Chronic venous ulcer treatment with topical sevoflurane.

Dear Editors, Vascular leg ulcers are a very common disease with a complicated management, a significant sanitary expense, as well as a significant repercussion in patient’s quality of life. An appropriate analgesic control is essential for the management of this condition. Themost commonly used therapeutic options to treat the pain are oral analgesics (Non-Steroidal Anti-Inflammatory Drugs (NSAID), acetaminophen, metamizole, tramadol, pregabalin and gabapentin), opiates and topical anaesthetic creams, such as lidocaíne or prilocaine. These therapies may lead to several adverse effects and complications, depending on the drug used and the characteristics of the patient (1,2). Sevoflurane is an inhalable, halogenated anaesthetic agent with an adequate safety profile, used for induction and maintenance of general anaesthesia in hospital and ambulatory surgery, and its efficacy as a topical anaesthetic in vascular leg ulcers has already been reported (1–5). We present the case of a 73-year-old woman with a personal history of arterial hypertension, morbid obesity, type 2 mellitus diabetes, apnoea-hypoventilation syndrome, chronic renal failure and ischaemic cardiopathy. She suffered from a deep venous thrombosis on her right lower limb. The patient complained of disabling and highly painful vascular ulcers on her lower limbs. Daily cures and topical and multiple oral antibiotics were prescribed with an improvement and recovery of the ulcers on her left lower limb. Nevertheless, the ulcers on her right lower limb increased in number with severe pain and discomfort. A dermatological examination showed several deep ulcers with erythematous edges, seropurulent exudate and whitish and haemorrhagic scabs over the anterolateral surface of her right leg (Figure 1). X-ray image of her right leg did not show any significant alterations. The ankle-brachial index was normal. An ultrasound for deep venous thrombosis detection was normal. Histological study showed a chronic inflammatory infiltrate, with granulation tissue and skin calcification (Figure 2). The culture was positive for methicillin-resistant and clindamycin-mupirocin-sensitive Staphylococcus aureus. The patient was admitted to the Internal Medicine Service. Treatment was initiated with clindamycin, right leg immobilisation and strict control of glycaemia and arterial blood pressure. Written consent from the patient and permission from the Pharmacy Department were obtained for the off-label use of topical sevoflurane for her painful right leg ulcers. Daily treatment was initiated with a saline solution, followed by direct irrigation of 10ml of liquid sevoflurane daily over the ulcers. An intense analgesic effect was reported in 10minutes, lasting 8 hours without using other systemic analgesics, and it allowed cleaning with chlorhexidine gluconate solution, surgical debridement of the necrotic tissue, and occlusive dressings Figure 1 Several ulcers with erythematous edges and seropurulent exudate over the anterolateral surface of the patient’s right leg.