Punch grafting for the treatment of ulcerated atrophie blanche.

Case report: A 79-year-old woman presented with a large painful ulcer on the lateral aspect of her left leg over a 6-month period and was diagnosed of ulcerated atrophie blanche. On an outpatient basis punch grafting was performed and 3 weeks after, complete epithelization was achieved. Discussion: Ulcerated atrophie blanche is a misdiagnosed disorder with painful lesions and, consequently, a high impact on quality of life. Atrophie blanche describes porcelain-white colored, red-dotted atrophic plaques on legs or feet. It may be due to multiple causes, usually associated with alterations in the microcirculation. All causes of atrophie blanche can be included in the term livedoid vasculopathy, a type of occlusive vasculopathy without vasculitis. Many patients with atrophie blanche and livedoid vasculopathy have also chronic venous insufficiency. Etiological treatment should be prescribed in order to avoid progression of the lesions. In case of chronic venous insufficiency, control of venous hypertension is essential. Without anti-edema measures, superficial, very painful, and resistant ulcers may appear. These ulcers can be considered a wound on scar tissue; therefore, it must be treated as a hard-to-heal wound. As we show in this case, punch grafting is an effective therapeutic alternative for wound closure and pain reduction of ulcerated atrophie blanche.

How does a chronic wound change a patient's social life? A European survey on social support and social participation.

Chronic wounds can severely limit patient's social life. This cross-sectional study investigated quantitatively social support of patients with chronic wounds, its association with health-related quality of life as well as qualitatively changes in social participation of these patients. Overall, 263 patients from seven countries participated. The most frequent wound class was leg ulcer (49.2%). Results revealed generally high levels of social support (mean global score: 5.5) as measured with the Multidimensional Scale of Perceived Social Support. However, individuals differed considerably (range 1.0-7.0). All dimensions of social support differed by patients' family and living situations (p < 0.001 to p = 0.040) and were positively correlated with generic health-related quality of life (r = 0.136-0.172). Having children, living with others and being in a relationship were significant predictors of having higher global social support. Patients reported great support from family members. Many participants reported no changes in relationships with friends. Wound care managers took an important role and provided additional emotional support. Patients reported a range of discontinued activities. Despite the high overall level of social support, inter-individual differences should be acknowledged. The importance of family carers should be acknowledged to be able to reduce caregiver burden and to ensure high-qualitative wound care.

Pain control with punch grafting in ulcers with underlying arteriolosclerosis.

OBJECTIVE: Martorell hypertensive ischaemic ulcers are often misdiagnosed and can be a clinical and therapeutic challenge. Controversy exists regarding both their underlying triggers and the type of treatment that should be carried out. This study was designed to compare the effectiveness of punch grafting and conventional therapy in pain reduction. METHOD: A single-centre retrospective study was performed, including 40 patients with a clinical diagnosis of a Martorell ulcer or post-traumatic ulcer secondary to arteriolopathy in the elderly, who were treated with punch grafting (n= 24) or conventional medical treatment (n=16). RESULTS: There was a statistically and clinically significant reduction in pain after punch grafting. The minimal overall reduction was of three points in visual analogue pain scores. Of the patients who received punch grafting, 80% reported a VAS pain score of 0 at the third follow-up, in contrast with the 44% (n=4) patients who were treated without punch grafting. The mean time to epithelialisation was 82.1 days in patients who received conventional treatment and 43.5 days in those who received punch grafts. CONCLUSION: Punch grafting is a simple, validated and cost-effective technique that can be performed on an outpatient basis, promotes wound healing and reduces pain. It may control pain and stimulate epithelialisation even if the wound does not present with optimum wound bed characteristics for graft taking. Pain reduction and faster epithelialisation are associated with improvements in patients' quality of life.

Early and Sequential Punch Grafting in the Spectrum of Arteriolopathy Ulcers in the Elderly.

INTRODUCTION: Posttraumatic ulcers secondary to age-related arteriolosclerosis may be included in the clinic-histopathological spectrum of the Martorell hypertensive ischemic ulcer. Histologically, they both present occlusive subcutaneous arteriolosclerosis. Considering these similarities, they could benefit from the same treatment. CASE REPORT: The authors present an 84-year-old white female who had a painful 9-cm x 4-cm ulcer of the central inner aspect of her left leg. The ulcer had developed 2 months prior after mild trauma, with good response to early and sequential punch grafting, combined with single-use negative pressure wound therapy and compression therapy. Pain reduction was obtained from the first punch grafting session. To achieve complete epithelialization 16 weeks after the first punch grafting procedure, 2 more sessions were necessary. CONCLUSIONS: Early punch grafting is an effective technique for pain control and healing promotion in Martorell ulcers. Punch grafting, which may be performed in an outpatient setting, is well tolerated by patients and may be repeated several times if necessary.

Bayesian Regression Model for a Cost-Utility and Cost-Effectiveness Analysis Comparing Punch Grafting Versus Usual Care for the Treatment of Chronic Wounds.

Punch grafting is a traditional technique used to promote epithelialization of hard-to-heal wounds. The main purpose of this observational study was to conduct a cost-utility analysis (CUA) and a cost-effectiveness analysis (CEA) comparing punch grafting (n = 46) with usual care (n = 34) for the treatment of chronic wounds in an outpatient specialized wound clinic from a public healthcare system perspective (Spanish National Health system) with a three-month time horizon. CUA outcome was quality-adjusted life years (QALYs) calculated from EuroQoL-5D, whereas CEA outcome was wound-free period. One-way sensitivity analyses, extreme scenario analysis, and re-analysis by subgroups were conducted to fight against uncertainty. Bayesian regression models were built to explore whether differences between groups in costs, wound-free period, and QALYs could be explained by other variables different to treatment. As main results, punch grafting was associated with a reduction of 37% in costs compared to usual care, whereas mean incremental utility (0.02 ± 0.03 QALYs) and mean incremental effectiveness (7.18 ± 5.30 days free of wound) were favorable to punch grafting. All sensitivity analyses proved the robustness of our models. To conclude, punch grafting is the dominant alternative over usual care because it is cheaper and its utility and effectiveness are greater.

Punch grafting for pain reduction in hard-to-heal ulcers.

OBJECTIVE: Punch-grafting is a traditional technique to enhance wound healing, which has been associated with significant pain reduction. There are few studies measuring pain reduction after punch grafting, our study was designed to measure this outcome. METHOD: Patients with hard-to-heal wounds treated with punch grafting were included in a single centre prospective study. Wound pain intensity was measured using a Visual Analogue Scale (VAS) at baseline (before the procedure) and at three time points after the procedure. Punch grafting was performed in an outpatient setting. Patient demographic data, wound aetiology and percentage of graft take were recorded. RESULTS: A total of 136 patients were included (62 men and 74 women). Mean age was 60±35 years and 51 (38%) had venous leg ulcers (VLU), 29 (21%) had postoperative wounds, 15 (11%) Martorell ulcers, 15 (11%) traumatic wounds, four (3%) arterial ulcers and 22 (16%) 'other' ulcers. Of the patients, 38 (28%) did not present with painful ulcers and, after punch grafting, all of them remained painless; 29 (21%) patients obtained >70% pain reduction, whereas 73 (54%) patients achieved pain suppression. Pain suppression did not depend on the percentage of graft take. CONCLUSION: Punch-grafting is a simple, technique that not only promotes wound healing but also reduces pain. It can also be performed on an outpatient basis. Further studies should be performed to achieve a better understanding of this beneficial finding. Declaration of interest: The authors have no conflicts of interest to declare.

Refractory palmoplantar pustulosis succesfully treated with apremilast.

Palmoplantar pustulosis is a chronic inflammatory disease which characterized by a eruption of sterile pustules on the palms and soles. Apremilast is an oral phosphodiesterase-4 inhibitor which is approved for the treatment of chronic plaque psoriasis and psoriatic arthritis. However, no clinical trial has been performed to confirm the efficacy of apremilast for palmoplantar pustulosis yet. Moreover, there are very few cases of this disease treated with apremilast. Herein, we describe a case of a refractory palmoplantar pustulosis succesfully treated with apremilast.

Efficacy and safety of a rosehip seed oil extract in the prevention and treatment of skin lesions in the hands of patients with type 1 diabetes mellitus caused by finger prick blood glucose monitoring; a randomized, open-label, controlled clinical trial. / Eficacia y seguridad del aceite de rosa mosqueta en las lesiones de los dedos provocadas por las punciones capilares para el control glucémico en niños con diabetes tipo 1; un ensayo clínico aleatorizado, abierto, controlado.

INTRODUCTION: This study was intended to assess the efficacy and safety of a rosehip seed oil (RHO) extract in the prevention and treatment of skin lesions in the hands of patients with type 1 diabetes mellitus (T1DM) caused by finger prick blood glucose monitoring. PATIENTS AND METHOD: A prospective, randomized, controlled, open-label, rater-blinded trial in patients aged 6-17 years with T1DM and intensive blood glucose control (≥7 finger pricks daily) for 12 days. Three main variables (erythema, skin thickening, and loss of skin integrity) were assessed using a scale ranging from 0 (absent) to 3 (severe involvement). The study was approved by the ethics committee of the hospital. RESULTS: Sixty-eight children, and thus 136 hands, were included; 80 hands received rosehip seed oil and 56 hands acted as controls. Baseline characteristics of both groups were similar, with 76.3% and 78.6% of the hands respectively showing skin lesions at study start. Median final global assessment was 0.10 (0.03; 0.30) in the group that received rosehip seed oil and 0.06 (0.00; 0.23) in the control group. A statistically significant improvement in global assessment was found in the control group (P=0.049). No significant differences were found when the medians of the other main variables were compared. No adverse effects were recorded. CONCLUSION: A high prevalence of skin lesions secondary to finger prick glucose monitoring, most of them mild lesions, was found at study start. Treatment with rosehip seed oil was safe and was not effective for improving skin lesions.

Preliminary experience of an expert panel using Triangle Wound Assessment for the evaluation of chronic wounds.

OBJECTIVE: Wound assessment is an essential part of wound management and has traditionally focused on the wound bed. The Triangle of Wound Assessment (Triangle) is a new assessment tool that includes a holistic evaluation of the patient with a wound. The aim of this pilot study was to describe the use of the Triangle in our clinical practice in Spain. METHODS: Prospective, consecutive patients, male and female, over 18 years old, with wounds of any aetiology and duration, who attended the centres involved in the study, were recruited between May and June 2017. The TWA was used during the first presentation, to assess the wound bed, edge and periwound skin. The study's expert panel met to discuss the results collected by the assessment, as well as the advantages and disadvantages of the system. RESULTS: We recruited 90 patients. Non-viable tissue (necrotic/sloughy) was recorded in 57.8% of the patients, elevated exudate (medium/high) in 52.2%. Approximately 25% of the patients had signs or symptoms of local infection. Maceration was the most prevalent issue recorded on the wound edge and periwound skin assessment, affecting 31.1% and 30.0% of the patients, respectively. The presence of hyperkeratosis was high for the study population as the main aeitologies of the wounds identified here were DFU. CONCLUSIONS: The implementation of Triangle Wound Assessment could help in the holistic approach to patient care by focusing on more than local wound care, identifying barriers to achieving wound healing and evaluating wound response and patient compliance.

Martorell Hypertensive Ischemic Ulcer Successfully Treated With Punch Skin Grafting.

Martorell hypertensive ischemic ulcer can be a real clinical and therapeutic challenge. Controversy exists regarding both the underlying triggers of the disease and the type of treatment that should be established. Early skin grafting has been suggested as an effective treatment to enhance pain reduction and wound healing in these patients. The authors present the case of a 68-year-old woman with well-controlled hypertension and diabetes who developed extremely painful, rapidly progressing bilateral ulcers on the distal aspect of her legs. Without previous surgical debridement, the lesions were covered with punch grafts. Pain and necrotic progression were immediately controlled and complete epithelialization was achieved in 7 weeks.

Validity and feasibility of the wound-QoL questionnaire on health-related quality of life in chronic wounds.

Chronic wounds have a major socioeconomic impact due to their frequency, chronicity, and societal costs. Patients experience substantial quality of life (QoL) impairments. The use of questionnaires for a continuous assessment of QoL and resulting interventions to improve the situation of the individual are an important cornerstone of a guideline-based wound care. The aim of this study was to investigate the validity of the Wound-QoL questionnaire. Patients with chronic wounds from two different centers were included in the prospective study. All patients completed the Wound-QoL and two other QoL questionnaires (European Quality of Life-5 Dimensions, EQ-5D, and Freiburg Life Quality Assessment for wounds, FLQA-wk) at baseline and at two more time points (4 and 8 weeks, respectively). Wound status was defined with an anchor question. Two hundred and twenty-seven patients (48.5% women) participated in the study. Mean age was 66.9 years (range 17-96, median 69.5). Indications were venous leg ulcers (40.1%), pyoderma gangraenosum (14.1%), diabetic or ischemic foot ulcers (5.3%), pressure ulcers (2.6%), and other etiologies (30.0%). The Wound-QoL showed good internal consistency, with high Cronbach's alpha in all the subscales and in the global scale in all time points (>0.8). Convergent validity was satisfactory since there were significantly (p ≤ 0.001) good correlations with the EQ-5D (range = 0.5-0.7) and FLQA-wk global score (r > 0.8) at every time point. Responsiveness was high, too. The Wound-QoL is a simple, valid tool for the longitudinal assessment of QoL in patients with chronic wounds. This questionnaire is suitable for use in clinical trials, quality of care studies and clinical routine.

The Vulva: An Uncommon Presentation of a Pressure Ulcer.

Pressure ulcers may develop in different locations. Vulvar pressure ulcers can be easily misdiagnosed and, moreover, have been rarely reported in the literature. Surgical procedures that involve prolonged pressure on this area may trigger these lesions. CASE REPORT: The authors present a case of a vulvar pressure ulcer secondary to the use of a perineal post to provide countertraction during surgical repair of a hip fracture. Diagnosis was made after excluding other possible causes with anatomopathological and microbiological analysis. Wound care was based on relieving local pressure. CONCLUSION: Faced with the acute development of ulcers in the external genitals of women after this kind of surgical procedure, even with the use of padded posts, diagnosis of a pressure ulcer should be considered after excluding other possible causes.