ABC of arterial and venous disease. Ulcerated lower limb

Medical-Grade Honey Is a Versatile Wound Care Product for the Elderly

Introduction

Ageing of the global population has led to an increase in the demand for the treatment of wounds, especially considering the challenges of managing wounds in the elderly. Therefore, more effective treatment strategies need to be explored. In this article, we aimed to compare medical-grade honey (MGH) products with other wound care products and to provide guidelines on using MGH in wounds commonly found in the elderly.

Methods

Based on literature research and expert opinion, an overview of commonly used wound care products and their wound healing characteristics is provided. In addition, literature-based classification of wounds in the elderly and the recommendations for treatments are provided.

Results

Frequently used wound care products include povidone-iodine, enzymatic products, absorbing dressings, larvae, silver dressings, and MGH dressings. Supported by systematic reviews and meta-analyses, MGH dressings were identified as the most potent and all-round wound care product compared to the others. Next, we provided basic guidelines for managing the most common wounds in the elderly, both acute and chronic, and specified how and which MGH products can be used in these wounds.

Conclusion

MGH is a widely applicable, safe, easy-to-use, and cost-effective product to manage wounds in the elderly. In case of doubt, refer to a trained wound care specialist who can support the treatment of difficult-to-heal wounds.

Growth factors and growth factor gene therapies for treating chronic wounds

Chronic wounds are an unmet clinical need affecting millions of patients globally, and current standards of care fail to consistently promote complete wound closure and prevent recurrence. Disruptions in growth factor signaling, a hallmark of chronic wounds, have led researchers to pursue growth factor therapies as potential supplements to standards of care. Initial studies delivering growth factors in protein form showed promise, with a few formulations reaching clinical trials and one obtaining clinical approval. However, protein-form growth factors are limited by instability and off-target effects. Gene therapy offers an alternative approach to deliver growth factors to the chronic wound environment, but safety concerns surrounding gene therapy as well as efficacy challenges in the gene delivery process have prevented clinical translation. Current growth factor delivery and gene therapy approaches have primarily used single growth factor formulations, but recent efforts have aimed to develop multi-growth factor approaches that are better suited to address growth factor insufficiencies in the chronic wound environment, and these strategies have demonstrated improved efficacy in preclinical studies. This review provides an overview of chronic wound healing, emphasizing the need and potential for growth factor therapies. It includes a summary of current standards of care, recent advances in growth factor, cell-based, and gene therapy approaches, and future perspectives for multi-growth factor therapeutics.

Endovenous ablation for venous leg ulcers

BACKGROUND

Venous leg ulcers (VLUs) are a serious manifestation of chronic venous disease affecting up to 3% of the adult population. This typically recalcitrant and recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The longstanding mainstay treatment for VLUs is compression therapy. Surgical removal of incompetent veins reduces the risk of ulcer recurrence. However, open surgery is an unpopular option amongst people with VLU, and many people are unsuitable for it. The efficacy of the newer, minimally-invasive endovenous techniques has been established in uncomplicated superficial venous disease, and these techniques can also be used in the management of VLU. When used with compression, endovenous ablation aims to further reduce pressure in the veins of the leg, which may impact ulcer healing.

OBJECTIVES

To determine the effects of superficial endovenous ablation on the healing and recurrence of venous leg ulcers and the quality of life of people with venous ulcer disease.

SEARCH METHODS

In April 2022 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scrutinised reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions on the language of publication, but there was a restriction on publication year from 1998 to April 2022 as superficial endovenous ablation is a comparatively new technology.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing endovenous ablative techniques with compression versus compression therapy alone for the treatment of VLU were eligible for inclusion. Studies needed to have assessed at least one of the following primary review outcomes related to objective measures of ulcer healing such as: proportion of ulcers healed at a given time point; time to complete healing; change in ulcer size; proportion of ulcers recurring over a given time period or at a specific point; or ulcer-free days. Secondary outcomes of interest were patient-reported quality of life, economic data and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for eligibility, extracted data, carried out risk of bias assessment using the Cochrane RoB 1 tool, and assessed GRADE certainty of evidence.

MAIN RESULTS

The previous version of this review found no RCTs meeting the inclusion criteria. In this update, we identified two eligible RCTs and included them in a meta-analysis. There was a total of 506 participants with an active VLU, with mean durations of 3.1 months ± 1.1 months in the EVRA trial and 60.5 months ± 96.4 months in the VUERT trial. Both trials randomised participants to endovenous treatment and compression or compression alone, however the compression alone group in the EVRA trial received deferred endovenous treatment (after ulcer healing or from six months). There is high-certainty evidence that combined endovenous ablation and compression compared with compression therapy alone, or compression with deferred endovenous treatment, improves time to complete ulcer healing (pooled hazard ratio (HR) 1.41, 95% CI 1.36 to 1.47; I2 = 0%; 2 studies, 466 participants). There is moderate-certainty evidence that the proportion of ulcers healed at 90 days is probably higher with combined endovenous ablation and compression compared with compression therapy alone or compression with deferred endovenous treatment (risk ratio (RR) 1.14, 95% CI 1.00 to 1.30; I2 = 0%; 2 studies, 466 participants). There is low-certainty evidence showing an unclear effect on ulcer recurrence at one year in people with healed ulcers with combined endovenous treatment and compression when compared with compression alone or compression with deferred endovenous treatment (RR 0.29, 95% CI 0.03 to 2.48; I2 = 78%; 2 studies, 460 participants). There is also low-certainty evidence that the median number of ulcer-free days at one year may not differ (306 (interquartile range (IQR) 240 to 328) days versus 278 (IQR 175 to 324) days) following combined endovenous treatment and compression when compared with compression and deferred endovenous treatment; (1 study, 450 participants). There is low-certainty evidence of an unclear effect in rates of thromboembolism between groups (RR 2.02, 95% CI 0.51 to 7.97; I2 = 78%, 2 studies, 506 participants). The addition of endovenous ablation to compression is probably cost-effective at one year (99% probability at GBP 20,000/QALY; 1 study; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Endovenous ablation of superficial venous incompetence in combination with compression improves leg ulcer healing when compared with compression alone. This conclusion is based on high-certainty evidence. There is moderate-certainty evidence to suggest that it is probably cost-effective at one year and low certainty evidence of unclear effects on recurrence and complications. Further research is needed to explore the additional benefit of endovenous ablation in ulcers of greater than six months duration and the optimal modality of endovenous ablation.

A New-Onset Facial Lesion in a Hospitalized COVID-19 Patient

Pressure ulcers form when skin is compressed against a bony prominence, often in the context of prolonged supine or prone-based care. Hospitalized, bedridden patients are at the highest risk of this complication, especially when preventative measures like regular rotational bed treatment are not employed. In this case report, we present a rare case of a COVID-19-related facial pressure ulcer that occurred in the context of regular rotational bed treatment. The lesion was managed by wound care and allowed to heal by secondary intention. Ultimately, we hope that this manuscript will raise awareness for this atypical ulcer location, especially as prone-position treatment approaches take hold.

Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

Atypical Wounds; Hyperbaric Oxygen Therapy

Patients with severe diabetic foot ulcerations that fail to heal with standard conventional therapies may be candidates for hyperbaric oxygen therapy; these patients also should be evaluated for atypical wound etiologies. Medical evaluation includes thorough history, physical examination, screening laboratory tests, and ulcer biopsy. During hyperbaric oxygen therapy, patients breathe 100% oxygen at 2 times to 3 times atmospheric pressure while enclosed in a hyperbaric chamber. Over time, administration of hyperbaric oxygen therapy can result in wound neovascularization and enhanced limb salvage. In patients with suspected atypical ulceration, referral to a multidisciplinary wound healing center is considered standard of care.

Evaluation of the introduction of the one-stop clinic and dedicated nurses for the ulcer cruris venosum care in the east of the Netherlands

Objective

In the Ziekenhuisgroep Twente Hospital, nurses from two community care organizations were trained to visit patients at home and provide adequate ulcer care. Furthermore, the one-stop clinic was introduced to set a diagnosis and treatment plan at the first visit in the hospital. The purpose of this study was to (a) evaluate if there is a difference in time to wound healing for patients with UCV treated by dedicated nurses compared to treatment by nurses in the Dermatology outpatient clinic and (b) determine if the one-stop clinic setting would lead to a difference in time to wound healing compared to the standard way of care.

Methods

In this retrospective cohort study, all files of patients with an ulcer in the Dermatology department of ZGT between 1 June 2010 and 1 June 2015 were studied.

Results

Out of a total of 385 new patients with an ulcer, 97 cases were included. Patients who were treated by dedicated nurses were significantly older ( p = 0.002) and had larger wounds ( p = 0.008). Age was not significantly related to time for wound closure (HR 0.99; 95% CI: 0.97–1.01, p = 0.226). After adjustment for confounders, there was no significant difference in time to wound closure between dedicated nurses (2.2 months (1.4–3.0)) versus hospital care (2.3 months (2.1–2.6)) (HR 1.01; 95% CI: 0.61–1.67, p = 0.961). The one-stop clinic led to a statistically shorter time to closure of the wound (1.8 versus 2.7 standard way of care, p = 0.007).

Conclusions

Time to wound closure is not statistically different between patients treated by dedicated nurses compared to hospital care when adjusted for the effects of the one-stop clinic. The one-stop clinic gives a significant better chance for faster time to wound closure controlled for both groups.

Defocused Shock Wave Therapy for Chronic Soft Tissue Wounds in the Lower Limbs: A Pilot Study

Chronic soft tissue wounds of the lower limbs are debilitating, painful and often unresponsive to advanced dressing treatments. Extracorporeal shock wave therapy (ESWT) could represent an alternative treatment. Ten patients with chronic soft tissue wounds of the legs, unresponsive to advanced dressing treatments for more than 3 mo, underwent three defocused ESWT sessions at 72-h intervals. In every session, the sum of 300 standard pulses + 100 pulses per square centimeter was applied at 0.15 mJ/mm² and 4 Hz over the edge of the wound. The wound size in square centimeters, Bates-Jensen Wound Assessment Tool and visual analogue scale were used as outcome measures. A significant reduction in wound size and Bates-Jensen Wound Assessment Tool and visual analogue scale values from pre-treatment to 90 d was observed. Seven of ten ulcers healed completely and nine of ten patients reported complete pain relief. Defocused ESWT represents a non-invasive, feasible strategy for difficult-to-treat soft tissue wounds of the lower limbs.

Pressure mapping with textile sensors for compression therapy monitoring

Compression therapy is the cornerstone of treatment in the case of venous leg ulcers. The therapy outcome is strictly dependent on the pressure distribution produced by bandages along the lower limb length. To date, pressure monitoring has been carried out using sensors that present considerable drawbacks, such as single point instead of distributed sensing, no shape conformability, bulkiness and constraints on patient's movements. In this work, matrix textile sensing technologies were explored in terms of their ability to measure the sub-bandage pressure with a suitable temporal and spatial resolution. A multilayered textile matrix based on a piezoresistive sensing principle was developed, calibrated and tested with human subjects, with the aim of assessing real-time distributed pressure sensing at the skin/bandage interface. Experimental tests were carried out on three healthy volunteers, using two different bandage types, from among those most commonly used. Such tests allowed the trends of pressure distribution to be evaluated over time, both at rest and during daily life activities. Results revealed that the proposed device enables the dynamic assessment of compression mapping, with a suitable spatial and temporal resolution (20 mm and 10 Hz, respectively). In addition, the sensor is flexible and conformable, thus well accepted by the patient. Overall, this study demonstrates the adequacy of the proposed piezoresistive textile sensor for the real-time monitoring of bandage-based therapeutic treatments.

Illness trajectories in patients suffering from leg ulcers: A qualitative study

The aim of this study was to identify illness trajectories in leg ulcers by analysing personal, social and relational dimensions related to leg ulcer onset and to the care process. Semi-structured interviews were conducted with 21 patients, one physician and four nurses. Patients’ medical records were also examined. Data were analysed using the grounded theory approach. Four illness trajectories were identified: possibility, denial, focus on illness and tragedy. The findings highlighted that leg ulcers can be experienced in different ways depending on the personal characteristics of the people suffering from them and the kind of relationship that exists between patients and healthcare professionals.

Hepatocyte Growth Factor Effects on Mesenchymal Stem Cells Derived from Human Arteries: A Novel Strategy to Accelerate Vascular Ulcer Wound Healing

Vascular ulcers are a serious complication of peripheral vascular disease, especially in diabetics. Several approaches to treat the wounds are proposed but they show poor outcomes and require long healing times. Hepatocyte Growth Factor/Scatter Factor (HGF/SF) is a pleiotropic cytokine exerting many biological activities through the c-Met receptor. This study was aimed at verifying whether HGF/SF influences proliferation, migration, and angiogenesis on mesenchymal stem cells isolated from human arteries (hVW-MSCs). hVW-MSCs were exposed to NIBSC HGF/SF (2.5, 5, 10, and 70 ng/mL) from 6 hrs to 7 days. HGF and c-MET mRNA and protein expression, cell proliferation (Alamar Blue and Ki-67 assay), migration (scratch and transwell assays), and angiogenesis (Matrigel) were investigated. hVW-MSCs displayed stemness features and expressed HGF and c-MET. HGF/SF did not increase hVW-MSC proliferation, whereas it enhanced the cell migration, the formation of capillary-like structures, and the expression of angiogenic markers (vWF, CD31, and KDR). The HGF/SF effects on hVW-MSC migration and angiogenic potential are of great interest to accelerate wound healing process. Local delivery of HGF/SF could therefore improve the healing of unresponsive vascular ulcers.

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.

Varicose veins of the legs among nurses: Occupational and demographic characteristics

This study aims to determine the relationship between occupational and demographic hazards that characterize varicose veins (VV) in the legs and their intensity among nurses.A cross-sectional study was carried out among 203 nurses from three general hospitals in Amol, Iran. The required subjects' information was collected through a self-filled questionnaire and the physical examination of the VV intensity was based on the Clinical finding using the Etiology, Anatomic finding, Pathophysiological standards. The prevalence of VV, with different degrees, was 72.4% (95% CI 65.7-78.4), with women having a higher prevalence compared with men (77.9% vs. 56.9%, P = 0.004). The other non-interventional risk variable was having longer years of service. Interventional variables were long-standing hours, overtime work and body mass index status. This study had determined the occupational risk variables on VV which could be interventional in improving the working nurses' environment and quality of life for their long-term career.

Endovenous thermal ablation for healing venous ulcers and preventing recurrence

BACKGROUND

Venous leg ulcers represent the worst extreme within the spectrum of chronic venous disease. Affecting up to 3% of the adult population, this typically chronic, recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The current mainstay of treatment for venous leg ulcers is compression therapy, which has been shown to enhance ulcer healing rates. Open surgery on the veins in the leg has been shown to reduce ulcer recurrence rates, but it is an unpopular option and many patients are unsuitable. The efficacy of the newer, minimally-invasive endovenous thermal techniques has been established in uncomplicated superficial venous disease, and these techniques are now beginning to be used in the management of venous ulceration, though the evidence for this treatment is currently unclear. It is hypothesised that, when used with compression, ablation may further reduce pressures in the leg veins, resulting in improved rates of healing. Furthermore, since long-term patient concordance with compression is relatively poor, it may prove more popular, effective and cost-effective to provide a single intervention to reduce recurrence, rather than life-long treatment with compression.

OBJECTIVES

To determine the effects of superficial endovenous thermal ablation on the healing, recurrence and quality of life of people with active or healed venous ulcers.

SEARCH METHODS

In August 2013 we searched Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions on the language of publication but there was a date restriction based on the fact that superficial endovenous thermal ablation is a comparatively new medical technology.

SELECTION CRITERIA

Randomised clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers were eligible for inclusion. Trials had to report on at least one objective measure of ulcer healing (primary outcome) such as proportion of ulcers healed at a given time point, time to complete healing, change in ulcer size, proportion of ulcers recurring over a given time period, or at a specific point, and ulcer-free days. Secondary outcomes sought included patient-reported quality of life, economic data and adverse events.

DATA COLLECTION AND ANALYSIS

Details of potentially eligible studies were extracted and summarised using a data extraction table. Data extraction and validity assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third review author.

MAIN RESULTS

No eligible randomised controlled trials were identified. There is an absence of evidence regarding the effects of superficial endovenous thermal ablation on ulcer healing, recurrence or quality of life of people with venous leg ulcer disease.

AUTHORS' CONCLUSIONS

The review identified no randomised controlled trials on the effects on ulcer healing, recurrence or quality of life, of superficial endovenous thermal ablation in people with active or healed venous leg ulcers. Adequately-powered, high quality randomised controlled trials comparing endovenous thermal ablative interventions with compression therapy are urgently required to explore this new treatment strategy. These should measure and report outcomes that include time to ulcer healing, ulcer recurrence, quality of life and cost-effectiveness.

An optical fiber Bragg grating force sensor for monitoring sub-bandage pressure during compression therapy

Graduated compression bandaging of the lower limbs is the primary therapy for venous leg ulcers with its efficacy believed to be predominantly dependent on the amount and the distribution of the compressive pressure applied. There has been on-going demand for an ideal sensor to facilitate in-vivo monitoring of the sub-bandage pressure. Several methods and devices have been reported but each has its limitations, such as bulkiness, low tolerance to movement, susceptible to thermal noise and single point sensing. An optical fiber force sensor is demonstrated, consisting of two arrays of fiber Bragg grating (FBG) entwined in a double helix form and packaged with contact-force sensitivity. This sensor array has inherent temperature immunity and is capable of real-time, distributed sensing of sub-bandage pressure. The calibration results of the sensor array, as well as the validation human trial results, are presented.

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.

Experiences with surgical treatment of chronic lower limb ulcers at a tertiary hospital in northwestern Tanzania: a prospective review of 300 cases

BACKGROUND

Chronic lower limb ulcers constitute a major public health problem of great important all over the world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting.

METHODS

This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0.

RESULTS

A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma (45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was 4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study period.

CONCLUSION

Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority of patients in our environment present late when the disease is already in advanced stages. Early recognition and aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close follow-up are urgently needed to improve outcomes of these patients in our environment.

Special considerations in wound bed preparation 2011: an update©

This article builds and expands upon the concept of wound bed preparation introduced by Sibbald et al in 2000 as a holistic approach to wound diagnosis and treatment of the cause and patient-centered concerns such as pain management, optimizing the components of local wound care: Debridement, Infection and persistent Inflammation, along with Moisture balance before Edge effect for healable but stalled chronic wounds.

The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease

BACKGROUND

Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-brachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients.

METHODS

A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded.

RESULTS

The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%.

CONCLUSION

Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.

Use of durometry in assessment of venous disease

OBJECTIVES

Ulceration of the lower limbs is a common debilitating complication of chronic venous hypertension. Detection of preulcerative skin changes would allow for identification of high-risk patients; early active treatment may prevent ulcer formation.

METHODS

Patients with isolated venous disease and volunteers attending outpatient clinics underwent assessment of their clinical, aetiological, anatomical and pathological (CEAP) classification. We employed an industrial durometer, an instrument that measures the hardness of metals and plastic, to assess skin induration. The durometer probe was rested perpendicular on their skin 15 cm above the medial malleolus in non-ulcerated tissue, with the patient and limb in recumbency. The average of four measurements was derived.

RESULTS

In 107 people, 203 lower limbs (mean age 55.6 years) were assessed. A significant difference in durometry readings was demonstrated between patients with CEAP classes 0, 1 and 2, and those with classes 4, 5 and 6 (P < 0.0005). There was statistically significant evidence that age and CEAP classification correlated with durometry (P < 0.0001).

CONCLUSION

Durometry is of potential value in the assessment and monitoring of preulcerative venous disease, and could help to identify high-risk patients. This would assist in the institution of timely and appropriate treatment.

Health-related quality of life and chronic venous leg ulceration: Part 2

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and social isolation. As nurses, much of the daily care provided for such patients focuses on the provision of wound care; often failing to fully address the wide ranging effects that the ulceration is having on the life of the sufferer. This article reviews the quantitative studies that have explored the health-related quality of life of patients with chronic venous leg ulceration and presents a synthesis of their findings.

Protocol for a pilot randomised controlled clinical trial to compare the effectiveness of a graduated three layer straight tubular bandaging system when compared to a standard short stretch compression bandaging system in the management of people with venous ulceration: 3VSS2008

Background

The incidence of venous ulceration is rising with the increasing age of the general population. Venous ulceration represents the most prevalent form of difficult to heal wounds and these problematic wounds require a significant amount of health care resources for treatment. Based on current knowledge multi-layer high compression system is described as the gold standard for treating venous ulcers. However, to date, despite our advances in venous ulcer therapy, no convincing low cost compression therapy studies have been conducted and there are no clear differences in the effectiveness of different types of high compression.

Methods/Design

The trial is designed as a pilot multicentre open label parallel group randomised trial. Male and female participants aged greater than 18 years with a venous ulcer confirmed by clinical assessment will be randomised to either the intervention compression bandage which consists of graduated lengths of 3 layers of elastic tubular compression bandage or to the short stretch inelastic compression bandage (control). The primary objective is to assess the percentage wound reduction from baseline compared to week 12 following randomisation. Randomisation will be allocated via a web based central independent randomisation service (nQuery v7) and stratified by study centre and wound size ≤ 10 cm² or >10 cm². Neither participants nor study staff will be blinded to treatment. Outcome assessments will be undertaken by an assessor who is blinded to the randomisation process.

Discussion

The aim of this study is to evaluate the efficacy and safety of two compression bandages; graduated three layer straight tubular bandaging (3L) when compared to standard short stretch (SS) compression bandaging in healing venous ulcers in patients with chronic venous ulceration. The trial investigates the differences in clinical outcomes of two currently accepted ways of treating people with venous ulcers. This study will help answer the question whether the 3L compression system or the SS compression system is associated with better outcomes.

Trial Registration

ACTRN12608000599370

An in silico approach to the analysis of acute wound healing

The complex interactions that characterize acute wound healing have stymied the development of effective therapeutic modalities. The use of computational models holds the promise to improve our basic approach to understanding the process. By modifying an existing ordinary differential equation model of systemic inflammation to simulate local wound healing, we expect to improve the understanding of the underlying complexities of wound healing and thus allow for the development of novel, targeted therapeutic strategies. The modifications in this local acute wound healing model include: evolution from a systemic model to a local model, the incorporation of fibroblast activity, and the effects of tissue oxygenation. Using these modifications we are able to simulate impaired wound healing in hypoxic wounds with varying levels of contamination. Possible therapeutic targets, such as fibroblast death rate and rate of fibroblast recruitment, have been identified by computational analysis. This model is a step toward constructing an integrative systems biology model of human wound healing.

Wound healing in older adults

Chronic wounds affect a substantial number of individuals throughout the world, and impose a significant psychological, physical and economic burden. As the population ages, the incidence of chronic wounds is also expected to rise. Clinicians struggle to find the optimal approaches to prevention and treatment of these nonhealing or slow-healing wounds. This review discusses current best practices and evidence-based recommendations for preventing and managing chronic wounds in general, as well as pressure ulcers, diabetic foot ulcers and venous leg ulcers specifically. This review highlights the significant gaps and inconsistencies in the current evidence base for chronic wound care, which have hindered making substantial progress in improving wound healing rates. It concludes with recommendations for improving the research and clinical knowledge base related to optimal wound-care practices.

Biologic therapeutics and molecular profiling to optimize wound healing

Non-healing wounds represent a significant cause of morbidity and mortality for a large portion of the adult population. Wounds that fail to heal are entrapped in a self-sustaining cycle of chronic inflammation leading to the destruction of the extracellular matrix. Among cancer patients, malnutrition, radiation, physical dehabilitation, chemotherapy, and the malignancy itself increase the likelihood of chronic wound formation, and these co-morbidity factors inhibit the normal wound healing process. Current wound treatments are aimed at some, but not all, of the underlying causes responsible for delayed healing of wounds. These impediments block the normal processes that allow normal progression through the specific stages of wound healing. This review summarizes the current information regarding the management and treatment of complex wounds that fail to heal normally and offers some insights into novel future therapies [Menke N, Ward KR, Diegelmann R. Non-healing wounds. Emerg Med Rep 2007; 28(4).,Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelmann RF. Impaired wound healing. Clin Dermatol 2007;25:19-25].

Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers

BACKGROUND

Healing of venous leg ulcers (VLUs) is often stalled despite compression therapy. Increased bacterial burden and chronic inflammation are 2 factors that may prevent these chronic VLUs (CVLUs) from healing. There is evidence that nanocrystalline silver dressings may reduce bacterial levels, decrease the chronic inflammatory response, and thus promote wound healing.

OBJECTIVE

To determine the effects of a nanocrystalline silver barrier dressing on wound microflora, wound inflammation, and healing in CVLUs.

METHOD

Stalled VLUs in 15 patients were managed using nanocrystalline silver dressings under 4-layer compression bandages. Paired skin biopsies at baseline and at an average of study week 6.5 were analyzed for bacteria and inflammatory infiltrates. Serum silver levels were monitored, and wound healing was assessed using planimetry.

RESULTS

VLUs in 4 patients healed, and 8 other patients completed the 12-week study. There was a significant reduction in the log10 total bacterial count between baseline and final biopsies (P = .011). Greater numbers of lymphocytes were associated with an increased reduction of ulcer size at week 6.5 and final assessment at week 12 (P < .05). Heavy neutrophilic infiltration in skin biopsies at week 6.5 was associated with high bacterial counts and delayed healing (P = .037). The median reduction in ulcer surface area for all patients was 83.5%. Serum silver levels increased slightly, but values were within the normal range.

CONCLUSION

A nanocrystalline silver dressing combined with 4-layer bandaging was safe and successful in promoting healing in stalled CVLUs. Healing was associated with a reduction in wound bacteria and neutrophilic inflammation with an associated persistent or high lymphocyte count, as determined by wound biopsy.

A review of the treatment for venous leg ulcers

Venous ulcers, sometimes termed varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. They are characterized by a cyclical pattern of healing and recurrence. There is a need to have a thorough assessment of patients with leg ulcers by an appropriately experienced clinician to maximize the chance of healing the ulcer. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are applied beneath the compression with a view to controlling exudate, comfort and to aid healing. There are a large number of dressing products and types available but the evidence to justify their use is poor. The main treatment for venous ulcers should therefore be the application of compression therapy with a simple, low adherent dressing.

Mechanisms of chronic skin ulceration linking lactate, transforming growth factor-beta, vascular endothelial growth factor, collagen remodeling, collagen stability, and defective angiogenesis

Up to one million people suffer from chronic skin ulcers in the US. Little is known of the mechanisms leading to tissue breakdown, although inadequate circulation and ischemia are common elements in most dermal ulcers. Collagen is the principal source of mechanical strength in most tissues, and its molecular and fibrillar stability is dependent on adequate oxygen supply. In wound repair, localized ischemia leads to fibrogenic responses culminating in elevated collagen synthesis and remodeling. This study examines factors influencing collagen turnover and stabilization before ulceration in "at risk" patients. Severely ischemic but uninjured ischemic skin (IS) was compared with patient- and site-matched non-ischemic skin. Biochemical mechanisms of tissue repair were activated in IS, with increased lactate, transforming growth factor-beta, vascular endothelial growth factor, collagen synthesis and matrix metalloproteinases (MMPs)-1 and 2. The absence of MMP-9 and inflammatory cells confirmed that this upregulation was inappropriate and not in response to injury. Molecular stability of collagen was reduced in IS, and there was increased susceptibility to enzymic degradation. In conclusion, chronic ischemia and long-term hypoxia result in elevated collagen remodeling in an oxygen-poor environment. Unstable collagen molecules are synthesized together with upregulated MMPs, resulting in collagen denaturation, defective angiogenesis, weaker skin, and predisposition to ulceration.

Improving quality of life in venous leg ulceration: a case study

It is not uncommon to find that patients with venous leg ulcers have a reduced quality of life, but to prevent inappropriate management and thus contribute to the chronicity of these wounds, clinical practice must be based on sound evidence and application of research. The choice of compression options is fairly wide, but occasionally problems are encountered with tailoring a particular product to a patient. In this case study, a number of challenges were presented to the nursing team in implementing evidence-based practice and accommodating patient choice, but these were overcome and the patient's quality of life has significantly improved.

Giving information on compression to patients with venous leg ulcers

Venous leg ulceration is a common condition that is more likely to affect the elderly (Alexander House Group, 1992; Coupe and Walukiewicz, 2000) and often has a psychological, as well as physical, impact on the individual (Charles, 1995). Many of those affected are cared for within the community (Maylor, 2002) and may become isolated because of the difficulties caused by their condition (Charles, 1995). Compression bandaging therapy has been shown as an effective treatment for venous leg ulcers (Loftus and Wheatley, 2000) but the bandages must be worn continually during treatment and therefore need to be socially and psychologically acceptable if the patient is to be happy with the treatment regimen (Pudner, 1998). Nurses need to be competent in the care of leg ulcers so that pain and discomfort are minimized and patients need to be willing to accept the treatment given.

Manifestations of cutaneous diabetic microangiopathy

The etiologies of a variety of skin conditions associated with diabetes have not been fully explained. One possible etiological factor is diabetic microangiopathy, which is known to affect the eyes and kidneys in patients with diabetes. There are many mechanisms by which diabetes may cause microangiopathy. These include excess sorbitol formation, increased glycation end products, oxidative damage, and protein kinase C overactivity. All of these processes occur in the skin, and the existence of a cutaneous diabetic microangiopathy has been well demonstrated. These microangiopathic changes are associated with abnormalities of skin perfusion. Because the skin plays a thermoregulatory role, there is significant capillary redundancy in normal skin. In diabetic patients, loss of capillaries is associated with a decrease in perfusion reserve. This lost reserve is demonstrable under stressed conditions, such as thermal stimulation. The associated failure of microvascular perfusion to meet the requirements of skin metabolism may result in diverse skin lesions in patients with diabetes. Many skin conditions peculiar to diabetes are fairly rare. Necrobiosis lipoidica diabeticorum (NLD) and diabetic bullae occur very infrequently as compared with diabetic retinopathy and nephropathy. Conversely, there is a correlation between diabetic microvascular disease and NLD. This correlation also exists with more common skin conditions, such as diabetic dermopathy. This relationship suggests that diabetic microangiopathy may contribute to these conditions even if it is not primarily causal. Clinically, the major significance of diabetic cutaneous microangiopathy is seen in skin ulceration which is very common and has a major impact on diabetic patients. Many factors contribute to the development of diabetic foot ulcers. Neuropathy, decreased large vessel perfusion, increased susceptibility to infection, and altered biomechanics all play a role, but there is no doubt that inadequate small blood vessel perfusion is a major cause of the inability to heal small wounds that eventually results in ulcer formation. The accessibility of skin capillaries makes cutaneous diabetic microangiopathy an attractive model for research on the evolution of microvascular disease in diabetic patients.

Abnormal Extracellular Matrix Metabolism in Chronically Ischemic Skin: A Mechanism for Dermal Failure in Leg Ulcers

Extracellular matrix (ECM) metabolism and homeostasis is sensitive to changes in oxygen tension manifest in ischemia. We hypothesize that in chronically ischemic limbs, abnormalities in uninjured skin, secondary to hypoxia, predispose to dermal breakdown. Paired biopsies of uninjured distal ischemic and proximal non-ischemic skin were harvested at below knee amputation from 14 patients with peripheral vascular disease following quantification of ischemia. Age- and site-matched controls were taken at total knee replacement (TKR) and varicose vein (VV) operations. Matrix metalloproteinase (MMP)-2 and -9 expression was determined using gelatin zymography, MMP-1 by western blotting and ELISA and tissue inhibitor of MMP (TIMP) by reverse zymography. Collagen content was measured by determining hydroxyproline levels, and collagen type I synthesis by ELISA. Collagen type I synthesis was upregulated in ischemic tissue compared with non-ischemic matched pairs (p<0.001) and both TKR and VV controls, however, there was no increase in collagen deposition. Levels of MMP-2 (p<0.0005) and TIMP-2 (p<0.01), were elevated in ischemic samples. MMP-9 was unaltered, signifying no inflammatory changes. Tissue ischemia was linked to elevated ECM turnover, associated with matrix failure when compounded with problems of matrix stabilization, likely in ischemia. This represents a potential mechanism for ulcer formation.

The role of vascular endothelial growth factor in wound healing

Revascularization of damaged tissue is a necessary part of wound healing. With unregulated or insufficient vessel growth, healing is delayed or pathological. Angiogenesis is regulated by expression of a variety of vascular growth factors and modulators, the most widely expressed and critical of which is vascular endothelial growth factor (VEGF). This protein is secreted by tissues in response to ischemic and inflammatory stimuli and results in endothelial migration, proliferation, and increased vascular permeability. The regulation of VEGF expression during wound healing is of considerable importance since angiogenesis appears to be disturbed in abnormally healing wounds. This paper describes the current state of knowledge of VEGF expression in wounds, regulation of expression, control of isoform specificity, and the effects of VEGF expression on blood vessels as they grow in wound healing, as understood from many different pathological paradigms.

The Validity, Reliability, Reproducibility and Extended Utility of Ankle to Brachial Pressure Index in Current Vascular Surgical Practice

BACKGROUND

Despite the increasing sophistication of vascular surgical practice, more than three decades after its introduction to clinical practice, the ankle to brachial pressure index (ABPI) remains the cornerstone of non-invasive assessment of the patient with symptomatic peripheral arterial disease (PAD).

AIM

To summarise what is known about ABPI and critically appraise its validity, reliability, reproducibility and extended utility.

METHODS

A MEDLINE (1966-2004) and Cochrane library search for articles relating to measurement of ABPI was undertaken; see text for further details.

RESULTS

There is considerable disagreement as to how ABPI should be measured. Furthermore, various factors, including the type of equipment used, and the experience of the operator, can result in significant inter- and intra-observer error. As such, care must be taken when interpreting data in the literature. ABPI is valuable in the assessment of patients with atypical symptoms, venous leg ulcers and after vascular and endovascular interventions. However, absolute pressures are probably more valuable in patients with critical limb ischaemia. ABPI is also useful in subjects with asymptomatic PAD where it correlates well with, and may be used in screening studies to quantify, cardiovascular risk.

CONCLUSIONS

While its apparent simplicity can beguile the unwary, ABPI will continue to have a key role in the assessment of symptomatic PAD. ABPI is also likely to have extended utility in health screening and institution of best medical therapy in asymptomatic subjects.

Efficacy of modern dressings in the treatment of leg ulcers: A systematic review

Healing of leg ulcers constitutes a major clinical problem. Local methods for accelerating the healing process include modern wound dressings, but it is unclear what impact these dressings have on ulcer healing. This study examines the collective evidence on the effectiveness of modern dressings in the treatment of leg ulcers. To this end, a meta-analysis was conducted covering randomized clinical trials identified following a systematic review of the literature in different databases. Estimates of effect were calculated according to the fixed effects model. Thirty-one studies met the inclusion criteria (26 on ulcers of venous etiology, 5 on ulcers of mixed or poorly differentiated etiology). We found no study that exclusively addressed arterial ulcers. Although studies displayed considerable methodological limitations, analysis showed no significant differences in terms of the proportion of healed ulcers or reduction in wound size for both modern and conventional dressings. Similarly, no significant differences were observed between the different modern dressings compared in the studies. Thus, the current medical literature is poor in supporting the use of modern dressings to improve the healing rate of leg ulcers. There is insufficient evidence to determine whether the choice of any specific dressing type affects the healing course of these ulcers. Well-conducted trials are warranted to reliably address this question.

Understanding the underlying causes of chronic leg ulceration

Leg ulcers are debilitating and have a significant negative impact on patients' quality of life. It is particularly important to understand the underlying causes of leg ulcers that are described as 'slow to heal' to ensure they are managed effectively.

Wound care for elderly patients: advances and clinical applications for practicing physicians

Chronic ulcers (wounds) are commonly encountered in medical practice, particularly in elderly patients who have chronic medical conditions. Health care providers must be adept at diagnosing chronic ulcers and optimizing medical treatment. We describe the best medical practice for the 4 common types of chronic ulcers: pressure ulcers, ischemic ulcers, venous ulcers, and neuropathic ulcers. We emphasize the importance of nutrition and proper wound care as a foundation for the management of all chronic ulcers. There is a unique therapeutic goal for each chronic ulcer. Pressure relief should be provided for both pressure ulcers and neuropathic ulcers. Ischemic ulcers require revascularization. Patients with venous ulcers need adequate edema control. We outline advances in each of these areas and discuss the newest developments in wound care, including growth factors, hyperbaric oxygen, and vacuum-assisted devices. Chronic ulcers in elderly patients can heal with proper diagnosis and good medical care.

Bilobed flaps for nonhealing ulcer treatment

Healing of round ulcers may be difficult particularly in the plantar area. Rigidity and thickness of the plantar skin do not allow fusiform excision and primary suturing. The bilobed flap is a simple reconstructive technique principally used to repair substantial defects in the facial region. The authors' experience with this local flap in the foot is presented with good short-term results. Between 1995 and 1998, five female and seven male neuropathic foot patients with round plantar ulcers were treated with bilobed flaps. The average age of the patients was 50 (range, 15-76). The average size of the ulcers was 1.6 cm (1-3.2 cm). Debridement and orthotic insoles were used at least for 3 months before considering bilobed flaps. Seven patients were diagnosed as type II diabetes mellitus, four patients had cerebral palsy, and another patient had meningomyelocele. The minimal follow-up period was 1 year (average, 19.5 months). The only complication was wound dehiscence at the lateral side of the heel in a type II diabetic. Subsequently, this complicated ulcer was managed with a sliding flap and skin graft without further problem. The study concluded that nonhealing foot ulcers can be effectively treated with a bilobed skin flap of healthy tissues rotated from nonweightbearing parts of the sole.

Effects of posture and venous insufficiency on endothelial-dependent and -independent cutaneous vasodilation in the perimalleolar region

OBJECTIVES

To assess the effects of posture, endothelial function and venous insufficiency on cutaneous microvascular vasodilator function in the gaiter area, in particular defining factors which may affect microangiopathy and ulcer formation.

METHODS

Endothelial-dependent and -independent vasodilator responses to incremental-doses of acetylcholine (Ach) and sodium nitroprusside (SNP) were evaluated in the perimalleolar region in the supine and standing positions in middle-aged patients with isolated superficial venous insufficiency (ISVI) (n = 25) and healthy controls (n = 28) using laser Doppler fluximetry (LDF) and iontophoresis of vasodilators.

RESULTS

The venoarteriolar reflex (vasoconstriction on standing) was equally present in both groups, and reduced the vasodilator responses to SNP in the upright position (e.g., for patients with ISVI, peak SNP response was 82 +/- 11 PU [standing] vs 123 +/- 15 PU [supine]). The presence of ISVI had no effect on endothelial vasodilator function in the supine position, but on standing cutaneous reactivity to Ach was significantly reduced (e.g., peak Ach response 69 +/- 8 PU [ISVI] vs 109 +/- 11 PU [controls], p < 0.003).

CONCLUSIONS

Upright posture impairs cutaneous endothelial-dependent vasodilation in the gaiter area of patients with ISVI. This may be of clinical and prognostic utility in identifying which patients with uncomplicated ISVI are at highest risk of tissue breakdown and ulcer formation in the gaiter area.

Jobst UlcerCARE compression hosiery for venous leg ulcers

Chronic venous insufficiency affects the productivity and well-being of millions of people worldwide and is the most common cause of leg ulcers. Treatment of leg ulcers accounts for 22% of district nurses' time and places a major financial burden on NHS resources. Compression bandaging has been recognized as the optimum approach for venous ulcers but is not always applied effectively. It is also costly and may lead to non-compliance. Compression hosiery is an alternative treatment approach. Review of relevant research shows JOBST UlcerCARE to be an effective treatment that is easy to apply, thereby maintaining patient independence. It also provides a major potential for cost savings to the NHS.

Causes, investigation and treatment of leg ulceration

Chronic ulceration of the lower leg is a frequent condition, with a prevalence of 3-5% in the population over 65 years of age. The incidence of ulceration is rising as a result of the ageing population and increased risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes. Ulcers can be defined as wounds with a 'full thickness depth' and a 'slow healing tendency'. In general, the slow healing tendency is not simply explained by depth and size, but caused by an underlying pathogenetic factor that needs to be removed to induce healing. The main causes are venous valve insufficiency, lower extremity arterial disease and diabetes. Less frequent conditions are infection, vasculitis, skin malignancies and ulcerating skin diseases such as pyoderma gangrenosum. But even rarer conditions exist, such as the recently discovered combination of vasculitis and hypercoagulability. For a proper treatment of patients with leg ulcers, it is important to be aware of the large differential diagnosis of leg ulceration.