1
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Bindlish S. Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An obesity medicine association (OMA) clinical practice statement (CPS) 2023. OBESITY PILLARS (ONLINE) 2023; 8:100092. [PMID: 38125656 PMCID: PMC10728709 DOI: 10.1016/j.obpill.2023.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 12/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians with an overview on obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Methods The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results Topics in this CPS include obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Obesity increases the risk of thrombosis and cardiovascular disease via fat mass and adiposopathic mechanisms. Treatment of thrombosis or thrombotic risk includes healthful nutrition, physical activity, and the requisite knowledge of how body weight affects anti-thrombotic medications. In addition to obesity-related thrombotic considerations of acute coronary syndrome and ischemic non-hemorrhagic stroke, this Clinical Practice Statement briefly reviews the diagnosis and management of clinically relevant presentations of deep vein thromboses, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, corona phlebectatica, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post-thrombotic syndrome, as well as lymphedema and lipedema - which should be included in the differential diagnosis of other edematous or enlargement disorders of the lower extremities. Conclusions This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on obesity, thrombosis, and venous/lymphatic disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.
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Affiliation(s)
- Shagun Bindlish
- Adjunct Faculty Touro University, 7554 Dublin Blvd, Dublin, CA, USA
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2
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Greif T, Alsawas M, Reid AT, Liu V, Prokop L, Murad MH, Powers JG. Targeting the Angiotensin Pathway in the Treatment of Cutaneous Fibrosis: A Systematic Review. JID INNOVATIONS 2023; 3:100231. [PMID: 37840767 PMCID: PMC10568560 DOI: 10.1016/j.xjidi.2023.100231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 08/03/2023] [Accepted: 08/22/2023] [Indexed: 10/17/2023] Open
Abstract
Acting on the renin-angiotensin-aldosterone system, angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are mechanisms of some of the most prescribed medications in the world. In addition to their routine use for the treatment of hypertension, such agents have gained attention for their influence on the angiotensin receptor pathway in fibrotic skin disorders, including scars and keloids. To evaluate the current level of evidence supporting the use of these agents, a systematic review related to ACE-Is/ARBs and cutaneous scarring was conducted. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from database inception through January 26, 2022. Two independent reviewers identified eligible studies for inclusion and extracted data. Data were insufficient for meta-analysis and are presented narratively. Of 461 citations identified, seven studies were included (199 patients). The studies included two randomized clinical trials, one comparative observation study, and four case reports. All the included studies reported statistically significant improvement in cutaneous scarring in patients using ACE-Is/ARBs compared with that in those treated with placebo/control using various outcome measures such as scar size and scar scales. However, much of the literature on this subject to date is limited by study design.
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Affiliation(s)
- Trenton Greif
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mouaz Alsawas
- Department of Pathology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander T. Reid
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Vincent Liu
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Larry Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - M. Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer G. Powers
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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3
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Silverberg J, Jackson JM, Kirsner RS, Adiri R, Friedman G, Gao XH, Billings SD, Kerkmann U. Narrative Review of the Pathogenesis of Stasis Dermatitis: An Inflammatory Skin Manifestation of Venous Hypertension. Dermatol Ther (Heidelb) 2023; 13:935-950. [PMID: 36949275 DOI: 10.1007/s13555-023-00908-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/17/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Stasis dermatitis (SD), also known as venous dermatitis, is a form of inflammatory dermatitis of the lower extremities that typically occurs in older individuals and represents a cutaneous manifestation of venous hypertension. Venous hypertension (also known as sustained ambulatory venous pressure) is most often due to retrograde blood flow, which occurs due to calf muscle pump failure. This failure is most commonly secondary to incompetent venous valves, valve destruction, or obstruction of the venous system. Many of the common symptoms associated with SD are caused by inflammatory processes. METHODS This review summarizes the pathogenesis and key role of inflammation in SD by reviewing inflammatory biomarkers associated with SD. The literature was selected though a high-level PubMed search focusing on keywords relating to inflammation associated with SD. RESULTS Venous reflux at the lower extremities causes venous hypertension, which leads to chronic venous insufficiency. High venous pressure due to venous hypertension promotes the local accumulation and extravasation of inflammatory cells across the vascular endothelium. Leukocyte trapping in the microcirculation and perivascular space is associated with trophic skin changes. Cell adhesion molecules are linked with the perpetuated influx of activated leukocytes into inflammatory sites. Here, inflammatory cells may influence the remodeling of the extracellular matrix by inducing the secretion of proteinases such as matrix metalloproteinases (MMPs). The increased expression of MMPs is associated with the formation of venous leg ulcers and lesions. Phosphodiesterase 4 activity has also been shown to be elevated in individuals with inflammatory dermatoses compared to healthy individuals. DISCUSSION Because inflammation is a key driver of the signs and symptoms of SD, several of the highlighted biomarkers of inflammation represent potential opportunities to target and interrupt molecular pathways of cutaneous inflammation and, therefore, remediate the signs and symptoms of SD. CONCLUSION Understanding the pathogenesis of SD may help clinicians identify drivers of inflammation to use as potential targets for the development of new treatment options.
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Affiliation(s)
- Jonathan Silverberg
- The George Washington University School of Medicine & Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - J Mark Jackson
- Division of Dermatology, University of Louisville, 501 S 2nd St, Louisville, KY, 40202, USA
| | - Robert S Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1295 NW 14th St, Miami, FL, 33125, USA
| | - Roni Adiri
- Pfizer Pharmaceuticals Israel Ltd., 9 Shenkar St, 4672509, Herzliya Pituach, Israel.
| | - Gary Friedman
- Pfizer Inc., 500 Arcola Rd, Collegeville, PA, 19426, USA
| | - Xing-Hua Gao
- Department of Dermatology, The First Hospital of China Medical University, 110001, Shenyang, China
| | - Steven D Billings
- Department of Pathology, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Urs Kerkmann
- Pfizer Pharma GmbH, Linkstraße 10, Postfach 610194 10922, 10785, Berlin, Germany
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Suehiro K, Morikage N, Harada T, Takeuchi Y, Mizoguchi T, Ike S, Otuska R, Kurazumi H, Suzuki R, Hamano K. Post-treatment course of acute lipodermatosclerosis. Phlebology 2023; 38:73-79. [PMID: 36529929 DOI: 10.1177/02683555221147473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to clarify whether acute lipodermatosclerosis (LDS) progress to chronic LDS without continued compression therapy. METHODS Between April 2015 and November 2021, 30 patients with acute/subacute LDS, which was diagnosed clinically by presence of isolated, poorly demarcated, tender erythema, and induration limited to the lower leg(s), visited our clinic and were able to be followed up for longer than a year. We reviewed their treatment results and the post-treatment courses. RESULTS In all cases, the symptoms in the acute phase subsided with compression bandages. After the discontinuation of compression therapy, 18 legs (56%) progressed to chronic LDS, and 14 legs (44%) did not. In the legs without progression, subcutaneous tissue in the affected leg was thicker compared with that in the contralateral leg (median 19.1 mm vs. 13.4 mm, p < 0.05) on the initial visit. In the legs with progression, the difference in subcutaneous tissue thickness between the affected and unaffected legs was not significant (10.0 mm vs. 7.6 mm). CONCLUSIONS Our findings suggest that in legs which later progress to chronic LDS, subcutaneous tissue contraction due to panniculitis is already present during the acute phase; therefore, long-term compression therapy is unlikely to improve the prognosis.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Takasuke Harada
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Yuriko Takeuchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Takahiro Mizoguchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Soichi Ike
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Ryo Otuska
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Hiroshi Kurazumi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Ryo Suzuki
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
| | - Kimikazu Hamano
- Division of Vascular Surgery, Department of Surgery and Clinical Science, 38152Yamaguchi University Graduate School of Medicine, Japan
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Klejtman T, Lazareth I, Yannoutsos A, Priollet P. Specific management of lipodermatosclerosis (sclerotic hypodermitis) in acute and chronic phase. JOURNAL DE MEDECINE VASCULAIRE 2022; 47:186-190. [PMID: 36344029 DOI: 10.1016/j.jdmv.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
Lipodermatosclerosis or sclerotic hypodermitis is presented as a complication of venous insufficiency and in particular of post-thrombotic syndrome with a high risk of progression to leg ulcers. However, it has also been described in obese patients without venous insufficiency, and even in the course of various systemic diseases including scleroderma. It most often affects middle-aged women and is usually bilateral, with a typically "inverted champagne bottle" leg appearance. The pathogenic role of venous hypertension explains why compression with bands or stockings is the basis of treatment. In acute phase, which may precede or complicate chronic forms, the pain is so severe that compression is not tolerated. In acute phase, non-steroidal anti-inflammatory drugs, intra-lesional use of triamcinolone, and capsaicin transdermal patches indicated for neuropathic pain have been proposed. In chronic forms, the treatment of superficial venous insufficiency and/or incontinent perforating veins, documented during a Duplex ultrasound scan, is usually proposed, whenever possible. In association with elastic compression, pentoxifylline and colchicine have been used without clear evidence of clinical efficacy. Finally, in the most advanced clinical presentation with the appearance of a sclerotic gaiter associated with ulcerations, surgical treatment with excision-cutaneous grafting associated or not with perforating veins ligation and a fasciotomy may be discussed as a last resort for treatment.
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Affiliation(s)
- T Klejtman
- Vascular medicine department, Saint-Joseph Hospital, 75014 Paris, France.
| | - I Lazareth
- Vascular medicine department, Saint-Joseph Hospital, 75014 Paris, France
| | - A Yannoutsos
- Vascular medicine department, Saint-Joseph Hospital, 75014 Paris, France
| | - P Priollet
- Vascular medicine department, Saint-Joseph Hospital, 75014 Paris, France
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6
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Webb E, Bissett B, Neeman T, Bowden F, Preston E, Mumford V. Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema. Lymphat Res Biol 2022; 21:160-168. [PMID: 35997601 PMCID: PMC10125391 DOI: 10.1089/lrb.2022.0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.
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Affiliation(s)
- Elizabeth Webb
- Physiotherapy Department, Calvary Public Hospital Bruce, Canberra, Australia.,Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Teresa Neeman
- Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine, Australian National University, Canberra, Australia
| | - Francis Bowden
- Medical School, Australian National University, Canberra, Australia
| | - Elisabeth Preston
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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7
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Anand NC, Takaichi M, Johnson EF, Wetter DA, Davis MDP, Alavi A. Suggestions for a New Clinical Classification Approach to Panniculitis Based on a Mayo Clinic Experience of 207 Cases. Am J Clin Dermatol 2022; 23:739-746. [PMID: 35849324 DOI: 10.1007/s40257-022-00709-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Panniculitis, or inflammation of adipose tissue, includes a heterogeneous group of disorders with similar morphologic presentations. Currently, panniculitides are classified based on histopathologic findings only. OBJECTIVE In this retrospective study of 207 cases of biopsy-proven panniculitis over 20 years at Mayo Clinic, we aimed to propose a new classification that integrates the clinical morphologic features with the histopathology of panniculitis. METHODS We collected patient demographic and lesion morphologic characteristics using lesion photographs and physician notes for each of our 207 cases, including location, ulceration, scale, pattern (unilateral versus circumferential), atrophy/sclerosis (cicatricial), redness, and swelling. RESULTS The panniculitides most likely to ulcerate were calciphylaxis (85.7% ulcerating), pancreatic panniculitis (66.6%), and α1-antitrypsin deficiency-associated panniculitis (100%). The panniculitides least likely to ulcerate were erythema nodosum and medication-induced and granulomatous panniculitis. This retrospective study used only descriptions in clinical notes and available medical photographs. CONCLUSION We present an updated classification schema of panniculitides based on clinical findings. The primary distinctions are based on ulceration, location, and number of lesions. Although complete distinction of all panniculitides based on clinical examination alone is not possible, we hope the proposed schema allows clinicians to tailor differential diagnoses.
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Affiliation(s)
| | | | - Emma F Johnson
- Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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8
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Rastel D, Pichot O. Auto-adjustable medical compression device to treat acute lipodermatosclerosis in superficial chronic venous disease, a case-report. JOURNAL DE MEDECINE VASCULAIRE 2022; 47:141-144. [PMID: 36055683 DOI: 10.1016/j.jdmv.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/27/2022] [Indexed: 06/15/2023]
Affiliation(s)
- D Rastel
- Vascular Medicine, 30, place Louis-Jouvet, 38100 Grenoble, France.
| | - O Pichot
- 7, rue Lesdiguières, 38000 Grenoble, France
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9
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Goldenberg M, Wang H, Walker T, Kaffenberger BH. Clinical and immunologic differences in cellulitis vs. pseudocellulitis. Expert Rev Clin Immunol 2021; 17:1003-1013. [PMID: 34263717 DOI: 10.1080/1744666x.2021.1953982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The immunologic mechanisms between cellulitis and pseudocellulitis differ greatly, even though their clinical presentations may overlap.Areas covered: This article discusses cellulitis and common entities within the pseudocellulitis spectrum including acute lymphedema, superficial venous thrombosis, allergic contact dermatitis, lipodermatosclerosis, stasis dermatitis, erythema nodosum, cutaneous gout, and bursitis. The literature search was conducted from PubMed search engine between March and May 2021.Expert commentary: While immunologic differences in cellulitis and the various entities of pseudocellulitis are clear, there is a practice gap in applying these differences to the clinic and hospital setting. Further, existing studies are weakened by the lack of a gold-standard diagnosis in this disease category. Additional work is necessary in developing a gold-standard for the diagnosis and secondly, to project these immunologic differences as biomarkers to differentiate sterile inflammation from a potential life threatening bacterial or fungal infection.
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Affiliation(s)
- Michael Goldenberg
- Division of Dermatology, Ohio State University College of Medicine, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Henry Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Trent Walker
- Division of Dermatology, Ohio State University College of Medicine, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Benjamin H Kaffenberger
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
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10
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Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review. Cardiol Ther 2021; 10:111-140. [PMID: 33704678 PMCID: PMC8126535 DOI: 10.1007/s40119-021-00213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE OF REVIEW Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. RECENT FINDINGS Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
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11
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Woźniak W, Danowska A, Mlosek RK. The use of high-frequency skin ultrasound in the diagnosis of lipodermatosclerosis. J Ultrason 2020; 20:e284-e290. [PMID: 33500796 PMCID: PMC7830071 DOI: 10.15557/jou.2020.0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Lipodermatosclerosis is a symptom of severe venous insufficiency, the diagnosis of which is based on the clinical picture. Although the histopathology of the skin and the subcutaneous tissue allows for the most reliable diagnosis, it is not recommended due to healing disorders. Aim The aim of this study was to assess the usefulness of high-frequency ultrasound in the diagnosis of lipodermatosclerosis. Materials and methods The study included 10 patients with lipodermatosclerosis who underwent Duplex Doppler ultrasound of lower limb veins, high-frequency ultrasound of the tibial skin, and radiography of the lower leg, all of which were analyzed in correlation with clinical symptoms. Results The study group included 9 women and 1 man aged 39–81 years. Manifestations of lipodermatosclerosis were detected in 14 limbs. High-frequency ultrasound showed that the mean dermis thickness at the affected sites was 2.63 mm, and was significantly thicker compared to healthy skin (1.45 mm) (p = 0.00002). Higher echogenicity was detected in the affected body regions in 85.7% of cases for the skin and 92.9% of cases for the subcutaneous tissue. Subcutaneous and vascular wall calcifications were detected in 92.9% and 78.6% of cases, respectively. Fibrosis was observed in all limbs, and compression sonoelastography showed that the compliance of the subcutaneous tissue was lower than that of muscles. The border between the skin and the subcutaneous tissue was blurred in 57.1% of cases. Radiography revealed thickening of the affected skin regions in all limbs, with calcifications detected in 85.7% of cases. A blurred border between the skin and the subcutaneous tissue was observed in 35.7% of limbs. Conclusion High-frequency ultrasonography of the skin and the subcutaneous tissue in the lower legs supported with radiological findings is highly useful in the diagnosis of lipodermatosclerosis.
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Affiliation(s)
- Witold Woźniak
- First Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Poland
| | - Anna Danowska
- First Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Poland
| | - Robert K Mlosek
- Ultrasound Diagnostic Department Faculty of Medical Sciences, Medical University of Warsaw, Warsaw, Poland
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12
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Affiliation(s)
- Mina Bakhtiar
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ansar Vance
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas Pugliese
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Shavit E, Marzano AV, Alavi A. Ulcerative versus non-ulcerative panniculitis: is it time for a novel clinical approach to panniculitis? Int J Dermatol 2020; 60:407-417. [PMID: 33040341 DOI: 10.1111/ijd.15224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/15/2020] [Accepted: 09/04/2020] [Indexed: 01/10/2023]
Abstract
Panniculitis, or inflammation of the fatty tissue, is an ongoing diagnostic challenge to both dermatologists and pathologists. The basis of the current panniculitis classification is histology, whether the inflammation is mainly located in the fibrovascular septa or in the adipose lobules thereafter with or without vasculitis. However, overall, the difficulty rises due to various terminologies and lack of clinical relevance with this classification. In addition to that, the majority of panniculitides have mixed infiltration of both lobular and septal and not a clear-cut distinction. The aim of this article is to provide a novel clinical algorithm to the diagnosis of panniculitis and thus to provide guidelines for all clinicians who may encounter this challenging condition in their clinical practice.
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Affiliation(s)
- Eran Shavit
- Division of Dermatology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada.,Dermatology Unit, Barzilai University Medical Center, Ashkelon, Israel.,The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba, Israel
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Afsaneh Alavi
- Division of Dermatology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
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14
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Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bissett B. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med 2020; 383:630-639. [PMID: 32786188 DOI: 10.1056/nejmoa1917197] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness. METHODS In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments. RESULTS A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial. CONCLUSIONS In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).
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Affiliation(s)
- Elizabeth Webb
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Teresa Neeman
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Francis J Bowden
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Jamie Gaida
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Virginia Mumford
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Bernie Bissett
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
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Leaker BD, Fuchs C, Tam J. When Wounds Are Good for You: The Regenerative Capacity of Fractional Resurfacing and Potential Utility in Chronic Wound Prevention. Adv Wound Care (New Rochelle) 2019; 8:679-691. [PMID: 31750016 DOI: 10.1089/wound.2019.0945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/03/2019] [Indexed: 12/24/2022] Open
Abstract
Significance: Fractional resurfacing involves producing arrays of microinjuries on the skin, by thermal or mechanical means, to trigger tissue regeneration. Originally developed for cosmetic enhancement, fractional resurfacing induces a broad array of improvements in the structural and functional qualities of the treated skin and is especially effective at returning defective skin to a more normal state. In addition to fascinating questions about the nature of this remarkable regenerative capacity, there may be potential utility in ulcer prevention by halting or even reversing the progressive decline in overall skin quality that usually precedes chronic wound development. Recent Advances: Photoaging and scarring are the two skin defects most commonly treated by fractional resurfacing, and the treatment produces profound and long-lasting improvements in skin quality, both clinically and at the cellular/histologic level. Chronic wounds usually occur in skin that is compromised by various pathologic factors, and many of the defects found in this ulcer-prone skin are similar to those that have seen improvements after fractional resurfacing. Critical Issues: The mechanisms responsible for the regenerative capacity of fractional resurfacing are mostly unknown, as is how ulcer-prone skin, which is usually afflicted by stressors external to the skin tissue itself, would respond to fractional resurfacing. Future Directions: Better understanding of the cellular and molecular mechanisms underlying the unique healing response to fractional resurfacing could reveal fundamental information about adult tissue regeneration, lead to improvements in current applications, as well as new therapies in other pathologic conditions.
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Affiliation(s)
- Ben D. Leaker
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- The Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Christiane Fuchs
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Joshua Tam
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
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Suehiro K, Morikage N, Harada T, Samura M, Nagase T, Mizoguchi T, Hamano K. Compression Therapy Using Bandages Successfully Manages Acute or Subacute Lipodermatosclerosis. Ann Vasc Dis 2019; 12:77-79. [PMID: 30931064 PMCID: PMC6434351 DOI: 10.3400/avd.cr.18-00135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We report nine cases with acute or subacute lipodermatosclerosis treated successfully using multilayer bandages. All patients were women aged 52-90 years. Before presenting to our clinic, all patients had been treated for a tentative diagnosis of cellulitis caused by bacterial infection or inflammation of unknown cause for 3-19 weeks without improvement. Initially, we instructed all patients or their caregivers regarding the bandaging technique to achieve an interface pressure of >40 mmHg. Subsequently, this technique was continued by patients/caregivers. Symptoms subsided within 2-7 weeks in all patients except one who had been noncompliant with the compression therapy.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takasuke Harada
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Makoto Samura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takashi Nagase
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takahiro Mizoguchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kimikazu Hamano
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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17
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Sermsathanasawadi N, Tarapongpun T, Pianchareonsin R, Puangpunngam N, Wongwanit C, Chinsakchai K, Mutirangura P, Ruangsetakit C. Customizing elastic pressure bandages for reuse to a predetermined, sub-bandage pressure: A randomized controlled trial. Phlebology 2017; 33:627-635. [DOI: 10.1177/0268355517746434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective A randomized clinical trial was performed to compare the effectiveness of unmarked bandages and customized bandages with visual markers in reproducing the desired sub-bandage pressure during self-bandaging by patients. Method Ninety patients were randomly allocated to two groups (“customized bandages” and “unmarked bandages”) and asked to perform self-bandaging three times. The achievement of a pressure between 35 and 45 mmHg in at least two of the three attempts was defined as adequate quality. Results Adequate quality was achieved by 33.0% when applying the unmarked bandages, and 60.0% when applying the customized bandages ( p = 0.02). Use of the customized bandage and previous experience of bandaging were independent predictors for the achievement of the predetermined sub-bandage pressure ( p = 0.005 and p = 0.021, respectively). Conclusion Customized bandages may achieve predetermined sub-bandage pressures more closely than standard, unmarked, compression bandages. Clinical trials registration ClinicalTrials.gov (NCT02729688). Effectiveness of a Pressure Indicator Guided and a Conventional Bandaging in Treatment of Venous Leg Ulcer. https://clinicaltrials.gov/ct2/show/NCT02729688
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Affiliation(s)
- Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tanakorn Tarapongpun
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rattana Pianchareonsin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Puangpunngam
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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18
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Ayele A, Tidman MJ, Biswas A. Pseudomembranous changes in the dermis: A novel observation and potential clue for evolving lipodermatosclerosis? J Cutan Pathol 2017; 44:1070-1074. [PMID: 28873249 DOI: 10.1111/cup.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022]
Abstract
Lipodermatosclerosis (LDS) is a well-recognized form of fibrosing panniculitis. Although chronic cases are readily diagnosed, early and evolving lesions may be clinically mistaken for cellulitis and other forms of panniculitis. Most pathologists are familiar with a pseudomembranous type of fat necrosis as a useful feature of chronic LDS. Although nonspecific, this distinctive pattern of fat necrosis helps in supporting a diagnosis of LDS in the appropriate clinical context. The histopathologic features of early and evolving LDS and those involving the dermis are less well documented. We report a case of early LDS showing extensive pseudomembranous changes in the dermis on a superficial skin biopsy where progression to a classic established lesion was documented clinically. We suspect that this previously unreported and unusual finding may be a histopathologic clue for evolving lesions of LDS.
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Affiliation(s)
- Adane Ayele
- Department of Dermatovenereology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael J Tidman
- Department of Dermatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Asok Biswas
- Department of Pathology, Western General Hospital and the University of Edinburgh, Edinburgh, UK
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20
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Abstract
BACKGROUND Patients with erythematous skin are likely to receive a diagnosis of cellulitis; however, the accuracy of this diagnosis is approximately only 33%. The diagnosis of cellulitis should be made only after a thorough evaluation of all possible differential diagnoses. Cellulitis may be a primary process (superficial spreading infective process involving only the epidermis and dermis) versus a secondary (reactive) process incited by a subcutaneous process, such as an abscess, tenosynovitis, necrotizing fasciitis, and osteomyelitis. CASE PRESENTATION A 50-year-old man was admitted to a general hospital with the diagnosis of cellulitis. He was initially treated with systemic antibiotics without improvement. Following consultation with a wound management physician, the patient received a diagnosis of a pretibial abscess and was treated with surgical evacuation and postoperative systemic antibiotic therapy guided by tissue cultures. A postoperative wound was successfully treated with inelastic compression therapy. CONCLUSIONS This case demonstrates the potential for misdiagnosis when evaluating erythematous skin. Furthermore, concluding that the erythema is due to a primary cellulitis may result in monotherapy with systemic antimicrobial agents. In such cases, making a correct diagnosis through a skillful and complete physical examination of the patient, coupled with appropriate investigations, will lead to the best possible outcome. A comprehensive treatment approach may include systemic antimicrobials, as well as surgical options and compression therapy.
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Affiliation(s)
- Vincent Maida
- Vincent Maida, MD, MSc, BSc, CCFP(PC), FCFP, ABHPM, is Associate Professor, Division of Palliative Care, University of Toronto; and Clinical Assistant Professor, Division of Palliative Care, McMaster University and Division of Palliative Medicine, William Osler Health System, Toronto, Ontario, Canada. Joyce T. W. Cheung, MD, BSc, CCFP, is a Palliative Medicine Consultant, Division of Palliative Medicine, William Osler Health System, Toronto, Ontario, Canada
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21
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Crisóstomo R, Candeias M, Armada-da-Silva P. Venous flow during manual lymphatic drainage applied to different regions of the lower extremity in people with and without chronic venous insufficiency: a cross-sectional study. Physiotherapy 2017; 103:81-89. [DOI: 10.1016/j.physio.2015.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 12/03/2015] [Indexed: 11/25/2022]
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Abstract
The diagnosis of panniculitis is felt to be a confusing topic by some pathologists. This summarical article presents inflammatory diseases of the subcutis in a systematic fashion, based on whether they are centered on fibrovascular septa or the adipose lobules, and whether morphologic vasculitis is present or not. Septocentric, non-vasculitis disorders include erythema nodosum, panniculitis that follows the use of "biological" therapeutic agents, lipodermatosclerosis, post-irradiation panniculitis, morphea profunda, and necrobiosis lipodica profunda. Polyarteritis nodosa and Behçet's disease are the conditions that are based in the subcutaneous septa with vasculitis. Predominantly-lobular panniculitides with no vasculitis include pancreatogenic panniculitis, the panniculitis of alpha-1-antitrypsin deficiency, panniculitis associated with lupus erythematosus and dermatomyositis, subcutaneous Sweet syndrome, eosinophilic panniculitis, factitial panniculitis, cold panniculitis, panniculitis following injections of corticosteroids, lipomembranous (ischemic) panniculitis; sclerema neonatorum and subcutaneous fat necrosis of the newborn, and Rosai-Dorfman disease of the subcutis. Erythema induratum and infectious panniculitis are vasculitic and lobulocentric conditions. This article reviews the histological features of these diseases.
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Affiliation(s)
- Mark R Wick
- Section of Dermatopathology,Dermatopathology, Division of Surgical Pathology & Cytopathology, University of Virginia Medical Center, Charlottesville, VA, USA.
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23
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Alavi A, Sibbald RG, Phillips TJ, Miller OF, Margolis DJ, Marston W, Woo K, Romanelli M, Kirsner RS. What's new: Management of venous leg ulcers: Approach to venous leg ulcers. J Am Acad Dermatol 2016; 74:627-40; quiz 641-2. [PMID: 26979354 DOI: 10.1016/j.jaad.2014.10.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/15/2014] [Accepted: 10/15/2014] [Indexed: 12/31/2022]
Abstract
Leg ulcerations are a common problem, with an estimated prevalence of 1% to 2% in the adult population. Venous leg ulcers are primarily treated in outpatient settings and often are managed by dermatologists. Recent advances in the diagnosis and treatment of leg ulcers combined with available evidence-based data will provide an update on this topic. A systematized approach and the judicious use of expensive advanced therapeutics are critical. Specialized arterial and venous studies are most commonly noninvasive. The ankle brachial pressure index can be performed with a handheld Doppler unit at the bedside by most clinicians. The vascular laboratory results and duplex Doppler findings are used to identify segmental defects and potential operative candidates. Studies of the venous system can also predict a subset of patients who may benefit from surgery. Successful leg ulcer management requires an interdisciplinary team to make the correct diagnosis, assess the vascular supply, and identify other modifiable factors to optimize healing. The aim of this continuing medical education article is to provide an update on the management of venous leg ulcers. Part I is focused on the approach to venous ulcer diagnostic testing.
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Affiliation(s)
- Afsaneh Alavi
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada.
| | - R Gary Sibbald
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada; Department of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tania J Phillips
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - O Fred Miller
- Department of Dermatology, Geisinger Health System, Danville, Pennsylvania
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William Marston
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Kevin Woo
- Faculty of Nursing, Queen's University, Kingston, Ontario, Canada
| | | | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
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Sermsathanasawadi N, Chatjaturapat C, Pianchareonsin R, Puangpunngam N, Wongwanit C, Chinsakchai K, Ruangsetakit C, Mutirangura P. Use of customised pressure-guided elastic bandages to improve efficacy of compression bandaging for venous ulcers. Int Wound J 2016; 14:636-640. [PMID: 27502619 DOI: 10.1111/iwj.12656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/08/2016] [Accepted: 07/10/2016] [Indexed: 11/30/2022] Open
Abstract
Compression bandaging is a major treatment of chronic venous ulcers. Its efficacy depends on the applied pressure, which is dependent on the skill of the individual applying the bandage. To improve the quality of bandaging by reducing the variability in compression bandage interface pressures, we changed elastic bandages into a customised version by marking them with circular ink stamps, applied when the stretch achieves an interface pressure between 35 and 45 mmHg. Repeated applications by 20 residents of the customised bandage and non-marked bandage to one smaller and one larger leg were evaluated by measuring the sub-bandage pressure. The results demonstrated that the target pressure range is more often attained with the customised bandage compared with the non-marked bandage. The customised bandage improved the efficacy of compression bandaging for venous ulcers, with optimal sub-bandage pressure.
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Affiliation(s)
- Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Choedpong Chatjaturapat
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rattana Pianchareonsin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Puangpunngam
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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25
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[Differential diagnosis of skin changes on the lower extremities in chronic venous insufficiency]. Wien Med Wochenschr 2016; 166:270-4. [PMID: 27379851 DOI: 10.1007/s10354-016-0478-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
Varicous veins and postthrombotic syndrome can make typical reversible or irreversible skin changes on the lower extremities if no treatment is initiated. The typical clinical signs should be recognised in an early stage and possible differential diagnoses have to be excluded.
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Alavi A, Sibbald RG, Phillips TJ, Miller OF, Margolis DJ, Marston W, Woo K, Romanelli M, Kirsner RS. What's new: Management of venous leg ulcers. J Am Acad Dermatol 2016; 74:643-64; quiz 665-6. [DOI: 10.1016/j.jaad.2015.03.059] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/28/2015] [Accepted: 03/30/2015] [Indexed: 12/31/2022]
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Falls, Balance Confidence, and Lower-Body Strength in Patients Seeking Outpatient Venous Ulcer Wound Care. Adv Skin Wound Care 2016; 29:85-93. [PMID: 26765161 DOI: 10.1097/01.asw.0000476071.11690.61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE & ABSTRACT To provide information about a quality improvement project examining falls in persons seeking outpatient wound care. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to:1. Describe the scope of the problem and the related quality improvement project. 2. Delineate the results of the project and their implications for treatment of patients with venous ulcers. OBJECTIVE The authors aim to examine fall occurrence and fall injuries in persons seeking outpatient wound care and to compare falls, balance confidence, and lower-body strength in persons with injection-related venous ulcers (IRVUs) versus persons with venous ulcers (VUs) related to other risk factors besides injection drugs (VUs-other). DESIGN This quality improvement project used a cross-sectional, comparative design. Participants responded to demographic questions, the Activities-specific Balance Confidence (ABC) Scale, fear of falling, fall numbers, and injuries and performed the 30-second chair-rise test. SETTING Outpatient wound service. PATIENTS Patients (N = 106; mean age, 59.94 years) included men (66%) and women. RESULTS Sixty patients reported falling; 47 were recurrent fallers. Twenty patients stated they were injured, but did not go to an emergency department. A higher number of total falls was significantly related to more comorbidities. Total falls were significantly related to fear of falling and ABC Scale scores. Those with VUs-other had significantly more comorbidities and higher body mass index values than those with IRVUs. Those with IRVUs were comparable to those VUs-other on number of falls and fear of falling, respectively. Those with IRVUs (7.30) performed significantly more chair rises than those with VUs-other (4.72). Persons with IRVUs had significantly higher ABC Scale scores (63.24%) than those with VUs-other (49.38%). CONCLUSIONS Falls are a common occurrence in persons seeking outpatient wound care. Despite greater strength sufficient to perform more chair rises among those with IRVUs, fall rates were comparable to those of weaker individuals with other types of VUs. With the high occurrence of falls during the project, long-term risk for fall injury would be high. Further research is needed to clarify interactions between VU risk and patient factors such as strength, age, agility, and impaired cognition.
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Choonhakarn C, Chaowattanapanit S, Julanon N. Lipodermatosclerosis: a clinicopathologic correlation. Int J Dermatol 2015; 55:303-8. [PMID: 26275890 DOI: 10.1111/ijd.12856] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/08/2014] [Accepted: 09/08/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lipodermatosclerosis (LDS) is a chronic fibrosing panniculitis associated with venous insufficiency. Although LDS is often a clinical diagnosis, it can be confused with other panniculitides. Microscopic examination is therefore essential to support the diagnosis in this condition. Histopathologic changes, however, have not been extensively defined. The purpose of this study was to characterize the histopathologic spectrum of this condition correlated with clinical manifestation. METHODS A total of 25 cases were collected retrospectively, and the clinical information and histopathologic findings were reviewed. RESULTS Of 25 patients, the female to male ratio was 4 : 1. The mean age was 54 years (range, 31-74 years). Clinical features were acute in eight (32%), subacute in 12 (48%), and chronic in five (20%). The microscopic study mostly demonstrated vascular stasis changes of varying degrees depending on the age of the lesion. Adipocyte necrosis with thickened septa, extravasation of erythrocytes, and lymphocytic infiltration were major findings in the early lesions. In the chronic lesion, lipomembranous fat necrosis with microcyst formation, vascular stasis changes in subcutaneous tissue, and septal fibrosis were predominant features. Iron deposition or hemosiderin extending to the subcutaneous layer was always seen in all specimens at the subacute and chronic stages. CONCLUSION The diagnosis of LDS still needs clinicopathologic correlation. The constellation of findings including septal fibrosis, lipomembranous fat necrosis, prominent vascular changes of stasis, and erythrocytic extravasation can be used to define LDS histopathologically. Interestingly, iron deposition in the subcutaneous tissue is a useful finding for this chronic condition.
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Affiliation(s)
- Charoen Choonhakarn
- Division of Dermatology, Department of Medicine, Srinagarind Hospital Medical School, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Suteeraporn Chaowattanapanit
- Division of Dermatology, Department of Medicine, Srinagarind Hospital Medical School, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Narachai Julanon
- Division of Dermatology, Department of Medicine, Srinagarind Hospital Medical School, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Suehiro K, Morikage N, Murakami M, Yamashita O, Harada T, Ueda K, Samura M, Tanaka Y, Nakamura K, Hamano K. Skin and subcutaneous tissue strain in legs with lymphedema and lipodermatosclerosis. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:1577-1583. [PMID: 25746908 DOI: 10.1016/j.ultrasmedbio.2015.01.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 11/06/2014] [Accepted: 01/21/2015] [Indexed: 06/04/2023]
Abstract
We compared skin and subcutaneous tissue strains in legs with lymphedema (LE) of varying severity and legs with lipodermatosclerosis (LDS) using real-time tissue elastography. Strain was assessed at the inner thigh and calf in 62 legs with LE (International Society of Lymphology [ISL] stage 0: 16, stage I: 5, stage II: 28, late stage II: 7, stage III: 6) and 15 legs with LDS. In thighs and calves with LE, skin strain and subcutaneous tissue strain did not significantly differ between ISL stage 0, that is, asymptomatic legs, and other stages. However, strain values in calves with LDS were lower than values in calves with stage 0, II and late II LE. These results indicate that skin and subcutaneous tissue strains were not lower in legs with symptomatic LE than in asymptomatic legs until an advanced stage.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Masanori Murakami
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Osamu Yamashita
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takasuke Harada
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Koshiro Ueda
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Makoto Samura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yuya Tanaka
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kaori Nakamura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kimikazu Hamano
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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Affiliation(s)
- Chung Sim Lim
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London and Charing Cross Hospital, London, UK
| | - Alun H Davies
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London and Charing Cross Hospital, London, UK
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Rabe E, Guex JJ, Morrison N, Ramelet AA, Schuller-Petrovic S, Scuderi A, Staelens I, Pannier F. Treatment of chronic venous disease with flavonoids: recommendations for treatment and further studies. Phlebology 2013; 28:308-19. [PMID: 23395842 DOI: 10.1177/0268355512471929] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES A variety of studies have suggested that flavonoids are effective for the treatment of CVD. However, many questions remain about their mechanism of action and when, how, and for what signs and symptoms they should be used. METHOD A panel of experts in CVD met in Budapest, Hungary in December 2011 to discuss the current state of knowledge of CVD and the role of flavonoids in its treatment. The discussion was based on a literature search in the current databases. The goals of this paper are recommendations for further studies on the use of flavonoids in the treatment of CVD. RESULTS There is good evidence to recommend the use of flavonoids in the treatment of CVD. However, because of the poor quality of some older clinical trials, inadequate reporting, and insufficient information, much work is still needed to firmly establish their clinical efficacy and to determine when and how they should be employed. In particular, long-term randomized, placebo-controlled, double-blind studies are needed to establish the efficacy and safety of flavonoids. Additional studies are also needed to establish their mechanism of action, pharmacokinetics, toxicity, and cost-effectiveness. CONCLUSIONS Aside from good evidence for the use of flavonoids in CVD further studies are indicated to establish long term treatment in this indication.
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Affiliation(s)
- E Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany.
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Abstract
Diseases of elderly adults are becoming increasingly important as life expectancy gradually rises worldwide. To promote healthy aging, it is important to understand the skin changes associated with aging. This review focuses on the special considerations for some of the more common dermatological disorders in elderly adults and examines presentation, contributing factors, and association with systemic diseases.
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Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. J Am Acad Dermatol 2012; 67:177.e1-9; quiz 185-6. [PMID: 22794816 DOI: 10.1016/j.jaad.2012.03.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/27/2012] [Accepted: 03/29/2012] [Indexed: 11/22/2022]
Abstract
Several common conditions can mimic cellulitis, creating a potential for misdiagnosis and incorrect management. The most common disorders mistaken for lower limb cellulitis include venous eczema, lipodermatosclerosis, irritant dermatitis, and lymphedema. The dermatologist is often consulted when a patient has failed to respond to therapy, and a thorough knowledge of the differential diagnosis is essential. This article focuses on entities that can mimic cellulitis, with an emphasis of elements of the history and physical examination that can help to distinguish between lower limb cellulitis and its simulators.
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Choonhakarn C, Chaowattanapanit S. Lipodermatosclerosis: improvement noted with hydroxychloroquine and pentoxifylline. J Am Acad Dermatol 2012; 66:1013-4. [PMID: 22583718 DOI: 10.1016/j.jaad.2011.11.942] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/07/2011] [Accepted: 11/15/2011] [Indexed: 11/24/2022]
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35
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Refractory lipodermatosclerosis treated with intralesional platelet-rich plasma. J Am Acad Dermatol 2011; 65:e157-8. [PMID: 22000891 DOI: 10.1016/j.jaad.2011.06.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 06/14/2011] [Accepted: 06/24/2011] [Indexed: 11/23/2022]
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