CASE REPORT - FEMALE, 76 YEARS OLD, CHRONIC NON-HEALING ULCERS ON THE LEFT LOWER LEG
causistic date: 31. 03. 2009, published: 24. 06. 2009
Alena Štukavcová, M.D., Dermatovenereology Out-patient Clinic, Hospital Uherské Hradiště
76-year-old female presented at our out-patient clinic with two years history of non-healing ulcers of the left lower leg. Initially she was treated by a surgeon that considered the ulcers as of trophic etiology. For the continuation of conservative therapy she was sent to our dermatovenereology out-patient clinic. Progression of leg ulcers with increasing pain led to the hospitalization at the Dermatology department of the hospital Uherské Hradiště. In family history there was ischemic heart disease of her mother and chronic renal insufficiency of her father. In her personal history there were common diseases of childhood, recently ischemic heart disease, supraventricular fibrillation treated by coumarin, mitral valve insufficiency, hypertension, non insulin dependent diabetes mellitus treated with peroral antidiabetics, mixed hyperlipidemia, liver steatosis and chronic venous insufficiency with varicose veins on both lower extremities. She had no history of erysipelas, thrombophlebitis or deep venous thrombosis. She underwent appendectomy, hysterectomy with bilateral adnexectomy, umbilical herniotomy. She is a non-smoker, abstinent, with no drug or other allergy. Her pharmacologic history includes Warfarin 3 mg, Micardis plus, Digoxin 0,125 mg, Betaloc SR, Detralex, Verospiron, Furon, Enelbin, Tulip 20 mg, Siofor 850 mg. Physiological functions are normal, weight stable. Laboratory examination showed borderline values of some parameters – haemoglobin 11.4 g/dl; haematocrit 35.9 % and MCH 27.9 pg, other lab tests were normal. The haemocoagulation values were checked regularly; Quick prothrombin time values were within 18.8 to 22.8 % and INR 2.87–3.42. Duplex sonography of the left lower leg showed atherosclerotic vessel wall changes of the crural arteries, without haemodynamically significant stenosis and light disturbance of peripheral perfusion. Deep venous system was without occlusion. The ulcers were thus of mixed etiology. In microbiological culture from the ulcer there were repeatedly found Staphylococcus aureus (+++) and Proteus mirabilis (+++). Lower leg ulcer therapy was performed on both outpatient and inpatient basis during two years and it had included many topical therapeutical preparations for wound healing: 1% solutio Rivanoli, solutio Betadini, Dermacyn, Nu gel, Flamigel, Flaminal, Ialugen plus dressing, Gentamicin ointment. The surrounding skin of the ulcer was treated with zinc paste; in combination with low concentration corticosteroid creams for eczematous changes. In severe eczema flare-ups Belogent cream was used. Compressive therapy with short-stretch elastic bandages was applied. Topical therapy of painful ulcers with moderate discharge and signs of inflammation was repeatedly supported by systemic targeted antibiotic therapy: Klacid 500 mg, Ciprinol 500 mg, Forcid sol. 850 mg, Amoxicillin 625 mg. Status localis before the application of Traumastem biodress dressing: there are four ulcers with irregular margins and moderate secretion on the left lower leg, the ulcer bed is atonic with some fibrin, margins contiguous, surrounding skin tight, shiny and slightly fibrotic, with loss of hair, varicose complex is present together with perimalleolar edema, but no signs of thrombophlebitis, Homans sign and deep palpation negative. Peripheral pulse is palpable, interdigital spaces without signs of mycosis. The size of the ulcers is 2.5×3 cm (above inner ankle), 5×3 cm (above outer ankle), 4×0.5 cm (dorsolaterally); and 0.5×0.5 cm (lateroproximally), respectively. Patient reports moderate pain. The treatment with bioactive dressing Traumastem biodress was started. At home the patient washed the ulcers with a stream of water. After the shower she applied wet dressing with Dermacyn solution for thirty minutes. The skin surrounding the ulcers was treated with cream base ambiderman with olive oil, because the patient did not tolerate zinc paste (it had caused extreme dryness and cracking of the skin). As a next step Traumasteml biodress adjusted to the size of the ulcer, so that it did not extend beyond the wound margins, was applied. Next it was covered by secondary dressing – tulle gras in vaselinum album, gauze pads. The dressing was fixed by hydrophile bandage and compression with two short-stretch bandages was applied. The frequency of changes of bandages depended on the degree of secretion and thus on the speed of Traumastem resorption. The changes of the dressings were done at the beginning on a daily basis, later every other day, when the granulation phase transited to the epithelization phase of healing. Status localis after two months of application of Traumastem biodress: granulating ulcer bed, epithelization from the wound margins, surrounding skin without signs of inflammation, wound size reduction of 60–70%: above the inner ankle 2×1.5 cm, above the outer ankle 2×2 cm, dorsolaterally 2.5×0.2 cm, ulcer localized lateroproximally healed. The patient reports no subjective pain. Status localis after four months of application of Traumastem biodress: rapidly continuing epithelization from the wound margins, the ulcer bed with healthy granulations, surrounding skin without inflammation, wound size reduction of 90%: above the inner ankle 0.4×0.4 cm, above the outer ankle 1×1 cm, the ulcer localized dorsolaterally healed. The patient reports subjectively no pain.
