Can folliculitis occur at the knee stump location after a Below-Knee Amputation (BKA)?

Folliculitis at Knee Stump Location After Below-Knee Amputation

Yes, folliculitis can definitely occur at the knee stump location following a Below-Knee Amputation (BKA), and it should be promptly treated to prevent complications that could compromise stump healing and prosthetic fitting.

Understanding Folliculitis in Amputation Stumps

Folliculitis is an inflammatory reaction in the superficial aspect of hair follicles that manifests as small (approximately 1mm) vesicles, pustules, or papulopustules 1. The amputation stump area is particularly vulnerable to folliculitis due to several factors:

• Constant pressure and friction from prosthetic devices
• Increased sweating in the socket environment
• Potential skin maceration from prosthetic liners
• Compromised skin barrier function due to surgical trauma

Risk Factors for Stump Complications

Several factors increase the risk of developing folliculitis and other skin complications at BKA sites:

• Diabetes (present in 93.8% of patients with stump complications in one study) 2
• Peripheral arterial disease 2
• Poor hygiene practices
• Improper socket fit causing excessive friction
• Inadequate stump care

Diagnosis of Folliculitis at Amputation Sites

Diagnosis is primarily clinical, based on:

• Presence of small pustules at hair follicle openings
• Erythema surrounding follicles
• Mild discomfort or pain
• Possible pruritus at the site

Management Approach

Immediate Interventions

1. Improve hygiene practices:

   • Thorough cleaning of the stump with antibacterial soap
   • Proper drying of the area before applying prosthesis
   • Daily changing of stump socks

2. Topical treatments:

   • Antibacterial cleansers containing chlorhexidine
   • Topical antibiotics if bacterial infection is suspected

3. Prosthetic management:

   • Temporary discontinuation of prosthesis use if severe
   • Evaluation of socket fit to reduce friction
   • Consider silicone liners which may reduce friction 3

Advanced Interventions for Severe or Persistent Cases

For cases that don't respond to basic measures:

1. Systemic antibiotics if bacterial infection is confirmed or suspected based on severity

   • First-line options include amoxicillin-clavulanate or cephalosporins 4
   • For beta-lactam allergies, clindamycin with gentamicin may be used 4

2. Negative pressure wound therapy (NPWT) for complicated cases:

   • Can be valuable for managing stump complications 5
   • Helps condition the stump for successful closure
   • May reduce healing time and prevent dehiscence 5

3. Surgical debridement for severe or refractory cases:

   • May be necessary if folliculitis progresses to deeper infection
   • A novel strategy employing staged operative debridement has shown 100% BKA salvage rates in patients without peripheral arterial disease 2

Prevention Strategies

1. Meticulous stump hygiene:

   • Daily washing with mild soap
   • Thorough drying before prosthetic application
   • Regular changing of stump socks

2. Prosthetic considerations:

   • Proper socket fit to minimize friction and pressure
   • Use of lightweight prosthetic materials and soft padding (e.g., silicone inserts) 4
   • Regular cleaning of prosthetic components

3. Skin barrier protection:

   • Application of skin protectants in high-friction areas
   • Monitoring for early signs of skin breakdown

Potential Complications if Untreated

If folliculitis at the knee stump is left untreated, it can lead to:

• Progression to deeper infection (furunculosis or carbuncles)
• Delayed wound healing (average healing time can extend from 71 days to 97 days) 3
• Prolonged hospitalization (average increase from 21 to 40 days) 6
• Inability to use prosthesis, delaying rehabilitation
• Potential need for surgical revision or higher-level amputation

When to Seek Specialist Care

Immediate specialist evaluation is warranted if:

• Folliculitis fails to respond to initial treatment within 48-72 hours
• Signs of spreading infection (increasing erythema, warmth)
• Systemic symptoms (fever, malaise)
• Development of deeper nodules suggesting furuncles
• Pain at rest or night pain (which may suggest deeper infection) 4

Proper management of folliculitis at BKA sites is crucial for maintaining stump integrity and ensuring successful prosthetic fitting and rehabilitation.