Localised scleroderma, also known as morphoea, is a rare autoimmune disease.1 The incidence of the disease is between 0.4 and 2.7 people per 100,000.2 It is caused by excessive subcutaneous collagen deposition which leads to tissue thickening, scarring and fibrosis.3 The clinical manifestation includes flaky, itchy skin lesions, which impair the barrier function of skin. Due to fibrosis of the affected tissue and vascular occlusion, once a skin lesions bursts, the wound can become difficult to heal.
The TIME principle (tissue, infection/inflammation, moisture and edge of wound) has been widely used in wound practice.4,5 However, it only focuses on the wound and does not completely meet the holistic needs of clinical practice.6 The TIME clinical decision support tool (TIME CDST) evolved from the TIME principle, and provides a sound theory for assessing and managing hard-to-heal wounds.7 The TIME CDST consists of five parts:
- Assessment (A)
- Bring (B)
- Control (C)
- Decision (D)
- Evaluation (E) (Table 1).
Table 1. The TIME clinical decision support tool (using ABCDE)
| Assess | Accurate assessment, measurement and diagnosis of the patient and their wound |
| Bring | Bring in the multidisciplinary team to promote holistic care |
| Control | Control and treat systemic causes |
| Decide | Decide appropriate treatment |
| Evaluate | Evaluate treatment and wound management goal |
TIME—tissue, infection/inflammation, moisture, edge of wound
Several factors can affect the healing process, such as the nature of the disease itself, unhealthy lifestyle habits, wound factors etc. Health professionals may also only focus on healing the wound, rather than treating the patient as a whole.
This case report describes a complex case of a hard-to-heal wound in a patient with localised scleroderma, treated using the TIME CDST (ABCDE) approach.
Patient consent
The patient was informed of the treatment approach to be taken and signed the consent form before any intervention.
Case report
The patient was a 44-year-old male with a diagnosis of localised scleroderma for five years. He had a smoking history of 20 years, averaging 10 cigarettes per day. Because the skin on the right side of the chest wall was broken and infected, he received wound care treatment in an outpatient department of a hospital in Shanghai, China for >4 months; however, the wound did not heal. The patient was admitted to our wound clinic on 30 November, 2018.
The patient complained of extreme itching of the skin, which caused skin damage through scratching. Physical examination showed pigmentation and thickening of the right chest wall with a leathery hardness to the touch, local tightening of the skin and difficulty in pinching it, an indistinct border and no Raynaud's phenomenon. There was a wound below the right nipple measuring 2.2cm×0.7cm, with a depth of 0.2cm. The wound was dry and had no exudation. There was an area of discoloured skin measuring 0.7cm×0.7cm on the right side of the wound. Around the wound, the skin was red, swollen and hot (Fig 1a). Blood tests showed antinuclear antibodies ANA(+), extractable nuclear antigen ENA(+) and an erythrocyte sedimentation rate (ESR) of 16mm/hour. Wound swabs showed the presence of Neisseria elongata. Chest x-ray and electrocardiogram (ECG) were normal. The patient's self-rating anxiety score (SAS)8 was 59 and his pain numerical score (NRS)9 was eight.
Assess: accurate assessment, measurement and diagnosis of the patient and their wound
We established a diagnosis and baseline characteristics for appropriate support were recorded including: comorbidities that may impact healing; wound type, location and size; wound bed condition; signs of infection/inflammation; pain location and intensity; and adherence/concordance to treatment.
The patient was well-nourished. The primary disease of localised scleroderma was the main factor affecting wound healing. Skin pathology showed hyperplasia of collagen fibres in the dermis and subcutaneous tissue, obvious thickening of the dermis, swelling and fibrosis of collagen, destruction of elastic fibres and thickening of the vessel wall. As cutaneous fibrosis is the main feature of localised scleroderma, this makes it more difficult to treat this type of wound. At the same time, the patient's 20-year history of smoking, anxiety and pain, all of which are also important factors in wound healing, increased the complexity of treating the wound.
Preliminary assessment of the wound showed a small area with no exudation but significant signs of infection.
Bring: bringing in multidisciplinary collaboration to promote holistic patient care
Multidisciplinary diagnosis and treatment adopts the international advanced treatment concept and management model. Multidisciplinary teams include endocrinologists, nutritionists, oncologists, vascular surgeons, pain specialists, radiologists, dermatologists and others.
Due to the patient's high pain score, longstanding history of smoking and anxiety, in addition to the wound specialist, the multidisciplinary team included dermatologists, pain specialists, respiratory specialists, and psychologists. A study has shown that Traditional Chinese Medicine (TCM)10 can effectively control the development of localised scleroderma, and so TCM doctors joined the multidisciplinary team and TCM was given alongside other treatments.
Control: controlling or treating underlying causes and barriers to wound healing
In this case, the corresponding control aim was to manage the patient's pain, smoking and skin fibrosis. Pain specialists provided oral paracetamol to reduce the patient's resting wound pain and increase his comfort. Wound specialists also relieved the patient's pain by gently removing old dressings, and cleaning, debriding and redressing the wound. The patient's wound was anaesthetised with lidocaine gel during mechanical debridement to decrease the patient's fear of pain from the debridement. As the wound healed, the patient's pain score gradually decreased. At the inflammatory phase of wound healing, the patient's pain score was zero.
Smoking reduces a patient's immunity and affects wound healing. Therefore, it was deemed urgent to control the patient's smoking. The patient quit smoking within two weeks due to the intervention of a respiratory doctor. The patient's anxiety level was also reduced with the support of a psychologist.
As localised scleroderma is a localised skin swelling that gradually develops into sclerotic atrophy of the skin, in addition to oral TCM to control fibrosis, skin care education for the patient was also strengthened, with particular attention paid to the following:
- Avoiding the sun, scratching and skin injury
- Keeping the skin clean and dry, and applying a gentle, oily, skin moisturiser
- Avoiding Raynaud's phenomenon, a peripheral circulation disease which manifests in spasming of the arterioles of the fingers and toes, under the stimulation of cold or emotional tension. The patient was therefore advised to keep warm.
Decide: deciding appropriate treatment
To determine the appropriate treatment based on the TIME principle,11 which included removing necrotic tissue, controlling infection and inflammation, keeping the wound moist and maintaining a good wound margin, a combination of mechanical debridement and autolytic debridement was used. The necrotic tissue was cleared with sterile scissors and toothed forceps. We used temporary retention of the ‘nibbling debridement’ method12 when the border was not clear and it was difficult to determine whether there was complete necrosis of the tissue. A unique hydrophilic fibre, antiseptic dressing was used. The dressing, which has a strong antibacterial effect, can absorb excessive wound fluid, form a gel, create a moist environment, and can also carry out autolytic wound debridement. Silver alginate dressing was also used to promote granulation growth and effectively control infection. The treatment timeframe is described in Table 2.
Table 2. Treatment timeframe
| Date | Wound description | Treatment |
|---|---|---|
| 30 November 2018 | Wound size: 2.2cm×0.7cm×0.2cmNo exudate presentNecrosis observable on woundPeriwound skin inflamed (red, hot, swollen) | Hydrogen peroxide used to disinfect woundWound irrigated with normal saline and debridedWound dressed with a hydrophilic fibre dressing, changed once every 3–4 days |
| 4 December 2018 | Wound size: 3.5cm×1.0cm×0.2cmSmall amount of exudateWound surface: presence of necrosis and infectionPeriwound skin is red, hot but no swelling | Treatment carried out as above |
| 14 December 2018 | Wound size: 1.2cm×1.0cm×0.2cmMedium level of exudateWound surface: presence of necrosis and infectionNo inflammation of periwound skin | Hydrogen peroxide used to disinfect woundWound irrigated with normal salineWound dressed with a silver alginate dressing, changed once every 4 days |
| 11 January 2019 | Wound completely healed |
Evaluate: evaluating and reassessment of wound management outcomes
Wound progression was recorded within given timelines. In the ABCDE approach, if no change is detected, each stage of the process is revisited, changing the treatment method as appropriate. This was also the case with the treatment and management of our patient. By day 41, the wound appeared to be completely healed (Fig 1d). The patient was followed up for one month without relapse.
Discussion
We evaluated the patient as a whole to determine the influencing factors for wound healing and which would require intervention. In this case, the reason the wound did not heal was related to microvascular occlusion and the neovascularisation disorder in localised scleroderma due to an imbalance of complement coagulation and anticoagulation.13
Studies have shown smoking to affect wound healing.14,15 Smoking has vasoconstrictive effects and increases free radical exposure, as well as other proinflammatory and immunomodulatory effects.16 A study of 606 patients demonstrated an increased frequency of digital ulcers in smokers.17 The patient in this case report had a long history of smoking and smoked every day. The patient was not able to quit smoking by himself but was able to do so following intervention by a respiratory doctor.
A study by Ball et al. reported that 53% of patients with scleroderma had painful or itchy skin.18 Pain has also been shown to affect wound healing through a variety of mechanisms.19 Our patient was evaluated for pain at each visit and given an appropriate intervention as required. Negative emotions (for example, depression, anxiety or stress) affect wound healing, and it has been shown that psychological interventions can promote wound healing.20,21 The patient was given positive psychological guidance through the intervention of a psychologist.
Effective preparation of a wound bed is considered to be the key to successful wound healing.22 In this case, a combination of mechanical debridement and autolytic debridement was used to remove the necrotic fibrous tissue in order to prepare the wound bed. Bacterial infection of the wound bed also affected wound healing and so antibacterial dressings were used.
This case report describes a complex case of hard-to-heal wound management in a patient with localised scleroderma. The use of TIME CDST not only promoted wound healing, but also relieved pain, reduced the patient's anxiety, and achieved the unexpected additional benefit of the patient quitting smoking.
Conclusion
This case shows the effectiveness of the TIME CDST in the treatment of a hard-to-heal localised scleroderma wound. The TIME principle is the first step to addressing the challenges in wound healing. Since its establishment, it has been widely integrated into research and practice. Its limitation, however, is that it focuses primarily on the local wound rather than on the patient as a whole. The TIME CDST, using the ABCDE approach, can be applied to wound management, and provides a framework for wound treatment to support good practice.
Reflective questions
- What are the components of TIME CDST?
- What measures should be taken to protect skin in localised scleroderma?
- What are the most important factors that need to be addressed in order to promote healing of hard-to-heal wounds?