You see this wound here, okay. All right, okay, all right. And I can see you, so that's great. So this is a woman who came from Hawaii. She spends a lot of time in Hawaii and she comes to the U.S. for a few months. Her family's here. She's in her 80s, but she's like a water exercise instructor even now. So extremely active, very healthy. Got this, so you see this, there is this raised lesion, but there are these openings. And when she came to us, this whole area is discolored. This is the back of the calf, mid-calf, and these openings drain copious amount of fluid. And sometimes it's like creamy, sometimes it's like serious. And she didn't know how this happened. She said, I was walking on the beach and one day somebody said, you've got something on the back of your leg. Did you know? She goes, no. And she went to some wound clinic there. They started on some antibiotic, topical, mupiricin, and dressings. And she comes to us and I hadn't seen anything like this before. So I said, you know, just treat it the way, a lot of times the way the wound presents, we treat it based on that. If it's draining, we put absorptive dressings. If we think it's an infection, we give some topical antibiotics and cleaning the wound and all those basics. And we started that. It all of a sudden started getting worse. She had no pain at this time. And so it became like very necrotic very soon. Look at this. And we were like, what is going on? And initially she didn't have pain, but then her leg started swelling. It became red. She had a lot of pain. And I'm thinking like, this is some infection cellulitis. First of all, you want to make sure that you're not missing a cellulitis that can make an 80 something year old very, very sick. So I talked to, and it became very necrotic. I think there was pus in there as well. So I talked to a wound surgeon who actually does a good treatment in the OR, just gets rid of all this tissue. He started on antibiotics. He did a big sort of excision, send this to pathology. There was nothing. There was not even an infection. There was like, it was really non-conclusive. So no idea. It is looking like what we call pyoderma, right, Elizabeth? So I reached out to her primary care and said, run a few tests. Does she have any immune disorder? No. But you always listen to your patients. So when she came, she said, I've never had a wound, but long ago when I was in my twenties, I had something on my finger and I needed steroids. And I said, oh, okay. So that kind of stuck with me that there was something that she needed steroids for. This was the excision that the surgeon did. So there was a lot of necrotic material, looked really good. Her leg edema came down, clean wound. And he said, whoa, this is good. We'll start treating it. So this is kind of in the whole bit of her calf. It's pretty large area. But just this was on the, it's July 28th. Just in a few days, it started spreading, like what you call pathology. So if you have a wound that is immunologically, it is an immune disorder. Basically, if you debride the wound, that phenomenon is called pathology, the wound becomes worse. So that's exactly what happened. This is like in a couple of weeks, no matter what we did, it became necrotic, this sloppy. And there was no systemic marker of infection. So her white blood cell count was totally normal. And then I realized this is not an infection. We are going the wrong pathway. Out of just how the wound was behaving, I said this is, and this was spreading so fast. I think the next picture is also like that. It kind of keeps going down her leg. So now her whole leg is becoming a wound in front of her eyes. And we're like, what is happening here? So I said, there's no infections. I'm just going to give her steroids and both topical immune-modulating drugs. So I started putting topical tacrolimus on her. It is available as a gel. And I put her on a steroid, like a taper. I started with 60 for like a couple of days out of just VIM. So nothing tells you what to do. I said, I checked with a primary. She had no contraindications at 60 for a few days, 40, really high dose, but a taper. And there was an immediate response in this whole area that you see extension down, that disappeared in like a couple of days, literally. So we knew that this was some kind of immune reaction. She had no systemic markers of it. She had never been diagnosed with anything like this, but it responded. So this is, you know, it kind of went back to its original shape. All the extension that had happened disappeared and she started forming skin on it. So this is all happening in the month of August. And then suddenly everything is nice. We didn't even debride anything. We didn't want to because we knew that it would not do well. And the skin just grew over this very large area. So her whole mid-calf is the wound right in the back, but big islands of skin, we were surprised at the, then she started having some, like she said, I think hallucinations with the steroids. So at that point I stopped them, but I continued with the tacrolimus, the topical tacrolimus, and that seemed to work. So in the end, we completely healed it. We had her coming like three times a week to the wound center because she was not able to put a dressing on this. So we figured she's making such good progress, why stop? So we kept calling her, we put a dressing on her, watch it. So the only thing that she went back to Hawaii, the only thing I told her was that you don't have a systemic immune disorder as at least your physicians have not been able to find anything at all. You're otherwise healthy. She was on no medication, exercising, and a non-smoker and all that. But there are some times I did some research that your skin can be, you can just have an immune disorder of the skin, isolated. So anytime you get a wound, it's going to behave like pyodermal, behave like an immunologically related wound. So you have to treat it with, you know, anti, like the anti-TNF inhibitors and steroids. But the thing is that she now knows that if she gets a surgical wound for some reason, or she gets a wound, she has a history that this wound is not going to heal and it would need steroids. So all this time it looked infected, but there were no systemic markers of infection and the wound behaved like a pyoderma. So that's what we did. So any questions, comments from Elizabeth? Yeah, I have a quick question about that. We work with a lot of pyoderma patients and this is a really interesting case because she's such a healthy lady. And I'm glad you went through the immunological parts of it because that would be one of my questions. And it's, for me, I've had the same issue where I've missed something like that. Or the patient says, oh, 20 years ago, I had some thing with my GI tract and it's forgotten. And then the dermatologist, we work with dermatology quite a bit to do infusions for particular patients. And we have one particular dermatologist here who is, he is so good. He is so on it. And he was the one that figured it out with one of my patients who was just getting worse and worse and worse and we couldn't figure out why. But one of my specific questions was, in the past, I would sometimes order the topical tacrolimus for patients to use, but it's so hard to get insurance to cover it. And I don't know if you have any tips or tricks or like if you have a compounding pharmacy that you use, because I have not had good luck with getting that for people. So this was for, the cost was about $300 or so for a large, for a tube. But we got her that good Rx thing and she got it for 50 bucks. Insurance will not pay for it. Patient has to. But she was like, if this is making me better, but she said, even $300 is a lot, but if this is what's making me better, then she would bring it. Our hospital doesn't carry it, or the wound center. But she said, if this is making me better, that's it, I would have hated for that not to work. But when it came down to 50, even that is a lot for many people, but at least it's not enormous. So we did good Rx. My nurses were able to figure that out, they're great. So yeah. All right. But good point. Sometimes you just have to think immunological disorder, even if there is, you know, the biopsy was totally not like pyoderma, it wasn't anything. So, all right, so this patient here, this is again, I think in her 89 or something lady. She, just a few months ago, started getting ulcers. She wears AFOs and they were sort of rubbing against her skin. She started getting these ulcers. Went to the ER, went to another wound doctor who saw her before me and said, oh, venous insufficiency, got VNA advised, just topical, regular standard wound care, absorptive dressings and compression bandaging three times a week with VNA. She comes to me, she's getting VNA. She keeps getting worse. And so much so that these areas, I think we didn't get that picture. I don't know why we didn't get that picture, but these areas became larger and larger. The whole leg is like somebody took a knife and started scraping her skin. And I'm like, what's going on? And she's like, comes in and she's all happy. I said, do you have any pain? Goes, no, okay, your legs look terrible. I feel like pain in my legs when I see your legs and you have no pain. I said, we can't keep doing compression. It's just getting worse. I don't know what to do. And then again, sometimes you get the tip from the patient and her nephew who came with her said, you know, doctor, she's had these wounds for some time, but she was given an antibiotic for something. I said, that was when her legs looked the best. I said, oh, and this doesn't look infected. But then I started thinking she's on Warfarin and you can get permanent necrosis, but that's usually very painful. So I reached out to her primary. I said, do you think it could be anything? I don't think so. I said, oh, okay. And so I said, well, I'll just culture it and see what happens. It is cultured the skin. Drew staff sensitive to gentamicin. And then my nurse practitioner said, you know what, let's rub gentamicin on her legs and just give her a course of Keflex. And with the older patients, instead of doing four times a day, we just do like a thousand twice a day. And in one week, she cleared up her whole leg. Everything healed up, one week. And I'm like, oh, it was a weird presentation of a staph infection on the skin. There is no cellulitis. There is no pain. There is no, but she just kept snuffing skin off. So have you had anything like that? No, I haven't had anything quite like that, but now I'm wondering by looking at that skin that maybe perhaps I had and I didn't realize it, or now I'm gonna just start looking a little more carefully on some of my patient's skin. But thank you for the regimen too, that you gave that gentamicin topical, then the PO Keflex. And you said it was a thousand BID with humidin? Yes. Okay. And I always keep the primary care involved. I usually don't prescribe antibiotics without their knowledge. This is an 86, 87 year old. I hate giving antibiotics to elderly geriatrics. But she responded like, like I'll show you the next picture as if there was nothing there. Oh, this is, see this? Isn't that terrible? Her whole neck became like that. All around from below the knee to her ankle. It was heartbreaking to see like, you know, and then this is it after the one week. As if there was nothing. Yeah. So no systemic signs. I mean, if there was so much staff, I don't know, it's just kind of, no idea. So, but she recovered. All right. So going on to the next one. So this one was a very interesting case. This woman, maybe in her 60s, 70s, I think diabetic, but no other real history said, oh, I've come to you because, oh, she went to a dermatologist first. A dermatologist referred her to me saying that this is a possible spider bite. Now you and I both know Elizabeth, there's never been a real spider bite. People come, oh, this is a spider bite. Did you see the spider? No. Okay. But what to do? Anyway, so she said spider bite, little necrotic area, but it's like a raised nodule. So it's not a typical wound, but there's necrosis in the middle. And then we're like, okay, they breathe it, cover it, not really sure what this was, not even sure whether we had the right kind of doctors that she should come to because it wasn't a typical wound. But anyway, she came to us, we said, but what happened was they started getting very necrotic. Look at this, just necrotic. I debrided the necrosis, it becomes necrotic again. You get some pink granulation, then it becomes necrotic. So I asked our surgical colleague, I said, why don't we do a good excision? Like just dig it all out, send it for surgical pathology. Let's see what happens. So he did a little bit of saucerization, cleaned it out. So this is what it looked like. And he said, oh, okay. This shows numerous bacteria, necrotic tissue, no malignancy. And so we started treating it with, it doesn't look as deep in this picture, but it actually was like a concavity. So we started putting wound back on it and it came to the surface. It became all pink and nice and suddenly started getting these necrotic areas again. And no idea why that was happening. She did give a history of red patches on the rest of her body, saying that she's always had this eczema. I didn't pay any attention to that because she had come from the dermatologist who had been treating her for the eczema. So I said, okay, go to your dermatologist for that. I'll just treat this lesion here because now it was a surgical wound we were treating. And then that started getting necrotic too. After healing like pink and nice to the cover, started getting necrotic again. So I involved ID, I involved oncology, I involved dermatology again. I involved rheumatology. We looked at vasculitis, all the markers. There was such an extensive work of Elizabeth and Mustafa. We ruled out vasculitis, no markers of that. So she went to rheumatology for that. She went to ID because this, the pathology showed actually now when we swabbed it and did a deep tissue culture, it was MRSA. So we said, oh, it's MRSA. MRSA gets you necrotic a lot of times. So she got IV antibiotics, but I did send her to oncology and they did a whole bunch of tests. They did biopsies. They said no evidence of any lymphoproliferative disease or no evidence of malignancy, nothing. All right, fine. So we concluded not a spider bite, but this would probably maybe started with a pimple or skin infection or MRSA. She was like, where would I get MRSA from? I mean, it did have MRSA and it was a heavy growth of MRSA. So we said, okay, fine. and then because it was necrotic, we did another surgical excision. This time we said, if there is MRSA, let's do a wider excision to get rid of all that. Again, you know, sort of healthy tissue there and did wound work again, started healing, and then she actually had, I will show you here. It doesn't show here very well, but do you see that little red mark on the bottom next to this? She started getting another area of necrosis right next to this, looking like what she had presented with. And that's when I started thinking this is something else. So I sent her back to the oncologist saying, you know, she's getting other areas of necrosis. She has all this eczema. Everybody put their head together. And in the end, the oncologist made a diagnosis of cutaneous lymphoma. So this was a cutaneous lymphoma. And, but that was made clinically because the biopsy did not show any malignancy or lymphoperative proliferative disorder. But here is my little, so oncologist made the clinical diagnosis. She got radiation to the area and that's what healed the ulcer. Believe it or not. It turned out that all that time, that eczema that she had was really cutaneous lymphoma. She had had it all along. It healed. This is the healed picture. I think we are covering the picture, at least my faces that the healed wound. So what is this cutaneous? This was, it is also called mycosis fungoides or cutaneous lymphoma. It is basically a very common type of cutaneous presentation of T-cell lymphoma. But it is often mistaken for psoriasis, chronic dermatitis, chronic fungal, and that leads to diagnosis for several years, which happened in this lady. But thankfully, as I said, it is very important to involve other specialists, kind of put your heads together, see what's going on. And so that did heal her wound. In the end. So very interesting, right? Yeah, we have some of these patients too, but I have not made the diagnoses of them. We usually get them after the fact when they have lots of wounds that we're managing. I have a quick question about the biopsy size. What, was it a punch or was it something that was larger? Oh, the surgical, the whole excision. Oh, they did the whole thing. Oh, okay. It was so necrotic, basically. It was basically necrosis and heavy MRSA. But it was, I think it was so necrotic that to diagnose a malignancy was not possible in that necrotic tissue. Maybe if we had, I think when she started getting the next lesion next to it, the oncologist just figured it out clinically because of the other lesions. He didn't even biopsy, he just said, go ahead and do radiation. So after the excisional biopsy, you didn't get the diagnosis there, right? No. Okay. Yeah. All right. So this one is again, a healthy woman, young retired nurse who had three cesarean sections and her last one was 20 years ago. And this is the cesarean section surgical incision. And she developed this draining. She said there was some drainage she noticed and then a hole. And so she went to a dermatologist who sent her to a surgeon. And the thing about this wound, although it looks small, it did probe a little deep and it was extremely painful, very painful for her. And so the surgeon said, you know, maybe, and it healed a couple of times and then would open up again. And so finally they came to us and she said, the surgeon said that maybe there's something that's causing it not to heal. And usually it's a stitch, like a stitch granuloma from way back when she said, she's a nurse, she said from like 20 years ago, why would that happen? And so he kind of did a little superficial exploration. He did not find any stitch. He said, if it doesn't close, then he'd go and explore it and see what's happening. So she comes to me and I said, you know, it's amazing that all this time you had no redness, nothing, and all of a sudden, why did you start having this? And so I just said, okay, we'll give it a last shot. If it doesn't heal, you go back to the surgeon. And I said, what I am thinking is that this is not a stitch. You probably had like, so see all the hair, you probably had a folliculitis or something and it happened to be near the incision. And because you've had three surgical incisions, three cesarean sections, the scar tissue, the weak area, you probably got a little pustule or something and then it broke open and it's not healing. And I said, so, okay, so, and because it's so painful, I cultured it, of course. I usually culture before I do any like steroid or other treatments. And I said, the culture was totally negative. No growth at all. And I said, why don't we, and she had had antibiotics prior to coming. I said, why don't we do doxycycline? You probably are using doxycycline as an anti-inflammatory, Elizabeth. I started using it quite a bit. I said, and I said, just do topical steroid cream with antifungal, which I use a lot. It is the clotrimazole and betamethasone combination just works somehow. So I said, use that and do doxycycline 100 BIT. It closed within a week. And then the thing was, okay, let's see if it stays closed. So I said, keep on the doxycycline for about 10 days or so and see what happens. So it closed flat, no, you know, you've seen stitch granulomas. Usually you get a little protuberant area or something, but that was nice and flat. Two days after we saw her again, this is nice and flat. I actually called her today just so that I could say that, oh, she has remained healed. So this was, I think, the 10th of April. She says, oh, no problem, no pain. But the first thing that disappeared even before she healed was she told me that her pain went away, which always tells me that, you know, there is inflammation and the doxy took care of it. If it works, it works like a charm. So for now she's healed, you'll see. All right, so that's one. This one is a very, very, a little sad, but an interesting case. Sometimes our goal is, as physiatrists, our goal is quality of life and function rather than healing a wound that could lead to loss of function. This is on the side of the hip, like upper thigh, hip, lateral side. There's a surgical incision. This is 89-year-old gentleman who had a hip replacement. I think it was in 2020. The hip, the replaced hip, the new joint became infected. The prosthetic joint became infected. He needed three other surgeries, washouts and things, that infection did not go away. He developed these draining sites in the wound. This is a surgical incision. There are two sites. As you see, they're protuberant, they close, they pop open, they drain copious amount of fluid. The drainage is excessive from these two areas. He came to me to say, you know, I want these healed because they keep, I keep changing pads, I can't reach the area. But this 89-year-old, I think he's going to be 90 in August, is active, is totally with it, alert and oriented, goes to the gym three times a week, does ankle weights, does his aerobics, requires no assistive device for walking. And the surgeon said, if I go back and try to change this joint that has like chronic infection, you may not be able to walk again. So I said, all right, I'll see if I can. And you know, every time he comes, the nurses are putting in Q-tips and trying to measure the depth of these areas. And then suddenly we realized these two areas are connected. So you put fluid on the top, it comes down through the bottom. And then I said, you know, let's just stop probing this because this probably may be sinus tract. This is probably a chronic infection that keeps fluid there and keeps draining out. So you don't want to close it. Because if you close it, that fluid is going to get infected. And I said, okay, let's diagnose it. A very simple diagnosis is injecting like a dye and looking under live fluoroscopy X-ray. So a very good friend of mine is a radiologist who did that study. And he calls me, he said, oh my God, he's got sinus tracts going all the way to the joint. I said, oh, okay. So here is, just to see that wound, it looks, it closes with a thin layer of skin, then opens up and starts draining. All right. Here's the, you see the prosthetic joint. You see all that fluid and you see tracking on the top of the joint itself, the metal. And then you have the two tracts above and below that are coming to the surface, which is where the openings are. He has had no sign of, he's on chronic suppressive antibiotics from the surgeon, like long-term, he takes it every day. He has no swelling in the area. There is no cellulitis. The skin is totally fine. It is just these two holes. So basically I said, you know, in order to give you some quality of life, I want to devise some kind of dressing that, that, you know, you're not wet all the time. You're not, you're not sort of going around with wet dressings, uncomfortable. And none of the dressings could hold the drainage. Anything we put layers on upon layers, you would cover with a tegaderm, do whatever we can. He said they get very wet. So he has a VNA, a very nice nurse that I know, but between the days of the VNA, he gets very, so he said that is really affecting his quality of like the wetness and the drainage. And although in these lectures, you're not supposed to say name brands, but I thought this is for teaching people to really know there's something called, what is it called dry max? Have you tried that Elizabeth? That worked the big sheets. So he did. We love dry max. We use it a lot for secondary dressings. Yeah. So, so I've told him, I'm not going to close these wounds. He still wants them closed, but he understands closing them is going to be a disaster because, and I've told the VNA, I've told our nurses, we are not measuring the depth. We are going to create false tracks. I mean, these are sinuses. These are not, these are not actual wounds. They are openings of, you know, so you can consider them wounds, but it's something that patient, it drains it. It's, but he's happy with the dry max. It keeps him dry. We put some, I think, Aquacel first, and then the dry max or something. And then we cover it with a tegaderm. So he's, you know, able to do this activity. So he continues to go to the gym, active as ever, great sense of humor, just love this guy. So I said, I will hate for you to get a joint replacement or do something and just not recover because, so we go back and forth, but he's still alive and kicking more than me. So sometimes you go for- Just a quick question. Yeah. How old was he? He's 89 now. 89, oh, okay. August, he will be 90. And this, the surgery was in 2020. It's about three years ago. Okay. Yep. All right. So then this is another similar looking guy. He's, this is, I think the last case. So this one is a neurosurgeon who did, this is a very active guy, does really very high level hiking and all that stuff, but had chronic back pain and a smoker. He, young guy, maybe late thirties, early forties, then he had a lumbar fusion with instrumentation, lower lumbar and sacral by the neurosurgeon. And the neurosurgeon calls me that I'm seeing him for post-op visit. He's developed some kind of this infection and like this boil on his incision. He has an incision where this is, and then he has another incision next to it. He said, I'm really concerned about infection. Can you please take a look? And so he was sent urgently. We got him in the same day. I think he was already on antibiotics. We saw this in a couple of days, it popped open and became a hole. So, and then another similar sort of a raised boil type area appeared lateral to it at a different site out of nowhere. And then he had two holes. So we have now these two holes. And they're both draining. We did culture, it didn't grow anything, but he was being given antibiotics because, the neurosurgeon and the IV were afraid because this is on top of the surgical site with instrument and hardware inside. So, and then these connected to each other. So one is connected under the skin to the other. And we said, you know, we were conservative. We kept packing with Aquacel, wishing for this to close, would get better, would start closing and open up again. And so several weeks went by and we were getting very frustrated. And then I said, you know, let's do a CT. I think we did a CT scan. I talked to the neurosurgeon and I said, you know, if this is not, I feel this is going from one to the other, right under the skin in the subcutaneous tissue. If this is not tracking to the spine or the hardware, I think what needs to be done is to slit it open, the skin, fillet the whole thing open, because we are packing this little tunnel, we are getting nowhere. We're sort of blindly trying, how will I treat? So opening it up, you know, and treat it like an open wound granulate from inside. And I thought he would do it because this is on top of his surgical site. I don't want to touch that. But when we did the CT scan, it really showed that this is nowhere close to the bone. It's right under the skin, doesn't extend to that. So he said, you go ahead and do it. I said, okay. Then I called my wound surgeon who also is in the wound center several days. And I said, why don't we both do this? So we kind of set it up as a, you know, totally sterile procedure. Got a bovie, got a knife, cut it open. What we did, the surprising thing was there was absolutely no bleeding there. You're like, huh, that's very odd. But the tissue was nice and pink. It wasn't very deep. I don't have a picture of how it looked like immediately because when we took it, there was a lot of reflections about a great picture. But we put a wound back on that because it was a nice clean wound with great granulation. And we said, let's put a wound back. And it started contracting right away. So that's what it looked like. So the two holes are now connected. As you can see, it's not very deep. There's healthy tissue there. And it closed very well with the wound back. So this is the closed wound. And very happy, all the team is very happy patient. This has been, it went on for, I think, let me see when he came. So, oh, let me get rid of this. I'm not sure where this, okay. So his, I think original date was, he started in July of 2020. And we are going, oh, sorry. What did I do? Did something wrong here? And between all of this, we were, I think I was showing you, where was I? I'm showing you this one, right? So, and I think this was almost August or September or something like that. And then, as I said, we healed this one. We are very happy. And then his wife calls and says, I see a little pustule. He's developed another one that raised area. We're like, I was ready to cry. I'm like, oh no, not again. Don't tell me if we're going to start from where we started the first time. So lo and behold, he had another of those right there. And we're like, no, we are back to square one. After all these months, we are back to square one. What's happening here? And then this popped open. And then there's this bulging tissue here. It is an open wound now. And then, of course, it now tracks. And then the nurses, every time they measure, they're like, it's getting deeper and deeper. And so I talked to the neurosurgeon again. I said, you know, I want to do a deep culture. We did a culture. He has, there were no growth in the culture. And so I said to him, when he came initially, there was no growth as well. There's no growth now. And I believe that this is inflammatory. Something is causing the inflammation. I don't know what is causing the inflammation, but this is inflammatory. So let me treat it as an inflammatory wound with some anti-inflammatory. I talked to one of the hospitalists who knew him, like internal medicine doctor who knew him, sorry. And I said, what do you think? And he said, let's do a trial of steroids, oral steroids. And I said, well, it's a risk because if it is an infection, it's going to go to his spine. So we said, let's just try it. And there's no sign of infection systemically or locally. So we started him on a taper with like 60, 40, just made it up. And he closed with the steroids. We were so nervous that he would break open again somewhere that I kept him on a low dose, like five milligrams for a few weeks after he healed. Then I went to every other day. Sorry. Is that me? Can you hear anything or no? You can hear me? We can hear you, but we don't hear anything else. I said, you know, let's just do that. So he healed. I kept him on because he was so nervous that he would do this again. Kept him on five for a long time, several weeks, then did five every other day, then went to 2.5. I would not stop the steroids, but he remained healed. But he remained healed. And this was back in 2020. He never opened up again. We don't know what was the inflammation. We don't know why it was there, but that's, so I'll show you the end result. So this is like a dimple that he's had, but it's closed. So again, I think to rule out infection is the thing and get everybody on board, the surgeon, primary care physician, so that everybody agrees. But I don't have an explanation of why. But sometimes if you think it's inflamed, then steroids or some of the, just a doxycycline or something like that should work in most of the wounds. So this was the last case. I would like to hear comments or anything else you guys want to share, and we'll call it an early night. No, that's really helpful to go through some of those cases at a different site because some of it mirrors things I've seen. And also just for this one particular last case, it reminds me of a patient of mine who I've been seeing for a very long time for different wounds, and she has autoimmune issues. So it just slows everything up anyway. But she had been on prednisone for a while. Low dose was then off of it, but still had cell sept on her regimen. And then she was in the hospital for a completely different reason and was put on steroids and some antibiotics, and the wounds took off and looked so much better within a week even. We'd been spending months just kind of plugging away little by little, and then suddenly it was just all better. And so it reminds me of that case. So I'm going to put that in the back of my mind because I have a couple of people I'm going to be seeing even this week. I'm thinking maybe I need to try like a round of doxy or I need to put them on like a Medrel dose pack. Yeah, you can. I mean, I did my own regimen. I start with 60. I think I do four days of 60. Then I go to 40. Then I go to 20, and I have them stay on 20 for some time, three to four weeks until I see. Then I go to 10. Then I taper it slowly. Then I leave them on five for some time. The couple of people, there's some other cases that I did. The one other thing about doxies, which I learned very recently, was that you can start with 100 BID to get the inflammation down. But if the wound is responding, you don't want to keep 100 BID for a long time because A, they don't need it. It does come in 20. You can go to 20 BID and 20 once a day because although the 20 is not doing the antibiotic effect, it does the same anti-inflammatory as you would get from 100. So it is still a very good anti-TNF inhibitor at 20. So you can maintain them at 20 so they don't get the resistant bacteria from antibiotic resistance from a high dose. So usually they say nothing is proven, but the practice regimen is maybe 10 days of 100 BID and then you can go down to 20 so that some of the very inflamed wounds, their inflammation still lingers on. It doesn't go away. But I've never had people, except for one person, but I think she had other mental issues. I don't believe that any of my elderly patients in the geriatric population have had any side effects from doxycycline. They've all done really well. So I feel quite safe in giving that. Thank you. That's really helpful. All right. Okay. Well, we have to get our community together somehow, but I really thank both of you and it was wonderful to hang out with you today.

wound cases

treatment

draining wound

necrotic wound

immune disorder

topical tacrolimus

chronic leg ulcers

staph infection