I
decided to speak about leg ulcers this week because of my very good friend
Rachel. Rachel has had leg ulcers for a couple of year now and finally today,
she got the opportunity to have a grafting procedure done on the leg ulcers.
What are Leg Ulcers?
Like
many other Sickle Cell warriors, leg ulcers are a big pain, physically and
visually. Leg ulcers are acute or chronic wounds that occur on the lower extremities
around the ankle, in areas with less subcutaneous fat, thin skin, and with
decreased blood flow. They are open sores marked by a complete loss of the top
layer of the skin (epidermis); which does not tend to heal quickly. Leg ulcers
are a chronic complication for people living with sickle cell disease. Ulcers
tend to be difficult to treat successfully, healing slowly over months or
years. They can severely disrupt quality of life, increase disability, require
extended absence from the workplace, and place a high burden of care on
healthcare systems.
They
may be classified as acute or chronic according to their duration, however,
there is no consensus as to a specific length of time to define chronicity. An
acute ulcer usually should heal in less than a month. Among chronic ulcers, a
duration of six months seems to define the most recalcitrant ulcers. It is not
uncommon for ulcers to last many years, often closing and re-opening repeatedly.
Leg ulcers are painful and often disabling complications of SCD. They tend to
be indolent, intractable and heal slowly over months to years. The pain may be
severe, excruciating, penetrating, sharp and stinging in nature. In most
patients, opioid analgesics are needed to achieve some pain relief.
In
the case of Rachel, her leg ulcers prevented her from doing a number of things
including walking and/or standing for long hours. Aside from the fact that both
of her legs were in bangages, the severe pain during the night was one of the
many things she endured. The physiological manifestations of leg ulcers
prevents many warriors from living normal pain free lives. I can only imagine
what having a persistent wound does to someone's psyche.
Causes
of Leg Ulcers
Most of the causes of leg ulcers in Sickle Cell Warriors especially is the lack of blood flow to the skin in the lower extremeties of the legs. Another huge fact is the problem of low immunity which prevents wounds to heal properly and timely. Other major causes are listed below.
- Obstruction
by dense sickled red cells
- Venous
incompetence (impaired blood flow)
- Bacterial
infections, trauma and inflammation
- Abnormal
autonomic control with excessive vasoconstriction when in the dependent
position
- Localized
blood clots
- Anemia
with decrease in oxygen carrying capacity
- Decreased
nitric oxide bioavailability leading to impaired endothelial function
- Arteriovenous
shunting that deprives the skin of oxygen
- Lower
musculoskeletal exercise tolerance and oxygen consumption due to the lowered
oxygen supply to the exercising muscles in SCD patients
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#10003 Sickle Cell Symptom #3 - Leg Ulcers
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Management
of Leg Ulcers
Management
can only be advised depending on how severe the leg ulcer is. This is usually
determined by the size, depth and duration of the particular leg ulcer
manifestation. The management of chronic leg ulcers in sickle cell patients can
be difficult and protracted. It often results in significant pain, limits
physical activity and potential employment, and reduces the quality of life for
these patients.
Coming
back to Rachel, her leg ulcer was chronic. It was deep, relatively large and
had persisted for a couple of years. In her case, the option given by the
doctors was to administer a skin graft on the wound to help in the healing
process. This is because it is a much better option for her since the wound has
not been able to heal on itself. However, with the help of a skin graft,
healing and closing up of the wound is possible.
With
regards to pharmaceutical intervention, studies show that arginine butyrate,
RGD peptide, L-cartinine report change in ulcer size However, RGD peptide
significantly reduces ulcer size and has reported incidences of complete wound
closure. Local treatment with either surgical or sharp debridement, hydrogels,
enzymatic digestion, or topical gm-CSF have been recommended but responses are
slow and often incomplete.
- Systemic therapies with zinc replacement that help with wound healing and use of antibiotics to prevent and control bacterial growth and infection of the ulcer.
- Regular cleaning and dressing of the wound is highly recommended. This helps greatly to improve circulation and treat any rising infections on the wound. Weekly cleaning to remove debris and dressing with clean bandages help to heal the wound quickly.
- Transfusion therapy has
been used to improve oxygen carrying capacity as well as to decrease levels of
hemoglobin S. It has also been used in preparation for surgery, and in the
treatment of non-healing leg ulcers. However, it is associated with significant
alloimmunization and iron overload which requires aggressive chelation therapy.
- Bed rest and elevation to reduce edema (accumulation of fluid) could be
beneficial in the treatment of lower extremity wounds. This helps prevent collection of fluid and bring it back to the heart. Elevation also reduces pressure to the blood vessels on the extremities and reduces swelling of the leg around the affected area.
- The use of compression
for sickle cell ulcers with reference to the use of either Unna's boot or
elastic compression bandages and absorbent dressings. This helps keep the blood pressure regulated but not stopped.
- And then of course the
use of skin grafts to influence wound healing and wound closure.
The
use of aggressive medical, wound, and physical therapeutic management is
recommended for the successful healing of a chronic wound and leg ulceration in
patients with SCD.
Prevention of Leg Ulcer
Since it is clear that leg ulcers are majorly caused by poor circulation and immunity, we can easily be able o prevent their occurrence especially among Sickle Cell Warriors.
Regular light exercise that is comfortable for the warrior is recommended. This may include but not limited to, walking, yoga, swimming or anything that promotes movement and circulation of oxygenated blood within the body.
Increasing intake of nutritional foods especially those that promote body detox and promotes wound healing such as green vegetables and fruits. These foods help build one's immune system to keep off bacteria and infection, improve wound healing and increases overall body energy.
Vitamin C helps in the healing process and increase in blood circulation. Vitamins E, B complex, Zinc and amino acids also help in healing and circulation. For blood clotting, Vitamin K is a huge factor. Being vigilant in your diet will help quicken the healing process. Dark green vegetables and fruits have a dense wealth of nutrition that help oxygenate blood among other things. Do stay away from sweets, refined sugars/carbs and animal protein that reduce and even stop the healing process.
As
far as Rachel is concerned, we wish her a full recovery post-surgery and
healing that will give her back a full life that she deserves.
All
the best Rachel.
Love
Life!
Lea
Ref
Pathophysiology and Multidisciplinary Management of Leg Wounds in Sickle Cell Disease: A Case Discussion and Literature Review
Leg Ulcers in Sickle Cell Disease
Treatments for leg ulcers in people with sickle cell disease
