Local treatment of non healing leg ulcers in a patient with hepatitis C virus infection

Abstract

Infection with hepatitis C virus (HCV), a blood-borne agent, is transmitted by apparent and inapparent parenteral procedures, frequently associated with autoimmune extrahepatic complications 1. Skin is one of the most frequently affected organs and the major skin diseases frequently associated with HCV infection include mixed cryoglobulinemia, porphyria cutaneatarda, palpable purpura, lichen planus cutaneous and necrotising vasculitis, often with very painful leg ulcers. Other skin disorders that may also be linked to hepatitis C are Behçet syndrome, erythaema multiforme and nodosum, malacoplakia, urticaria and pruritus 2. The leg ulcers due to cutaneous vasculitis may or may not be associated to cryoglobulins 3. These are chronic, non-healing ulcers difficult to treat with a significant impact on psychosocial aspects as well as on one's physical well-being 4, 5. We present a case of a 57-year-old female ex-addict who has been suffering from HCV infection for 10 years, cardiopathy, hypertension and arterio-venous pathology. She presented with non-healing ulcers over her right and left thighs for a duration of 3 years (Figure 1). During the 3 years prior to the admission, the patient was treated monthly by her general practitioner and twice a week by a home-care team. The patient was visited at first, in 2011, in our Ambulatory “Ulcers and Difficult Wounds”, Department of Plastic, Reconstructive and Aesthetic Surgery, Sapienza University of Rome. Clinically, the ulcer on the right thigh appeared oval in shape, 10 × 6 cm in size, of varying depth and involving bone, elevated margins and a sanious wound bed. There were also presence of nodules. It was smelly, not painful and indolent on palpation. On the left, the ulcer was smaller, about 7 × 4 cm in size with similar aspect. Dressing was performed everyday. During the dressing the wound was disinfected with sodium hypoclorite 0·05% (Amukine®, S.p.A., Genoa, Italy) and iodopividone 0·5% (Betadine®, Meda Pharma S.p.A., Milano, Italy). After a careful wound disinfection, a layer of the new collagenase plus hyaluronic acid ointment (Bionect Start®, FIDIA Pharmaceutical, Abano, Italy) was applied only on the ulcer area. One year after the first observation, the right ulcer underwent a slight improvement and the ulcer on the left healed (Figure 2). Although the patient did not undergo any type of systemic therapy, this local treatment induced a positive clinical response with rapid pain control of the skin lesions and also improved psychosocial functioning, which allowed better adherence to continuity of care in the patient. HCV-related skin ulcers may represent a therapeutic challenge, which should be managed by means of both local and systemic treatments. Maria G. Onesti, MD; Paolo Fioramonti, MD; Diego Massera, MD; Vittoria Amorosi, MD & Pasquale Fino, MD Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome “Sapienza”, Rome, Italy, [email protected]; [email protected] All authors hereby declare not to have any potential conflict of interests and not to have received funding for this work from any of the following organisations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI) and other(s). Each author participated sufficiently in the work to take public responsibility for the content. Special thanks to Dr. Franco Bartolomei for his help in preparing this manuscript.