Blistering Disorders of the Foot.

ABSTRACT: Multiple pathophysiologic and biomolecular processes lead to bullae, including disruption of adhesion molecules, accumulation of cell injury, and traumatic injury. Blistering disorders of the foot can cause symptoms such as pruritus, pain, and drainage and significantly impact quality of life. Microbiologic and histopathologic examination of tissue specimens should be considered for concerns regarding atypical etiology.This retrospective case series describes patients seen in a community hospital outpatient wound center in southeastern Wisconsin between January 2021 and June 2023 for atypical blistering disorders of the foot. The cases herein describe the history, clinical presentation, and treatment of three atypical blistering disorders of the foot. An 86-year-old man presented complaining of intensely pruritic blistering lesions to both feet. Histopathologic findings indicated eosinophilic infiltrate, and the patient was treated for an eosinophilic drug reaction. A 65-year-old man presented complaining of multiple painful blisters to the plantar aspect of both feet. Histopathologic examination of unroofed blister indicated bullous tinea. Finally, a 44-year-old man with long-standing type 1 diabetes presented complaining of a several-week history of a single blister to his anterior right foot of unknown etiology. The patient was diagnosed with bullosis diabeticorum.Blistering disorders of the foot are diagnostic challenges; diagnostic clarity is assisted by thorough history, clinical presentation, treatment response, microbial analysis, and histopathologic findings.

Clinical management of nonuremic calcific arteriolopathy: a report of three cases.

INTRODUCTION: Calcific arteriolopathy involves the deposition of insoluble calcium salts in the vasculature and soft tissues, leading to ischemia, thrombosis, and cutaneous necrosis. Calcific arteriolopathy is commonly associated with ESRD but can also occur outside of ESRD, known as NUC. OBJECTIVE: This article reviews the clinical management and outcomes of 3 cases of non-uremic calcific arteriolopathy. MATERIALS AND METHODS: This case series describes the clinical presentation and successful treatment of NUC in a community hospital-based outpatient wound center in southeastern Wisconsin. Factors presumed to be involved included chronic kidney disease-associated mineral bone disorder, dysregulation and deficiencies of the inhibitors of vascular calcifications, autoimmune dysfunction, and chronic inflammation. All 3 patients received multimodal treatment with wound hygiene, pain management, and infection control. In addition to these interventions, case 2 received NLFU. RESULTS: All 3 patients displayed increased tolerance of compression and debridement and successfully epithelialized with no discernible effect on long-term function or quality of life. Wound infection occurred in each case. The mean overall healing time was 20 weeks. CONCLUSION: The study findings suggest that successful management of NUC can be achieved using IV STS, early and aggressive infection treatment, pain control, and wound hygiene. In patients with NUC, NLFU may be an appropriate adjunct to expedite healing.

Impaired wound healing in diabetes.

Impaired wound healing for patients with diabetes is due to a constellation of structural, biochemical, cellular and microbial factors. Hyperglycaemia and its associated inflammation contribute to immune dysfunction, vascular damage, neuropathy, cellular senescence, impaired transition beyond the inflammatory stage, microbiome disruptions, failed extracellular matrix formation, growth factor and cytokine imbalance, limited re-epithelialisation, and alterations in fibroblast migration and proliferation. Optimising glycaemic control remains the primary intervention to prevent continual dysfunction and comorbid disease progression.

Cutaneous Manifestations of COVID-19 in Critical Care.

SARS-CoV-2 infection can cause virus-mediated endothelial dysfunction, which in turn may lead to coagulopathy and ischemic microangiopathy. In the critical care population, cutaneous skin manifestations related to vascular compromise due to COVID-19 include livedo and purpura. These lesions can be difficult to differentiate from other dermatologic conditions seen in this population, including skin failure and deep-tissue pressure injuries. In addition, similarities in underlying pathophysiological mechanisms of these skin conditions can cause diagnostic overlap. Skin failure is known to occur in critical care patients owing to disease severity and shunting of blood to vital organs. COVID-19-related ischemic lesions can mimic the clinical course of deep-tissue pressure injury. The viral endothelial dysfunction present in patients with COVID-19 decreases tissue tolerance, which can result in an increased risk of hospital-acquired pressure injury. Extrinsic factors can also complicate diagnosis of cutaneous lesions in patients with COVID-19.

A Retrospective Analysis of Clinical Use and Outcomes Using Viable Placental Membrane Allografts in Chronic Wounds.

INTRODUCTION: Viable placental membrane (vPM) has been shown to decrease time to healing, adverse wound events, and wound-related infections. Wound research exclusion criteria commonly exclude wound types other than diabetic foot ulcers and venous leg ulcers (VLUs), comorbidities including peripheral arterial disease (PAD) and uncontrolled diabetes mellitus (DM), and wounds with exposed bone or tendon. OBJECTIVE: This retrospective research study evaluated the clinical use and outcomes of the vPM with living mesenchymal stem cells used in chronic wound management in the community hospital outpatient department setting with the goal of comparing real-world use and outcomes of the product with use and outcomes described in the chronic wound literature. MATERIALS AND METHODS: A retrospective analysis on vPM treatments at a Wisconsin academic health system's community hospitals. Participants included all patients who received vPM therapy between July 1, 2016, and August 21, 2019. RESULTS: A total of 89 patients received vPM treatment during the study period (mean age, 70 years; 69% male [n = 61], 31% female [n = 28]). Wound types were 54% diabetic or neuropathic foot ulcers (n = 48), 17% VLUs (n = 15), 7% pressure injuries (n = 6), and 22% atypical wounds (n = 20). The average wound duration prior to vPM initiation was 104 days. Average wound size at presentation was 6.9 cm2. Of study participants 54% had PAD (n = 48), 63% had DM (n = 56), 33.7% had DM and PAD (n = 30), and 17% had exposed bone or tendon (n = 15). Average adjusted time to healing after initiation of vPM was 81.2 days. The percentage of wounds healed 12 weeks after initiation of vPM treatment was 57%. CONCLUSIONS: Effectiveness of vPM observed in controlled trials also was observed in this real-world study on vPM for multiple wound types, patients with comorbidities including PAD and uncontrolled DM, and wounds with exposed bone or tendon. Results of this study were not statistically different from those reported in the literature. More randomized controlled trials are needed to explore the efficacy of vPM on patient presentations common to wound healing centers.

Mechanical negative pressure wound therapy: real-world effectiveness in challenging patient presentations.

INTRODUCTION: When used for wound management, negative pressure wound therapy (NPWT) delivers subatmospheric pressure at the wound site, exerting multiple beneficial effects, including microstrain, macrostrain, edema management, granulation tissue formation, drainage management, and wound stabilization. Comparative effectiveness research has demonstrated similar wound healing and adverse event outcomes between traditional NPWT (tNPWT) and mechanical NPWT (mNPWT). Therefore, considerations for patient selection for mNPWT vs tNPWT are in alignment with current recommendations, including therapeutic goals, wound-related factors, patient satisfaction, quality of life, care setting, economic-related factors, and product design. CASE REPORTS: The 3 complex patient cases in the present report describe the routine use of mNPWT between December 18, 2020, and June 7, 2021, at a community hospital-based outpatient wound center within an academic health system, including 2 dehisced surgical incisions and 1 complicated venous leg ulcer. All patients received local standard of care, including surgical debridement, soap and water cleansing of the wound and extremity, hypochlorous acid 5-minute soak prior to dressing application, non-sting skin barrier periwound protection, smoking cessation and nutrition counseling, and chronic disease management. Case selections for mNPWT included: the need for frequent activity at work, minimal wound depth, lack of undermining, exudate, wound size, wound location allowing for the wound to fit comfortably beneath the mNPWT dressing, need for graft stabilization, protection of the site from repeated trauma, need for granulation tissue formation, and periwound inflammation. CONCLUSIONS: Mechanical NPWT is a convenient therapeutic option that appears to deliver healing outcomes comparable to those of tNPWT but with improved wound-related quality of life. These cases reveal the real-world effectiveness of mNPWT in challenging patient presentations and wounds that have stalled. The cases outline common endpoints for using advanced therapy in addition to wound closure, such as granulation tissue formation and quality of life.