Optimal Wound Care Management in Hidradenitis Suppurativa
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1 Journal of Dermatological Treatment ISSN: (Print) (Online) Journal homepage: Optimal Wound Care Management in Hidradenitis Suppurativa Abrahem Kazemi, Kelly Carnaggio, Maureen Clark, Cynthia Shephard & Ginette A. Okoye To cite this article: Abrahem Kazemi, Kelly Carnaggio, Maureen Clark, Cynthia Shephard & Ginette A. Okoye (2017): Optimal Wound Care Management in Hidradenitis Suppurativa, Journal of Dermatological Treatment, DOI: / To link to this article: Accepted author version posted online: 13 Jun Submit your article to this journal Article views: 4 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at Download by: [University of Toronto Libraries] Date: 20 June 2017, At: 13:23
2 Abrahem Kazemi a*, Kelly Carnaggio b, Maureen Clark b, Cynthia Shephard b, and Ginette A. Okoye a a Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, United States of America; b Wound Ostomy Nurse Consult Service, Johns Hopkins Bayview Medical Center, Baltimore, United States of America *Corresponding Author Details: Abrahem Kazemi Permanent Address: 8159 Old Barrington Blvd. Fairfax Station, Va Telephone Contact Number: Primary Abrahem.kazemi@bison.howard.edu Secondary abrahemkazemi@yahoo.com Word Count: 1895 words including titles, abstract, text, figures, tables, and references
3 Optimal Wound Care Management in Hidradenitis Suppurativa Hidradenitis suppurativa (HS) presents the problem of a chronic, relapsing, painful, draining wound. There is a myriad of HS wound care management strategies implemented by clinicians and patients that is centered around which dressings to use. Many factors affect which HS wound care dressing is the most appropriate to use such as the type of HS wound, cost, ease of application, patient comfort, absorbency, and odor management among many others. In this work, the authors prepare a set of guidelines for optimal HS wound care dressing use based on a tier system, ideal characteristics of HS dressings, and the type of HS lesion. The dressing recommendations focus on cost-effectiveness for patients, ease of accessibility, and ultimately, improvement in the quality of life of patients suffering from HS. Silver-impregnated foam is considered the most optimal HS wound care dressing because it contains nearly all characteristics of an ideal wound care dressing. However, it is expensive and difficult to access for patients, so other HS wound care dressings must be considered prior to utilizing silver-impregnated foam. Keyword: hidradenitis suppurativa; wound care; dressings; wound care management; costeffective; optimal management Introduction Hidradenitis suppurativa (HS) is a chronic inflammatory dermatologic disorder of hair follicles characterized by recurrent, tender subcutaneous nodules that heal with scarring and form draining sinus tracts over time [1]. The lesions of HS are commonly found in apocrine gland-rich regions such as in the axillae, groin, inguinal and peri-anal areas [1]. There are a myriad of possible triggers affecting the clinical course of flares such as over-activation of the immune system in response to microbial antigens, hormonal influences, obesity, and smoking [1]. During acute flares, patients present with tender subcutaneous nodules which drain malodorous purulent
4 material [2]. Due to the uncertain occurrence pattern of acute flares, patients face the dilemma of dealing with a chronic, recurrent, draining wound therefore leading to a poor quality of life (QoL) marred with physical, psychological, financial, social, and emotional distress [1, 2]. Although wound care management is a vital aspect of improving the impaired QoL for patients suffering from acute and chronic HS wounds [2, 3], guidelines for HS wound care management with specific dressings have rarely been presented in the literature. The most appropriate HS wound care dressings can help manage pain, odor, and clothing staining, therefore contributing to an improved QoL [1]. The ideal HS wound care dressings should be highly absorbent, conformable to the commonly affected anatomical locations of HS lesions, easily self-applied, cost effective, and easily accessible. Other desired characteristics for HS wound dressings include atraumatic adhesion and antimicrobial properties (Table 1). Different types of HS lesions (e.g. high drainage nodules or sinus tracts, painful HS nodules or ulcers, and post-operative wounds) require dressings with distinct characteristics to address the unique needs of these patients (Table 2). The cost and accessibility of wound care dressings present a barrier to optimal HS wound care management. The financial burden of acquiring dressings can be mitigated by insurance coverage, but some insurance plans do not include coverage of wound dressings. Thus, this paper attempts to describe a step-wise approach to identifying and utilizing appropriate HS wound care dressings. The following approach details the most cost-effective and easy-to-access dressings available at local pharmacies and supermarkets to the most effective, but expensive, dressings that are accessible only by prescription through a wound care center, or from a surgical supply company (Figure 1).
5 Tier 1 Dressings Tier 1 dressings include sanitary napkins, adult briefs, infant diapers, and gauze (Figure 1). These are the most affordable dressings available for HS wound care, especially since they can be bought in bulk. They are highly absorbent and can be used for high-drainage HS lesions. Tier 1 dressings are generally designed to wick moisture away, which can serve to protect the periwound skin from maceration. However, they are cumbersome and less comfortable than higher tier dressings. Gauze dressings are easy to obtain over the counter. However, they are not as absorbent as other Tier 1 dressings and are therefore more expensive since patients must frequently change this dressing. Additionally, gauze can adhere to HS lesions when the exudate dries, often leaving fibers on the wound bed. This ultimately leads to painful dressing changes. Tier 2 Dressing Abdominal pads are considered tier 2 dressings because they are more difficult to obtain overthe-counter, but can be obtained from a surgical supply company or online pharmacy. They are moderately absorbent, though bulky and more expensive than Tier 1 dressings. Tier 3 Dressings Hydrofiber dressings with silver, and calcium alginate dressings with silver are tier 3 dressings because they are not accessible over-the-counter and are more expensive than tier 1 or 2 dressings. However, they have an added antimicrobial activity due to their silver content not found in tier 1 or 2 dressings (Table 1) that allow for the patient to have an enhanced QoL with use. Tier 4 Dressing Silver-impregnated foam dressings possess most of the features of an ideal HS dressing as outlined in Table 1. The silver-impregnated foam dressing with an atraumatic adhesive may be
6 preferable in wound management than hydrofiber dressings with silver and calcium alginate dressings with silver since it has the added feature of not requiring adhesive tape for application [4, 5]. However, hydrofiber dressings with silver and calcium alginate dressings with silver as well as tier 1 and 2 dressings can be modified to depend less on traumatic adhesives by encouraging the use of certain types of clothing to hold the dressings in place. For example, biker shorts composed of compressive material that wick away moisture can be worn over tier 1, 2, and 3 dressings to secure them in place. This enhances their effectiveness by decreasing skin and peri-lesional trauma when applied to certain anatomical locations (e.g., groin, inguinal region) and further improves QoL by reducing the need to purchase tapes and bandages, since biker shorts can be washed and re-used [4-7]. Cost of HS Dressings Medicare and many commercial insurance companies cover hydrofiber dressings with silver and calcium alginate dressings with silver for daily dressing changes, while silver-impregnated foam is covered at 12 dressings per month (i.e. three dressing changes per week). The provider completes, signs, and faxes an order form for these supplies, and includes the diagnosis code, location of wounds, measurements, full- or partial-thickness wound status, and amount of drainage. This information may have to be updated monthly, requiring more frequent office visits. However, many of the large supply companies will allow order renewals without such frequent follow up if the provider communicates with the company to confirm the patient s ongoing need for wound care management. In contrast, if the patient does not have health insurance, or if the insurance company does not cover wound care supplies, some of the items in Figure 1 may be purchased online. For
7 example, the typical cost of one 4 x 4 dressing from tier 3 is $5-8 on amazon.com. Tier 2 products are also available for purchase in-bulk online as a more affordable alternative. This financial burden cannot be sustained by many uninsured patients, but they can rely on tier 1 or 2 dressings. Conclusion Though there are barriers to cost-effective, easily-accessible, and optimally functional HS wound care dressings, their impact on patients QoL may be worth the effort of discussing the over the counter options and/or assisting patients with ordering wound care supplies. Declaration of Interest The authors report no conflicts of interest. Geological Location This research was conducted in Baltimore, Maryland at the Johns Hopkins Bayview Medical Center Department of Dermatology.
8 1. Blattner C, Polley DC, Ferritto F, Elston DM. Central centrifugal cicatricial alopecia. Indian Dermatol Online J [Internet] Jan;4(1): Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. J Am Acad Dermatol [Internet]. 2003;49(1): Kimball AB, Gold MH, Zib B, Davis MW, Phase, Clobetasol Propionate Emulsion Formulation Foam, III Clinical Study Group. Clobetasol propionate emulsion formulation foam 0.05%: Review of phase II open-label and phase III randomized controlled trials in steroidresponsive dermatoses in adults and adolescents. J Am Acad Dermatol [Internet]. 2008;59(3):448,454. e1. 4. Ogunleye TA, McMichael A, Olsen EA. Central centrifugal cicatricial alopecia: What has been achieved, current clues for future research. Dermatol Clin [Internet]. 2014;32(2): Kyei A, Bergfeld WF, Piliang M, Summers P. Medical and environmental risk factors for the development of central centrifugal cicatricial alopecia: A population study. Arch Dermatol [Internet]. 2011;147(8): Sperling LC, Cowper SE. The histopathology of primary cicatricial alopecia. In: Seminars in cutaneous medicine and surgery [Internet]; 2006WB Saunders; p Gathers RC, Jankowski M, Eide M, Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia. J Am Acad Dermatol [Internet]. 2009;60(4): Khumalo N, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in african adults. Br J Dermatol [Internet]. 2007;157(5):981-8.
9 9. Dlova NC, Jordaan FH, Sarig O, Sprecher E. Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black south africans. J Am Acad Dermatol [Internet]. 2014;70(4):679,682. e1. Dressin g Type Regular Gauze Infant Diaper Adult brief Sanitar y Absorb ency Conform ability to Features of an Ideal Dressing for HS Ease Odor manage Atrau matic Antimicr obial Barri of self- intertrigin ous areas applica tion ment or Nonadhesi activity activ ityⱡ Accessi bility ve Light- Modera te Heavy Heavy er Com fort Cost & Ease of Heavy Napkin Abdom inal Modera te
10 (ABD) pad gauze Hydrofi Modera ber tewith Heavy silver Calciu Modera m tealginate Heavy with silver Silver- Modera impreg tenated Heavy foam Table 1. Features of Ideal Wound Care Dressings for HS [1, 5-9] ⱡ protects peri-wound skin from exudate, less leakage of exudate onto skin and clothing i.e., less staining of clothes
11 Table 2. Type of HS lesion, its recommended wound dressing, and respective rationale for its use Type of HS Lesion Recommended Wound Dressing Rationale High drainage nodule or sinus 1 st line: Regular gauze, infant diaper, sanitary napkin, adult brief, Use tier 1, 2, or 3 dressings to absorb high drainage output. For continuous high-output tracts or ABD pad; 2 nd line: hydrofiber with silver and calcium alginate with silver; 3 rd line: silverimpregnated foam drainage control, consider silverimpregnated foam dressings due to absorbing nature of the foam, and antimicrobial benefits of silver. Painful wound Silver-impregnated foam Atraumatic adhesive leads to less painful application and removal [4]. Post-operative wound after HS surgery Silver-impregnated foam Antimicrobial; absorbs neutrophils/other leukocytes, cellular debris, and bacteria into foam component, thereby promoting more efficient healing [5, 6].
12 Figure 1. Pyramid of HS wound care management based on cost & ease of accessibility (Tiers 1-4 from bottom to top)
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