Development of an in vitro fibrin clot model to evaluate fibrinolytic agents for wound care application

OBJECTIVE

To describe an in vitro fibrin clot model that could reliably assess the fibrinolytic activity of enzymatic debriding agents for wound care application.

METHOD

A model of a fibrin clot was reconstructed in vitro by mixture of human fibrinogen and (alpha)-thrombin supplemented with factor XIII. These clots were then treated with enzymatic ointments. Fibrinolytic activity was investigated by measuring D-dimer levels, using an automated immunoturbidimetric Liatest D-dimer assay.

RESULTS

Collagenase and papain-urea ointments demonstrated fibrinolytic activity which was macroscopically visible. Their effect was identical on the in vitro reconstructed fibrin clot and ex vivo collected wound fibrin clot; collagenase and papain-urea both induced a complete degradation and dissolution of both fibrin clots after 24 hours of treatment. This was associated with an increase in D-dimer concentration.

CONCLUSION

This reconstructed fibrin clot in vitro model has the potential to predict the efficacy of fibrinolytic agents and therefore appears to be a suitable model for in vitro assays.

DECLARATION OF INTEREST

This study was supported by a grant from URGO Laboratory.

[The challenge for dermatologists of early APECED diagnosis]

BACKGROUND

Polyglandular auto-immune syndrome type 1 (PAS-1) or auto-immune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder linked to auto-immune regulator (AIRE) gene mutations. Herein, we report the case of a 3-year-old boy with APECED emphasizing the wide phenotypic variability and the extent of skin lesions.

PATIENTS AND METHODS

A 3-year-old boy with a history of auto-immune hepatitis was referred for a generalized pruriginous urticaria-like eruption present for one month. He was born to non-consanguineous parents. Cutaneous examination revealed twenty-nail dystrophy, which had been present since the age of 2 years. Both direct microscopy and culture of nail samples were negative for Candida albicans. Esophagogastroduodenoscopy revealed esophageal candidiasis. A diagnosis of APECED was suspected and subsequently confirmed by molecular analysis of the AIRE gene, which showed two mutations. No other auto-immune endocrinopathies were found.

DISCUSSION

Our case report illustrates the phenotypic variability of APECED with the absence of typical manifestations such as Addison's disease and hypoparathyroidism. APECED should thus be systematically suspected in young children presenting with cutaneous lesions associated with mucocutaneous candidiasis or auto-immune disease, even in the absence of known endocrinopathies.

CONCLUSION

Dermatologists should be aware of this association since early diagnosis of APECED is critical in preventing life-threatening endocrinological crises.

Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers--a randomized controlled trial

Background

Stringent control of proteolytic activity represents a major therapeutic approach for wound-bed preparation.

Objectives

We tested whether a protease-modulating polyacrylate- (PA-) containing hydrogel resulted in a more efficient wound-bed preparation of venous leg ulcers when compared to an amorphous hydrogel without known protease-modulating properties.

Methods

Patients were randomized to the polyacrylate-based hydrogel (n = 34) or to an amorphous hydrogel (n = 41). Wound beds were evaluated by three blinded experts using photographs taken on days 0, 7 and 14.

Results

After 14 days of treatment there was an absolute decrease in fibrin and necrotic tissue of 37.6 ± 29.9 percentage points in the PA-based hydrogel group and by 16.8 ± 23.0 percentage points in the amorphous hydrogel group. The absolute increase in the proportion of ulcer area covered by granulation tissue was 36.0 ± 27.4 percentage points in the PA-based hydrogel group and 14.5 ± 22.0 percentage points in the control group. The differences between the groups were significant (decrease in fibrin and necrotic tissue P = 0.004 and increase in granulation tissue P = 0.0005, respectively).

Conclusion

In particular, long-standing wounds profited from the treatment with the PA-based hydrogel. These data suggest that PA-based hydrogel dressings can stimulate normalization of the wound environment, particularly in hard-to-heal ulcers.

Algorithm for dermocosmetic use in the management of cutaneous side-effects associated with targeted therapy in oncology

Currently, numerous patients who receive targeted chemotherapy for cancer suffer from disabling skin reactions due to cutaneous toxicity, which is a significant problem for an increasing number of patients and their treating physicians. In addition, using inappropriate personal hygiene products often worsens these otherwise manageable side-effects. Cosmetic products for personal hygiene and lesion camouflage are part of a patients’ well-being and an increasing number of physicians feel that they do not have adequate information to provide effective advice on concomitant cosmetic therapy. Although ample information is available in the literature on pharmaceutical treatment for cutaneous side-effects of chemotherapy, little is available for the concomitant use of dermatological skin-care products with medical treatments. The objective of this consensus study is to provide an algorithm for the appropriate use of dermatological cosmetics in the management of cutaneous toxicities associated with targeted chemotherapy such as epidermal growth factor receptor inhibitors and other monoclonal antibodies. These guidelines were developed by a French and German expert group of dermatologists and an oncologist for oncologists and primary care physicians who manage oncology patients. The information in this report is based on published data and the expert group’s opinion. Due to the current lack of clinical evidence, only a review of published recommendations including suggestions for concomitant cosmetic use was conducted.

[Chronic wound care leads to the bacterial contamination of the environment]

AIM

The aim of this study was to determine levels of bacterial contamination of the environment during chronic wound dressing changes.

METHODS

Sampling of chronic wounds and of the environment (air and surfaces) was performed during changing of chronic wound dressing. A series of samples was defined as the entire sample for a given day for a given patient. Five sequential samples of air and six samples of surfaces were taken for each series. Staphylococcus aureus, Pseudomonas aeruginosa and enterobacteria were specifically cultured.

RESULTS

Thirty series of samples were taken for 26 different patients. Twenty-seven out of these 30 series were colonized with one or two of the target species. For 13 series of the latter samples (13/27, 48.1%), bacteria isolated from the wound were recovered in the environment, namely S. aureus and P. aeruginosa. The six enterobacteria isolated from wounds were not retrieved in the environment. Air samples were more often positive than surfaces samples.

CONCLUSION

We demonstrated frequent contamination of the hospital environment with bacteria colonizing wounds during dressing changes. This indicates that wearing of masks and hand disinfection after contact with the environment constitute key measures in the control of bacterial cross-transmission.

[Efficacy of diuretics in the treatment of Morbihan's disease: three cases]

BACKGROUND

Morbihan's disease (MD), also known as 'persistent facial oedema' or 'rosaceous lymphoedema', is an uncommon facial condition that is difficult to treat. Its cause remains unclear.

AIM

We report three new cases of solid persistent facial oedema, which, after treatment with furosemide, showed dramatic improvement.

PATIENTS AND METHODS

Three men (respectively aged 38, 66 and 76 years) presented Morbihan's disease progressing respectively for 2, 5 and 8 years. These patients presented with facial oedema, mainly affecting the eyelids. The diagnosis of MD was based on clinical and laboratory criteria (after exclusion of other aetiologies such as sarcoidosis, lupus erythematosus, facial demodicidosis and rosacea). After several unsuccessful treatments (tetracyclines, synthetic antimalarials, danazol, systemic steroids and isotretinoin), the patients received diuretics: furosemide (60 mg/d) in two cases and spironolactone 75 mg twice daily for the third patient. The patients were evaluated after 1 month, then every 3 months.

RESULTS

Regression of oedema was complete or almost complete with follow-up of between 1 and 16 years. No adverse effects were reported.

DISCUSSION

Treatment of Morbihan's disease remains difficult and empirical. Diuretics may be of value since they help significantly reduce swelling even if they do not definitely cure patients.

Risk factors in facial hyperpigmentation in Maghrebian population - a case-control study

Triggering factors seem to be multiple in the pathogenesis of facial hyperpigmentation (FH), as dark skin types, pregnancy, sun exposure… The aim of this study was to investigate the risk factors for FH in Maghrebian population. Patients with FH were included in a case-controlled study. Following data were recorded: age, sex, parity, phototype, FH and hormonal-related history, endocrinological features, sunlight exposure, specific cultural behaviours, use of topic corticosteroids and sunscreens. One hundred women (mean age 29.5 ± 13.7 years) were included with 200 age-matched controls. Duration of FH was 32.9 ± 42.2 months. There was a statistically significant relation between FH and hirsutism (P = 0.009), troubles of menstruations (P = 0.008), but not with acne (P = 0.23) and contraceptive oral (P = 0.06) drugs or with history of thyroid disorders (P = 0.13). For cultural factors, there were a statistical significant relation with rubbing by flannel glove (P < 0.05), use of dark soap (P = 0.009) and traditional masks (P < 0.05) but both groups were used to go to hammam. A strong relation was observed between FH and use of topical corticosteroids: 40% in the FH group vs. 5% in the control group (P < 0.05). Both groups used to apply sunscreens: 70% in the FH group and 67% in the control group where as there were no differences in the two groups for sun exposure. No statistical differences were observed regarding to age, phototypes and grade of parity. Our study demonstrated a relation between FH and hyperestrogenemia, rubbing with a friction glove, use of moroccan traditional masks and application of topical steroids. The eviction of all these triggering factors could be an adjuvant recommendation in the assessment of FH.