Systemic sclerosis chronic ulcers: preliminary results of treatment with allogenic skin grafting in a cohort of Italian patients

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Systemic sclerosis (SSc) represents a heterogeneous group of rare diseases characterised by small vessel vasculopathy, production of autoantibodies and fibroblast dysfunction leading to increased deposition of extracellular matrix 1. Skin ulcers are a common manifestation of SSc. Patients often present painful and hard-to-heal lesions that markedly reduce the quality of life 2, 3. The prevalence of non-digital ulcers in Ssc patients is estimated at 4% 4; these ulcers have a multifactorial pathogenesis, and some authors have hypothesised a role for large vessel venous and arterial disease in the pathogenesis 5. An innovative approach for the management of chronic ulcers is reconstructive surgery using skin substitutes, particularly for large and deep ulcers 6, 7. Allograft using preserved cadaver skin can be used in the same way as a skin substitute (these kinds of grafts are not vascularised and finally the skin is desiccated and avascular necrosis occurs) and has been proved to be effective in both burns and chronic leg wounds. Some authors defined allograft as the ‘gold standard’ for temporary wound coverage 8, which provides a quick pain reduction and a barrier function, reduces bacterial contamination and promotes angiogenesis in the wound bed 8. The aim of this study was to retrospectively evaluate the effect of skin allograft in a cohort of consecutive SSc patients with painful chronic ulcers that were not responsive to modern advanced wound dressing. From January 2006 to December 2012, consecutive SSc subjects affected by chronic ulcer referred to our vascular surgery department for allogenic skin grafting were enrolled. Data were retrospectively retrieved from the clinical charts. The diagnosis of SSc was established using the American College of Rheumatology (ACR) criteria 9. The primary outcome was to assess the effectiveness in terms of pain reduction, which was evaluated using a visual analogue scale (VAS), complications and rate of infections. A total of 43 SSc patients (5 males and 38 females) were treated using allogenic skin grafting. The mean age at the time of intervention was 60.8 years (range 39–83 years). The ulcers were localised in the following areas: 34 lower extremities (10 digital), 8 upper extremities (3 digital) and 1 both upper and lower digital ulcers. The mean ulcer duration was 27 months (range 2–140 months). Patients, in addition to SSc, presented the following additional risk factors for ulcer development: venous insufficiency (13 patients), systemic arterial hypertension (17 patients), diabetes mellitus (3 patients), hypercholesterolaemia (5 patients) and obesity (1 patient). The most relevant result was a rapid reduction of ulcer-related pain. The VAS for pain at baseline was 7.55 cm (range 4–10 cm), and immediately after the procedure, it was significantly reduced by 84%, reaching a mean value of 1.18 cm (range 0–5 cm) (P < 0.001). All patients healed completely in less than 3 months, but 37% had an ulcer recurrence in the same location during the subsequent year. No serious side effects were recorded after the procedure. No patients presented an infection in the grafting area in the first 4 weeks after the surgery. Our study is the first describing the effectiveness of allogenic skin grafting in chronic ulcers in Ssc patients. The use of allogenic skin grafting was found to be a safe and effective treatment for SSc chronic ulcers in serious refractory situations. This procedure seems to favour wound healing and significantly reduces pain as compared with conservative dressing. The major limitations of our study were the retrospective collection of data with some missing values and the lack of a control group. Although the procedure is quite expensive, it may be considered in selected cases with poor outcome despite traditional therapy. Further studies and randomised controlled trials are needed to identify the prognostic factors of response to allografts and to help the selection of patients most suitable for the procedure. Simone Barsotti1, Vincenzo Mattaliano2, Anna d'Ascanio1, Giovanni Mosti2, Alessandra Della Rossa1, Chiara Mattaliano3, Dilia Giuggioli4, Enzo Giraldi5, Clodoveo Ferri4, & Marta Mosca1 1Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy [email protected] 2Angiology Department, Clinica MD Barbantini, Lucca, Italy 3Vulnologic Out-Patient Clinic, Fucecchio, Italy 4Rheumatology Unit, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy 5Day Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy

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