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76-year-old female does wound has a duration of one year and six months but it has had a wound in this area that has healed prior. ABI is normal she is not diabetic
The ideology of this wound has not been determined but I have been treating a difficult to treat pseudomonas in the wound.
What is curious to me is petechiae and the webbing in the first picture, Will come on within a day, and this skin is intact where the petechiae are. Then the next picture the one in the center is only four days later after applying triamcinolone to the skin. The wound itself we are treating with silver collagen / Polymem. Changing daily. This wound is extremely painful and the pain was greatly increased the day that all of the redness petechiae developed. The pain has been very difficult to manage we have a special morphine powder that is compounded and applied once a day with the dressing change to help manage the pain. Just curious if this has a vasculitis appearance or if there’s another direction that we need to be examining?
Thank you in advance for your expertise!
Jan 26, 2022 by Ronda Bowles, RN, BSN, CWON
5 replies
Cathy Milne
APRN, MSN, CWOCN-AP
Hi Rhonda,
Has this patient had a biopsy of the wound? If not, it would be advised…The patient appears to respond to a topical steroid -suggesting an inflammatory process - of which there are many. A rheumatological work up and atypical wound evaluation performed with biopsy, labs and cultures can be helpful here…
I don’t have other medical history or a list of meds that can be contributing or causative….if patient can tolerate some edema control, that can be adjunctively used in this case….
I’ll look to my colleagues for additional thoughts…
Jan 26, 2022
Ronda Bowles
RN, BSN, CWON
Thank you Cathy for your response- She has not had a biopsy of this wound she is a home care patient and It is extremely difficult for her to leave the home we do many of her wound visits via Telahealth. She also has Reynauds and lymphedema… But due to the pain we’ve not been able to do compression for at least a couple months now.
She’s on very minimal medication, Currently only taking her pain medication. Her nutrition is fair she does take Juvan twice a day but her appetite has decreased lately.
Jan 27, 2022
Ronda Bowles
RN, BSN, CWON
Thank you Cathy for your response- She has not had a biopsy of this wound she is a home care patient and It is extremely difficult for her to leave the home we do many of her wound visits via Telahealth. She also has Reynauds and lymphedema… But due to the pain we’ve not been able to do compression for at least a couple months now.
She’s on very minimal medication, Currently only taking her pain medication. Her nutrition is fair she does take Juvan twice a day but her appetite has decreased lately.
Jan 27, 2022
Ronda Bowles
RN, BSN, CWON
Thank you Cathy for your response- She has not had a biopsy of this wound she is a home care patient and It is extremely difficult for her to leave the home we do many of her wound visits via Telahealth. She also has Reynauds and lymphedema… But due to the pain we’ve not been able to do compression for at least a couple months now.
She’s on very minimal medication, Currently only taking her pain medication. Her nutrition is fair she does take Juvan twice a day but her appetite has decreased lately.
Jan 27, 2022
David Charash
DO,CWS,FACEP,FUHM
I would agree that a biopsy would be an important part of the evaluation. Pyoderma gangrenosum would be on my differential diagnosis. Is there any pathergy? The fact that there was improvement with topical steroid is certainly interesting. Using the Maverakis Criteria in conjunction with a biopsy may help point you in that direction.
Certainly treating the colonization vs infection and biofilm is important, and pain management will be key. If in fact this is Pyoderma Gangrenosum then topical vs systemic therapies in addition to ongoing expert wound care and patience will be required.
Jan 27, 2022
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