Punch grafting for pain reduction in hard-to-heal ulcers.

OBJECTIVE: Punch-grafting is a traditional technique to enhance wound healing, which has been associated with significant pain reduction. There are few studies measuring pain reduction after punch grafting, our study was designed to measure this outcome. METHOD: Patients with hard-to-heal wounds treated with punch grafting were included in a single centre prospective study. Wound pain intensity was measured using a Visual Analogue Scale (VAS) at baseline (before the procedure) and at three time points after the procedure. Punch grafting was performed in an outpatient setting. Patient demographic data, wound aetiology and percentage of graft take were recorded. RESULTS: A total of 136 patients were included (62 men and 74 women). Mean age was 60±35 years and 51 (38%) had venous leg ulcers (VLU), 29 (21%) had postoperative wounds, 15 (11%) Martorell ulcers, 15 (11%) traumatic wounds, four (3%) arterial ulcers and 22 (16%) 'other' ulcers. Of the patients, 38 (28%) did not present with painful ulcers and, after punch grafting, all of them remained painless; 29 (21%) patients obtained >70% pain reduction, whereas 73 (54%) patients achieved pain suppression. Pain suppression did not depend on the percentage of graft take. CONCLUSION: Punch-grafting is a simple, technique that not only promotes wound healing but also reduces pain. It can also be performed on an outpatient basis. Further studies should be performed to achieve a better understanding of this beneficial finding. Declaration of interest: The authors have no conflicts of interest to declare.

Factitious Ulcer Misdiagnosed as Pyoderma Gangrenosum.

Dermatitis artefacta may represent a real challenge for the clinician. As the patient does not admit self-inflicting the lesions, misdiagnosis with other diseases, such as pyoderma gangrenosum, is common. Consequently, these patients normally go through unnecessary tests and receive potentially harmful treatments as clinicians determine their diagnosis. The authors present the case of a recurrent factitious abdominal ulcer that was initially diagnosed and treated as pyoderma gangrenosum. This report focuses on the necessity of suspecting dermatitis artefacta when morphology, history, and treatment failures are difficult to explain. It is essential to establish a supportive and confident approach and avoid initial confrontation. In-patient treatment may be useful and long-term followup may prevent recurrences.