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Diamorphine-Metronidazole Gel Effective for Treatment of Painful Infected Leg Ulcers

2000; Elsevier BV; Volume: 20; Issue: 6 Linguagem: Inglês

10.1016/s0885-3924(00)00219-0

1873-6513

Petra Flock, Louise Gibbs, Nigel Sykes,

Diabetic Foot Ulcer Assessment and Management

To the Editor: Recently, there have been several case reports about the analgesic effect of topical opioids on painful skin lesions1Back I.N. Finlay I. Analgesic effect of topical opioids on painful skin ulcers.J Pain Symptom Manage. 1995; 10: 493Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 2Twillman R.K. Long T.D. Cathers T.A. Mueller D.W. Treatment of painful skin ulcers with topical opioids.J Pain Symptom Manage. 1999; 17: 288-292Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 3Krajnic M. Zylicz Z. Finlay I. et al.Potential uses of topical opioids in palliative care—report of 6 cases.Pain. 1999; 80: 121-125Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar. A ready-mixed hydrogel containing carboxymethylcellulose polymer (IntraSite gel) or a pharmacy-mixed gel containing carbomerum 974, sodium EDTA, trometamoleum, and propylene glycol have been mixed with either morphine or diamorphine in varying concentrations (0.08–0.3%)2Twillman R.K. Long T.D. Cathers T.A. Mueller D.W. Treatment of painful skin ulcers with topical opioids.J Pain Symptom Manage. 1999; 17: 288-292Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 3Krajnic M. Zylicz Z. Finlay I. et al.Potential uses of topical opioids in palliative care—report of 6 cases.Pain. 1999; 80: 121-125Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar. We would like to report a case in which a metronidazole-diamorphine gel had an analgesic effect equal to that of IntraSite-diamorphine gel. The patient, an 82-year-old woman with metastatic ovarian cancer, was admitted to a palliative care unit for treatment of painful leg ulcers. The legs were edematous and multiple ulcers (stage I–III) of varying sizes covered the entire circumference of both lower legs. Diclofenac 50 mg three times per day and coproxamol 2 tablets four times a day had been taken at home without achieving pain control. The pain improved slightly with applications of IntraSite gel, nonadhesive dressing and gentle bandaging, administration of oral morphine 5 mg every 4 hours, and, as needed, diclofenac 50 mg three times per day, and acetaminophen 1 g four times daily. On day 4 of her hospitalization, the patient developed signs of opioid toxicity. Because her only pain was related to her leg ulcers, it was decided to discontinue all oral pain medication and apply diamorphine gel topically (0.1% weight-to-weight solution—1 mg diamorphine/1 ml IntraSite gel). The patient was pain-free within one hour of application and remained pain free until the next dressing change 48 hours later. Signs of opioid toxicity resolved over the next couple of days. Because some of the leg ulcers had persistent foul smelling mucopurulent discharge, wound swabs were taken. Culture revealed mixed flora and anaerobes. It was then decided to switch the IntraSite-diamorphine gel to metronidazole-diamorphine gel (0.1% weight-to-weight solution—1 mg diamorphine/1 ml metronidazole gel [0.75%]). The patient remained pain-free and the leg ulcers started to heal. Our case not only supports previous reports that topical opioids have an analgesic effect without systemic side effects, but also indicates that diamorphine can be mixed into metronidazole gel instead of IntraSite gel. This might be particularly helpful in painful, infected wounds.