For an 80‑year‑old patient with end‑stage congestive heart failure and a chronic scalp ulcer, how should I apply Santyl (collagenase) and manage the periwound skin with CeraVe Healing Lotion?

Santyl Application Protocol for Chronic Scalp Ulcer

Apply Santyl once daily after cleansing the wound with normal saline, protect the periwound skin with CeraVe Healing Lotion before applying the ointment, and cover with a sterile gauze dressing. 1

Step-by-Step Application Procedure

1. Wound Cleansing

• Gently cleanse the wound of debris and digested material using a gauze pad saturated with normal saline solution 1
• Follow with a normal saline rinse to remove all cleansing residue 1
• For thick eschar, consider crosshatching with a #10 blade to allow better enzyme contact with necrotic tissue 1
• Remove loosened debris with forceps and scissors as tolerated 1

2. Infection Management (If Present)

• Apply appropriate topical antibiotic powder directly to the wound before Santyl application if infection is present 1
• Discontinue Santyl if infection does not respond to topical antibiotics until infection remission occurs 1
• The Society of Vascular Surgery recommends antimicrobial therapy for wounds with >1 × 10⁶ CFU or difficult-to-eradicate bacteria 2

3. Periwound Skin Protection

• Apply CeraVe Healing Lotion to intact periwound skin before Santyl application to prevent maceration 2
• Skin protectants are important adjuncts in wound care to maintain periwound integrity 2
• This step is critical given the patient's age and likely fragile skin 2

4. Santyl Application

• Apply Santyl ointment in a thin layer (approximately 2mm thick) directly to the wound bed 1
• Alternatively, apply to a sterile gauze pad first, then place on the wound 1
• Cover with a sterile gauze dressing and secure properly 1
• Change dressing once daily, or more frequently if soiled from incontinence 1

5. Duration of Treatment

• Continue Santyl until debridement of necrotic tissue is complete and granulation tissue is well established 1
• Enzymatic debridement is an acceptable alternative to surgical debridement for wound bed preparation 2
• Reassess wound size, depth, and exudate at each dressing change 3, 4

Important Considerations for This Patient

Cardiac Status Impact

• In end-stage CHF patients, wound healing is compromised due to poor tissue perfusion 2
• Monitor for signs of fluid overload that may worsen periwound edema and maceration 2
• The patient's cardiac status may limit tolerance for more aggressive debridement methods 2

Nutritional Support

• Initiate protein or amino acid supplementation immediately to improve wound healing, as this patient likely has cardiac cachexia 2, 3, 4
• Protein supplementation improves wound healing even in the presence of comorbidities (moderate-quality evidence) 2

Monitoring for Complications

• Watch for skin irritation, inflammation, and tissue maceration—the most common adverse effects of topical wound applications 2
• Frail elderly patients are more susceptible to adverse events from wound treatments 3
• If the wound fails to show improvement after 4-6 weeks of standard therapy, consider alternative approaches 2

Common Pitfalls to Avoid

• Do not use Santyl with incompatible cleansing agents such as hydrogen peroxide, Dakin's solution, or products containing heavy metals or acidic solutions, as these inactivate the enzyme 1
• Do not apply CeraVe directly into the wound bed—it should only be used on intact periwound skin 2
• Do not continue Santyl indefinitely—terminate once granulation tissue is established 1
• Do not use antibiotic dressings prophylactically, as they have shown no benefit in non-infected wounds 2