Leg ulcers: uncommon presentations

The Histopathology of Leg Ulcers

Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.

Skin Involvement in Paediatric Patients with Type 1 Diabetes

Skin involvement is an overlooked aspect in the management of paediatric patients with type 1 diabetes. A comprehensive search of published literature using the PubMed database was carried out using the following key terms: "children," "pediatric/paediatric patients," "skin," "skin disorders," "type 1 diabetes." Dermatological side effects are frequently observed among diabetic children and adolescents. Insulin-induced lipodystrophies and allergic contact dermatitis caused by insulin pumps or glycaemic sensors are the most common skin reactions in these patients. Furthermore, several diabetes-associated skin diseases such as necrobiosis lipoidica, granuloma annulare, vitiligo, and bullosis diabeticorum may already be present in paediatric patients. Paediatric diabetes specialists should pay attention to their patients' skin to recognize these disorders, identify the potential causes, and choose the most suitable treatment. Finally, the evaluation of skin concentrations of advanced glycation end-products using non-invasive diagnostic techniques may be used to assess the risk of chronic complications of diabetes as early as adolescence.

Atypical Pyoderma Gangrenosum in the Setting of Venous and Arterial Insufficiency

Ulcers of mixed etiology are diagnostically elusive and challenging to treat, especially when rare conditions are superimposed. Pyoderma gangrenosum (PG) is an autoinflammatory, ulcerative skin disease that is difficult to diagnose. Diagnostic criteria exist but there are no specific clinical tests to identify it. We discuss a case of PG initially diagnosed as venous ulcer in the setting of peripheral artery disease, complicated by superinfection, refractory to standard wound care, multiple surgical debridements, revascularization, negative pressure therapy, and parenteral antibiotics. Findings differentiating PG from other wound etiologies are explored, with the aim of improving clinical recognition of this condition.

Challenges of treating mixed arterial-venous disease of lower extremities

INTRODUCTION

Mixed arterial-venous lower extremity disease (AVLED) poses a unique challenge for clinicians. This review will outline the impact mixed AVLED has on patients and the healthcare system, by reviewing its epidemiology, diagnosis, current treatment, and the challenges encountered implementing therapies.

EVIDENCE ACQUISITION

An extensive search of current literature from online sources, journals and book chapters identified the current challenges facing the treatment of mixed arterial venous ulcers of the lower extremities and potential solutions to these challenges.

EVIDENCE SYNTHESIS

The challenges that are identified in the search are the time to heal AVLED, patient education and motivation, early detection of AVLED, wound care center development, treatment consensus from multidisciplinary team members, and cost of treatment.

CONCLUSIONS

AVLED ulcers are a challenging problem, but over time we have continued and will continue to improve patient care and tackle these difficult challenges as we have throughout the last century. A diagnostic algorithm to address how we approach these patients in terms of conservative care with wound care and compression and treat arterial and venous insufficiency is crucial. In looking to the future, continued standardization of wound care centers will overcome the social and financial challenges faced by patients and continued clinical research will improve targeted therapies and treatment challenges faced by physicians.

Algorithm and Software System for Treatment Application of Platelet-Rich Plasma on Problematic Skin Wounds

Recently a big interest arises to the automated diagnosis and digitalization of clinical data. The purpose of this article is to present treatment algorithm and software system for Problematic Skin Wounds (PSW) by using Platelet-Rich Plasma (PRP), based on the first study on platelet-rich plasma application carried out in Bulgaria. PSW-PRP-Project software system was developed for entering and processing medical data during PRP treatment, visualization of general patient information, treatment trend, as well as a module for training specialists through the created database. For a period of seven years around 100 patients have been treatment at the Department of Orthopaedics and Traumatology, UMBAL KANEV Ruse AD, by applying platelet-rich plasma. The algorithm for the use of platelet-rich plasma for treating problematic skin wounds allows for the proper and accurate treatment of patients with various problematic skin wounds with the purpose of solving the therapeutic problem and their complete recovery. The procedure’s course is determined based on assessment on three digital criteria TWS, TAS and TSWD. The algorithms are based on our results, obtained for the first in Bulgaria while treating problematic skin wounds by using platelet-rich plasma and successfully treating 92.78% of patients to full recovery.

Approaches to Microthrombotic Wounds: A Review of Pathogenesis and Clinical Features

GENERAL PURPOSE

To discuss the pathogenesis and clinical features of wounds caused by microthrombi formation under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Recall the etiology, risk factors, and pathophysiology of the various types of microthrombotic wounds.2. Describe the clinical manifestations and treatment of the various types of microthrombotic wounds.

ABSTRACT

Typical wounds such as diabetic foot ulcers, venous leg ulcers, pressure ulcers, and arterial ulcers are responsible for more than 70% of chronic wounds. Atypical wounds have broad differential diagnoses and can sometimes develop as a combination of different conditions. Regardless of the etiology, impaired blood circulation is characteristic of all chronic and acute wounds. Chronic wounds associated with microthrombi formation are an important group of atypical wounds commonly linked to an underlying systemic disease. In this perspective article, the pathogenesis and clinical features of wounds caused by microthrombi formation are discussed under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.

Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers

The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.

Influence of ulceration etiology on the global quality of life and its specific dimensions, including the control of pain, in patients with lower limb vascular insufficiency

Introduction

The results of previous studies suggest that the quality of life in patients with lower limb ulcerations is markedly poorer than in the general population – with regard to physical, mental and social spheres. This complex character of that parameter necessitates comprehensive analyses of its specific aspects, including the level of the acceptance of illness and associated pain symptoms.

Aim

To compare the quality of life and its specific dimensions in patients with lower limb ulcerations of various etiology.

Material and methods

Patients with the ulcerations resulting from venous (n = 101) or arterial pathologies (n = 98), or having mixed etiology (n = 99) were examined with the: 1) Skindex-29 instrument, 2) Acceptance of Illness Scale, 3) Beliefs about Pain Control Questionnaire, and 4) Coping Strategy Questionnaire.

Results

The average quality of life related to physical symptoms was significantly higher in patients with venous ulcerations. Patients with ulcerations of arterial etiology more frequently used catastrophizing, and less often ignored pain sensations, used coping self-statements, and increased their activity levels; they were characterized by lower levels of control and poorer ability to decrease the pain. The internal locus of pain control increased proportionally to the global quality of life scores and levels of illness acceptance. Control over pain and ability to decrease the pain were more effective in individuals who used ignoring pain sensations, increasing the activity level, coping self-statements, and reinterpreting pain than in those using catastrophizing or praying and hoping strategies.

Conclusions

Physical complaints seem to be the basic determinant of the quality of life in patients with the lower limb ulceration, irrespective of its etiology.

Impact of UK NICE clinical guidelines 168 on referrals to a specialist academic leg ulcer service

Background

Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management.

Aim

Determine the impact of CG168 on referrals to a leg ulcer service.

Methods

Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012–June 2013) and an 18-month period commencing six months after (January 2014–June 2015) publication of CG168 were compared.

Results

There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006).

Conclusions

Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.

The wound/burn guidelines - 4: Guidelines for the management of skin ulcers associated with connective tissue disease/vasculitis

The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.

Case series of lower-extremity chronic wounds managed with an antibacterial foam dressing bound with gentian violet and methylene blue

OBJECTIVE

To evaluate an antibacterial dressing for the management of lower-extremity chronic wounds with critical colonization.

DESIGN

A case series of n = 15 patients with lower-extremity chronic wounds were treated with an antibacterial foam dressing consisting of polyvinyl alcohol (PVA) foam bound with gentian violet and methylene blue (Hydrofera Blue; Hydrofera, LLC, Willimantic, Connecticut).

SETTING

An outpatient clinic in Ontario, Canada.

PATIENTS

The dressing was applied to diabetic foot ulcers (n = 8) and other venous/leg wound etiologies (n = 7). The study population was clinically challenging due to high mean body weight, extended wound durations, and high diabetes prevalence.

MAIN OUTCOME MEASURES

Wounds were assessed for clinical signs of superficial and deep/surrounding bacterial burden using the validated NERDS and STONEES mnemonic and with semiquantitative bacterial swabs. Changes in wound size, pain, and other clinical parameters were also recorded.

MAIN RESULTS

Improvements in surface critical colonization and pain score at the end of the study period were noted in some patients, especially in patients with diabetic foot ulcers. A decreasing wound size was observed in 8 of the 14 patients (57%) at week 4. One patient was excluded from wound size change analysis.

CONCLUSIONS

An antibacterial foam dressing consisting of PVA foam bound with gentian violet and methylene blue showed encouraging results in a clinically challenging study population. This dressing may be a suitable option for lower-extremity chronic wounds demonstrating an increased superficial bacterial burden. Further investigation focused on identifying the characteristics of patients who are most responsive to the dressing is warranted.

Necrobiosis Lipoidica Diabeticorum: A pediatric case report

Introduction: Necrobiosis lipoidica (NL) is a rare chronic granulomatous dermatitis that usually appears in the lower extremities. It affects about 0.3–1.2% of diabetic patients, the majority of whom have type 1 diabetes. The etiology and pathogenesis of this disorder are still unclear. NL is characterized by skin rash that usually affects the shins. The average onset is 30 years, with females being affected more commonly. There are very few reported cases of necrobiosis lipoidica in children.

Case report: We report a case of a 16 year old girl affected by type 1 diabetes mellitus (15 years disease duration) who developed an erythematous nodular rash on the lower extremities and interscapular area. In the suspect of necrobiosis lipoidica, a skin biopsy was performed (lower extremities and interscapular area). The microscopic evaluation of the pretibial lesions was suggestive of necrobiosis lipoidica. The smaller lesions in the interscapular area showed signs of perivascular dermatitis which could be consistent with early stages of necrobiosis lipoidica. Local treatment with tacrolimus determined a progressive improvement of the lesions.

Conclusion: In patients with T1DM, diagnosis of NL of the lower legs is usually unequivocal. However, diagnosis may be more challenging in the presence of lesions with recent onset and/or atypical clinical presentation and unusual site. In these cases, NL must always be taken in consideration in order to avoid misdiagnosis, wrong/late treatment decisions and progression to ulceration.

Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management

Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.

The locus of pain control in patients with lower limb ulcerations

AIMS AND OBJECTIVES

(1) To analyse the distribution of pain control profiles of individuals suffering from the lower limb ulcerations. (2) To identify sociodemographic and clinical factors determine the locus of pain control in this group of patients.

BACKGROUND

The locus of pain control can play a critical role in determining the quality of life in patients with lower limb ulcerations, and identification of individuals with an unfavourable pain control profile would enable the opportunity of offering them dedicated psychological counselling.

DESIGN

Quantitative survey.

METHODS

This study included 298 patients with lower limb ulcerations resulting from chronic venous insufficiency (n = 101), lower limb atherosclerosis (n = 98), or having mixed arteriovenous aetiology (n = 99). The study included the completion of the Polish version of the Beliefs about Pain Control Questionnaire.

RESULTS

The most important role in the control of pain was assigned to the powerful others locus. This locus correlated directly with poorer educational level and higher professional activity. Additionally, the intensity of usual pain correlated inversely with the powerful others locus. Respondents' age was the only sociodemographic variable decreasing the level of the internal locus. Moreover, the severity of usual and maximal pain and the area of ulceration correlated inversely with the internal locus of pain control. In contrast, the aetiology of lower limb ulceration did not affect significantly any of the dimensions of pain control.

CONCLUSION

The control of pain in ulceration patients is mostly determined by the support of medical personnel, which generally should be considered a negative finding. Relevance to clinical practice.  Determination of the locus of pain control should be included in the complex medical evaluation of individuals suffering from ulcerations.

Etiology and management of pyoderma gangrenosum: a comprehensive review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, necrotic ulceration. It typically affects patients in the third to sixth decades of life, with almost equal incidence in men and women. PG occurs most frequently on the lower extremities. Five clinical variants are currently recognized: classic, bullous, pustular, vegetative, and peristomal types. Half of PG cases are seen in association with systemic disease. Mimickers include infection, vascular insufficiency ulcers, systemic vasculitides, autoimmune disease, cancer, and exogenous tissue injury, among others. PG is often a diagnosis of exclusion, as there are no specific laboratory or histopathologic findings to confirm the diagnosis. PG thus presents many clinical challenges: it is difficult to diagnose, is frequently misdiagnosed, and often requires a work-up for underlying systemic disease. Successful management of PG typically requires multiple modalities to reduce inflammation and optimize wound healing, in addition to treatment of any underlying diseases. Prednisone and cyclosporine have been mainstays of systemic treatment for PG, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor-α inhibitors, for refractory cases of PG. Here, we review the clinical presentation and pathophysiology of PG, as well as its associated conditions, diagnostic work-up, and management.

Skin signs in diabetes mellitus

Diabetes mellitus is the most common endocrine disorder with continuously increasing prevalence. Blood vessels, nerves, eyes, kidneys and skin are affected, which causes both an enormous financial burden and a reduced quality of life of the affected patients. Long-standing diabetes may impair skin homeostasis resulting in skin manifestations in at least one third of all diabetics. The skin involvement may be the first presenting sign of diabetes, thus the respective skin signs should lead to diabetes focused diagnostic. Besides, the skin signs may be considered as a marker for the course of the disease or for the success of therapeutic interventions.

Topical morphine gel in the treatment of painful leg ulcers, a double-blind, placebo-controlled clinical trial: a pilot study

Chronic painful wounds, a major health problem, have a detrimental impact on the quality of life due to associated pain. Some clinical reports have suggested that local administration of morphine could be beneficial. The aim of this study was to evaluate the analgesic effect of topically applied morphine on chronic painful leg ulcers. Twenty-one patients were randomly assigned to receive either morphine or placebo in a randomised, placebo-controlled, crossover pilot study. Each patient was treated four times in total. Pain was measured by the visual analogue score (VAS) before application of gel, directly after and after 2, 6, 12 and 24 hours. Although an overall, clinically relevant, reduction of pain was observed upon treatment with morphine, the difference was not statistically significant. Morphine reduced pain scores more than placebo on treatment occasions 1 and 2. The difference was statistically significant only 2 hours after dressing on the first treatment occasion. Thus, our study did not demonstrate a consistent and globally significant difference in nociception in patients treated with morphine. However, the relatively small number of patients included in our study and other methodological limitations makes it difficult for us to draw general conclusions regarding efficacy of topically applied morphine as an effective treatment for some painful ulcers. Further studies are warranted to evaluate the value of topically applied morphine in the treatment of patients with chronic painful leg ulcers.

Necrobiosis lipoidica: early diagnosis and treatment with tacrolimus

We present a case of necrobiosis lipoidica (NL) with atypical early lesions and good response to topical tacrolimus. NL is a disease with clinical features that are seldom misinterpreted. Often histology just confirms the clinician's diagnosis. Only in rare cases, the clinical presentation and the involved body sites may be misleading. A 67-year-old diabetic woman was admitted to our department with a well-defined, persistent plaque on her left arm and on her right shin. Histologic examination of both lesions revealed features of NL despite the dissimilar clinical presentation. The patient was treated with 0.1% topical tacrolimus ointment twice daily for 8 weeks and once daily for 8 weeks. A significant improvement and no further lesions were observed after 1 year of follow-up. A high index of suspicion regarding NL lesions with atypical clinical presentation on different body sites is advised in order to avoid misdiagnosis, wrong treatment decisions and ulceration. Additionally, it appears that topical tacrolimus treatment is an effective therapeutic option in patients with recent, non-ulcerated NL lesions.

Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings

Chronic wounds are a major healthcare problem costing the United States billions of dollars a year. The American Academy of Dermatology has underscored the significance of wound care in dermatological practice. It is critical for all dermatologists to understand the elements of diagnosis and therapy. We emphasize major aspects of diagnosis and present a simple classification of wound dressings with guidelines for usage and relative cost data.

LEARNING OBJECTIVE

After completing this learning activity, participants should be able to diagnose common types of chronic wounds, formulate a therapeutic plan, and describe the major classes of topical therapies and dressings for the chronic wound.