The assessment and management of leg ulcers in rheumatoid arthritis

Acupuncture for rheumatoid vasculitis complicated by refractory foot ulcer: A case report

INTRODUCTION

Rheumatoid vasculitis (RV) is a frequently encountered complication of rheumatoid arthritis (RA), wherein skin vasculitis lesions are observed as a common clinical manifestation, encompassing skin purpura, erythema, vascular occlusion, ulcers, and gangrene. As a matter of fact, it marks the most severe extra-articular manifestation of RA. And the resultant ulcers tend to pose a greater challenge with regard to therapeutic interventions. We report a case of RV complicated by refractory foot ulcer that was successfully treated with puncture.

CASE PRESENTATION

A 62-year-old man with RV caused by RA developed refractory foot ulcers. Despite the application of topical antibiotics, the wound gradually expanded and remained unhealed for 7 months. Consequently, the patient sought an integrated therapeutic approach involving Traditional Chinese Medicine and was subsequently treated with acupuncture. After 12 weeks of acupuncture, the foot ulcers healed completely.

CONCLUSION

Acupuncture has the potential to facilitate wound healing and may serve as a viable alternative treatment modality for wounds unresponsive to traditional therapeutic interventions.

Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression

Lower extremity ulcers are a recognized complication of rheumatoid arthritis (RA). Their prevalence has not been assessed since the advent of more aggressive disease modifying antirheumatic therapies. The purpose of this study was to establish the period prevalence of lower extremity ulcers in a modern-day unselected cohort of patients with RA, and to report the features associated with ulcer development and response to therapy. Between June 2007 and June 2010, 366 RA patients were evaluated at the Georgetown Division of Rheumatology. Data were collected and analyzed retrospectively on demographics, antibody and prothrombotic profile, comorbidities, disease activity, and outcomes. The period prevalence of ulcers in this cohort of 366 patients with RA followed over 3 years was 4.37%. Patients with ulcers were predominantly female (81.25%) and more commonly African American (56.2%). The mean disease duration at ulcer development was 25.9 years. All patients with ulcers had erosive disease and 63% were seropositive. Only five patients (31.25%) healed over a mean follow-up of 22.8 months. However, in this small sample, treatment with anti-tumor necrosis factor-α (anti-TNFα) therapy was associated with significantly higher likelihood of healing (p = 0.039). In this modern-day cohort of patients with RA, we found a prevalence of lower extremity ulcers of 4.37% over 3 years. Only 31.25% of patients healed after a mean 22.8 months of follow-up. However, treatment with a biologic agent was associated with a significant increased likelihood of healing (RR 3.27, 95% CI 0.59-18.29, p = 0.039).

Chronic leg ulcers, part 1: do they affect a patient's social life?

This article describes a qualitative study into how chronic venous leg ulceration impacts on the social dimension of a patient's life and is presented in two parts. Part one will discuss the background to the study, give an overview of the existing literature and briefly describe the methodology used for the study. Part two will follow in the next issue and will present the findings of the study, which will be discussed in relation to the literature. The limitations of the study will be described, together with conclusions and recommendations for practice and further research.

Caring for patients with leg ulcers and an underlying vasculitic condition

It is not uncommon for nurses in the community to encounter patients with leg ulceration combined with rheumatic disease, particularly rheumatoid arthritis (RA). The aetiology of the leg ulcers in these cases is rarely straightforward, and the management of the ulcers is correspondingly complex. Management may be further complicated in the presence of vasculitis, an uncommon disorder in which inflammatory changes cause degradation of blood vessels. Rapid deterioration and pain are the main challenges with these cases. This article discusses the aetiology of vaculitic ulcers, and presents two case studies which were successfully managed using a new hydrogel dressing.

Sharing the burden: the complex practice of wound care in the community

Wound care in the community setting is often far from simple. Chronic wounds are the product of a complex interplay of processes that must all be addressed if healing, or an improvement in quality of life, is to be achieved. This case study highlights some of the complex issues faced in the community, and reinforces the need for all health professionals to continuously update their knowledge and skills.

Care study: the effect of pain on a patient with leg ulcers

The following care study aims to explore the effects of wound-related pain on a patient with leg ulceration. The study illustrates current deficits within the author's clinical area, a day hospital for elderly people, in relation to how both a patient's pain and quality of life are measured. It suggests means by which this could be overcome, e.g. by the use of appropriate pain and quality of life pain measurement scales. The case study also highlights the hospital-community divide, with reference to communication and the exchange of information relating to a patient's pain. It advocates optimizing interdisciplinary team communication and discusses how developing closer working relationships and improving education can play a part in enhancing communication. While this case study is concerned with an individual patient, it aims to demonstrate that the problems identified and the resulting indications for clinical practice will promote an increasingly holistic view of the patient and benefit all future patients with leg ulceration.

Leg ulcers in patients with rheumatoid arthritis--a prospective study of aetiology, wound healing and pain reduction after pinch grafting

OBJECTIVE

To study the aetiology of leg ulcers in patients with rheumatoid arthritis (RA) and to study healing and pain relief after pinch grafting.

METHODS

Twenty patients with RA and leg ulcers were studied. Diagnosis of the ulcers was founded on the clinical picture and measurements of the ankle-brachial pressure index. To detect vasculitis, skin biopsies were taken for immunohistochemistry and histopathology. Pain severity was assessed pre- and post-operatively using a visual analogue scale.

RESULTS

Ten of the 20 patients had ulcers with multifactorial aetiology. Fifteen had signs of venous insufficiency, 11 had histopathological evidence of vasculitis, four had reduced arterial circulation and two patients had diabetes. Healing after pinch grafting was found in eight patients, all of whom had an ulcer area less than 15 cm(2). Eleven out of 18 patients had pain reduction after pinch grafting.

CONCLUSION

The causation of leg ulcers in patients with RA was found to be multifactorial, with vasculitis and venous insufficiency as the main determinants. Pinch grafting seems to be a good alternative to conservative treatment for minor leg ulcers for these patients, regarding both wound healing and pain relief.