And at last, the Wound is Healed⋯ or, is it?! In Search of an Objective Way to Predict the Recurrence of Diabetic Foot Ulcers
Babak Hajhosseini, M.D.1, Geoffrey C. Gurtner, M.D.1, Chandan K. Sen, PhD2.
1Stanford University School of Medicine, Stanford, CA, USA, 2Indiana University, Indianapolis, IN, USA.
Diabetic foot ulcer (DFU) has a lifetime incidence of up to 34% among diabetics. Up to 49 million patients worldwide have a history of DFU which comprises the primary etiology for 75% of all amputations. The recurrence rate of DFUs is alarmingly high (40% within 1 year, and 65% within 5 years), with no reliable methods available to predict its occurrence. The current definition of "complete wound closure" relies on a visual assessment to determine "skin re-epithelialization without drainage". However, many of such presumably closed wounds may still remain "functionally" open and deficient in skin barrier function, putting them at higher risk of recidivism. We hypothesize that impaired skin barrier function is an early indicator of DFU recurrence, and propose a non-invasive, point-of-care testing to measure this property based on trans-epidermal water loss (TEWL).
METHODS: A NIH-funded prospective pilot study with collaboration between Stanford University and Ohio State University was conducted. Patient with DFUs were enrolled upon healing of their ulcers. TEWL was measured within the first week of wound closure, utilizing the hand-held DermaLab instrument (Cortex Technologies, Denmark). Patients were followed up for total of 3 months.
RESULTS:Thirty-one patients were enrolled. Ninety percent of healed wounds demonstrated higher TEWL compared to the contralateral reference side (p<0.001). The overall recurrence rate within 3 months after wound closure was 29%. The mean wound TEWL, measured within the first week after closure, was significantly higher in those who developed recurrent ulcer (42 vs 26; p=0.015). The cut-off value to maximize sensitivity and specificity of TEWL in predicting DFU recurrence was determined to be a wound TEWL ≥ 37 (75% sensitivity, 85% specificity).
CONCLUSION: Our preliminary data indicate a predictive capability for the TEWL, as higher TEWL values correlate with higher DFU recurrence rates. The current standard practice of solely relying on visual characteristics of the wound to determine its closure seems insufficient, and at times premature. Cost-effective objective measures to assess the restoration of skin barrier function that utilize simple point-of-care modalities should be incorporated into routine management of such a high-stake condition as a recurrent DFU.
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