Chronic wounds are notoriously challenging to heal as they are often halted in their normal healing process. The concept of TIME (Tissue, Inflammation/Infection, Moisture imbalance, Epithelial edge advancement) has been widely utilized in clinical practice to prepare wound beds and promote healing, particularly in longstanding wounds. Traditional methods of wound bed preparation are often inadequate in healing chronic wounds or they may not be tolerated by patients. A variety of interventions have been developed in recent decades to address these components and improve chronic wound outcomes. Evolutions in tissue preparation include emerging enzymatic debridement agents and ultrasound-assisted debridement. Wound infection can be managed through a variety of new methods including advanced wound dressings, surfactants, and fluorescence imaging. Portable negative pressure wound therapy devices provide a new, convenient method for exudate management. Finally, epithelial advancement can be enhanced with technologies such as cellular, acellular, and matrix-like products (CAMPs), topical medications, and electrical stimulation.

Objectives Diabetes mellitus (DM) affects over 422 million individuals globally. Diabetic foot ulcers (DFUs) stand out as a challenging complication of DM, affecting up to 34% of individuals with DM. Despite the prevalence of DFUs, clinical trials for DFUs often face slow and insufficient patient recruitment. We aimed to identify key determinants that impact subject recruitment rates in DFU clinical trials.Design Systematic review.Data sources ClinicalTrials.gov and PubMed were searched to identify DFU clinical studies published from 1 January 1990 to 9 April 2025.Eligibility criteria We included English-language publications of clinical trials aimed at healing DFUs that reported enrolment numbers, duration of enrolment and number of study centres.Data extraction and synthesis Records were extracted and subjected to two independent rounds of review by five authors (LZ, SP, RN, HL-T, and RK). Data were pooled and analysed using negative binomial regression, Kaplan-Meier methods and Cox proportional hazards models. Study enrolment and site enrolment rates, as well as time to complete study enrolment, were analysed. Between-study heterogeneity was assessed using the likelihood ratio test.Results 397 trials involving 31 955 participants were included. On average, DFU studies enrolled 4.24 patients per month (median: 1.65). US-based studies had slower recruitment than non-US studies, with a mean enrolment rate of 1.51 patients per site per month (median: 0.58). The average time to complete enrolment was 1.28 years. Studies that employed a higher number of study sites, were conducted outside the USA, studied behavioural or dietary supplement interventions, and began enrolment more recently, were more likely to have a higher enrolment rate. Longer time to complete enrolment was associated with a larger number of study sites, trials involving at least one US site, earlier starting enrolment year, and longer follow-up duration.Conclusions These findings have potential practical implications for the design and conduct of future DFU trials.

In this chapter, we will explore topical wound care and the evidence to support their use in diabetic foot ulcer patients. The chapter is divided into two main sections that will first explore dressings and then review topical growth factors and biologically active products. Various wound care compounds, dressings, and devices are discussed.

Inadequate literature has analyzed Merkel cell carcinoma (MCC) in ethnically diverse Hispanic and Black populations. Considering the rising proportion of MCC in such minority groups1 and the racial and ethnic heterogeneity of Miami-Dade County, we reviewed MCC data for patients in Miami, Florida. In this study, approved by the University of Miami Institutional Review Board, electronic medical records of 191 patients seen at the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine from January 2010 to February 2023 were examined retrospectively by two reviewers, P. V. W. and C. D.-E. The χ2 tests of independence and goodness-of-fit were used to verify any statistical significance between the observed and expected MCC rates in this patient group (p < 0.05). Patient demographics and variables are examined in Tables 1 and 2, respectively. Of the 191 patients diagnosed with MCC, most patients (178 of the 191 or 93%) were White; of which 56 or 31% where White Hispanic. Seventy-one percent (136) were men and 81% (155) were over the age of 60 years old. The median time from symptom onset to diagnosis was 98 days. Significantly more tumours were located on the face/head/neck than on the trunk or limbs (p = 0.00). At diagnosis, most tumours were stage I or stage III (p = 0.00) and small (size ≤ 2 cm, p = 0.00). MCC was more common in men than in women, with differences in stage at diagnosis (p = 0.03) and regional lymph node status (p = 0.01) between the two sexes also being significant. Women were more likely to present at a lower stage and negative regional lymph node status, signifying nonmetastatic disease. Out of the 126 patients with known primary or secondary MCC, a significant majority (96 of 126 or 76.2%) had primary MCC. Most patients (132 of 187 or 70.6%) were also referred from another facility for treatment (p = 0.00) and had no other concurrent malignancy (110 of 165 or 66.7%, p = 0.00). These results illustrate characteristics of MCC in a distinct, regionally Hispanic-predominant population. About one-third of the study population identified as Hispanic, and the majority of tumours were located on anatomical sites regularly exposed to sunlight. Although identification with an ethnic or racial group can be impacted by factors like skin colour, generational status and geographical nativity,2 our results suggest that actinic damage likely influences the development of MCC even in Hispanic populations. Moreover, most women in our cohort had nonmetastatic disease at presentation while most men had metastatic disease at presentation, suggesting possible delay in diagnosis, preferential referral to the University or more aggressive biology in men. It is known that MCC is a highly aggressive tumour, with metastasis being associated with lower survival rates and poorer outcomes.3 These findings align with recently published data showing women have improved survival.4 Interestingly, however, the range of time from symptom onset to diagnosis (20–638 days) was less than that of other tertiary care centres with similar published data.5 Although polyomavirus status in the study population was not found to be statistically significant, only about 25% (47 of 191) of our cohort underwent Merkel cell polyomavirus (MCPyV) testing. A total of 26 of these 47 patients (55.3%) were found to be virus-negative as compared to prior studies confirming MCPyV+ status in approximately 80% of cases.6, 7 Because MCPyV+ tumours have a better prognosis than MCPyV− tumours, identifying viral status is essential for prognostic predictability,7 especially in populations more likely to have sun-protected dark skin like Hispanic and Black patients. UV-driven versus virus-positive MCC prognostic data is still lacking for these populations even in large cohort studies,4, 8 and future studies are needed to see how viral status affects their MCC-specific survival. Study conception and design, data interpretation, and draft manuscript preparation were performed by Kayla D. Mashoudy. Data analysis and interpretation and material preparation were performed by Anil Dalling. Data collection was done by Caitlin Dowell-Esquivel and Peyton V. Warp. Robert S. Kirsner commented on previous versions of the manuscript and reviewed the final manuscript. All authors reviewed the results and approved the final version of the manuscript. The authors declare no conflict of interest. This study was reviewed and approved by the University of Miami Institutional Review Board; approval #20230362. This material is the authors' own original work, which has not been previously published elsewhere.

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

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INTRODUCTION:Inflammatory skin disorders compromise skin barrier health. Early and daily skincare use aims to maintain a life-long healthy skin barrier. Racial/ethnic and age variations in skin barrier properties, cultural differences, and clinical presentation of the inflammatory skin disorder influence the choice of treatment and skin care. Ceramide-containing skin care may play a role in restoring and maintaining a healthy skin barrier.METHODS:A panel of 6 dermatologists met to develop consensus statements based on their 8 previous publications on promoting skin barrier health throughout life using ceramide-containing skin care. The publications covered skin barrier integrity in the newborn and infant, and the role of the skin barrier in mitigating atopic dermatitis (AD); racial/ethnic variations in the skin barrier and implications for skin care; the role of the skin barrier in inflammatory skin conditions including acne, AD and psoriasis in skin of color (SOC) populations; skin barrier integrity in patients with rosacea; and xerosis in patients with diabetes mellitus. The panel synthesized the 8 publications, selected information from a literature review, and their expert opinions and experiences to create the statements. The consensus was reached through a modified Delphi method where the panel met face-to-face and followed up virtually.RESULTS:The panel adopted 6 consensus statements highlighting the importance of skin care in restoring/maintaining a healthy skin barrier in the populations mentioned above. Skin care suited to this role is gentle, has near-physiologic pH, is pleasant to use, and contains ceramides. This type of skin care can promote a healthy skin barrier and attenuate or delay inflammatory skin conditions.CONCLUSIONS:Adjunctive daily skin care throughout life promotes a healthy skin barrier and is beneficial in managing various inflammatory skin disorders in all populations. However, when choosing optimal treatment and skin care, physicians should consider variations in age, skin properties, presentation of the condition, and cultural differences. J Drugs Dermatol. 2023;22:2(Suppl 1):s3-14.

Epinephrine has been co-administered intradermally with an anesthetic for intraoperative hemostasis in dermatology for nearly a century at a concentration of 1:100,000. Many patients report undesirable side effects such as diaphoresis and tachycardia after repeated injections making it difficult for them to tolerate procedures. Currently there is an ongoing shortage of epinephrine that has presented an opportunity to revisit the concentration of epinephrine being administered for cutaneous hemostasis. In our study, concentrations of epinephrine ranging from 1:100,000, 1:500,000, and 1:1,000,000 were injected with 2% lidocaine in the right flank of pigs. Four replicates of each treatment group and control were analyzed per pig and a total of 3 pigs were evaluated in this study. Normal saline was injected as a negative control. After 7 minutes of infiltration, 1cm punch biopsies were taken in the area previously injected. Intraoperative bleeding was measured by weighing dry filter paper and then applying it to the biopsy site and weighing it again after 4 minutes of collection. Our study found that both 1:100,000 and 1:500,000 demonstrated a statistically significant reduction in bleeding compared to the control (p< 0.05) and 1:1,000,000 groups (p< 0.05). 1:1,000,000 was twice as effective as normal saline (p< 0.05) but was roughly half as effective as either 1:500,000 or 1:100,000. Based on our results, adequate hemostasis can be achieved despite using a five fold decrease in epinephrine. Epinephrine administered at a 5-fold lower concentration is equally as effective as the current standard of care. This new data suggests that not only can we reduce healthcare costs by using less epinephrine, but also patients are more likely to tolerate these procedures given the reduced epinephrine concentration.

Chronic wounds (CW), including diabetic foot ulcers (DFU) and venous leg ulcers (VLU) represent a major clinical challenge worldwide urgently needing better therapeutic solutions. The current paradigm describes chronic wounds as “stuck in a chronic inflammatory phase” which in acute wounds progresses through other phases of healing. This was based on studies comparing human CW to intact skin and studies from animal models that poorly resemble human condition. To decipher the role of inflammation in CW, we performed RNAseq of DFU (n=13) and VLU (n=11) and compared them to the human acute wounds (n=8) obtained three days post-wounding at the peak of inflammatory phase. We identified immune signaling pathways as suppressed in DFU and VLU compared to acute wounds. DFU revealed suppression of TREM1/FOXM1 pathway (p=0.01), contributing to decreased macrophage/neutrophil recruitment and function, which was confirmed in diabetic mouse model and prospective patients. Transcriptional data and immunostaining revealed decreased leukocyte populations including pro-inflammatory M1 macrophages in VLUs. Furthermore, genes important for immune cell recruitment were suppressed (p=0.001), which was confirmed by qPCR. Diminished inflammatory response was coupled with increased production of cortisol, a potent anti-inflammatory factor and wound healing inhibitor. Taken together we demonstrated de-regulated pro- and anti-inflammatory signals, poor recruitment of inflammatory cells in two major types of CW revealing a paradigm shift of lack of appropriate inflammatory response that does not reach acute wound inflammation and renders them incapable of progressing to healing. Our data underscore a new treatment strategy for DFU and VLU: to stimulate an acute wound-like inflammatory response to shift chronic into acute healing wounds.

BACKGROUND:Diabetes mellitus (DM)-related cutaneous disorders such as xerosis frequently occur in patients with type 1 and type 2 diabetes. Gentle cleansers and moisturizers are underused to prevent xerosis or provide effective early treatment and maintenance.METHODS:The project used a modified Delphi hybrid process comprising face-to-face discussions followed by an online review process. A panel of physicians who treat patients with diabetes with DM used information from literature searches coupled with expert opinions and their experience to develop a practical algorithm to improve outcomes for patients with DM-related xerosis.RESULTS:The algorithm for DM-related xerosis aims to inform dermatologists and other health care professionals caring for patients with DM. The first section of the algorithm addresses education and behavioral measures. Treatment adherence is a considerable challenge in people with DM, making education essential. The second section discusses the assessment of the skin condition. The third section reports on an interdisciplinary team-based approach to patients with DM-related xerosis. The algorithm describes treatment and maintenance approaches using cleansers and moisturizers for mild, moderate, and severe xerosis, distinguishing between the body, face, hands, and feet.CONCLUSION:The algorithm supports educating health care professionals and patients on xerosis prevention and treatment using ceramides-containing gentle cleansers and moisturizers to improve patient comfort and prevent complications. J Drugs Dermatol. 2023;22(4): doi:10.36849/JDD.7177 Citation: Kirsner RS, Andriessen A, Hanft JR, et al. Algorithm to improve patient comfort and treat diabetes mellitus-related xerosis. J Drugs Dermatol. 2023;22(4):356-363. doi:10.36849/JDD.7177.

Diabetic Foot Ulcers (DFUs) represent a significant burden to patients, health care professionals, and the US health care system, affecting up to 34% of persons with diabetes mellitus (DM). Among obstacles to improved outcomes is the inability early on in care to predict who will respond to standard care and who will not. Despite a number of evidence-based DFU care protocols, more than 50% of patients with DFUs fail to heal with standard care and those that do often recur. Therefore, there is an unmet need to accurately and consistently predict healing outcomes, differentiating healers from non-healers, as well as responders from non-responders. To accomplish this goal, we monitored the change in wound size of patients with chronic wounds weekly for 4 weeks and collected discarded wound dressings at each visit. We then analyzed the wound exudate captured by discarded wound dressings via mass spectrometry (LC-PASEF-TIMS-TOF) in order to identify specific protein biomarkers that can predict and/or monitor healing trajectory. First, we were able to validate expression of a number of previously reported molecules from chronic wound exudate (including DEF1, FGA, FGB, FN1, LCN2, MMP9, SERPINA1, VTDB). Moreover, our preliminary data identified spatially distinct localization of molecules at the center of the wound dressing (corresponding to wound bed) in comparison to the perimeter of the dressing (corresponding to wound edge), resulting in specific profiles that reflect the biology of the wound. Although we are still recruiting patients for the identification phase of our study, the preliminary data are very promising, and we envision these discoveries to advance further into product development of "smart" dressings for real-time monitoring of wound status.

BACKGROUND:Since 2017, the clinical use of IFSG has increased substantially in the United States, with some use in Europe and Asia as well. However, scant consensus data have been published on such use.OBJECTIVE:The authors sought to develop consensus recommendations for the clinical use of IFSG in the management of acute and chronic LEWs.METHODS:A panel of 8 expert clinicians in the United States used a 2-cycle NFG process to develop consensus statements based on their own clinical practice and the literature. At their initial meeting in October 2021, panel members discussed the management of DFUs, VLUs, atypical LEWs, and traumatic LEWs in their practices. Consensus statements were drafted, voted on, and rated by relative importance. At the second meeting in October 2022, the panel discussed the initial survey results; a second survey was conducted, and panel members revised the recommendations and indicated the relative importance of each in the final report. A systematic literature review of English-language articles published from January 2016 through November 2022 was conducted as well, using the search terms: "fish skin," "piscine graft," "fish tissue," "intact fish skin graft," "Cod skin," "Omega 3 fatty acid graft."RESULTS:Forty-three statements were generated and grouped into 5 sections comprising general recommendations for LEWs and recommendations specific to DFUs, VLUs, atypical LEWs, and traumatic LEWs. The primary general recommendation is the need to determine wound etiology based on clinical evaluation and reviewing related test results. For DFUs and VLUs, the main recommendations are to adhere to first-line therapy (ie, standard of care, follow conventional guidelines [multilayer compression therapy], offloading, and assessment of wound perfusion) before introducing IFSG.CONCLUSIONS:Publications on and clinical experience in the use of IFSGs have increased substantially in the past several years. The 43 consensus recommendations are meant to guide physicians in the optimal use of IFSG in the management of acute and chronic LEWs.

BACKGROUND:The incidence of keratinocyte carcinomas (KCs), comprising basal and squamous cell carcinomas, is rising in the United States. Chemoprevention is one modality by which patients can reduce the incidence of KCs.METHODS:We performed a retrospective review of 327 patients who employed a combination of imiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% cream in a field therapy regimen over the face/ears or scalp for chemoprevention.RESULTS:Patients had dramatically lower odds of having KCs in the treatment location (face/ears or scalp) in the one-year period after field treatment than in the one-year period preceding field treatment (OR=0.06, 95% CI: [0.02, 0.15]). Patients were also at lower odds of having KCs in non-treated areas the year after field treatment than in the year preceding it (OR=0.25, 95% CI: [0.14, 0.42]). Additionally, fewer cryotherapy sessions were performed for actinic keratoses in the treatment areas in the year after treatment (mean=1.5, SD=1.21) than the year preceding treatment (mean=2.3, SD=0.99; t=11.68, P&lt;0.001).CONCLUSIONS:A combination of imiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% cream were effective at reducing the incidence of new KCs for at least one year. Individualized treatment application frequency allowed for increased patient adherence. Prospective studies evaluating combination topical treatments for chemoprevention of KCs are needed to further assess the treatment effects found in this study. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.7334.

The objective of our study was to describe the characteristics of patients with chronic venous disease (CVD) from an ethnically diverse population of South Florida. We hypothesized that differences exist between Hispanic and non-Hispanic people with CVD. A prospective cohort of subjects was selected from a population of patients at the University of Miami Hospital and Clinics. Any adult age 18 – 95 who had venous reflux detected on duplex ultrasound of the lower extremities was contacted and questioned about study participation. Participants were divided into groups based on self-reported Hispanic/Latin ethnicity. Most of the 538 participants were women (66.7%) and, overall, 64.5% were Hispanic and 35.5% were non-Hispanic. Most of the participants were classified as overweight with 32% being Hispanic and 28.3% being non-Hispanic. We observed significant associations with ethnicity and number of pregnancies, history of varicose veins, and venous procedures. No significant association was found between Hispanic ethnicity and patient-reported history of deep venous thrombosis, smoking history, limitations in mobility, or anticoagulant medication use. There were significant associations observed between ethnicity and amount of physical activity, both days per week and minutes per week. Finally, Hispanics were more likely to have venous procedures performed. Clinicians should educate Hispanics females at early age about the risks of CVD associated with pregnancy and consider earlier screening for Hispanic multiparous females who may be at higher risk for CVD compared to their non-Hispanic counterparts, regardless of age and weight. Clinicians should also counsel Hispanic people with CVD early and aggressively about the benefit of physical activity. Future studies will randomize Hispanic people to these interventions to determine the effect on the prevalence of CVD.

Approximately 34% of people with diabetes will experience a diabetic foot ulcer (DFU) at some point throughout their lifetime. The perfusion of oxygen to the DFU is critical for promoting wound healing and closure. However, complications from diabetes can compromise the oxygenated flow to the wound site. Techniques such as transcutaneous oximetry and laser Doppler imaging have been used to assess perfusion to DFUs at discrete point-locations in the peri-wound. Widearea measurements of temporal oxygenation changes, as an indirect measure of perfusion, can provide additional insight of the oxygenated flow in the (peri-)wound and background tissue. Herein, our objective is to assess the differences in oxygenation flow patterns in and around the DFU regions and in the feet of control subjects as a potential biomarker for monitoring wound healing. Breath-holding (BH), as a stimulus, holds the potential to induce oxygenated flow pattern changes in the presence of wounds. In this study, 10 DFU and 3 control subjects were imaged using a hand-held near-infrared optical scanner (NIROS). Spatial-temporal oxygenation maps of hemoglobin-based parameters were acquired across an 120-second paradigm with 20 seconds of breath-hold. The oxygenation flow patterns obtained from Pearson's-based correlation maps across controls, healing DFU, and non-healing DFU indicated that flow patterns varied distinctly. Ongoing work is to correlate oxygenated flow patterns to clinical assessment of healing status in DFUs.

A stand-alone non-contact smartphone-based NIR imaging device has been developed to measure 2D tissue oxygenation maps. Oxygenation changes in diabetic foot ulcers using our smartphone-based device were similar to a commercial device.

Wounds and chronic oedema are common disorders, but rarely studied together. The objective of this cross-sectional study was to investigate the point-prevalence and risk factors of wounds on the leg, in chronic leg oedema. Forty sites in nine countries were included. Of 7077 patients with chronic leg oedema, 12.70% had wounds. Independent risk factors were: peripheral arterial disease (odds ratio (OR) 4.87, 95% confidence intervals (CI) 3.63-6.52), cellulitis within the past 12 months (OR 2.69, 95% CI 2.25-3.21), secondary lymphoedema (OR 2.64, 95% CI 1.93-3.60), being male (OR 2.08, 95% CI 1.78-2.44), being over 85 years of age (OR 1.80, 95% CI 1.23-2.62), underweight (OR 1.79, 95% CI 1.14-2.79), bed bound (OR 1.79, 95% CI 1.01-3.16), chair bound (OR 1.52, 95% CI 1.18-1.97), diabetes (OR 1.47, 95% CI 1.23-1.77), and walking with aid (OR 1 center dot 41, 95% CI 1.17-1.69). 43.22% of those with wounds had clinically defined well-controlled oedema, associated with a significantly lower risk of wounds (OR 0.50, 95% CI 0.42-0.58, P < .001). Hard/fibrotic tissue (OR 1.71, 95% CI 1.19-2.48), and a positive Stemmers sign (OR 1.57, 95% CI 1.05-2.35) were associated with wounds. The study reinforces the importance of measures to control oedema, as controlled swelling was associated with a 50% lower risk of wounds.

Negative outcomes associated with diabetic foot ulcers (DFUs) are devastating, ranging from lower limb amputations to death. One of the major contributing factors of impairment in DFUs healing is inefficient re-epithelialization marked by keratinocyte hyperproliferation and poor migration. Thus, we focused on the role of master-regulators, microRNAs (miRs), in regulation of re-epithelialization in DFUs. We collected tissue samples from DFUs (n=15), control skin samples (n=15), and human acute wounds (n=3) and performed LCM and transcriptomic analyses using Ingenuity Pathway Analysis (IPA). qPCR was used to analyze miR-193b-3p and its target genes. We performed gain- and loss-of function experiments. Wound re-epithelialization was evaluated using human ex vivo, diabetic murine in vivo, and human organotypic wound models. Formation of stress fibers was studied using immunocytochemistry and RhoA pull-down assay. miR-193b-3p was found significantly induced in the epidermis of DFUs, but not in acute wounds. Moreover, knockdown of miR-193b-3p promoted migration of human keratinocytes. The inhibition of miR-193b-3p expression in ex vivo human wounds and diabetic murine in vivo wounds accelerated re-epithelialization. Conversely, overexpression of this miR impaired re-epithelialization in a 3D organotypic wounds. The underlying mechanism of miR-193b-3p anti-migratory activity is through a disruption of stress fiber formation and a reduction of RhoA activity. Further in-depth genomic analysis revealed the target network of miR-193b-3p contributes to poor healing in DFUs. We confirmed suppression of downstream targets of miR-193b-3p in DFUs and further showed that this transcriptomic landscape found in non-healing DFUs can be reversed upon miR-193b-3p suppression. Together, we identified miR-193b-3p as an important regulator that represents a target for promotion of wound healing in DFUs.

Postherpetic neuralgia (PHN) represents a type of peripheral neuropathic pruritus that occurs after an episode of shingles and is characterized by localized pain, paresthesia, and itch, termed postherpetic itch (PHI); all may simultaneously exist within the same dermatomal distribution.1 Although PHI has been reported to affect up to 58% of patients with shingles,2 its exact pathophysiologic mechanism is poorly understood, and there are no proven specific treatments. Herein, we describe the case of a patient who presented with a painful and severely pruritic ulcer located on the left side of the neck that developed in the setting of PHN refractory to conventional treatments.