Correspondence
Management of Acute Cutaneous Wounds
N Engl J Med 2008; 359:2395-2396November 27, 2008
- Article
To the Editor:
In their article on the management of acute cutaneous wounds, Singer and Dagum (Sept. 4 issue)1 recommend topical nonsteroidal antiinflammatory drugs for the treatment of first-degree burns. They refer to a study that investigated the treatment of sunburn with a gel containing diclofenac sodium.2
Although erythema and pain are common in sunburn and in burns caused by heat, these two conditions differ in almost every other aspect, as pointed out by Urbach in 1996.3 Sunburn is initiated by the absorption of ultraviolet radiation by chromophores in the upper layers of the skin. Damage to DNA is the major initial event, leading to erythema that appears several hours after exposure and peaks at 8 to 24 hours.4 Even in blistering sunburned tissue, necrosis is almost invariably absent, and the tissue heals without scarring. In thermal injury, erythema and blistering occur almost immediately and are initiated by protein denaturation and tissue necrosis.5
Treatments that are effective for sunburn are not necessarily effective for other types of burns. Since diclofenac sodium has so far not been investigated in first-degree burns, a recommendation for its use seems inappropriate.
5 ReferencesFranz Trautinger, M.D.
Landesklinikum Sankt Poelten, 3400 Sankt Poelten, Austria
franz.trautinger@stpoelten. lknoe. at 1
Singer AJ ,Dagum AB . Current management of acute cutaneous wounds. N Engl J Med 2008;359:1037-1046
Full Text | Web of Science | Medline2
Magnette J ,Kienzler JL ,Alekxandrova I , et al. The efficacy and safety of low-dose diclofenac sodium 0.1% gel for the symptomatic relief of pain and erythema associated with superficial natural sunburn. Eur J Dermatol 2004;14:238-246
Web of Science | Medline3
Urbach F . Phototoxic skin reaction to UVR -- is “sunburn” a “burn”? Photodermatol Photoimmunol Photomed 1996;12:219-221
CrossRef | Web of Science | Medline4
Honigsmann H . Erythema and pigmentation. Photodermatol Photoimmunol Photomed 2002;18:75-81
CrossRef | Web of Science | Medline5
Kao CC ,Garner WL . Acute burns. Plast Reconstr Surg 2000;101:2482-2493
Medline
To the Editor:
In the video that accompanies the article by Singer and Dagum, the practitioner in the first chapter is wearing a long-sleeved white coat and shirt. These sleeves come very close to the surgical fields and to the wound itself, and they are a potential source of bacterial contamination. White-coat sleeves have been shown to be a site of high bacterial contamination.1 Evidence of reduced cross-transmission by short-sleeved white coats is not substantiated in the literature, and keeping forearms “sleeve-free” is not discussed in international recommendations.2,3 French and Canadian recommendations include the use of short-sleeved coats as an adjunctive measure to permit appropriate hand hygiene. A recent debate followed the proposition by the U.K. health secretary of a “bare below the elbows” dress code.4 To facilitate hand and forearm washing, we suggest that short-sleeved white coats should be worn for the management of wounds, as shown in chapter 3 of the video.
4 ReferencesAlexis Guyot, M.D.
Jean-Christophe Lucet, M.D., Ph.D.
Vincent Descamps, M.D., Ph.D.
Bichat–Claude-Bernard Hospital, 75018 Paris, France1
Loh W ,Ng VV ,Holton J . Bacterial flora on the white coats of medical students. J Hosp Infect 2000;45:65-68
CrossRef | Web of Science | Medline2
Boyce JM ,Pittet D , Healthcare Infection Control Practices Advisory Committee, et al. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23:Suppl:S3-S40
CrossRef | Web of Science | Medline3
World Alliance for Patient Safety. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization, 2006. (Accessed November 6, 2008, at http://www.who.int/patientsafety/information_centre/guidelines_hhad/en/index.html.)
4
The traditional white coat: goodbye, or au revoir? Lancet 2007;370:1102-1102
Web of Science | Medline
To the Editor:
For the treatment of subungual hematomas, it is not necessary to search for a portable cautery device, which may not be available in a primary care office. Instead, the time-honored approach is to heat the end of an unfolded paper clip in a flame and to use that metal to burn through the nail into the hematoma.
Jeffrey L. Kaufman, M.D.
Baystate Vascular Services, Springfield, MA 01107Author/Editor Response
Although we recognize, as Trautinger points out, that the pathobiology of sunburns may not be typical of most thermal burns, one of the most common causes of first-degree burns is sunburn. Thus, topical diclofenac sodium may be of use for many patients with first-degree burns. There is also evidence that other topical nonsteroidal antiinflammatory agents may be of benefit for thermal injuries. For example, a study of second-degree burns in adult sheep showed that topically applied ibuprofen decreased both local edema and prostanoid production in the burn tissue.1
We agree that all efforts should be made to reduce the risk of bacterial cross-contamination between patients and wounds. Previous studies have shown that white-coat sleeves often contain pathogenic bacteria such as Staphylococcus aureus.2,3 In these studies, a significant proportion of subjects laundered their coats only at monthly intervals. No study has shown contamination of white coats that were properly washed and changed on a daily basis. However, we agree with Guyot et al. that the use of clean short sleeves, as well as proper hand washing and gloves, should be encouraged.
Finally, as noted by Kaufman, in the absence of a portable cautery device, the end of an unfolded paper clip, heated in a flame, may be used to drain a subungual hematoma. Although we too have used this method in the past, in our experience it is now often difficult to find an alcohol lamp, let alone a match to light it.
3 ReferencesAdam J. Singer, M.D.
Alexander B. Dagum, M.D.
Stony Brook University, Stony Brook, NY 11794
adam.singer@stonybrook. edu 1
Demling RH ,Lalonde C . Topical ibuprofen decreases early postburn edema. Surgery 1987;102:857-861
Web of Science | Medline2
Wong D ,Nye K ,Hollis P . Microbial flora on doctors' white coats. BMJ 1991;303:1602-1604
CrossRef | Web of Science | Medline3
Loh W ,Ng VV ,Holton J . Bacterial flora on the white coats of medical students. J Hosp Infect 2000;45:65-68
CrossRef | Web of Science | Medline
