Chronic wounds in patients with underlying autoimmune diseases: A dermatological point of view

Over 20% of patients with chronic wounds have an autoimmune disease. Bullous autoimmune dermatoses hold a special place among the dermatological pathologies associated with chronic ulcers, Wound surfaces in this group of patients quickly become infected without prudent care. Besides, the treatment of ulcers in patients with bullous dermatoses is quite a challenging task, as even minimal skin injury during dressing changes can lead to the development of an ulcer defect. In this regard, a clinical case report of a female patient diagnosed with “pemphigus foliaceus with concomitant rapidly progressive multiple sclerosis” receiving biological therapy appears to have interesting features. The main complaint included chronic ulcerous defects in the intergluteal fold area, which persisted for a long period. In addition to standard therapy for pemphigus foliaceus, the female patient’s wound was treated with LUOFUCON extra silver alginate dressing for 3 weeks, which was changed every 7 days. During the therapy, almost complete epithelialization of the wound surface was achieved by day 12. This case demonstrates the need to pay careful attention to wound hygiene, especially in cases of hard-to-heal ulcers. The antimicrobial dressings, along with the sanitation of the wound surface, can effectively combat infection. Alginate dressings absorb wound fluid and maintain a moist environment, which, together with a powerful antibacterial effect, improves the wound microenvironment and promotes faster epithelialization. At the same time, the dressings neither stick to the wound bed, nor injure it during dressing changes, which is especially important in patients with bullous dermatoses.

1. Zhang L, Wang XT, Chu WL. Advances on the research and treatment of autoimmune disease-related chronic wounds. Zhonghua Shao Shang Yu Chuang Mian Xiu Fu Za Zhi. 2022;38(6):563–568. https://doi.org/10.3760/cma.j.cn501225-20220329-00101.

2. Patil S, Gs V, Sarode GS, Sarode SC, Khurayzi TA, Mohamed Beshir SE et al. Exploring the role of immunotherapeutic drugs in autoimmune diseases: A comprehensive review. J Oral Biol Craniofac Res. 2021;11(2):291–296. https://doi.org/10.1016/j.jobcr.2021.02.009.

3. Shanmugam VK. Vasculitic diseases and prothrombotic states contributing to delayed healing in chronic wounds. Curr Dermatol Rep. 2016;5(4):270–277. https://doi.org/10.1007/s13671-016-0157-2.

4. Yancey KB. The pathophysiology of autoimmune blistering diseases. J Clin Invest. 2005;115:825–828. https://doi.org/10.1172/JCI200524855.

5. Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune subepidermal bullous diseases of the skin and mucosae: clinical features, diagnosis, and management. Clin Rev Allergy Immunol. 2018;54:26–51. https://doi.org/10.1007/s12016-017-8633-4.

6. Vorobyev A, Ludwig RJ, Schmidt E. Clinical features and diagnosis of epidermolysis bullosa acquisita. Expert Rev Clin Immunol. 2017;13:157–169. https://doi.org/10.1080/1744666X.2016.1221343.

7. Sugai T, Ujiie H, Nakamura H, Kikuchi K, Iwata H, Shimizu H. Case of autoimmune intraepidermal and subepidermal blistering disease in which autoantibodies to desmoglein 1 and BP230 coexist. J Dermatol. 2019;46(6):e215-e216. https://doi.org/10.1111/1346-8138.14734.

8. Mosselhy DA, Assad M, Sironen T, Elbahri M. Nanotheranostics: A Possible Solution for Drug-Resistant Staphylococcus aureus and their Biofilms? Nanomaterials. 2021;11(1):82. https://doi.org/10.3390/nano11010082.

9. Taati Moghadam M, Khoshbayan A, Chegini Z, Farahani I, Shariati A. Bacteriophages, a new therapeutic solution for inhibiting multidrugresistant bacteria causing wound infection: lesson from animal models and clinical trials. Drug Des Devel Ther. 2020;14:1867–1883. https://doi.org/10.2147/DDDT.S251171.

10. Sweere JM, Ishak H, Sunkari V, Bach MS, Manasherob R, Yadava K et al. The Immune Response to Chronic Pseudomonas aeruginosa Wound Infection in Immunocompetent Mice. Adv Wound Care. 2020;9(2):35–47. https://doi.org/10.1089/wound.2019.1039.

11. Secor PR, Burgener EB, Kinnersley M, Jennings LK, Roman-Cruz V, Popescu M et al. Pf Bacteriophage and Their Impact on Pseudomonas Virulence, Mammalian Immunity, and Chronic Infections. Front Immunol. 2020;11:244. https://doi.org/10.3389/fimmu.2020.00244.

12. Sen CK, Mathew-Steiner SS, Das A, Sundaresan VB, Roy S. Electroceutical management of bacterial biofilms and surgical infection. Antioxid Redox Signal. 2020;33(10):713–724. https://doi.org/10.1089/ars.2020.8086.

13. Barki KG, Das A, Dixith S, Ghatak PD, Mathew-Steiner S, Schwab E et al. Electric Field Based Dressing Disrupts Mixed-Species Bacterial Biofilm Infection and Restores Functional Wound Healing. Ann Surg. 2019;269(4):756–766. https://doi.org/10.1097/SLA.0000000000002504.

14. Rahim K, Saleha S, Zhu X, Huo L, Basit A, Franco OL. Bacterial Contribution in Chronicity of Wounds. Microb Ecol. 2017;73(3):710–721. https://doi.org/10.1007/s00248-016-0867-9.

15. Ganesh K, Sinha M, Mathew-Steiner SS, Das A, Roy S, Sen CK. Chronic Wound Biofilm Model. Adv Wound Care. 2015;4(7):382–388. https://doi.org/10.1089/wound.2014.0587.

16. Wu YK, Cheng NC, Cheng CM. Biofilms in Chronic Wounds: Pathogenesis and Diagnosis. Trends Biotechnol. 2019;37(5):505–517. https://doi.org/10.1016/j.tibtech.2018.10.011.

17. Wolcott R, Fletcher J. The role of wound cleansing in the management of wounds. Wounds Int. 2014;1(1):25–30. Available at: https://woundsinternational.com/journal-articles/the-role-of-wound-cleansing-in-the-management-of-wounds.

18. Kamolz L-P, Wild T. Wound bed preparation: The impact of debridement and wound cleansing. Wound Medicine. 2013;1:44–50. https://doi.org/10.1016/j.wndm.2013.03.006.

19. Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In: Krasner DL, van Rijswijk L (eds.). Chronic Wound Care: The Essentials e-Book. Malvern, PA: HMP; 2018, pp. 47–62. Available at: https://whywoundcare.s3.amazonaws.com/Files/Chapter+5.pdf.

20. Alwadani N, Fatehi P. Synthetic and lignin-based surfactants: Challenges and opportunities. Carbon Resources Conversion. 2018;1(2):126–38. https://doi.org/10.1016/j.crcon.2018.07.006.

21. Jefferies JMC, Cooper T, Yam T, Clarke SC. Pseudomonas aeruginosa outbreaks in the neonatal intensive care unit – a systematic review of risk factors and environmental sources. J Med Microbiol. 2012;61(8):1052–1061. https://doi.org/10.1099/jmm.0.044818-0.

22. Percival SL, Mayer D, Kirsner RS, Schultz G, Weir D, Roy S, Alavi A, Romanelli M. Surfactants: Role in biofilm management and cellular behaviour. Int Wound J. 2019;16(3):753–760. https://doi.org/10.1111/iwj.13093.

23. Ge B, Wang H, Li J, Liu H, Yin Y, Zhang N, Qin S. Comprehensive Assessment of Nile Tilapia Skin (Oreochromis niloticus) Collagen Hydrogels for Wound Dressings. Mar Drugs. 2020;18(4):178. https://doi.org/10.3390/md18040178.

24. Yan C, Chen J, Wang C, Yuan M, Kang Y, Wu Z et al. Milk exosomes-mediated miR-31-5p delivery accelerates diabetic wound healing through promoting angiogenesis. Drug Deliv. 2022;29(1):214–228. https://doi.org/10.1080/10717544.2021.2023699.

25. Klement MR, Penrose CT, Bala A, Wellman SS, Bolognesi MP, Seyler TM. How Do Previous Solid Organ Transplant Recipients Fare After Primary Total Knee Arthroplasty? J Arthroplasty. 2016;31(3):609–15.e1. https://doi.org/10.1016/j.arth.2015.10.007.

26. Mabille C, Degboe Y, Constantin A, Barnetche T, Cantagrel A, Ruyssen-Witrand A. Infectious risk associated to orthopaedic surgery for rheumatoid arthritis patients treated by anti-TNFalpha. Joint Bone Spine. 2017;84(4):441–445. https://doi.org/10.1016/j.jbspin.2016.06.011.