The patient is a, otherwise healthy 84 yo woman who had a squamous cell carcinoma of the left pretrial area in 2018 that was treated with radiation. The area took 18 - 24 months to heal after XRT. Due to concerns about a new crusted area at the site, it was biopsied in April 2023; but has not healed since then. In August 2023, there was a 6 mm in diameter ulcer. In July of 2024, she had moved to another state and a wound care physician re-biopsied the area and curretted it, In the ensuing three months the ulcer has grown to its present size of 3.7 x 2.7 cm and is constantly painful. (Both biopsies showed no evidence of cancer.)
She has good pedal and dorsals pulses and has had arterial and venous studies of her leg show normal findings. Ankle Brachial and Toe Brachial Indexes are normal.Wound cultures have repeatedly grown out a mixture of Pseudomonas, Coagulase Negative Staph and Strep species.
12.12.23
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1.27.24
What is your diagnosis and what do you think is the best way to care for this ulcer?
From Dato Ong Cheng Leng, Malaysia: Pretibial area is notorious for slow wound healing because it is almost just ‘skin and bone’, with no muscle in between. Hence the very slow wound healing in 2018 after radiation treatment for squamous cell carcinoma ( five years ago), taking almost two years to do so. (Her peripheral arterial circulation is very good even now.) The other reason for slow healing may be the effect of radiation.
ReplyDeleteThe present ulcer at around the same area is not only not healing, but is enlarging rather rapidly. Biopsies have been negative for malignancies. I think this time on top of the same pretibial anatomical disadvantage and post-radiation effect, there is an additional third factor:- a chronic pseudomonas infection! This often occurs at the ‘lower’ lower limb regions like the lower legs, ankles or dorsum of feet because of the possible fecal origin of pseudomonas, which is confirmed by culture. If antibiotic cream used are of the common type, it not only has no effect on pseudomonas, but also inhibits the other competing bacteria. It is not uncommon to be treated with an antibiotic-steroid combination cream, the topical steroid can prevent ulcer healing.
May I suggest we repeat the skin biopsy and swab the ulcer again for culture and sensitivity, rule out drug allergy before giving a prolonged course of oral Bactrim. Gentamicin cream may be applied to hasten the healing.
Ulcers in this region heal very slowly. Along with increase in activity, elevation of the part and ankle exercises help to improve circulation. UV radiation stimulates wound healing and it also sterilizes.
ReplyDeleteIn India- we rely mostly on sun exposure.
Plasma rich fibrin matrix (PRFM) dressing can be tired.