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Official Journal of the Italian Association for Cutaneous Ulcers
Indexed/Abstracted in: EMBASE, Scopus, Emerging Sources Citation Index
Online ISSN 1827-1774
Balduzzi E., Bauducco M., Castagna S.
Struttura Complessa di Nefrologia e Dialisi, Azienda Ospedaliera Ordine Mauriziano, Torino, Italia
This report describes the case of a 53-year-old man in dialysis therapy since September 2007 for diabetic nephropathy (well compensated type 2 diabetes mellitus), who presented with a chronic neuropathic ulcer on the dorsal aspect of the left foot, dyschromia and lower limb edema. In 2005 an ulcer on the same limb resolved after escarectomy. An excoriation sustained the year before the current presentation resulted in a painless, irregular wound (University of Texas Stage 1A) measuring 7 cm by 4 cm, with sharp edges, fibrin, and abundant greenish non-malodorous exudate. The patient referred having no caregivers; self-care was poor. The treatment plan called for an interdisciplinary approach to wound management, which involved a nephrologist, dialysis nurses, 2 of which experienced in wound care, a diabetologist, and a plastic surgeon. The objective was to obtain good tissue granulation according to the TIME principles (Tissue management, Inflammation and infection control, Moisture balance, Epithelial advancement), in addition to improvement of patient compliance with treatment, management of nutrition and fluid intake, education in proper hygiene and skin hydration, and increase of self-esteem. Arterial echo-Doppler with buffer and photographic monitoring was performed. Medica-tions were applied three times a week during the dialysis session; treatment results were recorded over the course of five months. During the first two weeks, wound care comprised application of H2O2 and physiologic solution, and active carbon with silver dressings covered with flat gauze. Starting the third week, wound care continued with physiologic solution, hydrogel for autolysis (only four applications), polyurethane foam covered with transparent film or calcium alginate (to enhance absorption), with flat gauze, and vaseline oil to hydrate the skin. During the five months of treatment, two episodes of bacterial colonization occurred during the first month and two episodes of wound edge maceration during the long intervals between dialysis sessions. The medications were well tolerated and no allergic reactions were observed. The wound size decreased to 5 cm by 3.5 cm, the perilesional skin was pink. Wound healing with good tissue granulation progressed such that surgery or treatment with protease modulating matrix could be contemplated; the patient decided for the latter treatment option. Lower limb edema resolved and dyschromia decreased. Self-care and compliance with treatment improved; good glycemic compensation was maintained. Arterial Doppler revealed superficial circulation and good wound site perfusion. The abundant exudate was also associated with water retention, a common manifestation in dialysis patients. Ultrafiltration reduced the edema and the exudate, thus improving the exanthema of the extremities. After wound detersion, the wound bed appeared poorly hydrated; but at subsequent medications, the plaques were consistently saturated. The use of hydrogel was reduced and calcium alginate dressings were applied for the longer intervals between dialysis sessions. No further episodes of bacterial colonization were observed after application of active carbon with silver dressings and personal hygiene had improved. Increasingly, dialysis patients require help with wound care. A multidisciplinary approach to wound management can produce optimal results even in non-dedicated settings.