- Email: [email protected]
Interest of punch skin grafting for the treatment of painful ulcers
Journal des Maladies Vasculaires (2016) 41, 329—334
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Interest of punch skin grafting for the treatment of painful ulcers夽 Intérêt de la greffe cutanée en pastille dans la prise en charge d’ulcères algiques
C. Fourgeaud a,∗, G. Mouloise a, U. Michon-Pasturel a, S. Bonhomme a, I. Lazareth a, S. Meaume b, P. Priollet a a
Service de médecine vasculaire, groupe hospitalier Paris — Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France b Service de dermatologie, plaies et cicatrisation, hôpital Rothschild, 5, rue Santerre, 75012 Paris, France Received 27 July 2016; accepted 30 July 2016 Available online 3 September 2016
KEYWORDS Ulcer; Pain; Punch skin grafting
Summary Skin leg ulcers are chronic painful wounds. The treatment of these ulcers is crucial for patients because pain has a significant impact on their daily lives. The analgesic effect of punch skin grafting (PSG) for the treatment of painful ulcers is not well described. The objective of the study is to assess the level of pain in patients with an ulcerated wound and to see if there is an analgesic effect of PSG. Patient and methods. — A single-center, non-interventional study conducted in hospitalized patients with one or several ulcer(s) of any type and which has been painful for more than six weeks. Pain was assessed before, the day after a PSG and then on the way out of hospital by a questionnaire and a numeric pain rating scale. Permanent pain and pain peaks were identified. Results. — Forty-one patients were included (23 men and 18 women) with a mean age of 73 ± 21 years, 36% (n = 15) with arterial ulcers, 36% (n = 15) with venous ulcers, 12% (n = 5) with necrotic angiodermatitis, 12% (n = 5) with mixed ulcers and 4% (n = 2) with ‘‘other ulcers’’ (due to infection and use of hydroxycarbamide). On day 1 of PSG, patients showed an improvement in terms of permanent pain (77%, n = 24/31) and pain peaks (90%, n = 37/41) respectively and 90% (n = 28/31) and 95% (n = 39/41) on the last day at hospital. Reduction in the use of strong opioids was found in 13 patients (81%).
夽 Présentation affichée ayant rec ¸u le prix poster (prix René Rettori), 50e congrès du Collège franc ¸ais de pathologie vasculaire, Paris, mars 2016. ∗ Corresponding author. E-mail address: [email protected] (C. Fourgeaud).
http://dx.doi.org/10.1016/j.jmv.2016.08.002 0398-0499/© 2016 Elsevier Masson SAS. All rights reserved.
330
C. Fourgeaud et al. Conclusion. — Punch skin grafting is a simple and validated treatment, which can reduce or eliminate pain related to ulcers. It has an effect on permanent pain and pain peaks. Its efficiency is particularly demonstrated on venous ulcers and mixed ulcers but also initially painful ulcers such as necrotic angiodermatitis or arterial ulcers. © 2016 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Ulcère ; Douleur ; Greffe cutanée en pastille
Résumé Les ulcères cutanés sont des plaies chroniques douloureuses. Leur prise en charge est capitale pour les patients car la douleur a un impact lourd sur la vie quotidienne. L’effet antalgique de la greffe cutanée en pastilles (GCP) dans le traitement des ulcères algiques est peu décrit. L’objectif de l’étude était d’évaluer la douleur chez les malades ayant une plaie ulcéreuse afin de voir s’il existe un effet antalgique de la GCP. Patient et méthodes. — Il s’agissait d’une étude monocentrique, non interventionnelle réalisée chez des patients hospitalisés pour un ou des ulcère(s) de toute(s) nature(s), algiques, évoluant depuis plus de 4 semaines. La douleur a été évaluée avant, le lendemain d’une GCP puis à la sortie par un questionnaire et une mesure de l’échelle numérique de la douleur. La douleur permanente (DP) et les pics douloureux (PD) ont été distingués. Résultats. — Quarante et un patients ont été inclus (23 hommes et 18 femmes) d’âge moyen 73 ± 21 ans, dont 36 % (n = 15) d’ulcères artériels, 36 % (n = 15) d’ulcères veineux, 12 % (n = 5) d’angiodermites nécrotiques, 12 % (n = 5) souffrant d’ulcères mixtes et 4 % (n = 2) d’ulcères « autres » (dus à hydroxycarbamide et infectieux). À j1 de la GCP, les patients ont exprimé une amélioration des DP et des PD de respectivement 77 % (n = 24/31) et 90 % (n = 37/41) et de 90 % (n = 28/31) et 95 % (n = 39/41) à la sortie. Une réduction dans la consommation d’antalgique de palier III a été retrouvée chez 13 patients (81 %). Conclusion. — La GCP est une thérapeutique validée et simple qui permet de diminuer voire de supprimer, les douleurs des ulcères. Elle agit sur les DP et les PD. Son efficacité est particulièrement démontrée sur les ulcères veineux et mixtes mais aussi sur des ulcères initialement très douloureux comme les angiodermites nécrotiques ou les ulcères artériels. © 2016 Elsevier Masson SAS. Tous droits r´ eserv´ es.
Introduction We define a leg ulcer as a chronic wound, which has evolved for 4 to 6 weeks, situated between the leg and the foot, without any spontaneous healing. In most cases, it is due to a complication of a vascular disease. The most common types are venous (70 to 90%), arterial (5—15%) or microcirculatory. The census of leg ulcers is not simple because a lot of them are treated out the hospital and are partly due to selfmedication. This makes the epidemiological and economic data inaccurate and limited. Sixty thousand to five hundred thousand people will be affected [3], patients above the age of 65 seem to be affected the most [4]. The sex ratio is 3 women to 1 man [2]. A study conducted on the prevalence of leg ulcers within the population of London [5] has enabled to enhance the epidemiological data of leg ulcers and has shown the sharp rise of prevalence of leg ulcers with the increase of, being more frequent in women. Leg ulcers are an expensive condition because their healing time is long and there is a high risk of recurrence. The treatment of chronic ulcers is essential as it is a major public health problem and a growing socioeconomic burden [6]. In three quarters of the cases, leg ulcers are painful chronic sores. They presents themselves through a short lived pain, also known as pain peaks that can last from a few seconds to hours, possibly accompanied by a permanent background pain. The cause of the pain is multifactorial, which could be accentuated by an underlying neuropathy,
but also by dressing changes, cleaning and debridement of the wound, or a possible infection. Concerning the pain treatment of leg ulcers, there are national and international recommendations. The French recommendations are based upon professional agreement. Depending on the etiology of the ulcer, the pain can be more or less intense. Arterial ulcers as necrotic angiodermatitis are considered more painful than venous ulcers. However, venous ulcers can become extremely painful, as it has been shown through studies of life quality [1]. Pain management is a capital aspect in the treatment of patients as it can have a major impact on their day-to-day life. The treatment of a leg ulcer calls for different techniques, associated with etiological treatment, such as punch skin grafting (PSG). It is a simple method that obtains less than 0.5 cm in diameter of skin graft under a local anesthetic, removed from the patients’ thigh and placed on the recipient site of the ulcer (Fig. 1). The treatment may be carried out on an outpatient or during hospitalization (customary duration of 7 days). It allows a fast epithelialization of the wound, reducing the healing time. The grafts ease the pain due to growth factors brought by the cells [7]. Others painkiller techniques used to treat wounds, such as hypnosis or local anesthetic, contribute to saving oral medications, such as morphine, which is known for presenting numerous side effects. From our daily experience, we noticed that patients’ pain was relieved after punch skin grafting. This finding has also been demonstrated in a
Interest of punch skin grafting for the treatment of painful ulcers
Figure 1
331
Punch skin grafting on an ulcer of the left lateral malleolus.
Réalisation d’une greffe cutanée en pastille sur un ulcère de la malléole externe gauche.
Swedish article in 2008 [8]. The objective of our study was to measure the evolution of pain in patients hospitalized for one or more painful ulcers of different etiologies, before and after punch graft, to judge if pain relief existed after having used this method.
its anonymity with only the initials and the date of birth being noted to distinguish between patients. For data analysis, the qualitative variables are expressed as a percentage, and the quantitative variables are expressed as a mean with standard deviation.
Materials and methods Results This was a single-center, non-interventional prospective study, conducted in hospitalized patients within the Vascular Department in Saint-Joseph Hospital over the period of February through April 2015. Patients over the age of 18, hospitalized for the treatment of a wound were included. Inclusion criteria were patients with one or more ulcers of all origins, evolving for more than four weeks and that answered ‘‘yes’’ to the question ‘‘is the ulcer painful?’’ Patients with dementia were excluded. The evaluation of the primary end point was based on the level of permanent pain and pain peaks, before, the day after the punch skin grafting and upon the discharge from the hospital. We used the Numeric Pain Rating Scale (NPRS) and a questionnaire. When speaking about an ‘‘improvement’’ in pain, we used terms of suppressing or reducing (lowering at least one point on the NPRS). The questionnaire was original and the questions were developed for the relevance to the treatment and the pain of leg ulcers. A pilot test of our patient questionnaire was not carried out. Upon patient admission, pain was evaluated by the NPRS. The patient was re-seen after the punch skin grafting and upon discharge, in order to complete the questionnaire. To improve the response rate, the questionnaire was completed with the patient at each stage of the study, without influencing the answers. Clinical data was collected while respecting
During 2014, 1175 patients were hospitalized for the treatment of an ulcer, all etiology, within the vascular department of Paris Saint-Joseph Hospital. During this period, 1016 punch skin grafting were carried out in the department. Forty-one patients were included from February through April 2015 and no patients were excluded. The average age of our population was 73 ± 21 years. Amongst them, 73% (n = 30) were older than 65. The majority of the patients were men [55% (n = 22), compared to 45% (n = 19) women]. The average length of hospitalization was 10 days (from 4 to 23 days). Overweight and obesity are risk factors for ulcerative wounds. In our study, we used the international classification of the WHO 2004 [9] and observed that 56% (n = 23) of patients had a BMI > 25 kg/m2 . Nineteen percent of patients (n = 8) were assigned to class I (30 to 34.9 kg/m2 ) and class 2 (35 to 39.9 kg/m2 ) of obesity and 15% (n = 6) were morbidly obese (BMI > 40 kg/m2 ). A majority of men had a BMI > 25 kg/m2 (13 men versus 10 women), but there was a higher representation of women than men in the morbidly obese category (4 women versus 2 men). In our cohort, 68% of the patients (n = 28) presented a history of one or more punch grafts. The distribution of leg ulcers according to the etiology and the sex of the patient is represented in Table 1.
Table 1 Distribution of leg ulcers according to the etiology and the sex of the patient in our population study. Répartition de chaque type d’ulcère de la population étudiée. Ulcer etiology
n
%
Population study Arterial Venous Mixed Necrotic angiodermatitis Other
Ulcer etiology
n
%
Men 15 15 5 5 2
36 36 12 12 4
Arterial Venous Mixed Necrotic angiodermatitis Other
Ulcer etiology
n
%
5 10 0 3 2
33 67 0 60 100
Women 10 5 5 2 0
67 33 100 40 0
Arterial Venous Mixed Necrotic angiodermatitis Other
332
C. Fourgeaud et al.
Figure 2 A. Evaluation of permanent pain upon discharge, depending on the etiology of the ulcer. B. Evaluation of peak pain upon discharge, depending on the etiology of the ulcer. A. Évaluation de la douleur permanente selon le type d’ulcère à la sortie d’hospitalisation. B. Évaluation des pics de douleur selon le type d’ulcère à la sortie d’hospitalisation.
At baseline, 76% (n = 31) of the patients presented permanent pain on a daily basis. Amongst these patients, on the first day of the punch skin grafting, 77% (n = 24/31) of the patients showed an improvement of their pain (32% reducing, 45% suppressing, 23% stagnation). On the day of discharge, 90% (n = 28/31) of these patients showed an improvement of their pain (48% reducing, 42% de suppressing, 10% stagnation). Upon admission, 100% of the patients presented pain peaks. Amongst these patients, on the first day of the punch skin grafting, 90% (n = 37/41) of the patients showed an improvement of their pain (58% reducing, 32% suppressing, 10% stagnation). On the day of discharge, 95% (n = 39/41) of the patients showed an improvement of their pain (68% reducing, 27% suppressing, 5% stagnation). It should be noted that there was not a rise in the prescription of painkillers and that no adjunctive therapeutics such as hypnosis or Entonox gas were used. Evaluation of permanent pain upon discharge, depending on the etiology of the ulcer, showed that almost all of the patients had an improvement of their permanent pain, with a suppression for more than half necrotic angiodermatitis and venous ulcers. A third of the patients suffered from arterial ulcers and showed no improvement of their pain after a punch skin grafting (Fig. 2A). Evaluation of peak pain upon discharge, depending on each etiologic, showed that two patients presenting an
etiologic ulcer ‘‘other’’ showed a suppression in their peak pains and 60% of patients presenting mixed ulcers saw their pain completely disappear. Two patients represented a stagnation of peak pains, particularly those suffering from necrotic angiodermatitis (20%, n = 1) and arterial (6%, n = 11) (Fig. 2B). Amongst the 41 patients included, more than a third [39% (n = 16)] were taking strong opioid analgesics. The consumption of strong opioid analgesics, according to each type of ulcer is shown on Fig. 3. On the day of discharge, 81% (= 13) of patients that were taking strong opioid analgesics showed a decrease in their in relation to the period prior to the punch skin grafting. This is particularly clear with the arterial ulcers, mixed and ‘‘others’’ where all patients’ consumption decreased.
Debate Our study allowed us to demonstrate that a punch skin grafting enables an improvement of permanent and transitory pain of patients hospitalized for the treatment of painful leg ulcers of all nature. This is a preliminary study whose results are encouraging and deserve to be continued. The communication around chronic ulcerous wounds is important in regards to the price of treatment, the impact on the quality of life of the patients, and the compilation of
Interest of punch skin grafting for the treatment of painful ulcers
Figure 3
333
Consumption of strong opioid analgesics, according to each type of ulcer.
Consommation d’antalgiques de palier III en fonction de chaque type d’ulcère.
epidemiological data. Our study has shown that a punch graft is a valid and simple technique with a painkilling effect. Regarding enrolled patients, the population is a reflection of those described in the literature, apart from certain issues. Indeed, we enrolled a majority of men in our study, but the cohort stays small and the time of enrollment short. Despite the fact that the majority are more than 65 years old, five patients were in the age category of [40—50 years old] which shows that ulcerous diseases can affect younger working patients and have a significant impact on their daily and social lives. The literature suggests that obesity [10] is a risk factor in the development of ulcerous diseases especially that of venous ulcer, that is associated in cases of obesity by a hydrostatic pressure way. This type of ulcer occurs more often in women, which corresponds with our findings. In this study, the proportion of arterial to venous ulcers is the same-which is not the case in the general population. The differences observed could be associated with a bias of enrolment, linked to the specialization of the department. We have shown that the punch grafting is a treatment accepted by the patients because some have benefited from multiple grafts. The punch grafting has a pain relieving effect as early as the first graft and this effect was found with the consecutive grafts. Therefore, there is a benefit to graft patients with painful ulcers but also to repeat the action. Differences between ulcers, particularly concerning pain (prevalence of a type of pain, intensity) have been observed in this study. The strong prevalence and the high level of pain present in necrotic angiodermatitis are demonstrated, particularly by the consumption rate of strong opioid analgesics [8]. Our study has shown a stronger pain relief effect on permanent pain that on peak pains. This suggests that the decrease in painkillers, particularly opioids, needs to be done gradually and cautiously in these patients.
Venous ulcers were typically described as non-painful or slightly painful. However, in our cohort, daily pains were present, regardless of being transitory or permanent. Within this population, the punch grafting was shown to be genuinely effective on permanent pain. Therefore, the effectivity of the graft is that 100% (n = 4) of patients stopped using morphine upon discharge. Finally, we were able to see that arterial ulcers represented 1/3 of ulcers included. This could explain why the population is represented primarily by men whose risk factors such as tobacco, alcohol or dyslipidemia [10,11] could encourage arteriopathy problems and secondly, arterial ulcers. The latter is known to be usually painful [11], which has been observed in our study. We have observed that using the graft on this type of ulcer in comparison to other ulcers of other etiology is less effective. The most likely hypothesis to explain the lower efficiency of punch grafting in this population is that, either they are integrated in the context of chronic critical limb ischemia where there is deep former pain that is difficult to relieve, or because it was a ‘‘graft test’’ where failure is an argument to contemplate a revascularization. We were interested in evaluating the consumption of opioid analgesics because patients with leg ulcers were predominantly older, often polypathlogical and multi medicated. This increases the possibility of side effects and interaction of medications [12] particularly when taking morphine. As a result of the pain relieving effect of the punch grafting, we were able to observe that in more than ¾ of the cases there was a reduction in the consumption of opioids analgesics, more clearly apparent in certain categories of ulcers (venous, or necrotic angiodermatitis). However, this change in requirements must be conducted progressively, on a case by case basis and with caution as certain ulcers (arterial and necrotic angiodermatitis) maintain peak pains despite punch grafting.
334
C. Fourgeaud et al.
Conclusion
References
This preliminary study has enabled us to show that punch grafting allows considerable reduction, or even suppression, of pain caused by leg ulcers. It works just as well on permanent pain as it does on peak pains. Its effectiveness is abundantly clear for venous and mixed ulcers but also for ulcers that are initially very painful such as necrotic angiodermatitis and arterial ulcers. We have noticed that this pain relieving effect could participate in the reduction of consumption of opioid analgesics and consequently decrease their side effects. Nevertheless, this change in requirements must be conducted progressively and with caution. The punch skin grafting is a simple and cost effective treatment that can be performed at the bed of the patient or during a traditional hospitalization such as a day hospital. Its pain relief effect is quick and efficient. Due to its efficacy, from the first graft, renewal is well-accepted by the patient. Pain management is a key aspect in the care of patients suffering with a leg ulcer. It induces a restriction of basic activities, a lack of mobility or even disability, a cause for concern and a loss of income. It can therefore have a major impact on the patients’ day-to-day lives and may lead to social isolation or restriction in family or recreational activities. A punch skin graft enables an improvement in permanent pain and peak pains of leg ulcers, but could it have a final impact on the quality of daily life of the patients? These encouraging results, limited by the small size of this study, call for further investigation, particularly for the collection of longer-term data enabling an evaluation of the quality of life in these patients.
[1] Argumentaire. Recommandation pour la pratique clinique. Prise en charge de l’ulcère de jambe à prédominance veineuse hors pansement; 2006 [18 p.]. [2] Bonnetblanc JM. Ulcères de jambes. Paris: Doin Édition; 1996. p. 2. [3] Rames O, Sebo S, Pécault R, Agamaliyev E, Tuppin P, Rodde Dunet M, et al. Plaies chroniques en France : prévalence, caractéristiques et évolution. Améliorer l’organisation de la prise en charge en sortie d’hospitalisation. J Plaies Cicatrisation (JPC) 2014;14:12—8. [4] Senet P. Ulcères de jambes. Paris: Elsevier Masson; 2002. [5] Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg ulceration in a London population. QJM 2004;97:431—7. [6] Dereure O. Ulcères de jambe. Dermatologie. CHRU de Montpellier. Diapositive no 2. [http://www.med.univ-montp1. fr/Enseignement/Formation Continue/Soirees/FMC 280110 PEC plaies chroniques ulceres jambe.pdf. Consulté le 12/03/2015]. [7] Meaume S, Debure C, Lazareth I, Teot L. L’ulcère de jambe chez la personne âgée. Paris: Edition John Libbey Eurotext; 2002, 110 p. [8] Nordström A, Hansson C. Punch-grafting to enhance healing and to reduce pain in complicated leg and foot ulcers. Acta Derm Venereol 2008;88:389—91. [9] El Khatib K, Danino A, Malka G. Necrotic angiodermatitis: evaluation of an early skin graft treatment. Ann Chir Plast Esthet 2009;54:567—70. [10] Bernard N. L’insuffisance veineuse chronique; 2011 [http:// www.planetesante.ch/Maladies/Insuffisance-veineusechronique. Consulté le 29/04/2015]. [11] CEDEF. Item 137 — ulcère de jambe. Ann Dermatol Venereol 2012;139:A127—34. [12] Filbet M. Prise en charge médicamenteuse de la douleur chez la personne âgée. Centre national de ressources de lutte contre la douleur; 2005 [http://www.cnrd.fr/ Consulté le Prise-en-charge-medicamenteuse-de.html. 02/05/2015].
Disclosure of interest The authors declare that they have no competing interest.
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Interest of punch skin grafting for the treatment of painful ulcers夽 Intérêt de la greffe cutanée en pastille dans la prise en charge d’ulcères algiques
C. Fourgeaud a,∗, G. Mouloise a, U. Michon-Pasturel a, S. Bonhomme a, I. Lazareth a, S. Meaume b, P. Priollet a a
Service de médecine vasculaire, groupe hospitalier Paris — Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France b Service de dermatologie, plaies et cicatrisation, hôpital Rothschild, 5, rue Santerre, 75012 Paris, France Received 27 July 2016; accepted 30 July 2016 Available online 3 September 2016
KEYWORDS Ulcer; Pain; Punch skin grafting
Summary Skin leg ulcers are chronic painful wounds. The treatment of these ulcers is crucial for patients because pain has a significant impact on their daily lives. The analgesic effect of punch skin grafting (PSG) for the treatment of painful ulcers is not well described. The objective of the study is to assess the level of pain in patients with an ulcerated wound and to see if there is an analgesic effect of PSG. Patient and methods. — A single-center, non-interventional study conducted in hospitalized patients with one or several ulcer(s) of any type and which has been painful for more than six weeks. Pain was assessed before, the day after a PSG and then on the way out of hospital by a questionnaire and a numeric pain rating scale. Permanent pain and pain peaks were identified. Results. — Forty-one patients were included (23 men and 18 women) with a mean age of 73 ± 21 years, 36% (n = 15) with arterial ulcers, 36% (n = 15) with venous ulcers, 12% (n = 5) with necrotic angiodermatitis, 12% (n = 5) with mixed ulcers and 4% (n = 2) with ‘‘other ulcers’’ (due to infection and use of hydroxycarbamide). On day 1 of PSG, patients showed an improvement in terms of permanent pain (77%, n = 24/31) and pain peaks (90%, n = 37/41) respectively and 90% (n = 28/31) and 95% (n = 39/41) on the last day at hospital. Reduction in the use of strong opioids was found in 13 patients (81%).
夽 Présentation affichée ayant rec ¸u le prix poster (prix René Rettori), 50e congrès du Collège franc ¸ais de pathologie vasculaire, Paris, mars 2016. ∗ Corresponding author. E-mail address: [email protected] (C. Fourgeaud).
http://dx.doi.org/10.1016/j.jmv.2016.08.002 0398-0499/© 2016 Elsevier Masson SAS. All rights reserved.
330
C. Fourgeaud et al. Conclusion. — Punch skin grafting is a simple and validated treatment, which can reduce or eliminate pain related to ulcers. It has an effect on permanent pain and pain peaks. Its efficiency is particularly demonstrated on venous ulcers and mixed ulcers but also initially painful ulcers such as necrotic angiodermatitis or arterial ulcers. © 2016 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Ulcère ; Douleur ; Greffe cutanée en pastille
Résumé Les ulcères cutanés sont des plaies chroniques douloureuses. Leur prise en charge est capitale pour les patients car la douleur a un impact lourd sur la vie quotidienne. L’effet antalgique de la greffe cutanée en pastilles (GCP) dans le traitement des ulcères algiques est peu décrit. L’objectif de l’étude était d’évaluer la douleur chez les malades ayant une plaie ulcéreuse afin de voir s’il existe un effet antalgique de la GCP. Patient et méthodes. — Il s’agissait d’une étude monocentrique, non interventionnelle réalisée chez des patients hospitalisés pour un ou des ulcère(s) de toute(s) nature(s), algiques, évoluant depuis plus de 4 semaines. La douleur a été évaluée avant, le lendemain d’une GCP puis à la sortie par un questionnaire et une mesure de l’échelle numérique de la douleur. La douleur permanente (DP) et les pics douloureux (PD) ont été distingués. Résultats. — Quarante et un patients ont été inclus (23 hommes et 18 femmes) d’âge moyen 73 ± 21 ans, dont 36 % (n = 15) d’ulcères artériels, 36 % (n = 15) d’ulcères veineux, 12 % (n = 5) d’angiodermites nécrotiques, 12 % (n = 5) souffrant d’ulcères mixtes et 4 % (n = 2) d’ulcères « autres » (dus à hydroxycarbamide et infectieux). À j1 de la GCP, les patients ont exprimé une amélioration des DP et des PD de respectivement 77 % (n = 24/31) et 90 % (n = 37/41) et de 90 % (n = 28/31) et 95 % (n = 39/41) à la sortie. Une réduction dans la consommation d’antalgique de palier III a été retrouvée chez 13 patients (81 %). Conclusion. — La GCP est une thérapeutique validée et simple qui permet de diminuer voire de supprimer, les douleurs des ulcères. Elle agit sur les DP et les PD. Son efficacité est particulièrement démontrée sur les ulcères veineux et mixtes mais aussi sur des ulcères initialement très douloureux comme les angiodermites nécrotiques ou les ulcères artériels. © 2016 Elsevier Masson SAS. Tous droits r´ eserv´ es.
Introduction We define a leg ulcer as a chronic wound, which has evolved for 4 to 6 weeks, situated between the leg and the foot, without any spontaneous healing. In most cases, it is due to a complication of a vascular disease. The most common types are venous (70 to 90%), arterial (5—15%) or microcirculatory. The census of leg ulcers is not simple because a lot of them are treated out the hospital and are partly due to selfmedication. This makes the epidemiological and economic data inaccurate and limited. Sixty thousand to five hundred thousand people will be affected [3], patients above the age of 65 seem to be affected the most [4]. The sex ratio is 3 women to 1 man [2]. A study conducted on the prevalence of leg ulcers within the population of London [5] has enabled to enhance the epidemiological data of leg ulcers and has shown the sharp rise of prevalence of leg ulcers with the increase of, being more frequent in women. Leg ulcers are an expensive condition because their healing time is long and there is a high risk of recurrence. The treatment of chronic ulcers is essential as it is a major public health problem and a growing socioeconomic burden [6]. In three quarters of the cases, leg ulcers are painful chronic sores. They presents themselves through a short lived pain, also known as pain peaks that can last from a few seconds to hours, possibly accompanied by a permanent background pain. The cause of the pain is multifactorial, which could be accentuated by an underlying neuropathy,
but also by dressing changes, cleaning and debridement of the wound, or a possible infection. Concerning the pain treatment of leg ulcers, there are national and international recommendations. The French recommendations are based upon professional agreement. Depending on the etiology of the ulcer, the pain can be more or less intense. Arterial ulcers as necrotic angiodermatitis are considered more painful than venous ulcers. However, venous ulcers can become extremely painful, as it has been shown through studies of life quality [1]. Pain management is a capital aspect in the treatment of patients as it can have a major impact on their day-to-day life. The treatment of a leg ulcer calls for different techniques, associated with etiological treatment, such as punch skin grafting (PSG). It is a simple method that obtains less than 0.5 cm in diameter of skin graft under a local anesthetic, removed from the patients’ thigh and placed on the recipient site of the ulcer (Fig. 1). The treatment may be carried out on an outpatient or during hospitalization (customary duration of 7 days). It allows a fast epithelialization of the wound, reducing the healing time. The grafts ease the pain due to growth factors brought by the cells [7]. Others painkiller techniques used to treat wounds, such as hypnosis or local anesthetic, contribute to saving oral medications, such as morphine, which is known for presenting numerous side effects. From our daily experience, we noticed that patients’ pain was relieved after punch skin grafting. This finding has also been demonstrated in a
Interest of punch skin grafting for the treatment of painful ulcers
Figure 1
331
Punch skin grafting on an ulcer of the left lateral malleolus.
Réalisation d’une greffe cutanée en pastille sur un ulcère de la malléole externe gauche.
Swedish article in 2008 [8]. The objective of our study was to measure the evolution of pain in patients hospitalized for one or more painful ulcers of different etiologies, before and after punch graft, to judge if pain relief existed after having used this method.
its anonymity with only the initials and the date of birth being noted to distinguish between patients. For data analysis, the qualitative variables are expressed as a percentage, and the quantitative variables are expressed as a mean with standard deviation.
Materials and methods Results This was a single-center, non-interventional prospective study, conducted in hospitalized patients within the Vascular Department in Saint-Joseph Hospital over the period of February through April 2015. Patients over the age of 18, hospitalized for the treatment of a wound were included. Inclusion criteria were patients with one or more ulcers of all origins, evolving for more than four weeks and that answered ‘‘yes’’ to the question ‘‘is the ulcer painful?’’ Patients with dementia were excluded. The evaluation of the primary end point was based on the level of permanent pain and pain peaks, before, the day after the punch skin grafting and upon the discharge from the hospital. We used the Numeric Pain Rating Scale (NPRS) and a questionnaire. When speaking about an ‘‘improvement’’ in pain, we used terms of suppressing or reducing (lowering at least one point on the NPRS). The questionnaire was original and the questions were developed for the relevance to the treatment and the pain of leg ulcers. A pilot test of our patient questionnaire was not carried out. Upon patient admission, pain was evaluated by the NPRS. The patient was re-seen after the punch skin grafting and upon discharge, in order to complete the questionnaire. To improve the response rate, the questionnaire was completed with the patient at each stage of the study, without influencing the answers. Clinical data was collected while respecting
During 2014, 1175 patients were hospitalized for the treatment of an ulcer, all etiology, within the vascular department of Paris Saint-Joseph Hospital. During this period, 1016 punch skin grafting were carried out in the department. Forty-one patients were included from February through April 2015 and no patients were excluded. The average age of our population was 73 ± 21 years. Amongst them, 73% (n = 30) were older than 65. The majority of the patients were men [55% (n = 22), compared to 45% (n = 19) women]. The average length of hospitalization was 10 days (from 4 to 23 days). Overweight and obesity are risk factors for ulcerative wounds. In our study, we used the international classification of the WHO 2004 [9] and observed that 56% (n = 23) of patients had a BMI > 25 kg/m2 . Nineteen percent of patients (n = 8) were assigned to class I (30 to 34.9 kg/m2 ) and class 2 (35 to 39.9 kg/m2 ) of obesity and 15% (n = 6) were morbidly obese (BMI > 40 kg/m2 ). A majority of men had a BMI > 25 kg/m2 (13 men versus 10 women), but there was a higher representation of women than men in the morbidly obese category (4 women versus 2 men). In our cohort, 68% of the patients (n = 28) presented a history of one or more punch grafts. The distribution of leg ulcers according to the etiology and the sex of the patient is represented in Table 1.
Table 1 Distribution of leg ulcers according to the etiology and the sex of the patient in our population study. Répartition de chaque type d’ulcère de la population étudiée. Ulcer etiology
n
%
Population study Arterial Venous Mixed Necrotic angiodermatitis Other
Ulcer etiology
n
%
Men 15 15 5 5 2
36 36 12 12 4
Arterial Venous Mixed Necrotic angiodermatitis Other
Ulcer etiology
n
%
5 10 0 3 2
33 67 0 60 100
Women 10 5 5 2 0
67 33 100 40 0
Arterial Venous Mixed Necrotic angiodermatitis Other
332
C. Fourgeaud et al.
Figure 2 A. Evaluation of permanent pain upon discharge, depending on the etiology of the ulcer. B. Evaluation of peak pain upon discharge, depending on the etiology of the ulcer. A. Évaluation de la douleur permanente selon le type d’ulcère à la sortie d’hospitalisation. B. Évaluation des pics de douleur selon le type d’ulcère à la sortie d’hospitalisation.
At baseline, 76% (n = 31) of the patients presented permanent pain on a daily basis. Amongst these patients, on the first day of the punch skin grafting, 77% (n = 24/31) of the patients showed an improvement of their pain (32% reducing, 45% suppressing, 23% stagnation). On the day of discharge, 90% (n = 28/31) of these patients showed an improvement of their pain (48% reducing, 42% de suppressing, 10% stagnation). Upon admission, 100% of the patients presented pain peaks. Amongst these patients, on the first day of the punch skin grafting, 90% (n = 37/41) of the patients showed an improvement of their pain (58% reducing, 32% suppressing, 10% stagnation). On the day of discharge, 95% (n = 39/41) of the patients showed an improvement of their pain (68% reducing, 27% suppressing, 5% stagnation). It should be noted that there was not a rise in the prescription of painkillers and that no adjunctive therapeutics such as hypnosis or Entonox gas were used. Evaluation of permanent pain upon discharge, depending on the etiology of the ulcer, showed that almost all of the patients had an improvement of their permanent pain, with a suppression for more than half necrotic angiodermatitis and venous ulcers. A third of the patients suffered from arterial ulcers and showed no improvement of their pain after a punch skin grafting (Fig. 2A). Evaluation of peak pain upon discharge, depending on each etiologic, showed that two patients presenting an
etiologic ulcer ‘‘other’’ showed a suppression in their peak pains and 60% of patients presenting mixed ulcers saw their pain completely disappear. Two patients represented a stagnation of peak pains, particularly those suffering from necrotic angiodermatitis (20%, n = 1) and arterial (6%, n = 11) (Fig. 2B). Amongst the 41 patients included, more than a third [39% (n = 16)] were taking strong opioid analgesics. The consumption of strong opioid analgesics, according to each type of ulcer is shown on Fig. 3. On the day of discharge, 81% (= 13) of patients that were taking strong opioid analgesics showed a decrease in their in relation to the period prior to the punch skin grafting. This is particularly clear with the arterial ulcers, mixed and ‘‘others’’ where all patients’ consumption decreased.
Debate Our study allowed us to demonstrate that a punch skin grafting enables an improvement of permanent and transitory pain of patients hospitalized for the treatment of painful leg ulcers of all nature. This is a preliminary study whose results are encouraging and deserve to be continued. The communication around chronic ulcerous wounds is important in regards to the price of treatment, the impact on the quality of life of the patients, and the compilation of
Interest of punch skin grafting for the treatment of painful ulcers
Figure 3
333
Consumption of strong opioid analgesics, according to each type of ulcer.
Consommation d’antalgiques de palier III en fonction de chaque type d’ulcère.
epidemiological data. Our study has shown that a punch graft is a valid and simple technique with a painkilling effect. Regarding enrolled patients, the population is a reflection of those described in the literature, apart from certain issues. Indeed, we enrolled a majority of men in our study, but the cohort stays small and the time of enrollment short. Despite the fact that the majority are more than 65 years old, five patients were in the age category of [40—50 years old] which shows that ulcerous diseases can affect younger working patients and have a significant impact on their daily and social lives. The literature suggests that obesity [10] is a risk factor in the development of ulcerous diseases especially that of venous ulcer, that is associated in cases of obesity by a hydrostatic pressure way. This type of ulcer occurs more often in women, which corresponds with our findings. In this study, the proportion of arterial to venous ulcers is the same-which is not the case in the general population. The differences observed could be associated with a bias of enrolment, linked to the specialization of the department. We have shown that the punch grafting is a treatment accepted by the patients because some have benefited from multiple grafts. The punch grafting has a pain relieving effect as early as the first graft and this effect was found with the consecutive grafts. Therefore, there is a benefit to graft patients with painful ulcers but also to repeat the action. Differences between ulcers, particularly concerning pain (prevalence of a type of pain, intensity) have been observed in this study. The strong prevalence and the high level of pain present in necrotic angiodermatitis are demonstrated, particularly by the consumption rate of strong opioid analgesics [8]. Our study has shown a stronger pain relief effect on permanent pain that on peak pains. This suggests that the decrease in painkillers, particularly opioids, needs to be done gradually and cautiously in these patients.
Venous ulcers were typically described as non-painful or slightly painful. However, in our cohort, daily pains were present, regardless of being transitory or permanent. Within this population, the punch grafting was shown to be genuinely effective on permanent pain. Therefore, the effectivity of the graft is that 100% (n = 4) of patients stopped using morphine upon discharge. Finally, we were able to see that arterial ulcers represented 1/3 of ulcers included. This could explain why the population is represented primarily by men whose risk factors such as tobacco, alcohol or dyslipidemia [10,11] could encourage arteriopathy problems and secondly, arterial ulcers. The latter is known to be usually painful [11], which has been observed in our study. We have observed that using the graft on this type of ulcer in comparison to other ulcers of other etiology is less effective. The most likely hypothesis to explain the lower efficiency of punch grafting in this population is that, either they are integrated in the context of chronic critical limb ischemia where there is deep former pain that is difficult to relieve, or because it was a ‘‘graft test’’ where failure is an argument to contemplate a revascularization. We were interested in evaluating the consumption of opioid analgesics because patients with leg ulcers were predominantly older, often polypathlogical and multi medicated. This increases the possibility of side effects and interaction of medications [12] particularly when taking morphine. As a result of the pain relieving effect of the punch grafting, we were able to observe that in more than ¾ of the cases there was a reduction in the consumption of opioids analgesics, more clearly apparent in certain categories of ulcers (venous, or necrotic angiodermatitis). However, this change in requirements must be conducted progressively, on a case by case basis and with caution as certain ulcers (arterial and necrotic angiodermatitis) maintain peak pains despite punch grafting.
334
C. Fourgeaud et al.
Conclusion
References
This preliminary study has enabled us to show that punch grafting allows considerable reduction, or even suppression, of pain caused by leg ulcers. It works just as well on permanent pain as it does on peak pains. Its effectiveness is abundantly clear for venous and mixed ulcers but also for ulcers that are initially very painful such as necrotic angiodermatitis and arterial ulcers. We have noticed that this pain relieving effect could participate in the reduction of consumption of opioid analgesics and consequently decrease their side effects. Nevertheless, this change in requirements must be conducted progressively and with caution. The punch skin grafting is a simple and cost effective treatment that can be performed at the bed of the patient or during a traditional hospitalization such as a day hospital. Its pain relief effect is quick and efficient. Due to its efficacy, from the first graft, renewal is well-accepted by the patient. Pain management is a key aspect in the care of patients suffering with a leg ulcer. It induces a restriction of basic activities, a lack of mobility or even disability, a cause for concern and a loss of income. It can therefore have a major impact on the patients’ day-to-day lives and may lead to social isolation or restriction in family or recreational activities. A punch skin graft enables an improvement in permanent pain and peak pains of leg ulcers, but could it have a final impact on the quality of daily life of the patients? These encouraging results, limited by the small size of this study, call for further investigation, particularly for the collection of longer-term data enabling an evaluation of the quality of life in these patients.
[1] Argumentaire. Recommandation pour la pratique clinique. Prise en charge de l’ulcère de jambe à prédominance veineuse hors pansement; 2006 [18 p.]. [2] Bonnetblanc JM. Ulcères de jambes. Paris: Doin Édition; 1996. p. 2. [3] Rames O, Sebo S, Pécault R, Agamaliyev E, Tuppin P, Rodde Dunet M, et al. Plaies chroniques en France : prévalence, caractéristiques et évolution. Améliorer l’organisation de la prise en charge en sortie d’hospitalisation. J Plaies Cicatrisation (JPC) 2014;14:12—8. [4] Senet P. Ulcères de jambes. Paris: Elsevier Masson; 2002. [5] Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg ulceration in a London population. QJM 2004;97:431—7. [6] Dereure O. Ulcères de jambe. Dermatologie. CHRU de Montpellier. Diapositive no 2. [http://www.med.univ-montp1. fr/Enseignement/Formation Continue/Soirees/FMC 280110 PEC plaies chroniques ulceres jambe.pdf. Consulté le 12/03/2015]. [7] Meaume S, Debure C, Lazareth I, Teot L. L’ulcère de jambe chez la personne âgée. Paris: Edition John Libbey Eurotext; 2002, 110 p. [8] Nordström A, Hansson C. Punch-grafting to enhance healing and to reduce pain in complicated leg and foot ulcers. Acta Derm Venereol 2008;88:389—91. [9] El Khatib K, Danino A, Malka G. Necrotic angiodermatitis: evaluation of an early skin graft treatment. Ann Chir Plast Esthet 2009;54:567—70. [10] Bernard N. L’insuffisance veineuse chronique; 2011 [http:// www.planetesante.ch/Maladies/Insuffisance-veineusechronique. Consulté le 29/04/2015]. [11] CEDEF. Item 137 — ulcère de jambe. Ann Dermatol Venereol 2012;139:A127—34. [12] Filbet M. Prise en charge médicamenteuse de la douleur chez la personne âgée. Centre national de ressources de lutte contre la douleur; 2005 [http://www.cnrd.fr/ Consulté le Prise-en-charge-medicamenteuse-de.html. 02/05/2015].
Disclosure of interest The authors declare that they have no competing interest.