Development of Best Practice Guidelines for Cutaneous T-Cell Lymphoma (CTCL) Wound Care

Running head: PHYSICAL THERAPY INTERVENTION 1
Physical Therapy Intervention: Development of best practice guidelines for cutaneous
T-cell Lymphoma (CTCL) wound care
Name
Institution

PHYSICAL THERAPY INTERVENTION 2
Abstract
Background and purpose: The use of the traditional method of whirlpools in
controlling ulcerations in MF remains a great challenge. According to research, removal
of the gross contaminants and toxic debris from the wounds together with the dilution of
the surface bacteria is a threat that has been observed among many patients that
undergo the traditional treatment. The purpose of this work is to develop the guidelines
for an alternative treatment of wounds using Vashe Solution Therapy.
Case Description: It involved a 52-year old woman diagnosed with MF with notable
granulomatous lesions on the skin for seven years. In the past, the patient undertook a
treatment using tropical medications and recurrent courses of prednisone. At the
hospital, the patient underwent pathological diagnosis confirmed by the use of
histopathology.
Outcome: The patient was seen to have recovered from the wounds eight weeks after
the discharge from the hospital.
Discussion: The greatest improvement on the patient occurred after eight weeks of the
treatment and home care. The rehabilitation after her discharge from the hospital
focused on improvement of the healing of the wounds.

Introduction
The proposal for the use of the Vashe solution focused on treatment of wounds
by undergoing a total skin beam therapy. The Vashe treatment focus on home-based
care treatments for eight weeks with a weekly follow up with the physical for the
mSWAT measures that tests on the progress of the patient (Demierre et al., 2001). The
rationalization of the Vashe was effective against Pseudomonas and staph. Therefore,
the use of the Vashe solution therapy is more effective since it eliminates the possibility
of contamination contrary to the Whirlpool, which tend to worsen the condition.
The use of whirlpools in the CTCL is one of the commonly used method in the
control of the wound among patients. Nevertheless, a clear illustration of the defining
differences between cutaneous T-Cell Lymphoma and Mycosis Fungoides (MF) has
been a challenge contributing to medical complications in the treatment of the wounds
(Abel, Sendagorta and Hoppe,1986). Even though the method has attracted usage
especially in the treatment of wounds, the procedures involved have contributed to the
onset of the complications that continue to suppress many patients. The commonly
used method of the whirlpools is observed to the causative agent for many other
infections such as P.aeruginosa and S. aureus (Centers for Disease Control and
Prevention (CDC), 2000). Notably, there has been increasing need to develop a better
mechanism of treating the various wounds depending on the degree of the cancer as
well the systematic procedures involved in the treatment (Davison, Loiselle and
Nickerson, 2010). Therefore, the research focuses on establishing better guidelines that
would provide a better control and treatment of wounds without the use of the whirlpools
method, which has been observed to contribute greatly to various infections.

The use of the traditional method of whirlpools in controlling ulcerations in MF
remains a great challenge. According to research, removal of the gross contaminants
and toxic debris from the wounds together with the dilution of the surface bacteria is a
threat that has been observed among many patients that undergo the traditional
treatment. The cleansing effects of the whirlpools have been questionable. Similarly, the
WP therapy removes only up to four times the bacteria in the venous stasis ulcer. The
maximum reduction of bacteria using the WP therapy tends to increase the temperature
to 37.70C within a 20-minute immersion (Shin et al., 2007; Singh and Lebwohl, 2004).
Besides, the high-quality randomization and antimicrobial additives tend increase the
multiplication of the bacterial infection, which eventually contribute to the reemergence
of the wound.
A study by Trdget that involved burn victims showed a significant lethal strain of
the P. aeruginosa in the hydrotherapy (WP) even with weekly surveillance and
standardized disinfection protocols of the equipment (Stanwood and Pinzur, 1988;
Stevens et al., 2002). Consequently, the researcher related the existence of the
pathogen to the hydrotherapy that resulted in higher mortality rates and substantial
morbidity. Therefore, in order to reduce further infections among the patients the use of
the hydrotherapy needed to be eliminated since it contributed to the skin donor site
infections.
Recent studies also show that use of WP tend to damage the granulation tissue,
hinder the migration of the epidermal cells as well as causing maceration. In the study,
Hess asserts that the pressure applied on the wound surface through the WP therapy
vary greatly making it difficult to develop a monitoring and controlling mechanism. In the

process, the onset of unregulated and unspecified pressure damages the emerging
granulation tissue (Resnik and Vonderheid, 1993). In turn, the destruction hinders the
migration of the epidermal cells together with the neutrophils, which are the innate
immune response components of the body. Eventually, the effect results in maceration.
Importantly, the WP therapy tends to result in venous hypertension and vascular
congestion. The use of the WP therapy for the lower extremity regions tends to affect
the blood flow in that limb leading to a physiological decrease in the wound healing. The
complication is common in patients with venous inefficiency (Stevens et al., 2002;
Timothy, Butler and Luttrell, 2012). Although it is believed that the therapy also causes
effects on upper extremity, proper studies on that have not been established. The
various complications noticeable in the use of the WP therapy create the importance of
another therapy model that causes minimal harm and reduced infections to the patient
facilitating recovery.
Case Description
The permission to conduct the case study and to provide a report on the same
was approved by the Director of Physical Therapy Services of Lovelace Regional
Hospital. However, it was not necessary to receive an approval by the Institutional
Review Board since the patient signed a consent release of information and a consent
form. The above consent and permissions enabled the review of the essential health
records exclusively for academic purposes of completing this case report.
The case involved a 52-year old woman diagnosed with MF with notable
granulomatous lesions on the skin for seven years. In the past, the patient undertook a
treatment using tropical medications and recurrent courses of prednisone. At the

hospital, the patient underwent pathological diagnosis confirmed by the use of
histopathology. The patient showed stage III MF, a characteristic epidermotropism of
CTCL. She had extensive nodular lesions and plaque-like lesions over a large portion of
the skin. The patient also showed other symptoms of thick and keratotic lesions on the
palms and bilateral soles, severe and abnormal foot ambulation.
During the diagnosis, the patient underwent a hospitalization for foul-smelling
discharge from extensive skin lesions as well as ulcerations. At first, the lesions did not
respond to the oral ciprofloxacin treatment and metronidazole at the initial hospital.
Therefore, the treatment process took an alternative mechanism of culturing group B
streptococcus from the lesions. The culturing improved the treatment involving 3g of
intravenous ampicillin or sulbactam. The medication was given after every 6 hours with
an additional 2g of ceftazidine given to the patient after every 8 hours. Notably, the
patient did not show any symptoms of visceral disease. Using external beam therapy,
the patient underwent a radiation therapy of the whole body. The response was
monitored for the next 4 months as she received 24Gy to her back and hip together with
another 30Gy on her both feet and the left hand lesions.
Examination
The observation of the woman after four months of infection with the group B
streptococcus showed weeping and crusting of purulent fluid from almost all the lesions
in the body of the patient. The patient also had developed additional multiple lesions on
the entire body. Besides, the patient had a higher fever than normal, measured to be
100.50F. The results from the culturing of the contents of the wound showed the
presence of methicillin-resistant Staphylococcus aureus (MRSA). In order to establish

further analysis of the symptoms of the patient, she got further 5 days treatment using
1g of intravenous vancomycin at a time interval of 12 hours. Besides, the patient
received a further treatment with 500g of cilastatin or imipenem for 6 hours followed by
another 100mg of oral minocycline twice daily. The medication took 14 more days to
take note of any difference in the symptoms compared to the first test. Nevertheless, the
admission stage did not include the use of chemotherapy to treat the MF (Talpur,
Bassett and Duvic, 2008). The reason for the avoidance of chemotherapy was due to
the need to reduce the severity of anemia. Similarly, it limited the chances of the
inability of the patient to undertake blood transfusions effectively without the limitation of
religious beliefs.
One month later, the patient recorded a fever of 101.70F. Nonetheless, the
patient revealed drainage and pain from the extensive lesions in her body. She revealed
multiple ulcerated lesions on her chest wall, hand, inguinal region, feet, and back. The
average size of a single lesion measured 2x3 cm in diameter with discharge ranging
from serosanguineous to purulent. The MSRA from the cutaneous lesions was again
grown and different treatment carried out to make a comparison with the first two
treatments (Tsambiras et al., 2001). In this treatment, the patient was given 1g of
vancomycin within a time span of 12 hours and an additional 600mg of oral rifampin g
every day. After several days, the intravenous vancomycin was replaced with 1 oral
trimethropin or sulfamethoxazole, a double-strength tablet that could provide more
effective results. This procedure also avoided the use of chemotherapy even though the
patient showed severe anemic with a notable hemoglobin level of 6.9 g/dL. However,
the patient took erythropoietin to maintain a high hemoglobin level. The process of

hospitalization in this treatment did not show any new symptom; rather the symptoms
remained as stable as in the prior treatment resulting in the need for whole-body
electron beam therapy. Besides, the patient undertook whirlpool treatments. To ensure
topically treatment of the lesions, the patient was soaked in Domeboro.
The chronicity of the patient’s disease and the inability of using chemotherapy or
radiation therapy to control the situation led to the discharge of the patient to
conservative care and home health supportive care. After 16 days from the date of
release, the patient returned to the hospital for a whole-day pain in the entire body as
well as oozing lesions. To prevent further worsening of her condition, the patient
received aggressive management of her pains. Nevertheless, the patient developed
hypothermia leading to the worsening of her respiratory system. Eventually, she died
after some days of admission.
Tests and measures
Pain intensity level: Defense and Veterans Pain Rating Scale (DPRS) is an
instrument that integrates the system for rating the pain of a patient. The instrument was
used to increase the interpretability of the conditions of the patient upon the
administration of various treatments. The patient undertook a DVPRS-one pain intensity
NRS. The behavior of the patient such as sleep, mood, level of stress and general was
recorded as a guide to determining the degree of pain intensity of the patient. The
method used a systematic sample through a random sampling of the entire body of the
patient using a validation procedure. The procedure involved the determination of
matching words with the corresponding pain intensity earlier recorded in the NRS. The

validity testing of the patient correlated with the NPR. The DVPRS showed a higher
correlation of r = 0.929 (P < 0.001) (Tsambiras et al., 2001).
Relative percentage of body surface area affected by growth: The Severity
weighted assessment tool (SWAT) and the modified-SWAT (mSWAT) scores provide a
global measure of disease severity by incorporating information of total body surface
area (BSA) involved by each dimension. The extent of skin involvement is determined
by the extent of body surface area (BSA) of each type of lesion – patch, plaque, tumor.
The Lund-Browder chart is the most accurate method for estimating the percentage of
total BSA, and can take into account the. These tools are the most widely used tools for
skin scoring in patients with MF. The SWAT scores of the patient were obtained during
each treatment. The measurement took into consideration the percentage of the total
surface area of the body surface covered by the lesions. Thereafter the records were
multiplied by the weighting factor. That is, (patch % BSA X 1) + (plaque % BSA X 2) +
(tumor % x 3) (Meldrum, 2001; Molina, Zain and Arber, 2005). Thereafter, a comparison
with the standard measurements of BSA global assessments were established and
recorded. From the results, the correlation of the SWAT score and the BSA stabilized at
r = 0.95, P< 0.001. This is contrary to the global assessment which stood at r = 0.60, P<
0.001 (Mallo-García, Coto-Segura and Suárez-Casado, 2008). Therefore, the results of
the data showed a validity of the standard measures. The mixed responses of the
patient are due to the disparities in the SWAT score skin disease burden.
Target lesion skin scoring: the local index lesion skin scoring was used in this
case. The technique focused on establishing the effectiveness of the treatment of the
MF using whirlpool therapy and the Vashe wound therapy (Lund and Browder, 1944).

The method focused on monitoring the treatment of one lesion using the two types of
the aforementioned therapies striking a comparison of the effectiveness of either of the
therapies. Using the Composite Assessment of Index Lesion Severity, the procedure
drew an underlining difference in the effectiveness of the various lesions. The method
applied the multiplication model as well as an addition of the products of each of the
target lesion (Vonderheid, Tan and Cantor,1989). The test involved the determination of
the sums of the areas of every local lesion multiplied by weight of the respective lesion
type. The three major weights were patch = 1, plaque = 2 and tumor = 4 as observed
through the use of the mSWAT score. The use of the mSWAT reduces the CAILS
pigmentation severity score (Lee, Fritz and Golitz,1982; Lorincz, 1996). Similarly, it
eliminates the possibility of under- or overestimation in the BSA that is inevitable in the
CAILS. The tracking of the tumors involved the utilization of tumor column of the
mSWAT score followed by the summing of the product of the area of each lesion and
the height of the respective tumor.
Whirlpool, or hydrotherapy, has been used in Physical Therapy (PT) for a myriad
of conditions since its introduction. The modality was initially utilized to enhance
mechanical debridement and cleaning of wounds. It continues widespread acceptance
in contemporary care of wound healing and burn patients. Research concerning lack of
efficacy of whirlpools has demonstrated that S. Aureus as well as P. Aeruginosa can
persist in whirlpools despite chlorine disinfection (Jones, Wilson and Fox-Goguen, 2003;
Krejsgaard, Odum and Geisler, 2012). Despite the risk of opportunistic infections,
hydrotherapy continues to be utilized in the care of MF patients.
Intervention

The general physical therapy aims at increasing the postoperative rehabilitation
of an inpatient. The suggested therapy focuses on the elimination of the multiple
observable infections due to pressure during the treatment that contributes to the
breakdown of debris that facilitate further contamination of the nearby cells causing the
deterioration of the lesions rather than healing (Hofer et al., 1999). Besides, the physical
therapy applied objectively focuses on reducing the period of recovery of the lesions of
the patient. The physical intervention therapy included the use of Vashe wound therapy.
According to Herrmann et al (1995), the new management intervention focuses
on reducing pain as well enhancing the recovery rate of lesions through the use of a
better wound therapy rather than Whirlpool used in the treatment of MF. The use of the
Vashe wound therapy aims at enabling a better and less painful preparation mechanism
of the wound with little application of pressure. The complexity of each patient together
with the associated comorbidities creates the need to choose the most effective wound
treatment method, which the Vashe wound therapy maintains (Hess, Howard and
Attinger, 2003). The solution is effective under all environments especially the changing
temperature contrary to the use of the whirlpool therapy.
The ability of the Vashe therapy to cleanse effectively the wound will help in
accomplishing the wound bed preparation. Importantly, the preparation using Vashe
therapy is safe, natural, biocompatible, and effective. Vashe is a chemical component
that contains Hypochlorous acid (HOCl) making it safe for the treatment of the wound
(Heald, 2001; Herbert, Spencer and Grigg, 2004). The substance, developed through a
proprietary electrochemical process, is a preservative that eliminates the possibility of
microbial contamination of the wound contrary to the use of the whirlpool therapy.

Besides, the solution is non-cytotoxic, non-sensitizing, and non-irritating. This makes
applicable in the treatment of all the wounds regardless of the condition of the patient
(Fung et al., 2006; Heald, Mehlmauer and Martin, 2003). The absence of oral toxicity
and clinical contraindications enables effective use of the therapy in patients that
experiences various health conditions upon treatment as common in cancerous MF
treatments. In addition, the Vashe therapy enables bed preparation contrary to the
commonly used whirlpool therapy. The framework of bed preparation is important in the
management of wounds, specifically chronic wounds (Duvic, 2001). The ability to
manage the wounds limits the obstacles to the healing of the wounds like necrotic
tissue, exudate, and slough. The Vashe therapy also facilitates the healing of the body
through its own mechanisms such the leucocytes and neutrophils. The use of Vashe
solution as therapeutic substance contributes greatly to faster recovery of the patients
from wounds especially the lesions that appear in the whole due to cancer cells.
The Vashe wound solution was used in the patient’s lesions for six hours daily. In
order to consolidate the plan for using the Vashe solution as part of the POC
intervention, the physical therapist irrigated the pre-wound and the wound area with the
Vashe Wound Therapy (Van Vloten, 2003). The application aimed at removing all the
cellular debris as well as reducing the excessive wound drainage before the treatment
procedure began. The therapist then added more of the Vashe solution to pool the
wound deepening it to provide a sufficient area for the application of the treatment.
Thereafter, the wound was saturated and dressed using Vashe Wound Therapy
Solution for 5 minutes followed by the application of a wound dress to the wound bed for
5 minutes (Willemz et al., 2005). The use of the pre-soak method remains one of the

most effective procedure used by the Vashe Wound Therapy that enhances the healing
of the patient’s wound. Together with the directing flushing of the Vashe solution to the
wound for the specified contact time, the wound heals faster with minimal pressure.
The outpatient treatment involved visiting of the patient three times a week for
eight weeks and another two times a week for three weeks. The treatment time for the
patient took 10 minutes. The objectives of the treatment were to minimize the pain due
to the swelling of the wounds, to eliminate the oozing of extracts from the wound,
reduce the expansion and spread of the lesions, to restore the POC and strength and to
help the patient adhere to the home physical exercises. Through functional training and
improvement of bed mobility, the patient was able to reduce the multiplication of the
contaminating pathogens limiting any chance of deterioration of the lesions and the pain
of the patient.
Notably, the pain, extensive spread of the lesions and increased oozing of fluids
from the wound is due to pressure in the process of treatment and spread of the
contamination pathogens through the breakage of the skin debris. The initial stage of
recovery from lesions spread and pain from wounds is essential in the general control
process of treating a wound. A well-established system is essential in using the Vashe
Wound Therapy to provide the essential for the determination of the specific desired
outcomes. The Vash Therapy focuses on establishing the best temperature of operation
to provide the best results.
Outcomes
The treatment of the patient with the whirlpool therapy showed diverse results
depending on the stage of the wound treated. On treatment with the whirlpool therapy,

the patient develops anxiety and fear due to the pressure on her. Therefore, there was a
need to provide necessary training to the patient to ensure that she maintains the
stability of balancing after the treatment. Nevertheless, a treatment using Vashe
Solution Therapy did not show any effect as the patient could undertake her actions with
a lot of stability. On the fourth week of the rehabilitation, the patient showed reduced
lesions in the body as well as the size of particular lesions reduced significantly.
After seven weeks of the treatment, the patient gained observable progress with
notable drying of almost all the lesions in the body. The patient was able to move
around her home compound with a lot of ease. The oozing substances from the wound
stopped and the wounds started forming scars to attain the initial texture of the skin
surface. However, the healing procedure took up to eight weeks. At the eighth week, the
patient covered fully from the wounds without notable symptoms of any other infection.
Nevertheless, the signs did not disappear until after close to 24 weeks. Such notable
changes occurred faster upon using the Vashe therapy taking an estimated time of 5
weeks to heal completely.
Discussion
The most common CTCL is the MF that affects many patients on the skin.
According to research MF constitutes an approximated percentage of 65% as the
causative agent of cutaneous lymphomas. The research also shows that effect is more
prevalent in men as compared to women. The diagnosis of the MF conduction require
well established that functions to reduce pain and oozing substances from the wounds.
The degree of contamination is sometimes caused by the impending medical
procedures as evidence in the case of whirlpool method. Therefore, it is important to

develop the best method that would limit the degree of injury as it hastens the rate of
recovery. The emergence of other infections has been noted to arise due to the
improper models used in the treatment of wound.
A review of the mechanical adjuncts of wound care shows that the higher
temperatures of up to 39.00C tend to promote blood circulation on the surface of the
wound, which limits the healing time for the wound. Notably, the claim by Langenbeck
that WP decreases wound pain, accelerates healing and reduces suppuration and fever
is not true. A research on the grade III and IV patients with pressure ulcers indicated
that a conservative treatment plus whirlpool had higher wound systems than the other
methods. According to Bruce, the high evolution of the Pseudomonas aeruginosa in the
hospital environments is due to the hydrotherapy which whirlpools form part. The
pathogen causes septic shock, pneumonia, bacteremia and folliculitis in patients leading
to infections within the wound. The infections of the pathogen have been recorded in
many other hospitals that use whirlpools as a method of MF treatment.
The use of the whirlpool therapy over a long period tends to contribute to the
emergence of alternative infections that lengthen the recovery period of the
complication. Observably, the use of Vashe Solution Therapy tend to provide a solution
to the rising contamination due to the release of the debris which affect the general
functioning and healing state of the wound. Ethically, the procedure used during a
treatment of a patient must ensure the least harm to the patient contrary to what is
observable in the treatment of wound using the whirlpool therapy.
Essentially, the observable reduction of pain together with the time of exposure of the
patient to pathogenic microorganisms as well the recovery period is enhanced in the

use of the Vashe Solution wound therapy. It is important to note the period taken for the
completion of the surgical process of treating a wound using the whirlpool method and
the Vashe Solution. Notably, the procedure of using Vase takes nearly 10 minutes for
completion contrary to the Whirlpool therapy, which takes roughly 24 hours for
completion due to the multiple stages involved in the treatment of the wound. Besides,
the Vashe Solution tend to cause little harm since the little pressure is applicable
contrary to the use of the use of the whirlpool therapy that applies more pressure
causing injury to the patient.
The proportional conditions of recovery of the patients using the two methods
also vary greatly creating the preference for one and not the other one. The use of
Vashe Solution Wound therapy tends to provide bed site application contrary to the
Whirlpool therapy that requires the setting of a strategic zone for carrying out the
process of treatment (Olsen, Whittaker and Kim, 2011). Similarly, the degreed home
care and physical exercise is not required as much as observable in the treatment of a
similar wound using the whirlpool method or therapy.
The leukemia variant MF has a characteristic classic triad structure of
erythroderma, leukemia, and lymphadenopathy. The treatment of this kind of CTCL
requires both the application of the clinical prospects as well as the histological
information. The diagnostic standard for the skin condition is carried out using the light
microscopy (Mostow, Neckel and Oberhelman, 1993; Olsen, Vonderheid and Pimpinelli,
2007). In order to establish a clear and visible nonspecific changes, the skin is observed
at the later plaque stages other the initial patch phase. Nevertheless, characteristic
histologic epidermotrphism are observable at the early patch stage. Besides the light

microscopy, immunophenotyping is also another important component of the diagnosis
of the skin that provides information concerning the degree of damage of the skin.
Through often used in the whirlpool therapy, the diagnostic mechanism is also
applicable during the early stages of the Vashe Solution wound therapy.

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