Painful Leg Ulcers Research Articles

Leg ulcer and thigh telangiectasia associated with natural killer cell CD56 – large granular lymphocyte leukemia in a patient with pseudo-Felty syndrome

Clonal disorders of large granular lymphocytes (LGL) represent a rare spectrum of biologically distinct lymphoproliferative diseases originating either from mature T cells or natural killer cells. Both subtypes can manifest as indolent or aggressive disorders. We report a 77-year-old woman with rheumatoid arthritis, splenomegaly, and neutropenia who developed a painful leg ulcer refractory to treatment and thigh telangiectatic lesions. Because of the association of rheumatoid arthritis, splenomegaly, and nonspecific neutropenia, the diagnosis of Felty syndrome was initially made. Further investigation allowed the diagnosis of a CD56(-) natural killer-cell LGL leukemia and documented skin infiltration by natural killer cells. Cutaneous manifestations of LGL leukemia have been rarely reported. This report of pseudo-Felty syndrome with CD56(-) LGL leukemia, presenting with a leg ulcer and telangiectasia, enhances the role of dermatology in the diagnosis of hematologic neoplasia.

Kutane Nebenwirkungen einer Hydroxyurea-Therapie bei Polycythaemia vera

A 68-year-old women with polycythemia vera was treated with hydroxyurea for 8 years and developed painful ulcers on her lower legs, multiple hypertrophic actinic keratoses and a squamous cell carcinoma. After discontinuing hydroxyurea therapy the leg ulcers resolved within 8 weeks. The hypertrophic actinic keratoses and squamous cell carcinoma were treated with cryotherapy and excision, respectively. Hydroxyurea induces a variety of cutaneous side effects such as painful leg ulcers and squamous cell carcinomas. Given the wide variety of adverse cutaneous side effects associated with long-term hydroxyurea therapy, the first step in management is to insure that physicians and patients are aware of the specific risks of this treatment. Patients under hydroxyurea therapy should be monitored closely by dermatologists to early detect and treat the cutaneous side effects.

Pain-relieving properties of topically applied morphine on arterial leg ulcers: a pilot study

To assess whether topical morphine is pharmacologically effective in relieving pain from ulcers caused by arterial insufficiency and identify whether this effect is centrally or peripherally mediated. The analgesic effect of a topically applied hydrogel containing 0.5% of morphine was evaluated in a double-blind, placebo-controlled, three-way crossover pilot study involving nine patients with painful arterial leg ulcers. All patients had a baseline pain intensity of at least 5 on a 10-point numeric rating scale. They received the following three treatments in random order: morphine hydrogel plus a subcutaneous (SC) placebo infusion; placebo gel plus a SC infusion of 5mg morphine over six hours and a placebo gel plus a SC placebo infusion. Each treatment lasted one day. Pain was assessed during the first 24 hours after application of the hydrogel and the start of the subcutaneous infusion. There was a statistically significant difference between average baseline pain scores and those reported during treatment, but this difference was not clinically relevant. The three treatments did not differ in terms of the pain relief provided. Topical morphine does not have a clinically relevant analgesic effect in patients with painful arterial leg ulcers. Further research should focus on ulcers of other aetiology.

How evidence‐based is venous leg ulcer care? A survey in community settings

This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006. Compression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.

Estudo da correlação entre os níveis de hemoglobina fetal e o prognóstico dos pacientes com anemia falciforme

Os niveis de hemoglobina fetal (HbF) foram analisados em 47 pacientes com anemia falciforme, residentes em Fortaleza, capital do Ceara, com a finalidade de fornecer informacoes sobre a influencia da HbF no prognostico desta doenca. A determinacao dos valores hematologicos foi realizada em contador automatico de celulas sanguineas (modelo Sysmex KX-21N, Roche) e os niveis de HbF foram determinados pela tecnica da desnaturacao alcalina. Dentre os resultados foi demonstrada uma tendencia de menor numero de pacientes com crises vaso-oclusivas (p=0,0405) e ulceras de perna (p=0,0076) com o aumento dos niveis de HbF. Nao houve diferenca estatisticamente significativa na comparacao entre os niveis de HbF e os valores de hemacias, hemoglobina, hematocrito, leucocitos e plaquetas. Os resultados demonstram que os niveis de hemoglobina fetal podem ser utilizados como fator prognostico nos pacientes com anemia falciforme, no entanto nao deve ser a unica ferramenta diagnostica para prever o quadro clinico destes pacientes.

Potent Analgesic Effect of Tissue-Engineered Skin in a Terminal Patient with Severe Leg Ulcer Pain

Potent Analgesic Effect of Tissue-Engineered Skin in a Terminal Patient with Severe Leg Ulcer Pain

ORIGINAL RESEARCH–CLINICAL SCIENCE: Reducing wound pain in venous leg ulcers with Biatain Ibu: A randomized, controlled double‐blind clinical investigation on the performance and safety

Six out of 10 patients with chronic wounds suffer from persistent wound pain. A multinational and multicenter randomized double-blind clinical investigation of 122 patients compared two moist wound healing dressings: a nonadhesive foam dressing with ibuprofen (62 patients randomized to Biatain Ibu Nonadhesive Coloplast A/S) and a nonadhesive foam without ibuprofen (60 patients to Biatain Non-Adhesive-comparator). Patients were recruited from September 2005 to April 2006. The ibuprofen foam was considered successful if the pain relief on a five-point Verbal Rating Scale was higher than the comparator without compromising safety including appropriate healing rate. Additional endpoints were change in persistent wound pain between dressing changes and pain at dressing change on days 1-5 (double blind) and days 43-47 (single blind). The primary response variable, persistent pain relief, was significantly higher in the ibuprofen-foam group, as compared with the comparator on day 1-5, with a quick onset of action (p<0.05). Wound pain intensity was significantly reduced with the ibuprofen foam during day 1-5 with 40% from baseline, compared with 30% with the comparator (p<0.001). At day 43-47, the patients in the ibuprofen-foam group had a significant (p<0.05) reemergence of persistent pain and pain at dressing change (p<0.05) when the active dressing was changed to the comparator. Wound healing was similar in the ibuprofen foam and comparator group. No difference in adverse events between the comparator and the ibuprofen foam with local sustained release of low-dose ibuprofen was observed in this study. It was generally found that women reported less pain intensity than men, and pain intensity decreased with increasing age. In addition, pain intensity increased with initial pain intensity and increasing wound size. This study has demonstrated that the ibuprofen-foam dressing provided pain relief and reduced pain intensity without compromising healing or other safety parameters.

Potent Analgesic Effect of Tissue-Engineered Skin in a Terminal Patient with Severe Leg Ulcer Pain

COTO-SEGURA, PABLO MD*; VAZQUEZ-LOPEZ, FRANCISCO MD, PHD*; GARCIA-PEREZ, EVA BSC†; GARCIA, VERONICA BSC†; MEANA-INFIESTA, ALVARO MD, PHD†; PEREZ-OLIVA, NARCISO MD, PHD* Author Information

Frequency rhythmic electrical modulation system in the treatment of chronic painful leg ulcers

Electrical current has been recommended for use on chronic wounds; however, the ability of this modality to improve healing of various types of chronic ulcers, arterial, venous, mixed arterial and venous ulcers, diabetic, and pressure ulcers is not well established. The purpose of this study was to examine the effect of frequency rhytmic electrical modulation system (FREMS) on healing of chronic painful leg ulcers.Thirty-five patients with 43 chronic painful leg ulcers participated in the study. The subjects were separated into two random groups, one treated with FREMS and the control group. Our investigation focused on the control of the parameter changes important for ulcer healing: wound surface area, wound appearance (fibrin accumulations, exudation, granulation, and epithelization), ulcer surroundings and associated symptoms. All the parameters were monitored clinically at the beginning, after first, second, and third week, and at the end, after 1 and 2 months of administered therapy, when the scores were determined. Pain intensity was evaluated with visual analog scale (VAS). FREMS therapy was administrated through the device model Aptiva Ballet into sessions and several stages. Comparing the findings of decrease leg ulcer surface, pain, leg ulcer score, score of vicinity (statistically significant at the level P < 0.05) with the controls, it was established that FREMS system accelerated ulcer healing, reduced pain and demonstrated better effects compared to the control group. The results of the study indicate that FREMS therapy accelerates wound closure and depresses the pain of chronic leg ulcers.

Auftreten von Ulcera crurum in Zusammenhang mit der Einnahme von Anagrelid

Anamnese und klinischer Befund: Wir berichten über einen 38-jährigen Patienten mit äußerst schmerzhaften Ulcera crurum an beiden Außenknöcheln, die 6 Wochen nach Beginn einer Therapie mit Anagrelid bei Thrombozythämie erstmalig auftraten.

Punch-grafting to Enhance Healing and to Reduce Pain in Complicated Leg and Foot Ulcers

This article does not have an abstract.

Topical opioids for painful ulcers in systemic sclerosis

Painful cutaneous ulcers are frequent in systemic sclerosis (SSc). They are due to vasoconstriction and fibrosis, and are often located in digits and toes though they also occur at other...

Can venous and arterial leg ulcers be differentiated by the characteristics of the pain they produce?

To explore the characteristics of venous and arterial leg ulcer pain among people cared for in the community. There is little information available concerning the different characteristics of pain resulting from venous and arterial leg ulcers. The identification of clear differences in pain experience might aid recognition of arterial deterioration and provide a useful adjunct for existing diagnostic procedures. This was a prospective interview-based survey. Structured interviews were conducted with each of the participants in their home. Ulcer history, pain (McGill pain questionnaire and verbal rating scale) and factors influencing pain were assessed. Fifty-two women and 27 men aged 77.7 (SD 8.9) took part. Pain scores for least, average, worst and present pain varied widely, and arterial ulcers were associated with the highest average pain scores. Pain tended to be worst at night and least in the afternoon; arterial ulcers were more painful than venous ulcers on lying down. Venous leg ulcers were frequently described as throbbing, burning and itchy, while arterial ulcer pain tended to be described as sharp and hurting. Some characteristics of pain appeared to be suggestive of the leg ulcer type. Differences were found in the words chosen to describe the pain as well as the temporal and postural aspects of arterial and venous leg ulcer pain. More research is needed to confirm these preliminary findings. Patients' descriptions of pain have the potential to supplement other methods of differentiating between types of leg ulcer and provide an early-warning indicator for transition from venous to arterial ulceration.

Hydroxyurea-Induced Leg Ulcers Treated With a Protease-Modulating Matrix

The development of painful leg ulcers in the ankle area is a rare and only partially described complication in patients receiving high-dose, long-term hydroxyurea treatment for myeloproliferative diseases. Several reports have described treatments for chronic wound management with this type of lesion. We describe 2 patients who were diagnosed as having hydroxyurea-induced leg ulcers that were successfully treated with a freeze-dried sponge containing oxidized regenerated cellulose and bovine purified collagen. This dressing is able to modulate the activity of proteases such as plasmin, neutrophil-derived elastase, and matrix metalloproteinase by physically entrapping them and thus inhibiting their activity. This case demonstrates that topical application of a matrix metalloproteinase modulator can be a successful and safe treatment option for patients with hydroxyurea-induced recalcitrant leg ulcers.

Unusual Case of Calciphylaxis Associated With Metastatic Breast Carcinoma

Calciphylaxis is a relatively rare disorder associated with calcification of small- and medium-sized blood vessels, progressive ischemic skin necrosis, and ulcerations. It is usually seen in patients with end-stage renal disease with secondary hyperparathyroidism and is occasionally seen in primary hyperparathyroidism, hypercalcemia of malignancy, and end-stage liver disease. We report an unusual case of calciphylaxis seen in association with metastatic breast carcinoma in the absence of end-stage renal or parathyroid disease. A 73-year-old woman presented with painful leg ulcers. Serum calcium levels and parathormone levels were within normal limits. Skin biopsies from the ulcers revealed small- to medium-sized subcutaneous arteries with calcification of the media. Some of the arteries were narrowed by fibrointimal hyperplasia and fibrin thrombi. Calcification of the subcutaneous fat, fat necrosis, and suppuration were also seen. Calciphylaxis associated with metastatic osteolytic breast carcinoma is rare. Although end stage renal disease with secondary hyperparathyroidism is the most common cause of calciphylaxis, this case demonstrates that less common conditions with normal serum calcium and parathormone levels may also cause it.

Vaskulitische Ulcera cruris bei primärem Sjögren-Syndrom

Sjögren syndrome is a rare chronic systemic autoimmune disease characterized by progressive dryness of the mucous membranes. There are many variable clinical manifestations. A 40-year-old woman presented with painful leg ulcers refractory to various therapies. She had a history of xerostomia and xerophthalmia for several years. Based on clinical, serologic and histopathologic findings, we diagnosed leg ulcers in primary Sjögren syndrome. Combing immunosuppressive therapy with phase-adapted modern wound-therapy resulted in a complete healing of the ulcers. In the case of clinically atypical leg ulcers, Sjögren syndrome should be considered as a rare differential diagnostic possibility.

Efficacy of Granulocyte and Monocyte Adsorption Apheresis for Three Cases of Refractory Pyoderma Gangrenosum

Pyoderma gangrenosum presents with chronic skin ulcers and is histologically characterized by neutrophil infiltration throughout the dermis. It is also occasionally associated with ulcerative colitis, a type of inflammatory bowel disease, against which granulocyte and monocyte adsorption apheresis (GCAP) has recently shown remarkable efficacy. We performed GCAP on three refractory cases of pyoderma gangrenosum with painful bilateral leg ulcers and hereby report the results obtained. Patient 1 was a 43-year-old woman with a four-year history of recurrent painful skin ulcers treated with prednisolone and cyclosporine. Patient 2 was a 29-year-old woman who had been suffering from pyoderma gangrenosum with severe pain for two weeks, associated with an 11-year history of ulcerative colitis treated with prednisolone and salazosulfapyridine. Patient 3 was a 63-year-old man with a three-year history of recurrent ulcers with pain, suffering from rheumatoid arthritis treated with prednisolone and cyclophosphamide. The sizes of the lesions were reduced in all three patients following a weekly GCAP treatment for 10 or 11 consecutive weeks, and the re-epithelialization of ulcers were additionally observed in two patients. The pain disappeared dramatically in all three patients following two sessions of GCAP therapy. No adverse effects were observed for up to at least eight months after treatment. We therefore considered GCAP as one effective alternative to currently existing therapies, with regards to refractory cases of pyoderma gangrenosum.

Painful leg ulceration: a prospective, longitudinal cohort study

This study aimed to explore the relationship between pain mechanism, pain intensity, and leg ulcer characteristics using a 6-month longitudinal cohort study in a community setting in the north of England. Patients with leg ulceration referred consecutively to district nurses were invited to participate (n=96). The main outcome measures were pain intensity using daily visual analogue scores, leg ulcer characteristics (etiology, size, location, duration), and LANSS (Leeds Assessment of Neuropathic Symptoms and Signs). Results suggested that type, duration, position, and size of the leg ulcer had no effect on average daily pain scores. Using the LANSS questionnaire, 43.5% of respondents reported symptoms suggestive of a neuropathic mechanism to their pain. Patients with neuropathic symptoms had higher average daily pain scores (p<0.001). Fewer people had healed ulcers at 6 months with neuropathic symptoms compared with those with no neuropathic symptoms (30.8 vs. 52.1%). It would seem that the severity of pain can not be predicted by the type, size, position, or duration of ulceration. Patients who scored positively for neuropathic symptoms had higher average daily pain scores and fewer had healed leg ulcers at 6 months compared with those who did not experience neuropathic signs and symptoms.

A pilot (real‐life) randomised clinical evaluation of a pain‐relieving foam dressing: (ibuprofen‐foam versus local best practice)

The aim of the study was to evaluate a novel foam dressing with continuous low-level release of ibuprofen (Biatain-Ibu foam dressing, Coloplast A/S, Humlebaek, Denmark) in persons with leg ulcers compared to local best practice. An open comparative and prospective block-randomised study of 24 patients was conducted in a Canadian wound clinic. Twelve patients were randomised to ibuprofen-foam and 12 patients to local best practice. The study population consisted of patients with chronic, painful exudating leg ulcers. The patients rated their wound pain intensity at baseline and after the first dressing application. Pain intensity in the morning and evening was rated during a period of 1 week using a numeric box scale (NBS). A t-test compared the main differences in pain intensity and a five-point verbal rating scale measured the patients' pain relief. At the last clinical visit, pain after dressing change was assessed using an NBS. In addition, wound size, percentage of healthy granulation tissue and the presence of peri-ulcer erythema, were (all) evaluated at inclusion and the end of the study. The nurses and patients both evaluated the relative dressing performance and exudate management at the last study visit. This study demonstrates that the ibuprofen-foam dressing decreased wound pain in patients with leg ulcers compared to best practice. The ibuprofen-foam dressing was associated with: diminished chronic pain between dressing changes, reduced acute pain at dressing change, increased healthy granulation tissue, decreased peri-wound erythema and excellent exudate handling capacity. It can be concluded from the results of the study that the combination of foam with a continuous low-dose release of ibuprofen may offer a valuable new therapeutic approach to the reduction of wound pain.

Less pain with Biatain–Ibu: initial findings from a randomised, controlled, double‐blind clinical investigation on painful venous leg ulcers

Six out of 10 patients with chronic wounds suffer from persistent wound pain. A multinational and multicentre, randomised, double-blind clinical investigation of 122 patients compared two moist wound-healing dressings, a non adhesive foam dressing with ibuprofen (62 patients randomised to Biatain-Ibu non adhesive, Coloplast A/S) with a non adhesive foam without ibuprofen (60 to Biatain non adhesive). The ibuprofen-foam was regarded successful, if the pain relief on a 5-point verbal rating scale was higher than the comparator without compromising safety, including appropriate healing rate. Additional endpoints were change in persistent wound pain between dressing changes and pain at dressing change on days 1-5 and days 43-47. The primary response variable, persistent pain relief, was significantly higher in the ibuprofen-foam group compared with the comparator on days 1-5, with a quick onset of action (P < 0.05). The patients in the ibuprofen-foam group had a significant (P < 0.05) higher reduction in the persistent wound pain from baseline (40%) as the comparator (30%). Women reported less pain intensity than men, and pain intensity decreased with increasing age. In addition, pain intensity increased with increasing initial pain intensity and increasing wound size. Wound healing was similar in the ibuprofen-foam group to that of the comparator group. No difference in adverse events between placebo and local sustained release of low-dose ibuprofen was observed in this study. This study has demonstrated that the ibuprofen-foam dressing provided pain relief and reduced pain intensity without compromising healing or other safety parameters. The full report of this study will be published in Wound Repair and Regeneration.