Zinc Chloride Paste for the Debridement of Chronic Leg Ulcers VINCENT FALANGA, M.D. MANUEL IRIONDO, M.D.
ARTICLE
Abstract. Chronic leg ulcers present a difficult therapeutic problem, and their management requires frequent debridement. Thorough debridement of painful or extensive ulcerations is not always possible. Frequently, it must be done in the operating room, a situation accompanied by the potential complications of general anesthesia and by considerable expense. We present evidence for the effectiveness of zinc chloride paste as a relatively painless debriding agent in the management of chronic leg ulcers. When applied to the wound bed, zinc chloride paste fixes the tissue and leads to the formation of an eschar that falls off within a few days, leaving a granulating ulcer suitable for grafting. J Dermatol Surg Oncol 1990; 16:658-661.
INTRODUCTION Chronic leg ulcers are a difficult therapeutic problem. Those due to arterial insufficiency require revascularization of the affected limb, if technically possible. Neuropathic ulcers, as in patients with diabetes mellitus, respond at least partially to thorough avoidance of trauma and pressure. Other ulcers, such as pyoderma gangrenosum or those secondary to a vasculitis, benefit from systemic anti-inflammatory agents. Venous ulcers respond to elevation and graded compression of the affected limb.'
Common to all chronic leg ulcers is the frequent need for removal of necrotic and fibrotic tissue present in the wound bed. Satisfactory debridement may be achieved with the use of occlusive dressings,* but this is not always effective or possible. Thorough surgical debridement after local anesthesia is not practical in painful or extensive ulcerations. Frequently, debridement must be done in the operating room. This surgical procedure is accompanied by the potential problems associated with general anesthesia, which are of particular concern in elderly patients. Moreover, the expense associated with the use of the operating room is a further burden for patients afflicted by chronic and disabling ulcerations. We have been searching for ways to debride chronic leg ulcers when surgical debridement with local anesthesia is impractical or when occlusive dressing therapy is either not tolerated or ineffective. Noting the pioneering work of Mohs3 on the use of zinc chloride paste in gangrenous tissue, we have used this topical agent to achieve debridement of chronic leg ulcers. We present our experience with this method and suggest that zinc chloride paste may have a place in the management of these chronic wounds.
PATIENTS AND METHODS Vincent Falanga, M.D., and Manuel Iriondo, M.D., are from the Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida. Reprints are not available
We used zinc chloride paste in 4 patients followed in the leg ulcer clinic of our department. The zinc chloride paste was obtained from the School of Pharmacy, University of Wisconsin, Madison, Wisconsin. The formulation of this preparation is the J Derrnatol Surg Oncol 26:7 ]lily 1990
FALANGA AND IRIONDO
was followed by two layers of gauze; tape was used to keep the dressing in place. The patient was told not to disturb the dressing and to avoid contact with water for the next several days. RESULTS
FIGURE 1. Zinc
chloride paste applied with cotton appli-
cators to the ulcer of patient 4.
same reported by Mohs and consists of 34.5 ml of a saturated solution of zinc chloride, 10.0 grams of Sanguinaria canadensis as a binder, and 40.0 grams of stibnite (80 mesh sieve), which is responsible for the consistency and black color of the paste. One of us (MI) applied zinc chloride paste to the wound bed (Fig. 1).Although zinc chloride does not penetrate uninjured keratinized epithelium, care was taken to avoid contact with the surrounding unulcerated skin. No protective ointment was applied to the margins of the ulcer. The thickness of the applied paste, which determines the extent of vertical p e n e t r a t i ~ nwas , ~ approximately 1 mm. In the first two patients we studied, the entire ulcer bed was treated. Later, after we observed that horizontal spread of the preparation would cause the ulcer to enlarge slightly, a margin of approximately 2 mm from the ulcer’s edge was left untreated. The ulcer was then covered with cotton to absorb excess paste and with gauze impregnated with petrolatum. This
We have treated 5 leg ulcers in 4 patients with zinc chloride paste. Table 1 describes the clinical characteristics of these patients. None of the patients had evidence of significant arterial insufficiency, either clinically or by Doppler flow studies. The two patients with venous ulcers (1 and 2) had clinical evidence of venous insufficiency, such as varicosities, hyperpigmentation of skin surrounding the ulceration, and lipodermatosclerosis in one. These two patients also had abnormal venous plethysmography and venous recovery times. Patient 3 had sickle cell disease, but her hemoglobin studies showed an SC genotype. She had an additional but larger ulcer on the opposite leg, which was not treated with zinc chloride. Patient 4 had longstanding rheumatoid arthritis. Although the medial location of her ulcer suggested a venous etiology, venous plethysmography and recovery time were normal. Several biopsies from the edge of her ulcer showed no histologic evidence of vasculitis and no immunoreactant deposition by direct immunofluorescence. Final results are presented in Table 2. The application of zinc chloride paste caused no immediate discomfort. After approximately 3-4 hours, stinging and burning were experienced by all except patient 4, who reported absolutely no discomfort. The burning sensation resolved after 24-48 hours and was relieved by acetaminophen or codeine. Thereafter, the ulcers became painless even in patients 2 and 4, in whom ulcer pain had been a major complaint. The eschar that formed on the ulcer after the application of zinc chloride paste sloughed off after 5-7 days, either by itself or after one or two whirlpool treatments instituted for this
TABLE 1
Clinical Characteristics of the Ulcer(s) Treated with Zinc Chloride Paste
Patient
AgelSex
Leg Ulcer Characteristics Duration Etiology (years) Location
Size (cm2) ~
60/M 68/F 53/F 81/F
1 Dermatol
Surg Oncol 16:7 July 1990
Venous Venous Venous Sickle cell Rheumatoid
3 3 5 10 2
Lateral Anterior Lateral Medial Medial
63 24 95 79 50
659
ZINC CHLORIDE PASTE
TABLE 2
Results of Treatment with Zinc Chloride Paste Patient
1 2
3 4
Successful Debridement
Grafted
Graft Take
Yes Yes Yes No Yes
No No Yes Yes
Yes Yes
Outcome He a 1in g Healed Healed Not healed Not healed
reason (Fig. 2). No other mechanical means of debridement were used. No problems with bleeding were encountered when the eschar was removed. After the eschar came off, good to excellent granulation tissue (Figs. 3 and 4) was present in the ulcers of all patients except patient 3, whose ulcer remained unchanged and had yet to heal, 10 months later. Split-thickness grafting with either pinch (in patient 2, Figs. 5 and 6) or keratome strips (in patient 4) led to excellent take and spread of the grafts. Even without grafting, the formation of good granulation tissue by zinc chloride paste was followed by healing in 2 ulcers (patients 1 and 2).
FIGURE 3.
Patient 2. Ulcer before zinc chloride paste.
We report that the application of zinc chloride paste to chronic leg ulcerations causes thorough debridement and the formation of good granulation tissue. Ulcers treated in this fashion may heal by themselves or support split-thickness grafts. We feel that grafting could be done within a few days of removal of the eschar caused by zinc chloride paste.
Zinc chloride paste was first formulated by Mohs, whose goal was to obtain a preparation with the consistency and degree of tissue penetration necessary for the in vivo fixation of cutaneous tum o r ~The . ~ “fixed” tissue could then be removed in horizontal slices and under microscopic control to insure total removal of the tumor and maximum preservation of uninvolved t i ~ s u e .The ~ , ~term ”chemosurgery” was coined for describing this technique. More recently, the use of zinc chloride has been largely abandoned and replaced by a ”fresh tissue” technique, where horizontal slices of tissue are cut directly and without prior f i ~ a t i o n . ~ ’ ~ In his early, pioneering work and later, Mohs realized the potential of zinc chloride as a means to remove gangrenous tissue in a bloodless field and
FIGURE 2. Spontaneous sloughing of eschar produced by
FIGURE 4. Patient 2. Ulcer 7 days after treatment with
zinc chloride paste in patient 4.
zinc chloride paste. Good granulation tissue and healthy,
DISCUSSION
glistening tendons are present.
660
] Dermatol Sitrg Oncol 16:7 Iuly 1990
FALANGA AND IRIONDO
FIGURE 5. Patient 2. Pinch grafts have led to almost complete reepithelialization of ulcer 2 months after zinc chloride treatment.
with relatively little pain. He used the preparation in several patients with gangrene.3 It is unclear why this method for removing unwanted tissue has not become more widespread. Possible explanations include the unfamiliarity of most physicians with the properties of zinc chloride paste, its relatively slow action when compared to surgical means, the uncertainty about the depth of penetration and fixation, and the pain reported with the use of this paste. These concerns deserve comment. Although unfamiliar to many physicians, zinc chloride paste is not difficult to prepare and is still used by some dermatologic surgeons for removal of skin cancers. We believe its use may actually increase due to the epidemic of acquired immunodeficiency syndrome (AIDS). A relatively bloodless field may minimize the exposure of the surgeon to the infectious agent. As far as the rapidity of action of zinc chloride paste, this is not a realistic concern in the case of chronic leg ulcers, whose clinical course does not change rapidly. As shown in this report, debridement can be carried out over a period of several days, without any need for immediate action. A justified concern exists about controlling the extent of tissue penetration of zinc chloride paste. The thickness of the applied paste determines its vertical penetration. We suggest that a very thin film of paste be applied and that the procedure be Dermatol Surg Oncol 16:7 luly 1990
FIGURE 6. Ulcer in patient 2 is completely healed.
repeated after a few days if satisfactory debridement has not been achieved. One should also be cautious and not apply the paste up to the margin of the ulcer, since horizontal spread of the preparation will cause the ulcer to become larger. As a final but important point, we suggest that venous ulcers on bony prominences or immediately overlying tendons or bones not be treated with zinc chloride paste. As a rule, venous ulcers do not involve these deep structures, and zinc chloride may cause unnecessary necrosis of these otherwise healthy tissues. In summary, we have described the application of zinc chloride paste as a means of debridement of chronic leg ulcers. With certain cautions, this may become a useful means of thorough debridement that may be accomplished in the outpatient setting.
REFERENCES 1. Jarrett F, Hirsch S. Vascular Surgery of the Lower Extremity. St. Louis, CV Mosby, 1985. 2. Falanga V. Occlusive wound dressings. Arch Dermatol 124~872-877,1988. 3. Mohs FE. Chemosurgery. Microscopically Controlled Surgery for Skin Cancer. Springfield, Ill, Charles C Thomas, 1978. 4. Menn H. Current management of cancer of the skin. Postgrad Med 52161-164, 1972. 5. Menn H. Cancer of the skin: A common medical problem for the Florida physician. J Florida Med Assoc 63:67-70, 1976.
661
ARTICLE
Abstract. Chronic leg ulcers present a difficult therapeutic problem, and their management requires frequent debridement. Thorough debridement of painful or extensive ulcerations is not always possible. Frequently, it must be done in the operating room, a situation accompanied by the potential complications of general anesthesia and by considerable expense. We present evidence for the effectiveness of zinc chloride paste as a relatively painless debriding agent in the management of chronic leg ulcers. When applied to the wound bed, zinc chloride paste fixes the tissue and leads to the formation of an eschar that falls off within a few days, leaving a granulating ulcer suitable for grafting. J Dermatol Surg Oncol 1990; 16:658-661.
INTRODUCTION Chronic leg ulcers are a difficult therapeutic problem. Those due to arterial insufficiency require revascularization of the affected limb, if technically possible. Neuropathic ulcers, as in patients with diabetes mellitus, respond at least partially to thorough avoidance of trauma and pressure. Other ulcers, such as pyoderma gangrenosum or those secondary to a vasculitis, benefit from systemic anti-inflammatory agents. Venous ulcers respond to elevation and graded compression of the affected limb.'
Common to all chronic leg ulcers is the frequent need for removal of necrotic and fibrotic tissue present in the wound bed. Satisfactory debridement may be achieved with the use of occlusive dressings,* but this is not always effective or possible. Thorough surgical debridement after local anesthesia is not practical in painful or extensive ulcerations. Frequently, debridement must be done in the operating room. This surgical procedure is accompanied by the potential problems associated with general anesthesia, which are of particular concern in elderly patients. Moreover, the expense associated with the use of the operating room is a further burden for patients afflicted by chronic and disabling ulcerations. We have been searching for ways to debride chronic leg ulcers when surgical debridement with local anesthesia is impractical or when occlusive dressing therapy is either not tolerated or ineffective. Noting the pioneering work of Mohs3 on the use of zinc chloride paste in gangrenous tissue, we have used this topical agent to achieve debridement of chronic leg ulcers. We present our experience with this method and suggest that zinc chloride paste may have a place in the management of these chronic wounds.
PATIENTS AND METHODS Vincent Falanga, M.D., and Manuel Iriondo, M.D., are from the Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida. Reprints are not available
We used zinc chloride paste in 4 patients followed in the leg ulcer clinic of our department. The zinc chloride paste was obtained from the School of Pharmacy, University of Wisconsin, Madison, Wisconsin. The formulation of this preparation is the J Derrnatol Surg Oncol 26:7 ]lily 1990
FALANGA AND IRIONDO
was followed by two layers of gauze; tape was used to keep the dressing in place. The patient was told not to disturb the dressing and to avoid contact with water for the next several days. RESULTS
FIGURE 1. Zinc
chloride paste applied with cotton appli-
cators to the ulcer of patient 4.
same reported by Mohs and consists of 34.5 ml of a saturated solution of zinc chloride, 10.0 grams of Sanguinaria canadensis as a binder, and 40.0 grams of stibnite (80 mesh sieve), which is responsible for the consistency and black color of the paste. One of us (MI) applied zinc chloride paste to the wound bed (Fig. 1).Although zinc chloride does not penetrate uninjured keratinized epithelium, care was taken to avoid contact with the surrounding unulcerated skin. No protective ointment was applied to the margins of the ulcer. The thickness of the applied paste, which determines the extent of vertical p e n e t r a t i ~ nwas , ~ approximately 1 mm. In the first two patients we studied, the entire ulcer bed was treated. Later, after we observed that horizontal spread of the preparation would cause the ulcer to enlarge slightly, a margin of approximately 2 mm from the ulcer’s edge was left untreated. The ulcer was then covered with cotton to absorb excess paste and with gauze impregnated with petrolatum. This
We have treated 5 leg ulcers in 4 patients with zinc chloride paste. Table 1 describes the clinical characteristics of these patients. None of the patients had evidence of significant arterial insufficiency, either clinically or by Doppler flow studies. The two patients with venous ulcers (1 and 2) had clinical evidence of venous insufficiency, such as varicosities, hyperpigmentation of skin surrounding the ulceration, and lipodermatosclerosis in one. These two patients also had abnormal venous plethysmography and venous recovery times. Patient 3 had sickle cell disease, but her hemoglobin studies showed an SC genotype. She had an additional but larger ulcer on the opposite leg, which was not treated with zinc chloride. Patient 4 had longstanding rheumatoid arthritis. Although the medial location of her ulcer suggested a venous etiology, venous plethysmography and recovery time were normal. Several biopsies from the edge of her ulcer showed no histologic evidence of vasculitis and no immunoreactant deposition by direct immunofluorescence. Final results are presented in Table 2. The application of zinc chloride paste caused no immediate discomfort. After approximately 3-4 hours, stinging and burning were experienced by all except patient 4, who reported absolutely no discomfort. The burning sensation resolved after 24-48 hours and was relieved by acetaminophen or codeine. Thereafter, the ulcers became painless even in patients 2 and 4, in whom ulcer pain had been a major complaint. The eschar that formed on the ulcer after the application of zinc chloride paste sloughed off after 5-7 days, either by itself or after one or two whirlpool treatments instituted for this
TABLE 1
Clinical Characteristics of the Ulcer(s) Treated with Zinc Chloride Paste
Patient
AgelSex
Leg Ulcer Characteristics Duration Etiology (years) Location
Size (cm2) ~
60/M 68/F 53/F 81/F
1 Dermatol
Surg Oncol 16:7 July 1990
Venous Venous Venous Sickle cell Rheumatoid
3 3 5 10 2
Lateral Anterior Lateral Medial Medial
63 24 95 79 50
659
ZINC CHLORIDE PASTE
TABLE 2
Results of Treatment with Zinc Chloride Paste Patient
1 2
3 4
Successful Debridement
Grafted
Graft Take
Yes Yes Yes No Yes
No No Yes Yes
Yes Yes
Outcome He a 1in g Healed Healed Not healed Not healed
reason (Fig. 2). No other mechanical means of debridement were used. No problems with bleeding were encountered when the eschar was removed. After the eschar came off, good to excellent granulation tissue (Figs. 3 and 4) was present in the ulcers of all patients except patient 3, whose ulcer remained unchanged and had yet to heal, 10 months later. Split-thickness grafting with either pinch (in patient 2, Figs. 5 and 6) or keratome strips (in patient 4) led to excellent take and spread of the grafts. Even without grafting, the formation of good granulation tissue by zinc chloride paste was followed by healing in 2 ulcers (patients 1 and 2).
FIGURE 3.
Patient 2. Ulcer before zinc chloride paste.
We report that the application of zinc chloride paste to chronic leg ulcerations causes thorough debridement and the formation of good granulation tissue. Ulcers treated in this fashion may heal by themselves or support split-thickness grafts. We feel that grafting could be done within a few days of removal of the eschar caused by zinc chloride paste.
Zinc chloride paste was first formulated by Mohs, whose goal was to obtain a preparation with the consistency and degree of tissue penetration necessary for the in vivo fixation of cutaneous tum o r ~The . ~ “fixed” tissue could then be removed in horizontal slices and under microscopic control to insure total removal of the tumor and maximum preservation of uninvolved t i ~ s u e .The ~ , ~term ”chemosurgery” was coined for describing this technique. More recently, the use of zinc chloride has been largely abandoned and replaced by a ”fresh tissue” technique, where horizontal slices of tissue are cut directly and without prior f i ~ a t i o n . ~ ’ ~ In his early, pioneering work and later, Mohs realized the potential of zinc chloride as a means to remove gangrenous tissue in a bloodless field and
FIGURE 2. Spontaneous sloughing of eschar produced by
FIGURE 4. Patient 2. Ulcer 7 days after treatment with
zinc chloride paste in patient 4.
zinc chloride paste. Good granulation tissue and healthy,
DISCUSSION
glistening tendons are present.
660
] Dermatol Sitrg Oncol 16:7 Iuly 1990
FALANGA AND IRIONDO
FIGURE 5. Patient 2. Pinch grafts have led to almost complete reepithelialization of ulcer 2 months after zinc chloride treatment.
with relatively little pain. He used the preparation in several patients with gangrene.3 It is unclear why this method for removing unwanted tissue has not become more widespread. Possible explanations include the unfamiliarity of most physicians with the properties of zinc chloride paste, its relatively slow action when compared to surgical means, the uncertainty about the depth of penetration and fixation, and the pain reported with the use of this paste. These concerns deserve comment. Although unfamiliar to many physicians, zinc chloride paste is not difficult to prepare and is still used by some dermatologic surgeons for removal of skin cancers. We believe its use may actually increase due to the epidemic of acquired immunodeficiency syndrome (AIDS). A relatively bloodless field may minimize the exposure of the surgeon to the infectious agent. As far as the rapidity of action of zinc chloride paste, this is not a realistic concern in the case of chronic leg ulcers, whose clinical course does not change rapidly. As shown in this report, debridement can be carried out over a period of several days, without any need for immediate action. A justified concern exists about controlling the extent of tissue penetration of zinc chloride paste. The thickness of the applied paste determines its vertical penetration. We suggest that a very thin film of paste be applied and that the procedure be Dermatol Surg Oncol 16:7 luly 1990
FIGURE 6. Ulcer in patient 2 is completely healed.
repeated after a few days if satisfactory debridement has not been achieved. One should also be cautious and not apply the paste up to the margin of the ulcer, since horizontal spread of the preparation will cause the ulcer to become larger. As a final but important point, we suggest that venous ulcers on bony prominences or immediately overlying tendons or bones not be treated with zinc chloride paste. As a rule, venous ulcers do not involve these deep structures, and zinc chloride may cause unnecessary necrosis of these otherwise healthy tissues. In summary, we have described the application of zinc chloride paste as a means of debridement of chronic leg ulcers. With certain cautions, this may become a useful means of thorough debridement that may be accomplished in the outpatient setting.
REFERENCES 1. Jarrett F, Hirsch S. Vascular Surgery of the Lower Extremity. St. Louis, CV Mosby, 1985. 2. Falanga V. Occlusive wound dressings. Arch Dermatol 124~872-877,1988. 3. Mohs FE. Chemosurgery. Microscopically Controlled Surgery for Skin Cancer. Springfield, Ill, Charles C Thomas, 1978. 4. Menn H. Current management of cancer of the skin. Postgrad Med 52161-164, 1972. 5. Menn H. Cancer of the skin: A common medical problem for the Florida physician. J Florida Med Assoc 63:67-70, 1976.
661
