Blood, 1 February 2002, Vol. 99, No. 3, pp. 1096-1096
CORRESPONDENCE
To the editor:
Treatment of painful sickle cell leg ulcers with topical
opioids
Leg ulceration is a common and painful complication of sickle
cell anemia (SS). Leg ulcers tend to be indolent and intractable and
heal slowly over months or years. The pain of these ulcers may be
severe, excruciating, penetrating, sharp, and stinging in nature. In
most patients, oral or parenteral opioid analgesics may be needed to
achieve some pain relief. We wish to report our experience with 2 patients with SS and painful leg ulcers who achieved total pain relief
with the applications of topical opioids, thus decreasing the amount of
oral opioids taken to control the pain.
A 38-year-old African American woman with SS developed a painful 3.5 cm-by-3.5 cm ulcer on the medial aspect of the right ankle.
The pain was excruciating, stinging, and sharp in nature with an
intensity score of 10 on a 0 to 10 numerical verbal scale. The pain was
worst at night, woke her up frequently, and required treatment with 5 mg oxycodone every 2 to 3 hours. She consumed 16 to 18 tablets of
oxycodone per day, most of which were at night. The pain forced her to
walk with a limp and interfered with her activities of daily living. In
an effort to control the ulcer pain, one tablet of oxycodone was
dissolved in 1 to 2 mL water and applied to the leg ulcer topically
after mixing with the debridement ointment that she was using. This
gave her almost immediate pain relief, decreased the intensity of the
pain to 0, and reduced oxycodone consumption to 0 to 2 tablets per day.
The second patient was a 67-year-old African American woman with SS and
chronic bilateral painful ulcers on both ankles for more than
20 years. The pain was stinging and sharp in nature and was managed
with 100 mg meperidine orally every 2 hours as needed and topical
xylocaine ointment, with some relief. Measures to treat the
ulcers including transfusion, grafting, debridement, hyperbaric oxygen,
and growth factor therapy failed to induce healing. In an effort to
achieve better pain relief, one 100 mg meperidine tablet was dissolved
in water and applied to the ulcers with the xylocaine
ointment. This gave her almost immediate pain relief, with a longer
lasting effect than oral meperidine, and decreased the amount of
meperidine consumed per day.
Our experience with these 2 patients indicate that topical opioids may
be of value in relieving the pain of SS leg ulcers and decreasing the
amount of oral opioids taken to achieve pain relief. These findings
also indicate that peripheral opioid receptors do mediate peripheral
analgesia.1 Topical morphine has been reported to relieve
the pain of decubitus skin ulcers in cancer patients.2,3
To the best of my knowledge, this report is the first to show the
efficacy of topical opioids in sickle cell leg ulcers and that opioids
other than morphine are also effective.
Samir K. Ballas
Correspondence: Cardeza Foundation, 1015 Walnut Street,
Philadelphia, PA 19107; e-mail: samir.ballas{at}mail.tju.edu
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Krajnik M, Zylicz Z, Finley I, Luczak J, Van Sorge AA.
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Twillman RK, Long TD, Cathers TA, Mueller DW.
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