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Keep up with the changes in wound care.

NEWPORT, R.I. -- Taking care of wounds has changed a lot over the years, and family doctors need to keep up with the changes, Dr. Gary Cummins said at the annual conference of the Rhode Island Academy of Family Physicians.

"I'm amazed at the extent to which primary care is an essential part of wound care," said Dr. Cummins, a family doctor with the Wound Recovery Center at Kent Hospital, in Warwick, R.I.

For instance, when cleaning a wound, some of the topical solutions previously recommended such as-full-strength povidone-iodine (Betadine), hydrogen peroxide, and Dakin's solution actually destroy tissue and are not a good idea, he said.

"Hydrogen peroxide is toxic to newly formed cells, and Dakin's solution should not be used in acute wounds." Povidone-iodine can be used at diluted strengths, he added.

Another myth revolves around the idea of keeping the wound dry. "Grandma says, 'Let it [get air]; it will form a seal and heal underneath,' " Dr. Cummins said. "Grandma missed the boat on that one. If a wound is maintained in an appropriately moist environment, hard eschars don't form."

Moist wound healing decreases healing time, decreases infection, reduces trauma, decreases pain, and is more cost effective, he noted.

Wound assessment is a basic skill that family doctors need to have a handle on, he said. First, the doctor needs to note the location and description of the wound, such as "irregular border, rolled edge."

Next, look at the wound bed for evidence of necrosis, granulation, or fibrin. Then check to see if there is any exudate or odor.

And fourth, observe the surrounding skin texture, noting color and degree of moisture.

Once the wound has been assessed, the patient can be sent off for any necessary tests, such as the ankle-brachial index or transcutaneous oxygen monitoring.

For the ankle-brachial index test, "you want it to be 0.8 or above, although any thing 0.4 and over can potentially heal," Dr. Cummins noted.

For most simple wounds, Dr. Cummins recommended the following treatment: Debride the wound and clean it well.

To do so, apply 4% lidocaine (Xylocaine) gel, and leave in for 10-15 minutes to sufficiently anesthetize the wound. Then scrape it with a #15 blade to get rid of pus, dirt, or other substances without much pare, he said. After it's clean, put hydrogel or a topical antibiotic on it, cover with gauze or simple nonstick dressing, and reassess it as the clinical situation warrants.

If the wound is not healing in 4-6 weeks, it should probably be referred.

Dr. Cummins was asked whether a combination of sugar and povidone-iodine made into a paste was effective at wound healing.

"Sugar I alone I has been found not to be of value," he said. "The combination I can't comment on."

Predicting how well the wound will heal depends on many factors, according to Dr. Cummins.

Body build is a factor, since obese patients have more adipose tissue and have a harder time healing. Certain medications also can slow healing time, Dr. Cummins said. For instance, "hydroxyurea really significantly influences the body's ability to heal."

One long-term wound problem family doctors often see is chronic venous hypertension formerly referred to as varicose veins. There is really only one initial treatment for this, according to Dr. Cummins: compression and elevation. Compression can be achieved using compression wraps. Once edema has disappeared, then consider using elastic compression stockings to keep the problem at bay.

Some patients have trouble putting the stockings on by themselves. For them, Dr. Cummins recommends a lady's nylon as a first layer and an aid called a "stocking donner," a metal form that users can put the stockings on and then step into them.

"Or they can leave the stockings on for 2 or 3 days," he said.
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Title Annotation:Skin Disorders
Author:Frieden, Joyce
Publication:Family Practice News
Geographic Code:1USA
Date:Aug 1, 2004
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