Chronic folliculitis - edited summary

Chronic folliculitis - edited summary

Greg Penfold

7/21/1999

I have a 57 year old male BK patient who has been bothered for years by
recurrent popliteal folliculitis and deep abcesses. He is meticulous about
hygiene and washes his stump and liner each evening with povidone iodine
surgical scrub soap. He rinses well and dries the liner thoroughly. He has
been using an Iceross two tone liner for two years and was recently fit with
an Aegis liner. The thicker and softer liner did not help matters. His
physician is reluctant to prescribe antibiotics, which do not work very well
anyway with this problem. He had the same problem when he was wearing a
standard pelite liner and sock fit years ago. We felt that reducing friction
with a 3S system would help, but it hasn't. He is in otherwise good health
does not develop these skin problems anywhere else. Does anyone have
suggestions?

Thank you,
Gene Kautzer, CP

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Thanks to everyone who took the time to respond to my inquiry. The
following are the responses I received.
Your input has given me some new options to try with this patient. Gene
Kautzer, CP


Whenever this problem came up in my 30+ years of prosthetic care the solution
was always raise the posterior wall. This is a problem when there is so much
swelling but it must be done and the socket needs to be filled at regular
intervals as the swelling and folliculitis disappears.


It's allways thh hight and shape of the posterior wall .Your patient seats
alot and the whigt of his leg tend to ride on the proximal aspect of the
posterior wall and that can do the damage.
good luck


I have a similar patient (new to me) that I recently fit with an Iceross
comfort plus liner. He previously wore pelite/PTB. So far he has had no
recurrence of previous problems. He does however (initially without my
consent), use medicated powder in the area of concern. I don't know if my
success is from the liner, the powder or my exceptionally perfect fit (ha
ha), but so far so good.

My experience with popliteal folliculitis and abcesses over the years has been
that they are brought on by excessive pressure. Too many prosthetists
overtighten the AP dimension and some even dig out the popliteal on the positive
model (some call it a popliteal walnut). I do not think these problems are
related to hygiene or friction or liner thickness. Pressure distribution is the
key in my opinion.


I don't know if this will help much, but I have heard of folk being
advised to *trim* the hairs on their stumps. The theory is that shorter
hair means less for the liner to pull on. The hairs are not so readily
plucked and so no access for infection. Of course shaving should be
avoided due to the danger of ingrowing hair. I have no personal
experience of this so cannot verify its efficacy.



We have some success using a TEC liner instead of the Iceross with the
shuttle the PRO liner with shuttle lock has definitely helped some of my
chronic folliculitis patients.



Does your patient sweat quite a lot? If so, there is an antiperspirant
called Certain Dry (available from the pharmacist) that may help. It only
has to be applied every few days to be effective. Let me know if you need
more ideas.



I have a pt with a similar profile and I decided to use the TEC liner and
have him use medicated A&D. Dont know if it will work, but TEC says many
people have had success with this...we'll see.


Gene, one of mine has a similar problem, which has been controlled by using
a perforated pelite liner and socket which has been aerated with holes to
allow air flow.
This seems to have called an uneasy truce with the troublesome follicles.


While I haven't tried this, it appears logical that if you could get of the
follicles and associated sweat glands, you could get rid of the source of the
problem. Maybe an over the counter hair follicle electrolysis system coupled
with a an antiperspirant would help. There are some excellent prescription
antiperspirants available.
Hope this helps. If it does, I'd be interested in hearing back.


The TEC liner used with A&D ointment has offered more relief to people with
folliculitis problems than anything I have found. The problem is I find the
patient type most likely to have severe folliculitis, those with heavy
subcutaneous tissue, are also the hardest to manage in the TEC liner. I
think this is due to the larger volume change and more mobile soft tissue.

Your client reminds me of myself years ago, although I was much younger.
I am R-BK from a motorcycle accident in 1969 (the fun years) and since
getting a prosthesis in 1970 have used a PTB with a hard socket. I still
do, and I continue to ride a motorcycle daily.

During the 1970s I had chronic, deep soft tissue infections in the
posterior popliteal area. The abscesses would emerge every few months
and would respond to Kelfex 500mg QID after an I&D (incision and
drainage). For several years I did my own I&Ds using sterile technique,
Zylocaine with 2% epinephrine, and a surgical blade. My physician would
run a culture and sensitivity but we were never able to determine the
cause. The infections may have been caused by hair follicles (I actually
think not), necrotic tissue (hhhh, maybe), or a poor fitting prosthesis
(I suspect). Either way, it is often difficult to determine the exact
cause and therefore pinpoint the fix. I do know that since 1982 or so,
they have practically disappeared. Coinciding with that date, I changed
prosthetists, obtained a new prosthesis, and have not been troubled with
this problem since wearing a well designed socket. And if by chance (yes
I know, you folks all make perfect sockets :) your client has by chance
a poorly designed socket, all the phisohex, povidone iodine, and
whatever is not likely to alleviate his difficulty.
Be curious to read your responses and suggestions.


Can the AP be opened up?
Is the posterior wall too high?
Does he sit a great deal?
Have you tried a friction reducing interface between the socket and socks?
ie Shear guard?
Perhaps he is scrubbing his leg and liner so hard and throughly that he is
removing all flora both good and bad.
Has he tried any other ointments, gels on the area?
Just some questions that come to mind with this situation. No answers yet.



Refer him to a wound care specialist. They work with entrostomal doctors or
and with diabetic specialties. Iodine has been shown to be good for surface
cleaning only and long term use is discouraged in chronic care.



I have had some luck with this situation using the leather and gel
liners of yesteryear !!! The slipperiness ( ? ) of the liner seems to
help control this problem, if not eliminate it. I have found that the
Iceross, 3S, Alpha, etc., has sometimes compounded the situation, the
skin cannot move against the liner and receives the friction in an
indirect manner. Hope this can offer your patient some relief.



I have found socket design to be a key factor. Depending on residual-limb
length, and weight bearing capability (available surface area), socket
design can cause such problems, especially if they erupt superior to the
socket margin.


Gene - I've seen some of these folks too. The best treatments I have found
are to increase the AP dimension of the socket slightly and to keep the
posterior wall high enough to fully enclose the tissue. If you can get the
physician to prescribe a long-term (about three months) course of low dosage
antibiotics as well it can be helpful



I have a young man in the same boat. I've even had him in a hard socket and
that didn't work. He's had the abscesses removed and nothing has changed.
He's now back in a 3S socket because he prefers that type of suspension.
If you find the answer I would really appreciate your letting me know.


Regarding your ? about chronic folliculitis, I recommend you give Carl Casper
at TEC a call. At his course I attended in 95 he spent so time dicussing
this. I believe he suffered fron folliculitis himself. It motivated him to
invent the TEC LINER.