Scientific evidence on leg ulcers as leprosy sequel

This is an Integrative Literature Review (ILR). In order to identify the theme and research question, the PICo strategy was used, in the sequence the search was carried out in Index to Nursing and Allied Health Literature (CINAHL), Latin American & Caribbean Literature in Health Sciences (LILACS), (BDENF), EMBASE (Elsevier), PUBMED (National Library of Medicine), SCOPUS (Elsevier), Web of Science (Clarivate Analytics) databases. Specific descriptors were selected for each of them and respective search strategies were created. The languages considered were English, Portuguese and Spanish. The ILR period was indeterminate. For the study selection, the Ryyan tool was used and allowed two of the authors to independently include, exclude or remain undecided, disagreements were solved by a third party. The selected articles have been ranked according to the Agency for Healthcare Research and Quality (AHRQ). And for interpretation of results, the articles were grouped by similarity and categorized into author, country year, level of evidence, objectives and results, conclusion and recommendation.

Results

415 studies were identified and 10 were included in the review. The main outcome was the topical treatment of ulcers, the vulnerabilities and the determinants that afflict those affected by leprosy were not studied.

Conclusion

There is no strong evidence on therapies for the treatment of leprosy-induced leg ulcers that support the reduction of disabling sequel caused by disease perpetuating stigma and social inequality.

Leprosy; Wounds and Injuries; Skin ulcer

Databases	Strategy
CINHAL	(leprosy OR “hansen diseases”) AND (ulcer OR wound OR “chronic wounds”)
EMBASE	(leprosy OR “hansen diseases”) AND (ulcer OR wound OR “chronic wounds”)
LILAC’s/BDENF	(mh:hanseníase OR tw:hanseniase OR tw:lepra$) AND (mh:”ulcera da perna OR tw: “ulcera da perna”) (Portuguese)
PUBMED	(“hansen diseases” [all field] OR “leprosy”[MeSH Terms] OR “leprosy”[All Fields]) AND (ulcer”[MeSH Terms] OR “ulcer”[All Fields]) AND (“leg”[MeSH Terms] OR “leg”[All Fields])
SCOPUS	(leprosy OR “Hansen diseases”) AND ulcer AND leg
Web of science	(leprosy OR “Hansen diseases”) AND ulcer AND leg

Author/year/country	Level of Evidence	Objectives and Results	Conclusion/ recommendation
Bogaert et al.⁽¹⁷⁾ 1990. Domenican Republic	3	- To assess the efficacy of treatment of leprosy ulcer with topical and systemic phenytoin. At the first week, all ulcers showed decreased exudate and vast granulation tissue. Reassessed in 3-6 weeks, twenty patients had complete healing of lesions 2-4 cm in diameter. In lesions above four centimeters, seven showed a marked improvement in granulation.	The findings show that phenytoin is a valuable treatment option for this population.
Kaada B.et al.⁽¹⁸⁾ 1988. Norway	3	- To describe a study using transcutaneous neural stimulation (TNS) aimed at accelerating the healing of ulcers of people with leprosy sequel. The 19 patients treated daily had complete healing.	TNS is a convenient method to use and can be applied by the patient himself.
Noe et al.⁽²²⁾1974. United States	5	- To describe a case of leprosy with left leg ulcer sequel. With the Unna boot, there was complete healing.	Case of leprosy treated successfully.
Quege et al.⁽²⁵⁾ 2008. Brazil	2	- Compare the action of a latex biomembrane and EFA-based product on the microbiota of people with infected chronic wounds. The socio-demographic profile of patients was presented. The in vitro results showed absence of activity of both products on the microorganisms isolated from the lesions. The in vivo analysis that the EFA presented positive antimicrobial effect on Enterobacter aerogenes and the latex biomembrane on Pseudomonas aeruginosa.	The search for alternatives in the treatment of chronic infected wounds is important, because the systemic antibiotic therapy, because it leads to bacterial resistance.
Hu X, et al.⁽²⁴⁾ 2011. China	1	- To assess the effect of rhGM-CSF, growth factor on wound healing, topically applied was beneficial for ulcers such as leprosy sequel.	Controlled clinical studies are needed to support the therapeutic effect of rhGM-CSF.
Gomes et al.⁽²⁶⁾ .2007. Brazil	4	- To set the epidemiological profile of ulcerated and non-ulcerated leprosy treated at Hospital das Clínicas de Ribeirão Preto 2003/2004. Analysis showed 25 individuals (32%), 69.6% were males, 91.1% were white and smear positive (62%), had ulcerations located in the lower limbs (68%), classified as grade II disability (72%; p<0.01). In the operational classification, 80% of those who presented ulcers were multibacillary while 12% paucibacillary (p<0.05).	The Groups were epidemiologically similar. Ulcerations of leprosy appear to be related to the degree II of incapacity and to the positivity of the bacilloscopy, in classifications (spectral and operational).
Griffts, G et al.⁽²³⁾ 1966. Republic of Togo	5	- To describe two cases of people with ulcers in the lower limbs as leprosy sequel. One of the thighs treated with polybactrin (bacitracin, neomycin and polymyxin) spray, vaseline gauze, and dressing with daily exchange was completely healed in three months. The other ulcer in the leg, with nine months of healing healed almost completely. Using the above sequence of treatment and thereafter, cream and dressing.	The use of polybactrim was feasible for the healing of cases.
Nagaraju et al.⁽¹⁹⁾ 2017. India	3	- Demonstrating the efficacy of the autologous Platelet-Rich Fibrin Matrix (PRFM) in unhealed trophic ulcers in patients treated for leprosy. Seven patients treated with leprosy, with nine unhealed trophic ulcers in more than six weeks, after receiving several treatments. With scanning, area measurements and volume. The ulcers received weekly treatment and healed (5 weeks).	The application of PRFM has brought satisfaction to the patient since it is easy to apply, simple and safe.
Mumford et al.⁽²⁰⁾1988. India	3	- To assess the efficacy of a hydrocolloid occlusive dressing in the treatment of chronic leprosy ulcers. Seventy-seven ulcers were selected, four of which were legged in people sequestrated by leprosy. The occlusive hydrocolloid had an important role in the management of ulcers that did not respond to traditional treatments.	Randomized clinical trials are required to confirm the response of chronic ulcers to hydrocolloid use.
Malhota et al,⁽²¹⁾ 1991. India	3	- To compare the action of zinc oxide (cream) and phenytoin (powder) on trophic leprosy ulcers with daily changes. None of the ulcers healed completely in the first six weeks. At 12 weeks, 79% of the ulcers treated with phenytoin had healed above 50% and in the zinc oxide group 29%.	The favorable results of this study suggest the completion of controlled study inpatients to investigate topical phenytoin compared to topical zinc therapy in the treatment of trophic ulcers

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[1] Corresponding author Heloísa Cristina Passos Guimarães https://orcid.org/0000-0001-9062-114X E-mail: clinicapes@ilsl.br