Title

APWCA2009 - Apr 04, 2009

Author(s)
  with Matthew Johnson, RN.C, CCRN

Presented at: Philadelphia, PA

Background
A 48 year old woman presented to our facility with a severe case of biopsy proven cutaneous leukocytoclastic vasculitis unresponsive to high dose Prednisone. On admission she was noted to have countless necrotic ulcerations and areas of palpable purpura over her feet, legs, abdomen, buttocks, arms and fingers. She was also noted to have many early stage lesions. The largest necrotic ulcerations were located on the dorsum of both feet. Ulcerations were very painful and pruritic. There was no evidence of any cellulitis. She had 2+ pedal and pretibial edema and normal PT and DP Pulses bilaterally. PMH: significant for obesity, 45 pack year history of cigarette use and hyperlipidemia. Surgical history was significant for a vaginal hysterectomy. Patient was not on any medications known to cause vasculitis.

Methods
The patient was initially treated with 1 Gram Solumedrol daily IV with dramatic improvement in symptoms within 3 days. Goals for treating the ulcerations were to minimize discomfort, prevent infection and to keep the open ulcerations moist. The dry necrotic ulcerations were not disturbed. The largest open ulcerations were treated with Silver Sulfadiazene Cream, non-adherent dressings and roll gauze. Legs were elevated on several pillows to minimize edema. Patients pain was treated q 4 hours prn with Oxycodone 5/325mg and pruritus was treated with Diphenhydramine 25 mg q 4-6 hours prn. She was discharged after a 3 day hospital stay on Prednisone 40 mg PO twice a day and Extra Strength Acetaminophen for pain. Patient was also given a referral for smoking cessation. Unfortunately, she was readmitted to our facility one week later with a presumed cellulitis of both feet. She was evaluated by a plastic surgeon who noted some separation of the eschar edges and some liquefaction, but no cellulitis. He recommended preserving the eschars for as long as possible given patients poor wound healing capability due to high dose steroids. Silver Sulfadiazine Cream was applied to the separated wound edges with non-stick secondary dressing and roll gauze wrap. Many of the early stage lesions present during the first hospitalization had resolved and there were no new ulcerations. The patient remained hospitalized at the time this abstract was submitted.

Results
Our patient presented with palpable purpura and necrotizing ulcerations - the hallmarks of cutaneous vasculitis. She responded well to high dose Solumedrol, pain control and local wound care.

Conclusion
She will require ongoing evaluation and management of her deep, necrotic wounds by the wound care team and close monitoring for the development of secondary infection.