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Catella J, Guillot N, Nader E, Skinner S, Poutrel S, Hot A, Connes P, Fromy B. Controversies in the pathophysiology of leg ulcers in sickle cell disease. Br J Haematol 2024; 205:61-70. [PMID: 38867511 DOI: 10.1111/bjh.19584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/27/2024] [Indexed: 06/14/2024]
Abstract
Patients with sickle cell disease (SCD) often experience painful vaso-occlusive crises and chronic haemolytic anaemia, as well as various acute and chronic complications, such as leg ulcers. Leg ulcers are characterized by their unpredictability, debilitating pain and prolonged healing process. The pathophysiology of SCD leg ulcers is not well defined. Known risk factors include male gender, poor social conditions, malnutrition and a lack of compression therapy when oedema occurs. Leg ulcers typically start with spontaneous pain, followed by induration, hyperpigmentation, blister formation and destruction of the epidermis. SCD is characterized by chronic haemolysis, increased oxidative stress and decreased nitric oxide bioavailability, which promote ischaemia and inflammation and consequently impair vascular function in the skin. This cutaneous vasculopathy, coupled with venostasis around the ankle, creates an ideal environment for local vaso-occlusive crises, which can result in the development of leg ulcers that resemble arterial ulcers. Following the development of the ulcer, healing is hindered as a result of factors commonly observed in venous ulceration, including venous insufficiency, oedema and impaired angiogenesis. All of these factors are modulated by genetic factors. However, our current understanding of these genetic factors remains limited and does not yet enable us to accurately predict ulceration susceptibility.
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Affiliation(s)
- Judith Catella
- Service de Médecine Interne et Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique (LBTI UMR 5305), CNRS/Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Guillot
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Elie Nader
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sarah Skinner
- Clinical Research and Epidemiology Unit, Montpellier University, Montpellier, France
| | - Solène Poutrel
- Service de Médecine Interne et Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Arnaud Hot
- Service de Médecine Interne et Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Philippe Connes
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Berengère Fromy
- Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique (LBTI UMR 5305), CNRS/Université Claude Bernard Lyon 1, Lyon, France
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Patel JR, Montejano R, Hopkins C, Siatecka H, Rosen T. The Curious Case of a Painful Leg Ulcer. Cureus 2024; 16:e54127. [PMID: 38487135 PMCID: PMC10939161 DOI: 10.7759/cureus.54127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
Sickle cell disease is a condition that can involve numerous organ systems secondary to vascular occlusion. Herein, we present a case of a 21-year-old male with sickle cell disease requiring long-term hydroxyurea therapy. Upon migrating to the United States from Yemen, the patient developed a rapidly progressive, exquisitely painful ulcer on his right lower extremity. Given his country of origin, a broad differential, including select infectious diseases, was essential. Moreover, establishing the unequivocally correct diagnosis was crucial to determine proper and safe therapy. Ultimately, a lesional biopsy demonstrated numerous sickled red blood cells occluding blood vessels, leading to the diagnosis of sickle cell disease-related leg ulceration.
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Affiliation(s)
- Jay R Patel
- Dermatology, Baylor College of Medicine, Houston, USA
| | | | | | - Hanna Siatecka
- Pathology and Immunology, Baylor College of Medicine, Houston, USA
| | - Theodore Rosen
- Dermatology, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, USA
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Caboche-Salouhi P, Le Seac'h A, Lionnet F, Santin A, Mattioni S, Tamboura F, Steichen O, Barbaud A, Senet P. "SCULP" study: The benefits of skin graft pellets on the pain of sickle cell leg ulcers (SCLU). JOURNAL DE MEDECINE VASCULAIRE 2023; 48:100-104. [PMID: 37914454 DOI: 10.1016/j.jdmv.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/20/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Leg ulcers associated with major sickle cell disease (SCLU) are a chronic, painful complication, often treated by autologous skin graft. The analgesic effect of skin grafting in SCLU is poorly studied. The aim of this study was to evaluate the effect of skin grafting on the pain and healing of SCLU. METHODS Patients hospitalized for SCLU skin grafting were included in a retrospective and prospective observational cohort, between 2019 and 2023: 53 autologous pinch grafts were performed on a total of 35 SCLUs in 25 sickle cell patients. The primary endpoint was the evaluation of the analgesic effect of the skin graft, measured by visual analog scale (VAS) and weekly cumulative analgesic consumption between day (D)0, D7 and D30. Wound healing was assessed by variation in wound areas between D0 and D30. RESULTS Twenty-five patients with a median age range of 45.5years old were included, 68% were men, SS genotype was present in 96% of the cases. At D7, a significant decrease in VAS and consumption of analgesics of all classes was observed. At D30, only a significant decrease in VAS and consumption of mild opioids was present, as well as a significant reduction in wound surface area compared with D0. CONCLUSION Pinch grafts have a significant early analgesic effect in the management of patients with SCLU, and significantly notice reduction of wound surface area within one month.
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Affiliation(s)
- P Caboche-Salouhi
- Paris Cité University, Faculty of Medicine, Paris, France; Dermatology-Allergology and Vascular Medicine Department, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France.
| | - A Le Seac'h
- Dermatology-Allergology and Vascular Medicine Department, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France; Sorbonne University, Faculty of Medicine, Paris, France
| | - F Lionnet
- Department of Internal Medicine, Sickle Cell Reference Center, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Santin
- Department of Internal Medicine, Sickle Cell Reference Center, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
| | - S Mattioni
- Department of Internal Medicine, Sickle Cell Reference Center, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
| | - F Tamboura
- Dermatology-Allergology and Vascular Medicine Department, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
| | - O Steichen
- Sorbonne University, Faculty of Medicine, Paris, France; Department of Internal Medicine, Sickle Cell Reference Center, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Barbaud
- Dermatology-Allergology and Vascular Medicine Department, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France; Sorbonne University, Faculty of Medicine, Paris, France
| | - P Senet
- Dermatology-Allergology and Vascular Medicine Department, Hôpital Tenon, Assistance publique-Hôpitaux de Paris, Paris, France
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Alshurafa A, Alkhatib M, Abu-Tineh M, Yassin MA. Sickle cell leg ulcer successfully managed by hyperbaric oxygen: a case report. Front Med (Lausanne) 2023; 10:1171971. [PMID: 37396892 PMCID: PMC10310543 DOI: 10.3389/fmed.2023.1171971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023] Open
Abstract
Sickle cell leg ulcers (SCLUs) are usually chronic, painful, and devastating complications of sickle cell disease. Skin vaso-occlusion with compromised blood flow, chronic inflammation, and endothelial dysfunction is thought to be the underlying mechanism. It is usually slow to heal, and it may become chronic and superinfected. The management of SCLUs is usually challenging and requires a multidisciplinary team. Multiple systemic and local therapies have been tried in SCLU treatment. However, the outcome is variable: currently, there are no official recommendations for the best effective treatment. Herein, we report a 34-year-old male patient with non-transfusion-dependent sickle cell disease who was suffering from a chronic left ankle ulcer and was successfully managed with hyperbaric oxygen therapy, resulting in a complete resolution of this devastating complication.
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Affiliation(s)
- Awni Alshurafa
- Hematology Department, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Alkhatib
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
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Oyedeji CI, Hodulik KL, Telen MJ, Strouse JJ. Management of Older Adults with Sickle Cell Disease: Considerations for Current and Emerging Therapies. Drugs Aging 2023; 40:317-334. [PMID: 36853587 PMCID: PMC10979738 DOI: 10.1007/s40266-023-01014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 03/01/2023]
Abstract
People with sickle cell disease (SCD) are living longer than ever before, with the median survival increasing from age 14 years in 1973, beyond age 40 years in the 1990s, and as high as 61 years in recent cohorts from academic centers. Improvements in survival have been attributed to initiatives, such as newborn screening, penicillin prophylaxis, vaccination against encapsulated organisms, better detection and treatment of splenic sequestration, and improved transfusion support. There are an estimated 100,000 people living with SCD in the United States and millions of people with SCD globally. Given that the number of older adults with SCD will likely continue to increase as survival improves, better evidence on how to manage this population is needed. When managing older adults with SCD (defined herein as age ≥ 40 years), healthcare providers should consider the potential pitfalls of extrapolating evidence from existing studies on current and emerging therapies that have typically been conducted with participants at mean ages far below 40 years. Older adults with SCD have historically had little to no representation in clinical trials; therefore, more guidance is needed on how to use current and emerging therapies in this population. This article summarizes the available evidence for managing older adults with SCD and discusses potential challenges to using approved and emerging drugs in this population.
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Affiliation(s)
- Charity I Oyedeji
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Claude D. Pepper Older Americans Independence Center, Durham, NC, USA.
- Department of Medicine, and Duke Comprehensive Sickle Cell Center, Duke University School of Medicine, 315 Trent Dr., Suite 266, DUMC Box 3939, Durham, NC, 27710, USA.
| | - Kimberly L Hodulik
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John J Strouse
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Claude D. Pepper Older Americans Independence Center, Durham, NC, USA
- Department of Medicine, and Duke Comprehensive Sickle Cell Center, Duke University School of Medicine, 315 Trent Dr., Suite 266, DUMC Box 3939, Durham, NC, 27710, USA
- Division of Pediatric Hematology-Oncology, Duke University, Durham, NC, USA
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Eswaran H, Googe P, Vedak P, Marston WA, Moll S. Livedoid vasculopathy: A review with focus on terminology and pathogenesis. Vasc Med 2022; 27:593-603. [PMID: 36285834 PMCID: PMC9732787 DOI: 10.1177/1358863x221130380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Livedoid vasculopathy (LV) is a rare thrombotic vasculopathy of the dermis characterized by painful, relapsing ulcers over the lower extremities. Diagnosis is challenging due to the overlap in clinical appearance and nomenclature with other skin disorders. Treatment selection is complicated by poor understanding of the pathogenesis of LV and lack of robust clinical trials evaluating therapy efficacy. The terminology and pathophysiology of LV are reviewed here, along with its epidemiology, clinical and histologic features, and treatment options. A diagnostic pathway is suggested to guide providers in evaluating for comorbidities, referring to appropriate specialists, and choosing from the available classes of therapy.
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Affiliation(s)
- Harish Eswaran
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
| | - Paul Googe
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Priyanka Vedak
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Marston
- Department of Surgery, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephan Moll
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
- Blood Research Center, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
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Tolu SS, Van Doren L. Acute and chronic pain management in patients with sickle cell disease in the modern era: A comprehensive review. Transfus Apher Sci 2022; 61:103533. [DOI: 10.1016/j.transci.2022.103533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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