Cath Lab Digest

History and Wound Description

Ms. M, a 69-year-old patient, developed shingles localized to her right back and shoulder area in February 2000. She complained of severe pain. On examination, she had an area of multiple partial- and full-thickness eschar of approximately 10 cm that was dry and sunken below the surface level. Ms. M's skin was dry and black in many areas on her back and posterior shoulder, and a central necrotic major area was dry and hard (see Figure 1). In addition, the eschar was retracting and placing the surrounding normal skin under tension and causing pain.

Diagnosis

Ms. M had a severe case of shingles. Herpes zoster or shingles is a viral infection that results in the development of erythematous pustules that erupt and can be painful and drain. Most cases are self-limited and will resolve without actual ulcer formation or eschar. However, they can leave scars from the inflammatory process. This is an unusually extreme case where the pustules coalesced and formed a large ulcerated area. When it became dry, the ulcer developed dry eschar.

Treatment

After discussing possible options, we recognized the need to hydrate the wound before we could attempt any type of debridement. An amorphous hydrogel (DuoDERM® hydroactive gel, ConvaTec, a Bristol Myers Squibb Company, Princeton, NJ) was used to help soften the eschar. However, once it became hydrated, we assumed some drainage would occur; therefore, calcium alginate (Kaltostat®, ConvaTec, a Bristol Myers Squibb Company, Princeton, NJ) was placed at the bottom of the wound edge before covering the wound with a transparent covered hydrocolloid (SignaDress®, ConvaTec, a Bristol Myers Squibb Company, Princeton, NJ). The alginate would help absorb and control any heavy drainage that might occur. The alginate was placed along the bottom edge of the primary product being used and at the wound's edge because the patient was quite active. Otherwise, gravity would pull the drainage toward the bottom of the wound, resulting in leakage beneath the dressing.

Three days after treatment was initiated, we noted to our surprise and delight that 30% of the black eschar had already loosened to the point where the physician was able to gently debride it with pickups and scissors and cause no pain or bleeding. Ms. M said she felt much better because the wound was now covered and not exposed. The tightness of the skin was resolving and her pain was reduced. The physician now felt confident that the wound regimen was appropriate. Ms. M and her husband were instructed on how to do the dressing change every 2 to 3 days based on drainage and the appearance of the hydrocolloid, which had a special marking line that indicated when it was time to be changed. Because only slight to moderate drainage was evident, the alginate and hydrogel were not necessary at this time.

Ms. M's physician saw her 2 weeks later. The remaining necrotic tissue had lifted and separated so it could again gently be debrided in the office. Moist wound healing allowed this wound to improve without surgical debridement or the use of enzymatic agents or frequent dressings. Ms. M's last visit for this problem was 3 weeks later. The wound was completely healed and dressings were discontinued.

Discussion

This case of severe shingles demonstrates that moist wound healing is a technique that can be used for a wide variety of wounds. By following basic principles of wound care, this wound healed very rapidly. A simple hydrogel was used first to soften the eschar. In 3 days with the help of a hydrocolloid dressing, the wound was hydrated and the eschar softened. The hesitancy in treating this patient with moist wound healing was the result of the physician's unfamiliarity with this disease's process regarding response to moist wound healing. This accounted for the physician's desire to re-examine the patient after 3 days of treatment.