title: Procedural pain management in the treatment of scleroderma digital ulcers.
abstract: OBJECTIVE
  Digital ulcers (DU) may develop in half of systemic sclerosis (SSc) patients; they are often resistant to treatments. Deep wound debridement is crucial for DU healing, but very difficult to carry out without adequate procedural pain management. Here, we report the results of our experience on procedural pain management in scleroderma DU.
  
  
  METHODS
  The study included 51 DU observed in 32 consecutive SSc patients; procedural pain was treated following a definite schedule: local lidocaine and prilocaine (25 mg of either agent per gram of cream, EMLA 5%) were initially used in all cases, followed by local and oral morphine, according to the severity of pain scored on a 10 cm visual analogue scale (VAS).
  
  
  RESULTS
  At baseline, higher pain VAS was recorded in more severe (p=0.0001) and/or infected DU (p=0.0001). Good compliance to DU debridement was observed in patients with mild pain (VAS ≤4) treated with only EMLA, and in 5 cases with moderate-severe pain (VAS >4) at baseline. While, the majority of DU with moderate-severe pain (34/39) needed a combined therapy with EMLA and local morphine (8/34) or with EMLA, local and oral morphine (26/34). On the whole, pain management during DU debridement required only EMLA application in 33% of cases, EMLA plus local morphine in 16%, while combined EMLA, local and oral morphine were necessary in 51%, generally with more severe and/or infected lesions.
  
  
  CONCLUSIONS
  The present study showed valuable control of procedural pain during DU debridement with sequential, combined analgesic treatment.
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Dilia
authors.initials: D
authors.lastname: Giuggioli
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Andreina
authors.initials: A
authors.lastname: Manfredi
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Caterina
authors.initials: C
authors.lastname: Vacchi
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Sebastiani
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Amelia
authors.initials: A
authors.lastname: Spinella
authors.affiliation: Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
authors.forename: Clodoveo
authors.initials: C
authors.lastname: Ferri
mesh_terms: D000279:Administration, Cutaneous; D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D019162:Anesthetics, Combined / Q000008:administration & dosage*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D003646:Debridement / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D005260:Female; D005385:Fingers; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage*; D000077442:Lidocaine, Prilocaine Drug Combination; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage*; D009824:Ointments; D010146:Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D010147:Pain Measurement; D011318:Prilocaine / Q000008:administration & dosage*; D012595:Scleroderma, Systemic / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D012720:Severity of Illness Index; D012883:Skin Ulcer / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D019162:Anesthetics, Combined; D000779:Anesthetics, Local; D000077442:Lidocaine, Prilocaine Drug Combination; D009824:Ointments; D011318:Prilocaine; D009020:Morphine; D008012:Lidocaine