A 2-month-old infant presented to the emergency department with hemorrhagic shock secondary to a rapidly enlarging lower extremity vascular lesion. The lower extremity soft tissue abnormality had been noted soon after birth and was being observed for progressive growth. The patient’s parents noted spontaneous rupture of the lesion with significant bleeding, which prompted this presentation. Upon admission to the hospital and after hemodynamic stabilization, a lesion biopsy was performed. The patient was diagnosed with fibrosarcoma, and chemotherapy was begun. Although initial chemotherapy was well tolerated, the protocol was changed when genetic test results encouraged the initiation of targeted therapy. The patient’s immediate clinical state at presentation to the emergency department and medical floor required resuscitation with a red blood cell transfusion, platelets, and granulocyte growth factors because thrombocytopenia and neutropenia were also present.
Once hemodynamically stable and receiving the targeted regimen, the patient was discharged home. His very large, open fibrosarcoma was managed by plastics with topical antibiotic ointment, petrolatum-impregnated gauze, and Kerlix gauze (Covidien, Dublin, Ireland). The mass was located on the medial interphase between the ankle and foot, at the joint area; therefore, the patient was given a plastic foot-supporting prosthesis to avoid foot drop. The author was consulted to help with care approximately 3 to 4 weeks after discharge (Figure 1).
The tissue mass was receding, yet the open wound had not made progress toward healing; it was still large, almost fungating, with an unpleasant smell, thin exudate, no granulation tissue, and jagged base. The parents were afraid to clean the area well and only gently wiped the surface. In addition, the patient had tracheomalacia and poor tolerance for oral feeding. The author was concerned about the adequacy of nutrition and the amino acids status for optimal healing. The patient’s diet was changed to calorie- and protein-enriched formula to optimize nutrition. Wound management was changed to an antimicrobial skin and wound cleanser (BIAKŌS; Sanara MedTech, Fort Worth, TX) with each dressing change (every 3 days) and hydrophobic dialkylcarbamoyl chloride outer dressing to decrease likely colonization between cleaning sessions and provide physical coverage for the next 2 weeks. The solution was tested on a small area for 10 minutes before full application.
At the next appointment, 8 days later, the wound was smaller, clean, and drier. The patient’s mother was excited that the foul smell was eliminated. Unfortunately, granulation tissue growth was not appreciated. Hydrolyzed collagen powder (Hycol; Sanara MedTech, Fort Worth, TX) was added to the regimen. The parents were taught to cleanse the wound first by applying the antimicrobial cleanser to the wound directly, then moistening a gauze with the cleanser and allowing it to stay on the wound for 2 to 3 minutes, after which gently but thoroughly cleaning the outside wound bed with water and allowing it to dry. The second step was to apply hydrolyzed collagen powder, cover with a hydrocolloid polyester contact mesh layer (UrgoTul; Urgo Medical North America, Fort Worth, TX), and finally outer Kerlix (Figure 2). This was repeated every 4 to 5 days.
When the patient returned 10 days later, healthy granulation tissue was visible. In addition, areas of epithelial islands were developing (Figure 3 and Figure 4). The wound healed completely within 6 weeks of the management change (Figure 5).