Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 50-55

Chronic leg ulcers in patients with sickle cell anemia: Experience with compression therapy in Nigeria


1 Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
2 IAMRAT, College of Medicine, University of Ibadan, Oyo State, Nigeria
3 Federal Medical Centre, Owo, Ondo State, Nigeria
4 Department of Surgery, University College Hospital, Ibadan, Nigeria
5 Sickle Cell Hope Alive Foundation (SCHAF), Ibadan, Oyo State, Nigeria

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Ayodele O Ogunkeyede
Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Kwara State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_16_17

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  Abstract 

Objective/Purpose: A pilot study to assess the efficacy of compression therapy on the healing rate of chronic leg ulcers (CLUs) in patients with sickle cell anemia (SCA) in Nigeria.
Materials and Methods: A cohort study of patients with SCA and CLU complication was conducted using simple random sampling method to enroll patients from communities in Ibadan, Oyo State, Nigeria. A total of 18 patients with SCA having a total of 25 chronic leg ulcers and ankle brachial pressure index >1 were treated with a high compression bandage of four layers on a weekly basis after wound assessment for a period of 3 months. Wilcoxon signed-rank test was used to compare wound area at pre- and postintervention.
Results: The enrolled patients with SCA were in the age range of 19–44 years, and mean ± SD was 28.8 ± 6.5 years. The initial median ulcer size was 38.4 cm2 (range 0.5–416 cm2); 21 leg ulcers (84%) were >10 cm2 in size at the beginning of the study. These leg ulcers had been present for a median age of 7 years (range 1–22 years). The compression therapy technique achieved >50% healing rate in 16 legs (64%) with an initial ulcer size of 0.5–312 cm2. Four leg ulcers (16%) were completely healed during the study. The postintervention median ulcer size was 18.6 cm2 in all the 25 leg ulcers studied (P < 0.001).
Conclusion: Compression wound therapy promotes a positive healing rate of the CLUs in patients with SCA in Nigeria.

Keywords: Chronic leg ulcer, compression therapy, healing rate, sickle cell anemia, venous incompetence, wound dressing, cohort study


How to cite this article:
Ogunkeyede AO, Babalola OA, Ilesanmi OS, Odetunde AB, Aderibigbe R, Adebayo W, Falusi AG. Chronic leg ulcers in patients with sickle cell anemia: Experience with compression therapy in Nigeria. Nigerian J Plast Surg 2017;13:50-5

How to cite this URL:
Ogunkeyede AO, Babalola OA, Ilesanmi OS, Odetunde AB, Aderibigbe R, Adebayo W, Falusi AG. Chronic leg ulcers in patients with sickle cell anemia: Experience with compression therapy in Nigeria. Nigerian J Plast Surg [serial online] 2017 [cited 2018 May 26];13:50-5. Available from: http://www.njps.org/text.asp?2017/13/2/50/230802


  Introduction Top


Chronic leg ulcers (CLUs) are the major cause of morbidity in patients with homozygous sickle cell anemia (SCA), but rarely a reason for mortality in them.[1] SCA has a wide spectrum, and the effect of the genetic modifications of HbF levels, the involvement of alpha or beta thalassemia, and the beta-S-haplotype may be involved in the clinical course and the occurrence of leg ulcers in these patients.[2] The incidence ranges from 8 to 75% in adolescent and adults.[1] CLU is defined as a defect in the skin below the level of the knee and above the “foot” persisting for six or more weeks.[3]

Chronic leg ulceration limits education, subsequent employment potential, and social life. Many patients with SCA having CLU drop out from school due to prolonged stay in the hospital.

The etiology of CLU in patients with SCA is multifactorial but usually coexists with venous stasis. Recent studies have established a significant role of venous insufficiency in the development of CLU in patients with SCA.[1],[4],[5] Compression therapy has also been suggested in the treatment of CLU in patients with SCA.[1] Leg ulcer resulting from venous anomalies is described as venous leg ulcer.[6] The defining factors for venous leg ulcers are ankle/brachial pressure indices (ABPI) > 0.8 with ulcer affecting the leg with no evidence, which was suggestive of skin cancers, rheumatoid vasculitis, or diabetes.[7] Compression therapy accelerates the healing of chronic venous ulcer and reduces the recurrence of leg ulcers.[6],[7],[8] Hence, there is a need to conduct this pilot study to assess the efficacy of compression wound therapy in accelerating healing rate in CLUs in patients with SCA.

In Nigeria, most patients with SCA having CLUs are placed on routine wound dressing with dressing agents such as Edinburgh University Solution of Lime (EUSOL), honey, and adhesives to support.[9],[10] Hence, the CLUs in SCA are generally referred to as “nonhealing” ulcers because of the ulcers’ resistance to healing using the routine wound dressing.[9],[11] The use of compression therapy will, therefore, be a great technique to improve the healing rate in these selected patients and reduce ulcer recurrence.[6]


  Patients and methods Top


A cohort study of patients with SCA having CLU was conducted among communities in Ibadan, Oyo State, South-West Nigeria. Participants were patients with CLUs who voluntarily reported for the pilot study from their various healthcare facilities in Ibadan metropolis. The study was conducted from March 2015 to June 2015. Their earlier consulting clinics were located in the following health facilities in Ibadan: State Hospital, Ring Road, Ibadan; Adeoyo Maternity State Hospital, Yemetu; and University College Hospital, Ibadan. After informed consent and institutional ethical clearance were obtained, 18 patients with SCA having active leg ulcers were recruited for the therapy and interviewed using a pretested semi-structured questionnaire. Data collected included the patients’ sociodemographic information, as well as a history of previous ulcers and current ulcers including the treatments. The hemoglobin phenotype, average hemoglobin concentration value during the period of the study, and the clinical features of the leg ulcers were documented.

At the beginning of the study, “Time Zero”—T0—blood samples were collected for hematological analysis, and this was repeated at the end of the first and second months of the compression therapy, that is, T1 and T2, respectively, from all the patients. An average of the three values was calculated for determining the stable hemoglobin level during the study.

All the enrolled patients had CLUs with ABPI > 1 and no evidence suggestive of skin cancer, rheumatoid vasculitis, or diabetes. They all underwent weekly four-layer compression bandage technique.

The personnel involved were trained with regard to the proper documentation and technique of applying the compression to achieve a high compression bandage system of four layers, which was developed to apply a high pressure at the ankle and gradually less toward the knee. The diameter of the ankle is important, because the pressure beneath elastic bandages is greater for narrow ankles and least for wide ankles.

The four-layer compression bandaging system [which consists of 3M Coban compression bandage (3M, United Kingdom), crepe bandages, soft wool] was applied over the dressing. The 3M Coban Bandages should be applied on top of the soft wool/padding (subcompression wadding bandage) apart from two layers of crepe bandages. The soft wool prevents friction and pressure damage over bony prominences, and the 3M Coban Bandages should be applied from the toe to knee at 50% stretch and with 50% overlap. This produces an effective and sustained pressure that lasts for a week before the wound dressing is changed.

Dressing and bandages were changed once each week, and the same dressing agent of 10% povidone-iodine (JAWA International Limited, Nigeria) was used for all the patients except in those having "wound at risk", for whom, slow-releasing silver-based dressing (Exasalt T7 by Crawford Healthcare, Medline Industries) was applied.

The patients were treated in the supine position, and the wound assessment forms were entered during each visit. The ulcer size and area were measured in centimeters (both transverse and longitudinal dimensions) each week with a transparent ruler. Other features of the ulcers were entered in the wound assessment form. Ulcers >10 cm2 were considered as large ulcers.

Data analysis

The analysis of factors related to the leg ulcer such as sociodemographic variables, cause, size, and the duration of ulceration was made for each leg. The median wound sizes at pre- and postintervention were compared with Wilcoxon signed-rank test. Linear regression was used to compare wound healing rate and hemoglobin level.


  Results Top


The enrolled patients with SCA were in the age range of 19–44 years, and the mean (SD) age was 28.8 (6.5) years with 12 female and six male patients. As shown in [Figure 1], 12 (66.7%) of the patients developed the "first ulcer" in the second decade of life, while 10 patients seen during the study with leg ulcers were in their third decade of life (55.6%).
Figure 1: Age distribution of the patients when they developed ulcers for the first time, and age during the study

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All the patients in this study had ABPI of >1 with ulcers affecting the lower leg and ankle area.

[Table 1] shows the patients’ clinical parameters of the ulcers. The ulcers involved the ankle areas of the leg except in one patient with ulcer on the dorsum of the foot. Twenty-two (88%) leg ulcers were spontaneous in origin. The left leg was involved in 16 patients, with both leg involvements in seven patients. Twenty-one (84%) leg ulcers were >10 cm2 in area at the beginning of the intervention, while 9 (47.6%) were >10 cm2 in size at the end of the study as shown in [Figure 2].
Table 1: Clinical parameters of the affected legs in the study

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Figure 2: Ulcer areas before and after compression therapy (CTx—compression therapy)

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The average range of hemoglobin level in the study was 4.27–8.37 g/dL with a mean (SD) of 6.39 (1.3) g/dL as shown in [Figure 3]. Healing rate was not statistically affected by Hb level; r = −0.077 and P = 0.719.
Figure 3: Healing rate and the hemoglobin levels of patients

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Previous care for the CLUs included routine alternate day wound dressing with honey in 12 legs, dressing with EUSOL in six legs, skin grafting in three leg ulcers, and compression therapy wound care in two leg ulcers. However, because of lack of funds, the patients defaulted. Some patients resorted to the use of herbs at one point or the other during the course of treating the leg ulcers.

These ulcers had been present for a median age of 7 years (range 1–22 years). The compression therapy technique achieved ≥50% healing in 16 legs (64%) with an initial ulcer size of 0.5–312 cm2. Four leg ulcers (16%) were completely healed during the study. The initial median ulcer size was 38.4 cm2 (range 0.5–416 cm2), and the postintervention median ulcer size was 18.6 cm2 (range 0.0–272 cm2) (P < 0.001) [Table 2]. Generally, most patients’ ulcers healed at a considerable rate as shown in [Figure 4].
Table 2: Median and range of ulcer size before and after compression therapy

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Figure 4: Ulcer appearances before and after 3-month compression therapy (CTx) of some selected patients

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  Discussion Top


The sizes of ulcers in this pilot study were significant with about 84% of the ulcers greater than 10 cm2 in area. Ulcers >10 cm2 were considered large ulcers in this study.[7] The large ulcers were noticed to heal at a considerable rate during the study period, as 12 (57.14%) of the 21 legs with >10 cm2 area progressed to <10 cm2 area by the end of the 3-month study [Figure 2]. Most of the ulcers occurred spontaneously, which was at variance with many studies;[5],[12] however, the contribution of microtrauma and skin ischemic necrosis consequences on the recurrent sickling of the red blood cells cannot be ruled out. The age of the development of the first leg ulcers in patients with SCA in our study was in the second decade of life in 56% of the patients, which was similar to other studies.[5] This could be very important in planning prevention programs to reduce the incidence of CLUs in patients with SCA in Nigeria.

The left leg was more involved (64%; 16 CLU), which was in agreement with other studies.[9],[11],[12] The reason for this is not very clear, but it could be possibly related to the effect of the nondominant leg, which is usually more exposed to injuries, because for most patients, their right legs are dominant. However, further studies will be needed to elucidate the reason for the dominance. All the patients in the study had previously been treated with topical povidone-iodine as the dressing agent because of its antiseptic activity, as it is not known to increase the rate of wound healing.[8]

However, prior to the study, 72% of the patients had routine wound dressing with honey and EUSOL, which was similar to earlier reports[9],[10] with 28% having other forms of care such as skin grafting and compression therapy. There was poor outcome in patients who had skin grafting with ulcer recurrence within 3 months, which was similar to other earlier reports.[11],[13] The two patients who had prior compression bandages defaulted after two sessions because of lack of funds to continue the therapy.

Our results clearly showed an accelerated healing rate over the 3-month study period when compared to the period wherein the patients had been on routine wound dressing that ranged between 1 and 22 years with a median age of 7 years.Many forms of treatment had been advocated, which included topical dressing, systemic medication with zinc, split thickness skin graft, the use of flaps, and recurrent blood transfusion. Many of these methods of treatment neither gave satisfactory results nor accelerated the rate of healing of large CLU in SCA significantly.[13] Our experience during this pilot study showed that the healing of CLU in SCA could be accelerated with compression therapy when the personnel involved were adequately trained and appropriate equipment and elastic bandages were available. High-compression four-layer bandaging therapy system achieves up to 40 mmHg around the ankle and graduated to 20 mmHg just below the knee. It is associated with rapid ulcer healing and a reduction of recurrence.[14] Compression therapy is a noninvasive therapy that can be undertaken by nurses with a good learning curve. The study showed that these large ulcers heal at a considerable rate with compression therapy [Figure 2].

There is no available literature documenting the use of compression therapy in the treatment of CLU in patients with SCA in Nigeria, though there are claims for its anecdotal use in some hospitals.


  Conclusion Top


This pilot study showed that compression therapy offers a more effective healing rate than the traditional routine wound dressing in patients with SCA having large CLUs. The technique can easily be taught to nurses who routinely dress leg ulcers in our hospitals. A longer intervention of compression therapy treatment will promote a positive healing rate of the CLUs in patients with SCA in Nigeria. Other important factors to consider while promoting accelerated healing rate is good nutrition, regular hematologic clinic visits for review, and the prompt management of ulcer occurrence. However, a larger number of patients with CLU need to be studied to understand the epidemiology, social characteristics, and the genetics of these CLUs in patients with SCA.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clare A, FitzHenley M, Harris J, Hambleton I, Serjeant GR. Chronic leg ulceration in homozygous sickle cell disease: The role of venous incompetence. Br J Haematol 2002;119:567-71.  Back to cited text no. 1
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2.
Falusi AG, Kulozik EA. Relationship of foetal haemoglobin levels and βs haplotypes in homozygous sickle cell disease. Eur J Haematol 1990;45:1-4.  Back to cited text no. 2
    
3.
Nelzen O, Bergqvist D, Lindhagen A, Hallböök T. Chronic leg ulcers: An underestimated problem in primary health care among elderly patients. J Epidemiol Community Health 1991;45:184-7.  Back to cited text no. 3
    
4.
Mohan JS, Jacqueline E, Marshall JM, Hambleton IR, Serjeant GR. Abnormal venous function in patients with homozygous sickle cell (SS) disease and chronic leg ulcers. Clin Sci 2000;98:667-72.  Back to cited text no. 4
    
5.
Cumming V, King L, Fraser R, Serjeant G, Reid M. Venous incompetence, poverty and lactate dehydrogenase in Jamaica are important predictors of leg ulceration in sickle cell anaemia. Br J Haematol 2008;142:119-25.  Back to cited text no. 5
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6.
O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012;11:CD000265.  Back to cited text no. 6
    
7.
Moffatt CJ, Franks PJ, Oldroyd M, Bosanquet N, Brown P, Greenhalgh RM et al. Community clinics for leg ulcers and impact on healing. BMJ 1992;305:1389-92.  Back to cited text no. 7
    
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Lazarus G, Valle MF, Malas M, Qazi U, Maruthur NM, Doggett D et al. Chronic venous leg ulcer treatment: Future research needs. Wound Repair Regen 2014;22:34-42.  Back to cited text no. 8
    
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Akinyanju O, Akinsete I. Leg ulceration in sickle cell disease in Nigeria. Trop Geogr Med 1979;31:87-91.  Back to cited text no. 9
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Idaewor P, Enosolease M, Momoh M. Leg ulceration in a population of Nigerian patients with sickle cell anaemia—Twenty years experience. J Med Biomed Res 2004;1:18-21.  Back to cited text no. 10
    
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Durosinmi M, Gevao S, Esan G. Chronic leg ulcers in sickle cell disease: Experience in Ibadan, Nigeria. Afr J Med Med Sci 1991;20:11-4.  Back to cited text no. 11
    
12.
Bazuaye G, Nwannadi A, Olayemi E. Leg ulcers in adult sickle cell disease patients in Benin City, Nigeria. Gomal J Med Sci 2010;8:190-4.  Back to cited text no. 12
    
13.
Koshy M, Entsuah R, Koranda A, Kraus A, Johnson R, Bellvue R et al. Leg ulcers in patients with sickle cell disease [see comments]. Blood 1989;74:1403-8.  Back to cited text no. 13
    
14.
Fletcher J, Moffatt C, Partsch H, Vowden K, Vowden P. Principles of compression in venous disease. A Practitioner’s Guide to Treatment and Prevention of Venous Leg Ulcers. Wounds International; 2013. Available from: www.woundsinternational.com. [Last accessed on 2018 Mar 31].  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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