Laurel M. Morton

Dressings for chronic wounds.

Covering wounds, acute and chronic, is one of the most fundamental activities of any medical practitioner. Although wound dressings primarily serve to contain the “good” and keep out the “bad,” research has characterized more specifically the sophisticated interaction between the human wound bed and its dressing counterpart. Wound dressings for todays chronic wounds come in many flavors, ranging from the classic types of moisture‐retentive dressings to silver‐coated varieties to biologic dressings serving as skin substitutes. Moisture‐retentive dressing types include foams, films, hydrogels, hydrocolloids, and alginates. Appropriate use of these dressings can help to keep the wound bed moist, which allows for epithelial migration, angiogenesis, retention of growth factors, autolytic debridement, and maintenance of electrical gradients.

Wound healing and treating wounds: Differential diagnosis and evaluation of chronic wounds.

Wounds are an excellent example of how the field of dermatology represents a cross-section of many medical disciplines. For instance, wounds may be caused by trauma, vascular insufficiency, and underlying medical conditions, such as diabetes, hypertension, and rheumatologic and inflammatory disease. This continuing medical education article provides an overview of wound healing and the pathophysiology of chronic wounds and reviews the broad differential diagnosis of chronic wounds. It also describes the initial steps necessary in evaluating a chronic wound and determining its underlying etiology.

Wound healing update.

The management of acute and chronic wounds has drastically changed within the past 20 years. This update focuses on the most recent recommendations for acute wound care as well as new technologies that are available for chronic wounds.

Ablative Fractional Carbon Dioxide Laser in the Treatment of Chronic, Posttraumatic, Lower-Extremity Ulcers in Elderly Patients

IMPORTANCE Treating posttraumatic lower extremity wounds can be challenging, especially in elderly patients. Recently, the use of fractional carbon dioxide laser has been shown to improve wound healing in scar-related wounds. We used this treatment modality in posttraumatic wounds that were slow to heal in 3 elderly patients. OBSERVATIONS Each wound underwent one fractional carbon dioxide laser treatment. The wound base was treated at 30 mJ and 5% density. The entire wound edge and 1 to 2 cm into the normal surrounding skin were treated at 50 mJ and 5% density. One pass was completed at 150 Hz per treatment. Treatments were well tolerated with only mild discomfort. Each wound healed by 60% or greater within 3 weeks. No adverse events were reported aside from mild and transient erythema at site of treatment. CONCLUSIONS AND RELEVANCE Fractional carbon dioxide laser treatment appeared to accelerate healing in each of these posttraumatic wounds. It may be a helpful adjunct in nonhealing posttraumatic wounds.

Treatment of ulcers with ablative fractional lasers.

Chronic, nonhealing ulcers are a frustrating therapeutic challenge and investigation of innovative therapies continues to be an important research pursuit. One unique and newly applied intervention is the use of ablative fractional lasers. This technology has recently been employed for the treatment of hypertrophic, disfiguring and function-limiting scars, and was first shown to induce healing of chronic wounds in patients with persistent ulcers and erosions within traumatic scars. Recent reports suggest it may be applicable for other types of chronic wounds as well. The mechanism of action for this modality remains to be elucidated but possible factors include laser-induced collagen remodeling, photomicrodebridement and disruption of biofilms, and induction of a proper wound healing cascade.

The evolution of laser surgery for acne and other scarring processes.

The treatment of acne scars is an important part of a laser specialists practice. For the last 20 years, the technology available for this application has progressed from nonablative to ablative and eventually to fractional lasers that are effective for a range of scar types. Although patients with mild to severe acne scarring have long been good laser candidates, we are beginning to understand the use of lasers for severe traumatic scars which can be disfiguring and functionally limiting in nature.

Foreseeing the future of skin tightening.

Sagging skin accompanies aging nearly universally. The ability to tighten skin is highly desired among aging patients, especially if it can be performed noninvasively or minimally invasively. Twelve years ago, it may have been difficult to predict just how dramatically skin-tightening technologywouldadvance following in the footsteps of the first monopolar radiofrequency (RF) skin-tightening device on the market (SoltaMedical,Hayward,CA). This technology has been significantly modified since its inception and has inspired diverse forms of RF, light-based, focused ultrasound, and combination technologies for skin tightening. Predicting the future is a perilous exercise at the best. In the field of skin tightening, it is no less problematic.

An evaluation of the association for the advancement of wound care venous ulcer guideline and recommendations for further research.

OBJECTIVE: The goals of this study were to analyze the 2010 update of the Association for the Advancement of Wound Care (AAWC) Venous Ulcer Guideline (VUG) and examine recommendations with less than A-level evidence to identify important research questions. DATA SOURCES: The AAWC VUG may be found at http://aawconline.org/professional-resources/resources and at the National Guideline Clearinghouse, http://www.guideline.gov. Supporting references for each recommendation, compiled by the AAWC Guideline Task Force from MEDLINE, CINAHL, and EMBASE databases, may be viewed at the first website. STUDY SELECTION: The literature identified in support of the AAWC VUG recommendations with less than A-level evidence was evaluated and is summarized below. DATA EXTRACTION: Questions requiring further research in venous ulcer (VU) care were developed from recommendations having less than A-level support and that fall under the following topics: diagnosis, documentation, prevention, wound care, adjunctive interventions, and palliation. DATA SYNTHESIS: Practitioners lack strong evidence for several generally accepted recommendations of this synthesis of VU guidelines concerning the following: diagnostic or screening validity of varicosities, timing of biopsies for differential diagnosis, clinic visit frequency, criteria for changing VU care plans, and effective VU preventive parameters. Bedside surgical debridement, several biologic interventions, certain types of grafting, and the comparative efficacy of intravascular surgical procedures also require rigorous examination. Adjunctive interventions to be investigated include systemic pain management, topical biophysical treatments, novel devices, pharmaceuticals, timing, methods and procedures for some surgical interventions. CONCLUSIONS: Better evidence for recommendations with less than A-level support may improve the quality and consistency of VU care, reduce costs, and improve resource use.

Commentary on Clinical and Histopathological Assessment of Facial Melasma After Low-Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Laser.

The article by Hofbauer Parra and colleagues illustrates an important point about treating melasma: safely used lasers improve the condition, but it nearly always recurs. In all 16 patients who completed the study, melasma severity improved between 25% and 75%, but at 3 months after therapy, 81% of patients had recurrence of their condition. When taking on the responsibility of treating these patients, the author of this commentary recommends a 3-step process. First, always proceed with caution as lasers used unwisely can exacerbate the condition or cause untoward side effects. Second, consider a multimodality approach that includes both photoprotection and medical and procedural interventions. Finally, manage patient expectations regarding efficacy and risk of recurrence.