Wound Care
The most severe cases of mpox evolve over weeks to months. Patients develop multiple necrotic lesions that progress and become secondarily infected until the immune system reconstitutes sufficiently to clear the virus. Therefore, in addition to systemic antiviral therapy and rapid ART, high quality longitudinal wound care provided by a specialist becomes a critical component of management of the severe mpox patient.
In patients with skin and tissue loss resulting in fat, muscle, or bone exposure, advanced wound care principles following the DIME method (Devitalized tissue/Debridement, Infection/Inflammation, Moisture management, Edge). Addressing devitalized tissue or debridement can be done with autolytic, enzymatic (collagenase), ultrasonic or surgical/sharp debridement. The method of debridement that is appropriate is dependent on the patient’s pain and ability to tolerate procedures.
Bacterial superinfection is common in these most severe mpox cases. All suspected infections should be cultured, either with biopsy or using the Levine technique, prior to initiation of antibiotic therapy. The ulcers should be cleansed with hypochlorous acid solution, wound cleanser, or mild soap such as baby shampoo. Other chemical cleansers such as sodium hypochlorite solutions, chlorhexadine, alcohol containing solutions, povodine iodine, and hydrogen peroxide should be avoided as they are cytotoxic with a lower therapeutic index than hypochlorous acid.
Moisture management in the ulcers and periwound skin is also essential for healing. The base of the wound requires enough moisture to promote healing without causing maceration of the periwound. A moist wound environment reduces pain, promotes autolytic debridement, collagen formation and epithelialization. Scar formation is also reduced. Moisture can be added to the base of the wound, if needed, by applying hydrogels, hydropolymer, or hydrocolloid dressings. Excess moisture, or heavy exudate, can be managed with alginate, hydrofiber, foam, or superabsorbent dressings.
Despite severe wounds with full thickness necrosis, severe mpox cases can recover complete tissue regeneration with quality wound care (Figure 3).