Mini review: leg ulcers - a secondary complication of sickle cell disease

Leg Ulcers in Sickle Cell Disease: A Multifactorial Analysis Highlights the Hemolytic Profile

Sickle cell disease (SCD) is characterized by the presence of the variant S hemoglobin (HbS). The homozygous genotype (HbSS) is sickle cell anemia (SCA), while the double heterozygous of HbS and HbC (HbSC) is defined as SC hemoglobinopathy. The pathophysiology is based on chronic hemolysis, inflammation, endothelial dysfunction, and vaso-occlusion, which results in vasculopathy and serious clinical manifestations. Sickle leg ulcers (SLUs) are cutaneous lesions around the malleoli frequent in 20% of Brazilian patients with SCD. SLUs present a variable clinical and laboratory pattern modulated by several characteristics that are not fully understood. Hence, this study aimed to investigate laboratory biomarkers and genetic and clinical parameters associated with the development of SLUs. This descriptive cross-sectional study included 69 SCD patients, 52 without SLU (SLU-) and 17 with active or previous SLU history (SLU+). The results showed a higher incidence of SLU in SCA patients and there was no observed association of α-3.7 Kb thalassemia in SLU occurrence. Alterations in NO metabolism and hemolysis were associated with clinical evolution and severity of SLU, in addition to hemolysis modulating the etiology and recurrence of SLU. Our multifactorial analyses demonstrate and extend the role of hemolysis driving the pathophysiological mechanism of SLU.

O SENTIDO DO TRABALHO PARA HOMENS COM ANEMIA FALCIFORME E ÚLCERAS FALCÊMICAS

RESUMO Objetivo: analisar o sentido do trabalho para homens com anemia falciforme e úlceras falcêmicas e discutir os desafios que eles enfrentam para manterem-se no mundo do trabalho. Método: estudo qualitativo e descritivo, desenvolvido em dois cenários, um ambulatório de curativos de um hospital de grande porte e uma clínica de enfermagem em estomaterapia, ambos vinculados a uma universidade pública do Rio de Janeiro, Brasil. A coleta de dados ocorreu de agosto a novembro de 2019, por meio de entrevista semiestruturada, com 20 homens com úlceras falcêmicas. A análise lexical dos dados foi realizada a partir do software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires. Resultados: verificou-se a penosidade física, social e psicológica que a ferida origina nos homens que atuam no mundo do trabalho. Além disso, constatou-se que o trabalho representa um valor importante para o homem, além de ser visto como refúgio para lidar com a dor imposta pela ferida. Conclusão: o trabalho representa utilidade e satisfação, pois possibilita prover materialmente o homem e suas famílias, reafirma sua virilidade e seu domínio nos contextos familiar e social, o faz sentir-se útil e produtivo. Mas, contraditoriamente, também produz sofrimento quando esses homens precisam se manter no trabalho com dor, cansaço, vergonha e frustração decorrentes de uma doença e de uma lesão que altera sua imagem corporal e sua produtividade, além de gerar sentimento de repulsa no seu coletivo profissional.

THE MEANING OF WORK FOR MEN WITH SICKLE-CELL ANEMIA AND ULCERS

ABSTRACT Objective: to analyze the meaning of work for men with sickle-cell anemia and ulcers and to discuss the challenges they face to remain in the world of work. Method: a qualitative and descriptive study developed in two settings: an outpatient service specialized in dressings of a large-sized hospital and a Stomatherapy Nursing clinic, both linked to a public university from Rio de Janeiro, Brazil. Data collection took place from August to November 2018 by means of semi-structured interviews with 20 men who had sickle-cell ulcers. Lexical data analysis was performed in the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software. Results: the physical, social and psychological hardships caused by the wounds in men who are active in the world of work were verified. In addition to that, it was found that work is of important value for men, in addition to considering it as a shelter to deal with the pain imposed by the wounds. Conclusion: work represents usefulness and satisfaction, as it makes it possible to materially provide for men and their families and it reasserts their virility and their dominance in the family and social contexts, in addition to making them feel useful and productive. However, on the other hand, it also produces distress when these men need to stay at work with pain, tiredness, shame and frustration arising from a disease and an injury that alter their body image and productivity, in addition to generating feelings of disgust in their professional collective.

Common, But Neglected: A Comprehensive Review of Leg Ulcers in Sickle Cell Disease

OBJECTIVE

To compile available evidence to better understand the management of leg ulcers in sickle cell disease (SCD), as well as describe potential therapeutic steps that may be required to improve the quality of life of patients with SCD leg ulcers.

DATA SOURCES

MEDLINE, PubMed, EMBASE, and Web of Science databases.

STUDY SELECTION

A comprehensive search was conducted to retrieve relevant studies using the keywords "sickle cell disease and leg ulcer," "ulcer treatments, diagnosis and sickle cell," and "wound sickle cell." Studies published through July 2020 were included.

DATA EXTRACTION

Two independent authors selected all studies that assessed the relationship between leg ulcer and SCD identified from online databases.

DATA SYNTHESIS

The authors have summarized updated information on pathophysiology (vasculopathy linked to chronic hemolysis and endothelial dysfunction), diagnosis, and available treatment options to unravel the dermohematologic connection between leg ulcers and SCD.

CONCLUSIONS

It is the authors' hope that this detailed discussion of the information available on leg ulcers and SCD will lead to a better appreciation of this clinical problem by the clinicians and researchers and in turn have a long-term positive effect on the quality of life of patients with SCD. Researchers should design new trials considering these insights and potential therapeutic approaches based on current knowledge.

PROFILE OF WOMEN WITH LEG ULCERS DUE TO SICKLE CELL DISEASE

Objective: to characterize the profile of women with leg ulcers resulting from sickle cell disease treated at a public health institution in Brazil. Method: historical cohort study conducted in the outpatient sector with a sample of women with sickle cell disease and leg ulcer, followed from 1998 to 2014. The data were extracted from the medical record and included sociodemographic, clinical and ulcer-related variables, and underwent descriptive statistical analysis. Results: of the 17 women, 64.7% were cured, 58.8% were aged between 30 and 39 years, 64.7% declared themselves brown, 70.6% were without partners, 41.2% had incomplete elementary education, 52, 9% had an income of 2 to 3 minimum wages, 70.6% were eutrophic and 82.4% used vitamin supplements. Women had a total of 29 ulcers, 52.9% had a single ulcer, 41.4% were located in the malleolar region, 55.17% were between 2 and 36 months, all classified as stage 3. The treatment was with coverings and Unna’s boot. Conclusion: the women received care from specialist nurses and most were cured with up to eight months of follow-up, which required a nursing consultation, including clinical evaluation, topical treatment and application of compression therapy.

PERFIL DE MULHERES COM ÚLCERAS DA PERNA DECORRENTES DE DOENÇA FALCIFORME

Objetivo:caracterizar o perfil de mulheres com úlceras da perna decorrentes da doença falciforme atendidas em uma instituição pública de saúde do Brasil. Método: estudo de coorte histórica realizado no setor ambulatorial com amostra de mulheres com doença falciforme e úlcera da perna, acompanhadas de 1998 a 2014. Os dados foram extraídos do prontuário e contemplaram variáveis sociodemográficas, clínicas e relacionadas à úlcera, e passaram por análise estatística descritiva. Resultados: das 17 mulheres, 64,7% obtiveram cura, 58,8% tinham idade entre 30 e 39 anos, 64,7% se autodeclaram pardas, 70,6% estavam sem parceiros, 41,2% possuíam ensino fundamental incompleto, 52,9% tinham renda de 2 a 3 salários mínimos, 70,6% eram eutróficas e 82,4% faziam uso de suplementos vitamínicos. As mulheres apresentaram o total de 29 úlceras, 52,9% tinham úlcera única, 41,4% localizadas na região maleolar, 55,17% com existência entre 2 e 36 meses, todas classificadas em estágio 3. O tratamento foi com coberturas e bota de Unna. Conclusão: as mulheres receberam cuidados de enfermeiros especialistas e a maioria obteve a cura com até oito meses de acompanhamento que demandou a consulta de enfermagem, contemplando a avaliação clínica, o tratamento tópico e aplicação da terapia de compressão.

Interventions for treating leg ulcers in people with sickle cell disease

BACKGROUND

The frequency of skin ulceration makes an important contributor to the morbidity burden in people with sickle cell disease. Many treatment options are available to the healthcare professional, although it is uncertain which treatments have been assessed for effectiveness in people with sickle cell disease. This is an update of a previously published Cochrane Review.

OBJECTIVES

To assess the clinical effectiveness and harms of interventions for treating leg ulcers in people with sickle cell disease.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We searched LILACS (1982 to January 2020), ISI Web of Knowledge (1985 to January 2020), and the Clinical Trials Search Portal of the World Health Organization (January 2020). We checked the reference lists of all the trials identified. We also contacted those groups or individuals who may have completed relevant randomised trials in this area. Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 13 January 2020; date of the last search of the Cochrane Wounds Group Trials Register: 17 February 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for treating leg ulcers in people with sickle cell disease compared to placebo or an alternative treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion. All three authors independently assessed the risk of bias of the included studies and extracted data. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

Six studies met the inclusion criteria (198 participants with 250 ulcers). Each trial investigated a different intervention and within this review we have grouped these as systemic pharmaceutical interventions (L-cartinine, arginine butyrate, isoxsuprine) and topical pharmaceutical interventions (Solcoseryl® cream, arginine-glycine-aspartic acid (RGD) peptide dressing and topical antibiotics). No trials on non-pharmaceutical interventions were included in the review. All trials had an overall unclear or high risk of bias, and drug companies sponsored four of them. We were unable to pool findings due to the heterogeneity in outcome definitions, and inconsistency between the units of randomisation and analysis. Three interventions reported on the change in ulcer size (arginine butyrate, RGD peptide, L-cartinine). Of these, only arginine butyrate showed a reduction of ulcer size compared with a control group, mean reduction -5.10 cm² (95% CI -9.65 to -0.55), but we are uncertain whether this reduces ulcer size compared to standard care alone as the certainty of the evidence has been assessed as very low. Three trials reported on complete leg ulcer closure (isoxsuprine, arginine butyrate, RGD peptide matrix; very low quality of evidence). None reported a clinical benefit. No trial reported on: the time to complete ulcer healing; ulcer-free survival following treatment for sickle cell leg ulcers; quality of life measures; incidence of amputation or harms.

AUTHORS' CONCLUSIONS

Given the very low quality of the evidence identified in this updated Cochrane Review we are uncertain whether any of the assessed pharmaceutical interventions reduce ulcer size or result in leg ulcer closure in treated participants compared to controls. However, this intervention was assessed as having a high risk of bias due to inadequacies in the single trial report. Other included studies were also assessed as having an unclear or high risk of bias. The harm profile of the all interventions remains inconclusive.

Association between inflammatory molecules, nitric oxide metabolites and leg ulcers in individuals with sickle cell anemia

Introduction

Leg ulcers (LUs) are relatively common in patients with sickle cell anemia (SCA). The role of inflammation and nitric oxide (NO) pathways in the pathophysiology of the LU is not understood.

Objective

The aim of this study was to verify the association between inflammatory molecules and nitric oxide metabolites (NOx) and the occurrence of the LU in patients with SCA.

Method

It was a cross-sectional study on adult participants with SCA followed at Fundação Hemominas, a public blood center in Brazil. Eligible participants were recruited and included in one of two groups: Group 1, comprised of cases with SCA (Hb SS) and at least one LU at the time of inclusion in the study and Group 2, comprised of controls with SCA without a history of LU, matched by sex and age to cases. Participants were interviewed to obtain sociodemographic data and blood samples were collected. Clinical and laboratory data were abstracted from medical records. Nitric oxide metabolites (NOx) and inflammatory molecules were quantified using an immunoassay and Multiplex xMAP® technology, respectively. Eighty-seven individuals were included, ranging in age from 17 to 61 years (mean 40 ± 10.7 years); 30 had LU and 57 were controls without LU.

Results

Participants with LU had significantly higher levels of interleukin 8 (IL-8), IL-10, IL-15, NOx and platelet and white blood cell (WBC) counts, when compared to those without LU. Participants with LU had a significantly higher risk of having a history of osteomyelitis and a higher use of antiseptic soap in bathing, when compared to those without LU.

Conclusion

In conclusion, our results showed that NOx, inflammatory molecules and hematological features were associated with LU in Brazilian adults with SCA.

Leg ulcers in sickle cell disease patients

Leg ulcers are the most common cutaneous complication of sickle cell disease. These lesions occur mainly in homozygous forms, are slow to heal and often relapse, causing negative physical, emotional, and economic impacts. In this paper, we discuss the clinical presentation, diagnosis, and pathophysiology of sickle cell leg ulcers and their implications for treatment.