Aesthetic Dermatology

Case Report

A 64-year-old woman presented to the Vanderbilt University Medical Center, Nashville, Tennessee, with right-sided abdominal pain, nausea, and dysuria of several days' duration 3 months after a cadaveric renal transplant and administration of cyclosporine and methylprednisolone. Pyelonephritis and acute tubular necrosis were diagnosed. Urine and blood cultures grew Escherichia coli and ultrasound imaging revealed ureteral obstruction of the transplanted kidney. Piperacillin/tazobactam and vancomycin were administered, and a right-sided nephrostomy tube was placed. One month later, the nephrostomy tube was removed and the ureter was reimplanted. The surgical wound, however, failed to close. Intravenous antibiotic administration was continued and wet-to-dry dressings were applied twice daily. In 3 days, the wound rapidly enlarged, became severely painful, and developed a black eschar. Despite repeated debridement, the black eschar would re-form within 24 hours after the procedure. Blood cultures were negative for fungus or bacteria but positive for cytomegalovirus. Piperacillin/tazobactam and vancomycin were continued, ganciclovir was added to the therapeutic regimen, and the dermatology department was consulted.

A large ulceration measuring 20X17 cm with a depth of 5.2 cm developed in the lower right quadrant of the abdomen (Figure 1). The ulcer base was pink, friable, and covered with a fragile black eschar. Histologic evaluation of the ulcer base revealed full-thickness epidermal necrosis, numerous neutrophils, and dermal edema (Figure 2). A superficial layer of hyphae and fungal fruiting bodies was noted (Figures 3 and 4). Tissue culture from the wound grew Aspergillus niger and a diagnosis of primary cutaneous aspergillosis was made.

PLEASE REFER TO THE PDF TO VIEW THE FIGURES

The patient underwent wide debridement of the abdominal wound and administration of maximal doses of liposomal amphotericin Β. Despite aggressive treatment, she rapidly deteriorated and died 14 days later. 

Comment

Aspergillus is a ubiquitous saprophytic mold that belongs to the class Ascomycetes and is commonly found in soil, water, and decaying vegetation.¹ Although rarely a pathogen in immunocompetent individuals, it commonly affects immunocompromised individuals and is second in incidence in this population (Candida infection is most prevalent).² The name Aspergillus was proposed in 1729 when Pietro Antonio Micheli, an Italian priest and biologist, noted that the organism resembled the aspergillum used to sprinkle holy water.³ To date, more than 900 species of Aspergillus have been defined. The most prevalent human pathogens include Aspergillus flavus, Aspergillus fumigatus, A niger, Aspergillus terreus, and Aspergillus ustus.^3-5

Risk factors for Aspergillus infection include inherited immunodeficiency disorders, organ transplantation, chronic corticosteroid and/or broad-spectrum antibiotic administration, cytotoxic chemotherapy, prolonged granulocytopenia, cirrhosis, diabetes mellitus, uremia, local tissue injury (ie, burn, surgical manipulation), underlying malignancy, chronic alcoholism, neonatal status, and cytomegalovirus infection.⁶ Risk factors specific to solid organ transplant recipients include prolonged surgeries; laparotomies, excluding those at transplantation; uremia; neutropenia; cytomegalovirus infection; and administration of high-dose corticosteroids, tacrolimus, or cyclosporine.⁷

Cutaneous aspergillosis is classically described as primary or secondary. Secondary disease occurs via hematogenous dissemination, often from a pulmonary focus, or by extension from a contiguous anatomic site.2 In primary cutaneous aspergillosis, breaks in the skin are directly inoculated by airborne spores or contaminated materials.⁸ The use of adhesive tape is a common risk factor. Intermittent stripping of the stratum corneum with dressing changes presumably induces sufficient mechanical trauma to permit infection following contact with contaminated arm boards, intravenous catheters, tape, or gauze.^8-14 Ongoing construction/renovation or air circulation systems harboring Aspergillus species may contribute to aerial dissemination of spores.^3,15 Potted plants in a hematology ward have been reported as a source of A terreus infection, and certain foods, especially pepper (ground black pepper) and tea (regular and herbal tea), have high rates of contamination with Aspergillus species.^16,17 Primary cutaneous aspergillosis begins as an erythematous fluctuant nodule that undergoes rapid ulceration, which produces a central black eschar.⁸A flavus is the most common pathogen in primary cutaneous aspergillosis, but infection with Aspergillus glaucus, A niger, A terreus, and A ustus also have been described.² Primary cutaneous aspergillosis in solid organ transplant recipients is uncommon, and to our knowledge, this is the first reported case caused by A niger. In this population, cutaneous aspergillosis can occur as a primary infection directly in the surgical wound or as nodules near a site of a break in the epidermis that is different than the primary surgical wound.⁹ Patients present with fever, changes in the wound surface, swelling, induration, and tenderness. Interestingly, primary cutaneous aspergillosis in solid organ transplant recipients generally occurs despite a neutrophil count within reference range.⁹ Rapid diagnosis can be made by potassium hydroxide examination of the wound as well as skin biopsy and tissue culture.¹⁵ Because Aspergillus tends to invade blood vessels of the dermis and subcutaneous tissues, biopsy specimens should be taken from the center of the lesion and should include subcutaneous fat. Mycelial forms of the organism may be found within the epidermis and dermis. Aspergillus is a dichotomous branching fungus with septate hyphae measuring 3 µm in diameter and branching at a 45º angle. The fruiting body rarely is observed in tissue samples unless an overwhelming number of organisms are present.^5,9,18 The fungal elements may be visualized with hematoxylin and eosin stain but are highlighted by Gomori methenamine-silver or periodic acid-Schiff stains. Tissue cultures should be grown in Sabouraud dextrose agar. The diagnosis of primary cutaneous aspergillosis can be made only after excluding other sites of infection.

Successful treatment of primary cutaneous aspergillosis requires a high index of suspicion, with early diagnosis and aggressive management. Primary cutaneous aspergillosis should be considered in the differential diagnosis of necrotizing skin lesions and nonhealing surgical wounds in immunosuppressed patients. Maximized immunosurveillance is critical and immunosuppressive medications should be decreased or discontinued if possible. Necrotic tissue requires debridement. However, as demonstrated in our patient, debridement alone may be insufficient for eradication of the infection, especially in immunocompromised patients. Antifungal antibiotics should be administered as soon as possible. The classic antimicrobial drug of choice is intravenous ampho- tericin Β.^2,3,19,20 This drug is fungicidal both in vitro and in vivo, with a low incidence of resistance.^21,22 However, studies have shown better survival rates with voriconazole compared with amphotericin Β as initial therapy for invasive aspergillosis.^23,24 Caspofungin combined with voriconazole also has been shown to be particularly effective as initial treatment of invasive aspergillosis in solid organ transplant recipients with renal dysfunction or A fumigatus infections.²⁵

Case Report

A 64-year-old woman presented to the Vanderbilt University Medical Center, Nashville, Tennessee, with right-sided abdominal pain, nausea, and dysuria of several days' duration 3 months after a cadaveric renal transplant and administration of cyclosporine and methylprednisolone. Pyelonephritis and acute tubular necrosis were diagnosed. Urine and blood cultures grew Escherichia coli and ultrasound imaging revealed ureteral obstruction of the transplanted kidney. Piperacillin/tazobactam and vancomycin were administered, and a right-sided nephrostomy tube was placed. One month later, the nephrostomy tube was removed and the ureter was reimplanted. The surgical wound, however, failed to close. Intravenous antibiotic administration was continued and wet-to-dry dressings were applied twice daily. In 3 days, the wound rapidly enlarged, became severely painful, and developed a black eschar. Despite repeated debridement, the black eschar would re-form within 24 hours after the procedure. Blood cultures were negative for fungus or bacteria but positive for cytomegalovirus. Piperacillin/tazobactam and vancomycin were continued, ganciclovir was added to the therapeutic regimen, and the dermatology department was consulted.

A large ulceration measuring 20X17 cm with a depth of 5.2 cm developed in the lower right quadrant of the abdomen (Figure 1). The ulcer base was pink, friable, and covered with a fragile black eschar. Histologic evaluation of the ulcer base revealed full-thickness epidermal necrosis, numerous neutrophils, and dermal edema (Figure 2). A superficial layer of hyphae and fungal fruiting bodies was noted (Figures 3 and 4). Tissue culture from the wound grew Aspergillus niger and a diagnosis of primary cutaneous aspergillosis was made.

PLEASE REFER TO THE PDF TO VIEW THE FIGURES

The patient underwent wide debridement of the abdominal wound and administration of maximal doses of liposomal amphotericin Β. Despite aggressive treatment, she rapidly deteriorated and died 14 days later. 

Comment

Aspergillus is a ubiquitous saprophytic mold that belongs to the class Ascomycetes and is commonly found in soil, water, and decaying vegetation.¹ Although rarely a pathogen in immunocompetent individuals, it commonly affects immunocompromised individuals and is second in incidence in this population (Candida infection is most prevalent).² The name Aspergillus was proposed in 1729 when Pietro Antonio Micheli, an Italian priest and biologist, noted that the organism resembled the aspergillum used to sprinkle holy water.³ To date, more than 900 species of Aspergillus have been defined. The most prevalent human pathogens include Aspergillus flavus, Aspergillus fumigatus, A niger, Aspergillus terreus, and Aspergillus ustus.^3-5

Risk factors for Aspergillus infection include inherited immunodeficiency disorders, organ transplantation, chronic corticosteroid and/or broad-spectrum antibiotic administration, cytotoxic chemotherapy, prolonged granulocytopenia, cirrhosis, diabetes mellitus, uremia, local tissue injury (ie, burn, surgical manipulation), underlying malignancy, chronic alcoholism, neonatal status, and cytomegalovirus infection.⁶ Risk factors specific to solid organ transplant recipients include prolonged surgeries; laparotomies, excluding those at transplantation; uremia; neutropenia; cytomegalovirus infection; and administration of high-dose corticosteroids, tacrolimus, or cyclosporine.⁷

Cutaneous aspergillosis is classically described as primary or secondary. Secondary disease occurs via hematogenous dissemination, often from a pulmonary focus, or by extension from a contiguous anatomic site.2 In primary cutaneous aspergillosis, breaks in the skin are directly inoculated by airborne spores or contaminated materials.⁸ The use of adhesive tape is a common risk factor. Intermittent stripping of the stratum corneum with dressing changes presumably induces sufficient mechanical trauma to permit infection following contact with contaminated arm boards, intravenous catheters, tape, or gauze.^8-14 Ongoing construction/renovation or air circulation systems harboring Aspergillus species may contribute to aerial dissemination of spores.^3,15 Potted plants in a hematology ward have been reported as a source of A terreus infection, and certain foods, especially pepper (ground black pepper) and tea (regular and herbal tea), have high rates of contamination with Aspergillus species.^16,17 Primary cutaneous aspergillosis begins as an erythematous fluctuant nodule that undergoes rapid ulceration, which produces a central black eschar.⁸A flavus is the most common pathogen in primary cutaneous aspergillosis, but infection with Aspergillus glaucus, A niger, A terreus, and A ustus also have been described.² Primary cutaneous aspergillosis in solid organ transplant recipients is uncommon, and to our knowledge, this is the first reported case caused by A niger. In this population, cutaneous aspergillosis can occur as a primary infection directly in the surgical wound or as nodules near a site of a break in the epidermis that is different than the primary surgical wound.⁹ Patients present with fever, changes in the wound surface, swelling, induration, and tenderness. Interestingly, primary cutaneous aspergillosis in solid organ transplant recipients generally occurs despite a neutrophil count within reference range.⁹ Rapid diagnosis can be made by potassium hydroxide examination of the wound as well as skin biopsy and tissue culture.¹⁵ Because Aspergillus tends to invade blood vessels of the dermis and subcutaneous tissues, biopsy specimens should be taken from the center of the lesion and should include subcutaneous fat. Mycelial forms of the organism may be found within the epidermis and dermis. Aspergillus is a dichotomous branching fungus with septate hyphae measuring 3 µm in diameter and branching at a 45º angle. The fruiting body rarely is observed in tissue samples unless an overwhelming number of organisms are present.^5,9,18 The fungal elements may be visualized with hematoxylin and eosin stain but are highlighted by Gomori methenamine-silver or periodic acid-Schiff stains. Tissue cultures should be grown in Sabouraud dextrose agar. The diagnosis of primary cutaneous aspergillosis can be made only after excluding other sites of infection.

Successful treatment of primary cutaneous aspergillosis requires a high index of suspicion, with early diagnosis and aggressive management. Primary cutaneous aspergillosis should be considered in the differential diagnosis of necrotizing skin lesions and nonhealing surgical wounds in immunosuppressed patients. Maximized immunosurveillance is critical and immunosuppressive medications should be decreased or discontinued if possible. Necrotic tissue requires debridement. However, as demonstrated in our patient, debridement alone may be insufficient for eradication of the infection, especially in immunocompromised patients. Antifungal antibiotics should be administered as soon as possible. The classic antimicrobial drug of choice is intravenous ampho- tericin Β.^2,3,19,20 This drug is fungicidal both in vitro and in vivo, with a low incidence of resistance.^21,22 However, studies have shown better survival rates with voriconazole compared with amphotericin Β as initial therapy for invasive aspergillosis.^23,24 Caspofungin combined with voriconazole also has been shown to be particularly effective as initial treatment of invasive aspergillosis in solid organ transplant recipients with renal dysfunction or A fumigatus infections.²⁵

Case Report

A 64-year-old woman presented to the Vanderbilt University Medical Center, Nashville, Tennessee, with right-sided abdominal pain, nausea, and dysuria of several days' duration 3 months after a cadaveric renal transplant and administration of cyclosporine and methylprednisolone. Pyelonephritis and acute tubular necrosis were diagnosed. Urine and blood cultures grew Escherichia coli and ultrasound imaging revealed ureteral obstruction of the transplanted kidney. Piperacillin/tazobactam and vancomycin were administered, and a right-sided nephrostomy tube was placed. One month later, the nephrostomy tube was removed and the ureter was reimplanted. The surgical wound, however, failed to close. Intravenous antibiotic administration was continued and wet-to-dry dressings were applied twice daily. In 3 days, the wound rapidly enlarged, became severely painful, and developed a black eschar. Despite repeated debridement, the black eschar would re-form within 24 hours after the procedure. Blood cultures were negative for fungus or bacteria but positive for cytomegalovirus. Piperacillin/tazobactam and vancomycin were continued, ganciclovir was added to the therapeutic regimen, and the dermatology department was consulted.

A large ulceration measuring 20X17 cm with a depth of 5.2 cm developed in the lower right quadrant of the abdomen (Figure 1). The ulcer base was pink, friable, and covered with a fragile black eschar. Histologic evaluation of the ulcer base revealed full-thickness epidermal necrosis, numerous neutrophils, and dermal edema (Figure 2). A superficial layer of hyphae and fungal fruiting bodies was noted (Figures 3 and 4). Tissue culture from the wound grew Aspergillus niger and a diagnosis of primary cutaneous aspergillosis was made.

PLEASE REFER TO THE PDF TO VIEW THE FIGURES

The patient underwent wide debridement of the abdominal wound and administration of maximal doses of liposomal amphotericin Β. Despite aggressive treatment, she rapidly deteriorated and died 14 days later. 

Comment

Aspergillus is a ubiquitous saprophytic mold that belongs to the class Ascomycetes and is commonly found in soil, water, and decaying vegetation.¹ Although rarely a pathogen in immunocompetent individuals, it commonly affects immunocompromised individuals and is second in incidence in this population (Candida infection is most prevalent).² The name Aspergillus was proposed in 1729 when Pietro Antonio Micheli, an Italian priest and biologist, noted that the organism resembled the aspergillum used to sprinkle holy water.³ To date, more than 900 species of Aspergillus have been defined. The most prevalent human pathogens include Aspergillus flavus, Aspergillus fumigatus, A niger, Aspergillus terreus, and Aspergillus ustus.^3-5

Risk factors for Aspergillus infection include inherited immunodeficiency disorders, organ transplantation, chronic corticosteroid and/or broad-spectrum antibiotic administration, cytotoxic chemotherapy, prolonged granulocytopenia, cirrhosis, diabetes mellitus, uremia, local tissue injury (ie, burn, surgical manipulation), underlying malignancy, chronic alcoholism, neonatal status, and cytomegalovirus infection.⁶ Risk factors specific to solid organ transplant recipients include prolonged surgeries; laparotomies, excluding those at transplantation; uremia; neutropenia; cytomegalovirus infection; and administration of high-dose corticosteroids, tacrolimus, or cyclosporine.⁷

Cutaneous aspergillosis is classically described as primary or secondary. Secondary disease occurs via hematogenous dissemination, often from a pulmonary focus, or by extension from a contiguous anatomic site.2 In primary cutaneous aspergillosis, breaks in the skin are directly inoculated by airborne spores or contaminated materials.⁸ The use of adhesive tape is a common risk factor. Intermittent stripping of the stratum corneum with dressing changes presumably induces sufficient mechanical trauma to permit infection following contact with contaminated arm boards, intravenous catheters, tape, or gauze.^8-14 Ongoing construction/renovation or air circulation systems harboring Aspergillus species may contribute to aerial dissemination of spores.^3,15 Potted plants in a hematology ward have been reported as a source of A terreus infection, and certain foods, especially pepper (ground black pepper) and tea (regular and herbal tea), have high rates of contamination with Aspergillus species.^16,17 Primary cutaneous aspergillosis begins as an erythematous fluctuant nodule that undergoes rapid ulceration, which produces a central black eschar.⁸A flavus is the most common pathogen in primary cutaneous aspergillosis, but infection with Aspergillus glaucus, A niger, A terreus, and A ustus also have been described.² Primary cutaneous aspergillosis in solid organ transplant recipients is uncommon, and to our knowledge, this is the first reported case caused by A niger. In this population, cutaneous aspergillosis can occur as a primary infection directly in the surgical wound or as nodules near a site of a break in the epidermis that is different than the primary surgical wound.⁹ Patients present with fever, changes in the wound surface, swelling, induration, and tenderness. Interestingly, primary cutaneous aspergillosis in solid organ transplant recipients generally occurs despite a neutrophil count within reference range.⁹ Rapid diagnosis can be made by potassium hydroxide examination of the wound as well as skin biopsy and tissue culture.¹⁵ Because Aspergillus tends to invade blood vessels of the dermis and subcutaneous tissues, biopsy specimens should be taken from the center of the lesion and should include subcutaneous fat. Mycelial forms of the organism may be found within the epidermis and dermis. Aspergillus is a dichotomous branching fungus with septate hyphae measuring 3 µm in diameter and branching at a 45º angle. The fruiting body rarely is observed in tissue samples unless an overwhelming number of organisms are present.^5,9,18 The fungal elements may be visualized with hematoxylin and eosin stain but are highlighted by Gomori methenamine-silver or periodic acid-Schiff stains. Tissue cultures should be grown in Sabouraud dextrose agar. The diagnosis of primary cutaneous aspergillosis can be made only after excluding other sites of infection.

Successful treatment of primary cutaneous aspergillosis requires a high index of suspicion, with early diagnosis and aggressive management. Primary cutaneous aspergillosis should be considered in the differential diagnosis of necrotizing skin lesions and nonhealing surgical wounds in immunosuppressed patients. Maximized immunosurveillance is critical and immunosuppressive medications should be decreased or discontinued if possible. Necrotic tissue requires debridement. However, as demonstrated in our patient, debridement alone may be insufficient for eradication of the infection, especially in immunocompromised patients. Antifungal antibiotics should be administered as soon as possible. The classic antimicrobial drug of choice is intravenous ampho- tericin Β.^2,3,19,20 This drug is fungicidal both in vitro and in vivo, with a low incidence of resistance.^21,22 However, studies have shown better survival rates with voriconazole compared with amphotericin Β as initial therapy for invasive aspergillosis.^23,24 Caspofungin combined with voriconazole also has been shown to be particularly effective as initial treatment of invasive aspergillosis in solid organ transplant recipients with renal dysfunction or A fumigatus infections.²⁵

BALTIMORE — The cutaneous adhesive Dermabond can be applied to the margins of a wound to buttress atrophied, thin skin enough to achieve adequate primary closure with sutures, Dr. Michael Bain reported at the annual meeting of the American Society of Plastic Surgeons.

Physicians have always had a difficult time suturing lacerations or defects created from the removal of cancer because sutures tear the skin of older patients with steroid-induced skin atrophy or genetically thin skin, said Dr. Bain, a plastic surgeon in private practice in Newport Beach, Calif.

"There are so many patients out there who in the past have needed skin grafting when they got a bad laceration," he said in an interview. "You could also use this technique in infants who have very thin skin."

After a standard wound preparation, Dermabond is applied 3 mm from the wound margins. Simple sutures placed either through or behind the Dermabond close the wound without tearing the skin. "You have to make certain that you don't get any Dermabond into the incision or into the wound because that will prevent healing," he said.

Dr. Bain has used the technique on about 15–20 patients without any problems. He said that his colleagues, as well as trauma surgeons, also have begun using the technique successfully.

By allowing the closure of wounds in thin skin, the technique may prevent the need for prolonged wound care, according to Dr. Bain, who presented the method on a poster. He and his coinvestigators have no conflicts of interest with regard to Ethicon Inc., the manufacturer of Dermabond.

The cutaneous adhesive, Dermabond, is applied 3 mm from the wound margins.

The healing wound is shown 3 weeks after the graft-sparing procedure. Photos courtesy Dr. Michael Bain

BALTIMORE — The cutaneous adhesive Dermabond can be applied to the margins of a wound to buttress atrophied, thin skin enough to achieve adequate primary closure with sutures, Dr. Michael Bain reported at the annual meeting of the American Society of Plastic Surgeons.

Physicians have always had a difficult time suturing lacerations or defects created from the removal of cancer because sutures tear the skin of older patients with steroid-induced skin atrophy or genetically thin skin, said Dr. Bain, a plastic surgeon in private practice in Newport Beach, Calif.

"There are so many patients out there who in the past have needed skin grafting when they got a bad laceration," he said in an interview. "You could also use this technique in infants who have very thin skin."

After a standard wound preparation, Dermabond is applied 3 mm from the wound margins. Simple sutures placed either through or behind the Dermabond close the wound without tearing the skin. "You have to make certain that you don't get any Dermabond into the incision or into the wound because that will prevent healing," he said.

Dr. Bain has used the technique on about 15–20 patients without any problems. He said that his colleagues, as well as trauma surgeons, also have begun using the technique successfully.

By allowing the closure of wounds in thin skin, the technique may prevent the need for prolonged wound care, according to Dr. Bain, who presented the method on a poster. He and his coinvestigators have no conflicts of interest with regard to Ethicon Inc., the manufacturer of Dermabond.

The cutaneous adhesive, Dermabond, is applied 3 mm from the wound margins.

The healing wound is shown 3 weeks after the graft-sparing procedure. Photos courtesy Dr. Michael Bain

BALTIMORE — The cutaneous adhesive Dermabond can be applied to the margins of a wound to buttress atrophied, thin skin enough to achieve adequate primary closure with sutures, Dr. Michael Bain reported at the annual meeting of the American Society of Plastic Surgeons.

Physicians have always had a difficult time suturing lacerations or defects created from the removal of cancer because sutures tear the skin of older patients with steroid-induced skin atrophy or genetically thin skin, said Dr. Bain, a plastic surgeon in private practice in Newport Beach, Calif.

"There are so many patients out there who in the past have needed skin grafting when they got a bad laceration," he said in an interview. "You could also use this technique in infants who have very thin skin."

After a standard wound preparation, Dermabond is applied 3 mm from the wound margins. Simple sutures placed either through or behind the Dermabond close the wound without tearing the skin. "You have to make certain that you don't get any Dermabond into the incision or into the wound because that will prevent healing," he said.

Dr. Bain has used the technique on about 15–20 patients without any problems. He said that his colleagues, as well as trauma surgeons, also have begun using the technique successfully.

By allowing the closure of wounds in thin skin, the technique may prevent the need for prolonged wound care, according to Dr. Bain, who presented the method on a poster. He and his coinvestigators have no conflicts of interest with regard to Ethicon Inc., the manufacturer of Dermabond.

The cutaneous adhesive, Dermabond, is applied 3 mm from the wound margins.

The healing wound is shown 3 weeks after the graft-sparing procedure. Photos courtesy Dr. Michael Bain

BALTIMORE — Oasis wound matrix provides a low-maintenance scaffold for split-thickness skin graft donor sites to grow new epidermis over several weeks without significant pain for the patient, Dr. James C. Yuen said in a poster presented at the annual meeting of the American Society of Plastic Surgeons.

Since Oasis was approved by the Food and Drug Administration in 2000, few articles have been published on its use, none of which describes using it for dressing split-thickness skin graft donor sites, according to Dr. Yuen of the division of plastic and reconstructive surgery at the University of Arkansas, Little Rock.

Oasis is derived from porcine intestinal mucosa and acts as an extracellular matrix to support cell adherence, he said.

The material contains key components of the dermal extracellular matrix (collagen, elastin, glycosaminoglycans, glycoproteins, proteoglycans, and growth hormones) to promote rapid cellular proliferation and capillary ingrowth.

During 2003–2006, Dr. Yuen and his colleague, Dr. Julio Hochberg, also of the university, used Oasis to reepithelialize split-thickness skin graft donor sites on the thighs of 131 patients.

Epithelialization was complete after 1–3 weeks in all but two patients who had delayed healing beyond 1 month. Few patients experienced significant pain at the donor site because the material protects nerve endings, the investigators suggested.

Once Oasis is placed directly over the wound, Xeroform (Kendall Inc.) is placed to cover the matrix, followed by nonadherent Telfa gauze (Kendall), 4-by-4-inch dry gauze pads, and then Tegaderm tape (3M Health Care) for smaller donor sites or a circumferential wrap with Kerlix (Kendall) for larger sites. Dr. Yuen said that neither he nor Dr. Hochberg has any conflicts of interest with the manufacturers of any the products used in the procedure.

The investigators typically changed the dressing 4–6 days after surgery, but it was done earlier if there was excessive drainage soaking through the dressing.

Subsequent dressing changes occurred every 2–3 days, leaving the Oasis wound matrix and Xeroform in place each time.

The scab-like wound matrix peels off easily after reepithelialization is complete, Dr. Yuen said.

BALTIMORE — Oasis wound matrix provides a low-maintenance scaffold for split-thickness skin graft donor sites to grow new epidermis over several weeks without significant pain for the patient, Dr. James C. Yuen said in a poster presented at the annual meeting of the American Society of Plastic Surgeons.

Since Oasis was approved by the Food and Drug Administration in 2000, few articles have been published on its use, none of which describes using it for dressing split-thickness skin graft donor sites, according to Dr. Yuen of the division of plastic and reconstructive surgery at the University of Arkansas, Little Rock.

Oasis is derived from porcine intestinal mucosa and acts as an extracellular matrix to support cell adherence, he said.

The material contains key components of the dermal extracellular matrix (collagen, elastin, glycosaminoglycans, glycoproteins, proteoglycans, and growth hormones) to promote rapid cellular proliferation and capillary ingrowth.

During 2003–2006, Dr. Yuen and his colleague, Dr. Julio Hochberg, also of the university, used Oasis to reepithelialize split-thickness skin graft donor sites on the thighs of 131 patients.

Epithelialization was complete after 1–3 weeks in all but two patients who had delayed healing beyond 1 month. Few patients experienced significant pain at the donor site because the material protects nerve endings, the investigators suggested.

Once Oasis is placed directly over the wound, Xeroform (Kendall Inc.) is placed to cover the matrix, followed by nonadherent Telfa gauze (Kendall), 4-by-4-inch dry gauze pads, and then Tegaderm tape (3M Health Care) for smaller donor sites or a circumferential wrap with Kerlix (Kendall) for larger sites. Dr. Yuen said that neither he nor Dr. Hochberg has any conflicts of interest with the manufacturers of any the products used in the procedure.

The investigators typically changed the dressing 4–6 days after surgery, but it was done earlier if there was excessive drainage soaking through the dressing.

Subsequent dressing changes occurred every 2–3 days, leaving the Oasis wound matrix and Xeroform in place each time.

The scab-like wound matrix peels off easily after reepithelialization is complete, Dr. Yuen said.

BALTIMORE — Oasis wound matrix provides a low-maintenance scaffold for split-thickness skin graft donor sites to grow new epidermis over several weeks without significant pain for the patient, Dr. James C. Yuen said in a poster presented at the annual meeting of the American Society of Plastic Surgeons.

Since Oasis was approved by the Food and Drug Administration in 2000, few articles have been published on its use, none of which describes using it for dressing split-thickness skin graft donor sites, according to Dr. Yuen of the division of plastic and reconstructive surgery at the University of Arkansas, Little Rock.

Oasis is derived from porcine intestinal mucosa and acts as an extracellular matrix to support cell adherence, he said.

The material contains key components of the dermal extracellular matrix (collagen, elastin, glycosaminoglycans, glycoproteins, proteoglycans, and growth hormones) to promote rapid cellular proliferation and capillary ingrowth.

During 2003–2006, Dr. Yuen and his colleague, Dr. Julio Hochberg, also of the university, used Oasis to reepithelialize split-thickness skin graft donor sites on the thighs of 131 patients.

Epithelialization was complete after 1–3 weeks in all but two patients who had delayed healing beyond 1 month. Few patients experienced significant pain at the donor site because the material protects nerve endings, the investigators suggested.

Once Oasis is placed directly over the wound, Xeroform (Kendall Inc.) is placed to cover the matrix, followed by nonadherent Telfa gauze (Kendall), 4-by-4-inch dry gauze pads, and then Tegaderm tape (3M Health Care) for smaller donor sites or a circumferential wrap with Kerlix (Kendall) for larger sites. Dr. Yuen said that neither he nor Dr. Hochberg has any conflicts of interest with the manufacturers of any the products used in the procedure.

The investigators typically changed the dressing 4–6 days after surgery, but it was done earlier if there was excessive drainage soaking through the dressing.

Subsequent dressing changes occurred every 2–3 days, leaving the Oasis wound matrix and Xeroform in place each time.

The scab-like wound matrix peels off easily after reepithelialization is complete, Dr. Yuen said.

WASHINGTON — Monotherapy may not be enough in the treatment of diabetic wound infections.

These infections are not caused by the planktonic or individual cellular form of mainly single-species bacteria proliferating in the wound, but rather are caused by a complex, multicell vegetative mixed-bacterial state known as a biofilm, which has to be treated as a unique and dangerous organism in its own right, if treatment is to prove effective, according to Dr. Randall Wolcott, of the department of microbiology and immunology at Texas Tech University, Lubbock.

The medical biofilm concept of infection is a fairly new one, and a recent review noted that almost every bodily system is affected by a biofilm disease, said Dr. Wolcott at a meeting sponsored by George Washington University Hospital.

He estimated that every year, more than 10 million people come down with biofilm diseases, from endocarditis to necrotizing fasciitis, which translates to more than 500,000 people a year who die from the disease.

And if all these infections are really biofilms, then the next therapeutic step is to move from antibiotic monotherapies to include the use of antibiofilm agents and aggressive treatments, Dr. Wolcott said.

His recommended combined treatment is only in its infancy, but it involves frequent, very aggressive debridement, coupled with biocide treatments that include heavy metal agents such as silver, gallium, and selenium. It is important to rotate treatments in order to prevent selective adaptation of the biofilm, which can happen not in weeks or months, but in days.

It is also critical to include the use of specific antibiofilm agents such as lactoferrin and xylitol, which are approved by the Food and Drug Administration for other purposes. He has even experimentally used predatory bacteriophages and various plant extracts known for their antibiofilm properties. Ultimately, "once you suppress the biofilm below a certain level … the wound starts contracting" and normal host healing can begin, he said.

This understanding is very new, and few people are being trained enough to understand it as yet. "I just got a [2007] medical microbiology text and it does not mention biofilms," he said.

However, physicians see biofilms in diabetic foot wounds every day without realizing it: the so-called slough that physicians routinely remove, or not, said Dr. Wolcott. Many physicians believe slough is merely a mixture of white blood cells, protein, and deteriorated host tissue, but it is actually part of a complex biofilm—and one that will return, if even "one cell remains" still virulent, exactly as before without proper treatment.

Once bacteria attach to a wounded surface, "they form a microcolony. Once they reach a critical density, they start form-sensing, and they rise up above the surface and they start forming all these complex structures. One of those structures infests itself around the vasculature and they invade the host down through the vascular system. [They also] rise up over the surface for community defenses," he said.

This vegetative state behaves like a single organism "made of billions of billions of cells" including multiple bacterial species. A large portion of this "organism"—and he stressed treating it as such—includes gluey, sugar-protein matrices formed within the first 5 minutes of biofilm development. These protect the bacteria from harm by walling them off—not only from the host immune system, but also from many of the treatments that are used, Dr. Wolcott said.

Within 30 minutes, the biofilm is rising from the surface. It is controlled centrally by various intercellular communication molecules that act almost like hormones, and it reproduces by vegetative breaking and single-cell "seeds."

The biofilm components summon white blood cells, with their phagocytic enzymes, which actually can provide nutrients for the biofilm; this explains much of the biochemistry we see, according to Dr. Wolcott.

The bacteria give up their individuality and live for the colony, with different regions producing different proteins. One clinically important factor is that there are portions of the biofilm where the cells upregulate gene transfer to create phenotypic and genotypic diversity to survive. This includes the potential for transferring antibiotic resistance across species.

Dr. Wolcott had no disclosures other than the use of materials that are not FDA approved for these indications.

WASHINGTON — Monotherapy may not be enough in the treatment of diabetic wound infections.

These infections are not caused by the planktonic or individual cellular form of mainly single-species bacteria proliferating in the wound, but rather are caused by a complex, multicell vegetative mixed-bacterial state known as a biofilm, which has to be treated as a unique and dangerous organism in its own right, if treatment is to prove effective, according to Dr. Randall Wolcott, of the department of microbiology and immunology at Texas Tech University, Lubbock.

The medical biofilm concept of infection is a fairly new one, and a recent review noted that almost every bodily system is affected by a biofilm disease, said Dr. Wolcott at a meeting sponsored by George Washington University Hospital.

He estimated that every year, more than 10 million people come down with biofilm diseases, from endocarditis to necrotizing fasciitis, which translates to more than 500,000 people a year who die from the disease.

And if all these infections are really biofilms, then the next therapeutic step is to move from antibiotic monotherapies to include the use of antibiofilm agents and aggressive treatments, Dr. Wolcott said.

His recommended combined treatment is only in its infancy, but it involves frequent, very aggressive debridement, coupled with biocide treatments that include heavy metal agents such as silver, gallium, and selenium. It is important to rotate treatments in order to prevent selective adaptation of the biofilm, which can happen not in weeks or months, but in days.

It is also critical to include the use of specific antibiofilm agents such as lactoferrin and xylitol, which are approved by the Food and Drug Administration for other purposes. He has even experimentally used predatory bacteriophages and various plant extracts known for their antibiofilm properties. Ultimately, "once you suppress the biofilm below a certain level … the wound starts contracting" and normal host healing can begin, he said.

This understanding is very new, and few people are being trained enough to understand it as yet. "I just got a [2007] medical microbiology text and it does not mention biofilms," he said.

However, physicians see biofilms in diabetic foot wounds every day without realizing it: the so-called slough that physicians routinely remove, or not, said Dr. Wolcott. Many physicians believe slough is merely a mixture of white blood cells, protein, and deteriorated host tissue, but it is actually part of a complex biofilm—and one that will return, if even "one cell remains" still virulent, exactly as before without proper treatment.

Once bacteria attach to a wounded surface, "they form a microcolony. Once they reach a critical density, they start form-sensing, and they rise up above the surface and they start forming all these complex structures. One of those structures infests itself around the vasculature and they invade the host down through the vascular system. [They also] rise up over the surface for community defenses," he said.

This vegetative state behaves like a single organism "made of billions of billions of cells" including multiple bacterial species. A large portion of this "organism"—and he stressed treating it as such—includes gluey, sugar-protein matrices formed within the first 5 minutes of biofilm development. These protect the bacteria from harm by walling them off—not only from the host immune system, but also from many of the treatments that are used, Dr. Wolcott said.

Within 30 minutes, the biofilm is rising from the surface. It is controlled centrally by various intercellular communication molecules that act almost like hormones, and it reproduces by vegetative breaking and single-cell "seeds."

The biofilm components summon white blood cells, with their phagocytic enzymes, which actually can provide nutrients for the biofilm; this explains much of the biochemistry we see, according to Dr. Wolcott.

The bacteria give up their individuality and live for the colony, with different regions producing different proteins. One clinically important factor is that there are portions of the biofilm where the cells upregulate gene transfer to create phenotypic and genotypic diversity to survive. This includes the potential for transferring antibiotic resistance across species.

Dr. Wolcott had no disclosures other than the use of materials that are not FDA approved for these indications.

WASHINGTON — Monotherapy may not be enough in the treatment of diabetic wound infections.

These infections are not caused by the planktonic or individual cellular form of mainly single-species bacteria proliferating in the wound, but rather are caused by a complex, multicell vegetative mixed-bacterial state known as a biofilm, which has to be treated as a unique and dangerous organism in its own right, if treatment is to prove effective, according to Dr. Randall Wolcott, of the department of microbiology and immunology at Texas Tech University, Lubbock.

The medical biofilm concept of infection is a fairly new one, and a recent review noted that almost every bodily system is affected by a biofilm disease, said Dr. Wolcott at a meeting sponsored by George Washington University Hospital.

He estimated that every year, more than 10 million people come down with biofilm diseases, from endocarditis to necrotizing fasciitis, which translates to more than 500,000 people a year who die from the disease.

And if all these infections are really biofilms, then the next therapeutic step is to move from antibiotic monotherapies to include the use of antibiofilm agents and aggressive treatments, Dr. Wolcott said.

His recommended combined treatment is only in its infancy, but it involves frequent, very aggressive debridement, coupled with biocide treatments that include heavy metal agents such as silver, gallium, and selenium. It is important to rotate treatments in order to prevent selective adaptation of the biofilm, which can happen not in weeks or months, but in days.

It is also critical to include the use of specific antibiofilm agents such as lactoferrin and xylitol, which are approved by the Food and Drug Administration for other purposes. He has even experimentally used predatory bacteriophages and various plant extracts known for their antibiofilm properties. Ultimately, "once you suppress the biofilm below a certain level … the wound starts contracting" and normal host healing can begin, he said.

This understanding is very new, and few people are being trained enough to understand it as yet. "I just got a [2007] medical microbiology text and it does not mention biofilms," he said.

However, physicians see biofilms in diabetic foot wounds every day without realizing it: the so-called slough that physicians routinely remove, or not, said Dr. Wolcott. Many physicians believe slough is merely a mixture of white blood cells, protein, and deteriorated host tissue, but it is actually part of a complex biofilm—and one that will return, if even "one cell remains" still virulent, exactly as before without proper treatment.

Once bacteria attach to a wounded surface, "they form a microcolony. Once they reach a critical density, they start form-sensing, and they rise up above the surface and they start forming all these complex structures. One of those structures infests itself around the vasculature and they invade the host down through the vascular system. [They also] rise up over the surface for community defenses," he said.

This vegetative state behaves like a single organism "made of billions of billions of cells" including multiple bacterial species. A large portion of this "organism"—and he stressed treating it as such—includes gluey, sugar-protein matrices formed within the first 5 minutes of biofilm development. These protect the bacteria from harm by walling them off—not only from the host immune system, but also from many of the treatments that are used, Dr. Wolcott said.

Within 30 minutes, the biofilm is rising from the surface. It is controlled centrally by various intercellular communication molecules that act almost like hormones, and it reproduces by vegetative breaking and single-cell "seeds."

The biofilm components summon white blood cells, with their phagocytic enzymes, which actually can provide nutrients for the biofilm; this explains much of the biochemistry we see, according to Dr. Wolcott.

The bacteria give up their individuality and live for the colony, with different regions producing different proteins. One clinically important factor is that there are portions of the biofilm where the cells upregulate gene transfer to create phenotypic and genotypic diversity to survive. This includes the potential for transferring antibiotic resistance across species.

Dr. Wolcott had no disclosures other than the use of materials that are not FDA approved for these indications.

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.