Chronic leg ulcers and eczema

[Eczema of wound surroundings : Genesis, diagnostics and treatment]

Skin changes in the surrounding areas of wounds are a frequently occurring multidisciplinary challenge in the care of patients with wounds, especially in older people. These are often inflammatory skin diseases like eczema that can be caused by various factors. These include allergens, noxa, incorrect skin care or prolonged contact with moisture. In the diagnostics, detailed medical history, clinical examination and allergological tests play important roles. Eczema can mostly be treated symptomatically with topical glucocorticoids. Calcineurin inhibitors are an alternative treatment, especially for longer term topical applications. In cases of impetiginized lesions, appropriate antimicrobial therapy should also be carried out. For long-term and preventive treatment the adequate use of skin care and skin protection products that help to strengthen or restore the skin barrier is decisive as well as the education of the patients and, if necessary, their relatives.

Evidence that venous hypertension causes stasis dermatitis

A clinical model to examine the hypothesis that venous hypertension of the lower leg per se can cause lower leg stasis dermatitis is described. To prove this concept, we retrospectively studied a consecutive series of 38 patients with lower leg dermatitis who underwent phlebological examination at our consultation over a period of four years. Among those patients who had an insufficiency of the superficial veins only, without insufficiency of the deep veins, 22 had undergone patch testing to common allergens in phlebology. We found 10 patients with a stasis dermatitis of the lower leg and an incompetent great saphenous vein, six of whom had no detectable contact sensitization at all and another four exclusively to phlebologically irrelevant substances, e.g. nickel, cobalt, chromate or epoxid resin. All these 10 patients showed long saphenous vein incompetence from the groin to the medial aspect of the leg. All were operated by classical flush ligation and saphenectomy. Lower leg dermatitis healed in all 10 patients within 8–12 weeks and no recurrence was observed (1 year follow-up). These results support clinical experience that venous hypertension alone indeed can cause lower leg dermatitis.

Contact sensitization in patients with lower extremity dermatitis in the South Moravian region, Czech Republic

Objectives

The aim of the study was to determine the frequency of contact sensitization in patients with lower extremity dermatitis.

Methods

Between the years 2001 and 2007, the authors investigated 462 patients (mean age 49.1 years, 196 men and 266 women) with the eczema/dermatitis localized on their lower extremities, including feet. The patients were investigated with epicutaneous tests of the European Standard Series and also with other special patch tests.

Results

The most frequent allergens were balsam of Peru, 44/462 (9.5%); wool alcohols, 41/462 (8.9%); nickel sulphate, 39/462 (8.4%); propolis, 35/462 (7.6%); fragrance mix, 34 (7.4%) and colophony, 29/462 (6.3%).

Conclusions

In patients with lower extremity dermatitis the frequency of contact sensitization is still high, and therefore investigation with epicutaneous tests should belong to the routine dermatological diagnostic procedure in these patients.

Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management

Topical antibiotics are widely used to treat cutaneous, ocular, and otic infections. Allergic contact dermatitis to topical antibiotics is a rare but well-documented side effect, especially in at-risk populations. The purpose of this article is to review the epidemiology, responsible allergens, and management of allergic contact dermatitis to topical antibiotics.

LEARNING OBJECTIVE

After completing this learning activity, participants should be able to describe the epidemiology of allergic contact dermatitis related to topical antibiotics; show knowledge of the most common allergenic topical antibiotics; and understand the allergenic cross-reactivity pattern amongst topical antibiotics.

Dermatologic Complications of Chronic Venous Disease: Medical Management and Beyond

Patients with venous insufficiency commonly develop complications which can result in significant morbidity and occasional mortality. Venous leg ulcers, the most prevalent type of lower extremity ulcer, are the most frequent sequela of venous insufficiency and negatively affect quality of life for the patient. Most have focused on venous ulceration, but other complications may arise including dermatitis, atrophie blanche, lipodermatosclerosis, and malignancy. Contact dermatitis is a common complication seen in the treatment of venous disease. Patients with venous insufficiency have a disrupted epidermal barrier, making them more susceptible than the general population to contact sensitization and subsequent dermatitis. Venous dermatitis is often the first manifestation of venous insufficiency and needs to be addressed promptly. Atrophie blanche, an end point of a variety of conditions, appears as atrophic plaques of ivory white skin with telangiectasias. Lipodermatosclerosis is an indurated plaque in the medial malleolus which can, at times, be quite tender and painful. Malignant degeneration is a rare but important complication of venous disease since tumors which develop in the setting of an ulcer tend to be more aggressive. Pain is a feature of venous disease often overlooked and commonly undertreated. Finally, psychosocial issues such as anxiety and depression are more common in patients with venous disease and should be adequately addressed. Recognizing these complications of chronic venous insufficiency is important as early intervention is the key to preventing unnecessary patient suffering and discomfort.

Compression and peri-ulcer skin in outpatients' venous leg ulcers: results of a French survey

OBJECTIVE

To evaluate concordance with compression therapy in ambulatory patients with venous leg ulcers.

METHOD

This was a prospective observational survey conducted in general practice. Consecutive patients with venous leg ulcers about to receive a non-adherent primary dressing and with no contraindication to compression bandaging were selected. At the inclusion visit, size, local aspect of the ulcer and the peri-ulcer skin were scored. Patients were asked about concordance with compression and were given a questionnaire to be completed at home. If patients were seen at a three-week follow-up visit, ulcer and peri-ulcer characteristics and concordance were reassessed.

RESULTS

A total of 2842 patients were included, of whom 2532 were re-evaluated at three weeks and 1397 (49%) returned their questionnaire. A compression bandage was already available for 62.9% of these patients, and 62.7% said they used it on a daily basis, 23.3% wore it one or two days per week and 13.7% wore it irregularly or never. There was a statistically significant correlation between concordance with compression and ulcer and peri-ulcer skin severity scores (p < 0.001 and p = 0.042 respectively). At the follow-up visit, concordance with compression therapy improved (80.1% were wearing it regularly). Ulcer, peri-ulcer skin severity scores and ulcer size were significantly lower (p < 0.001) when concordance with compression therapy was good. However, 65.6% of patients considered applying compression very difficult; 45% considered it very unaesthetic and 23% judge wearing it to be very painful, while 9% thought it may worsen their ulcer.

CONCLUSION

On a short-term basis, concordance with compression can be substantially improved by simple measures with a clear favourable consequence on both ulcer status and peri-ulcer skin aspect when a non-adherent primary dressing is used. However, the acceptability of compression to patients is poor, and continuous effort is required to convince them of its importance.

Compression therapy

Compression therapy, either active or passive, is the cornerstone of treatment for all venous and lymphatic disorders. Its major limitations are poor patient compliance, difficulty to apply in the elderly, and insufficient knowledge and skill in the majority of physicians. New modalities, such as four-layer bandage, tubular gradient compression, or new textile technologies, may secure a better application in difficult cases such as leg ulcers.