|Year : 2018 | Volume
| Issue : 2 | Page : 75-78
Suction blister epidermal grafting for neuropathic ulcer in leprosy
Reeza Edward Yuwantana1, Yohanes Widodo Wirohadidjojo2
1 Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
2 Department of Dermatology and Venereology, Faculty of Medicine, Public Health And Nursing Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
|Date of Web Publication||21-Sep-2018|
Dr. Yohanes Widodo Wirohadidjojo
Department of Dermatology and Venereology, Radiopoetro Building 3FL, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Jalan Farmako, Sekip Utara, Yogyakarta 55281
Source of Support: None, Conflict of Interest: None
Leprosy is one of the leading causes of chronic wound cases, especially in endemic countries, where the successfulness of disease elimination has not been followed by reduced rates of leprosy-related disabilities. Chronic nonhealing ulcers are often difficult to treat and have a significant impact on the patient's quality of life as well as an economic burden. Suction blister epidermal grafting (SBEG) was invented as an alternative approach for recalcitrant cases with some advantages above conventional skin grafting techniques. However, availability of sophisticated technologies to harvest grafts is a common problem in most facilities in Indonesia along with prohibitive cost for most patients who are below the poverty line. To overcome such limitations, we implemented a simplified SBEG procedure using daily medical instruments and equipments to provide an affordable service to a neuropathic plantar ulcer patient due to leprosy with satisfying result.
Keywords: Disability, leprosy, neuropathic ulcer, plantar ulcer, suction blister epidermal grafting
|How to cite this article:|
Yuwantana RE, Wirohadidjojo YW. Suction blister epidermal grafting for neuropathic ulcer in leprosy. J Dermatol Dermatol Surg 2018;22:75-8
| Introduction|| |
Chronic ulcers have been a wearisome challenge for multidisciplinary health practitioners. Among various underlying conditions, leprosy as a neglected tropical infection contributes a significant portion for the development of chronic wounds. Plantar or tropical ulcers due to neuropathy is the leading cause of serious disability, especially in endemic areas. Frustrating response to standard therapies, negative impacts on quality of life as well as great burden to health system are among the substantial problems that remain to be solved.,
Skin grafting methods invented decades ago offer innovative wound closure techniques for these recalcitrant cases. However, conventional procedures are not free from weaknesses and limitations. A newer harvesting technique to obtain epidermal sheets through suction blister epidermal grafting (SBEG) was introduced by Kiistala and Mustakallio and emerged as modification of epidermal grafting which is considered cost-effective with minimal morbidity., We report the use of SBEG to accelerate wound closure for chronic neuropathic ulcer in patients with a multibacillary leprosy background.
| Case Report|| |
A 28-year-old female patient was referred with a chronic wound on her sole. Physical examination showed ulceration on the right sole, 3 cm × 2 cm × 1.5 cm in dimension with irregular border and calluses. The base of the ulcer was free from pus and necrotic tissues with poor granulation tissue. The patient has a background of multibacillary leprosy-borderline lepromatous type and has been released from therapy for 9 months. The wound started to appear approximately 16 months before examination when she was still under multidrug therapy (MDT) regiments. The patient could not recall the exact cause of the wound. She has reported her complaints to several doctors and treated with various topical agents without any improvement.
Due to the stagnant progress of the wound closure, SBEG procedure was offered and accepted by the patient. The patient did not show any contraindications to the procedure of routine blood clotting, and blood glucose parameters all were within the normal limits. The patient was given a brief explanation about the whole procedure and signed a written informed consent. The first phase of the procedure was the harvesting of the epidermal grafts (EGs) from the determined donor site [Figure 1], which was the right anteromedial thigh. Donor locations were marked in accordance to the estimated amount of blister roofs that would be sufficient to cover the whole surface of the recipient site. Donor sites were sterilized and anesthetized locally with tumescent (1:125.000). Three 10-cm3 syringes were lined up straight perpendicular to the skin surface and functioned as suction cups. Initial suctions were triggered by connecting the 10-cm3 syringes to a 20cm3 syringe via three-way connectors, then subsequently continued by linking the suction cups to gastric suction apparatus, maintaining an uninterrupted negative pressure at 500 mmHg as long as desired. Full blister formation was observed after 2 h of continuous suction.
|Figure 1: Preparation of donor sites. Representative steps of the first phase in sequence: (a) Marking of the donor sites, (b) injection of tumescent anesthesia, and (c and d) three syringes put in line as suction cups, negative pressure initiated by pulling the cups with another syringe and locked afterward|
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The next phase was the implantation of the grafts to the ulcer lesion in a standard operating room [Figure 2]. Operation area was sterilized by 10% povidone-iodine and 70% alcohol. Blister roofs were detached cautiously by cutting it right at the margin between the blister peripheral wall and the surrounding skin. The harvested grafts were immediately put on Sofra-tulle® with the outer surface in contact and transferred to 0.9% sterile saline-filled Petri dish More Details.
|Figure 2: Harvesting and implantation. Preparation and implantation of grafts in sequence: (a) Fully formed unilocular blisters, (b) preparation of recipient site, (c) cutting of the blister roofs to obtain the epidermal sheets, and (d) implantation of blister grafts to the wound bed|
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The epidermal sheets stuck on Sofra-tulle® were then implanted with gentle pressure until the whole wound base was sufficiently covered [Figure 3]. Sofra-tulle® was then released with forcep. The ulcer was closed (in sequence) with needle-punctured Tegaderm®, sterile gauze layers, intact Tegaderm®, and tightly fixated. Oral cefixime 2 × 100 mg was given for 5 days as prophylaxis.
|Figure 3: Implantation of the grafts (continued). (a-c) Adjustment of grafts' placement until all grafts have covered the entire wound bed area; grafts were rechecked for rolled or overlapping sheets, and (d) final dressing of the wound|
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The wound dressing was left untouched until the 7th day continued with regular changing. Week 1 evaluation showed that the grafts were successfully taken by the wound bed. Improvement of the ulcer dimension and wound bed appearance started to be observed from the 2nd week. Topical 1% silver sulfadiazine was prescribed to accommodate wound reepithelialization. There were no signs of bleeding, graft failure, or secondary infection. Final evaluation on the 60th day showed a complete closure of the wound [Figure 4].
|Figure 4: Clinical progress of the recipient site. Clinical progress of the wound: (a) preoperative, (b) day 7, (c) day 10, (d) day 14, (e) day 21, (f) day 35, (g) day 49, and (h) day 63|
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| Discussion|| |
The successfulness of MDT program to reach the target for leprosy elimination has not been followed by a similar trend in the number of leprosy-related disabilities. Attentions are now being focused to attempts to decrease the disability rate among leprosy patients. Chronic ulcerations, mainly on plantar, are one of the most commonly seen complications with a tendency to recur. Current strategies in wound cares have been shown to be disappointing at times, while newer treatments are in practical limited due to the prohibitive cost and unavailability in most health facilities.
Autologous skin grafting is one of the well-known alternative procedures for wound closure. However, conventional techniques require hospitalization, patient immobility, and high cost. EG was later invented to overcome those challenges with lower risk of scarring, faster donor healing, and lesser pain. The procedure also can be done without hospitalization and significantly reduces the use of an anesthetic agent.,,
Development of newer technologies ensures health practitioners to provide a service that is more effective and time efficient. Various recent publications reported the successfulness of SBEG using a new epidermal harvesting system (Cellutome®) to treat chronic ulcers with various backgrounds. A study from Prakash et al. concluded that the success rates of EG are comparable with STSG, around 85%–100%.,,
We tried to overcome such limitations by using a simplified suction system with a double-syringe method conjoined by a three-way connector, angiosterometer, and modified respiratory/gastric suction machine. A similar method has been used in our hospital for vitiligo patient. With this method, we may provide a cost-effective procedure which is affordable to most patients due to the limited coverage of our National Health Insurance System.
We judge the successfulness of our procedure based on the achievement of full reepithelization, which was seen 2 months after SBEG. The mechanisms behind the effect are believed to be endogenous stimulation to intrinsic wound healing orchestra involving migration and proliferation of keratinocytes from the wound edges. An observation on intact microdome blister has shown that viable basal cells are capable to secrete multiple growth factors. Grafts also have been shown to contain melanocyte, Langerhans cell as well as epidermal stem cells.,
The patient's compliance was without doubt played a very important part. We look forward to keep implementing our SBEG procedure to more chronic ulcer patients in order to get a better judgment of the performance and effectiveness of such technique. We have shown that SBEG should be considered as a cost-effective choice which can contribute to ongoing vigorous works to decrease the global burden due to leprosy and its related disabilities.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
van Brakel WH, Sihombing B, Djarir H, Beise K, Kusumawardhani L, Yulihane R, et al.
Disability in people affected by leprosy: The role of impairment, activity, social participation, stigma and discrimination. Glob Health Action 2012;1:1-11.
Slim FJ, Keukenkamp R, van Schie CH, Faber WR, Nollet F. Foot impairments and limitations in walking activities in people affected by leprosy. J Rehabil Med 2011;43:32-8.
Kiistala U, Mustakallio KK. Dermo-epidermal separation with suction. Electron microscopic and histochemical study of initial events of blistering on human skin. J Invest Dermatol 1967;48:466-77.
Herskovitz I, Hughes OB, Macquhae F, Rakosi A, Kirsner R. Epidermal skin grafting. Int Wound J 2016;13 Suppl 3:52-6.
Alberts CJ, Smith WC, Meima A, Wang L, Richardus JH. The potential effect of the world health organization's 2011-2015 global leprosy strategy on the prevalence of grade 2 disability: A trend analysis. Bull World Health Organ 2011;89:487-95.
Kirsner RS, Bernstein B, Bhatia A, Lantis J, Le L, Lincoln K, et al.
Clinical experience and best practices using epidermal skin grafts on wounds. Wounds 2015;27:282-92.
Hachach-Haram N, Bystrzonowski N, Kanapathy M, Smith O, Harding K, Mosahebi A, et al.
A prospective, multicentre study on the use of epidermal grafts to optimize outpatient wound management. Int Wound J 2017;14:241-9.
Costanzo U, Streit M, Braathen LR. Autologous suction blister grafting for chronic leg ulcers. J Eur Acad Dermatol Venereol 2008;22:7-10.
Richmond NA, Lamel SA, Braun LR, Vivas AC, Serena T, Kirsner RS, et al.
Epidermal grafting using a novel suction blister-harvesting system for the treatment of pyoderma gangrenosum. JAMA Dermatol 2014;150:999-1000.
Serena TE. Use of epidermal grafts in wounds: A review of an automated epidermal harvesting system. J Wound Care 2015;24:30-4.
Prakash TV, Chaudhary A, Purushothaman S, Smitha KV, Arvind V. Epidermal grafting for chronic complex wounds in India: A Case series. Cureus 2016;8:e516.
Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006;45:411-7.
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