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Article published Feb 4, 2008 Healing an old wound New treatment gives Maryville woman hope after 25 years
By Ginny Baxter Methodist Medical Center of Oak Ridge
It began with a sunburned ankle in June 1983 and became a decades-long battle with a painful wound that would not heal.
Loretta Bryan, 72, of Maryville suffered a severe sunburn 25 years ago. As the burn began to fade, itchy dots appeared on the skin around her right ankle. Bryan saw a dermatologist in South Carolina, where she lived at the time. He unsuccessfully treated the condition with dressings and eventually performed a biopsy.
“The biopsy showed that I had a small vessel disease called atrophie blanche. It’s very rare … one in a million,” she said.
Atrophie blanche is a inflammation of small arteries in the skin. It is caused by the body developing an immune reaction to its own tissue. The typical patient is a middle-aged woman, and wounds usually develop on the legs and ankles.
The area where tissue was removed for Bryan’s biopsy did not heal. Her dermatologist used various compression bandages on the now larger wound, but none of the treatments helped for very long.
Eventually, she found another dermatology clinic. “They tried different dressings, and the ulcer still wouldn’t heal,” she said. “Then I went to the dermatology clinic at Duke University Medical Center. The wound would heal up and break down.
“I couldn’t walk for any length of time,” she added. “Sometimes, I used a walker.”
As the years passed, Bryan saw various dermatologists, wound specialists at Duke, vascular surgeons, and a pain specialist. Treatments included injections of heparin, an anti-clotting drug; a procedure called “apheresis” and more bandages containing various medications.
“I was allergic to the heparin, and it didn’t help, anyway,” Bryan noted. Apheresis involved inserting IVs into each of her arms, removing white cells, cleansing them, and returning them to her blood.
“It helped a little, but it was a one time shot.”Not going away
Ten years ago, Bryan developed another non-healing ulcer on the other side of her right foot. She attributes it to her underlying small blood vessel disease.
Her health problems continued to mount. A blockage developed in her thigh, and she had to have stents implanted. Stents are tiny tubes placed inside blood vessels to keep the vessels open and allow blood to flow properly.
About five years ago, Bryan moved to East Tennessee and began seeing a vascular surgeon in Knoxville. “He tried different medications, but couldn’t do much for me.” She also continued to see doctors at Duke.
A year ago, Bryan learned about new wound treatment technology in Oak Ridge from her daughter, who works for a home health agency. One of the daughter’s patients was receiving treatment at the wound center.
Bryan became a patient of Dr. David Stanley, medical director of the Methodist Medical Center Wound Treatment Center and a board-certified vascular surgeon with specialized training in wound care. He did a thorough evaluation and discovered that Bryan had some important circulation problems that had not been previously diagnosed and were interfering with the healing process.The root of the problem
Doctors had been treating the atrophie blanche and a disease of the large arteries without realizing that Bryan also had severe vein problems and scar tissue in her leg around the ulcers.
“Treatment of the veins with medication and compression dressings could not be successful because of inadequate oxygen flow to the damaged tissue,” Dr. Stanley explained.
He thought a new treatment called hyperbaric oxygen therapy might improve the oxygen problem and promote healing.
“No one has reported treating atrophie blanche with hyperbaric oxygen therapy to my knowledge,” Stanley said. “I have seen only two or three cases of it in my vascular surgery experience and none this severe.” Even so, he thought the treatment might help, and it has.
During hyperbaric treatment, a patient rests in a comfortable hyperbaric chamber and breathes pure oxygen that is gradually pressurized. Each treatment lasts about 90 minutes. By inhaling pure oxygen under pressure in the chamber, patients dissolve more oxygen in their red blood cells and plasma. The oxygen circulates throughout the body, reaching tissues that are not receiving enough oxygen under normal circumstances. This action promotes healing.Road to wellness
“It’s a big improvement. After about 50 treatments, my ulcers are much, much smaller,” Bryan said. Stanley stopped hyperbaric treatment before the ulcers healed completely in the hope that they would heal without additional treatment. According to Bryan, the ulcers have not changed since hyperbaric treatments ended, and she will have several more treatments in the near future.
Apligraf® is another new treatment that Bryan has received. She had a traditional skin graft, but it was only partially successful. Apligraf is a living, skin-like graft substance that is grown in a laboratory from human skin cells. Applying it to a wound is easy and painless. Unlike conventional skin grafts, patients do not undergo surgery. No skin has to be removed from another part of the patient’s body for a graft, which means there is no new wound that could be as difficult to heal as the original ulcer.
Like human skin, Apligraf has an outer protective layer of cells and an inner layer of cells that are important in healing. The healing process is promoted by the ability of these cells to provide structural support, growth factors and specialized proteins to the chronic wound.
“Mrs. Bryan is a very motivated and cooperative patient, and with careful follow-up by our vascular surgery specialists, she has a very good long-term prognosis,” according to Stanley.
“We have consulted vascular surgery specialists, who are assisting in the artery and vein problems,” he added. “After her ulcers are completely healed, Mrs. Bryan will need some minor vein surgery and light support hose to avoid recurrent ulcers. The wound center will also follow her skin oxygen levels, and she will continue the medications prescribed for small artery disease.”