Alleviating Venous Ulcer Pain

Laura Bolton, PhD, FAPWCA, Adjunct Associate Professor, Department of Surgery, UMDNJ, WOUNDS Editorial Advisory Board Member and Department Editor

Dear Readers:

  Pain is one of the most dreaded and least understood complications of chronic and acute wounds. Through the years research has confirmed that that moisture-retentive topical primary wound dressings can alleviate pain compared to gauze dressings in chronic venous1 or pressure2 ulcers and in acute burns3 surgical excisions4 or traumatic wounds.5 A recent Cochrane review concluded that a topical eutectic mixture (at lowest possible temperature of solidification) of 2.5% each of the two local anesthetics lidocaine and prilocaine (LP cream) reduced pain during venous ulcer debridement.6 The World Health Organization (WHO)7 has proposed a three-step ladder of systemic pain relief for cancer patients recommending oral non-opioids, such as aspirin and paracetamol, to address basic pain plus additional “adjuvants” to manage anxiety if needed. As pain increases to mild or moderate levels, the second step on the pain ladder adds a mild opioid such as codeine. The third step calls for a stronger opioid such as morphine as pain becomes moderate or severe. The right drug or combination is given every 3–6 hours to maintain freedom from cancer pain. How would the WHO pain ladder work for venous ulcer patients? Would chronic morphine use delay healing?8 Two studies summarized below suggest a different set of analgesic principles to achieve safe and effective venous ulcer pain relief.

Topical Cream or Inhaled Nitrous Oxide for Debridement Pain


1. Arnold TE, Stanley JC, Fellows EP, et al. Prospective, multicenter study of managing lower extremity venous ulcers. Ann Vasc Surg. 1994;8(4):356–362.

2. Heyneman A, Beele H, Vanderwee K, Defloor T. A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. J Clin Nurs. 2008;17(9):1164–1173.

3. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma. 1990;30(7):857–865.

4. Nemeth AJ, Eaglstein WH, Taylor JR, Peerson LJ, Falanga V. Faster healing and less pain in skin biopsy sites treated with an occlusive dressing. Arch Dermatol. 1991;127(11):1679–1683.

5. Hermans MH. Hydrocolloid dressings versus tulle gauze in the treatment of abrasions in cyclists. Int J Sports Med. 1991;12(6):581–584.

6. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev. 2003;(1):CD001177.

7. World Health Organization Pain Ladder. Available at: Accessed: July 1, 2010.

8. Martin JL, Koodie L, Krishnan AG, Charboneau R, Barke RA, Roy S. Chronic morphine administration delays wound healing by inhibiting immune cell recruitment to the wound site. Am J Pathol. 2010;176(2):786–799.

9. Association for the Advancement of Wound Care (AAWC). Summary algorithm for venous ulcer care with annotations of available evidence. Malvern, PA: Association for the Advancement of Wound Care. 2005; National Guideline Clearinghouse. Available at: Accessed: July 7, 2010.

10. Nemeth KA, Harrison MB, Graham ID, Burke S. Understanding venous leg ulcer pain: results of a longitudinal study. Ostomy Wound Manage. 2004;50(1):34–46.

11. Guarnera G, Tinelli G, Abeni D, Di Pietro C, Sampogna F, Tabolli S. Pain and quality of life in patients with vascular leg ulcers: an Italian multicentre study. J Wound Care.

2007;16(8):347–351. 12. Romanelli, M. Objective measurement of venous ulcer debridement and granulation with a skin color reflectance analyzer. WOUNDS. 1997;9(4):122–126.

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