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Author Archives: drogunlana

  HomeDr. Babajide A. Ogunlana, DPM, FACFAS Wes  |  Articles by: drogunlana
Author drogunlana Categories Foot & Ankle Disorder, Medical 1 Comment on A Guide To Non-Opioid Alternatives For Pain Management

A Guide To Non-Opioid Alternatives For Pain Management

In the midst of the ongoing opioid crisis, this author emphasizes obtaining thorough patient and medication histories, strategies for minimizing opioid use, and maximizing the benefits of non-opioid alternatives.

Patients often present for treatment aimed at alleviating pain and improving their quality of life. As physicians in the age of the opioid crisis, we are torn between acting as responsible stewards of opioid treatment while providing enough medication to alleviate pain, which is often surgically-induced. As we try to understand and follow evolving guidelines, policies and rules on pain management, we need to broaden our understanding and, most importantly, be open to utilizing available alternatives.

While there are many resources regarding pain and opioids, there is not much evidence-based data for physicians to follow. The Centers for Medicare and Medicaid Services (CMS), state departments of public health and human services (DPHHS) programs, health insurance carriers, big box pharmacies and hospitals all have their own programs. The Centers for Disease Control and Prevention, however, provides some clinical practice guidelines, including a mobile app.1

 

Understanding The Importance Of Patient Communication In Pain Management

Informing a patient of the risks of addiction and use of opioids is just as important as informing them about the risks and complications of a particular procedure. Start the conversation about post-operative pain control prior to scheduling surgery. Be realistic about surgically-induced pain and the modalities available to decrease this pain. Increase your patients’ understanding that medication will decrease but not eliminate their pain.

Have a conversation about which medications you will prescribe, the limited number of pills you will provide and/or the number of planned refills, even if it is zero. Provide supporting references to hospital, pharmacy or insurance policies regarding opioid-naïve patients and chronically opioid-exposed patients. Be prepared to treat pain in patients recovering from addiction as well, which requires additional consideration.

Are our psychosocial histories adequate? Do we know if our patients have a history of previous chronic opioid use or addiction, psychological or sexual abuse, anxiety, depression or bipolar disease or tobacco, alcohol or illicit drug abuse? Are they facing socioeconomic challenges?

These are all risk factors for long term post-operative opioid use, chronic opioid dependence and future addiction. Limiting and/or eliminating opioid use in this population may prevent future addiction.2

During the postoperative period, keep an open dialogue with patients. These phone calls or office visits should serve as a reminder regarding the healing process and the progression of post-operative pain levels. Take this opportunity to remind them about non-opioid alternative pain management techniques, such as those recommended by the American Pain Society.3

 

What You Should Know About A Multifaceted Approach To Non-Opioid Surgical Pain Management

Multi-modal pain management is optimal for all pain control, not just surgical pain. Providers have many options from which to choose.

Local anesthetics. This begins with adequate pedal and regional blocks (with or without ultrasound guidance). Neuraxial anesthesia and peripheral nerve blocks are excellent for pain prevention and relief. Despite the use of general anesthesia, local infiltration with pedal and regional blocks using local anesthetics are still beneficial prior to any incision.4

Local infiltration of Exparel® (Pacira BioSciences), a newly marketed encapsulated liposomal bupivacaine preparation, can be an excellent postoperative choice. This non-opioid agent can provide 48 to 72 hours of anesthesia. It is important to note that Exparel is contraindicated for intra-articular use.5 The FDA may be reviewing additional long-acting injectable local anesthetic preparations in the next few years.

Gabapentinoids. When employing gabapentin or pregabalin (Lyrica®, Pfizer), it is best to administer these medications at least two hours prior to surgery. These drugs shut down excitatory neurotransmitters and decrease upregulation of the central nervous system. However, these drugs do depress the respiratory system so one should exercise caution with these medications for patients who are at high risk for respiratory depression.

Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Whether one opts for IV or oral administration, these drugs do have a place in perioperative pain management. These medications decrease the release of pro-inflammatory prostaglandins and peripheral pain mediators.

In a presentation at a symposium on postoperative pain, David L. Nelson MD, an orthopedic hand surgeon, provided an excellent guideline for perioperative use of multimodal pain prevention and management in the orthopedic patient.6 His protocol includes the following steps:

1. Discuss the issue of pain with the patient before surgery.

2. Utilize a NSAID (naproxen sodium or celecoxib) and long-acting acetaminophen the morning of surgery.

3. Use lidocaine in the incisional area preoperatively.

4. Ensure careful tissue handling.

5. Utilize 0.5% marcaine with epinephrine in the surgical site postoperatively.

6. Have the patient use a NSAID (naproxen sodium or celecoxib) and long-acting acetaminophen after surgery.

7. Phone the patient on the first postoperative day to reinforce the pain management protocol.

8. Ask patients about their postoperative pain.

Ketamine. This is an effective drug agonist of the N-methyl-D-aspartate (NMDA) receptors and has become an adjunct intraoperatively. It continues to be more popular in the treatment of chronic opioid-dependent patients and those recovering from addiction.7 I recommend having a conversation with your local anesthesiologist about the use of this drug in your operative patients.

Alpha-2 agonists. Clonidine and dexmedetomidine hydrochloride (Precedex™, Pfizer) can be useful agents. These drugs can provide sedation, decreased anxiety, sympatholytic effects and analgesia. However, it is important to be aware that they can cause bradycardia and hypotension due to their effect on blood flow.

Non-Opioid Pain Control Options In The Non-Surgical Patient

Podiatrists also see a significant number of non-surgical patients that need to manage pain. Although the approaches and options may differ, there are multiple diverse choices that one can employ.

NSAIDs and acetaminophen. In my experience, these are among the main treatment options that most patients and physicians use to manage pain. In a recent lecture at the annual meeting of the American Academy of Pain Medicine, Brian Hainline, MD, maintained that acetaminophen in particular is “vastly, vastly under-prescribed” for acute pain.8 Dr. Hainline noted that acetaminophen and appropriate use of an anti-inflammatory drug can actually augment each other. For athletes who have pain but want to compete the same day, if they don’t have any biomechanical limitations, acetaminophen is a viable option for pain management, according to Dr. Hainline, the Chief Medical Officer of the National Collegiate Athletic Association.8

Massage and soaking. Massage for 10 to 20 minutes can be beneficial for pain management, in my experience. An adjunctive option, massage may decrease pain and muscular tension, and one can supplement this with traditional pain-relieving topical preparations such as IcyHot®. Essential oils such as peppermint oil, lavender oil, black pepper oil, juniper oil, arnica oil and rosemary oil have also been more in vogue recently.9

Soaking the feet, lower extremities and body can have a relaxing effect, which relieves anxiety, and subsequently decreases pain levels in patients. Traditional soaking preparations have Epsom salt bases that reportedly provide magnesium through the skin, relieving muscular aches.10 Other alternatives include adding one half-cup of apple cider vinegar and one half-cup of Epsom salt to one quart of warm water. Magnesium deficiency is often found in patients with fibromyalgia, migraine and chronic muscle spasms.10

Sleep. Sleep disturbances worsen chronic pain and musculoskeletal diseases.11 Establishing a regular sleep pattern should be a top priority. For those having trouble sleeping due to pain, one may initially consider over-the-counter preparations, such as diphenhydramine-based preparations or melatonin. Physicians must never overlook sleep apnea and refer patients to sleep medicine specialists when necessary for treatment.11

 

Could Complementary Therapies And Diet Changes Have An Impact In Pain Reduction?

Complementary modalities can have a place in providing pain control and improving health. The National Center for Complementary and Alternative Health can provide a wealth of information on this topic.12

Herbs and supplements. Turmeric is the most common herbal preparation people use to decrease inflammation.12 Researchers have suggested that eight to 12 weeks of turmeric extract 1,000 mg/day can reduce arthritic symptoms similar to the improvement patients may get with naproxen or diclofenac.13

Glucosamine chondroitin, according to the National Center for Complementary and Integrative Health, is a safe and well tolerated supplement.14 Glucosamine chondroitin can provide relief from osteoarthritic symptoms when patients take it in recommended doses. However, physicians must remember that glucosamine chondroitin may interfere with warfarin and high doses of the medication may harm the kidneys, and interfere with glucose metabolism in those with diabetes.14 

Anti-inflammatory diets. Getting any patient to change his or her diet can be extremely difficult. That said, diet modification can be a great addition to pain treatment and when it is successful, patients have expressed remarkable improvement in my clinical experience. Increased body mass index (BMI) is associated with increased pain, anxiety, fatigue and decreased activity, and quality of life in patients with fibromyalgia.15

Patients with pain should avoid inflammatory foods such as refined grains (rice, white potatoes, pasta, and bread), deep fried foods, pre-packaged/fast foods, corn oil, dairy products, soda, trans fats, margarines and grain-fed meats. Conversely, one should consume anti-inflammatory foods such as raw nuts, sweet potatoes, root vegetables, green tea, wild caught fish, bone broths, eggs, dark chocolate, garlic olive oil, coconut oil, avocado, green leafy vegetables and berries regularly. These changes may improve BMI and be beneficial to the patient’s general health.15

 

What About The Roles Of Cognitive Behavioral Therapy And Relaxation Techniques?

Cognitive behavioral therapy and relaxation techniques. Cognitive behavioral therapy addresses some of the underlying issues, such as anxiety, fear, distress and avoidance, that make the perception of physical pain worse.16 Counseling provides the opportunity for support groups along with the introduction to self-management techniques for coping and relaxation.16

Periodic deep breathing and meditation can be helpful. Movement with meditation such as yoga and tai chi can be extremely beneficial in increasing relaxation with range of motion, stretching and toning exercises.16

 

Where Do Opioids Fit In A Multimodal Approach To Pain?

While there a variety of non-opioid options for pain management, opioids still may play a role in treatment algorithms. However, it is essential to ensure proper opioid stewardship.

In the area of perioperative pain control, I follow the motto “give patients only what they need.”

Why should we limit the number of opioids we prescribe?

The Centers for Disease Control and Prevention (CDC) reports that 20 percent of patients who are still taking opioids at 10 days postoperatively will continue to take opioids a year later. That figure rises to 40 percent for those on opioids at 30 days post-op.17 The CDC also notes that 32 percent of opioid addicts report their first exposure from someone else’s medical supply.4

Despite these alarming numbers, in a recent survey in Outpatient Surgery magazine, 44 percent of physicians noted they do not decrease the number of opioids they prescribe due to the convenience of fewer postoperative phone calls from patients.4

There are relatively recent CDC guidelines on chronic pain management.1 Overall, they serve as excellent reminder of the risks of combining medications as well as reinforcing that we should provide the lowest amount of opioid medication for the shortest time possible. However, what is the magic number or should there be one?

Many resources recommend three days of opioid medication with reassessment at that time.1,18

Published limits for an initial prescription in an opioid-naïve patient range from five to seven days of opioids and a maximum of 50 morphine milligram equivalents (MMEs) or less per day.18 No longer should physicians provide prescriptions for 35, 40, 50 or 60 pills.

Some limits on opioid prescriptions are written into state laws. In the state of Michigan, the Michigan Opioid Prescribing Engagement Network (OPEN) has been in place since 2016 with the support of the Michigan Department of Public Health and Human Services, Blue Cross/Blue Shield and the Institute for Healthcare Policy and Innovation at the University of Michigan. This network has released evidence-based opioid prescription guidelines for 25 different surgeries.19 However, we should remember that we may need to be flexible based on a patient’s individual needs.

We won’t address the emerging role of cannabinoids in pain control in this article. We can’t list all of the alternative treatments or modalities available. However, it is important for the provider to realize that we don’t understand exactly how much pain experienced by an individual is due to structural/physical changes versus the body’s response to psychosocial stressors.

 

In Conclusion

As prescribers, it is our responsibility to understand a variety of ways to help our patients control pain adequately and safely. In an age when opioid addiction continues to grow, familiarity and comfort with alternative options to supplement or replace opioids may help improve outcomes and avoid risk.

Dr. Painter is the Immediate Past President for the American Board of Podiatric Medicine, and is in practice in Great Falls, Montana. She is an Adjunct Professor at the Pacific Northwest College of Osteopathic Medicine and an Adjunct Professor of Podiatry at the Idaho College of Osteopathic Medicine.

References
  1. Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain. Available at: https: www.cdc.gov/drugoverdose/prescribing/guideline.html . Published August 28, 2019. Accessed April 15, 2020.
  2. PainEDU. Improving pain treatment through education. Available at: www.painedu.org . Accessed April 15, 2020.
  3. American Academy of Pain Medicine. AAPM pain treatment guidelines. https://drogunlana.com/2020/05/05/aspirin-for-prevention/ . Accessed May 5, 2020.
  4. Cook D. A nation in crisis. Outpatient Surgery. 2020:10-16. Available at: http://magazine.outpatientsurgery.net/i/1198986-special-edition-opioids-january-2020-subscribe-to-outpatient-surgery-magazine/0 . Published January 2020. Accessed April 21, 2020.
  5. Pacira BioSciences. Exparel website. Available at: www.exparel.com . Accessed April 15, 2020.
  6. Nelson DL. Managing surgical pain in the opioid epidemic era. Symposium presented at: 2014 American Academy of Orthopedic Surgeons Annual Meeting. March 11-15, 2014. New Orleans, La. Available at: http://www.davidlnelson.md/PainSymposium2014AAOS.htm  Accessed April 16, 2020.
  7. Ye F, Wu Y, Zhou C. Effect of intravenous ketamine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Medicine (Baltimore). 2017;96(51):e9147.
  8. Hainline B. Pain management in athletes. Lecture presented at: American Academy of Pain Medicine Annual Meeting. February 28, 2020. Vancouver, BC.
  9. Sparks D. Home remedies: what are the benefits of aromatherapy? Mayo Clinic News Network website. Available at: https://newsnetwork.mayoclinic.org/discussion/home-remedies-what-are-the-benefits-of-aromatherapy/ . Published May 8, 2019. Accessed April 17, 2020.
  10. Why take an Epsom salt bath? WebMD. Available at: https://www.webmd.com/a-to-z-guides/epsom-salt-bath#1. Reviewed July 20, 2017. Accessed April 21, 2020.
  11. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552.
  12. National Center for Complementary and Integrative Health website. Available at: https://www.nccih.nih.gov/. Accessed April 17, 2020.
  13. Daily JW, Yang M, Park S. Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. J Med Food. 2016;19(8):717-729.
  14. National Center for Complementary and Integrative Health. Glucosamine and chondroitin for osteoarthritis. Available at: https://www.nccih.nih.gov/health/glucosamine-and-chondroitin-for-osteoarthritis. Accessed April 21, 2020.
  15. Brusca SB, Abramson SB, Scher JU. Microbiome and mucosal inflammation as extra-articular triggers for rheumatoid arthritis and autoimmunity. Curr Opin Rheumatol. 2014;26(1):101-107.
  16. Schubiner H. Mindfulness, CBT and ACT for chronic pain. Psychology Today. Available at: https://www.psychologytoday.com/us/blog/unlearn-your-pain/201412/mindfulness-cbt-and-act-chronic-pain . Published December 8, 2014. Accessed April 21, 2020.
  17. Hoots BE, Xu L, Kariisa M, et al. 2018 annual surveillance report of drug-related risks and outcomes. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf . Accessed April 21, 2020.
  18. Centers for Disease Control and Prevention. Calculating total daily dose of opioids for safer dosage. Available at: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf . Accessed April 21, 2020.
  19. Opioid Prescribing Engagement Network. Prescribing recommendations. Available at: https://michigan-open.org/prescribing-recommendations/ . Updated February 25, 2020. Accessed April 21, 2020.
May 05, 2020
Volume 33 – Number 5 – May 2020
By Gina Painter, DPM, FACFAS, FACPM, FFRCPS, Glasg.

Addressing Impingement Issues After Total Ankle Replacement
Author drogunlana Categories Medical 0 comment

Addressing Impingement Issues After Total Ankle Replacement

As total ankle replacements (TARs) become more prevalent, it is essential for surgeons to be able to properly assess and address complications. Impingement of the bone or soft tissues can be a significant cause of pain after TAR. With this in mind, the authors provide salient diagnostic insights and offer perspective on conservative and surgical treatments for impingement, including open and arthroscopic repair. 

Total ankle replacement (TAR) is becoming an increasingly viable treatment method for ankle arthritis. Researchers have shown that TAR is a non-inferior option to ankle arthrodesis and recent data even demonstrates a trend toward better quality of life in patients who had TAR in comparison to those who had a tibiotalar arthrodesis.1-3 Due to continued improvements in technique and implant design, there has been an increase of published data on long-term survivorship of total ankle arthroplasty.4 Despite these improvements, there are still common postoperative complications surgeons may need to address.4-6

A common but often aggravating complication is gutter pain secondary to soft tissue or bony impingement. Multiple total ankle designs reportedly cause symptomatic gutter impingement in patients post-operatively.7-11 In a 2013 study involving four different ankle replacement systems and a total of 489 procedures, Schubert and colleagues reported a seven percent incidence of symptomatic gutter impingement.12 The exact etiology behind painful malleolar gutters following TAR remains unclear but the causes seem to be complex and multifactorial in nature. Potential inciting factors include technical error, ectopic bone formation, implant design, oversized components, inadequate ligamentous balancing, undercorrection of varus/valgus deformity or component loosening.9,12-15 

Pertinent Pearls In The Diagnosis Of Ankle Impingement After TAR 

The diagnosis of true ankle impingement following total ankle replacement hinges on history and physical exam in combination with radiographic evidence. The pain is localized upon palpation of the medial and lateral gutters. Additionally, eliciting pain with range of motion of the ankle joint in the sagittal and coronal planes may help localize the area of impingement. Symptoms of focal gutter pain usually present three to six months following implantation as the patient increases activity.14 

One then correlates the clinical findings with radiographic evidence, most commonly in the form of heterotopic ossification or abutment of the talar implant against the malleoli. Although osteophytes and ectopic bone ossification may be common following TAR, studies show that heterotopic ossification may not be associated with functional outcomes.16,17 Therefore, it is important to assess the clinical relevance of ossifications in relation to gutter pain. Heterotopic ossification may or may not coincide with synovial impingement following total ankle replacement.18

When there is uncertainty, utilizing other diagnostic tools may be beneficial. Employing computed tomography (CT) can allow surgeons to further assess the positioning of the prosthetic component and osseous impingements. Computed tomography is preferable to magnetic resonance imaging (MRI) because artifacts secondary to the metallic components may impede detailed assessment.19 

Diagnostic injection with local anesthetic is another useful tool in localizing the area of pain. Due to varus or valgus deformity in the ankle joint, patients often have limited use of the posterior tibial or peroneal tendons prior to ankle replacement. After correction of the deformity, patients may commonly experience inflammation and pain in those tendons because of increased activity. A diagnostic injection within the ankle joint or tendon sheaths can help delineate whether the pain is extra-articular in nature or secondary to impingement.

Conservative Treatment For Impingement After TAR: What You Need To Know 

Before considering another surgery to address gutter impingement pain following total ankle replacement, one should exhaust conservative treatments. In the early post-operative period, the patient may aggravate gutter pain from increasing activity in concurrence with post-operative inflammation. Patients may benefit from a few weeks of offloading with immobilization, rest or bracing.

Intra-articular corticosteroid injections offer another conservative treatment that can help decrease inflammation in the capsular tissues of the ankle joint. With this reduced inflammation, the reduced pressure from the thickened capsular tissue may help relieve the impingement within the medial or lateral gutters. It is important to clean the outside of the ankle prior to injection with betadine or chlorhexidine gluconate swabs so as to avoid infection to the prostheses. Also, one should avoid contacting the needle with the metallic implant as this can accelerate wear.

While it is possible that these conservative treatments may provide symptom relief, there are no current studies, to our knowledge, that assess the efficacy of these treatments for impingement symptoms following total ankle replacement.

Assessing Surgical Options For Post-TAR Ankle Impingement 

Prophylactic gutter resection is not part of the surgical technique with most available TAR systems. However, in our opinion and experience, certain prostheses such as the Scandinavian Total Ankle Replacement (STAR™, Stryker) allow for gutter decompression through talar margin resection. Schuberth and colleagues found that patients who had prophylactic gutter debridement had a significantly lower incidence of secondary gutter resection than those who did not.12 

Gaudot and colleagues have also identified mobile-bearing implant systems as a potential cause of malleolar gutter pain because of the excessive subluxation of the polyethylene insert.19 Thus, adopting a fixed-bearing implant design may avoid gutter impingement. Yet the evidence is unclear on whether there is a significant difference between the two types of prostheses.

If a surgeon encounters painful malleolar gutters following TAR, it is paramount to identify the underlying cause for proper treatment. Technical error leading to malpositioning of the prosthesis is a common cause of gutter impingement pain (see top image to the left). In cases in which pain is due to malpositioned prostheses, surgeons may need to perform periprosthetic osteotomies (supramalleolar or inframalleolar) or revisional arthroplasty (see bottom image to left) to correct the deformity. The goal is to realign the joint in order to take pressure off of the symptomatic gutter. In instances of mild malposition of the prothesis, upsizing of the polyethylene insert is an option to alleviate symptoms through increased separation of the tibial and talar components.14 However, one must carefully consider the potential loss in range of motion.

Osseous overgrowth causing impingement may also attribute to aseptic loosening of the talar component.20 In such instances, a CT scan can provide a detailed assessment of the bone stock beneath the talar component. Bone cyst curettage and bone grafting may be beneficial in conjunction with resection of the osseous overgrowth. Cyst recurrence is common and complete filling of each individual cyst is often difficult.21 Therefore, revisional arthroplasty or even ankle arthrodesis may be the only solutions.

If one addresses malalignment or aseptic loosening of the prosthesis appropriately, one can perform malleolar gutter debridement through an arthroscopic or open approach.22-24 A 2.9 mm, 70-degree scope is ideal for malleolar gutter debridement. Use of an ankle distractor is the surgeon’s preference.22-24 Utilizing a combination of the shaver and grasper, the surgeon should continue to debride the gutters until there is distinct visualization of clear space between the talar bone/component and the malleoli. Once the debridement is complete, one should be able to fit the shaver within the gutters without difficulty. The advantage of arthroscopic debridement is a quicker return to activity as opposed to the open approach. However, there is significant risk of damaging the ankle components with the arthroscopic instruments due to a confined space to use the instrumentation. It is important to avoid contact to the metallic components with the shaver or burr. One must also be aware of the reflection off of the metallic component when entering the ankle joint with the shaver or burr (see top image to the right). If the surgeon is not cognizant of the orientation of the instrumentation, he or she may unintentionally damage the ankle components, and leave inflammatory debris within the ankle joint.

Debridement through an open approach allows for easier visualization and consequently a more thorough debridement of the malleolar gutters. An open approach may also decrease operating time. In instances of posterior gutter impingement secondary to ectopic ossification, an open arthrotomy is the preferred treatment option. This allows for direct visualization of the neurovascular structures that are in close proximity and difficult to avoid through an arthroscopic approach. For the open approach, one makes the incision directly over the painful gutter, taking care to protect neurovascular and tendinous structures. The surgeon can employ osteotomes and electric burrs to resect osteophytes and ectopic ossifications.

Postoperatively, patients that undergo debridement through an open ankle arthrotomy should be non-weightbearing in a posterior splint for approximately two weeks with subsequent physical therapy and progression back to regular shoes. Conversely, the patients that have arthroscopic debridement may immediately perform protected weightbearing and begin physical therapy after the first post-operative visit at one week.

Concluding Thoughts 

Total ankle prostheses continue to show improvement in long-term survivorship with each evolution of implant design. Accordingly, as prostheses show increasing longevity, complications will perpetually arise following total ankle replacement. Impingement issues after total ankle replacement are a common but complex complication that require careful consideration for management. Detailed preoperative and postoperative assessments of the patient are necessary in order to properly treat symptomatic gutter impingement. Surgeons should understand the underlying causes contributing to painful impingement so they can properly address them in conjunction with gutter debridement.

Dr. Chu is a Foot and Ankle Fellow with Coordinated Health-Lehigh Valley in Bethlehem, Pa. 

Dr. Brigido is the Director of the Coordinated Health-Lehigh Valley Fellowship in Bethlehem, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. Dr. Brigido is board-certified in foot surgery and rearfoot/ankle surgery. 

References

1. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007;89(9):1899-1905.

2. Saltzman CL, Mann RA, Ahrens JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009;30(7):579-596.

3. Dalat F, Trouillet F, Fessy MH, Bourdin M, Besse JL. Comparison of quality of life following total ankle arthroplasty and ankle arthrodesis: retrospective study of 54 cases. Orthop Traumatol Surg Res. 2014;100(7):761-766.

4. Clough T, Bodo K, Majeed H, Davenport J, Karski M. Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants. Bone Joint J. 2019;101-B(1):47-54.

5. Rippstein PF, Huber M, Naal FD. Management of specific complications related to total ankle arthroplasty. Foot Ankle Clin N Am. 2012;17:707-717.

6. Jonck JH, Myerson MS. Revision total ankle replacement. Foot Ankle Clin N Am. 2012;17(4):687-706.

7. Koivu H, Kohonen I, Mattila K, Loyttyniemi E, Tiusanen H. Long-term results of Scandinavian Total Ankle Replacement. Foot Ankle Int. 2017;38(7):723-731.

8. Cerrato R, Myerson MS. Total ankle replacement: the Agility LP prosthesis. Foot Ankle Clin. 2008;13(3):485-494.

9. Rippstein PF, Huber M, Coetzee JC, Naal FD. Total ankle replacement with use of a new three-component implant. J Bone Joint Surg Am. 2011;93(15):1426-1435.

10. Harston A, Lazarides AL, Adams SB Jr, DeOrio JK, Easley ME, Nunley JA 2nd. Midterm outcomes of a fixed-bearing total ankle arthroplasty with deformity analysis. Foot Ankle Int. 2017;38(12):1295-1300.

11. Nunley JA, Adams SB, Easley ME, DeOrio JK. Prospective randomized trial comparing mobile-bearing and fixed-bearing total ankle replacement. Foot Ankle Int. 2019;40(11):1239- 1248.

12. Schuberth JM, Babu NS, Richey JM, Christensen JC. Gutter impingement after total ankle arthroplasty. Foot Ankle Int. 2013;34(3):329- 337.

13. Gross CE, Adams SB, Easley M, Nunley JA 2nd, DeOrio JK. Surgical treatment of bony and soft-tissue impingement in total ankle arthroplasty. Foot Ankle Spec. 2017;10(1):37-42.

14. Schuberth JM, Wood DA, Christensen JC. Gutter impingement in total ankle arthroplasty. Foot Ankle Spec. 2016;9(2):145-158.

15. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger ASE. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am. 2011;93(9):830-839.

16. Choi WJ, Lee JW. Heterotopic ossification after total ankle arthroplasty. J Bone Joint Surg Br. 2011;93(11):1508-1512.

17. Bemenderfer TB, Davis WH, Anderson RB, et al. Heterotopic ossification in total ankle arthroplasty: case series and systematic review. J Foot Ankle Surg. 2020. [Epub ahead of print] Available at: https://www.jfas.org/article/ S1067-2516(19)30452-1/fulltext . Published January 16, 2020. Accessed April 14, 2020.

18. Besse J, Bevernage BD, Leemrijse T. Revision of total ankle replacements. Tech Foot Ankle Surg. 2011;10(4):176-188.

19. Gaudot F, Colombier J-A, Bonnin M, Judet T. A controlled, comparative study of a fixed-bearing versus mobile-bearing ankle arthroplasty. Foot Ankle Int. 2014;35(2):131-140.

20. Younger A, Penner M, Wing K. Mobile-bearing total ankle arthroplasty. Foot Ankle Clin. 2008;13(3):496-508.

21. Besse J-L, Lienhart C, Fessy M-H. Outcomes following cyst curettage and bone grafting for the management of periprosthetic cystic evolution after AES total ankle replacement. Clin Podiatr Med Surg. 2013;30(2):157-170.

22. Richardson AB, DeOrio JK, Parekh SG. Arthroscopic debridement: effective treatment for impingement after total ankle arthroplasty. Curr Rev Musculoskelet Med. 2012;5(2)171-175.

23. Shirzad K, Viens NA, DeOrio JK. Arthroscopic treatment of impingement after total ankle arthroplasty: technique tip. Foot Ankle Int. 2011;32(7):727-729.

24. Kim BS, Choi WJ, Kim J, Lee JW. Residual pain due to soft-tissue impingement after uncomplicated total ankle replacement. Bone Joint J. 2013;95-B(3):378-383.

May 04, 2020
Volume 33 – Number 5 – May 2020
Pages: 26 – 29
By Anson K. Chu, DPM, AACFAS and Stephen A. Brigido, DPM, FACFAS
Author drogunlana Categories LifeStyle, Medical 0 comment

Could COVID Toes Be An Emerging Acro-Ischemia Symptom Of The COVID-19 Virus?

By Nicholas A. Campitelli, DPM, FACFAS and Kelly Kubiak DPM

COVID-19, caused by the novel coronavirus named SARS-CoV-2, causes a variety of clinical symptoms with the most common symptoms being a dry cough, fever, myalgia and fatigue.1 Less common symptoms include dyspnea, sputum production and diarrhea. However, as the COVID-19 virus continues to spread across the world, new information about the disease is emerging all the time.

One now hears the term COVID toes being noted when patients who have the COVID-19 virus present with extremity symptoms. These patients may or may not carry an official diagnosis of COVID-19. These patients may present with a digital ischemic appearance of purplish or red lesions on their toe(s) that are often painful.2 However, one could easily confuse the presentation of such symptoms for frostbite, Raynaud’s disease or chilblains. Most reports of such a phenomenon are seen primarily in younger populations with or without other symptoms.3

The exact cause of these symptoms is still unknown. One prominent theory involves a likely underrecognized vascular component to the disease.4 The COVID-19 virus is known to attack cells in the lung via the angiotensin converting enzyme 2 (ACE2) receptor. The ACE2 receptor is not limited to just the lungs. It is also found in other organs including the heart, kidney and intestines. The ACE2 receptor is also found on endothelial cells that line vessels throughout the whole circulatory system, including the very small vessels in the toes.4 Researchers out of the Pathology and Cardiology Departments from University Hospital Zurich, in Zurich, Switzerland speculate that the virus attaching in these small vessels results in the vascular symptoms now known as COVID toes.4

What Recent Case Reports Reveal About COVID Toes

As information on the novel coronavirus continues to evolve, more research on COVID toes may emerge. In a recent report out of China, Zhang and colleagues discussed seven critical patients with the COVID-19 virus, who had an average age of 59 years and clinical symptoms including finger/toe cyanosis, skin bullae and dry gangrene to the digits. These patients also reportedly had prolonged prothrombin time (PT), an elevated D-dimer level and diagnosed disseminated intravascular coagulation (DIC). Five of the seven patients ended up dying from the COVID-19 virus.5 

However, most reports on COVID toes come from various news media and seem to be in younger age groups with many of these patients not having any respiratory symptoms.3 A press release from the French National Union of Dermatologists and Venereologists warns of skin manifestations of COVID-19 that the group classifies as acrosyndromes.2 This group defines symptoms as the appearance of pseudo-frostbite, a sudden appearance of persistent and sometimes painful redness, and transient hive lesions on the fingers and/or toes.2

In a recent case study out of Italy from the International Federation of Podiatrists, Mazzotta and Troccoli describe self-healing lesions in children and adolescents, and believe the etiology is vascular in nature.3 Kerri Purdy, MD, FRCPC, president of the Canadian Dermatology Association, also agrees with a vascular origin.6 In a recent interview, Dr. Purdy stated that the presentation is similar to chilblains but she believes the etiology is vascular, not thermal, in nature. She attributes it to small vessel blockages as emerging evidence points to the COVID-19 virus contributing to a hypercoagulable state.6

Physicians in France and Spain also report lower extremity symptoms in various younger populations.2,3 As the aforementioned report out of China shows, COVID toe is not limited to the young but may possibly be the only symptom present in a patient with the COVID-19 virus.5

Our Experience With A Possible Presentation Of COVID-Related Pedal Symptoms

Here one can see a photograph of the patient taken at initial presentation on April 6, 2020. Her chief concern was severely painful reddish and purple lesions to her toes bilaterally. On April 6, 2020, a 13-year-old female presented to the office complaining of severely painful reddish and purple lesions to her toes bilaterally (see top two photos to right). Her symptoms began several weeks Here one can see a photograph of the patient taken at initial presentation on April 6, 2020. Her chief concern was severely painful reddish and purple lesions to her toes bilaterally. earlier and an ER physician originally treated this as cellulitis with an antibiotic. The condition eventually spread to multiple toes with blisters developing on some of the lesions (see next two photos to right). The pain was so severe the patientHere one can see a photo taken prior to presentation to the author's office, on March 31, 2020. Her symptoms were present for a few weeks, with pain making shoe gear intolerable. could not tolerate shoes.

The initial presentation was consistent with Raynaud’s disease as it was almost certainly some Here one can see a photograph taken by the patient's mother one day prior to presentation at the author's office. Even with treatment by the ER for presumed cellulitis, the lesions progressed and some even blistered.type of vasculopathy. The patient denied trauma and did not exhibit any signs or symptoms of infection. The patient had palpable dorsalis pedis and posterior tibial pulses, a sluggish capillary refill time and toes cool to the touch consistent with Raynaud’s disease. The family shared this suspicion as they noted a family history of Raynaud’s disease. At this time, this seemed to be the most likely diagnosis. We dispensed a prescription for nitroglycerin paste for the patient’s pain and symptoms.

Over ten days after presentation to the author's office, the patient related improvement in symptoms, as seen in these photos.Ten days later, the patient reported an improvement in her symptoms and clinical presentation, which was confirmed with pictures sent by the patient’s mother (see next two photos to right).

Over ten days after presentation to the author's office, the patient related improvement in symptoms, as seen in these photos.At this point in time, similar symptoms began to appear in reports of children around the world connected to COVID-19. Further questioning of the patient and her mother confirmed that the patient had a serious flu-like condition the previous month. There were also siblings in the household who had exhibited a fever, sore throat and cough approximately two weeks in duration. These siblings also tested negative for influenza and strep. When the patient began experiencing exhaustion and shortness of breath, she never had testing for influenza due to her siblings’ negative status. She did, however, test negative for mononucleosis. Her pediatrician prescribed an antibiotic and an inhaler. She did not receive a COVID-19 test.

Anecdotally, we learned through social media of a 13-year-old male from the same school of the first patient who exhibited similar symptoms and painful complaints about his toes. His symptoms had a six-week duration and consisted of erythema Here one can see a photo of a 13-year-old male from same school of the first patient who exhibited similar symptoms and painful complaints about his toes. His symptoms had a six-week duration and consisted of erythema and pain to his toes. and pain to his toes (see bottom two images to right). The erythema eventually progressed to purpuric-appearing lesions on all of the toes very similar in nature to the previous patient. His Here one can see a photo of a 13-year-old male from same school of the first patient who exhibited similar symptoms and painful complaints about his toes. His symptoms had a six-week duration and consisted of erythema and pain to his toes. pediatrician prescribed oral steroids three weeks after the initial presentation of symptoms and this treatment eventually allowed the patient to tolerate shoe gear. This patient displayed no clinical symptoms of the COVID-19 virus and had no other pertinent findings such as fever or dermatological lesions elsewhere. Accordingly, the patient was not tested for COVID-19 at that time.

In Conclusion

The aforementioned cases provide anecdotal evidence of two patients in the same geographic area who presented with symptoms that are possibly consistent with COVID toes albeit without a confirmed diagnosis of the COVID-19 virus. Both patients were in their early teens and early reports have suggested that COVID toes appear to be most prevalent in this age group.3 Both patients described color changes and a painful presentation with four to six weeks of symptoms before noting improvement. Only one of the patients exhibited crusted lesions as noted in an aforementioned report out of France.2 One patient had other symptoms suggestive of the COVID-19 virus and the other patient did not. This is consistent with similar findings in another recent report out of Spain that noted COVID toe in both symptomatic and asymptomatic patients.7 While these authors recommended topical corticosteroid treatment for patients with these lesions, other cautions exist regarding the use of systemic steroids in patients with the COVID-10 virus so practitioners should exercise caution in this population.7,8 

For the presented patients above, improvement occurred with nitroglycerin paste and topical steroids respectively.  It may be prudent to also suggest that similar patients exercise caution and self-quarantine due to the possible association with the COVID-19 virus.

At the present time, there is limited, if any, true scientific literature to guide clinical decision making in the diagnosis of these questionable COVID toes. This presents difficulty in presenting a possible diagnosis yet to be proven scientifically or backed with peer-reviewed literature. With that said, there is evidence to suggest that the two aforementioned patients who presented with pain, red-to-blue colored lesions and vasculitis to their toes could possibly have had COVID toes. The symptom timeline along with the presence of the virus in the United States supports this. Certainly, more research is necessary to specifically correlate known COVID-19 status and COVID toe presentation before we can confirm the true etiology and association of COVID toes.

Dr. Campitelli is the Director of the Podiatric Residency Program at the Western Reserve Hospital in Cuyahoga Falls, Ohio. He is an Adjunct Clinical Professor at the Kent State University School of Podiatric Medicine

Dr. Kubiak is a third-year podiatric surgery resident at the Western Reserve Hospital in Cuyahoga Falls, Ohio. 

References

  1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
  2. La Revue du Praticien. Covid revealing acrosyndromes. Available at: https://drogunlana.com/2020/04/30/the-benifits-of-middle-age-fitness/ .  Accessed April 27, 2020.
  3. Mazzotta F, Troccoli T. Acute acro-ischemia in the child at the time of COVID-19. International Federation of Podiatrists. Available at: https://www.fip-ifp.org/wp-content/uploads/2020/04/acroischemia-ENG.pdf. Accessed April 27, 2020.
  4. Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020. Available at: https://doi.org/10.1016/S0140-6736(20)30937-5. Accessed April 27, 2020.
  5. Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia. Chinese J Hematol. 2020;41(0):E006.
  6. Young L. ‘COVID toes’ could be another symptom of coronavirus infection: experts. Global News. Available at: https://globalnews.ca/news/6848644/covid-toes-skin-rash-coronavirus-symptom/ . Published April 21, 2020. Accessed April 27, 2020.
  7. Consejo General de Colegios Oficiales de Podólogos de España:  COVID-19 Compatible Case Register.  Available at: https://drogunlana.com/2020/04/30/the-benifits-of-middle-age-fitness/ . Accessed April 27, 2020.
  8. World Health Organization. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected . Accessed April 29, 2020.
April 30, 2020
By Nicholas A Campitelli DPM FACFAS
Diabetic Foot Ulcers
Author drogunlana Categories Diabetic Foot Management, Health care 0 comment

Can Remote Ischemic Conditioning Promote Healing In Diabetic Foot Ulcers?

The prevalence of diabetes is on the rise worldwide. As podiatrists and diabetic foot experts, we know the deleterious effects of diabetes on the tissues of the lower extremity. Among diabetes-related complications, the treatment and management of diabetic foot ulcers (DFUs) remains major challenges for patients, caregivers and health-care systems alike. Multiple disrupted physiologic processes, including decreases in cellular signaling and growth factor responsiveness, lead to microvascular dysfunction and diminished peripheral blood flow that can contribute to the lack of healing in people with DFUs.

Successful translation of novel therapeutic modalities into clinical algorithms for DFU management may fulfill an unmet need that is of increasing importance given the global diabetes epidemic. There is an abundance of clinical evidence that remote ischemic conditioning is cardioprotective but can it provide the same protection to the microvascular circulation of patients with diabetes, and accordingly help increase healing rates in patients with DFUs?

Researchers initially studied remote ischemic conditioning (RIC) as a potential protective strategy for cardiac function. In 1986, Murry and colleagues discovered that short repetitive bouts of occlusion and reperfusion of a coronary artery in dogs subsequently protected the heart against a myocardial infarction.1 In 1993, Przyklenk and team conducted a study that is considered the first evidence for the remote application of tissue conditioning.2 This study showed that brief controlled periods of occlusion and reperfusion of a canine coronary artery also protected remote cardiac tissue not directly supplied by this artery when subjected to a subsequent sustained ischemic episode.

Drawing upon on this data, researchers began investigating whether remote ischemic conditioning provided analogous benefits to patients with tissue ischemia injuries. Subsequent clinical studies in human models have concluded that remote ischemic conditioning is safe, well-tolerated and produces a systemic phenomenon that has beneficial effects in other organs such as lung, liver, kidney, intestines and the brain as well as skeletal muscle tissues.3,4

 

What The Research Reveals About Endothelial Dysfunction, Microvascular Disease And Remote Ischemic Conditioning

Ischemic Conditioning Promote Healing In Diabetic Foot Ulcers?While the prevailing thinking is that the etiology of diabetic microvascular disease is multifactorial, a consistent finding in patients with diabetes is endothelial dysfunction.5 There is a known correlation between the long-term effects of elevated glucose levels and the alteration of endothelial cell function.5 An impairment in the formation of vasodilators such as nitric oxide along with increases in the formation of several vasoconstrictors speed the progression of microvascular disease.6 It is generally accepted that hyperglycemia resulting from uncontrolled diabetes leads to an impairment of nitric oxide production and activity.6,7 Prolonged elevated glucose levels generate oxidants in smooth muscle that may diminish nitric oxide signaling, decreasing the responsiveness of endothelium-dependent vasodilation, especially in the microcirculation.6,7 The effects of this cascade of events are decreased functional perfusion and tissue hypoxia in the lower extremity, particularly the feet, complicating DFU healing.

There is scientific evidence indicating that one effect of remote ischemic conditioning is an increase in nitric oxide production.7 One hypothesis is that the repetitive inflation and deflation of a blood pressure cuff has a shearing effect on the vasculature that results in the release of nitric oxide.7 Researchers have suggested that remote ischemic conditioning may contribute to improved endothelial function, resulting in enhanced vascular performance.7 Reversal of tissue hypoxia and increases in peripheral circulation could potentially improve wound healing, especially in patients who are not candidates for other vascular interventions.

In a 2011 study, Kraemer and colleagues treated 27 healthy patients with remote ischemic conditioning and examined tissue oxygenation and capillary blood flow in the anterolateral aspect of the left thigh.8 After patients had three five-minute cycles of remote ischemic conditioning to the contralateral upper arm, researchers found statistically significant increases from baseline measurements of 29 and 35 percent in tissue oxygenation and capillary blood flow respectively. These increases occurred during the third reperfusion phase.8 The results of this study appear to support evidence of increased microvascular blood flow in the lower extremity, furthering the idea that remote ischemic conditioning could potentially aid in DFU healing.

In a 2014 double-blind, prospective, randomized study involving 40 patients with aseptic and infected DFUs, Shaked and colleagues assessed the efficacy of remote ischemic conditioning as an adjunct to standard of care treatment.9 Applying blood pressure cuffs to both arms of all the patients, researchers inflated and deflated the cuffs for three five-minute cycles. The study group had their cuffs inflated to 200 mmHg while the control group had their cuffs inflated to 10 mmHg. The patients in the study group had remote ischemic conditioning treatments every two weeks and were followed for a total of six weeks. For the patients who completed the study, nine out of 22 patients (41 percent) in the treatment arm achieved complete wound healing in comparison to zero out of 12 patients in the control group.

 

Could Remote Ischemic Conditioning Have An Impact In Limb Salvage Protocols? 

Most clinical remote ischemic conditioning treatment studies use a standard blood pressure cuff or similar device applied to the upper or lower extremity to produce the cycles of non-lethal ischemia. Treatment typically consists of three or four cycles that medical personnel can administer over approximately 40 minutes by inflating and deflating the blood pressure cuff every five minutes. Clinicians reportedly achieve the greatest effects with treatments every 72 hours or two to three times a week.10

The occlusion pressure needs to be at least 25 mm above the patient’s systolic pressure, which averages 125 mmHg but can be much higher.10 Therefore, medical personnel need to determine the patient’s systolic pressure first and monitor it throughout treatment. One option is to go arbitrarily high on all patients but even a set pressure of 200 mm leaves nine percent of patients with DFUs uncovered and is very uncomfortable for all patients, potentially reducing compliance.10 Thus, integrating such treatments into regular clinical practice would be costly in time and medical staff resources as well as patient satisfaction.Remote-Ischemic-Conditioning

An emerging modality, the HomeCuff Wound Therapy device (LifeCuff Technologies), is reportedly showing promise in early studies.11 According to the company, this automated remote ischemic conditioning device is specifically designed for home use with easy application to the arm by the patient or a caregiver. The modality operates through a single push-button, which is pre-programmed to deliver an automated 40-minute treatment cycle without the need for medical personnel, thus reducing the cost of treatment. Unlike standard blood pressure cuffs that can only apply a single set pressure, the HomeCuff Wound Therapy device applies variable occlusive pressure based on intermittent readings of extremity blood pressure from software within the cuff.10,11 This facilitates the delivery of remote ischemic conditioning at the most effective yet comfortable level.10,11

The device has a built-in electronic monitoring system that collects and transmits adherence to treatment regimen data and vital sign values to a secure and HIPAA-compliant database. Early case studies showed promising results with the use of the HomeCuff Wound Therapy device two to three times weekly to treat patients with DFUs.10

 

How Remote Ischemic Conditioning Helped Heal An Ulcer Of Three Months In Duration 

A 68-year-old male presented with a three-month history of a neuropathic ulcer (4.75 cm2) to the left first metatarsal head (see first photo above). His past medical history included non-insulin-dependent diabetes mellitus (NIDDM), diabetic neuropathy, stage 3 cardiovascular disease, cirrhosis, anemia and hepatic encephalopathy. The patient previously tried and failed multiple advanced wound care therapies before using the HomeCuff Wound Therapy device. He began 40-minute treatments with this modality three times weekly. Secondary wound dressings consisted of Drawtex® hydroconductive wound dressing (Beier Drawtex Healthcare), ABD padding, rolled gauze and Coban. The wound completely healed in seven weeks (see second photo above).

 

Concluding Thoughts 

Preliminary case study results utilizing remote ischemic conditioning as an adjunctive therapy in the treatment of hard-to-heal DFUs appear promising. Further research into remote ischemic conditioning is necessary in order to prove its utility in wound care. A full understanding of preclinical data as well as the methods and mechanisms involved with remote ischemic conditioning will help wound care clinicians determine when and if to employ remote ischemic conditioning as an adjunctive therapy. Randomized clinical trials may help facilitate the translation of such new technologies to a clinically feasible paradigm for home use.

Dr. Cole is the Medical Director of the Wound Care Center at University Hospitals Ahuja Medical Center in Beachwood, Ohio. She is also an Adjunct Professor and Director of Wound Care Research at the Kent State University School of Podiatric Medicine. 

Ms. Coe is a Clinical Research Coordinator in Wound Care Research at the Kent State University College of Podiatric Medicine. Since 2015, she has been a Certified Clinical Research Professional through the Society of Clinical Research Associates (SOCRA). 

References

1. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation. 1986;74(5):1124-36.

2. Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemic ‘preconditioning’ protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation. 1993;87(3):893–899.

3. Vasdekis SN, Athanasiadis D, Lazaris A, et al. The role of remote ischemic preconditioning in the treatment of atherosclerotic diseases. Brain Behav. 2013;3(6):606–616.

4. Lim SY, Hausenloy DJ. Remote ischemic conditioning: from bench to bedside. Front Physiol. 2012;3:27.

5. Avogaro A, Albiero M, Menegazzo L, de Kreutzenberg S, Fadini GP. Endothelial dysfunction in diabetes: the role of reparatory mechanisms. Diabetes Care. 2011;34 Suppl 2(Suppl 2):S285– S290.

6. Cohen RA. Role of nitric oxide in diabetic complications. Am J Ther. 2005;12(6):499–502.

7. Kimura M, Ueda K, Goto C, et al. Repetition of ischemic preconditioning augments endothelium-dependent vasodilation in humans: role of endothelium-derived nitric oxide and endothelial progenitor cells. Arterioscler Thromb Vasc Biol. 2007;27(6):1403–1410.

8. Kraemer R, Lorenzen J, Kabbani M, et al. Acute effects of remote ischemic preconditioning on cutaneous microcirculation–a controlled prospective cohort study. BMC Surg. 2011;11:32.

9. Shaked G, Czeiger D, Abu Arar A, Katz T, Harman-Boehm I, Sebbag G. Intermittent cycles of remote ischemic preconditioning augment diabetic foot ulcer healing. Wound Repair Regen. 2015;23(2):191–196.

10. Personal communication with Thomas Moore, BA, Chairman and CEO of LifeCuff Technologies, on January 9, January 11 and February 27, 2020.

11. Garratt KN, Leschinsky B. Remote ischemic conditioning: the commercial market: LifeCuff perspective. J Cardiovasc Pharmacol Ther. 2017;22(5):408–413.

April 28, 2020
Volume 33 – Number 5 – May 2020
Pages: 12 – 16
By Windy Cole, DPM and Stacey Coe, BA, CCRP
Author drogunlana Categories Insights 0 comment

Keys To Diagnosing And Treating Xerotic Skin Conditions

Given the common nature of xerotic skin disorders as well as the varied array of etiologies and treatments, these authors offer a thorough review of the literature on conditions ranging from ichthyosis and atopic dermatitis to venous stasis dermatitis and asteatotic dermatitis. 

Xerosis is a very common skin disorder characterized by excessively dry skin. Other terms for this disorder include xerosis cutis and xeroderma. Xerosis can be a primary pathology associated with loss of the normal water content of the epidermis. Xerotic skin can also occur secondary to associated skin disorders and systemic disease. Underlying all xerotic skin disorders is excess water loss from the epidermis.

Skin requires a water content of 10 to 15 percent to remain intact and maintain normal function.1 Three main deficiencies in the skin lead to the development of xerosis including deficiency in natural moisturizing factors; deficiency in the skin lipids or ceramides; and deficiency in moisture in the epidermis that is mediated by aquaporin water channels.2-7 Natural moisturizing factors are isolated to the stratum corneum in high concentration in the corneocytes. These factors consist of amino acids and their derivatives including lactate, urea and inorganic salts.2 Lipids in the stratum corneum modulate water loss. Deficiencies of these cutaneous lipids can increase epidermal water loss up to 75 times that of normal skin.8

Ceramides are the main lipids in the stratum corneum. Numerous risk factors contribute to loss of cutaneous lipids and predispose individuals to develop xerotic skin disorders. This may include decreased sebaceous and sweat gland activity associated with aging; anti-androgen therapy, which decreases sebum production; exposure to degreasing agents including soaps and solvents; and exposure to dry environments.

Xerosis has variable presentation depending on its severity. Mild xerosis can exhibit accentuation of skin lines and resemble the appearance of cracked porcelain due to epidermal water loss. Xerosis affects the normal desquamation process of the epidermis, leading to the development of thin flakes on the skin surface. With more severe xerosis, one will see pruritic, dry, cracked and fissured skin. Severe xerosis can produce an inflammatory dermatitis with localized erythema and edema. Clinicians may note xerotic skin on numerous areas of the body including the lower extremity, upper extremity, abdomen and face.

Patients of increased age are at significantly higher risk of developing xerotic skin disorders.9 Sebaceous gland activity decreases significantly after 70 years of age in women and 80 years of age in men.10 Sweat gland function also declines with age.11 Skin thickness decreases with age, leading to increased water loss from the skin to the environment.12 Environmental factors are also significant risk factors for the development of xerosis. In winter months when humidity decreases, xerosis occurs much more frequently. Xerotic skin disorders are more common in dry climates with low humidity.

Basic treatment for all xerotic skin disorders aims to minimize cutaneous water loss. Lazar and Lazar identified the following methods to prevent water loss and lubricate the skin:

• reduce the frequency of bathing, showering and skin cleansing;

• increase room humidity;

• limit exposure to soaps, detergents, solvents and water;

• avoid friction from washcloths, clothing and other abrasives; and

• use emollients frequently.13

Moisturizers are a mainstay in the treatment of xerotic skin. The skin contains natural moisturizers including ceramides, glycerol, urea and lactic acid. Many moisturizers contain these elements aiming to supplement these natural moisturizing agents. Skin care products that both improve skin hydration and improve barrier function are wise choices. Specific products should contain both rehydrating and lipid-restoring components. Urea has the largest body of evidence for the treatment of xerosis.14 Combining urea with moisturizing agents and ceramides can improve its effectiveness.

Aiming to address multiple key deficiencies in skin hydration, Weber and colleagues formulated a topical formulation containing glyceryl glucoside, natural moisturizing factors and ceramide, and found it to be an effective treatment modality for xerosis.15

Addressing Asteatotic Dermatitis And Ichthyosis In The Podiatric Patient 

Asteatotic dermatitis is an inflammatory dermatitis secondary to severely xerotic skin. Other terms for this disorder include xerotic dermatitis, xerotic eczema and eczema craquelé. Asteatotic dermatitis most commonly occurs in elderly people with underlying xerosis.

Asteatotic dermatitis can be generalized or localized. Generalized disease is often associated with underlying systemic disease. Localized forms most commonly occur on the pretibial areas. Patients with asteatotic dermatitis exhibit dry, cracked and polygonal fissured skin with scaling and pruritis. Secondary erythema, edema and excoriations can develop from scratching. Fissures with superficial bleeding can occur when the skin develops cracks deep enough to damage dermal capillaries.

Known as “winter itch,” asteatotic dermatitis most commonly occurs in the winter months when environmental humidity is the lowest. Asteatotic dermatitis is prevalent in the elderly due to decreased sebaceous and sweat gland activity associated with aging. Aside from climate and age, certain medications, including diuretics, retinoids and protein kinase inhibitors, can also contribute to the development of asteatotic dermatitis.16

In addition to the preventative skin care recommended by Lazar and Lazar, topical steroid ointments under occlusion and Unna boots are treatment options for asteatotic eczema.13,17 Topical calcineurin inhibitors, including pimecrolimus and tacrolimus cream, show efficacy in the treatment of asteatotic dermatitis.18 Recently, endogenous phospholipids, N-palmitoylethanolamine and N-acetylethanolamine, that are part of the endocannabinoid system have proven to be effective treatments for asteatotic dermatitis with efficacy superior to traditional emollients.19

Ichthyosis is a group of skin disorders characterized by excessive dry, scaling skin. The name for this disorder comes from the Greek word, ichthys, meaning fish, since this disorder is known for its xerotic scales. Both inherited and acquired forms of ichthyosis exist with the most common form being ichthyosis vulgaris, an inherited autosomal-dominant disorder that commonly begins in childhood.20 Patients with ichthyosis vulgaris have xerotic skin with fine white scales. Scaling is most common on the extensor surfaces of the extremities. Acquired ichthyosis typically occurs in adults and is associated with medications that inhibit sterol synthesis in epidermal cells (nicotinic acid) or underlying systemic diseases including Hodgkin’s lymphoma, leukemia, sarcoidosis, human immunodeficiency virus (HIV), hypothyroidism, hepatitis, malabsorption and bone marrow transplantation.21 Acquired ichthyosis appears as small white scales on the extremities.

Clinicians may treat ichthyosis with topical creams and emollients to hydrate the skin and keratolytics to remove scales.

Creams containing a high percentage of urea or lactic acid can be very effective treatment options for ichthyosis.22 Oral retinoids such as acitretin (Soriatane) and isotretinoin have a general anti-keratinizing effect, and the literature suggests effectiveness in the treatment of more severe cases of ichthyosis.20

What Are The Best Approaches For Atopic And Venous Stasis Dermatitis? 

Atopic dermatitis is an inflammatory skin disorder, which is often associated with xerotic skin. This disorder presents as dry, itchy, red, swollen and cracked skin. There is often serous drainage and the presentation can vary with age. A total body distribution is more typical in infancy. For children, it is more common to see atopic dermatitis in the back of the knees and the front of the elbows. The feet and hands are the most common sites in adults.

Frequently, atopic dermatitis is associated with allergies and asthma. Several factors are thought to contribute to the development of atopic dermatitis including genetics, immune system dysfunction, environmental triggers and disruption of skin permeability. Dry skin secondary to dry climate, frequent washing and harsh chemicals increases the risk of developing atopic dermatitis.23

Treatment of atopic dermatitis varies based on the severity of the disease. Basic treatment involves avoiding aggravating environments and keeping the skin moist with moisturizers and emollients.24 Mild to moderate disease may respond to topical corticosteroids.25 Oral corticosteroids and calcineurin inhibitors are applicable for the treatment of more severe and resistant cases.23,26-28

Venous stasis dermatitis is a common inflammatory disorder affecting the skin of the lower extremities. It is frequently one of the first manifestations of chronic venous insufficiency, when retrograde blood flow through incompetent valves leads to venous hypertension and the eventual extravasation of red blood cells and ferric iron into dermal tissues. Dermal tissue changes results both directly from venous hypertension and from an inflammatory process mediated by metalloproteinases that are upregulated by ferric iron in extravasated red blood cells.29

Stasis dermatitis appears as erythematous, scaling, eczematous patches on the lower extremity. The medial ankle is the most common site, owing to its relatively poor blood supply. Skin lesions can vary in distribution from small patches to areas encompassing the entire lower leg below the knee and involving the dorsal foot. Long-standing skin lesions can present with lichenification and hyperpigmentation. Additionally, chronic venous insufficiency and hypertension can lead to skin induration and progression to lipodermatosclerosis.30

The treatment of stasis dermatitis involves management of the underlying venous insufficiency and edema. One typically treats this condition through compression therapy.29 Xerotic skin in areas of quiescent dermatitis often responds to emollients and moisturizers. Mid-potency topical steroids are applicable for short durations in the management of acute inflammation and pruritus. Long-term and high-potency topical corticosteroids are not desirable as they can lead to steroid-induced cutaneous atrophy, which can increase the risk of developing venous skin ulcerations.31,32

While topical calcineurin inhibitors are only approved for the treatment of atopic dermatitis, they are reportedly effective treatment modalities for many inflammatory skin disorders including stasis dermatitis.33,34 Tacrolimus has specifically proven effective in the treatment of stasis dermatitis.35 Maroo and colleagues found a combination of topical tacrolimus and oral doxycycline to be effective for stasis dermatitis.36

What Is The Relationship Between Systemic Disease And Xerotic Skin? 

Several systemic diseases can cause xerosis and the workup of xerotic skin changes should include consideration of underlying systemic disease. Disorders including diabetes mellitus, thyroid disease and severe renal disease are frequently associated with xerotic skin. Treatment of xerosis secondary to systemic disease typically involves management of the underlying disease state as well as symptomatic management.

It is common to observe xerotic skin in patients with diabetes mellitus. Dry skin has the potential to fissure, increasing the risk of foot ulceration and infection in patients with diabetes mellitus.37,38

The nervous system plays an important role in maintaining adequate skin hydration. Diabetic polyneuropathy affects small sympathetic nerves, resulting in atrophy of sweat glands and decreased sudomotor response.39-42

Additionally, microcirculatory disease in patients with diabetes can lead to dry, rough, atrophic skin. Namgoong and team specifically examined the effect of peripheral neuropathy and microangiopathy on skin hydration in the feet of patients with diabetes mellitus.43 These researchers found a significant correlation between skin hydration and microvascularity, but no significant correlation between skin hydration and peripheral nerve function.

Hypothyroidism is a disorder of the endocrine system in which the thyroid gland fails to produce adequate amounts of thyroid hormone. Thyroid dysfunction is more common in women and people over the age of 60. This underproduction of thyroid hormones decreases the activity of the sweat glands, resulting in dry, xerotic skin.44 Skin changes in hypothyroidism include coarse, thin, scaly skin.45 The prevailing theory is that reduction of thyroid hormone alters sterol synthesis in epidermal keratinocytes, leading to xerotic skin changes.46 Treatment of hypothyroid-associated skin changes involves treatment of the underlying endocrine disorder with thyroid hormone supplementation.

Skin disorders are also extremely common in patients with chronic renal failure (CRF) and end-stage renal disease (ESRD).47 Xerosis is the most common skin disorder associated with renal disease, reportedly occurring in over 80 percent of patients with chronic renal failure.48 When it comes to the development of xerosis in chronic renal failure and ESRD, researchers have proposed several etiologies including decreased sweat production, decreased sebum production, reduced lipids in the skin surface, altered vitamin A metabolism, loss of or reduction in epidermal water content, and disruption of the integrity of the stratum corneum.49,50

In chronic renal failure and ESRD, reduced glomerular filtration rate leads to accumulation of waste products, including urea, creatinine, sodium, calcium, and phosphate, that are some of the main agents associated with the pathogenesis of skin disease in severe renal disease.51 Patients with severe xerosis secondary to renal disease can develop ichthyosis. Moisturizers with 5-10% urea cream or 2-3% salicylic acid are options for the treatment of uremic xerosis.49,52

In Conclusion 

Xerotic skin disorders are very common and have numerous etiologies including local and systemic disease. Both age and environmental factors play significant roles in the development of these disorders. Management of xerotic skin varies based on severity and pathology, and frequently involves management of environmental risk factors, emollients and moisturizers, and treatment of underlying disease states.

Dr. Hoffman is an Attending Physician in the Department of Orthopedics at Denver Health Medical Center. She is an Assistant Professor in the Department of Orthopedics at the University of Colorado School of Medicine. She is an Attending Physician for the Highland/Presbyterian St. Luke’s Medical Center Residency Program. 

Dr. Jerabek is an Attending Physician in the Department of Orthopedics at Denver Health Medical Center. She is an Assistant Professor in the Department of Orthopedics at the University of Colorado School of Medicine. 

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April 03, 2020
Volume 33 – Number 4 – April 2020
Pages: 36 – 41
By Kristine Hoffman DPM, FACFAS and Morgan Jerabek, DPM
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