Treatment of Painful Cutaneous Wounds
by Michael Maier, DPM
 Chronic cutaneous wounds, such as those caused by pressure, venous
insufficiency, neuropathy, or arterial disease, may cause considerable pain and can be
challenging to treat. Often severe pain interferes with treatment protocols because
patients are unwilling or unable to comply with necessary regimens. For example,
compression bandaging, which is necessary for the treatment of venous stasis disease,1
may cause extreme discomfort, and noncompliance that significantly delays wound healing.
Additionally, pain activates the sympathetic branch of the autonomic nervous system,
triggering a physiological response that slows wound healing.2 Treating
wound-related pain is essential for optimal wound healing. In the European Wound
Management Position Statement, Briggs, Torra and Bou3 demonstrated the
complexity of wound pain and its effect on treatment. The authors stressed the importance
of using a combination of techniques that focused not only on physiological factors, but
also on psychological and emotional factors. This article reviews the neurology and
biochemistry involved in wound pain and discusses treatment options, including noninvasive
techniques such as electrical stimulation, ultrasound, and pulsed radio frequency energy.
Background
Cutaneous wounds normally heal in predictable stages: hemostasis and inflammation,
granulation, epithelialization, maturation and remodeling. However, when the process is
disturbed at any stage, a chronic wound may result.4 A variety of factors can contribute
to nonhealing, including infection, inadequate pressure relief, uncontrolled swelling,
impaired blood supply, malnutrition and poor glycemic control. In general, if an acute
wound fails to heal within four to six weeks, it should be considered chronic. Treatment
protocols vary according to the wound cause(s) (see Table 1).4
The most common chronic wounds are pressure (decubital) ulcers, venous insufficiency
leg ulcers, arterial insufficiency ulcers, and diabetic foot ulcers (which may be a
combination of the previous). Pressure ulcers frequently occur in immobile patients or
those with some form of paralysis or orthopedic deformity. Pressure from a bed, footrest,
shoe or other device restricts cutaneous blood flow causing tissue breakdown and
ulceration. Venous leg ulcers are the result of inadequate venous drainage in the legs.
Over time, increased tissue congestion and impaired venous blood flow compromises the skin
and leads to overt ulceration. Arterial insufficiency ulcers often result from minor skin
trauma in the setting of impaired blood flow. Finally, diabetic foot ulcers occur as a
result of the repetitive trauma of walking in the setting of impaired sensation and often
abnormal mechanics.
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— May 2010
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