10.5826/dpc.1301a19
 Introduction: Digital ulcers represent a current public health issue, due to the relevant difficulties in their management and their tendency to become chronic, non-healing lesions.
We present an observational study of 28 patients referred to our Wound Care Service, focused on multidisciplinary and dermatological management.
Objectives: Our case series represents an opportunity to discuss the main comorbidities that affect these kinds of patients and to present an evidence-based protocol that has proved highly effective in our clinical practice.
Methods: We collected the clinical data of 28 patients referred to our Wound Care Service at S.Orsola-Malpighi Hospital, where they were all clinically evaluated; subsequently a local treatment was set up with dressings and the application of topical medications, while for most of them a further multidisciplinary evaluation was required to control the underlying disease and to avoid relapses.
Results: Digital ulcers were divided into 5 categories, based on the causative agent: peripheral artery disease, diabetes associated wounds, mixed wounds, pressure wounds and immune-mediated diseases associated with wounds. Each group received a specific management, based on the characteristics of the ulcer and the underlying comorbidities.                                                         
Conclusions: The clinical evaluation of digital wounds requires a thorough knowledge of the possible causes behind the onset of these ulcerative forms. In case of suspicion, send the patient for a specialist evaluation, to carry out a proper management of the case. A multidisciplinary approach in the management of these wounds is necessary to achieve a precise diagnosis and a correct treatment.
text/xml
2160-9381
2424
en
Bianca Maria Piraccini
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dressing
Digital Ulcers: Multidisciplinary Approach and Dermatological Management
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-02-26
2023-01-31
2023-02-27
e2023019
Dermatol Pract Concept
 Introduction: Digital ulcers represent a current public health issue, due to the relevant difficulties in their management and their tendency to become chronic, non-healing lesions.
We present an observational study of 28 patients referred to our Wound Care Service, focused on multidisciplinary and dermatological management.
Objectives: Our case series represents an opportunity to discuss the main comorbidities that affect these kinds of patients and to present an evidence-based protocol that has proved highly effective in our clinical practice.
Methods: We collected the clinical data of 28 patients referred to our Wound Care Service at S.Orsola-Malpighi Hospital, where they were all clinically evaluated; subsequently a local treatment was set up with dressings and the application of topical medications, while for most of them a further multidisciplinary evaluation was required to control the underlying disease and to avoid relapses.
Results: Digital ulcers were divided into 5 categories, based on the causative agent: peripheral artery disease, diabetes associated wounds, mixed wounds, pressure wounds and immune-mediated diseases associated with wounds. Each group received a specific management, based on the characteristics of the ulcer and the underlying comorbidities.                                                         
Conclusions: The clinical evaluation of digital wounds requires a thorough knowledge of the possible causes behind the onset of these ulcerative forms. In case of suspicion, send the patient for a specialist evaluation, to carry out a proper management of the case. A multidisciplinary approach in the management of these wounds is necessary to achieve a precise diagnosis and a correct treatment.
Bianca Maria Piraccini
2023/01/31
10.5826/dpc.1301a19
e2023019
IRCCS Azienda Ospedaliero-Universitaria di Bologna; Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale (DIMES) Alma Mater Studiorum – Università di Bologna, Italia
2160-9381
dressing
en
e2023019
Fink AM, Kottas-Heldenberg A, Mayer W, et al. Lupus anticoagulant and venous leg ulceration. Br J Dermatol. 2002;146(2):308-310. doi:10.1046/j.0007-0963.2001.04546.x
Digital Ulcers: Multidisciplinary Approach and Dermatological Management
https://dpcj.org/index.php/dpc/article/download/2424/1944
              Digital Ulcers: Multidisciplinary Approach
                  and Dermatological Management
       Michela Starace1,2, Gionathan Orioni1,2, Aurora Alessandrini1,2, Francesca Bruni1,2,
               Carlotta Baraldi1,2, Cosimo Misciali1,2, Bianca Maria Piraccini1,2


1 Dermatology Unit- IRCCS Azienda Ospedaliero-Universitaria di Bologna
2 Department of Experimental, Diagnostic and Specialty Medicine Alma Mater Studiorum University of Bologna, Italy



Key words: digital ulcer, multidisciplinary approach, dermatology, diabetes, ischaemic wound
Citation: Starace M, Orioni G, Alessandrini A, et al. Digital Ulcers: Multidisciplinary Approach And Dermatological Management.
Dermatol Pract Concept. 2023;13(1):e2023019. DOI: https://doi.org/10.5826/dpc.1301a19
Accepted: June 9, 2022; Published: January 2023
Copyright: ©2023 Starace et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Gionathan Orioni, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Dipartimento di Medicina Specialistica,
Diagnostica e Sperimentale (DIMES) Alma Mater Studiorum – Università di Bologna, Via Massarenti 1, 40138 Bologna, Italy.
Telephone number +390512144838 E-mail: gionathan.orioni@studio.unibo.it




  ABSTRACT             Introduction: Digital ulcers represent a current public health issue, due to the relevant difficulties in
                       their management and their tendency to become chronic, non-healing lesions.
                       Objectives: Our case series represents an opportunity to discuss the main comorbidities of digital
                       ulcers and to present an evidence-based treatment protocol that has proved highly effective in our
                       clinical practice.
                       Methods: We collected the clinical data about clinical features, associated diseases and diagnostic
                       therapeutical procedures of 28 patients with digital ulcers referred to our Wound Care Service at S.
                       Orsola-Malpighi Hospital.
                       Results: Digital ulcers were divided into 5 categories, based on the causative agent: peripheral artery
                       disease: 5/16 females and 4/12 males, diabetes-associated wounds: 2/16 females and 1/12 males, mixed
                       wounds: 4/12 males, pressure wounds: 3/16 females and 2/12 males, and immune-mediated diseases
                       associated with wounds: 6/16 females and 1/12 males. Each group received specific management,
                       based on the characteristics of the ulcer and the underlying comorbidities.
                       Conclusions: The clinical evaluation of digital wounds requires a thorough knowledge of their
                       ­aetiopathogenesis. A multidisciplinary approach is necessary to achieve a precise diagnosis and correct
                        treatment.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023019                                                                        1
Introduction                                                       ambulatorial mechanical debridement was performed. Gauze
                                                                   soaked in iodine was used as the main antiseptic medication.
With the increase in life expectancy, more and more patients
are suffering from chronic diseases and an increasingly inno-
vative and personal approach, which includes the collabora-        Results
tion between specialists from various branches of medicine
                                                                   From January 2020 to June 2021, we treated 28 patients
and surgery, is now part of a comprehensive care plan [1].
                                                                   with DU, 12 males and 16 females (Table 1). Median age
    Limb chronic ulcers have an increasing incidence, due to
                                                                   was 72.6 years (range 38-97 years): average age of males
the higher prevalence of chronic vascular and metabolic dis-
                                                                   was 68.3 years, that of females 75.9 years. The toes were
eases, such as peripheral artery disease (PAD) and diabetes
                                                                   the most common site of DU (24 patients), with 16 patients
mellitus, which play the main role in their aetiology.
                                                                   having ulcers of several digits (ranging from 2 digits to 4);
    Within the category of limb chronic ulcers, digital ulcers
                                                                   finger ulcers were present in 4 patients, one of them having
(DU) represent a small but peculiar group, due to their diffi-
                                                                   DU in 3 fingers, the other 3 in one finger.
cult management and their scarce tendency to heal.
                                                                      The diseases detected as causes of DU were as follows:
    We present an observational study of 28 patients with
                                                                   peripheral artery disease (PAD): 9 cases, all with DU of the
DU referred to our Wound Care Service, focusing on multi-
                                                                   toes; type 2 diabetes mellitus with poor glycaemic control:
disciplinary and dermatological management.
                                                                   3 patients, all with DU of the toes; association of PAD with
                                                                   type 2 diabetes mellitus: 4 patients, 3 with DU of the toes
Methods                                                            and 1 of a finger; pressure ulcers with toe involvement: 5
                                                                   patients; vasculitis: 3 patients with DU of the toes; systemic
We collected the clinical data of patients with DU referred        sclerosis (SSc) in 4 patients, 3 with DU of the fingers and
to the Wound Care Service (a tertiary referral center) of the      1 of a toe.
Dermatology Unit of the S.Orsola-Malpighi Hospital over
a period of 18 months, from January 2020 to June 2021.
                                                                   PAD-Associated DU
Only patients presenting with non-healing digital ulcers
                                                                   The 9 patients with PAD were evaluated by specific imag-
of the limbs, present for at least 6 weeks, were enrolled.
                                                                   ing investigation (color duplex ultrasound, computed tomo-
Demographic and clinical data were collected, including
                                                                   graphic angiography, magnetic resonance angiography) and
associated comorbidities and their therapy and previous ul-
                                                                   then referred to a vascular surgeon for possible revascular-
cerative episodes in other cutaneous areas. Diagnosis of the
                                                                   ization. Only 4 cases were revascularized, while in the other
disease that caused the DU was based on clinical history,
                                                                   5 the procedure was not possible due to the poor general
laboratory evaluation and histopathological study, when
                                                                   conditions and the high anaesthetic risk. The topical medica-
necessary. Management of these conditions was based on
                                                                   tion of the DU after debridement in all these patients was an
the main International Guidelines for the management of
                                                                   Iodine-based antiseptic dressing or a soft silicon foam dress-
peripheral artery disease in patients with foot ulcers and di-
                                                                   ing, in order to diminish the risk of bacterial superinfection
abetes [2-4] and on the evidence-based protocol for diabetic
                                                                   of necrotic tissue (Figure 1a). All the cases that underwent
foot u
     ­ lcers [5].
                                                                   revascularization showed a better outcome compared to the
    All the digital wounds were assessed for excluding any
                                                                   other cases, with a significant reduction in healing times.
signs of local or surrounding infection. In particular, the
                                                                   No correlations with any lymphatic drainage impairment
presence of at least 3 or more STONEES criteria (Size is big-
                                                                   were found in this group of patients after specific imaging
ger, Temperature elevated, Os, New breakdown, Exudate,
                                                                   investigation.
Erythema, Smell) lead to a systemic antibiotic treatment. The
presence of at least three NERDS criteria (Nonhealing, Exu-
date Increase, Red friable granulation, Debris) was followed       Diabetes-Associated DU
by a topical antimicrobial therapy [3].                            Seven patients presented type 2 diabetes mellitus in poor
    The evaluation of pain associated with the DU was per-         glycaemic control, associated with the presence of DU. In
formed using the VAS (visual analogue scale). All patients         3 cases diabetes was identified as the primary cause of the
with pain equal or superior to 5 on the VAS scale, despite ad-     ulcerative lesions, as laboratory and technical evaluations
equate medication and non-responder to paracetamol, were           excluded other comorbidities: these patients were referred to
managed by our Pain Therapy Service.                               the Diabetology service for a review of their metabolic sta-
    Despite the cause of the DU, mechanical debridement of         tus and chronic hypoglycaemic therapy and underwent local
the necrotic tissues was performed in all cases. In three cases,   medications with gauze soaked in iodine to accelerate wound
the use of local medications was preceded by a total surgi-        healing. A better clinical outcome was achieved only after
cal debridement of necrotic tissue. In the other patients, an      the diminishment of these patients’ plasma glucose values.

2                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e2023019
                           Table 1. Clinical characteristics of the patients with digital ulcers.
     Patient       Age         Sex           Number of wounds                      Localization                Aetiology
 1                    50        F                        2                              toe                    Diabetes II
 2                    70        M                        2                              toe               Diabetes II and PAD
 3                    95        F                        4                              toe                         PAD
 4                    80        M                        3                             finger                       SSc
 5                    64        M                        2                              toe                         PAD
 6                    81        F                        1                              toe                         PAD
 7                    50        M                        1                             finger             Diabetes II and PAD
 8                    82        F                        1                              toe                  Pressure ulcer
 9                    82        F                        4                              toe                    Vasculitis
 10                   83        M                        2                              toe                    Diabetes II
 11                   58        M                        1                              toe                         PAD
 12                   81        M                        1                              toe               Diabetes II and PAD
 13                   83        F                        1                              toe                    Vasculitis
 14                   46        M                        3                              toe                  Pressure ulcer
 15                   69        M                        1                              toe               Diabetes II and PAD
 16                   97        F                        5                              toe                         PAD
 17                   89        F                        2                              toe                    Diabetes II
 18                   92        F                        4                              toe                         PAD
 19                   84        F                        2                              toe                  Pressure ulcer
 20                   56        F                        1                              toe                         SSc
 21                   64        F                        3                              toe                    Vasculitis
 22                   80        F                        2                              toe                         PAD
 23                   80        M                        3                              toe                  Pressure ulcer
 24                   83        F                        2                              toe                  Pressure ulcer
 25                   58        M                        1                              toe                         PAD
 26                   58        F                        1                             finger                       SSc
 27                   38        F                        1                             finger                       SSc
 28                   80        M                        2                              toe                         PAD

M: Male; F: Female; PAD: peripheral artery disease; SSc: systemic sclerosis.


     In 4 patients, type 2 diabetes was associated with arteri-         polyneuropathy of the lower limbs (1 case). In these cases,
opathy of the large vessels of the lower limbs that required            mechanical debridement of the eschar followed by topical
prompt revascularization (Figure 1b). Surgery increased the             therapy with iodine gauzes was associated with a physiatrist
chances of wound healing in these patients.                             consultation that lead to the prescription of plantar orthosis
     Obesity and metabolic syndrome are often present in                and anti-decubitus mattresses. All the procedures allowed
patients with diabetes II and PAD, as they recognize a sed-             wound healing with restoration of the physical integrity of
entary lifestyle as a common denominator, associated with               the toe skin (Figure 1c).
unbalanced nutrition. However, no direct correlations were
found between these factors and the development of digital              Immune-Mediated Disease-Associated DU
ulcerative lesions.                                                     Four patients, 3 with DU of the fingers and 1 of a toe suf-
                                                                        fered from SSc (Figure 1d). A skin biopsy of the DU showed
Pressure DU                                                             in all cases skin calcinosis. These patients were managed
Five patients with pressure ulcers of the feet developed toe            through the close collaboration of rheumatologists.
lesions as an effect of continuous forces directed to the distal               One patient with DU of the toe was affected by rheu-
pulp, causing progressive skin ischemia above bone prom-                matoid arthritis and 2 by systemic lupus erythematous. A
inences4. These patients were bedbound due to progressive               biopsy of the perilesional skin showed leukocytoclastic vas-
neurological diseases, such as multiple sclerosis with spinal           culitis with fibrinoid necrosis of the vessel walls and promi-
involvement (4 cases) or a severe form of motor-sensitive               nent polymorphonuclear cell infiltration.

Original Article | Dermatol Pract Concept. 2023;13(1):e2023019                                                                      3
    Figure 1. Clinical images of patients with digital ulcers of different aetiology. A 92-year-old female patient with two recently occurring
    ischemic ulcers at her right first toe, in the context of peripheral artery disease (A); a 50-year-old female patient with extensive necrosis
    at her distal phalanx of the right first toe, in the context of poorly controlled diabetes mellitus (B); an 82-year-old female patient with
    a well-demarcated pressure ulcer at the fourth finger of her left foot (C); an 80-year-old male patient with a necrotic ulcer at the distal
    phalanx of the fourth finger of his left hand, in the context of systemic sclerosis (D).




      The clinical suspicion of autoimmune disease in this                  and on the respective aetiologies. The multidisciplinary man-
group of patients derived from suggestive anamnestic data                   agement of the different cases represents the standard model
collection and from the execution of skin biopsies of the ul-               to get better the outcome of patients suffering from multiple
cerative lesions. A subsequent rheumatological evaluation                   comorbidities.
confirmed the clinical suspicion.
                                                                            PAD-Associated DU

Discussion                                                                  The term peripheral arterial disease defines the lower ex-
                                                                            tremity artery disease, including obstruction at the aortoil-
Our literature search could not identify any studies that col-              iac, femoropopliteal and infrapopliteal arterial segments [5].
lected such a large number of cases regarding DU of both fin-               Studies have shown an increased risk of cardiovascular mor-
gers and toes, making a subdivision based on clinical aspects               tality, as well as of morbidity from myocardial infarction



4                                                                                Original Article | Dermatol Pract Concept. 2023;13(1):e2023019
and stroke in patients with asymptomatic or symptomatic             must be carried out [19]. It is important to assess the pedal
arterial disease [2]. The distal localization of the vascular ob-   pulses, and unless a pulse is clearly palpable, all patients
struction leads to the formation of chronic ulcerative lesions      with foot ulcers should undergo non-invasive vascular
of the acral extremities, mainly of the lower limbs, with the       testing, to determine if the patient would benefit from re-
appearance of necrotic eschars of the distal phalanges of the       vascularization. In an observational study, shorter time to
toes. These ulcers are at high risk of bacterial superinfection.    revascularization (<8 weeks) was associated with a higher
The association with both uncontrolled type II diabetes mel-        possibility of healing of ischaemic foot ulcers [20]. In ad-
litus is common, therefore in these patients, the evaluation of     dition, it is mandatory that every patient be evaluated for
the arterial function with imaging techniques should always         proper orthotics, and appropriate footwear should be pre-
be associated with laboratory monitoring of the glycaemic           scribed that adequately protects the foot from trauma in-
state, as type II diabetes comorbidity greatly impairs local        duced by shoes and alleviates pressure, considering the fact
wound management [6].                                               that pressure and pain sensation are often impaired in these
    The symptoms and signs of PAD are variable and range            patients [21].
from the classic symptom of claudication to other non–
joint-related limb symptoms (atypical leg symptoms) or              Pressure DU
are absent [7-10]. In these cases, the DU may be the first          Prolonged bed rest caused by paraplegia and various central
sign that leads to the diagnosis. The vascular examination          nervous system diseases plays an important role in the forma-
for PAD includes pulse palpation, auscultation for femoral          tion of pressure acral lesions, which follow prolonged skin
bruits, and inspection of the legs and feet [8]. To confirm the     ischemia and are especially located above bony prominences.
diagnosis of PAD, abnormal physical examination findings            The first signs of ischemia are the formation of calluses at the
must be confirmed with diagnostic testing [5]. Studies for          level of the toepads. If not recognized and treated, they lead
anatomic imaging assessment (duplex ultrasound, computed            to the formation of painless and difficult-to-treat chronic ul-
tomography angiography [CTA], or magnetic resonance                 cers. The application of physical means such as intermittent
angiography [MRA], invasive angiography) are generally              pneumatic compression devices and the evaluation from ex-
reserved for highly symptomatic patients in whom revascu-           pert physiotherapists is necessary in these patients, in order
larization is being considered [9].                                 to prevent the extension of the wound and the arising of
    Patients with PAD associated with skin ulcers fall into a       other similar lesions in other toes [22].
high-risk cardiovascular group, due to the signs of advanced           In people suffering from advanced neurological con-
       10
disease : for this category, a careful multidisciplinary evalu-     ditions, spasticity is significantly associated with the de-
ation is important in order to select patients eligible for sur-    velopment of pressure ulcers in typical and even atypical
gical revascularization and to increase the chance of wound         locations [23]. Severe spastic conditions might facilitate
healing, as well as of reducing a progression of disease [11].      wound onset in various ways: increased tonus of the limbs
    Adequate pharmacological therapy associated with a              leads to immobility and to a reduced capacity to reposition
healthy lifestyle is mandatory for the chronic management           the body, with an abnormal pressure redistribution. This
of this disease and to reduce the global cardiovascular risk        prolonged rigidity causes severe soft tissue injury [4, 24]. A
[12, 13].                                                           comprehensive assessment is warranted with a focus on iden-
                                                                    tifying the source of pressure, contributing factors, underly-
Diabetes-Associated DU                                              ing comorbidities, and elements affecting wound healing.
As for diabetic foot ulcers, they occur in between 12 and              Pressure redistribution targeting the duration and/or
25% of patients with type 2 diabetes mellitus [14] and              magnitude of loading is critical [25, 26]. Evidence exists that
­precede 84% of all non-trauma limb amputations in this             advanced support surfaces are superior to standard hospital
growing slice of the population [15].                               beds in preventing and managing pressure injuries. However,
    A diabetic foot ulcer is defined as any skin breakdown          no clear advantage has been identified for one specific ad-
on the foot of a diabetic person [16]. Early recognition            vanced support surface over another [27].
of the skin defect and treatment prevents its progression              There is strong evidence that a moist wound environ-
to a chronic wound that is often recalcitrant to therapy            ment accelerates healing in this type of DU: occlusive dress-
[17-18].                                                            ings seem to be superior to more-traditional simple gauze,
    When a patient with a diabetic foot ulcer is first seen,        especially in terms of maintaining a moist wound environ-
a comprehensive history and treatment plan must be put              ment [28]. Ultimately the dressing selection may be guided
into place. Then, a laboratory evaluation based on their            by the characteristics of the wound, balance of moisture and
metabolic status, and the monitoring for any complications          exudate, bacterial control, debridement balance, ease of use,
(e.g. heart disease, renal failure, retinopathy, neuropathy)        cost, and patient preference [29].



Original Article | Dermatol Pract Concept. 2023;13(1):e2023019                                                                    5
Immune-Mediated Disease-Associated DU                                                                the autoimmune disease is imperative. Adalimumab with
Inflammatory and autoimmune systemic diseases may first                                              methotrexate (MTX) has shown promise in RA-associated
become clinically evident with the appearance of an ischemic                                         ulcers [39]. Improving wound bed preparation by the appli-
digital wound. SSc is the best described among these types                                           cation of moisture-retentive dressings has been shown to be
of conditions [30]. Cutaneous and/or systemic vasculitis can                                         beneficial [40].
also present with the formation of necrotic lesions involving                                            Systemic lupus erythematosus (SLE) is a systemic auto-
the fingers of the limbs, both the upper and lower ones. SSc is                                      immune connective tissue disease that can affect most or-
an immune-mediated disease that represents a major clinical                                          gan systems. Ulcerations are not infrequent and, like other
challenge for physicians and patients. For the patient, SSc                                          connective tissue diseases, they are multifactorial [41].
is associated with great uncertainty of outcome and devel-                                           ­Vasculitis, noninflammatory thrombosis of small or large
opment of manifestations that are potentially lethal or can                                          vessels, venous insufficiency, lupus profundus, lichen pla-
reduce quality of life [31].                                                                         nus overlap, and drug-induced lupus syndrome has been
      The problem of digital ulcers is increasingly reco­                                            associated with leg ulcerations. The ulcers are usually pain-
gnised [32]. DU occur in around half of SSc cases during their                                       ful, sharply margined, or punched out. Adjacent skin can
disease history, and about one in five patients might have this                                      appear erythematous, purpuric, or rolled and violaceous.
complication at any one time [33, 34]. There is now a better                                         ­Histological examination of vasculitis ulcers in SLE shows
appreciation of the effects of digital ulcers, which include im-                                     a leukocytoclastic vasculitis with fibrinoid necrosis of the
paired function, pain, and loss of employment, as well as the                                        vessel walls and prominent polymorphonuclear cell infiltra-
more obvious medical complications of cellulitis, osteomy-                                           tion. Thrombocclusive histologic findings can be associated
elitis, digital infarction, and severe pain. Treatment of digital                                    with the presence of antiphospholipid antibodies (lupus an-
ulcers with drugs or systemic therapies needs to be com-                                             ticoagulant) [42]. SLE-associated leg ulcers are a therapeutic
bined with appropriate expert local care and dressings, and                                          challenge, as local wound care is not always sufficient. The
this treatment usually benefits from specialist nurse input.                                         underlying cause of the ulceration needs to be established
Evidence-based treatments include phosphodiesterase-5 in-                                            and treated. If vasculitis is present, systemic corticosteroids
hibitors and endothelin receptor antagonists, although some                                          with cytotoxic agents should be utilized [37].
studies have not shown a clear treatment benefit [35, 36].
      Rheumatoid arthritis (RA) is a chronic, inflammatory                                           Conclusion
autoimmune disorder expressed most commonly as a sym-
metrical, deforming arthropathy [37]. A well-known cause                                             The clinical evaluation of DUs requires a thorough knowl-
of ulceration in rheumatoid arthritis is vasculitis. Vessels of                                      edge of their possible causes. A careful clinical evaluation is
different sizes may be affected. These patients will require                                         necessary together with laboratory and imaging technique
systemic therapy because mortality can be high [38].                                                 investigations. A multidisciplinary approach in the manage-
      Workup for the patients should include a complete his-                                         ment of these wounds is the only effective way to achieve
tory and thorough physical exam, screening laboratory stud-                                          a precise diagnosis and a correct treatment, as described
ies and biopsies. Treatment is a challenge, but stabilizing                                          in Figure 2.



                                                                           Clinical assessment of the wound



    Assess the lower       Exclude a bacterial            Evaluate the      Evaluate the pain with
                                                           degree of                                                                                            Exclude a paraneoplastic
    extremity pulses     superinfection using the                               the VAS scale              Presence of a history of      Make a skin biopsy
                                                          mobilization                                                                                         syndrome if an acute onset
                         NERDS/STONEES criteria                                                            diabetes mellitus with a       if an AD and/or a      with multiple lesions are
                                                                                                           scarce glycemic control      secondary vasculitis   associated with a neoplastic
   Make a doppler                                                                    Refer to a pain
  ultrasound exam if                                                                  management                                         history is present              history
                                  Start with                   Refer to a
 they are not present       antiseptics and/or            physiotherapist            specialist if not
                               antimicrobials              if the patient is           adeguately          Exclude a concomitant
                                    topics                bedbound or if a             controlled           involvement of large
                                                                                                                                                                         An oncological
         Refer to an         if clinical signs of           rehabilitation                                   vessels with an ECD
                                                                                                                                                Refer to a            evaluation is required
         angiologic         local infection are               program is                                         ultrasound
                                                                                                                                             rheumatologist
       examination if              present                     required                                                                          for an
       perfusion signs
                                                                                                                                               evaluation
       are not present
                                                                                                                     Refer to a
                                    Start systemic antibiotics and refer to an infectious                       diabetologist for the
                                    disease specialist if clinical and laboratory signs of                       correct metabolic
                                        deep and progressive infection are present                                 management




Figure 2. Clinical evaluation in the management of digital wounds. NERDS: Nonhealing, Exudate Increase, Red friable granulation, Debris;
STONEES: Size is bigger, Temperature elevated, Os, New breakdown, Exudate, Erythema, Smell; VAS: visual analogue scale; ECD: echo
colour doppler; AD: autoimmune disease.


6                                                                                                        Original Article | Dermatol Pract Concept. 2023;13(1):e2023019
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