In this month’s Evidence Corner, Dr. Laura Bolton reviews 2 very interesting studies of psychosocial stress and its effects on wound healing. The articles, “Hostile marital interactions, proinflammatory cytokine production, and wound healing” and “Social facilitation of wound healing,” appeared in Archives of General Psychiatry and Psychoneuroendocrinology, respectively. The 2 studies, one in humans and the other in hamsters, revealed stress effects on the biochemistry of the healing process and slower healing. I suspect that these 2 journals are not frequently read by those of us in wound healing research, so Dr. Bolton has done us a service by calling attention to these works and the significance of the findings for improving good wound care.
Voigt et al. (Economic study of collagen-glycosaminoglycan biodegradable matrix for chronic wounds) present a retrospective analysis comparing the economics of split-thickness skin grafting (STSG) versus the use of the Integra® Bilayer Matrix Wound Dressing (BMWD) for treating chronic wounds. Although the BMWD is indicated for the treatment of full-thickness burns, it has been reported to have utility for the off-label use of chronic wound treatment. While the study focused mainly on the economics of use, time to healing appeared comparable between the groups, and the outcomes with BMWD were judged to be good. There were no significant differences in charges to patients between the 2 treatments studied. It will be interesting to follow future investigations on chronic wounds adequately powered to compare BMWD to other treatment approaches.
Oh and Phillips (Sex hormones and wound healing) present a comprehensive literature review and commentary on the effects of estrogens and androgens on wound healing. While most of the published data comes from animal studies, there are also some interesting clinical reports. The authors discuss the importance of expanding knowledge in this area in order to develop possible new approaches for wound therapy, especially in the geriatric population and in post-menopausal women where many are at risk for chronic wounds.
In Department Editor Dr. Tania Phillips’ Diagnostic Dilemmas, Shafii et al. report a case of Cutaneous Fungal Bipolaris Infection in a patient presenting with a shallow left medial ankle ulcer that continued to worsen over the course of 3 weeks. After referral to the authors’ center, culture and histologic evaluations revealed the presence of dematiaceous hyphomycete fungi, Bipolaris, as the infectious agent. Small numbers of Staphylococcus, Pseudomonas, and Streptococcus were also present. In the immunocompromised patient, it is important to prevent local expansion and possible dissemination of the infection by surgical excision with or without systemic antifungal treatment. Following admission to the hospital for treatment and diagnosis, the Bipolaris species was confirmed as the offending organism. After instituting intravenous itraconazole, the wound improved over the course of a week, and surgical intervention was not required. The authors discuss the history of clinical infections caused by dematiaceous fungi, the importance of histopathological and mycological studies for diagnosis, and the management approach for cutaneous Bipolaris infection, a rare cause of chronic, nonhealing ulcers.
Zelent et al. (Malignant melanoma masquerading as a decubitus heel ulceration) describe a patient with a poorly-to-nonhealing foot ulcer treated conservatively at several centers and also by allografting. Following poor results despite all interventions, a tissue biopsy was performed and revealed the presence of malignant melanoma. Although it may not be feasible or appropriate to biopsy every poorly healing chronic wound, the authors subscribe to the suggestion in the literature “…that biopsy should be performed in patients with nonhealing ulcerations of 6 months duration or longer in order to exclude malignancy.”
David T. Rovee, PhD