Watch Dr Koullias Present the Treatment Plan for a Nonhealing Skin Cancer Excision Wound

In this presentation, George Koullias, MD, describes the treatment plan for an 82-year-old man with a nonhealing skin cancer excision wound.

This video was sponsored by ConvaTec.

Transcription:

After excision of the squamous cell carcinoma in his calf, our patient underwent additional treatment with radiation therapy. While radiation is a common treatment for these cancerous lesions, it can often result in unintended injury and fibrosis to overlying skin and contribute to poor wound healing capability. Wounds complicated by prior radiation therapy can also be complicated by scar formation and epibole of the edges, which is an inversion of the skin around the periphery of the ulcer.

As this patient also has overlying significant venous insufficiency with varicose veins and leg swelling, I started his treatment plan with venous intervention including saphenous vein ligation, division and stripping, to remove dilated veins from the extremity and reduce the amount of venous congestion. Followed by sclerotherapy of small vessels around the ulcer and microphlebectomy, which is removal of small varicose veins near the ulcer, all of them in order to manage the underlying venous insufficiency and reduce the amount of venous congestion that is present around the ulcer and stalls its healing. I then initiated the wound hygiene protocol with cleansing, debridement, and refashioning of the edges, which is particularly important to promote healing, especially in the setting of radiation therapy wounds.

In this wound, compromised by the cellular alterations of radiation exposure, I elected to proceed initially with hyperbaric oxygen therapy followed by applications of antimicrobial collagen extracellular matrix dressings weekly for 4 weeks. Followed afterwards by the weekly application of dehydrated placental allografts in order, during the step 4 of the protocol, to treat the resultant impact from the radiation and jumpstart the wound healing process in our patient.

However, my expectations that this product would move the wound to the proliferative phase from the stalled stage of the inflammatory phase were not met, and there were no changes in the clinical metrics of our wound. The wound stagnated with no decrease in area, volume, or diameter reduction. This strategy [in] this patient proved to be unsuccessful, and it was abandoned. I continued with a wound hygiene protocol but changed the dressing in step 4 of the protocol to AQUACEL^® Ag Advantage to better handle the wound exudate and also manage the biofilm within the dressing.

In this challenging wound, the course appeared to be turning after very few applications of the AQUACEL^® Ag Advantage. With granulation tissue formation appearing at the periphery of the wound, the wound started to contract and continued to improve and increase in size all the way to complete healing, as you can see from my presentation pictures.

The overall course of treatment of our wound, in this complicated patient using the wound hygiene and AQUACEL^® Ag Advantage, was almost 18 months, but the patient was ultimately able to heal this complex wound in spite of the radiation effects on the tissue around the wound, in spite [of] his very severe venous insufficiency, and in spite his significant immunocompromising state due to the presence of his chronic leukemia.

I hope you enjoyed our case.