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

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HEMOSTASIS INFLAMMATION

PROLIFERATION REMODELING

Damaged vessels constrict to slow

blood flow. Platelets aggregate to stop

bleeding. Leukocytes

migrate into tissue to initiate

inflammatory process.

Neutrophils secrete chemicals

to kill bacteria. Macrophages

engulf and digest foreign particles and

necrotic debris. Macrophages

release angiogenic substances

to stimulate capillary growth and

granulation tissue.

Fibroblasts proliferate In the wound and

Secrete glycoproteins and collagen. Epidermal Cells migrate from the

wound edge. Granulation tissue is

formed from macrophages,

fibroblasts and new capillaries.

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

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Inflammatory

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Proliferative

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Remodeling

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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

8 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

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

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The Chronic Wound 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

10 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.

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Systemic Co-morbidities

Vasculitis Rheumatoid disease Lupus (SLE) Scleroderma Wegener’s Granulomatosis Polyarteritis Nodosa

Diabetes Polycythemia Vera Renal failure Chemotherapy Radiation Pyoderma

Gangrenosum

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Good H&P

HPI – Wounding PMH PSH Past wounding hx Etiology Location Treatment Response

Meds Family hx ROS Thorough exam Skin Wounding Vascular supply Infection 14

General Appearance

Cushingoid (puffy) appearance

Rheumatoid joints

Cachexia

Scleroderma skin

General Appearance

Abnormal affect and behavior

Focal neurologic deficit

Tobacco

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DIABETES

Cell Membrane

A.G.E.’s

WBC Function

Ischemia Angio-

genesis

Neuropathy

Tissue Compliance

Diabetes

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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 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

20 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

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Autoimmune Disorders

Rheumatoid Arthritis Crohns Disease Pernicious Anemia Ulcerative Colitis Antiphospholipid Syn. Graves Disease Wegener’s

Granulomatosis 22

Psoriasis Systemic Lupus Polymyositis Dermatomyositis Ankylosing

Spondylitis Sjogren’s Syndrome Autoimmune

Hemolytic anemia

Autoimmune Mechanism 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

23 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

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 24

Rheumatoid Disease

Systemic Treatment: High dose steroids, cyclophosphamide, Dapsone, disease modifying agents

Wound treatment: Standard wound care, bioengineered skin, growth factors

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Rheumatoid Leg Ulcers

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Systemic Lupus (SLE) 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

27 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

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Scleroderma (C.R.E.S.T.) 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

29 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 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)

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www.medicinenet.com/wegeners_granulomatosis/article.htm

Cryoglobulinemia 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

32 www.vasculitisfoundation.org/education/forms/cryoglobulinemia/

Raynaud’s 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 33

Goundry B, Diagnosis and Management of Raynauds Phenomenon. BMJ 2012 : 344:e289

Vasculitis

Inflammation of blood vessels of unknown etiology

Thrombosis of capillaries leading to local tissue hypoxia

Prevalent in elderly Male = female

34 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

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Factor V Leiden Mutation 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

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Lee P, Prasad K in International journal of Lower Extremity Wounds, Mani R, Ed. Pp 4 - 12

Sickle Cell Disease 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

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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

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Budisavijevic M, et al. Calciphylaxis in Chronic renal Failure. J. Am. Soc. Nephrology 1996; 7: 978-982

Protein Energy Malnutrition 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

39 Possinger C. Nutrition & Wound Care – From Treatment to Prevention. Catholic Medical Partners (CMP) IPA April, 2014

ABC’s of Nutrition Assessment

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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

42 Barbul and Kavalukas. Nutrition and Wound Healing, an Update Plast. Reconstr. Surg. 2011; 127

10% loss

20% loss

30% loss

Wound

Muscle

Aging ↑ 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

43 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

↓ 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

44 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

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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

Bevacizumab - Monoclonal antibody against VEGF inhibits angiogenesis in tumor and healthy tissue alike.

BIG impediment to wound healing

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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

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Clark, Cone et al, 2008 Feldmeier JJ. Hyperbaric Oxygen Therapy Committee Report Undersea and Hyperbaric Medical Society Gesell LB Ed.

Hypoxic

Hypocellular Hypovascular

Radiation Related Wounds

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Pyoderma Gangrenosum Painful ulcers of varying

depth and size Purulent wound bed

and blue-black edge Most commonly

associated with underlying autoimmune or malignant disease

Pathergy!

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Factitious Disorder Accompanies various

psychiatric disorders Lesions in various

stages of healing Well circumscribed

borders Areas accessible and

reachable with hands Usually sparing back

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ETOH Induced High-Velocity Pavement Wound

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Smoking Impedes healing by:

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

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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

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Summary

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!

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Thank you !

Lee C. Ruotsi, MD, CWS, UHM lruotsi@chsbuffalo.org