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Bandini G, Alunno A, Alcacer-Pitarch B, Ruaro B, Galetti I, El-Aoufy K, Pinheiro F, Campanaro G, Jade J, Di Donato S, Muir L, Moggi Pignone A, Bellando Randone S, Del Galdo F, McMahan ZH, Matucci-Cerinic M, Hughes M. Patients' unmet needs and treatment preferences concerning digital ulcers in systemic sclerosis. Rheumatology (Oxford) 2024:keae130. [PMID: 38430476 DOI: 10.1093/rheumatology/keae130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/21/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION Digital ulcers (DUs) significantly impact on quality of life and function in patients with systemic sclerosis (SSc). The aim of our survey was to explore patients' perspectives and their unmet needs concerning SSc-DUs. MATERIALS SSc patients were invited through international patient associations and social media to participate in an online survey. RESULTS 358 responses were obtained from 34 countries: US (65.6%), UK (11.5%) and Canada (4.5%). Recurrent DUs are common: >10 DUs (46.1%), 5-10 DUs (21.5%), 1-5 DUs (28.5%), 1 DU (3.9%). Fingertip DUs were most frequent (84.9%), followed by those overlying the interphalangeal joints (50.8%). The impact of DUs in patients is broad, from broad-ranging emotional impacts to impact on activities of daily living, and personal relationships. Half (51.7%) of respondents reported that they received wound/ulcer care, most often provided by non-specialist wound care clinics (63.8%). There was significant variation in local (wound) DU care, in particular the use of debridement and pain management. DU-related education was only provided to one-third of patients. One-quarter (24.6%) were 'very satisfied' or 'satisfied' that the provided DU treatment(s) relieved their DU symptoms. Pain, limited hand function, and ulcer duration/chronicity were the main reasons for patients to consider changing DU treatment. CONCLUSIONS Our data show that there is a large variation in DU treatment between countries. Patient access to specialist wound-care services is limited and only a small proportion of patients had their DU needs met. Moreover, patient education is often neglected. Evidence-based treatment pathways are urgently needed for DU management.
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Affiliation(s)
- Giulia Bandini
- Department of Experimental and Clinical Medicine, Division of Internal Medicine, University of Florence, Italy
| | - Alessia Alunno
- University of L'Aquila, Department of Clinical Medicine, Life Health and Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | | | - Barbara Ruaro
- Pulmonology Unit, University of Trieste, Department of Medical Surgical and Health Sciences, Hospital of Cattinara, Trieste, Italy
| | - Ilaria Galetti
- FESCA (Federation of European Scleroderma Associations) Belgium, & GILS (Gruppo Italiano, Lotta alla Sclerodermia), Italy
| | - Khadija El-Aoufy
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Filipe Pinheiro
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Giulia Campanaro
- Department of Experimental and Clinical Medicine, Division of Internal Medicine, University of Florence, Italy
| | - Judith Jade
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stefano Di Donato
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Lindsay Muir
- Department of Hand Surgery, Salford Royal, Salford, UK
| | - Alberto Moggi Pignone
- Department of Experimental and Clinical Medicine, Division of Internal Medicine, University of Florence, Italy
| | - Silvia Bellando Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Italy
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Zsuzsanna H McMahan
- Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, USA
| | - Marco Matucci-Cerinic
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS San Raffaele Hospital, Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), Milan, Italy
| | - Michael Hughes
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Djuric CM, Chavez B. Understanding the most commonly billed diagnoses in the outpatient wound clinic. Nurse Pract 2021; 46:10-13. [PMID: 34554954 DOI: 10.1097/01.npr.0000790524.95810.b8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Janowska A, Papa G, Romanelli M, Davini G, Oranges T, Stocco C, Arnez ZM, Dini V. 5% Lidocaine Hydrochloride Cream for Wound Pain Relief: A Multicentre Observational Study. J INVEST SURG 2020; 35:49-52. [PMID: 32969736 DOI: 10.1080/08941939.2020.1821134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Lidocaine hydrochloride is frequently used for management of painful wounds. This prospective, multicentre study examined the effects of 5% lidocaine cream on wound pain relief. MATERIAL AND METHODS The study included 78 patients with painful wounds treated with 5% Lidocaine cream for two weeks in two Italian Hospitals. Patients' perception of pain was recorded by, using the 5-point Visual Rate Scale and the 11-point Numerical Pain Rating Scale. All medications and adverse events were evaluated in a daily diary. The primary outcome of the study was establishing the wound pain relief based on the results of 5-VRS and pain intensity based on the 11-NPRS testing from baseline to the end of treatment. Clinical aspects and adverse events were also collected. RESULTS Seventy-eight patients had a median age of 67.5 years (range 18-96 years). 62.8% were women. The wounds included traumatic wounds (n = 39), venous ulcers (n = 25), post-surgical wounds (n = 6) pyoderma gangrenosum (n = 6), vasculitis (n = 1) and pressure ulcer (n = 1). The intensity of pain significantly decreased from the baseline level established at the beginning of treatment (mean score 6.7 - 1.90) - to the level at end of treatment (3.0 - 2.23-; p < 0.0001). 9 patients prematurely stopped the treatment for healing (n = 4), wound improvement (n = 2) and adverse events related to the treatment. (n = 3). 13 patients presented a total of 25 adverse events, 4 of them were related to the treatment. CONCLUSION The treatment of painful wounds with 5% Lidocaine Cream for 14 days resulted in reduced pain intensity, and showed high safety and tolerability.
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Affiliation(s)
- Agata Janowska
- Department of Dermatology, University of Pisa, Pisa, Italy
| | - Giovanni Papa
- Department of, Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, Trieste, Italy
| | | | - Giulia Davini
- Department of Dermatology, University of Pisa, Pisa, Italy
| | - Teresa Oranges
- Department of Dermatology, University of Pisa, Pisa, Italy.,Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Chiara Stocco
- Department of, Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, Trieste, Italy
| | - Zoran Marji Arnez
- Department of, Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, Trieste, Italy
| | - Valentina Dini
- Department of Dermatology, University of Pisa, Pisa, Italy
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Hughes M, Alcacer-Pitarch B, Allanore Y, Baron M, Boin F, Bruni C, Chung L, Del Galdo F, Denton CP, Matucci-Cerinic M. Digital ulcers: should debridement be a standard of care in systemic sclerosis? THE LANCET. RHEUMATOLOGY 2020; 2:e302-e307. [PMID: 38273475 DOI: 10.1016/s2665-9913(19)30164-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 01/02/2023]
Abstract
Digital ulcers are a serious, recurrent complication in patients with systemic sclerosis. They are often slow to heal and exquisitely painful. Local wound care, such as debridement of the wound bed, is an essential component in the management of digital ulcers in systemic sclerosis. However, digital ulcer debridement is not a standard of care, and there is substantial international variation in the use of this approach. In this Viewpoint, we discuss the assessment of the wound bed and different methods of debridement using the model of tissue management, infection and inflammation, moisture control, and wound edge or epidermal advancement, known as TIME. We highlight the challenges in standard practice and the need for research into local wound care for this type of ulceration, before suggesting a potential roadmap to develop a standardised approach to support ulcer debridement in systemic sclerosis. Debridement might be the missing component in optimising the management of digital ulcers and we propose that the approach should be rigorously investigated as a standard of care in this common complication of systemic sclerosis.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Begonya Alcacer-Pitarch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Murray Baron
- Division of Rheumatology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Christopher P Denton
- Department of Rheumatology, Royal Free Hospital, University College London, London, UK
| | - Marco Matucci-Cerinic
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Digital ulcer debridement in systemic sclerosis: a systematic literature review. Clin Rheumatol 2020; 39:805-811. [PMID: 31955323 DOI: 10.1007/s10067-019-04924-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/15/2019] [Accepted: 12/29/2019] [Indexed: 10/25/2022]
Abstract
Optimal wound care is an essential component in the management of systemic sclerosis (SSc) digital ulcers (DUs). DU debridement has been suggested to reduce ulcer-related pain and improve tissue healing. However, only a minority of rheumatologists perform DU debridement, and there is no standard of care/protocol. Our objectives were to (i) evaluate the current evidence for the use of debridement in DU management and (ii) assess whether there are any specific protocols. A systematic literature review was performed searching the PubMed database (between 01/01/1950-01/03/2019) in accordance with PRISMA guidelines. Two independent reviewers screened and extracted the abstracts/full manuscripts. Articles in English, which focussed on SSc-DU debridement/curettage, were included. Exclusion criteria included studies of juvenile/paediatric patients and basic/non-clinical research. Our search identified 1497 studies of which 4 studies were included in our final analysis. Three studies used scalpel debridement, and one study used this in combination with autolytic debridement. No studies specifically reported the effect on DU healing from debridement. Autolytic debridement with hyaluronate-based products was associated with significant ulcer pain and inflammation. Local anaesthetic significantly reduces pain both during and after debridement. Combined local and oral analgesia is often required for more severe or infected DUs. DU (scalpel and autolytic) debridement is being used by some clinicians in rheumatology; however, there are no standardised protocols. To improve wound care for SSc-DUs, future research should focus on developing a standardised protocol for SSc-DU debridement, with a view to facilitate randomised controlled trials to demonstrate safety and treatment efficacy.Key Points• Optimal wound care is an essential component in the management of systemic sclerosis-digital ulcers.• 'Sharp' debridement uses a scalpel, whereas 'autolytic' debridement uses dressings to optimize endogenous tissue lysis.• There is significant variation in the use of digital ulcer debridement in systemic sclerosis.• A standardized protocol and randomized controlled trials are needed to demonstrate debridement the safety and efficacy of digital ulcer debridement in systemic sclerosis.
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Review of local wound management for scleroderma-associated digital ulcers. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 3:66-70. [PMID: 32099902 DOI: 10.5301/jsrd.5000268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Digital ulcers (DU) are a common clinical problem in systemic sclerosis (SSc); however, there is no standardization of local wound care protocols for management of these lesions. There is a well-recognized need to develop and standardize non-pharmacological management of DU in patients with SSc, and to adopt these protocols in future clinical trials that focus on DU healing. The purpose of this review is to outline the types of DU that occur in SSc, and provide an update on the principles of wound management for these lesions based on the current literature and expert opinion.
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Defining Skin Ulcers in Systemic Sclerosis: Systematic Literature Review and Proposed World Scleroderma Foundation (WSF) definition. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:115-120. [PMID: 30569018 DOI: 10.5301/jsrd.5000236] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose There is a lack of a valid, definition for skin ulcers in SSc to be used in clinical trials. Our aim was to develop a consensus definition for SSc-skin ulcers based on the results of a systematic literature review (SLR) for skin ulcer definitions and expert opinion; and to evaluate its face validity, reliability and feasibility. Methods SLR for skin ulcer definitions was conducted using PubMed, Web of Science, and Cochrane library for articles published from inception to January 1st, 2016. SSc experts were to discuss the definitions' categories and vote for the relevant terms. Reliability of the definition were tested in a second expert meeting, seven SSc experts evaluated 7 SSc pts with skin lesions twice. Face validity and feasibility evaluated by sending out case report forms(CRFs) to 4 SSc experts, they were asked to use the definition in 5 pts each. Results A total of 3464 abstracts and titles were screened, and 446 articles were fully evaluated. Of these, 66 met eligibility criteria and skin ulcer definitions were extracted. SSc experts discussed, refined and voted on the consensus definition using nominal process. Kappa for inter-, intra-rater rater agreement was 0.51, 0.90 respectively. The mean time to decide if the lesion is an ulcer was 7.4 sec. All investigators endorsed the face validity of the new definition in the CRFs. Conclusion Using a SLR and a nominal technique, we developed a preliminary consensus-based definition of SSc-skin ulcers. Face validity, feasibility and reliability were demonstrated for the developed definition.
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