Punch grafting for the treatment of ulcerated atrophie blanche

Case report

A 79-year-old woman presented with a large painful ulcer on the lateral aspect of her left leg over a 6-month period. Her medical history included well-controlled hypertension. Physical examination showed signs of chronic venous insufficiency and atrophie blanche extending over perilesional skin, malleolar area and foot dorsum (Figure 1(a) and (b)). On an outpatient basis punch grafting was performed. Grafts were obtained with a surgical blade (Figure 2(a) and (b)). The grafted ulcer was covered with alginate sheet and Unna boot as compression bandaging. The donor site was the lateral aspect of the thigh and it was also covered with an alginate dressing. One-week immobilization and bed rest were recommended and thromboprophylaxis was prescribed. The first dressing change took place 1 week after the procedure and no cleansing of the wound bed was performed. Pain greatly decreased in the following days after grafting. Dressing changes were scheduled on a weekly basis. Three weeks after punch grafting, complete epithelization was achieved (Figure 2(c)). An adjustable compression wrap device was prescribed to prevent recurrence. In the follow up visit 2 months later complete epithelization was maintained.OPEN IN VIEWER

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Figure 2.

(a) Large painful ulcer on the lateral aspect of her left leg. (b) Punch grafting was performed. (c) Complete epithelization was achieved 3 weeks after.

Discussion

Ulcerated atrophie blanche is a misdiagnosed disorder with painful lesions and, consequently, a high impact on quality of life. Atrophie blanche is a French term internationally used to describe porcelain-white colored, red-dotted atrophic plaques on legs or feet. It may be due to multiple causes. Therefore, it is essential to make a complete clinical history when this alteration is found.^1,2

Any disorder that produces microcirculatory flow diminution can cause tissue infarction and these consecutive scar areas. The most frequent cause of atrophie blanche is chronic venous insufficiency, as seen in the case we are reporting. ¹ Nevertheless, other possible causes are hypercoagulability states, collagenopathies, fibrinolysis alteration, or any other cause of coagulation alteration. All these primary or secondary causes of atrophie blanche can be included in the term livedoid vasculopathy, a type of occlusive vasculopathy without vasculitis. Livedoid vasculopathy is usually found in middle aged women, with purpuric painful papules on the dorsum of the feet and infra-malleolar region, progressing to ulcers and atrophie blanche areas. Therefore, when atrophie blanche without venous insufficiency is found, it is necessary to perform a thrombophilia blood test and biopsies of the wound edge to rule out livedoid vasculopathy.

Etiological treatment of the associated diseases should be prescribed in order to avoid progression of the lesions. In case of chronic venous insufficiency, control of venous hypertension with anti-edema measures, compression therapy, and endovenous treatment, if possible, is essential.^2,3 Compression therapy must be adjusted to the patient´s tolerance, as these lesions are usually very painful. Without compression therapy or anti-edema measures, superficial ulcers may appear, with a whitish sclerotic background and very vascularized dotted areas. These ulcers are very painful and resistant to treatment as they appear in scar areas.

Punch grafting is a traditional method to obtain thin split-thickness skin grafts containing epidermis and papillary dermis, to promote epithelialization. Grafts are obtained under local anesthesia with a punch, curette, or surgical blade and are placed directly on the wound bed. The donor site is normally the thigh, which heals by secondary intention. The procedure can be performed on an outpatient basis. Punch grafting, associated with compression therapy accelerates wound healing and decreases pain.^4–6

Taking into account that ulcerated white atrophy can be considered a wound on scar tissue, it must be treated as a hard-to-heal wound.

As we have just shown in this case, punch grafting is an effective therapeutic alternative for wound closure and pain reduction of ulcerated atrophie blanche.