Consensus on the diagnosis and management of chronic leg ulcers - Brazilian Society of Dermatology

Use of low-level laser therapy as an adjuvant therapy for phlebostatic lesions

Low-intensity laser therapy (LILT) is commonly used as an adjuvant therapy for treating injuries. This integrative literature review was carried out in the MEDLINE, LILACS, CUMED, BDENF, SPORTDiscus, Dentistry & Oral Sciences Source, Academic Source and CINAHL databases. Among the inclusion criteria were: range from 2011 to 2021, in English, Portuguese and Spanish and any study, with the exception of preprints and books. The question was answered: "What is the effectiveness described in the literature of using low-intensity laser therapy (LILT) in the treatment of venous lesions?" The wavelength used in studies varied from 635 nm of red ray to 780 nm of infrared ray, generating healing improvement at any length. LBI presented itself as a low-cost and easy-to-apply adjuvant option, alleviating pain complaints and improving healing in patients with vasculogenic lesions.

Compression therapy in patients with venous leg ulcers: a best practice implementation project

INTRODUCTION AND OBJECTIVES

Venous leg ulcers are the most common ulcerations of the lower extremities. Compression is the most important consideration and the gold standard treatment for venous leg ulcers. This implementation project aimed to promote best practices in the management of venous leg ulcers in a rural community-care setting.

METHODS

This project was guided by the JBI Evidence Implementation Framework, which is grounded in audit and feedback processes, along with a structured approach to identifying and managing barriers to compliance with recommended best practices.

RESULTS

Compliance with best practices increased for most audit criteria. The use of compression therapy increased from 16.7% to 60%, documentation increased from 6.7% to 50%, replacement of compression bandages from 6.7% to 60%, patient education from 0% to 46.7%, and holistic assessment from 0% to 13%. However, compliance for individualized interventions to promote adherence remained at 0%.

CONCLUSIONS

This project succeeded in introducing compression therapy as a basic treatment for venous ulcers. However, continued improvement in the care for venous ulcers and guarantee of long-term implementation of evidence are necessary.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A212.

Accelerating Healing and Relieving Pain: High-Intensity Laser Therapy for Paraneoplastic Cutaneous Vasculitis Associated with Multiple Myeloma

BACKGROUND Leukocytoclastic vasculitis (LCV) is an atypical form of cutaneous paraneoplastic manifestation. Its association with multiple myeloma (MM) is even rarer and is associated with poor prognosis and short survival, regardless of the therapy instituted. Different treatment approaches are necessary. We present a case in which LCV was the first manifestation of MM, and high-intensity laser therapy (HILT) was used as an option to accelerate healing and control pain. CASE REPORT A 76-year-old woman presented with pain and paresthesia in her lower limbs, associated with palpable purpura. The clinical diagnosis was small-vessel vasculitis. Laboratory tests showed an elevated gamma globulin monoclonal peak on protein electrophoresis. The immunophenotypic study of bone marrow aspirates led to the diagnosis of MM. Due to pain refractory to conventional analgesics, and the progressive evolution of the lesions, despite corticosteroid therapy, we performed photo-biomodulation with a neodymium-doped yttrium aluminum garnet laser (Nd: YAG), wavelength 1064 nanometers, using a 7-mm probe and energy density 6 J/cm². After the first session, the patient was referred for pain management, and after 5 weeks, we observed complete healing in ulcerated lesions and involution of bullous lesions. CONCLUSIONS This case report shows the positive effects of the Nd: YAG laser in modulating healing and reducing pain. HILT is an innovative, non-invasive, and effective treatment and should be considered a promising technique to accelerate healing and controlling pain.

Diagnosing and Managing Venous Stasis Disease and Leg Ulcers

Venous insufficiency is a common medical condition that affects many individuals, especially those with advanced age. Chronic venous insufficiency can lead to secondary cutaneous changes that most commonly present as stasis dermatitis but can progress to more serious venous ulcers. Although venous ulcers are the most common cause of lower extremity ulcers, the differential diagnosis of leg ulcers is broad. This article will discuss clinical clues to help guide patient workup and will review basic clinical evaluation and management of common leg ulcers.

Preclinical Trial of Ocotea puberula (Rich.) Nees ("Canela-Guaicá") in Wound Healing: Validation of a Traditional Medicine Practice Used by Indigenous Groups in Southern Brazil

Background

"Canela-guaicá," "guaicá," or "canela-sebo" [Ocotea puberula (Rich.) Nees] is a native species that is traditionally used by Kaingang indigenous groups for wound healing in southern Brazil. The aim of this study was to extract the mucilage from O. puberula barks, perform its phytochemical and physicochemical characterization, and investigate its healing potential.

Methods

A murine wound model was used as a preclinical trial for authentication of the traditional knowledge from Kaingang indigenous communities.

Results

Alkaloids and polysaccharides were identified by usual qualitative reactions and Fourier-transform infrared spectroscopy. This natural product showed thermal stability and pseudoplastic properties that were considered suitable for the intended use. A higher initial exacerbation of inflammatory response after 7 days, an improved angiogenesis after 14 days, and an increased wound shrinkage after 21 days were statistically significant for the "canela-guaicá" bark extract in the preclinical trial when compared to the silver calcium alginate dressing (positive control).

Conclusion

The healing potential of the "canela-guaicá" bark extract, traditionally used by the Kaingang indigenous community from southern Brazil, was preclinically validated. This study paves the way for designing novel wound dressings containing this natural product in order to treat acute and chronic wounds.

Targeted Drug Delivery to the Central Nervous System Using Extracellular Vesicles

The blood brain barrier (BBB) maintains the homeostasis of the central nervous system (CNS) and protects the brain from toxic substances present in the circulating blood. However, the impermeability of the BBB to drugs is a hurdle for CNS drug development, which hinders the distribution of the most therapeutic molecules into the brain. Therefore, scientists have been striving to develop safe and effective technologies to advance drug penetration into the CNS with higher targeting properties and lower off-targeting side effects. This review will discuss the limitation of artificial nanomedicine in CNS drug delivery and the use of natural extracellular vesicles (EVs), as therapeutic vehicles to achieve targeted delivery to the CNS. Information on clinical trials regarding CNS targeted drug delivery using EVs is very limited. Thus, this review will also briefly highlight the recent clinical studies on targeted drug delivery in the peripheral nervous system to shed light on potential strategies for CNS drug delivery. Different technologies engaged in pre- and post-isolation have been implemented to further utilize and optimize the natural property of EVs. EVs from various sources have also been applied in the engineering of EVs for CNS targeted drug delivery in vitro and in vivo. Here, the future feasibility of those studies in clinic will be discussed.

[Modern concept about trophic venous ulcers]

Venous trophic ulcer is a common complication of chronic venous diseases that have a negative impact on the quality of life and result negative socio-economic consequences. There are three main theories of development of venous trophic ulcers. The criterion is visible trophic changes of skin (CEAP class C4). If correction of etiological factor of ulcer is impossible, local management is preferred. There are various wound coverings which can be used for the treatment of trophic ulcers. However, data on their effectiveness are sometimes unavailable. Therefore, it is necessary to systematize knowledge about modern measures and methods of exposure to trophic ulcers. The authors also discuss current understanding of pathophysiology, symptoms and diagnosis of venous trophic ulcers.

Chronic Venous Leg Ulcer in Klinefelter Syndrome Treated with Platelet-Rich Fibrin: A Case Report

Venous leg ulcers (VLUs) are the most common causes of leg ulcers due to venous insufficiency. Most cases persist for more than 6 weeks, referred to as chronic VLUs. These chronic ulcers have been described as a manifestation of Klinefelter syndrome (KS). Platelet-rich fibrin (PRF) is a second-generation platelet concentrate, which contains growth factors required for chronic wound healing. The use of PRF in the management of VLUs in KS has not been reported, to the best of our knowledge. We report a case of chronic VLU associated with KS in a 41-year-old man treated with PRF. Dermatological examination showed a tender, shallow, irregular ulcer partly covered with hard, yellow necrotic tissue on the anterior side of the lower-left leg and hyperpigmented indurated skin on both lower legs. The diagnosis of venous ulcer was established based on clinical manifestation and supported by the result of Doppler ultrasound showed chronic venous insufficiency. Histopathological examination, which showed epidermal acanthosis, dermal fibrosis, and thickening with hemosiderin deposits consistent with the diagnosis of venous ulcer. The patient presented with eunuchoid features characterized by long extremities, gynecomastia, increased fat distribution around the hips, scanty pubic hairs, and small testes. Laboratory tests found decreased levels of testosterone, increased levels of follicle-stimulating and luteinizing hormone, and bilateral testicular atrophy was found from testicular ultrasound. These physical examinations and laboratory findings supported the diagnosis of KS. The patient was treated with PRF dressing once a week. After 7 weeks of treatment with PRF, the ulcer almost reached complete closure. PRF gives a good result in a chronic VLU with KS.

Photodynamic Therapy for the Treatment of Infected Leg Ulcers-A Pilot Study

Chronic and infected leg ulcers (LUs) are painful, debilitating, resistant to antibiotics, and immensely reduce a patient’s quality of life. The purpose of our study was to demonstrate the efficacy of photodynamic therapy (PDT) for the treatment of infected chronic LUs. Patients were randomized into two experimental groups: the first group received 5-aminolevulinic acid photodynamic therapy (ALA-PDT) (10 patients), and the second group of 10 patients received local octenidine dihydrochloride (Octenilin gel) exposed to a placebo light source with an inserted filter that mimiced red light. In the PDT group, we used 20% ALA topically applied for 4 hrs and irradiation from a Diomed laser source with a wavelength of 630 nm at a fluency of 80 J/cm². ALA-PDT was performed 10 times during a 14-day hospitalization in 10 patients of both sexes aged 40–85 years with chronic leg ulcers. Treatments were carried out at 3-week intervals for 3–5 cycles. At 8-month follow-up with the PDT group, complete remission (CR) was obtained in four patients (40%), partial response (>50% reduction in ulcer diameter) in four patients (40%), and no response in two patients (20%) who additionally developed deterioration of the local condition with swelling, erythema, and inflammation. To assess the degree of pain during the trials, we used a numeric rating scale (NRS). From the preliminary results obtained, we concluded that PDT can be used to treat leg ulcers as a minimally invasive and effective method with no serious side effects, although further studies on a larger group of patients with LUs are warranted.