Case 167: Painful Resistant Stasis Ulcer Healed as Outpatient

This 85 year old lady had not responded to the care of a central Philadelphia medical clinic. A visiting nurse was asked to treat her and follow her course at home. As the treatments appeared to offer no benefit, the visiting nurse referred her for boot treatment on the 21st of September, 1989. Her ulcer caused her constant pain and perhaps contributed to her one block limitation in walking. She was treated as an outpatient with our usual program: cultures to determine the presence and antibiotic-sensitivities of any bacterial pathogens, an appropriate oral antibiotic to prevent septic emboli with pumping, local infiltration of the lesion and its immediate area with antibiotic (commonly initially gentamicin) and, if pain is excessive, Lidocaine, application of a wet-to-dry sterile dressing soaked with Sea Soaks containing antibiotic and, finally, Long-Boot therapy.

She healed and found her walking improved. She returned in June 1990 with a small tender area that again responded quickly to boot therapy. Unfortunately, in early 1992, she was found to have a large adenocarcinoma of her stomach which rapidly took her life.

Comments: These lesions are instructive to observe and palpate. The skin on presentation is commonly firm and tender. Transcutaneous PO2 levels around the lesion are commonly very low. With pumping the skin softens and, after several treatments, the TcPO2 rises. We think, but have not proven, that the development of tender firm areas with low TcPO2 levels are likely to break down and believe that early boot treatment may prevent that breakdown. There is clearly room for clinical research in this area.