Wounds Rheumatoid Arthritis

Slow-Healing Wounds Common in Rheumatoid Arthritis

Slow-healing wounds, including leg and foot ulcers, are a known complication of several autoimmune inflammatory diseases, including rheumatoid arthritis (RA), lupus and scleroderma. For many people, these wounds can take months or even years to heal.

“People with RA develop wounds for many reasons,” says Eric Matteson, MD, chairman of rheumatology at Mayo Clinic in Rochester, Minn. “One is that they may have low-grade vasculitis – inflammation affecting the small blood vessels in the skin. When the wound is related to the underlying systemic inflammation of rheumatoid arthritis, not having that inflammation under control makes it much more difficult to achieve good wound healing.”

In addition to vasculitis, other factors may play a role in slow wound healing and lower extremity (LE) ulcer development in people with RA. These include trauma related to joint deformity, neuropathy (nerves that don’t work properly), venous insufficiency (poor blood circulation by veins), arterial disease (poor blood circulation by arteries) and Felty’s Syndrome (a rare condition involving RA, a swollen spleen, decreased white blood cell count, and repeated infections). Risk factors for LE ulcers include age, rheumatoid factor positivity, presence of rheumatoid nodules and venous thromboembolism (blood clots in the vein). Patients with RA who had LE ulcers were at a 2-fold risk for early death.

Autoimmune Diseases Also Linked to Larger Wounds, More Pain

A group of researchers, led by Dr. Matteson, examined 813 people with RA over a period of more than 25 years and published their results in Journal of Rheumatology in 2014. Of the group studied, 125 patients developed LE ulcers and the longer the disease duration, the more likely they were to develop an LE ulcer: at 5 years after diagnosis, 5% of participants had developed one but by 25 years, 26% of patients had developed one.

A 2011 study published in Clinical Rheumatology looked at a group of 366 patients with RA seen over the course of 3 years. The researchers found that 16 (4%) patients developed LE ulcers during the timeframe and only 5 of the 16 (31%) were healed after 23 months. However, treatment with a biologic agent was associated with an increased likelihood of healing.

The same group of scientists continued their work at a wound-treatment center and found that an unusually high number of the patients with non-healing wounds (23%) also had autoimmune disorders, like RA and lupus. Results of this study were published in International Wound Journal in 2012.

“I saw that people who had autoimmune disease did not respond as well to the usual wound care treatments,” says study scientist Victoria Shanmugam, MD, director of the division of rheumatology, and associate professor of medicine at The George Washington University Medical Faculty Associates in Washington DC. “These patients had larger wounds at the first visit, had higher pain scores and took significantly longer to heal – 14.5 months compared to just over 10 months for other patients,” she explains. “Clearly, there is something in the autoimmune milieu that is inhibiting wound healing,” says Dr. Shanmugam.

What To Do If You Have a Wound

If you get injured or develop a LE wound or ulcer, be sure to do the following:

  • Gently cleanse the wound with mild soap and lukewarm water and pat it dry.
  • Apply a sterile bandage.
  • Increase your protein intake to speed tissue repair.
  • Ask your rheumatologist whether you need more aggressive treatment of your underlying autoimmune disease to get systemic inflammation under control.

Contact your doctor right away if you notice any of these signs of trouble:

  • Persistent, increased pain in the area of the wound
  • Discoloration of the wound near its edges – often a dark or bluish color
  • Increased drainage from the wound
  • Redness or swelling around or spreading away from the wound
  • A foul odor coming from the wound

Treatment of Slow-Healing Wounds

Treating your underlying autoimmune disease improves wound healing. “There is concern about using potent immune suppressants in people with open wounds,” Dr. Shanmugam says, noting that there is a theoretical concern that immunosuppressive drugs interfere with wound healing. “But in a cohort of rheumatoid arthritis patients, we found that aggressive treatment before skin graft surgery resulted in better outcomes.”

If you have a slow-healing wound, treatment in multidisciplinary limb salvage center may help. Specialized treatments include special dressings, hyperbaric oxygen, growth factors, bioengineered skin substitutes and skin grafts.

Dr. Matteson says that successful wound care requires cooperation and vigilance. “Perhaps the biggest message here is that treating people with autoimmune-related wounds really calls for a team approach among the rheumatologist, wound-care specialist and surgeon,” says Dr. Matteson.

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