Addressing the Pain: Considering Patient Priorities when Choosing a Dressing

    Ulcerations on the lower extremities affect about 2.5 million people in the US.¹ Various common conditions that may cause ulcerations include venous insufficiency, peripheral arterial disease, connective tissue disorders, diabetes, microthrombotic disease, and vasculitis.

Whatever the cause of the ulcerations, the road to healing is often long and impacts not only the cost of healthcare but also, more importantly, the quality of life of the person and family involved.

    A significant aspect of wound healing is choosing a wound care product that will address not only the needs of both the wound and the patient. Clinical wound management product choice decisions are based on the amount of drainage, location of the wound, wound bed condition, wound size, and underlying cause of the wound. For the patient, ease of application (often in response to physical limitations from aging and disease processes), availability of the product, and level of comfort are important. Often, ulcerations are painful regardless of the underlying condition. One foam dressing allowed patients with painful ulcerations to obtain a better level of comfort, was easy to apply, and promoted wound healing.

Case Studies

    Case 1. Ms. Z, a 77-year-old Caucasian woman, presented with an ulcer on the lateral aspect of her left heel (see Figure 1). The ulcer was spontaneous with no known trauma. Her medical history included diabetes mellitus type II with neurological manifestations, hypertension, hyperlipidemia, rheumatoid arthritis, and coronary artery disease.

    Initial ulcer treatment provided by her primary care physician included Duoderm (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ) applied to the ulcer every 1 to 3 days. Ms. Z presented to the dermatology clinic about 2 weeks later with macerated periwound skin. The wound measured 5 mm x 5 mm x 22 mm and the wound bed contained 100% pink tissue with no odor or erythema. The area was tender when Ms. Z walked despite her use of diabetic shoes with inserts that were recently checked. She rated pain in the ulcer as 10 out of 10 mainly when she walked (put weight on the affected area) and noted no nighttime or claudication type pain. A recent ankle/brachial index showed biphasic blood flow to the affected lower extremity but the ratio could not be calculated due to medial calcinosis. The area was difficult for her to reach to change dressings.

    Treatment. Clinicians sought to address Ms. Z’s main issues — finding a dressing that not only will keep her comfortable but also one that she is able to apply and maintain. They determined that because the original dressing of choice may have contributed to the increased moisture/maceration around the wound, topical care was changed to Polysporin® powder (Warner-Lambert, Morris Plains, NJ) and gauze daily. On her return visit to clinic, the integrity of the periwound had improved — her skin was intact and no maceration was noted but she was still rating her pain at 10 out of 10. In addition, the daily dressing change involving the powder and gauze was difficult to perform — she often missed the site because she could not physically bend to reach it very well. To address localized pain, her care regimen was changed to topical lidocaine 2% gel applied one to four times a day and covered with gauze. 

    At her next visit, Ms. Z reported the lidocaine had provided minimal relief but she still had difficulty doing the frequent dressing changes. Her ulcer size was unchanged and no signs/symptoms of infection were noted. Her pain remained at about 10 out of 10, mainly with weight bearing. The decision was made to stop the lidocaine gel and gauze dressing regimen and try Mepilex® Border Self-Adherent Soft Silicone Foam Dressing (Mölnlycke Health Care, Newtown, Pa.), a waterproof dressing that can stay in place for several days. After the foam dressing was applied in the office, Ms. Z reported an immediate decrease in the pain to 6 out of 10, saying, “It feels better already.” The foam dressing offered additional padding and comfort to her diabetic shoes and did not compromise the fit.

    By her next visit, Ms. Z’s pain decreased to 2 out of 10. She reported rare discomfort as compared to “pain all the time when I would walk.” Her periwound skin was intact with no erythema or odor from the ulcer. Her wound bed continued to show 100% pink tissue and her wound size was stable at 5 mm. Ms. Z is able to leave the dressing in place for 3 days, she can shower, and she is able to apply the dressing herself because gauze and tape are not necessary — once the border foam dressing is situated, it stays in place.

    With the foam dressing, Ms. Z was able to achieve good pain relief results and the foam is providing both pressure relief and a moist environment for healing. Her ulcer healing continues to be monitored. In the patient’s view, the product is excellent.

    Case 2. Ms. B, a 68-year-old Caucasian woman, presented to the dermatology department with ulcers on her right foot. The ulcers began spontaneously with no known trauma. Her medical history included chronic renal failure (she was on hemodialysis); thrombotic thrombocytopenic purpura; hypertension; cerebrovascular accident; and seizures. Ms. B’s initial wound treatment included Duoderm (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ) and compression hose. She rated the pain in her ulcers as 10 out of 10 — the pain was not related to activity and she experienced no nighttime/ischemic pain and no claudication pain. On her initial visit, only two ulcers were present on her right foot at the medial malleolus and the lateral malleolus. The wound borders had a round, punched-out appearance. The wound beds contained pale white tissue and the ulcers demonstrated atrophie blanche type changes. Ms. B had positive dorsalis pedis pulses. On subsequent visits, additional ulcers were noted on Ms. B’s left foot (see Figure 2).

    Treatment. The goal was to find a dressing/wound treatment that would make Ms. B more comfortable and protect the ulcers. The initial product was chosen with the thought that its semi-occlusive nature would provide some comfort, but Ms. B’s pain had not decreased by her return visit. Her clinicians decided to apply lidocaine gel 2% under the dressing.

    This new regimen offered no improvement in the condition of ulcers and Ms. B’s pain level was still 10 out of 10. By now, Ms. B had developed ulcers on the left foot. The soft silicone border foam dressing was applied to ulcers on both feet. Ms. B immediately noted increased comfort and decreased pain — “about half of what it had been” and was given the product to take home.

    On Ms. B’s return visit, the ulcers on her right foot had healed but several scattered pinpoint ulcerations remained on the left foot around the lateral malleolus. Her pain decreased to a 2 to 4 out of 10 with foam dressing and she can leave it in place for about 3 days with no trauma to the skin from the product.

Conclusion

    Using a soft silicone border foam dressing can decrease a patient’s level of pain as well as protect ulcer sites. This is especially important when wounds may be slow to heal as a result of other conditions and the patient sees no end in sight from the discomfort. A product that relieves the distress from pain and frequent difficult-to-negotiate dressing changes can improve quality of life for everyone involved in the patient’s care.

1. Seaman S. Evaluation and management of lower extremity ulcers: adherence to prescribed therapy can save limbs. Advances for Nurse Practitioners. 2002;10(3): 32–47.