Regular Post
placeholder logo we treat feet podiatry

Skin Substitutes, what you need to know

Baltimore Foot Doctor, Baltimore Podiatrist, Dr. Daniels Diabetic Foot Blog, Uncategorized, We Treat Feet Staff , , , , ,

Dr. Mikel Daniels

Dr. Mikel Daniels

President , Chief Medical Officer, and Managing Member at WeTreatFeet
8 articles

Skin substitutes are an important tool in wound care management. They are designed to replace damaged or missing skin and promote healing in difficult-to-treat wounds. There are both high-cost and low-cost skin substitutes available on the market, each with their own unique benefits and drawbacks. Recent changes by the Centers for Medicare and Medicaid Services (CMS) have had an impact on the use of skin substitutes in wound care.

High-cost skin substitutes are typically derived from human or animal tissues and are designed to closely mimic the structure and function of natural skin. They are often used in complex wounds that are slow to heal or have poor blood flow. While high-cost skin substitutes can be effective in promoting wound healing, they are also expensive and may not be covered by insurance.

Low-cost skin substitutes, on the other hand, are often made from synthetic materials and are more affordable than high-cost options. They may not have the same level of complexity as high-cost skin substitutes, but they can still be effective in promoting wound healing. Low-cost skin substitutes are often used in less complex wounds or in cases where insurance coverage is an issue.

Recent changes by CMS have had an impact on the use of skin substitutes in wound care. In 2021, CMS changed the way it reimburses providers for skin substitutes. The new payment system, known as the Outpatient Prospective Payment System (OPPS), sets a fixed payment rate for each skin substitute. This has caused some controversy in the wound care community, as some providers argue that the fixed payment rate may not cover the actual cost of high-cost skin substitutes.

The changes by CMS have also led to increased scrutiny of the use of skin substitutes in wound care. CMS now requires providers to document the medical necessity of using a skin substitute and to use the lowest-cost option that is appropriate for the wound. This has led some providers to reevaluate their use of skin substitutes and to consider alternative treatment options.

Despite the changes by CMS, skin substitutes remain an important tool in wound care management. Providers must carefully weigh the benefits and drawbacks of high-cost and low-cost options and make decisions based on the individual needs of each patient. With proper use and documentation, skin substitutes can be an effective tool in promoting wound healing and improving patient outcomes.

#CTP #wetreatfeet #podiatry #skinsubstitute #woundcare

Published by

Dr. Mikel Daniels

Dr. Mikel Daniels
President , Chief Medical Officer, and Managing Member at WeTreatFeet
Published • 22h
8 articles
Skin Substitutes, a quick primer CTP wetreatfeet podiatry skinsubstitute woundcare
Regular Post
foot lesion

Why does my diabetic foot hurt?

Dr. Daniels Diabetic Foot Blog , , , , ,

In diabetics, neuropathy is defined as a loss of protective sensation.  The condition occurs in what we call and stocking and glove distribution.  It starts at the distal ends of the toes and fingers, and moves proximally up the foot/hand into the leg/arm.  While there are many causes of peripheral neuropathy, diabetes is the most common.

Neuropathy can occur in several forms.  The most common is sensory neuropathy.  This is a change in the ability of the patient to feel their feet and hands.  Starting in a stocking and glove distribution, a patient will not feel items touching their toes and feet.  Over time, patient can step on objects such as glass shards, nails, or tacks, and will not feel it.  This is a significant risk for infections and amputation.

Neuropathy can also occur as a motor neuropathy.  This is a loss of function in the distal most muscles, and can be combined with sensory neuropathy to be called sensorimotor neuropathy.  The most common examples of this include the development of hammertoes in a neuropathy foot, or ankle contractures causing ulcerations in the ball of the foot.

Lastly, neuropathy can cause an autonomic issue.  This will be symptoms such as a loss of ability to sweat or release oils (also called sebum) from the skin.  This is the type of neuropathy that also involves the cardiovascular system, gastrointestinal system, and genitourinary system.

With loss of sensation and function, patients become higher risk for infections, wounds and amputation.  Daily foot examinations, proper shoe gear, and regular diabetic foot care can prevent many problems.   So that begs the question, if I can’t feel it, why does it hurt?

60-70% of diabetics will eventually suffer from this condition.  The best way to think about it, is to use the telephone as an analogy.  If you are on the phone, and there is static, you can still hear, right?  The more static, the louder you have to yell to have the person on the other end hear you, until eventually there is so much static that you can’t hear anything, and they you hang up.  This is what happens with your nerves.

Each and every nerve in your body is connected directly to your brain.  Millions and millions of individual wires, from every aspect of your body, connected directly to your brain.  As neuropathy advances, the static to your brain increases.  Patients perceive this as neuropathic symptoms, burning, tingling, fire, ices, etc.  The louder the static, the more symptoms, until finally your brain hangs up, and then you have a complete loss of sensation.  This basically means that you can remove portions of your foot without anesthesia and not know it.

Treatments for painful diabetic neuropathy include proper glucose control, diet, exercise, and many different medication options.  You may have even seen a television commercial for Lyrica for example.  There are also sensory feedback options, cold laser and other light treatments, and even surgical options for releasing the nerves.

Best treatment for diabetic Neuropathy is prevention.  Good glucose control, exercise, and preventive foot care are essential.  Treatment once you have symptoms has been successful, but not for everyone.  You may not know you even have it.  The doctors at WeTreatFeet are well versed in this process and can offer you many cutting-edge treatments.  Call today if you want to have t

Regular Post

What is a diabetic foot skin graft?

Dr. Daniels Diabetic Foot Blog , , , ,

Open wounds on diabetic feet is a significant and often expensive problem to treat.  Diabetic foot wounds, according to Medscape, direct costs for these specific wounds are   $9-13 million dollars yearly. [1]  While we have many different modalities for treating wounds, one treatment type stands out, skin grafts.

A Cochrane review done in February 2016 indicated that these grafts are effective in increasing healing rates.[2]  However, long term success, and cost effectiveness remains uncertain.  The grafts themselves are expensive, running between a few hundred to a few thousand dollars.  However, the overall cost to the community of diabetic wounds is astronomical.  These range from $11,710 to $16,883 per patient with a foot ulcer. [3]

When one says skin graft, most people naturally are thinking autografts.  These are skin grafts that come from the patient.  Skin, removed from another area such as the thigh, is transplanted over a wound.  This treatment originated 3000 years ago in India.  In 1804, an Italian surgeon, Boronio performed a full thickness graft on a sheep.  However, it was 1823 when Bunger reconstructed a nose with graft that these started to be used on a regular basis in medicine.[4]  While these remain a popular option for burns and traumatic wounds, it has fallen out of favor in diabetic foot wounds due to the high comorbidities, such as graft site infection.  I always tell my own patients that I am not a big fan of making a new wound to fix an old wound.

Allografts are grafts from the same species, placed on a different individual.  We often us a product called Theraskin, which is cadaveric skin.[5]  While this is actual human skin, it doesn’t incorporate as well as autograft, and may require several applications.  Apligraf® is a unique, advanced treatment for healing. It is created from cells taken from fetal foreskin, that are cultured and grown to form healthy human skin.[6]  It is actually alive in a dish when it arrives, and must be applied in a specified time frame, or it will die.

Xenografts are a group of grafts that are made from animal products.  These include fish skins, cow bladder, pig intestine, etc.  These contain collage that is the building blood for skin, and often work as scaffolding, helping wounds heal but providing the building blocks for skin.

The latest groups of grafts are amniotic.  These are grafts made from placenta, umbilical cord, or amniotic sac.  These are harvested at birth, prepared to remove all diseases and viruses, then transplanted into wounds.  These are the grafts that possess stem cells, and help the wound develop its own skin.

Not every wound responds to every treatment, and not all wounds were alike.  The challenge wound care physicians face is using an appropriate graft in the correct situation.  Venous wounds, arterial wounds, traumatic wounds, etc. will respond differently to treatments.  Only a skilled, experienced physician, who deals with large quantities of wounds on a regular basis, can tell you which one of the grafts may be right for your wound.  Due to the high costs of these products, this is critical, because applying the wrong product may actually make the wound worse, delaying healing, increasing the risk of infection or amputation.

If you have questions about your wound, or if you need treatment for a chronic wound, call our experts, and we will do everything we can to prevent complications, reduce amputation risk, and help treat the wound.

 

[1] http://www.medscape.com/viewarticle/821908

[2] http://www.cochrane.org/CD011255/WOUNDS_skin-grafting-and-tissue-replacement-treating-foot-ulcers-people-diabetes

[3] http://www.medscape.com/viewarticle/821908

[4] http://plasticsurgery.stanford.edu/content/dam/sm/plasticsurgery/documents/education/microsurgery/FlapsSelectedReadings.pdf

[5] http://theraskin.com/

[6] http://www.apligraf.com/patient/what_is_apligraf/what_is_apligraf.html

Regular Post

Modern diabetic wound issues

Dr. Daniels Diabetic Foot Blog , , , ,

Diabetic foot wounds are among the most common complications of diabetes, and are some of the more difficult conditions to treat.  In the USA, yearly, approximately 8% of diabetic Medicare beneficiaries have a foot ulcer.  When these occur, 1.8% of these patients will have an amputation. These are further elevated for patients with lower extremity peripheral artery disease.[i]  The costs of diabetic foot ulcerations range from $12,211 for hospitalizations without amputation, to $34,671 for patients requiring an amputation.[ii]

It is fairly simple to understand why prevention of the first wound or amputation is so crucial.  Somewhere between 50-79% of people hospitalized with a diabetic foot infection will be either unable to work, or unemployed after the episode.[iii]  These events, while often not life threatening, (can become so if not treated) can have significant influences on entire households.  This includes children and spouses.

In our practice, we have a comprehensive policy for diabetic foot prevention.  The first and most important step is education.  I often get asked during new diabetic evaluation questions related to when foot loss or lower extremity amputation will occur (as most of these patients have friends or family members who have had an amputation).  My answer is always the same.  While we can’t prevent every amputation, most are probably avoidable with simple steps.  The American College of Foot and Ankle Surgeons has set specific guidelines for diabetic foot care.  These include:

  • Inspect your feet daily
  • Bathe feet in lukewarm, never hot, water
  • Be gentle when bathing your feet.
  • Moisturize your feet but not between your toes.
  • Cut nails carefully.
  • Never treat corns or calluses yourself.
  • Wear clean, dry socks.
  • Consider socks made specifically for patients with diabetes. Wear socks to bed. Shake out your shoes and feel the inside before wearing.
  • Keep your feet warm and dry. Never walk barefoot.
  • Take care of your diabetes.
  • Don’t smoke.
  • Get periodic foot exams. [iv]

In our office, we make sure that all diabetics start out with a yearly diabetic foot examination.  This assumes no known preexisting conditions for example vascular disease, neuropathy, or deformities.  As risk factors increase, so do visit frequency.  The range can be from twice yearly all the way up to weekly.  Our doctors know how to evaluate and treat these problems, and have strategies to prevent wounds.

If you have a wound, all is not lost.  First, make sure you get this checked by a qualified physician as soon as possible. Tomorrow is never advisable.  Second, I always tell patients that this is a 2 step process; first is getting the wound healed, second is keeping the wound healed.  The rate of re-ulceration is reported as high as 35–40% over 3 years, and that increasing to 70% over the 5years after the first wound.[v]  Five-year mortality rates after a diabetic foot ulceration have been reported to be between 43 and 55 percent, and can be as high as 74 percent in patients with lower-extremity amputation.[vi]  Prevention is crucial to longevity of patients with diabetes.

Our internal ulceration and amputation rates are much lower than the average throughout the country.  If you are diabetic, even if you have no complications, get your feet checked today.  It may save your life.  Our doctors offer same day and next day appointments, and we provide night and weekend coverage at several area hospitals.

 

 

 

[i] https://effectivehealthcare.ahrq.gov/topics/diabetes-foot-ulcer-amputation-prevalence/research/

[ii] Barshes 2012; Barshes 2014

[iii] Van Acker K, et al., 2014; Hogg FRA, et al., 2012; GoodridgeD, et al. 2005

[iv] http://www.acfas.org/footankleinfo/diabetic-guidelines.htm

[v] http://www.woundsinternational.com/media/other-resources/_/1097/files/dfj12-4-181-6.pdf

[vi] http://barefoot-science.com/pages/diabetes/