Treatment of a, dermal fungal infection, complicated by a ... - Cutimed

Cutimed ® Sorbact ®physicalattraction Hands-on Case Report 11Treatment of a,dermal fungal infection,complicated by a,secondary bacterial infection,James McGuire DPM, PT, CPed, FAPWCA, FAPWHc

2Treatment of a dermal fungal infection,complicated by a secondary bacterialinfection using a novel hydrophobicdressingJAMES MCGUIREDPM, PT, CPED, FAPWCA, FAPWHCIntroductionPedal dermal fungal infections are traditionallytreated using a combination of drying agents, antifungalpowders, creams or gels and if necessary anoral antifungal agent. Frequently these infectionsare complicated by local tissue inflammation fromthe destruction of fungal and bacterial cells andsecondary invasion of bacteria from resident skinflora in the intertrigenous spaces. The resulting cellulitisnecessitates the addition of an antibiotic toaddress the invasion of bacteria from the denudedinterspaces. In order to promote drying of the skinand resolution of the infection, interdigital spacersof foam, gauze or lamb’s wool are used to promoteairflow between the toes.Cutimed ® Sorbact ® , a unique hydrophobic dressingmaterial, has been demonstrated in a number ofcases to help in the treatment of surface fungalinfections by reducing the number of propagatingmicrobes on the surface of the skin thereby allowingthe body’s own defenses to gain the upper handin suppressing the spread of the fungus in thetissues.¹Microbes, including fungi, are irreversibly boundthrough hydrophobic interaction to the DACC(dialkylcarbamoylchloride) fatty acid coating on thedressing surface, allowing them to be disposed ofat dressing changes. This unique wound dressing,without a chemically active agent but with a uniquemode of action, can contribute to the healing ofmycotic infections of the feet.Patient history55 year old Hispanic male with Type I Diabetes presentedto the wound center with a severely ulceratedforefoot. He was initially seen by his PCP who placedhim on Econazole nitrate cream and daily warm saltsoaks for one week for what was diagnosed as atinea pedis infection of the 2nd and 3rd interspacesof the left foot. The cream was applied manually andoccluded with a DSD twice daily with once dailysoaks with Epsom salts and warm water. This resultedin a spread of the infection to all the interspacesduring the course of the next week with bullae formationand a marked loss of skin, increase in edema,ascending cellulitis, and pain.He eventually went to the ER where he was diagnosedas having an allergic reaction to the Econazole.The Econazole cream was discontinued and he wasplaced on Silvadene cream and plain dry dressingswhile he worked during the day, and Epsom saltsoaks at night, leaving the toes open while he slept.He failed to progress and sought the advice of alocal podiatric physician who felt he had developeda secondary bacterial cellulitis. He took cultures ofthe open areas and started him on Bactrim DS witha continuation of the Silvadene cream and drysterile dressings. He referred him to the woundcenter at his institution for follow up and managementone week later.Cutimed ® Sorbact ® , which is available in severalvariants (e.g., ribbon gauze, swabs, wound contactlayer, etc.), appears to present a genuine alternativeto conventional antimycotic therapies in the treatmentof fungal infections. In addition to neutralizingthe effect of the microbes, the fungal and bacterialpathogens present in the interspaces are notexpected to develop resistance to the dressings’mode of action.

3Treatment historyWhen he presented to the wound center he wasstill inflamed, painful, and draining with only a slightreduction in the advance of the cellulitis from theBactrim DS and a strong odor emanating from thefoot (Fig 1,2). The culture and sensitivity performedat the initial visit came back positive for StaphylococcusAureus sensitive to Bactrim and Pseudomonasaeruginosa sensitive to Ciprofloxacin withfungal elements noted. X-rays were taken to ruleout osteomyelitits. He was diagnosed as having asevere tinea pedis with a secondary cellulitis frombacterial invasion into the denuded areas in theinterspaces complicated by continuous occlusionwith creams and repeated soaking.Fig. 1The Bactrim was continued and he was started onCiprofloxacin and the use of Cutimed ® Sorbact ®ribbon gauze to all the interspaces changed daily.He was also placed in a surgical shoe and told tostay off his feet. The following week Trychophytonrubrum was identified as the fungal agent. After oneweek using the Cutimed ® Sorbact ® ribbon gauze hispain and the odor had almost completely resolved(1/10) and he had little or no drainage from the interspaces(Figure 3).There was only a small open area that remained inthe 3rd interspace, with almost complete resolutionof the active scaling and discoloration dorsally.Treatment with Cutimed ® Sorbact ® ribbon gauzewas continued for the next week with completehealing of the open areas. In time, resolution of thehemosiderosis and exfoliation of the peeling skinwould complete the healing process (Figure 4).ConclusionMaceration and occlusion of bacteria and fungi inbetween skin folds and in the interdigital areas onthe foot provides the perfect environment for rapidproliferation of the organisms. Seclusion of the footin a closed toe shoe during much of the day makesmatters worse and further exacerbates developinginfections of the foot. The dressing material of Cutimed ®Sorbact ® ribbon gauze, by virtue of its DACC (dialkylcarbamoyl-chloride)coating, is able to irreversiblybind microbes with cell-surface hydrophobicity (CSH)and remove them from active interaction with the hosttissues. Physically binding actively dividing bacteriawithout killing the microbes not only reduces thesheer numbers of microbes but also decreases theamount of inflammatory bacterial and fungal debristhat accumulates from cell death created by antibioticand antifungal topical or oral medications.Fig. 2Fig. 3By providing a dry environment, eliminating intenseinflammation created by antigenic cellular debrisas well as decreasing cell numbers, the dressing isable to decrease pain and odor while allowing thetissues to heal without topical antiinfective agents.References1. Claesson M, Bulgakow B, Blomqvist P,Andersson K (Sweden). A promising alternative inthe treatment of dermal fungal infections. Firstpublished in "Medizin & Praxis". 2006, Germany.Fig. 4

4AuthorJames McGuire DPM, PT, CPed, FAPWCA, FAPWHcTemple University, Leonard S. Abrams Center for Advanced Wound Healing, Foot and Ankle Institute at theSchool of Podiatric Medicine, 1801 N. Broad Street, Philadelphia, PA 19122, U.S.A.Temple University, Department of Podiatric Medicine and Orthopedics at the Temple University School ofPodiatric Medicine, 1801 N. Broad Street, Philadelphia, PA 19122, U.S.A.70550-00545-01 08/2012