Wound closure by secondary intention is successful in the treatment of squamous cell carcinomas in recessive dystrophic epiderm

ARTICLE

ejd.2010.1251

Auteur(s) : Romina RODRÍGUEZ-LOJO rodriguezlojo@hotmail.com, Beatriz FERNÁNDEZ-JORGE, Ana DE ANDRÉS, Carmen PEÑA, Jesús GARCÍA-SILVA

Servicio de Dermatología, CHU A Coruña, Sir John Moore, s/n. 15001, A Coruña, Spain

Surgical management of cutaneous squamous cell carcinomas (CSCC) in patients with severe generalised recessive dystrophic epidermolysis bullosa (SGRDEB) is hindered by the fragility of their skin. We present a patient with SGRDEB who underwent excision of multiple CSCC, with wound closure by secondary intention, obtaining good results without significant associated complications.

A 49-year-old woman diagnosed with SGRDEB had been seen in our department since 1998. She had significant skin fragility, extensive areas of scarring and associated systemic complications (chronic renal failure, chronic anaemia, secondary hyperparathyroidism and protein-calorie malnutrition). In 1999 she underwent surgery in the Plastic Surgery department for CSCC in her left leg, and reconstruction with a split-skin graft. This had a poor outcome, with necrosis and total graft loss.

The patient continued to develop many CSCC while being seen in our department over an 11-year follow-up period. It was decided to resect the tumours and to proceed with wound closure by secondary intention (figure 1A), excising a total of 31 squamous cell carcinomas. All tumours were located on the lower limbs except one on the right forearm and another on her scalp. Tumour size ranged from 1.3 to 7.5 cm. From 1 to 6 carcinomas were excised in each surgical procedure.

The interventions were performed under local anaesthesia as an outpatient procedure. After excising the tumour and a margin of 3-5 mm, haemostasis was performed carefully, leaving the wound to close by secondary intention. The wound was covered with an extra thin hydrocolloid dressing (Urgotul^®) or silicone mesh netting (Mepitel^®) with povidone-iodine gel (Betadine^®). After surgery, the wound was cleaned every other day with saline, applying Betadine^® solution, silver sulfadiazine or mupirocin ointment, covering the surgical wound with a hydrocolloid dressing (Urgotul^®) and bandage. The patient was seen once a week for the wound dressing and to observe progress, and visits were later spaced out. In the first week after surgery abundant granulation tissue was observed, with complete wound closure within 4-6 weeks (figure 1B).

CSCC are a frequent cause of death in patients with SGRDEB [1, 2]. It has been suggested that possible factors contributing to this aggressiveness are the structural alteration of the basement membrane, which facilitates tumour invasion, and also the reduction in circulating NK cells [2]. Surgical treatment is complex. Different techniques, such as flaps, grafts and artificial grafts have been described [1-6]. We opted for wound closure by secondary intention, which has a series of benefits:

• – Surgical procedures were performed under local anaesthesia, avoiding intubation complications due to fragile mucosa. Also, general anaesthesia is not risk-free because of the multiple associated systemic diseases.
• – Hospitalisation was not required.
• – It is possible to excise multiple tumours in a single intervention, thus avoiding delay in surgical treatment.
• – There is less manipulation of surrounding skin.
• – The technique is appropriate in patients with extensive skin scarring, which prevents mobilising skin easily for skin flaps and limits the areas of skin that are suitable for use as donor skin grafts.

The main disadvantage of wound closure by secondary intention is the delay in wound reepithelialisation, which is furthered by the malnutrition, requiring careful wound dressing for several weeks. However these patients are used to meticulous wound dressing because traumatic skin injuries are commonplace. We also believe that the total healing time is acceptable, and that good nutritional control is important to help enhance the wound healing process.

In our experience, wound closure by secondary intention is a useful and safe option in the surgical treatment of cutaneous squamous cell carcinomas in patients with epidermolysis bullosa.

Disclosure

Acknowledgements: We would like to thank M^a Angeles Fernández Entralgo for her fundamental work and collaboration in patient follow-up and care. Financial support: none. Conflict of interest: none.

References

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