Skin ulcers: DermaClub’s treatment options

Skin ulcers refer to the loss of epidermal and dermal tissue that causes a discontinuity in the skin organ.
The most frequent causes of skin ulcers are: trauma, surgery, vascular problems and skin tumors. Ulcers can therefore be divided into different categories including traumatic, surgical, vascular and tumor etc. The most common types of ulcer are vascular, venous, arterial or mixed.
Pressure ulcers (bedsores or decubitus ulcers) are instead caused by the restricted blood flow to a limited area of the skin due to pressure. They mainly form during prolonged hospital stays in individuals with limited mobility. The ulcers are distinguished by their location, such as in the case of sacral decubitus ulcers or calcaneal decubitus ulcers.

Regardless of the causes that led to the formation of the skin ulcer or pressure sore, a myriad of spontaneous bodily functions that repair damage and close the lesion immediately come into play.
The body’s natural repair and wound healing process is so complex that it is a good rule of medicine to try to interfere with it as little as possible.
The treatment for ulcers and pressure sores have two important medical objectives:

1. Help the patient to be in the best possible condition for the proper reparative processes to take place
2. Remove any factors that may interfere with the repair process

The reparative process

The reparative process is a network of actions and interactions involving all the cells of the skin organ. This includes keratinocytes, fibroblasts, endotheliocytes, nerve cells and immunocompetent cells, as well as cells that have rushed from the blood, such as white blood cells, red blood cells, and platelets. Each of these cells bring with it one or more soluble factors capable of commanding actions that will contribute to the ulcer closing process.
During the reparative process the ulcer can be pictured as the opening of a large construction site within which thousands of workers and machines move in all directions seemingly without a specific purpose, but in fact, they are all working towards the same goal. In the case of ulcers, this goal is to rebuild the missing tissue.

The reparative process: oxygen and bacteria

When an ulcer forms, an abnormality occurs in that oxygen from the air penetrates the tissue and bacteria colonize the walls and bottom of the ulcer.
This abnormality lies in the fact that, normally, oxygen and bacteria are only found on the outer stratum corneum layer and are not present within deeper skin layers.

Oxygen and bacteria play an integral and indispensable role in the repair process. Oxygen prevents the development of anaerobic bacteria, which can attack and destroy tissue making the ulcer larger. At the same time, bacteria participate in keeping the ulcer itself clean by scavenging dead cells by digesting them with their enzymes.
It is important that the processes undertaken by oxygen and bacteria are not interrupted.

The reparative process: stem cells

Stem cells are reserve cells that can regenerate destroyed tissues. Stem cells are usually dormant, but will be activated when the ulcer forms.
The skin is the organ with the largest number of stem cells, including within the epidermis, dermis and adipose pad. This means, in theory, that the skin’s reparative capabilities are infinite.

In order to perform their tasks correctly, stem cells must not be negatively interfered with by medication. Antibiotic use in the treatment of ulcers and pressure sores.
Although many treatment protocols for ulcers and pressure sores include the use of antibiotics, these should not be used except for in extreme cases. As mentioned, the ulcer is constantly being colonized by bacteria and the use of an antibiotic could temporarily decrease the bacterial load. This does not help the closure of the ulcer and could result in the development of more dangerous bacterial strains that are antibiotic resistant. The risk of the development of bacterial resistance to antibiotics is also the reason why antibiotics are never directly used directly on ulcers or sores. It is relatively rare for an ulcer or pressure sore to become infected, meaning that topical antiseptics are usually sufficient to control bacterial overgrowth.

Dressing an ulcer or pressure sore

The purpose of a dressing is to create a suitable environment for tissue repair.
Therefore, the dressing must allow the passage of oxygen, must not interfere with bacteria, and must not harm the very delicate blood and repair cells.

The dressing

Dressing the ulcer or pressure sore protects it from any trauma, stops any foreign bodies from entering the wound and prevents the wound being contaminated by any bacteria that shouldn’t be there.

The dressing must also allow oxygen to flow and must be able to absorb exudates from the ulcer or pressure sore, making cotton gauze an excellent choice.

Coverings with nonwoven fabric (TNT) gauze, band-aids, medicated plasters, and synthetic materials of all kinds should be avoided.

Dressing products

There are a plethora of products to dress a wound, but few meet all the characteristics that are essential for ulcer and pressure sore care:

1. oxygen permeability;
2. respect for the bacteria within the ulcer and pressure sore;
3. compliant with regenerating cells

Those listed in the table are to be avoided

Table 1: Products to avoid

DermaClub recommends: PEG Ointment with allantoin

PolyEthyleneGlycols (PEGs) are synthetic polymers that, when mixed appropriately, create an ointment similar to Vaseline but with the opposite properties.
When highly purified PEGs with no impurities are used, a restorative balm that is suitable for the treatment of ulcers and pressure sores is obtained.
Table 2 compares the properties of PEG Ointment to those of Vaseline.
With the addition of allantoin, a natural compound that has healing properties, PEG Ointment is the ideal dressing for ulcers, wounds, and pressure sores.

Detersion disinfection of ulcers and pressure sores

Ulcers and pressure sores can self-deter and self-disinfect mainly due to the recall and presence of neutrophils, which are white blood cells capable of digesting dead tissue and excess bacteria.
However, when changing the dressing, it is good practice to flush the ulcer or pressure sore with cleansing antiseptic in an aqueous solution.
Why to use a cleansing antiseptic in aqueous solution?
Washing the wound with a cleansing antiseptic in aqueous solution during dressing changes removes cellular debris, exudates and excess bacteria. Using a disinfectant is important, as a simple aqueous disinfectant has no cleansing action and is therefore practically useless for the purpose of washing.
“Quaternary ammonium” disinfectants have both antiseptic and detergent properties.
The best known of this category is benzalkonium chloride.
Many disinfectant products based on benzalkonium chloride, or its derivatives, in aqueous solution are commercially available.

The Eschar Problem

Eschar is non-viable tissue that forms above the ulcer or pressure sore and prevents its closure.
The color of eschar can be necrotic black or fibrinolytic yellow. For proper repair to take place, eschar should always be removed.
Necrotic eschar must be surgically removed. After a few days of dressing the wound with PEG Ointment, the necrotic eschar will retract and lift from the edge of the ulcer or the pressure sore (retraction of the eschar).
At this point, the margin will need to be lifted with surgical forceps and, with blunt-tipped scissors, the eschar will be peeled off. This procedure is not painful because the nerve endings that were destroyed when the necrotic eschar was formed are missing.
Fibrinolytic eschar, on the other hand, will reabsorb on its own with the use of PEG Ointment dressing.

A summary of the principles of ulcer and pressure sore care

1. Clinical assessment of the ulcer or pressure sore and its possible causes
2. Patient assessment, concomitant diseases, deficiencies, and possible remedies
3. Pain assessment
4. Measurement of ulcer or pressure sore
5. Washing/disinfection with benzalkonium chloride aqueous solution
6. Application of cotton gauze smeared with PEG Ointmemt
7. Secure the dressing, where possible, with tubular mesh gauze (Surgifix) or with paper/silk tape patches placed on the periphery of the dressing with cotton gauze. Securing the dressing should in no way impede the passage of air.
8. Change the dressing once a day
9. If the exudate is intense, change the dressing twice a day until the exudate has reduced.

The advent of photodynamic therapy in the treatment of ulcers and pressure sores

Photodynamic therapy (PDT) originated in dermatology for the treatment of actinic keratoses and UV-induced epitheliomas. However, it is clear to see why PDT could help the re-epithelialization of ulcers.
In the photo below, the area treated with PDT has been repaired twice as fast as the part treated with standard dressings. Photodynamic therapy has become integral in the treatment of ulcers and pressure sores.
In short, one PDT session per week is performed according to the following schedule:

• The ulcer or pressure sore is cleaned with benzalkonium chloride solution A photosensitizer (10% 5-aminolevulinic acid) in PEG Ointment with allantoin is applied onto the ulcer or pressure sore. The area to treat is then covered with polyethylene film to dress the ulcer or pressure sore and to enable absorption.
• After two hours, the dressing is removed and the ulcer or pressure sore is exposed to 630 nm light through the administration of 75 J/cm2 of light energy for ten minutes.
• After completion, PEG Ointment is reapplied.
• At home, the patient continues with PEG Ointment dressings as already described

Photodynamic therapy reduces the repair time of ulcers or pressure sores by about half. It also reduces patient discomfort and dressing costs.
Photodynamic therapy is particularly useful for difficult ulcers that become chronic and/or that don’t heal with dressings alone.