Sir,

Punch grafting is a technique that has been widely employed for the treatment of wounds and foot and leg ulcers [1–3]. It is easy to implement, is complication-free, and is nowadays considered again an important therapeutic alternative as many ulcers fail to heal completely despite well-conducted care [3]. The principle of such grafting consists of obtaining thin, split-thickness skin grafts (STSG) containing the epidermis and papillary dermis, which promote wound re-epithelialization and the release of growth factors and cells [2]. It considerably shortens the healing time [3]. The HAS recommends its use for recalcitrant ulcers (> six months) and ulcers larger than 10 cm² [4]. A study by Conde-Montero demonstrated its value in reducing pain in all types of ulcers, yet especially in necrotic angiodermatitis [5]. The preparation phase is essential in order to acquire an adequate ulcer bed for graft reception. The management of causative and etiological factors is also necessary to optimize the results [2,4]. Particularly in venous ulcers, it is necessary to educate patients on the need to respect healthy lifestyle measures and wear compression bandages. It is equally important to manage co-morbidities, recommend lymphatic and venous drainage, prevent trauma, and treat wounds early [4]. Herein, we report the case of a recalcitrant, venous leg ulcer treated with punch grafting. Our case illustrates the interest in this technique and underlines the need to have all the optimal conditions accompanying the healing and manage the etiological and promoting factors.

A 44-year-old male patient presented with a history of a venous ulcer on the right leg evolving for three years with chronic venous insufficiency at a surgical stage, for which he was operated one year previously and also benefited from platelet-rich plasma (PRP) sessions without a clear improvement. A clinical examination revealed a roughly oval ulcer, 6 × 5 cm in diameter, with a budding and fibrinous surface, located on the medial malleolus. An examination of the skin around the lesion revealed signs of chronic venous insufficiency, such as ochre dermatitis and varicosities (Fig. 1a). Doppler ultrasound of the arterial and venous network revealed venous insufficiency without arterial involvement. Compression bandages were prescribed. The preparation of the ulcer bed was performed by chemical dressings such as hydrocolloids, the mechanical debridement of the fibrin, and the revival of the ulcer edges with CO₂ laser. The patient, then, underwent punch grafting harvested from the thigh (Figs. 1b and 1c). Complete healing was observed after five months with a two-year follow-up and no recurrence (Fig. 1d).

Figure 1: (a) The fibrinous venous ulcer located on the medial malleolus surrounded by ochre dermatitis. (b) The venous ulcer bed after chemical and mechanical debridement. (c) Re-epithelialization and punch grafting. (d) Complete healing after five months with a two-year follow-up.

The interest in this technique lies in the fact that it is simple, effective, and complication-free. In addition to producing an analgesic effect, it accelerates and optimizes healing.

REFERENCES

1. García-Madrid M, Sanz-Corbalán I, Tardáguila-García A, Molines-Barroso RJ, López-Moral M, Lázaro-Martínez JL. Punch grafting for the management of hard-to-heal diabetic foot ulcers:A prospective case series. Int J Low Extrem Wounds. 2021;153473462110310.

2. Ren S-Y, Liu Y-S, Zhu G-J, Liu M, Shi S-H, Ren X-D, et al. Strategies and challenges in the treatment of chronic venous leg ulcers. World J Clin Cases. 2020;8:5070 85.

3. Groening L, Holthuis L, Polesie S, Sönnergren H. Clinical outcomes of punch-grafting for chronic leg and foot ulcers:A retrospective non-comparative cohort study. Acta Derm Venereol. 2017;97:131-2.

4. Vasileva M, Brishkoska Boshkovski V, Petrov A, Zisovska E. Treatment of venous ulcers in drug addicts:A case report. Our Dermatol Online. 2021;12:439-41.

5. Conde-Montero E, de Farias Khayat Y, Pérez Jerónimo L, Vázquez AP, Marín LR, Guisado S, et al. Punch grafting for pain reduction in hard-to-heal ulcers. J Wound Care. 2020;29:194-7.