Venous ulcers

Venous leg ulcerations: a treatment update

OPINION STATEMENT

Selecting the appropriate treatment for venous leg ulcerations is essential for optimal wound healing and patient quality of life. Compression therapy remains the mainstay of treatment for these wounds. Compression methods should be carefully selected and tailored for compatibility with patients' daily life. Pain management should not be neglected. When response to compression therapy is limited, adjuvant therapy such as medication, débridement, or surgical procedures should be considered on an individual basis.

Plasma applications in medicine with a special focus on dermatology

The recent tremendous progress in understanding physical plasma phenomenon, together with the development of new plasma sources has put growing focus on the application of plasmas in health care. Active plasma components, such as molecules, atoms, ions, electrons and photons, reactive species, ultraviolet radiation, optical and infrared emission and heat have the ability of activating, controlling and catalysing reactions and complex biochemical procedures. Thermal and non-thermal (i.e. cold) plasmas - both already widely established in medicine - are used for various therapeutic applications. Particularly in dermatology, plasma applications hold big potential, for example, in wound healing, such as efficient disinfection or sterilization, therapy of various skin infections or tissue regeneration. This review gives an overview on potential plasma applications in medicine - including the recent research on skin diseases - and summarizes possible interactions between plasmas and living tissue.

Clinician's perspectives on the treatment of venous leg ulceration

Treatment of venous leg ulcers (VLU) represents a considerable challenge to the health care professional and to the patient alike. Much of the current literature regarding VLU focuses on either wound pathophysiology and treatment of chronic venous insufficiency or the patients' experience of the condition. We present two studies that examine more closely the clinicians' experience of treating VLU and reflect upon how that understanding may further enhance better outcomes for patients in the future. The first of these studies is a qualitative investigation of 49 clinicians treating VLU in the UK and USA. The second is a quantitative, online survey of 304 clinicians' beliefs, attitudes and practices in the UK, Germany and USA. Findings show that the clinicians' experience of treating VLU is often accompanied by frustration and dissatisfaction with treatment challenges and uncertain outcomes. Practices and treatment choices were found to vary widely and differ by countries. We conclude that a key aspect in improving VLU treatment is in listening to the frustrations of the clinician when considering new approaches to therapy.

Venous Leg Ulcers and Emotional Consequences

Venous leg ulcers are a chronic disease that affects populations around the world. For sufferers, it leads to physical, social, economic, and emotional consequences. The aim of this study was to assess the presence of anxiety and depression, as well as to investigate possible associations with sociodemographic variables. A total of 30 patients, both men and women, with venous ulcers receiving care under outpatient treatment in a teaching hospital of a provincial city of São Paulo State, were included in this study. The evaluation tools used were the following: the Hospital Anxiety and Depression Scale (HADS) and a sociodemographic questionnaire that included job status, religion, marital status, gender, duration of disease, and age. A descriptive analysis of the data was performed. Statistical analysis used means, the Student t test, and the χ 2 test. Anxiety was identified in 30% of the patients and depression in 40%. No statistically significant correlation was found between anxiety or depression and the sociodemographic variables. Patients with chronic venous ulcers may present with anxiety and depression independent of socioeconomic variables such as religion, occupation, marital status, and duration of lesion.

Surgical pathology to describe the clinical margin of debridement of chronic wounds using a wound electronic medical record

BACKGROUND

Chronic wounds, including diabetic foot ulcers (DFU), pressure ulcers (PU), and venous ulcers (VU) result from multiple physiologic impairments. Operative debridement is a mainstay of treatment to remove nonviable tissue and to stimulate wound healing. Unlike tumor resection, however, operative wound specimens are not routinely sent for pathology. The objective of this study was to describe the pathology present in chronic wounds.

STUDY DESIGN

Pathology reports of the skin edge and wound base from 397 initial debridements in 336 consecutive patients with chronic wounds were retrospectively reviewed. All data were entered and stored in a Wound Electronic Medical Record. Pathology data were extracted from the Wound Electronic Medical Record, coded, and quantified.

RESULTS

Up to 15 distinct histopathologic findings across 7 tissue types were observed after review of pathology reports from chronic wounds. Specifically, the pathology of epidermis revealed hyperkeratosis: 66% in DFUs, 31% in PUs, and 29% in VUs. Dermal pathology revealed fibrosis in 49% of DFUs, 30% of PUs, and 15% of VUs. Wound bed pathology revealed necrosis in the subcutaneous tissue in 67% of DFUs, 55% of PUs, and 19% of VUs. Fibrosis was reported in between 19% and 52% of all wound types. Acute osteomyelitis was present in 39% of DFUs, 33% of PUs, and 29% of VUs.

CONCLUSIONS

This observational study of the histopathology of initial surgical debridement of chronic wounds revealed a wide range of findings across multiple tissue levels. Although certain findings such as osteomyelitis and gangrene have been shown to directly relate to impaired wound healing and amputation, other findings require additional investigation. To rigorously define a margin of debridement, a prospective study relating histopathology and clinical outcomes such as healing rates and amputation is needed.

Interrelation of immunity and tissue repair or regeneration

Although tremendous progress has been achieved in understanding the molecular basis of tissue repair and regeneration in diverse model organisms, the tendency of mammals for imperfect healing and scarring rather than regeneration remains unexplained. Moreover, conditions of impaired wound healing, e.g. non-healing skin ulcers associated with diabetes mellitus or vascular disease, as well as excessive scarring, represent major clinical and socio-economical problems. The development of innovative strategies to improve tissue repair and regeneration is therefore an important task that requires a more thorough understanding of the underlying molecular and cellular mechanisms. There is substantial evidence in different model organisms that the immune system is of primary importance in determining the quality of the repair response, including the extent of scarring, and the restoration of organ structure and function. Findings in diverse species support a correlation between the loss of regeneration capacity and maturation of immune competence. However, in recent years, there is increasing evidence on conditions where the immune response promotes repair and ensures local tissue protection. Hence, the relationship between repair and the immune response is complex and there is evidence for both negative and positive roles. We present an overview on recent evidence that highlights the immune system to be key to efficient repair or its failure. First, we summarize studies in different model systems that reveal both promoting and impeding roles of the immune system on the regeneration and repair capacity. This part is followed by a delineation of diverse inflammatory cell types, selected peptide growth factors and their receptors as well as signaling pathways controlling inflammation during tissue repair. Finally, we report on new mechanistic insights on how these inflammatory pathways impair healing under pathological conditions and discuss therapeutic implications.

Six-month mortality risks in long-term care residents with chronic ulcers

Chronic ulcers are a common problem in long-term care. Residents with ongoing ulcers are often frail and at risk for mortality. This study evaluated the relationship between wound characteristics and other health predictors with 6-month mortality in nursing home residents. The subjects included were nursing home residents seen by the wound consult service from 1998 to 2007 with an ongoing chronic ulcer. This was a retrospective cohort study. Data were manually and electronically abstracted for each resident. Six-month mortality was collected as the primary outcome. Statistical comparisons were made using logistic regression with a final multivariant model. Four hundred and forty residents were seen with 411 records reviewed. Ulcer area was not associated with mortality; however, chronic ulcer number was associated with 6-month mortality with an odds ratio of 1.32 (95% CI 1.07-1.63). Other significant risk factors included heart failure, dementia, cancer, depression and blindness with all factors having an odds ratio greater than 1.75. Higher haemoglobin and venous insufficiency were protective of 6-month mortality. Ulcer number is an important predictor for 6-month mortality. The presence of multiple ulcers and comorbid health concerns may influence discussion of prognosis for healing and for potential end of life discussions.

Deregulation of keratinocyte differentiation and activation: a hallmark of venous ulcers

Epidermal morphology of chronic wounds differs from that of normal epidermis. Biopsies of non-healing edges obtained from patients with venous ulcers show thick and hyperproliferative epidermis with mitosis present in suprabasal layers. This epidermis is also hyper-keratotic and parakeratotic. This suggests incomplete activation and differentiation of keratinocytes. To identify molecular changes that lead to pathogenic alterations in keratinocyte activation and differentiation pathways we isolated mRNA from non-healing edges deriving from venous ulcers patients and determined transcriptional profiles using Affymetrix chips. Obtained transcriptional profiles were compared to those from healthy, unwounded skin. As previously indicated by histology, we found deregulation of differentiation and activation markers. We also found differential regulation of signalling molecules that regulate these two processes. Early differentiation markers, keratins K1/K10 and a subset of small proline-rich proteins, along with the late differentiation marker filaggrin were suppressed, whereas late differentiation markers involucrin, transgultaminase 1 and another subset of small proline-rich proteins were induced in ulcers when compared to healthy skin. Surprisingly, desomosomal and tight junction components were also deregulated. Keratinocyte activation markers keratins K6/K16/K17 were induced. We conclude that keratinocytes at the non-healing edges of venous ulcers do not execute either activation or differentiation pathway, resulting in thick callus-like formation at the edge of a venous ulcers.