Leave eschar alone

Remember how as a child your mother told you “not to pick”? As a mom myself, I think it had more to do with the fingernails-on-a-chalkboard reaction to that repetitive action and the subsequent blood than the notion that the scar was protecting the boo-boo from further damage and infection and it best be left alone.

Wound care specialists, however, know (and subsequently, related guidelines have been developed) that eschar/necrotic tissue keeps a wound covered and helps facilitate healing. Concern that eschar prohibits accurate assessment for the most part is assuaged by the realization that if no other signs of trouble are present (such as warmth, redness, and the like) that herald infection or suggest debridement is warranted, the “dead” tissue is best left undisturbed. Obviously, there are exceptions, but the rule of thumb (more accurately, the rule of foot) with regard to heel wound eschar should be: Leave it alone.

Care to debate?

When wound care sucks

It is no surprise that I — the Hoover/Oreck queen of my family — have more than an abiding interest in anything with the word vacuum in its name. Plus, the concept vacuum-assisted therapy was just beginning to really take off when I took the reins of Ostomy Wound Management.

Through the years, OWM has provided numerous articles and supplements on negative pressure wound therapy (NPWT). Morykwas and Argenta published their groundbreaking article on the use of subatmospheric pressure in wound care in 1997, but according to Miller’s¹ aggressive search, their concept is predated in Russian medical literature by 11 years. However, despite NPWT's 20-plus year history, and although the visual makes sense, no one is completely sure why sucking backwards on a tightly adhered dressing helps heal a wound. Current thinking is that NPWT promotes wound healing by 1) removing exudate from wounds to help establish fluid balance, 2) providing a moist wound environment, and 3) removing slough — this to potentially decrease wound bacterial burden, edema, and third-space fluids; increase blood flow and growth factors; and promote white cells and fibroblasts.^1,2 But NPWT research mostly involves one specific company’s product, and randomized, controlled trials are somewhat lacking. Plus, the 411 from patients isn’t always positive: NPWT treatment, as well as the post-treatment process of extracting the foam dressing of the manufacturer most associated with the wound vac,³ is painful.⁴

Which makes me wonder if this is why the brouhaha surrounding NPWT 5 to 10 years ago is diminished. Or maybe wound vac-ing has become an established part of wound care, lessening the din. After all, KCI was touted for providing its negative pressure prowess in the post-earthquake relief efforts in Haiti. Various studies show different products and dressings (for example, medicinal honey⁵) are used concomitantly to enhance treatment and counter negative side effects. Clinicians are rethinking the amount of pressure needed.⁶ What do Morykwas and Argenta think about the product size, mobility, and dressing options now available? What do you think?  

Great articles from OWM on NPWT include:

1.     Negative Pressure Wound Therapy: "A Rose by Any Other Name"

2. Negative Pressure Wound Therapy Achieved by Vacuum-Assisted Closure: Evaluating the Assumptions

3. Can You Help?: Making the Dressing Changing Process Less Painful

4. Managing Wound Pain in Patients with Vacuum-Assisted Closure Devices

5. Active Leptospermum Honey and Negative Pressure Wound Therapy for Nonhealing Postsurgical Wounds

6. The Effect of Intermittent and Variable Negative Pressure Wound Therapy on Wound Edge Microvascula

Intertrigo: skin is also a concern in obesity

Say what you will about recent concern that obesity is a disease and not a lifestyle choice, the number of overweight and morbidly overweight persons in the world is increasing. This pandemic affects healthcare providers challenged to manage the comorbid conditions resulting from obesity, payors seeking responsible ways to finance care, and society in general. Airlines (Samoa, the most prominent example) want to charge by weight; some companies require the purchase of an extra seat for the bigger among us. A popular reality show follows the struggles of a select few to embrace healthy eating and exercise habits.

But food, activity, and public opinion are but a few of the issues. Persons with areas of adjacent excessive skin folds are susceptible to intertrigo, a bacterial, fungal, or viral infection that develops as a result of inflammation when skin rubs against skin. Common areas are the inner thighs, genitalia, armpits, under the breasts, the underside of the belly, behind the ears, and the web spaces between the toes and fingers. Usually appearing as red and raw, intertrigo may itch, ooze, and feel sore. You can read more about intertrigo at: 

Intertrigo in the Obese Patient: Finding the Silver Lining
An Overview of Dermatological Conditions Commonly Associated with the Obese Patient