Successful treatment of scleroderma-related cutaneous ulcer with suction blister grafting

Abstract

We presented a case of systemic sclerosis (SSc) in a 53year-old Japanese woman with a refractory toe ulcer, which was successfully treated with suction-blister grafting. A 53year-old Japanese woman with scleroderma presented with the ischemic lesions on the toe tips in November 2001. Over the preceding 20 years, she had suVered from sclerodactylia, arthralgia and Raynaud’s phenomina during cold weather. For more than 5 years, she had repeatedly several episodes of pitting ulcers on the Wnger and toe tips, which were treated with intravenous alprostadil injections and topical antibiotics. In October 2001, a painful ulcer Wrst appeared on her right third toe and worsened rapidly. She was introduced to our hospital. Physical examination revealed diVuse cutaneous sclerosis over the hands, arms, legs, and face. Results of laboratory studies showed the following abnormal values: anti-nuclear antibody 320£ (homogeneous), anti-SS-A antibody 190 IU dLi1, hemoglobin 9.9 g dLi1 and CRP 0.7 mg dLi1. The diagnosis of a diVuse type of systemic sclerosis (SSc) was made on the basis of typical clinical presentations. She was admitted to our hospital and started on intravenous alprostadil therapy once a day. Despite additional conservative treatments including systemic antibiotics and topical prostandin, the ulcer had expanded in size and it had remained extremely painful. Over the following 2 months, the ulcer extended to the entire middle toe with necrotic distal phalanx (Fig. 1a, b). After control of the infection with prolonged courses of intraveneous antibiotics, she underwent surgical therapy. The necrotic bone was removed at the PIP joint, and the ulcer was thoroughly debrided and cleansed under local anesthesia. Subsequently, artiWcial bilayer dermis (Pelnac, Gunze, Osaka, Japan) was applied to the ulcer bed. Twentyeight days later, the ulcer was cleaned accurately (Fig. 1c) and a suction blister was applied as described below. The donor area, the inner thigh, was disinfected with popidone iodine. The proximal end of a 20 ml disposal syringe was placed on the donor skin and suction was applied with the same size syringe connected through a three-way tap (Fig. 1d). It was locked and the negative pressure in the syringe was retained carefully. Vesicles started to form after about 1 h of continuous suction, and they enlarged and coalesced to form a complete blister after 2 h (Fig. 1e). After the roof of the bulla was removed by cutting the periphery of the blister with a small scissors, the epidermal graft was lifted gently with intertulle gauze, which was precut same size as the graft. The graft stuck to the intertulle gauze was placed on the cleaned ulcer (Fig. 1f) and Wxed spokewise with steristrip tape, and thereafter a pressure dressing was applied. The dressing gauze was removed after 7 days. There was complete improvement of the graft after another 7 days (Fig. 1g, h). SSc is a connective tissue disease characterized by cutaneous and visceral Wbrosis, as well as vascular disease involving arterioles, and medium arteries of peripheral circulation [1]. Skin ulcers are clinical problems in SSc that are diYcult to resolve. Although various medicines-like vasodilators, hemorheologic agents, and endothelin receptor antagonist (Bosentan) have been reported to be beneWcial in treating acral ulcers and ischemia, the most eVective therapy remains elusive [2]. Surgical procedures such as microvascular revascularization, digital arterial reconstruction, and peripheral sympathetectomy are used as a last resort, as they are invasive Y. Ichiki (&) · Y. Kitajima Department of Dermatology, School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan e-mail: yoichiki@gifu-u.ac.jp