A 37-year-old man with a history of intravenous drug use is admitted to the hospital for treatment of cellulitis due to chronic lower extremity venous stasis ulcers. Intravenous antibiotic therapy is administered, and saline-moistened wet-to-dry gauze dressing changes are performed. Following resolution of the cellulitis, the patient is evaluated for potential wound coverage with skin grafting. He declines the procedure but agrees to perform any recommended wound care. Examination of the affected area on the left lower leg is shown in the exhibit. Irrigation of the wound is performed. Which of the following is the best next step in management of this patient's wound?

Question

A 37-year-old man with a history of intravenous drug use is admitted to the hospital for treatment of cellulitis due to chronic lower extremity venous stasis ulcers.  Intravenous antibiotic therapy is administered, and saline-moistened wet-to-dry gauze dressing changes are performed.  Following resolution of the cellulitis, the patient is evaluated for potential wound coverage with skin grafting.  He declines the procedure but agrees to perform any recommended wound care.  Examination of the affected area on the left lower leg is shown in the exhibit.  Irrigation of the wound is performed.  Which of the following is the best next step in management of this patient's wound?

Quizplus · Accepted Answer

11ec25c8_d8bd_1599_bc81_af434bd65081_MD0003_00 This patient with chronic venous stasis ulcers developed cellulitis and was managed with antibiotics and wet-to-dry dressings. He now has noninfected wounds with healthy, granulation tissue (ie, reddish, well-vascularized connective tissue) at the base. Wound dressings are an important element of the wound healing process that can affect the rate of healing; they are typically chosen based on the condition of the wound. Wet-to-dry dressings are commonly used for wounds that are infected, have just been freshly debrided, or have devitalized tissue or fibrinous slough at the base. They are typically performed twice a day and involve placing gauze that has been moistened (typically with saline) onto the wound. As the gauze dries, it adheres to the wound bed and, when it is removed, debrides devitalized tissue. Once devitalized tissue is removed and the wound has healthy granulation tissue (as in this patient), wet-to-dry dressings should be discontinued, because they can nonselectively debride the delicate granulation tissue that serves as a base for epithelial migration (ie, reepithelization). Instead, nonadherent and moisture-retaining dressings should be used. Moist wounds heal faster than dry wounds because wound fluid contains factors that promote wound healing (eg, platelet-derived growth factor, fibroblast growth factor, matrix metalloproteases). In addition, a moist environment promotes reepithelization. Because of these benefits, wounds should also not be left open to the air and allowed to dry out (Choice C). (Choice B) Dakin solution (0.25% bleach) may be used in wet-to-dry dressings to treat infected wounds (especially those with Pseudomonas). However, it is corrosive to healthy tissue and is contraindicated in this noninfected, healing wound with healthy granulation tissue. (Choice D) Performing sharp debridement down to bleeding (ie, viable) tissue is helpful when a wound has extensive slough or necrotic tissue at its surface. In contrast, this wound has well-vascularized granulation tissue without slough or necrosis; debridement is not indicated. Educational objective: Wound dressings are an important element of the healing process. Wet-to-dry dressings are commonly used for wounds that are infected or have devitalized tissue or slough. Once healthy granulation tissue appears, dressings are switched to nonadherent, moisture-retaining dressings to promote healing and epithelialization. References: Wound dressings and comparative effectiveness data. (http://www.ncbi.nlm.nih.gov/pubmed/25126472)

A 37-Year-Old Man with a History of Intravenous Drug Use