Review of local wound management for scleroderma-associated digital ulcers

Abstract

REVIEW population is a potentially heterogeneous population and thus, standardizing wound care protocols is crucial. Furthermore, it is important to standardize DU outcome measures, for example, assessments of healing and development of new lesions, during the design phase of DU clinical trials. In general, there is a paucity of evidence on the wound care for managing SSc patients. The purpose of this manuscript is to review the current recommendations for local wound management in patients with ulcerations, which we believe to be applicable to digital ulcers. The overarching goal is to develop recommendations for local wound care for SSc-associated DUs that might be a useful starting point for future clinical trial design. Role of tissue perfusion in digital ulcer healing The importance of local wound perfusion in both SScrelated DU development and healing has been demonstrated by flow-mediated dilatation, laser Doppler imaging (LDI) and thermography (12-14). An increase in DU perfusion correlates with healing, and LDI has successfully been implemented as an outcome measure in a clinical trial (15). Similarly, a study investigating power Doppler ultrasonography found that ulnar artery occlusion was a predictor of new or recurrent DUs in patients with SSc (16). Thus, documentation of adequate perfusion by noninvasive measures of blood flow is an important initial step for DU evaluation and may be used both for assessment of severity of vasculopathy as well as likely responsiveness to vasoactive treatments (17).

Raynaud phenomenon and digital ulcers in systemic sclerosis

“…97,98 Furthermore, meticulous wound care is mandatory for all ulcers to prevent infection and to minimise further tissue damage/loss. 99 The ulcer wound bed should be closely examined for signs of inflammation/infection, hyperproliferation around the wound edges, evidence of exposure of the deeper structures (e.g. bone and tendon) and hydration status.…”

Digital ulcers: should debridement be a standard of care in systemic sclerosis?

“…Furthermore, the lack of a standardised wound care protocol for SSc-DUs has important potential implications for the study design of randomised controlled trials of drug therapies for ulcers because differences in wound care could significantly influence DU healing. 35 The acronym 'TIME' was developed by wound healing experts as a framework to help identify the key role and components of optimal wound bed preparation. 36 This acronym relates to tissue management, infection and inflammation, moisture control, and advancement of the wound edge/epidermal advancement.…”

<p>Management of digital ulcers in systemic sclerosis</p>

“…In selected cases of DUs with thick necrosis, the application of collagenase-based ointments may promote the removal of necrotic tissue in ischemic DUs. 66 Recently, the use of ultrasonic-assisted wound debridement has been proposed for SSc DUs. This procedure uses low-frequency ultrasound waves, is considered less traumatic and painful thanstandard debridement, and may allow more effective removal of nonviable tissue from the lesion.…”

“…Moreover, the efficacy of these solutions in SSc DUs is still under review. 66 The moisture balance is crucial in the management of wounds, and in SSc patients' DUs may improve wound healing, promoting granulation-tissue formation and managing exudate, preventing maceration of the surrounding skin. To our knowledge, no advanced dressings have been investigated yet for the management of DUs in SSc patients, and thus the general principles for wound management may be applied.…”

“…72 Although no literature data are available for the management of SSc DUs, topical hydrocolloid dressings have been suggested as the treatment of choice. 4,66 In our experience, the management of moisture imbalance obtainable with these medications is not always satisfying, and due to the high risk of infections in SSc DUs, the use of dressings with antimicrobial activity should be preferable. In particular, silver-containing dressings may help in controlling local infections, reducing the need for systemic and topical antibiotics.…”