Pain Management During Scleroderma Digital Ulcer Debridement Results In Improved Outcomes

Controlling procedural pain in the debridement of scleroderma-associated digital ulcers led to better outcomes and treatment adherence among patients, according to recent research.

Originally described at the American College of Rheumatology Annual Meeting 2013, the study monitored treatment of 51 digital ulcers in 32 systemic sclerosis (SSc) patients at a rheumatology clinic in Italy between January 2012 and December 2012 inclusive. Procedural pain was addressed in an ascending sequence beginning with local lidocaine and/or prilocaine cream (25 mg/g of either or 5% EMLA cream).

A paper entitled “Procedural pain management in the treatment of scleroderma digital ulcers“ published in the journal Clinical And Experimental Rheumatology (Clin Exp Rheumatol. 2014;Epub ahead of print 2014 Dec 22) coauthored by D. Giuggioli, A. Manfredi, C. Vacchi, M. Sebastiani, A. Spinella, and C. Ferri, of the Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Medical Schooll at Modena, Italy, notes that digital ulcers (DU) may develop in half of systemic sclerosis (SSc) patients and frequently prove resistant to treatment. Consequently, they observe that deep wound debridement is crucial for digital ulcer healing, but is very difficult to execute without adequate procedural pain management.

In the paper, the researchers report results of their experiences administering procedural pain management to patients with scleroderma DU.

The study observed 51 DU in 32 consecutive SSc patients which were treated in an ascending sequence following a strict schedule beginning in all cases with local lidocaine and prilocaine (25 mg of either agent per gram of cream, EMLA 5 percent). If deemed necessary, this was followed by local and oral morphine, and, depending on pain severity, scored on a 10 cm visual analogue scale (VAS).

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The scientists report that at baseline, higher pain VAS was recorded in more severe and/or infected DU cases, and that good compliance to DU debridement was observed in patients with mild pain treated only with EMLA, and in five cases with moderate-severe pain at baseline. They note that a majority of DU with moderate-severe pain needed a combined therapy with EMLA and local morphine or with EMLA and both local and oral morphine, and that overall, pain management during DU debridement required only EMLA application in 33 percent of cases, EMLA plus local morphine in 16 percent, and combined EMLA, local and oral morphine were necessary in 51 percent — generally and not unexpectedly in those cases with more severe and/or infected lesions, according to the researchers.

Follow-up observation noted that patients showed good compliance throughout the treatment cycle that included systemic prophylactic measures to prevent additional digital ulcer development that included administration of calcium channel blockers, prostanoids, anti-ET-1 and/or antibiotics, and that these systemic and local treatments during follow-up led to the clinical features improvement of digital ulcers in more than 50 percent of the patients, including size, depth, perilesional erythema and infection characteristics. Only one patient failed to respond to treatment, requiring digit amputation due to gangrene and osteomyelitis.

The coauthors conclude that their study demonstrated beneficial control of procedural pain during DU debridement with sequential, combined analgesic treatment.

Sources:
Clinical And Experimental Rheumatology