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Bullous Case Study: Malecore, M

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Treatment with Intrasite Conformable of bullous lesions in Lyell's syndrome


M. Malecore CS, C. Brillante IP, C. Chiarini IP, S. Fasciolo IP, A. Gasbarra IP, E. Pugnotti IP, R. Traffano Anzelotti IP.
Policlinico Gemelli, Department of Infectious Diseases, Rome

 

Introduction
Lyell's syndrome is a generalised reactional mucocutaneous condition of Epidermolysis Bullous caused by an immune system reaction to a medicine.
It is very likely that several aetiological factors are involved : a genetically determined problem with the metabolisation of medicines and an immune reaction with cellular mediation.


Epidermal necrosis seems to be the cutaneous consequence of abnormal activation of programmed cell death messages (apoptosis).


Lyell's syndrome is different from other characteristic pathological conditions such as the local bullous lesions of polymorphic erythema and generalised, fixed drug-related erythema. There is a continuum of severity between a syndrome defined as Steven-Johnson syndrome and Lyell's syndrome: these two entities may be considered as the expression of the same pathological process with different degrees of severity. The factor which triggers these syndromes is linked in both cases to the taking of certain medicines.

 

The patient
This case describes the treatment of a 17-year-old female admitted to our centre after an initial stay in another establishment. When she arrived, a detailed medical assessment followed by a diagnosis enabled the following treatment objectives to be defined :

  1. Alleviating the painful symptomatology and anxiety component associated with the condition.
  2. Preventing the onset of infection and ensuring hydroelectrolytic balance by maintaining the perfusion of vital organs.
  3. Ensuring correct psychological support in order to promote good self-perception and adaptation to body changes.

Aim
The aim of this case study is to show that a suitable coordinated programme of care can significantly improve :

  • Patient care
  • The control of clinical symptoms
  • Healing outcome


The nursing challenge
Dressing the lesions was the most complex aspect to be undertaken because of the severity of the patient's general condition and, in particular, the extent of the wounds, which corresponded to epidermal-dermal detachment over the entire surface of the body.

 

Nursing interventions
Dressings were applied to the patient under sedation, with two nurses responsible for the treatment, one responsible for putting the patient into the lateral decubitus position and one responsible for passing the sterile material required for treatment.


The materials used were prepared on a special trolley, in accordance with normal departmental procedure, and included the use of personal protection equipment.


Dressings were first applied to the back of the body, starting with the head and finishing with the lower limbs.


Once the patient was in the lateral decubitus position, she was rinsed with copious amounts of Ringer's solution and the previous dressings were removed.


The same process was repeated in the dorsal decubitus position with the application of a non-adhesive silver nitrate dressing on both sides.
The products used on the wounds where there was epidermal-dermal detachment were hydrogel dressings ( Intrasite Conformable), except on the periorbital areas, the mammary areolas, around the urethra, the vagina and the lips, which were treated with gentamycin and silver sulfadiazine 1% antibiotic ointments and a healing cream (Phytostimulin TM ).


Particular attention was paid to dressing the hands, which quickly became painful and hypersensitive. Each finger was dressed with hydrogel after spontaneous detachment of the necrotic epidermis.


The protocol was carried out as quickly as possible so as to avoid prolonging the period of sedation and exposing the lesions to the air.


Outcome
The first objective was achieved by medicinal means.
The second was achieved thanks to good haemodynamic compensation under monitoring, and the coordinated choice of medical devices used.


It was at this moment that the team, after reviewing the literature about the treatment, discussed the most appropriate local treatment. It was mutually agreed that the patient should undergo treatment with Intrasite Conformable a hydrogel dressing, re-impregnated every 24 hours simply with Intrasite Gel a hydrogel without changing the dressing within 48 hours (a protocol maintained during the first seven days of treatment). The eye contours, the mammary areola and the area of the vulva were spared this protocol. The reasons for this choice are based on the aetiology of the disease as well as on a desire to offer a treatment which ensures good patient compliance when the dressing is applied, changed and reapplied.


The third objective, which is just as essential as the preceding ones, was achieved by encouraging the establishment of a dialogue aimed at reinforcing self-esteem, and this was carried out by all the team members.

 

Figure 1 Figure 2 Figure 3
Patient prior to treatment with Intrasite Conformable Patient with Intrasite Conformable in-situ Patient with Intrasite Conformable in-situ
Figure 4 Figure 5 Figure 6
Patient's abdomen after treatment with Intrasite Conformable Patient's back after treatment with Intrasite Conformable Patient's legs after treatment with Intrasite Conformable
Figure 7 Figure 8 Figure 9
Patient's legs after treatment with
Intrasite Conformable
Patient's hands after treatment with
Intrasite Conformable
Patient's hands after treatment with
Intrasite Conformable