A treatment algorithm to identify therapeutic approaches for leg ulcers in patients with sickle cell disease

Abstract

Sickle cell leg ulcers (SCLUs) are a common complication of sickle cell disease (SCD). Patients who develop ulcers appear to have a more severe haemolysis-associated vasculopathy than individuals who do not develop them, and manifest other complications such as priapism and pulmonary hypertension. SCLUs are slow to heal and often recur, affecting both the emotional and physical well-being of patients. Here we summarise what is known about the pathophysiology of SCLUs, describe available treatment options and propose a treatment algorithm.

Leg ulcers in sickle cell patients: management challenges

“…1,2,8 The use of a triple antibiotic cream has been advocated for the treatment of ulcers in patients with SCD after a prospective trial showed a statistically significant decrease in ulcer size. 19 The study population, however, had only 15 patients. 19 A review by Cochrane in 2014 cited a clinical trial using an arginine-glycine-aspartic acid peptide matrix on sickle cell leg ulcers as the only trial achieving noticeable benefit after treatment, with statistically significant decrease in sickle cell leg ulcer size.…”

“…19 The study population, however, had only 15 patients. 19 A review by Cochrane in 2014 cited a clinical trial using an arginine-glycine-aspartic acid peptide matrix on sickle cell leg ulcers as the only trial achieving noticeable benefit after treatment, with statistically significant decrease in sickle cell leg ulcer size. The Cochrane Group, however, also stated that the study carries a risk of bias and recommends further studies.…”

“…19 The results are also hypothesized to be due to modifying effects on inflammatory mediators in the wound bed. 19 Negative pressure wound therapy has been reported to be beneficial in healing chronic wounds of multiple etiologies.…”

“…19 The results are also hypothesized to be due to modifying effects on inflammatory mediators in the wound bed. 19 Negative pressure wound therapy has been reported to be beneficial in healing chronic wounds of multiple etiologies. Opara et al have reported its effectiveness in bringing 15 ulcers in nine patients with SCD to a graftable state within 6-10 days of negative pressure wound therapy use, and subsequent skin graft take of 98%-100% in all ulcers.…”

“…18 A variety of trials have used different types of skin substitutes and allogenic keratinocytes have shown some improvement in a small number of sickle cell leg ulcers, but the scarce evidence and overwhelming cost of these treatment modalities limit their use. 19 The nature of ulcers, with significant amounts of necrotic tissue and adherent biofilm, necessitates frequent debridement in patients with SCD. This may be chemical, using the previously mentioned dressing types, or mechanical.…”