Ask the Doctor About Skin Breakdown

Answers to questions submitted during September 2004. Request for more questions will be asked for in the future.

Disclaimer

"Ask the Doctor" is an informational and educational program provided by National Rehabilitation Hospital ("NRH") to provide general information on spinal cord injury. Information posted on the "Ask the Doctor" site is provided solely for informational and educational purposes only and is not intended nor implied to be the diagnosis or treatment of a medical condition or a substitute for professional medical advice relative to your specific medical conditions. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding your medical condition.

We would like your feedback and suggestions.

Dr. Suzanne Groah, Director of the RRTC on SCI: Promoting Health and Preventing Complications through Exercise, as well as Director of spinal cord injury research at the National Rehabilitation Hospital in D.C.

Question: Happy to hear about your service. I would like to understand it better. I was injured about 1.5 years ago and broke my back at T-11/12. I am complete they say, and had zero function return of any kind to date. I have terrible pain. Heavy pins and needles, burning skin, and very hard stiffness and burning when I sleep after a few hours at my waist line (point of injury). My rear end also gets a numb feeling and painful even when I lay on my side to sleep. I have 3 teenagers am 48 years old and am having a rough time with the pains and complications. I would love some suggestions. I am on Nurontin, and Baclofen but these don’t seem to do much, if anything.

Answer: Pain can be particularly troublesome after a spinal cord injury. After spinal cord injury you can have pain from different sources, such as bones, muscles, ligaments and tendons, usually termed musculoskeletal pain. You can also have pain from your internal organs, termed visceral pain. Additionally, after spinal cord injury pain can come from nerves and/or the spinal cord. This kind of pain is called neuropathic pain. Options for treatment might include anti-seizure medications such as neurontin, tegretol; antidepressant medications; antispasticity medications; certain medications usually used to treat irregular heart rhythms. Also, there are some surgical procedures that work for some people, including implanting a pump that pumps medication around the spinal cord and spinal cord stimulation.

Question: Enough with the new injury people! What about us quarter-of-a-century-plus-and-still-hanging-in folks? Aging with a disability, middle age and on up. Wearing out shoulders, etc. What about a Doctor is In for us folks?

Answer: Shoulder overuse is one of the biggest problems for people surviving with spinal cord injury. The shoulder wasn’t meant to do the work of the legs and hips, but that is what it is forced to do often after spinal cord injury. Shoulder injuries often occur because of overuse and because of muscle imbalances. The chest muscles tend to be stronger than the upper back muscles which cause the shoulder joint to be rotated forward putting you at higher risk of injury. We talked a little bit about this topic in an IRLU Web cast on Wed, Nov 17th. See the ILRU website for a transcript and archive of that Web cast.

Question: I would like to ask a question regarding kidney infections and how to keep from getting them. I have tried D-Mannose, drinking a lot of water, sphincterotomy. What is the best solution? Bypass the bladder? Catherization, which leads to infections, Medication? What type works best?

Answer: With bladder or kidney infections, it is important, even though you have had a sphincterotomy, to make sure that your bladder is draining adequately. You can talk with your urologist about doing a test such as a cystogam, cystoscopy and/or urodynamic testing. It is also important to make sure there are no bladder or kidney stones causing repeat/recurrent infections. Once you know how your bladder and kidneys are functioning, then you can approach the problem with more knowledge. For example, medications instilled into the bladder are gaining popularity both to decrease bladder spasms and to prevent infection/stones. Unfortunately, although many people report benefit, the research doesn’t support that Vitamin C or Cranberry tablets help to prevent infection.

Question: I was shot in the throat two years ago, with a T1 injury. I was paralyzed from my neck down. The bullet severed my spinal cord, and exited out my back. Today, I am able to move my arms, left hand, sit up, and transfer myself in and out of a car and in bed. I move around, and have avoided skin break downs, which is quite a miracle. I continue to gain more feeling and movement. The doctor says that I have a complete injury, and does not believe that I have all these feelings with such a significant injury. I have sensation all the way down to my toes. If I sit too long, my bottom and legs begin to hurt, and many other type feelings. I even moved my left toe voluntarily two days ago. How am I able to feel and do this much with an injury like so? My neurologist says that my nerves sometimes send mixed signals, and when I think my foot hurts, that it is probably not so. But when I rub my foot, it feels better. Why won't he believe that I am progressing?

Answer: Even though we may characterize your injury as “complete” doesn’t mean that you don’t have any feelings below the level of your injury. It just means by our standardized neurological exam you don’t have any feeling or movement that we test for. Often, people with complete injuries tell me that they have feelings just like you describe.

Question: Two weeks ago, I had been in bed for about 5 hours. My toe began to burn. In a matter of minutes, a blister formed, and grew before my eyes, covering the entire top part of my toe. I had not injured it, and it wasn't a pressure sore. I wore sandals that day, so it wasn't my shoes. I immediately went to the hospital thinking that it could be a circulation problem. The doctor opened it up, tested for bacteria, and discovered that there was none, and sent me home. Two days later, my skin turned a deep red, moving down along my toe. (My toe is large, and almost as long as my pinkie finger!) I thought it was infected and returned to the hospital. They admitted me to the hospital for three days on IV antibiotics. They wanted to be safe because they were not sure why my toe had done this. They said I had good circulation in my legs and feet. I went home because the redness lighted up, until two days later. The redness became darker and moved down my toe again. I was on a strong antibiotic, and it still looked infected. Finally, fours weeks later it has healed. Can you tell me what could have caused that to happen? I need to know because I am scared that it will happen again causing it to become a serious problem.

Answer: First and foremost it is important to make sure that there is no infection. Sometimes, this takes having to have a test such as a bone scan to make sure there isn’t a deep infection causing these problems. This is important to determine because the consequences are serious. If there is no infection, other considerations might be looking harder at circulation or a pain syndrome in which certain parts of the body get very red a swollen, termed complex regional pain syndrome.

Question: My niece was injured in a car accident with a broken neck on July 3 of this year. At the time she was paralyzed from the neck down, but after surgery she regained feeling from the waist up. She still cannot pick up anything with her fingers or use her hands, but can move her arms and hands. She is still paralyzed from the waist down. Her injuries are in the C6 and C7 vertebrae. My question is, what are her chances of ever walking again, and will she be able to regain use of her hands and fingers? What type of rehab should she be in right now, and should she have the rehab daily? She already has suffered with a kidney infection and two pressure sores. People that sustain injuries as such, are they normally transferred to a rehab center from the hospital before going home? She was sent home without rehab, and I am very concerned about her, and would like to help her. She is 40yrs. old. Please advise me on some kind of help that I could get for her. Thank you.

Answer: It is difficult to give any specific information on your niece’s injury or recovery without fully examining her. For the most part, if a person has a spinal cord injury then a course of specialized spinal cord injury rehabilitation is beneficial. There are some minimum requirements maintained by rehabilitation hospitals (for example, being able to tolerate a total of 3 hours of therapy each day), also. To answer your questions, your niece can consult with a physician specializing in spinal cord injury medical rehabilitation. Then, the injury, prognosis, and if and how she may benefit from rehabilitation, and in what setting, can be established.

Question: I obtained a spinal cord injury in 1976 at the age of 24. The injury was a contusion/laceration at L-1 and L-2. I was very fortunate to experience a good bit of "return" and have walked unassisted after a year of physical therapy. I continue to have a drop foot on the right which has been operated on twice: a triple arthrodesis (sp?) and a tendon transfer. The bottom of my right leg is atrophied. (I regret the tendon transfer for several reasons but I am able to walk without the short leg brace.) On my left side I have never regained sensation or use of some of the muscles in the thigh. So, to a large degree I have a hidden disability. My continuing problem is back pain caused by very deep muscle contractions on my left lower back. The pain starts off about the size of a golf ball and then grows to the size of a basketball as more muscles contract. This causes increased numbness and heaviness in my left leg. And a whopping back ache that is relentless. My back feels like a piece of steel, rock hard. I believe my gait has something to do with it because I have some muscles that are quite weak and others compensate for that. I do function, work every day. But I desperately want to know how I can keep the deep muscles from contracting. Hot showers will help, getting a massage will help. Are there exercises or anything else that could prevent the pain? Any advice is greatly appreciated! Thank you.

Answer: When you have an incomplete injury as you’ve described and you are highly functioning and mobile, you run the risk of overuse and muscle imbalances. Often, it is very helpful in these situations to start off by seeing a physical therapist who has experience with spinal cord injuries and has some “manual” therapy experience. The following website lists certified manual therapists: http://www.aaompt.org/. Also, a therapist will be able to give you a series of exercises specifically for you that you can do at the gym or at home.

Question: I have tried to get insurance to pay for a functional electric stimaster because I don't feel as a C5 quad I can exercise my arms enough to get cardio. My shoulder is sore a lot. I have been told by South Carolina DHHS it is experimental, they won't cover it. Am I never going to have data to prove my case????

Answer: Unfortunately, many insurance companies do not pay for what they determine is additional equipment. There has been a heightened awareness of the risk of cardiovascular disease, heart disease and diabetes in people with spinal cord injuries. We are looking more at this as well as the potential benefits of exercise. Hopefully, we will make progress toward getting more equipment that can improve the quality and quantity of life for people with spinal cord injuries reimbursed. Until then, we think it is best to exercise in moderation, while being careful not to overuse your shoulders. Also, we think it is important to have periodic screening for high cholesterol (and other blood lipids), diabetes and perhaps heart disease.

Question: My level of injury is T-12-L1. I have been paralyzed for 12 years now. I have had multiple surgeries on pressure sores throughout the past few years. I got one about 15 months ago that finally ate through to the bone. I developed osteomylitis and had to have about 5 inches of my femur removed. I now have a sore started on the opposite side now (on my behind). What can I do to keep from getting these things? I do raises and have a good roho cushion, but it seems like I'm damned if I do, and damned if I don't. The doctors around here aren't aggressive enough with these sores. The closest good hospital is about 200 miles from where I live. Do you have any suggestions?

Answer: Unfortunately, once you have skin breakdown, your skin is not as strong, putting that area at greater risk for further skin breakdown. It is important if you have had a sore to get your seating system reevaluated by a spinal cord injury specialist, and if possible, get a computerized seating evaluation. The following is a list of resources and other considerations discussed in the last “Ask the Doctor” session on skin problems:

Resources for information about pressure sores:

As a general source, the NSCIA resource center website:
http://www.spinalcord.org/html/resources/

Also, the Paralyzed Veterans of America: http://www.PVA.org

Consumer Guidelines

Pressure Ulcers : What You Should Know A Consumer Guide for People with Spinal Cord Injury

This guide is intended to help you and those who assist with your care learn how to prevent pressure ulcers. If a pressure ulcer develops, this guide will help you spot it early so that you can seek appropriate treatment. The more you know about this problem, the better able you will be to participate fully in the decisions that need to be made for treatment. This guideline was produced by PVA on behalf of the Consortium for Spinal Cord Medicine.

Spinal Cord Injury - InfoSheet #13 --Date: Revised, December, 2000
http://www.spinalcord.uab.edu/show.asp?durki=21486

Skin: It's too Much Pressure! http://www.craighospital.org/SCI/METS/skin.asp

http://calder.med.miami.edu/pointis/sciman.html?

For your doctor or health care provider, from the PVA:

Medical Guidelines

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury
	Pressure ulcers are a frequent, costly and potentially life-threatening complication of spinal cord injury. This guideline is intended for health-care professionals to use when making clinical decisions about prevention and treatment of pressure ulcers following a spinal cord injury. This guide was produced by PVA on behalf of the Consortium for Spinal Cord Medicine.

Things to do to help prevent sores:

• Check your skin carefully in the morning and in the evening . . . have someone help check areas that are hard to see if need be
• Move, move, move! (though being a "mover" does NOT mean you can skip your . . . pressure reliefs)
• Frequent pressure reliefs (every 15-20 minutes!)
• Properly fitting equipment, including your wheelchair, cushion, mattress
• Having a seating evaluation by an specialist in SCI care, including a computerized pressure mapping
• Protect your skin during daily activities (Are you transferring safely? Do you have any heavy seams on your clothing that might cause pressure? Are your footrests positioned properly?)
• Good nutrition, including recommended amounts of protein, vitamins and minerals
• Good hygiene, including keeping skin clean and dry
• Drink plenty of water
• Do not smoke, use drugs, or alcohol
• Consider supplementing with vitamins A, C, and zinc if deficiencies are suspected (do not overdo it --- too much of any of these is also dangerous!)
• Control (not necessarily eliminate) spasticity

If you have a sore you should be evaluated by a specialist who can give you some more recommendations. It's also helpful to have 'another set of eyes' watching the sore. Along with some of the recommendations above your health care provider might suggest:

• Staying off the sore completely
• Sleeping/resting on your stomach
• Any of a variety of ointments, creams, dressings, etc
• Increasing the amount of protein in your diet
• A VAC (vacuum assisted closure) system if there is a tunnel or cavity
• A medication to promote healing (ask your doctor about an anabolic steroid medication called oxandrolone)
• A blood test to make sure you are not anemic

Question: I've been paralyzed for twenty eight years. When I first got hurt, I had very few skin breakdowns. It seems in my older years (forty-six) my skin breaks down much easier. I recline more than I ever have and seldom sit up past ten hours (which was my normal right after my accident). Is there anyway I can get my skin back to a more elastic, stronger condition?

Answer: Look at the ideas above. Remember, approximately 90-95 percent of decubitus ulcers are preventable with proper care!

Questions: Just wandering if one thinks there may be a problem starting because of the normal symptoms, will antibiotics stop it in its tracks? When they fester on the inside before breaking the skin, would the antibiotic stop it and heal the inside?

Answer: This is an important point --- when a decubitus ulcer starts, the damage occurs from the inside out, although this does not necessarily mean that an infection is present. An antibiotic alone will rarely, if ever solve the problem. A decubitus was most likely caused by too much pressure, sheering, or some type of injury to the skin. So, first and foremost, it is important to get off the affected area and relieve the pressure! If there is an infection, an antibiotic may help in addition to all of the other suggestions above.

Question: What are some of the solutions for an extremely boney protuberance of the cocxyx? My daughter's weight is just about right for her size and disability, and any additional weight just goes around her middle, and doesn't build up fat pads around her tail bone. She is 18, suffers from Cerebral Palsy, and is recovering from a nasty stage 2 decubitus. The end of her spine is so close the surface of the skin that I can see this will be a constant problem. Is there a surgical procedure that is the answer? I have thought about asking a plastic surgeon to insert something under the skin--silicone?? I don't know. Is that a ridiculous idea? Will an orthopedic surgeon correct the problem? She already sits with a custom made individual air celled cushion, so we don't think her chair could be any better. Any ideas you can give will be greatly appreciated.

Answer: It's important to emphasize the benefit of a seating evaluation and pressure mapping that directs the customization of the seating system, including the cushion. Another consideration is to evaluate for any pressure over the bony prominence during sitting, transfers, or other activities.

Occasionally, surgery is performed for a bony prominence that has or has the potential to contribute to skin breakdown. This requires finding a surgeon that has treated other people with the same condition.

Question: I have had a spinal cord injury for 30 years. I am 46 years old. I have not had a pressure sore in over three years. Should I do something more than the usual routine (checking skin for red spots, pressure relief's, avoiding skin injury, etc.) to stay "sore free"? Will my skin be more likely to break down? Thanks in advance.

Answer: See the ideas above for skin protection. As the skin ages, changes cause it to break down somewhat more easily. Also, chronic diseases that are more likely to occur with age affect your overall nutritional and health status, which also can negatively affect your skin.

Question: A person with SCI has foot drop on one foot causing the foot to roll to the outside some. After 14 years in wheelchair a sore formed on bottom of that foot where the foot rests on side from rolling, under a callas. The callas was fine until after a new wheelchair purchase, wheelchair was not fit properly, too much pressure on feet, on too short a footrest.

Is it normal for a sore to take more then three months to heal? What can be done to prevent it again? Seems like now since the callas is gone, the foot is easily red and won't heal. I am too paranoid to wear a shoe on that foot always having to lift the leg and rest on top of the other leg thus causing redness on top of my other leg while sitting in the wheelchair.

Answer: See the bulleted items above. Sometimes a sore will take very long to heal, especially if all of the pressure has not been adequately relieved and other risk factors persist such as inadequate nutrition, fluid intake, or you smoke (see bulleted items above). When you changed your seating system it is important to make sure that all equipment is properly fitting now and pressure has been COMPLETELY relieved from the foot.

Question: My Mother sits in her wheelchair except when she sleeps. Recently, I've noticed she has foot long red circles on the backs of her legs. She even has blisters. What can we do to prevent this and what can we do to assist the healing process?

Answer: If redness does not disappear within a half hour, then that is by definition a decubitus ulcer. These need to be taken care of before they turn into something much worse that leads to bedrest for weeks or even months! If blisters are present, consideration should be given to seeing by a health care provider. Also, an SCI therapist, preferably at a rehabilitation hospital that specializes in SCI care, might help with an evaluation of seating, pressure reliefs, and transfers. Whenever a decubitus is present, decreasing the amount of time spent in her wheelchair until healing occurs should be considered. This could range from bedrest for several days to frequent rest periods out of the chair.

Question: Because I have had breakdowns that have healed, I still have scare tissue that is always susceptible to a breakdown. Is there anyway of toughening up that area?

Answer: Any time you have skin breakdown, your skin is a bit weaker the next time around. The best things everyone can do are preventative (remember, the vast majority of decubitus ulcers are preventable!). See the bulleted ideas above.

Question: How can one determine what cushion is best for what situation? And will any insurers pay for different types of cushions? For example, I use a high profile Rojo for my wheelchair. But when traveling, I bring a ByBy Decubiti as a backup, and now use it for sitting in the seat in the plane. I will probably use it while sitting in a canoe or kayak. And I probably need to begin using it in the van seat that I drive from. No one seems to be giving practical info about pressure-relief cushion use; is this advice available anywhere? In the course of figuring it out ourselves, many people develop ulcers!

Answer: The best cushion for any given individual is just that....individual. A seating evaluation done by an expert specializing in SCI is a good way to get a well-fitting seating system. There are advanced computer systems available in many rehabilitation hospitals now that will give a fairly accurate representation of any high risk areas - this is called pressure mapping. This can be done with cushions that are currently being used. Remember: it's not all about the cushion....pressure reliefs, proper nutrition, an appropriate seating system, and not smoking also help prevent ulcers!

Question: C5/C6 with healing decubis at the base of my spine. How do I get rid of the scar/callous skin after wound closure? It builds up then breaks off leaving bleeding tissue. Any info greatly appreciated.

Answer: A visit to a health care provider should be considered in cases of new skin breakdown or non-healing skin breakdown. Also, there are a variety of lubricating creams, ointments, and dressings out on the market right now. Whether these work or not is somewhat of an individual thing and some trial and error may be required to determine what works best for a given individual.

Question: I am a recent (4-12-03) T-11 paraplegic. Up to that point, I had done a pretty good job of keeping this body in decent shape -- no smoking, drinking, unnecessary risks; happily married (31 years) with two grown-up sons; no broken bones or hospitalizations other than a tonsillectomy when I was 9; I worked hard and exercised when convenient; and I had made it my goal to never have to see a doctor other than checkups. I am an optimistic, glass 3/4 full, do-my-best-at-everything, things will take care of themselves kind of guy. For 52 years I had lived a great life, for which I was very grateful. Since my injury, I have been introduced in the past year (for the first time) to: pneumonia, bursitis, pressure sore on my ankle, hemorrhoids, cholesterol medication (mid 200's total), diabetes medicine (A1c of 6.6), blood pressure medicine (140/90 average), fungal infection and Aetna Insurance. I now go to a gym (I have a personal trainer) twice a week and play basketball 2 hours a week. I drive and do volunteer work at the United Cerebral Palsy office. I have been confused and worried about skin problems ever since: the nurses at the hospital told me about it; a friend of mine who was injured a little bit after I was had several bouts of decubitis; and I learned of another acquaintance who has been a T-10 para for 23 years with no skin breakdown.

My questions: Since life is this exciting after SCI, what are the top 5 (or 10 or other magical number) main things I should look out for to avoid skin breakdown? How does one find the extra 1 or 2 hours a day to reassure oneself that things are OK? And how can one ever find the time to go back to work?

Answer: Often times certain diseases may be present but may go undiagnosed because few or no symptoms does not bring someone to the doctor. If another condition, such as an SCI, occurs resulting in more visits to the health care provider, other problems may be diagnosed earlier than otherwise would have. That said, many chronic conditions are more common in individuals with SCI (these include but are not limited to certain cardiovascular disease, diabetes, high cholesterol, and certain cancers).

A healthy fear of decubitus ulcers is often a good thing and encourages people to think harder about prevention. Review the bulleted items above and make sure you are doing everything you can to prevent skin breakdown.

Question: What is thought to be the best wheelchair cushion to use? Will eating more animal protein help? Should any supplements help? Such as zinc?

Answer: The best cushion is a very individual thing. A rehabilitation therapist who specializes in the care of people with SCI is a valuable ally and can do a seating evaluation including pressure mapping with a variety of cushions.

Unfortunately, with aging we frequently see malnutrition. As people age, making sure to maintain a diet with adequate energy (protein) certainly helps to maintain skin health. Additionally, animal studies have established a specific role for certain nutrients such as the amino acid arginine, the vitamins A, B, and C, and the elements selenium, manganese, zinc, and copper, in skin health. Basically, vitamins and supplements such as zinc aid in skin healing when levels are low. If these levels are normal, though, there may not be much benefit from taking supplements. Thus, getting the recommended amounts of nutrients and protein in your diet is important, while too much of certain nutrients can be harmful as well!

Question: I have a tunnel on my right sacral. You can get a Q-tip in it - almost 5 cm. It has been treated with Iodoform(tm) 1/2" packed lightly. This did nothing. Then the doctor prescribed AquaCell AG(tm), which has not worked. I am on a "Clinatron at home(tm)" bed and stay flat. We wondered why the bed did not help and an OT came and pressure mapped me in bed (I do not get up). The mapping showed pressure beginning at 10º and was red at 30º. I use a Permobile Chairman 2K(tm) that has tilt, recline, height adjustments, an elevating leg rests. I use a ROHO(tm) cushion. There is no pressure in my chair, but my wound-care specialist wants me in the heated circulating silicone. I have seen two doctors at different hospitals -- referred by the first. I have never been hospitalized. I am 53 and pushed a chair for 16 years, but my shoulders wore out. I never had a skin problem. I have gone from a standard power chair to one that tilted to the one I'm using now. (This sore happened when I used the tilt chair.) I am fortunate to have the luxury of telecommuting from home in bed.

Answer: If the fit and positioning are correct in the chair, there shouldn't be any pressure on the sacrum. One of the worst positions for their sacrum is "sitting" semi-reclined in bed...it puts a lot of sheer forces on the sacrum! Depending on how wide the tunnel is and other characteristics of a wound, there is an option called the VAC system. A health care provider can help decide if this option makes sense.

Question: In general I have very good health. I eat right in order to watch my weight, I take quite a few vitamins, and I stretch out every morning and night. I am a C4-C5 quadriplegic male, and I really only have the one issue of peripherals skin damage. I work 40 plus hours a week, which means I am up in my chair by at least 6:15 in the morning and out of my chair around 10:30 in the evening. What I tend to get skin-damage-wise is an extremely chapped, macerated area of tissue just below my left buttock in the fold of the skin. The area will eventually get so raw that it will crack and bleed. I have been a quadriplegic for 15 years, and it is the one health concern I cannot find a remedy to. I tried using different barrier creams in the evening, tegaderm, elastogel, etc.

Answer: Macerated brings to mind accumulation of moisture. Making sure to manage moisture is an important part of skin protection. Sometimes this may mean changing clothes during the day, monitoring how loose or tight the clothes are, and evaluating whether there is any sensitivity to certain fabrics.

A cautionary note - there are a lot of creams, pastes, etc. out there, and none of them are the "magic cream" that prevents all sores. Trial and error with these creams, etc is often required.

Question: How successful is a flap surgery when the cause of the hole was due to MRSA?

Answer: Success of a flap surgery depends on many factors, including location, depth, severity of the wound, type of flap done, blood supply, nutritional status, bowel and bladder care, seating system and pressure on the area post-surgery, among others.

Question: My daughter is 26 years old, with recent spinal cord injury. She frequently gets red pressure areas on her heels and under her little toes. What should I do to prevent this from happening? Right now, I am elevating her feet with pillows as much as possible, but this prevents her from moving around in her chair. I also massage the areas and have been using foam boots, but she is still getting them
She uses jobst stocking with open toes because her circulation is very bad, but these are very tight around the top of the foot, and she frequently gets these constricting type of marks. I have them on two hours and off two hours, but then her feet become swollen. Your advice will be appreciated.

Answer: Evaluation of wheelchair seating is a valuable tool in assessing the cause of pressure on any part of the body. While elevating the legs might help foot swelling, it is important to remember that this might change pressure and sitting posture in the chair.
It is important to be very careful with any type of compression garment, as they might cause excessive constriction leading to further skin breakdown. Evaluation by a health care provider, a seating evaluation, reevaluating the fit of the jobst stockings, periodically elevation of the feet (while monitoring the seating situation at the same time), and medications for swelling are considerations.

Question: These are copies of some e-mails I've sent to different doctors over the last couple of months. The latest diagnosis is that I have vasculitis. Any help would be greatly appreciated.

I am a T-12 L-1 Paraplegic 3 years out. I was an in & out patient at ----------. I have tried all types of therapy including PT, pool, acupuncture, rakie, diet, drugs, herbs & on & on. Roxicodone, Actiq & Klonopin are 3 drugs that I have been recently prescribed by a high placed pain management specialist . I read all the literature that I could find on them. The reason I am taking them is because of a long battle with a shooting, exploding pain down my left leg that has resulted in some of the most intense pain I've ever experienced and open up ulcers on my leg. At one point they even asked if I was putting cigars out on my leg. Cauda Equina Syndrome was another diagnosis that came upon the scene.

Is any one else experiencing what I am going through that you have heard of? I have gotten sick from some of this medication

I was reading up on some of the articles written about cauda equina syndrome and in most cases it recommends surgery right away or permanent paraplegia will set in. Now obviously I am already paralyzed but I am wondering if there was anything else I could do to help the effects of this disease. We spoke about the next attack I should go to the emergency room and have them call you or someone from Kessler. Can you tell me again what they would treat an attack with and is it something that I can have a prescription for, have on hand and inject on my own. I would really like to do something about this as the attacks are getting more and more painful and I hope they are not doing more damage to an already sensitive area. You spoke about talking to Dr ----- I was wondering if you had a chance to do that.

I am a T12- L1 paraplegic. About 9 months ago I started to develop lesions on my legs. They are not pressure sores rather they just appear under the skin as a very pink/ red color then open up into the ulcers
I am an out patient where I went to see my main doctors Dr. ------- as well as a skin specialist there from there. I went to see a dermatologist Dr.------- at another hospital outpatient where a biopsied was completed. The results were:

The presence of an ulcer may be related to prior trauma. In addition there are also aggregates of thick - walled blood vessels, therefore st.sis ulcer is also possible. From there I have been to see a Dr. --------- call to get the exact creams and washes used from him). I was treated with a variety of skin creams ,silver sulfadiazine, collageenase, Lidex gel.os cleocint gel1% , benzaclin gel 50g and Burows solution soaked pads to soak my legs with. Dr. ----- has given up and doesn't know what it is or the cause.

A response I received from -------:
I spoke with the Director of Wound Care here at ----------, Dr. -------, regarding your problems. He suggested that you check out several things. He feels that your first evaluation should be by an endocrinologist to see if you have occult diabetes. Next, you should be seen by an infectious disease specialist to rule out fungal infection or Tuberculosis. He also thinks that the ulcers need to be biopsied. I hope this information is helpful. If these things do not assist you in healing, please feel free to email me for further information.

Answer: Vasculitis is inflammation of the blood vessels causing problems with the skin. Some hospitals have Vasculitis Centers, and often a Rheumatologist will treat vasculitis. It is often benefical to focus on trying to find an answer with the fewest number of health care providers as possible because when there are many people treating one person the situation becomes very confusing because each doctor may not know what the other one is doing.

Question: I use aloe vera on my husband's sores (the plant--cut the gel out). It is the only thing that works and it works fantastic. The hospital tried to get rid of a sore for 9 weeks and I got rid of it in a week!

Question: I care for Charlie who has an injury at C6/7 since 1999. He had a Roho bed overlay that worked great preventing pressure sore for awhile. He developed an ulcer on each hip a few months ago. The areas were just red without breakdown for about a year and even though we thought we were being diligent they broke down. When they did break skin they got really bad really quick! He had surgical debridement and now is on woundvac which appears to be working. He has now developed an ulcer on each ankle. I am using accuzyme to kept necrotic tissue to a minimum and an Allevyn dressing. It is almost impossible to keep pressure off his ankles. Do you have any ideas?

He has a visiting wound care nurse but she doesn't offer any different suggestions than I have mentioned. I am a LPN so I have a little knowledge of wound care but it doesn't seem to matter. Are there any vitamins or supplements that would help with healing? He takes a Multi-vitamin, Vitamin E and Vitamin C.

Answer: See the bulleted items above. The most important thing is that a specific piece of equipment or cream/dressing might help, but won't on its own prevent skin breakdown. It is important not to forget the influence of nutrition, hydration, equipment issues, pressure reliefs, etc., on skin integrity.

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