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Release Date: 03/28/2018 Expiration Date: 12/31/2020
James McGuire, DPM, PT, LPed
Leonard Abrams Center for Advanced Wound Healing
Department of Podiatric Medicine and Orthopedics
Temple University School of Podiatric Medicine
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TAPE STARTS – [00:00]
Speaker: Very good, Dr. McGuire.
Jim McGuire: Alright. One more. So you go to suffer through just one more. If you like me, good. If you don't, it's just one more torturous moment. So that guy with ADD sits down. Okay. Now, I haven't got anymore. Nobody call me with this pre-engagement while Pamela was talking. And objectives here. We are going to verbalize it, identify and discuss again and we are going to talk a little bit about pain management and we kind of touched on it before and again it's becoming more of a problem today with regards to the monitoring that's going on. I mean I have to go on the Pennsylvania website on every patient that I think about writing any kind of pain med, that's any kind of class related pain med and look them up. I got to see what they have been taken. I got to get what their thing is. I got to register that I am on the right to prescription and let him know and then I have to make a decision as to what to give them. And it's a struggle trying to maintain pain management. Now, we have been very successful with using things like Neurontin or Lyrica as an adjunct to that. Sometimes using something like a tranquilizer or something at night to help them go to sleep and not have discomfort that prevents them from sleeping or maybe a sleep aid, trying to do some physical things like electrical stim, TENS unit and other things to help with pain but they are all -- some of these things are restricted with regards to Medicaid patients being able to get access to them.
Like they have no extra funds, so this is not something that's covered. They are not going to get it. So TENS units are hard to get for people just for pain management when it's not certain types of discomfort. But anyway, warmth tends to aggravate symptoms of lot of these lower extremity ulcer problem, so some cool shower, cool bath, cold application sometimes help and then some kind of compression and I have kind of taken the motto that some compressions are better than none. So if they can't wear 30, try 20. If they can't wear 20, try 10. If they can't wear 10, try 8. I don't care what you wear. Some kind of compression. Something if they can't maintain it for very long, wear as long as you can, then take it off and elevate. Wear as long as you can, take it off and elevate. The problem with that's the patient's fatigue of doing these things that are necessary to take care of their care. They just stop. They are just tired. They are tired of managing the problem. They are tired of having to deal with the problem. They can't bend over to get stockings on. All these donning devices are great but they cost money. So what do you do for somebody that needs a donning device but they won't buy it. They can't buy it. They can do the bubble tube or they can do the slip-on thing or they can do the little hook things where you pull them up. There is a lot of devices out there to help you don stockings and you can use the two layers, which help a little bit but one of the things that was very encouraging to me was my mother-in-law had severe lower extremity edema from inactivity and just kind of sitting with their legs bend all day. And I was trying to get a two-layer stocking on her to get 30 pounds of pressure on her leg. And every time went to her house, she only had on 15. You know that top layer the one that you pull on that makes it looks nice.
But I was shocked that how much edema actually went down with the person who was wearing just 15. She got significant improvement, so my motto has always been, I don't care what you are going to wear, just some kind of compression. You have to wear a two pairs of sup-hose or something. Then whatever it is. If there is a little compression on that leg, you are going to do a little better. Except TEDs. They have no compression. They have no place in medicine. No evidence. Don't use TED hose. I just told you to use sup-hose. I didn't say a thing. There is no evidence for sup-hose either. Okay. TEDs are dead. No, I agree. There is a lot of -- like you shouldn't use TED hose as edema reducing device. Now, we have used a lot of the sleeve related things like Tubigrip and some of these other things. I don't know anything other to call it other than Tubigrip. It's like Band-Aid. I am using a product names, spank me please. But then we have used that. I do know this is that fussy, wale, sleeve technology whatever it is, which is like a fishnet stocking that actually have been extremely well-tolerated by patients and they like it very much. If you choose the right size one for the limb that they do seem to tolerate using that. They can basically feel air through it, so it feels nice to them. You can roll it up and change dressings and pull it back down, so that's why it's very helpful for patient. You can take a shower with it because it doesn't really absorb a lot of water and it will dry. Claudication sign is secondary to longstanding venous hypertension. You may see what is claudication of the limb because of venous backup that prevents arterial inflow, so you begin to get claudicatory symptoms associated with ambulation that are really related to the veins.
Ambulation produces really high limb pressures, overwhelms the capacity and then you get to see some cramping of the leg. Not for most of the women I have seen in Phili. I think that Spandex mostly has a female product, I have to admit. Because most of my friends don't but I would agree with you that they are just as ugly on men. Anything that shows you real anatomy is probably not a good idea and I have had a speech to a medical school students who come in with those tops on and like that Spandex tights that they wear and it's like, do you realize you kind of look like you just spray painted your body and you are in a clinic like a medical clinic. I don't know how to explain this to young women that it's not right. Anyway, except telling them to go change, which is more embarrassing. So there is always high pressure when you get pain in the limb. It's little different than peripheral arterial disease. You need a humor like medicine plus humor. If you don’t like it, okay. I don't like every comedian I hear either. Venous dermatitis, which we looked at. Lymphatic dermatitis, which Heather mentioned. Compression for these things, trying to manage these, trying to keep -- you got to control the fluid, so there is a brand new dressing out for stuff like this that is a hydroconductive roll dressing to wrap around the entire limb, which pulls that fluid outward away from the limb into whatever the secondary dressing is.
Lot of the fluid management bandages that you have available to you now absorb tremendous amounts of fluid. They also are very expensive and you also can't get them as often as you like. My biggest complaint with the system right now is that people who have massive amounts of fluid can only get certain types of dressing three times a week. And there is this restriction. It should be based on fluid output. It should be based on how much the patient needs for fluid management but they are not. They are just based on some sort of arbitrary time limit of three days or five days or maybe three per week or whatever it is. I have my patients using -- they use paper towels in between. They are wrapping their legs with paper towels and other stupid things. They have $20 dressing on Monday and paper towels on Tuesday and $20 dressing on Wednesday and paper towels on Thursday. It makes no sense to me. Antimicrobials, topical antibiotics are not really indicated for most of these patients but topical antiseptics or cleansers. Some of them are very effective. We have used hypochlorous acid a lot lately. I found that very effective. It does not irritate the skin. It's somewhat anti-inflammatory. It has some anti-inflammatory properties associated with it. It kills bacteria, does not kill cells. Very, very cell friendly. You can put it on wounds. You can wash all the wounds with it. We clean patient's feet with it and legs with it and it's sort of our go-to antiseptic cleanser these days. Hypochlorous acid. There are several of them out. Different products. It's about six of them come out over the last two or three years. Super-oxygenated water, hypochlorous acid. I will give you company names later.
I will tell you who I use or I like but that's okay. Because I speak for them if you paid attention, company, yeah, anyway. Only because that’s has been very helpful. Like that you could gargle with that stuff. You can like pour. Anything you can put in your eye, you can put on wound, right? That's sort of standard in life. If you can pour it in your eye, you can go on anything. This stuff does not burn in your eye anymore than water would. They tried that. So company said it didn't, so I said it. I don't know, let's see. No, it doesn't. It also takes care of gum disease. And then topical anti-inflammatories. You got to be careful with the use of topical steroids with how much you are using and the potency that you are using. So in initial chronic problem -- sorry, I should say in acute problem, you might use a high potency steroid but not for a long periods of time. Maybe for a week or two and then you got to start decreasing the potency of the steroid you are using. And then after a couple of weeks, you got to start thinking about, can I continue using steroids longer than this because you may be having some serious skin breakdown problems associated with steroids. I am up and down about steroids. You know, I know they cause some damage or cause some irritation but people get so much better sometimes with them for short periods of time and particularly under occlusion, they look much better and a lot of that inflammation that's in the tissues that's causing the symptoms that you see is reduced by topical steroids. And there is oral steroids also. Whether or not, how long you are going to dose them and how much you are going to dose them. We use a lot of short-term like Medrol Dosepak, which is actually a fairly low amount of steroid but if you do repetitive Medrol Packs, you might as well keep them on a low dose steroid for a while. As a podiatrist, I like have medical agreement on that or medical management and their medical doctors often wouldn't agree with that. Diabetic that throws the sugars off.
They are to get fluid changes and other things associated with long-term steroid use, so you have to be careful. And then periwound topicals to make sure that the periwound is healthy and the skin is healthy. We use a lot of like lipoid creams and lipid-based creams and other things on a periwound skin to help the skin be as healthy as possible. There is ankle flare. If you have patient with ankle flare, compression is the thing and just them into compression. This is kind of early in the running sometimes for a lot of people where we just see lots of little varicose veins are on the ankle and nobody ever told them to like use compression. Particularly, men tend to like not wear stockings as much or wear knee-high related things as much. And it's really hard to get them to move in to wearing knee-high stocking all the time, but it's very helpful. Hemosiderosis, which is this kind of chronic venous hypertension results in this passive hyperemia of the lower extremity all the time. You will see this widened endothelial cell junctions where RBCs get kind of pushed out into the subcutaneous space. They are digested by the macrophages and polys in the subcutaneous space and what they leave behind is this hemosiderin deposition or brown strain in the skin, which builds up over time when you have chronic repetitive inflammation. That's one with pyoderma. And that's another one with venous insufficiency. What do you for that? Compression. You can use anti-inflammatory short term. We use doxycycline a lot for some of the inflammatory processes because conditions that we see in patients have shown that doxy and Keflex in low doses are slight anti-inflammatory and have an anti-inflammatory effect. So if you use low dose doxycycline like 50 mg once a day for a prolong period of time to help reduce inflammation in the tissues.
If you can't get 50, you can do 100 once a day. But you don't use a typical full dose like two doxy's a day. You don't need that much doxycycline to get the anti-inflammatory effect, but it is a very low anti-inflammatory effect and usually you don't see patients notice it that much that there is a big improvement in pain or decrease in pain with use again. Periwound topical, we talked about and then [indecipherable] [14:30] biologics if you have patients that have a condition that would respond to that, such as pyoderma. Lipodermatosclerosis or the development of this lipo edema, these areas of induration and fibrosis associated with that, again compression for everything. Periwound topicals to make sure that the skin is taken care of appropriately. Lot of times we don’t pay attention -- when we are treating this wound, we are not looking at the leg and we are not giving them topical medications to improve the skin, to improve that exfoliation that they have. I like to try to work with patients so that they are actually showering and putting on some kind of compression. Lot of things we apply stay on for days. So they can't shower and then the other leg starts to get all this exfoliative buildup on it and they are really not washing. They are not washing their foot. They are not washing anywhere. So almost anything I can do to that they can take off and put on, I like better. When they have a wound or skin condition that really requires constantly putting something on to make it look better. Manual lift drainage or congestive drainage and then exercise and then especially with lipodermatosclerosis, they respond dramatically to getting them to lymphatic therapist that can help with their condition. The problem we have in Phili and we are a big city and you think there would be lots of certified lymphatic therapist around. They are not.
And a lot of them are very exclusive to upper extremities working with breast cancer patients and patients that have had mastectomies and have edema associated with that, but they don't want lower extremity cases. They don't like legs. There is only a few that do. They are right up to here with volume. They can't treat anymore. I don’t know what the answer is. That's in the city. I can't imagine what it's like out here. When you are outside the urban area of Phoenix and you are like in the country and you have got lymphedema, there is nothing to do. Like where do you go? Who do you go to? You drive 200 miles five days a week for lymphatic drainage. They will just give up and it's sad because they need more people like Heather and more people like you do that out there for this type of patient. Okay. Ulceration. Using the [indecipherable] [16:56] around the ankle areas where you see them but you can't see them kind of anywhere. They can be anything from little tiny ulcers all over the leg to this accumulation of ulcers in larger area. There is a soupy draining wound. They tend to get secondary infections and biofilms a lot. They create odor problems and they create social problems for patients. You know if you had one of your patients -- I can think about 10 of them right now. If I put that guy down right there and you all go for a break, he'd be alone. He'd be all by himself. He will be over there. Because they just smell so bad. The family can't take it and trying to do some odor management with these patients and help them with -- I will bring them into clinic three times a week if I have to and just clean them up real good, put a new dressing on them and manage just to get some of that edema down. It's only way to do it. They are not able to do this at home very effectively. So then these are problems with the wounds. I don't want to get into a whole wound discussion, but there is all kinds of products out there today.
One of my arguments says we have ton of products with limited data and lots of money. So which ones do we use? I am really tending to use things that are very absorptive and antimicrobial and trying to find ways to manage get rid of biofilms, keep the wound clean, keep the fluid down with this inexpensive product that I can find. Because some of them are just outrageous. That's blotch of scarring, corticosteroids help a little bit. Emollients for sure because it's very friable skin. They scratches and breaks and peels. And silicone dressing just like you would for any other kind of scar to improve scarring. You can apply a silicone dressing to these and improve that. Dermal disruption, ulceration, really the treatments are the same. When you have things like this, the roll dressings that help absorb fluid and move fluid away. This hydro-conductive roll that we're playing with now, I don't even know if it's on the market yet, but it's going to be one of your favorite dressings because it really works terrific in moving fluid away from the limb to the secondary dressing. You got to put something under it because it sticks because all things that absorb a lot of fluid have the potential to stick and be painful. So on a limb like these, we would put like ADAPTIC or some sort of non-sticky layer underneath and then put this hydroconductive over it or you just have to patch on all these -- how many like superabsorbents can you put on one patient and get it paid for. You would use 20, really, but can you get them all paid for that one patient? It's hard. Vasculitis. This is the kind of skin you see. Just treat the skin. Don't just treat the compression and the edema problems. Think about their social problems. These are patients that have -- you know, they have poor body image. They have poor family relationships. They eat poorly. They don't get out much. They are very depressed patients lots of the time.
And we need to encourage them and we need to teach them exercise. We need to give people hope. Need to like be there for them every week and be the kind of person that when they see you, that's a good day. So it's not like oh, crap. I have to admit that. I do this. I have this thing I tell the students, which is outside the room I see the patients come in and there is a little part of me that dies because this is like this guy is here again. And I tell him, you stand outside the door, you take a deep breath and you go. It's show time and you are the doctor they are here to see today. And when you walk out, you can be tired but you can't be tired when you go in. So varicose vein, surgical treatment, lots of surgeries out there possible for them, although they are only indicated certain small percentage of patients. You can't do perforator surgery on everybody that's out there. It's helpful in some patients but not in most. The guys that do perforator surgery turn down more patients that I send them than accept. And they send them back for just compression and wound care. But you can't go in there and ablate the perforators and reduce the pressure to the skin and get a short-term reduction in conditions that are causing the ulcer and have the ulcer improve. But I think they eventually -- that shuttles a ton of fluid to the deep system and they end up with problems associated with doing those things later. So you have to think it through. Make sure you have a good surgeon that knows how to do these. Non-operatives; physical therapy, massage, .lymph drainage, which we are going to see. Drug therapies; diuretics, benzopyrones, antimicrobials is all kinds of things to treat filariasis and various operative therapies that are effy as to whether they help with some of these problems. Diuretics, we already talked about. They are not really indicated to me on this lower extremity edema. They are indicated for reducing fluid overload in the system associated with systemic diseases and not lower extremity swelling.
Benzopyrones are used occasionally but they are not commonly used to treat edema. Anti-microbial agents, when you think the patient has an infection. Don't use them routinely all the time. Obviously, you don't want to develop resistant species on your patients and you will if you continue to use them regularly. Nutraceuticals. One of the things I have done is you know all these ads they have now about anti-inflammatory nutraceuticals like turmeric and stuff like that, that stuff actually works. It's actually anti-inflammatory. It actually does reduce inflammation. So almost all of my patients are out there are all on turmeric because they can't take anything else. They can't take NSAIDs but they can take turmeric and curcumin. Curcumin is the best herb out there. Horny Goat Weed. What a great name for herb. What do you take? Horny Goat Weed. Yes. Immunotherapy, if you have immunological problem. They are just giving me the hook over there. Gene therapy will be out there eventually. They may be able to do something to help induce some problems with gene related but this is not commonplace today. And that's another cartoon. I'm trying.
TAPE ENDS - [23:24]