MRI - ?debatable role Wound cultures can be helpful or misleading Slide 19 Infection Legs Mostly clinical diagnosis ?Cellulitis vs. ?Stasis dermatitis vs. ?Ostemyelitis Essentially the same work up as feet Slide 20 Diabetic Foot Infections (DFI) Mostly polymicrobial Aerobic GPC, especially staphylococci Aerobic GNB, if chronic Anaerobes, if ischemic or necrotic Foul odour of necrosis +/- pseudomonas Slide 21 Reasonable Empiric Antibiotics 1 st line Keflex (500 mg BID-QID) Clindamycin (300-600 mg TID) 2 nd line Clindamycin + cipro (250-500 mg OD-BID) Clavulin (500 mg TID/875 mg BID) If MRSA Clindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg BID) Note: clindamycin requires no adjustment for renal function and covers MRSA! Slide 22 Parenteral Antibiotics Suggested Indications Failed oral antibiotics Abscess or ?abscess (surgical consult pending) Sepsis Dialysis Side effects from oral antibiotics Impaired immune response Past response of frequent flyers ?Non-adherence to oral medications? No data support the superiority of any specific antibiotic agent or treatment strategy, route, or duration of therapy Lipsky et. al., 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2012;54(12):132-173 Slide 23 Imaging for Osteomyelitis Details Pineda C, Vargas A, Rodriguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am. 2006;20(4):789825. Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(11):24642471. Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. Arch Intern Med. 2007;167(2):125132 ModalitySensitivity (%) Specificity (%) X-ray43 to 7565 to 83 Bone scan Technetium-99m methylene diphosphonate 69 to 10038 to 82 Gallium-67 citrate scan25 to 8067 to 85 WBC Scan Technetium-99m hexamethyl-propyleneamine oxime-labeled 9080 to 90 MRI82 to 10075 to 96 Slide 24 Dr. Todd YipMSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014 Slide 25 Skin Manifestations of Diabetes Type 1 Periungal telangiectasia Necrobiosis lipoidica diabetacorum Bullosis diabeticorum Vitiligo Lichen ruber planus Type 2 Yellow nails Diabetic thick skin Acrochordons (skin tags) Diabetic dermopathy Skin spots and pigmented pretibial papules Acanthosis nigricans Acquired perforating dermatosis Calciphylaxis Eruptive xanthoma Granuloma annulare Slide 26 Skin Manifestations of Drugs A number of reactions, too many to list Van hattem, Bootsma AH, Thio HB. Cleveland Clinic Journal of Medicine: 75(11): 772-787 Slide 27 Three Recent Cases Slide 28 Slide 29 Slide 30 Slide 31 My Main Differential Diagnosis Dry skin (autonomic) Fungus/tinea ??Psoriasis ??Something else that responds to topical steroid If psoriasis, then it is recommended not to debride So, confirming a diagnosis will affect the treatment approach (i.e. it affects management) Slide 32 ?Psoriasis Usually 2-3 referrals per to Dr. Telford, RJH Psoriasis Clinic dermatologist for ?Psoriasis not previously diagnosed? For estimated >95% of referrals, Dr. Telford agrees psoriasis may or may agree with foot involvement Prevalence = 2-4% general population Prevalence among patients with diabetes? Disclaimer: Dr. Telfords consultation is pending for these cases. Slide 33 Recent Literature: Psoriasis-Diabetes Link Independent risk factor in the development of T2DM Population-based cohort study (n=108132) HR 1.14 (mild psoriasis); 1.30 (severe psoriasis) Arch Dermatol. 2012;148(9):995-1000. Associated with an increased prevalence and incidence of diabetes Systematic review and meta-analysis 27 Cohort, case-control, and cross-sectional studies from 1980-2012 Prevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27 JAMA Dermatol. 2013; 149(1)84-91. Slide 34 Questions Is the reverse true? That is, Is the incidence and prevalence of psoriasis higher amongst those with diabetes? Is diabetes and independent risk factor for psoriasis? Is psoriasis more prevalent among those with severe diabetes? Or, those who have or at high risk of foot ulcers? Slide 35 Three Recent Cases Slide 36 Simple Treatment Approach If unsure, consider treat with least potentially harmful agent first Moisturizer Hydrophilic petrolatum Atrac-Tain Anti-fungal Anti-dandruff shampoo foot wash Lamisil 1% OD Steroid ointment Clobetasol 0.05% OD (affected areas only) Dermatology referral