Kompressionstherapie bei Patienten mit Ulcus cruris venosum

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

[Randomized clinical trial of compression therapy of the lower legs in patients with psoriasis]

BACKGROUND

Psoriatic plaques at the distal lower extremities are notoriously treatment resistant. Medical compression therapy could potentially be a useful supplementary therapeutic measure at this site. However, there is concern that the Koebner phenomenon may cause a worsening of the skin condition. Therefore, the purpose of this study was to investigate the effects of compression therapy on psoriatic plaques in the presence of coexisting edema of the lower legs.

PATIENTS AND METHODS

Compression therapy was performed in addition to standard of care on one lower leg for 4 weeks (half-side test) in patients with psoriatic plaques and edema on both lower legs. The primary endpoint of the study was clinical response of the psoriatic plaques on the lower legs measured with the lesion severity score (LSS) and the locally affected body surface area in a side-by-side comparison at week 4 compared with baseline. Secondary endpoints were related to patient-reported outcomes.

RESULTS

Data from 30 patients were included in the analysis. In the descriptive analysis, the mean LSS results and the subjective pain reported by the patients showed a slightly greater improvement on the compressed lower leg compared with the non-compressed lower leg. None of the patients showed evidence of the Koebner phenomenon induced by compression therapy.

CONCLUSION

This is the first clinical study that systematically investigated the impact of compression therapy on psoriatic plaques. During the study period of 4 weeks, there was no significant improvement in psoriatic plaques; however, there was also no evidence of worsening of the skin condition. Thus, anti-edematous compression therapy can be performed in psoriasis patients without causing complications if basic contraindications are considered.

[Treatment of chronic wounds]

The treatment of chronic wounds often poses a therapeutic challenge. Assessment of the pathogenesis of the wound, causative and symptomatic interventions are key. Concerning treatment-concepts the evaluation of comorbidities, pain management, the nutrition status of as well as the mobility of the patient are recommended.

[Modern management of chronic wounds]

The treatment of patients with chronic wounds is a multiprofessional challenge. Based on a comprehensive diagnosis and integrated into a causal treatment concept, patients should always be treated with a modern wound therapy. This wound therapy should try to take into account many different factors such as the wound healing phases, infection status, exudate levels, but also individual patient wishes. Especially in the case of chronic wounds of the lower extremities and edema, compression therapy is also very important for therapy and recurrence prophylaxis. In addition, the pain, which is usually very distressing, should be recorded and adequately treated or avoided. Modern moist wound therapy can then support the healing of patients with chronic wounds, reduce complications and thus improve their quality of life.

[Diagnosis and therapy of erysipelas: A position paper of the Society Initiative Chronische Wunde (ICW) e. V.]

Erysipelas is a bacterial soft tissue infection caused by β-haemolytic streptococci that spreads proximally along the lymphatic system of the skin. The entry sites of the pathogens can be minor injuries or chronic wounds. The diagnosis of erysipelas is made clinically by the spreading eythema and overheating of the skin, the reduced general condition with fever and chills as well as by means of serological inflammation parameters and must be distinguished from numerous differential diagnoses.Systemic therapy is carried out with penicillin usually. In local therapy, the value of measures such as compression therapy or cooling is currently still controversial. Long-term therapy of the lymphoedema and the consistent avoidance and treatment of entry sites are essential, especially for the prevention of recurrence.

[Is compression therapy contraindicated for lower leg erysipelas? : Results of a retrospective analysis]

In many medical expert recommendations and guidelines, the use of compression therapy for acute erysipelas is designated as a contraindication. Due to the sometimes massive oedema, compression therapy is nevertheless used in some clinics. This led to the question whether compression therapy for erysipelas of the lower leg actually leads to complications due to the acute infection and thus represents a contraindication. For the period 01 January 2018 to 30 June 2019, the records of 56 inpatients with acute erysipelas of the lower leg who received compression therapy in addition to systemic antibiotic therapy were retrospectively evaluated. The duration of inpatient treatment, the infection parameters determined as part of the ward routine and any complications that occurred were evaluated. While treated as inpatients the blood parameters for infection clearly dropped. Compression therapy was started on admission day in 92.9% of patients and continued until discharge. None of the patients showed an increase in fever or clinical signs of sepsis during the hospital stay. In this retrospective analysis it could be shown for the first time that compression therapy does not cause a clinical worsening or trigger a septic clinical picture in patients with acute erysipelas. Therefore, the authors consider the declaration of acute erysipelas as contraindication for compression therapy as not justified.

[Chronic leg ulcers]

Chronic wounds often manifest as ulcers on the lower legs. The main causes of chronic leg ulcers are chronic venous insufficiency and/or peripheral arterial occlusive disease in approximately 80% of all patients. However, there are also numerous other potentially relevant factors which can cause or almost impede the healing of chronic leg ulcers. Therefore, disease such as vasculitis, livedo vasculopathy, pyoderma gangrenosum, necrobiosis lipoidica, Martorell hypertensive leg ulcer, calciphylaxis, infectious diseases, neoplasms, drugs, cutaneous artefacts and genetic defects are exemplarily presented. The successful therapy of patients with chronic leg ulcers is only possible on the basis of an adequate diagnosis. Therapeutic options include conservative, surgical and interventional treatment options. In particular the consequent implementation of compression therapy is of very great importance in the therapy of most patients with chronic leg ulcers and edema. However, a permanent effective treatment always requires a causally oriented therapy, which usually needs an interdisciplinary and interprofessional approach.

[Quality of self-applied compression bandages in patients with chronic venous ulcers : Results of a prospective clinical study]

BACKGROUND

For effective compression therapy in patients with venous leg ulcers, sufficient pressure is essential. In everyday life, it is often the patients themselves who apply the compression bandages. Many of these patients have restriction in their movement and had been rarely trained adequately. Hence, there was the question of how efficient are the autonomously applied compression bandages of those patients.

PATIENTS AND METHODS

In all, 100 consecutive patients with venous leg ulcer were asked to apply compression bandages on their own leg. We documented both the achieved compression and formal criteria of correct performance.

RESULTS

A total of 59 women and 41 men with an average age of 70.3 years were included in the study. Overall 43 patients were not able to apply a compression bandage because of physical limitations. The measured pressure values in the remaining 57 patients ranged between 6 and 93 mm Hg (mean 28.3 mm Hg). Eleven patients reached the prescribed effective compression pressure. Of these, formal errors were found in 6 patients, so that only 5 patients had correctly applied the compression bandages.

CONCLUSION

Our data show that most patients with venous leg ulcers are not able to apply effective compression therapy with short-stretch bandages to themselves. Multilayer systems, adaptive compression bandages, and ulcer stocking systems today are possibly easier and more effective therapy options. Alternatively short-stretch bandages could be applied by trained persons but only under the control with pressure measuring probes.

[Compression therapy of venous leg ulcers in the decongestion phase]

Compression therapy is the basis for successful treatment in most patients with venous leg ulcers. Concerning compression therapy, the initial phase of decongestion and the following phase of maintenance should be differentiated. While in the maintenance phase (ulcer) stocking systems are now frequently recommended, in the decongestion phase compression bandages are mostly still used, which however are often inappropriately applied. In German-speaking countries, compression therapy with short-stretch bandages has a long tradition. However, their correct application requires good training and monitoring, which is often lacking in daily practice. Less error-prone treatment alternatives are multicomponent systems, some of which have an optical marker for the control of the correct subbandage pressure. In another new type of compression system, which is called adaptive or wrap bandages, the compression pressure can be adjusted using a Velcro fastener. Accompanying intermittent pneumatic compression therapy can also be used in the decongestion phase. Thus, there are now several different treatment options that can be used for the decongestion phase in patients with venous leg ulcers. Often bandages with short-stretch materials are very prone to errors and should in most cases be replaced by other compression systems today. The patient's preference, need, and capability should be considered when selecting the appropriate system for the individual patient.

Moderne Wundauflagen für die Therapie chronischer Wunden

The incidence of chronic wounds is increasing in developed Western countries. There are many causes for chronic or non-healing wounds. A multidisciplinary diagnostic approach and attention to underlying disorders are essential. A modern, moist, and phase adapted wound therapy is also essential. Modern wound dressings include activated charcoal, alginates, hyaluronic acid, hydrofibers, hydrogels, hydrocolloids, impregnated gauze, collagen, moist methods, proteolytic enzymes, foams, semipermeable membranes and silver dressings. Because of the lack of comparative investigations the phase-adapted use of wound dressings is still empiric. Application of modern wound dressings may help to create an optimized wound milieu and accelerate healing. Treatment of the underlying causes is an absolute requirement for long-term complete healing.