Leprosy Mailing List – September 6th, 2007
Ref.: Main factors
contributing to foot ulcers in leprosy
From: Salafia A., Mumbai, India
Dear Salvatore,
Let me expose my views. I agree with Dr Theuvenet (LML
September 4th , 2007), motor unbalance is a
significant factors; others have mentioned sensory loss. From my experience spanning
over 35 years and more than 40 thousand ulcers treated I dare to
say:
1. Motor
unbalance and sensory loss are part of the story, but not the whole
story. As a matter of
fact there a patients (in my data, about 6-7 %) who have protective
sensation and yet they have ulcers.
Therefore there must be other factors too.
2. In
my book "Treatment of Neuritis in Leprosy. Medical and
Surgical" I mentioned (actually there is a full page on it)
the importance of "Nerva Vasorum" in the pathogenesis
of ulcers. Let me quote: "...
Sympathetic system is damaged quite early in leprosy ... and leads to
dryness of skin. It
appears that the functional recovery of in the autonomic system is
slower than in the sensory one. ... In a permanently denervated area,
cooling will cause arteriolar constriction and venous dilatation and
hence oedema. Loss of
vasoconstriction tone, causes venous stasis, accumulation of
metabolites, reduced oxygenation and increased carbon dioxide content,
leading to further damage. Oedema
is the rule at this stage. Healing
of ulcers will be impaired and delayed by the poor blood flow and
accumulation of noxious substances. A dry skin ... is more
liable to trauma, cracking and secondary infection, both bacterial and
fungal."
Therefore, there are three main factors
contributing to the ulcers, motor unbalance, sensory loss and loss of
sympathetic modality too. We
can, to certain extend, correct the motor unbalance, but -so far- we
have no solution (even with the latest microsurgical tools at our
disposal) for correcting the sensory loss and sympathetic loss. Until we solve these problems,
the ulcers will recur again and again.
If the patient stays in bed, the ulcer may heal, but the moment
he/she puts the foot down, the ulcer will reappear.
Best regards,
Antonio
Dr. A.
Salafia
Chief of Reconstructive Surgery
Vimala Dermatological Centre, Mumbai, India
