Case and Research Letters
Punch Grafting for the Treatment of Martorell Hypertensive Ischemic Leg Ulcer
Tratamiento de la úlcera isquémica hipertensiva de Martorell con microinjertos autólogos en sello
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Herpes zoster multiplex presenting with clusters of vesicles in a zosteriform distribution affecting the L5 dermatome on the left leg (A and B, tibial crest and plantar arch) as well as D6 (C) on the left side and S2 (D) on the right side.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Rodríguez-Lomba, A. Sánchez-Herrero, R. Suárez-Fernández, A. Pulido-Pérez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Lomba" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Sánchez-Herrero" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Suárez-Fernández" ] 3 => array:2 [ "nombre" => "A." 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Guisado Muñoz, E. Conde Montero, P. de la Cueva Dobao" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Guisado Muñoz" "email" => array:1 [ 0 => "sole_dad72@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Conde Montero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "de la Cueva Dobao" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro de especialidades Vicente Soldevilla, Madrid, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Infanta Leonor, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la úlcera isquémica hipertensiva de Martorell con microinjertos autólogos en sello" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 716 "Ancho" => 1255 "Tamanyo" => 129778 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Ulcer measuring 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm on the lateral surface of the distal third of the right leg, which had appeared 3 months earlier. B, Coverage with punch grafts 2 weeks later. C, Complete epithelization 3 weeks after the intervention.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Martorell hypertensive ischemic leg ulcer (HYTILU) is an ischemic lesion caused by the obstruction of small arterioles, in the absence of signs of vasculitis; it is frequently refractive and is extremely painful. Clinical presentation is characterized by rapid growth and difficult pain management.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> While there is no benchmark treatment for this lesion, it is essential to manage the inflammation and pain. The most common form of management, with dressing in a moist environment, provides unsatisfactory results. Treatment with punch grafting,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> however, is associated with greater anti-inflammatory and analgesic capacity, and shorter healing time.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report 3 clinical cases of Martorell HYTILU treated with punch grafting, with effective pain management and complete healing in 3 to 8 weeks. The patients were aged between 72 and 83 years and all of them had a history of hypertension and dyslipidemia. One of the patients had diabetes mellitus. They presented ulcers with similar clinical characteristics, with an erythematous-violaceous lesion that was painful to the touch, with irregular hyperemic borders, slough in the wound bed with lacunar infarcts, no clinical data suggesting infection, and a context of phlebolymphedema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The lesions were located on the distal and medial third of the anterior, lateral, and posterior surface of the lower extremities, and had developed over periods ranging from 2 months to 3 years; all the lesions were associated with traumatic triggering events. In the initial clinical assessment, the mean pain score on a visual analog scale (VAS) was 10/10, with pain occurring predominantly at night, and with no improvement after analgesic treatment, even with opioids, or after elevating the affected extremity. The distal pulses were present and the ankle-brachial pressure index (ABPI) was approximately 1 (normal range) in all the patients. Blood and urine workup revealed no significant findings. Blood pressure and glucose were normal during the healing process in all patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Initial treatment was with betamethasone 0.5% cream on the borders every 72<span class="elsevierStyleHsp" style=""></span>hours for 15 days, autolytic debridement with twice-weekly dressing in a moist environment, and low-elasticity compression bandages (minimum estimated pressure, 20<span class="elsevierStyleHsp" style=""></span>mmHg). This management provided adequate preparation of the bed in a period of between 2 and 3 weeks, with reduction of pain on the VAS of between 2 and 3 points. After adequate granulation tissue was obtained in the wound bed, fine punch grafting was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient was instructed to rest the limb during the first 5 days after the grafting procedure and wound care involved changing the dressing once per week (bioactive protease-inhibiting dressing with a polyester mesh and alginate as a secondary dressing), combined with compression bandages; the graft take rate was between 90% and 100%. Full epithelization was achieved between 3 and 8 weeks after grafting (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). No complications were recorded at the donor site (anterior lateral surface of the thigh) or at the recipient site.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnosis of Martorell HYTILU is essentially clinical, although it has its own characteristic histology, which will reveal obstruction of the subcutaneous arterioles. The etiology and pathogenesis of the lesion are still not fully understood, although some studies associate the lesion with a history of long-term hypertension; however, hypertension, whether properly managed or not, is not considered sufficient and must therefore be associated with other abnormalities. The lesion is frequently associated with underlying diseases such as diabetes, obesity, chronic venous insufficiency, and peripheral artery disease. The most common local management option is dressing in a moist environment with bioactive bandages, despite the fact that this does not control the inflammatory process in Martorell HYTILU.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> Different authors have reported the analgesic effect of fine punch grafting in Martorell HYTILU.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,4</span></a> These split-thickness “postage-stamp” grafts, obtained using a punch, curette, or scalpel, include the epidermis and dermis, down to the superficial papillary dermis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In wounds with a considerable amount of slough, although the graft does not take adequately, vasodilating cytokines, growth factors and angiogenic factors are still released, which allows for modulation in arteriolar vasospasm.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> The analgesic effect of punch grafting, without prior administration of analgesics, has been reported 5<span class="elsevierStyleHsp" style=""></span>hours after the grafting procedure, with regression of the erythematous-violaceous halo between 3 and 17 days after the graft.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Adjuvant negative-pressure therapy is an interesting therapeutic option for promoting punch graft take, mainly in suboptimal beds and beds in complicated anatomical locations, such as the Achilles tendon.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our 3 cases of Martorell HYTILU, punch grafting allowed for healing periods of less than 2 months, with control of the associated pain. It is a safe and efficient therapeutic option that is easy to apply in the outpatient setting, with low additional morbidity for the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Guisado Muñoz S. Tratamiento de la úlcera isquémica hipertensiva de Martorell con microinjertos autólogos en sello. Actas Dermosifiliogr. 2019;110:689–690.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 716 "Ancho" => 1255 "Tamanyo" => 129778 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Ulcer measuring 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm on the lateral surface of the distal third of the right leg, which had appeared 3 months earlier. B, Coverage with punch grafts 2 weeks later. C, Complete epithelization 3 weeks after the intervention.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Arteriolosclerotic ulcer of Martorell" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.D. Vuerstaek" 1 => "S.W. Reeder" 2 => "C.J. Henquet" 3 => "H.A. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 12 | 27 |
| 2024 Octubre | 93 | 74 | 167 |
| 2024 Septiembre | 84 | 45 | 129 |
| 2024 Agosto | 118 | 68 | 186 |
| 2024 Julio | 80 | 37 | 117 |
| 2024 Junio | 118 | 47 | 165 |
| 2024 Mayo | 108 | 39 | 147 |
| 2024 Abril | 89 | 38 | 127 |
| 2024 Marzo | 99 | 35 | 134 |
| 2024 Febrero | 79 | 43 | 122 |
| 2024 Enero | 72 | 45 | 117 |
| 2023 Diciembre | 66 | 33 | 99 |
| 2023 Noviembre | 89 | 47 | 136 |
| 2023 Octubre | 100 | 56 | 156 |
| 2023 Septiembre | 64 | 35 | 99 |
| 2023 Agosto | 67 | 18 | 85 |
| 2023 Julio | 87 | 41 | 128 |
| 2023 Junio | 76 | 27 | 103 |
| 2023 Mayo | 97 | 34 | 131 |
| 2023 Abril | 77 | 23 | 100 |
| 2023 Marzo | 66 | 29 | 95 |
| 2023 Febrero | 55 | 23 | 78 |
| 2023 Enero | 50 | 25 | 75 |
| 2022 Diciembre | 88 | 34 | 122 |
| 2022 Noviembre | 70 | 32 | 102 |
| 2022 Octubre | 51 | 33 | 84 |
| 2022 Septiembre | 71 | 45 | 116 |
| 2022 Agosto | 44 | 28 | 72 |
| 2022 Julio | 46 | 51 | 97 |
| 2022 Junio | 31 | 33 | 64 |
| 2022 Mayo | 65 | 42 | 107 |
| 2022 Abril | 81 | 38 | 119 |
| 2022 Marzo | 74 | 69 | 143 |
| 2022 Febrero | 90 | 36 | 126 |
| 2022 Enero | 96 | 32 | 128 |
| 2021 Diciembre | 75 | 44 | 119 |
| 2021 Noviembre | 79 | 48 | 127 |
| 2021 Octubre | 94 | 59 | 153 |
| 2021 Septiembre | 71 | 43 | 114 |
| 2021 Agosto | 71 | 32 | 103 |
| 2021 Julio | 43 | 20 | 63 |
| 2021 Junio | 45 | 26 | 71 |
| 2021 Mayo | 68 | 41 | 109 |
| 2021 Abril | 189 | 74 | 263 |
| 2021 Marzo | 95 | 36 | 131 |
| 2021 Febrero | 72 | 21 | 93 |
| 2021 Enero | 70 | 21 | 91 |
| 2020 Diciembre | 59 | 21 | 80 |
| 2020 Noviembre | 25 | 14 | 39 |
| 2020 Octubre | 35 | 10 | 45 |
| 2020 Septiembre | 23 | 15 | 38 |
| 2020 Agosto | 27 | 20 | 47 |
| 2020 Julio | 17 | 12 | 29 |
| 2020 Junio | 21 | 21 | 42 |
| 2020 Mayo | 19 | 10 | 29 |
| 2020 Abril | 13 | 8 | 21 |
| 2020 Marzo | 22 | 10 | 32 |
| 2020 Febrero | 1 | 2 | 3 |
| 2019 Noviembre | 1 | 0 | 1 |
| 2019 Agosto | 1 | 0 | 1 |
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