Pain in Leg Ulcers

This may be severe in all types of ulcer with the possible exception of diabetic sensory neuropathy.

“The pain of leg ulceration can dominate patients’ lives an can have serious psychological and social effects on patients’ quality of life” (Hildegard 1995)

Pain causes the release of catecholamines via the limbic system.

Pain increases levels of adrenaline, nor adrenaline and steroids

Pain often decreases appetite, reduces mobility and may lead to depression.

Pain is a response to tissue damage

Pain influences patient compliance

Causes of Pain

Ischaemia

It is well known that pain caused by arterial insufficiency is common in arterial ulcers.

Try to improve the blood supply to relieve pain e.g.

Infection

An increase in pain may be caused by infection. As the elderly do not often exhibit the classic immune response, consider this possibility, even if there are no other features such as cellulitis.

Treatment consists of combating the infection i.e.

Instruct patients to return if pain increases when using long term dressings.

Atrophy blanche

Areas of white fibrosis with pinpoints of red capillaries try to get through the fibrous tissue.

This condition is often pre-ulcerative so management is directed towards preventing deterioration e.g.

Assessment of pain

Venous ulcers may be extremely painful, pain may be severe at night in purely venous ulcers. About two thirds have severe pain and about the same percentage suffer sleep disturbance. About one third have constant pain (Hofman 1997).

About half also report itching (Pasero 1995), especially in later stages of healing.

Clearly superficial ulcers can be more painful than deep ones.

A possible rating scale (pain is only a subjective experience at the moment)

1. mild 2. discomforting 3. distressing 4. horrible 5. excrutiating

Factors

Is the pain continuous or related to standing up (transitory grade 5 stabbing pain is sometimes reported) or interventions. Chronic pain usually requires treatment.

Take time to discuss pain with the patient, they will be pleased it is being taken seriously.

Some patients under report pain.

Explain that compression therapy may initially increase pain.

Take pain into account in dressing choice, document after dressing changes.

Monitor effectiveness of analgesic treatments.

Chart improvement in pain as ulcer heals.

Pain à inability to tolerate pressure dressing à sitting out at night and reduced mobility à increased leg oedema à ulcer gets worse à more pain.

Management of pain

Limb position Dressing and compression

Consider analgesia before dressing changes Non-adherent dressings

Soak off sticky dressings Allow patients to remove own dressing if they want to

Check for allergy to dressings Entonox if dressing causes distress

Pain is often less after dressing change, may reduce maceration from wet dressing or pulling off the wound bed from dry ones. Consider more frequent changes, consider teaching patient to change at home.

Moist would healing principle – hydrogel or hydrocolloids may bathe nerve endings so reduce pain, both on application while in situ. Debridement is also painless.

Moist wound healing dressings prevent nerve endings drying out and keep wound bed warm.

Dressings impregnated with iodine may sting.

Topical analgesia may be used in small ulcers or before debridement, of limited use in long term pain.

Systemic analgesics, antidepressants, anti-convulsants.

Deep dull constant pain – use centrally acting analgesics in divided doses e.g. buprenorphone 200 mg sublingually 8 hourly.

Superficial burning type pain – try compound analgesics e.g. dihydrocodein and paracetamol 4-6 hourly.

Tell patients analgesics will not be addictive – analgesia is part of curative treatment.

Preventing pain is easier than treating pain.

Tiredness often exacerbates pain – analgesia before bedtime.

Skin grafting is usually very effective.