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Pain Management in Patients with Chronic Wounds

  • Wound Care and Healing (H Lev-Tov, Section Editor)
  • Published:
Current Dermatology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Chronic wounds are increasing in prevalence and are often associated with significant pain, which can have a major impact on quality of life. Safe and effective pain management can be challenging, an unfortunate reality that is highlighted by the ongoing opioid crisis. This review aims to provide an evidence-based framework for pharmacologic and non-pharmacologic pain management in patients with chronic wounds.

Recent Findings

As reflected in the new CDC guidelines, no study has shown that long-term opioid use mitigates chronic pain. Non-pharmacologic therapies, including virtual reality and acupuncture, have shown efficacy and are promising adjuvant therapies for pain management.

Summary

Non-opioid pharmacotherapies and non-pharmacologic therapies are preferable to opioids for chronic pain related to non-healing wounds. The experience of pain is a subjective and complex biopsychosocial process that necessitates a rational, personalized, and often multimodal approach to management.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. • Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–71. Provides a good overview of the burden that chronic wounds pose to society and the relevance from a public health prespective.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007;(386):1–32.

  3. Kurz X, Kahn SR, Abenhaim L, Clement D, Norgren L, Baccaglini U, et al. Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies. Int Angiol. 1999;18(2):83–102.

    CAS  PubMed  Google Scholar 

  4. Ma H, O'Donnell TF, Rosen NA, Iafrati MD. The real cost of treating venous ulcers in a contemporary vascular practice. J Vasc Surg Venous Lymphat Disord. 2014;2(4):355–61.

    Article  PubMed  Google Scholar 

  5. •• Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and management of lower-extremity ulcers. N Engl J Med. 2017;377(16):1559–67. Thorough but concise overview on how to manage patients with chronic wounds, including venous, arterial, diabetic, and pressure ulcers.

    Article  PubMed  Google Scholar 

  6. Green J, Jester R, McKinley R, Pooler A. The impact of chronic venous leg ulcers: a systematic review. J Wound Care. 2014;23(12):601–12.

    Article  CAS  PubMed  Google Scholar 

  7. Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons N. Burden of venous leg ulcers in the United States. J Med Econ. 2014;17(5):347–56.

    Article  PubMed  Google Scholar 

  8. 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.

    PubMed  Google Scholar 

  9. McGinnis E, Briggs M, Collinson M, Wilson L, Dealey C, Brown J, et al. Pressure ulcer related pain in community populations: a prevalence survey. BMC Nurs. 2014;13:16.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Ahn H, Stechmiller J, Fillingim R, Lyon D, Garvan C. Bodily pain intensity in nursing home residents with pressure ulcers: analysis of national minimum data set 3.0. Res Nurs Health. 2015;38(3):207–12.

    Article  PubMed  Google Scholar 

  11. Ribu L, Rustøen T, Birkeland K, Hanestad BR, Paul SM, Miaskowski C. The prevalence and occurrence of diabetic foot ulcer pain and its impact on health-related quality of life. J Pain. 2006;7(4):290–9.

    Article  PubMed  Google Scholar 

  12. Krasner D. Painful venous ulcers: themes and stories about living with the pain and suffering. J Wound Ostomy Continence Nurs. 1998;25(3):158–68.

    CAS  PubMed  Google Scholar 

  13. Woo KY. Meeting the challenges of wound-associated pain: anticipatory pain, anxiety, stress, and wound healing. Ostomy Wound Manage. 2008;54(9):10–2.

    PubMed  Google Scholar 

  14. Broadbent E, Petrie KJ, Alley PG, Booth RJ. Psychological stress impairs early wound repair following surgery. Psychosom Med. 2003;65(5):865–9.

    Article  PubMed  Google Scholar 

  15. Ebrecht M, Hextall J, Kirtley LG, Taylor A, Dyson M, Weinman J. Perceived stress and cortisol levels predict speed of wound healing in healthy male adults. Psychoneuroendocrinology. 2004;29(6):798–809.

    Article  CAS  PubMed  Google Scholar 

  16. Lazarus GS, Cooper DM, Knighton DR, Percoraro RE, Rodeheaver G, Robson MC. Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Repair Regen. 1994;2(3):165–70.

    Article  CAS  PubMed  Google Scholar 

  17. Li J, Chen J, Kirsner R. Pathophysiology of acute wound healing. Clin Dermatol. 2007;25(1):9–18.

    Article  CAS  PubMed  Google Scholar 

  18. Alavi A, Sibbald RG, Phillips TJ, Miller OF, Margolis DJ, Marston W, et al. What’s new: management of venous leg ulcers: Approach to venous leg ulcers. J Am Acad Dermatol. 2016;74(4):627–40; quiz 41–2–40.

    Article  PubMed  Google Scholar 

  19. Korting HC, Schöllmann C, White RJ. Management of minor acute cutaneous wounds: importance of wound healing in a moist environment. J Eur Acad Dermatol Venereol. 2011;25(2):130–7.

    Article  CAS  PubMed  Google Scholar 

  20. Loot MA, Kenter SB, Au FL, van Galen WJ, Middelkoop E, Bos JD, et al. Fibroblasts derived from chronic diabetic ulcers differ in their response to stimulation with EGF, IGF-I, bFGF and PDGF-AB compared to controls. Eur J Cell Biol. 2002;81(3):153–60.

    Article  PubMed  Google Scholar 

  21. Stojadinovic O, Brem H, Vouthounis C, Lee B, Fallon J, Stallcup M, et al. Molecular pathogenesis of chronic wounds: the role of beta-catenin and c-myc in the inhibition of epithelialization and wound healing. Am J Pathol. 2005;167(1):59–69.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. • Herskovitz I, MacQuhae FE, Dickerson JE, Cargill DI, Slade HB, Margolis DJ, et al. Opioids’ effect on healing of venous leg ulcers. J Invest Dermatol. 2017;137(12):2646–9. Study found that a high percentage of patients with chronic venous ulcers were prescribed opioids and that opioid use was negatively associated with wound healing.

    Article  CAS  PubMed  Google Scholar 

  23. •• Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154–63. Paper outlines the opioid crisis in the USA and provides an in-depth prospective on the close correlation between rising opioid prescriptions, opioid abuse, and related morbidty and mortality.

    Article  CAS  PubMed  Google Scholar 

  24. Crane EH. Emergency Department Visits Involving Narcotic Pain Relievers. The CBHSQ report. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Rockville, MD.2015.

  25. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581–624.

    Article  PubMed  Google Scholar 

  26. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S240–52.

    Article  Google Scholar 

  27. • Woller SA, Eddinger KA, Corr M, Yaksh TL. An overview of pathways encoding nociception. Clin Exp Rheumatol. 2017;35(Suppl 107(5)):40–6. See article for a detailed review of noceptive pain pathway neuroanatomy and phyiology.

    PubMed  PubMed Central  Google Scholar 

  28. Horn C, Blischke Y, Kunz M, Lautenbacher S. Does pain necessarily have an affective component? Negative evidence from blink reflex experiments. Pain Res Manag. 2012;17(1):15–24.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Bechert K, Abraham SE. Pain management and wound care. J Am Col Certif Wound Spec. 2009;1(2):65–71.

    PubMed  PubMed Central  Google Scholar 

  30. Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990;41(3):273–81.

    Article  CAS  PubMed  Google Scholar 

  31. Benigni JP, Sadoun S, Allaert FA, Vin F. Efficacy of class 1 elastic compression stockings in the early stages of chronic venous disease. A comparative study. Int Angiol. 2003;22(4):383–92.

    CAS  PubMed  Google Scholar 

  32. Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012;12:CD001733.

    PubMed  Google Scholar 

  33. Parsa H, Zangivand AA, Hajimaghsoudi L. The effect of pentoxifylline on chronic venous ulcers. Wounds. 2012;24(7):190–4.

    PubMed  Google Scholar 

  34. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012;11:CD003230.

    PubMed  Google Scholar 

  35. • Peppin JF, Albrecht PJ, Argoff C, Gustorff B, Pappagallo M, Rice FL, et al. Skin matters: a review of topical treatments for chronic pain. Part two: treatments and applications. Pain Ther. 2015;4(1):33–50. See article for detailed review of topical therapies for chronic pain, including numerous citations for studies looking at various pharmacotherapies.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Gammaitoni AR, Alvarez NA, Galer BS. Safety and tolerability of the lidocaine patch 5%, a targeted peripheral analgesic: a review of the literature. J Clin Pharmacol. 2003;43(2):111–7.

    Article  CAS  PubMed  Google Scholar 

  37. Tandan R, Lewis GA, Krusinski PB, Badger GB, Fries TJ. Topical capsaicin in painful diabetic neuropathy. Controlled study with long-term follow-up. Diabetes Care. 1992;15(1):8–14.

    Article  CAS  PubMed  Google Scholar 

  38. Biesbroeck R, Bril V, Hollander P, Kabadi U, Schwartz S, Singh SP, et al. A double-blind comparison of topical capsaicin and oral amitriptyline in painful diabetic neuropathy. Adv Ther. 1995;12(2):111–20.

    CAS  PubMed  Google Scholar 

  39. Arapoglou V, Katsenis K, Syrigos KN, Dimakakos EP, Zakopoulou N, Gjødsbøl K, et al. Analgesic efficacy of an ibuprofen-releasing foam dressing compared with local best practice for painful exuding wounds. J Wound Care. 2011;20(7):319–20, 22–5–25.

    Article  CAS  PubMed  Google Scholar 

  40. Gottrup F, Jørgensen B, Karlsmark T, Sibbald RG, Rimdeika R, Harding K, et al. Reducing wound pain in venous leg ulcers with Biatain Ibu: a randomized, controlled double-blind clinical investigation on the performance and safety. Wound Repair Regen. 2008;16(5):615–25.

    Article  PubMed  Google Scholar 

  41. Bastami S, Frödin T, Ahlner J, Uppugunduri S. Topical morphine gel in the treatment of painful leg ulcers, a double-blind, placebo-controlled clinical trial: a pilot study. Int Wound J. 2012;9(4):419–27.

    Article  PubMed  Google Scholar 

  42. Jansen MM, van der Horst JC, van der Valk PG, Kuks PF, Zylicz Z, van Sorge AA. Pain-relieving properties of topically applied morphine on arterial leg ulcers: a pilot study. J Wound Care. 2009;18(7):306–11.

    Article  CAS  PubMed  Google Scholar 

  43. Vernassiere C, Cornet C, Trechot P, Alla F, Truchetet F, Cuny JF, et al. Study to determine the efficacy of topical morphine on painful chronic skin ulcers. J Wound Care. 2005;14(6):289–93.

    Article  CAS  PubMed  Google Scholar 

  44. Zeppetella G, Paul J, Ribeiro MD. Analgesic efficacy of morphine applied topically to painful ulcers. J Pain Symptom Manag. 2003;25(6):555–8.

    Article  CAS  Google Scholar 

  45. Krajnik M, Zylicz Z, Finlay I, Luczak J, van Sorge AA. Potential uses of topical opioids in palliative care—report of 6 cases. Pain. 1999;80(1–2):121–5.

    Article  CAS  PubMed  Google Scholar 

  46. Twillman RK, Long TD, Cathers TA, Mueller DW. Treatment of painful skin ulcers with topical opioids. J Pain Symptom Manag. 1999;17(4):288–92.

    Article  CAS  Google Scholar 

  47. Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med. 1995;332(25):1685–90.

    Article  CAS  PubMed  Google Scholar 

  48. Stein C, Küchler S. Non-analgesic effects of opioids: peripheral opioid effects on inflammation and wound healing. Curr Pharm Des. 2012;18(37):6053–69.

    Article  CAS  PubMed  Google Scholar 

  49. • Peppin JF, Albrecht PJ, Argoff C, Gustorff B, Pappagallo M, Rice FL, et al. Skin matters: a review of topical treatments for chronic pain. Part one: skin physiology and delivery systems. Pain Ther. 2015;4(1):17–32. See article for detailed review of topical therapies for chronic pain, including numerous citations for studies looking at various pharmacotherapies.

    Article  PubMed Central  PubMed  Google Scholar 

  50. • Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162–73. Updated evidence-based guidelines from the Special Interest Group on Neuropathic Pain (NeuPSIG) of the International Association for the Study of Pain for pharmalogical management of neuropathic pain.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  51. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician. 2010;56(6):514–7. e202-5

    PubMed  PubMed Central  Google Scholar 

  52. •• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45. Updated CDC guidelines on prescribing opioids for chronic pain, which recommend non-opioid and non-pharmacologic therapies, citing the lack of evidence for opioids.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Bakhle YS, Botting RM. Cyclooxygenase-2 and its regulation in inflammation. Mediat Inflamm. 1996;5(5):305–23.

    Article  CAS  Google Scholar 

  54. Glass JS, Hardy CL, Meeks NM, Carroll BT. Acute pain management in dermatology: risk assessment and treatment. J Am Acad Dermatol. 2015;73(4):543–60. quiz 61-2

    Article  PubMed  Google Scholar 

  55. Derry S, Moore RA. Single dose oral aspirin for acute postoperative pain in adults. Cochrane Database Syst Rev. 2012;4:CD002067.

    Google Scholar 

  56. de Oliveira Carvalho PE, Magolbo NG, De Aquino RF, Weller CD. Oral aspirin for treating venous leg ulcers. Cochrane Database Syst Rev. 2016;2:CD009432.

    PubMed  Google Scholar 

  57. Imani F, Motavaf M, Safari S, Alavian SM. The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepat Mon. 2014;14(10):e23539.

    Article  PubMed Central  PubMed  Google Scholar 

  58. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102(4):822–31.

    Article  CAS  PubMed  Google Scholar 

  59. Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database Syst Rev. 2011;9:CD008659.

    Google Scholar 

  60. De Oliveira GS, Castro-Alves LJ, McCarthy RJ. Single-dose systemic acetaminophen to prevent postoperative pain: a meta-analysis of randomized controlled trials. Clin J Pain. 2015;31(1):86–93.

    Article  PubMed  Google Scholar 

  61. Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother. 2010;44(3):489–506.

    Article  CAS  PubMed  Google Scholar 

  62. Frieden TR, Houry D. Reducing the risks of relief—the CDC opioid-prescribing guideline. N Engl J Med. 2016;374(16):1501–4.

    Article  PubMed Central  PubMed  Google Scholar 

  63. Derry S, Derry CJ, Moore RA. Single dose oral ibuprofen plus oxycodone for acute postoperative pain in adults. Cochrane Database Syst Rev. 2013;6:CD010289.

    Google Scholar 

  64. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104(3):570–87.

    Article  CAS  PubMed  Google Scholar 

  65. Sicuteri F, Rainò L, Geppetti P. Substance P and endogenous opioids: how and where they could play a role in cluster headache. Cephalalgia. 1983;3(Suppl 1):143–5.

    Article  PubMed  Google Scholar 

  66. Delgado AV, McManus AT, Chambers JP. Exogenous administration of substance P enhances wound healing in a novel skin-injury model. Exp Biol Med (Maywood). 2005;230(4):271–80.

    Article  CAS  Google Scholar 

  67. Dubon MJ, Park KS. The mechanisms of substance P-mediated migration of bone marrow-derived mesenchymal stem cell-like ST2 cells. Int J Mol Med. 2016;37(4):1105–11.

    Article  CAS  PubMed  Google Scholar 

  68. Shanmugam VK, Couch KS, McNish S, Amdur RL. Relationship between opioid treatment and rate of healing in chronic wounds. Wound Repair Regen. 2017;25(1):120–30.

    Article  PubMed Central  PubMed  Google Scholar 

  69. Yim E, Vivas A, Maderal A, Kirsner RS. Neuropathy and ankle mobility abnormalities in patients with chronic venous disease. JAMA Dermatol. 2014;150(4):385–9.

    Article  PubMed  Google Scholar 

  70. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database Syst Rev. 2007;4:CD005454.

    Google Scholar 

  71. Gahimer J, Wernicke J, Yalcin I, Ossanna MJ, Wulster-Radcliffe M, Viktrup L. A retrospective pooled analysis of duloxetine safety in 23,983 subjects. Curr Med Res Opin. 2007;23(1):175–84.

    Article  CAS  PubMed  Google Scholar 

  72. Goldstein DJ, Lu Y, Detke MJ, Lee TC, Iyengar S. Duloxetine vs. placebo in patients with painful diabetic neuropathy. Pain. 2005;116(1–2):109–18.

    Article  CAS  PubMed  Google Scholar 

  73. Kremer M, Salvat E, Muller A, Yalcin I, Barrot M. Antidepressants and gabapentinoids in neuropathic pain: mechanistic insights. Neuroscience. 2016;338:183–206.

    Article  CAS  PubMed  Google Scholar 

  74. Yesilyurt O, Dogrul A, Gul H, Seyrek M, Kusmez O, Ozkan Y, et al. Topical cannabinoid enhances topical morphine antinociception. Pain. 2003;105(1–2):303–8.

    Article  CAS  PubMed  Google Scholar 

  75. Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9):955–6.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  76. Kroenke K, Cheville A. Management of chronic pain in the aftermath of the opioid backlash. JAMA. 2017;317(23):2365–6.

    Article  PubMed  Google Scholar 

  77. Federman DG, Poulin LM, Ruser CB, Kravetz JD. Implementation of shared medical appointments to offer battlefield acupuncture efficiently to veterans with pain. Acupunct Med 2017.

  78. Mahrer NE, Gold JI. The use of virtual reality for pain control: a review. Curr Pain Headache Rep. 2009;13(2):100–9.

    Article  PubMed  Google Scholar 

  79. Hua Y, Qiu R, Yao WY, Zhang Q, Chen XL. The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs. Pain Manag Nurs. 2015;16(5):685–91.

    Article  PubMed  Google Scholar 

  80. Jeffs D, Dorman D, Brown S, Files A, Graves T, Kirk E, et al. Effect of virtual reality on adolescent pain during burn wound care. J Burn Care Res. 2014;35(5):395–408.

    Article  PubMed  Google Scholar 

  81. Faber AW, Patterson DR, Bremer M. Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients. J Burn Care Res. 2013;34(5):563–8.

    Article  PubMed  Google Scholar 

  82. Upton D, Solowiej K, Hender C, Woodyatt KY. Stress and pain associated with dressing change in patients with chronic wounds. J Wound Care. 2012;21(2):53. 4, 6,8 passim, 61

    Article  CAS  PubMed  Google Scholar 

  83. Maani CV, Hoffman HG, Morrow M, Maiers A, Gaylord K, McGhee LL, et al. Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles. J Trauma. 2011;71(1 Suppl):S125–30.

    Article  PubMed Central  PubMed  Google Scholar 

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Authorship

Every author listed meets the qualifications for authorship and has had the opportunity to read and comment upon the submitted manuscript.

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Authors and Affiliations

  1. Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

    Joshua S. Mervis

  2. Department of Medicine, Yale University School of Medicine, New Haven, CT, USA

    Daniel G. Federman

  3. VA Connecticut Healthcare System, 11ACSL, 950 Campbell Ave., West Haven, CT, 06516, USA

    Daniel G. Federman

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  1. Joshua S. Mervis
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  2. Daniel G. Federman
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Correspondence to Daniel G. Federman.

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This article is part of the Topical Collection on Wound Care and Healing

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Mervis, J.S., Federman, D.G. Pain Management in Patients with Chronic Wounds. Curr Derm Rep 7, 136–146 (2018). https://doi.org/10.1007/s13671-018-0220-2

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