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Pain in Chronic Wounds: Mechanism and Management 309
Moisture Balance
It is essential that the dressings applied to the wound keep the wound moist.
Wounds which are either too dry or which present with excessive discharge pose
problems. Excessive exudative discharge from the wound site causes maceration
and damage to the area around the wound, and greater the damage to the
“peri-wound” area, greater will be the intensity of the patient’ s pain. Such wounds
are to be dressed with absorbent dressing to soak up the exudate. A skin barrier can
be used to protect the peri-wound area from maceration (Lebrun et al. 2010).
Management of Specific Wounds
Diabetic Foot Ulcer
The gold-standard for management of a diabetic ulcer is debridement, management
of infec tion and revascularization as indicated (Alexiadou and Doupis 2012)
Debridement of a wound can be surgical, enzymatic, biologic or autolytic. Surgical
debridement, as the name suggests, is the removal of dead tissue and hyperkeratosis
using a scalpel (Lebrun et al. 2010) Debridement is carried out until the wound bed
appears healthy. Enzymatic debridement involves the use of enzymes like collagenase, streptokinase, and streptodornase to remove dead necrotic tissue while
sparing healthy tissue (Smith 2008). Biological debridement is done using maggots
which eat away dead tissue. This particular treatment has been found effective in the
management of infection by resistant organisms such as MRSA (Singer et al. 2017).
In autolytic debridement, dressings which create a moist woun d environment are
used so that host defence mechanisms can clear necrotic tissue using body’s own
enzymes.
Off-loading of the ulcer has to be done adequately, otherwise there will be a
significant delay in ulcer healing. The gold standard method of off—loading is the
application of non- removable total contact cast which is indicated for ulcers located
at the fore-foot or mid-foot (Alexiadou and Doupis 2012). Other management
strategies utilised in diabetic ulcers include the use of growth factors, extracellular
matrix proteins, bioengineered skin substitutes, MMP modulators, negative pressure wound therapy, and hyperbaric oxygen therapy.
Venous Ulcers
The standard of care is compression therapy which has the benefit of decreasing the
rate of ulcer recurrence. Elastic (e.g., Ace wraps), inelastic (e.g., Unna boot) or
intermittent pneumatic compression can be used. Compliance to therapy can be
restricted by pain, drainage, contact dermatitis etc. Use of compression therapy is
absolutely contraindicated in patients with suspected or proven arterial disease.
310 A. G. Goswami et al.
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Leg elevation, to treat venous leg ulcers, when used with compression therapy, is
reported to decrease pain as well as oedema. It is recommended to keep the limb
elevated for around 30 minutes, three or four times in a day after excluding any
congestive cardiac failure. Dressings can be used under the compression bandages
to help faster healing. No single dressing has been found to have any benefit over
the other (Collins and Seraj 2010).
Medications commonly prescribed to patients with venous ulcers include aspirin
(which may promote ulcer healing by improving the microcirculation), pentoxyphylline (increases red cell deformability to benefit the microcirculation), oral zinc,
iloprost and antibiotics and antiseptics for infection control. Surgical management
of venous ulcers is undertaken in patients with chronic ulcers refractory to conservative management. Debridement of ulcers helps promote healing but the
presence of significant necrotic tissue requiring a lot of debridement should prompt
an investigation for an arterial disease as pure venous ulcers seldom require much
debridement. Skin grafting can be used in patients with large refractory ulcers and
surgery for the venous insufficiency can be performed in severe cases.
Ischaemic Leg Ulcers
The cornerstone of successful management of any arterial ulcer is the restoration of
blood flow to the ischaemic limb. The method of revascularization to be employed
can b e decided based on the preference and experience of the operating surgeon.
Medical management includes cessation of smoking, treatment of hyperlipidaemia
if required, administration of anti-platelet medications and the use of drugs such as
pentoxyphylline which improve microcirculation by decreasing platelet aggregation
(Grey et al. 2006).
Novel methods for the management pain in ischemic ulcers include the use of
lumbar sympathectomy and spinal cord stimulators. Kothari et al. showed in their
study on 147 patients that the use of percutaneous lumbar sympathectomy was safe
and effective (Kothari et al. 2017). The efficacy of lumbar sympathetic block in pain
management was also reported by Lawange et al. (2020) and Ghazali et al. (Ghazali
and Hussin 2019). Approaches in spinal cord stimulation (SCS) offers a significant
chronic pain control technique that is feasible and evidence-based. Implantable,
non-pharmacologic leads are used with good evidence of safety and efficacy.
Although it widely used for chronic pain control, thus obviating the need for heavy
dose analgesia, research in understanding the mechanism of its effect lags behind
clinical success (Caylor et al. 2019).
Conclusion
Pain in chronic wounds is a source of anguish and immense morbidity for the
patient, which significantly affects the quality of life. The clinical problem of pain in
wounds lies in the difficulty in quantification, sensitization, and abnormal
Pain in Chronic Wounds: Mechanism and Management 311
psychosomatic effects. However, adequate assessment of the wound, understanding
the mechanism behind the genesis of pain in such wounds and individualising its
management can positively impact the physiological and psychological aspects of
patient’s wellbeing and the wound healing. Wherever possible, systematic approach
to pain management should be stressed upon following WHO pain assessment and
management ladder and especially the wound pain management protocol existing in
the clinician’s armamentarium and as per the available resources. Care should be
taken to reduce modifiable causes of pain, as experience of pain negatively affects
wound healing in the long run.
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