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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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Yosipovitch G, Nedorost ST, Silverberg JI, Friedman AJ, Canosa JM, Cha A. Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management. Am J Clin Dermatol 2023; 24:275-286. [PMID: 36800152 PMCID: PMC9968263 DOI: 10.1007/s40257-022-00753-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/18/2023]
Abstract
Stasis dermatitis is a chronic inflammatory skin disease of the lower extremities. It typically occurs in older individuals and is the cutaneous manifestation of venous hypertension caused by venous reflux. Such retrograde venous blood flow is the result of incompetent venous valves, valve destruction, or venous obstruction. Stasis dermatitis is eczematous. The associated impairment of venous valves may cause swelling of the legs, leading to serious conditions including venous ulcerations. Diagnosis can be challenging because of its clinical resemblance to other skin conditions and poor clinical recognition by physicians. The cornerstones of stasis dermatitis treatment are compression therapy to ameliorate pain and swelling, topical treatments to alleviate secondary skin changes, and interventional treatment options to correct the underlying causes of venous reflux. Given the central role of inflammation of the lower extremities in driving the cutaneous changes characteristic of stasis dermatitis, new therapeutic approaches that target the inflammation are under clinical evaluation in patients with stasis dermatitis.
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Affiliation(s)
- Gil Yosipovitch
- Miami Itch Center, Miller School of Medicine, University of Miami, Miami, FL USA
| | | | - Jonathan I. Silverberg
- The George Washington University School of Medicine and Health Sciences, Washington, DC USA
| | | | | | - Amy Cha
- Pfizer Inc., New York, NY USA
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Bock KJ, Ehmann JS, Muldoon J. The 24-hour interval compression plan: part 2-lifestyle and therapeutic regimens to manage chronic oedema case series. J Wound Care 2022; 31:218-223. [PMID: 35199599 DOI: 10.12968/jowc.2022.31.3.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this case series was to retrospectively assess the impact on volume control and patients' quality of life (QOL) when a night-time garment was added to their previous compression regimen for a full 24-hour interval compression plan. METHOD Patients who had a history of chronic oedema presented to one of two oedema management centres in the US for treatment for oedema exacerbation and/or suboptimal performance of their current garments. Objective data examined were circumferential limb volume (cm3) measurements and QOL measured with the Lymphoedema QOL Tool (LYMQOL-Leg and LYMQOL-Arm). Subjective comments on functional abilities and perception of improvement with a compression plan that comprised a 24-hour interval were documented. RESULTS All three patients presented in this case series had a reduction in limb volume and improvement in QOL when their daytime regimen of garments was updated and new night-time garments were added. Their subjective comments indicated improvement in activities of daily living and ease of controlling daytime oedema with a 24-hour interval compression plan. CONCLUSION This case series illustrates the need for clinicians to create a partnership with the patient to promote concordance and adherence as part of their individual 24-hour interval compression plan. This partnership allows the plan to be uniquely changed and adjusted to allow each patient to feel in control of refreshing their mood, their skin and their garments.
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Affiliation(s)
- Karen J Bock
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, Kansas, US
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Bar L, Brandis S, Marks D. Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review. Patient Prefer Adherence 2021; 15:2085-2102. [PMID: 34556978 PMCID: PMC8455298 DOI: 10.2147/ppa.s323766] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings. METHODS A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance. RESULTS We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates. CONCLUSION Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes. TRIAL REGISTRATION Open Science Framework: ACTRN12620000544976p.
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Affiliation(s)
- Laila Bar
- Department of Occupational Therapy, Bond University, Faculty of Health Science and Medicine, Queensland, Australia
- Correspondence: Laila Bar Email
| | - Susan Brandis
- Department of Occupational Therapy, Bond University, Faculty of Health Science and Medicine, Queensland, Australia
| | - Darryn Marks
- Department of Physiotherapy, Bond University, Faculty of Health Science and Medicine, Queensland, Australia
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Galanaud J, Genty‐Vermorel C, Rolland C, Comte A, Ouvry P, Bertaina I, Verrière F, Bosson J. Compression stockings to prevent postthrombotic syndrome: Literature overview and presentation of the CELEST trial. Res Pract Thromb Haemost 2020; 4:1239-1250. [PMID: 33313464 PMCID: PMC7695566 DOI: 10.1002/rth2.12445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022] Open
Abstract
Postthrombotic syndrome (PTS) is a burdensome and costly complication of deep vein thrombosis (DVT) that develops in 20%-40% of patients within 2 years after proximal DVT. In the absence of effective curative treatment, management of PTS relies on its prevention after DVT. The effectiveness of elastic compression stockings (ECS) to prevent PTS is uncertain. We present an overview of published studies assessing the efficacy of ECS to prevent PTS and present the protocol for the CELEST clinical trial. While previous open-label randomized trials have reported a 50% risk reduction in PTS in patients treated with >30 mm Hg ankle pressure ECS, a large double-blind trial reported no effect of ECS. We discuss the main potential limitations of these trials, including a placebo effect and suboptimal compliance to ECS. We present the protocol of the CELEST double-blind randomized trial comparing 2 years of high strength (ankle pressure 35 mm Hg) versus lower strength (ankle pressure 25 mm Hg) ECS in the prevention of PTS after a first acute symptomatic, unilateral, proximal DVT. The use of lower-strength ECS than that used in previous studies should favor compliance. CELEST may provide important evidence about the efficacy of ECS in the prevention of PTS after DVT. The results will be interpreted in the light of results from recent clinical trials assessing ECS for PTS prevention that reported that the duration of ECS use should be tailored to the individual, if ECS are efficacious in the prevention of PTS.
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Affiliation(s)
- Jean‐Philippe Galanaud
- Department of Vascular MedicineMontpellier University HospitalMontpellierFrance
- Department of MedicineSunnybrook Health Sciences Centre and University of TorontoTorontoONCanada
| | - Céline Genty‐Vermorel
- Department of Public HealthUniversity Grenoble AlpesCNRSGrenoble‐Alpes University HospitalTIMC‐IMAGF38000GrenobleFrance
| | - Carole Rolland
- Department of Public HealthUniversity Grenoble AlpesCNRSGrenoble‐Alpes University HospitalTIMC‐IMAGF38000GrenobleFrance
| | - Alexa Comte
- Department of Public HealthUniversity Grenoble AlpesCNRSGrenoble‐Alpes University HospitalTIMC‐IMAGF38000GrenobleFrance
| | - Pierre Ouvry
- Vascular Medicine PhysicianSt Aubin sur ScieFrance
| | | | | | - Jean‐Luc Bosson
- Department of Public HealthUniversity Grenoble AlpesCNRSGrenoble‐Alpes University HospitalTIMC‐IMAGF38000GrenobleFrance
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Gong JM, Du JS, Han DM, Wang XY, Qi SL. Reasons for patient non-compliance with compression stockings as a treatment for varicose veins in the lower limbs: A qualitative study. PLoS One 2020; 15:e0231218. [PMID: 32343695 PMCID: PMC7188228 DOI: 10.1371/journal.pone.0231218] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/18/2020] [Indexed: 11/18/2022] Open
Abstract
The study aims to explore the comprehensive reasons for patients’ non-compliance with graded elastic compression stockings (GECS) as the treatment for lower limb varicose veins. Phenomenological analysis was applied in this qualitative study. The patients diagnosed with lower limb varicose veins and undergoing elective surgery who showed non-compliance with GECS as the treatment were invited to have semi-structured, in-depth, face-to-face interviews. Colaizzi method was employed to analyze the data for emerging themes associated with the reasons for patients’ non-compliance. Four main themes and nine subthemes related to the reasons for non-compliance with GECS for lower limb varicose veins were summarized. The main themes that emerged were (1) gaps in the knowledge of GECS therapy as a treatment for lower limb varicose veins, (2) few recommendations from the doctors and nurses, (3) disadvantages of GECS, and (4) sociopsychological factors. These themes provide data for policy and planning to improve patients’ compliance with GECS in China. Patients, healthcare professionals, and policy makers should share the responsibility to improve patients’ compliance with GECS therapy.
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Affiliation(s)
- Jian-Mei Gong
- Nursing School of Jilin University, Changchun, China
| | - Jian-Shi Du
- Nursing School of Jilin University, Changchun, China
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- * E-mail:
| | - Dong-Mei Han
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xin-Yu Wang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shao-Long Qi
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
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Abstract
Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.
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Suehiro K, Morikage N, Harada T, Samura M, Takeuchi Y, Mizoguchi T, Hamano K. Self-Care-Based Treatment Using Ordinary Elastic Bandages for Venous Leg Ulcers. Ann Vasc Dis 2017; 10. [PMID: 29147163 PMCID: PMC5684162 DOI: 10.3400/avd.oa.17-00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy. Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the "no-intentional-stretch" bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs. Results: The median ulcer size was 6.5 cm2 (range, 1-105 cm2). The median number of clinic visits until healing was six (range, 3-35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%. Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.
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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
| | - Yuriko Takeuchi
- 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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Özdemir ÖC, Sevim S, Duygu E, Tuğral A, Bakar Y. The effects of short-term use of compression stockings on health related quality of life in patients with chronic venous insufficiency. J Phys Ther Sci 2016; 28:1988-92. [PMID: 27512248 PMCID: PMC4968490 DOI: 10.1589/jpts.28.1988] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/07/2016] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study was aimed to analyse the effects of short-term use of compression stockings (CS) on symptoms and QoL in patients with Chronic Venous Insufficiency (CVI). [Subjects and Methods] Based on the CEAP classification C2 and C3, 117 patients with CVI were enrolled in this study. The participants were divided into two groups. The control group refused to use CS, however, was advised to do exercises and take skin care whereas the CS group used CS and performed exercise. The data were collected by using Nottingham Health Profile (NHP), Venous Insufficiency Epidemiological and Economic Study (VEINES-QoL/Sym) and Beck Depression Inventory (BDI) at baseline and after four weeks of treatment and compared within and in between groups. [Results] The comparison of pre- and post-treatment differences between groups was statistically significant for all parameters. In the study group, pre- and post-treatment scores for each parameter were significantly different. However, elevated scores in the control group suggested worsening of the illness. [Conclusion] This study established that short-term use of CS in patients with CVI significantly improved disease specific and general QoL by reducing venous symptoms. Further studies with larger sample size are necessary to confirm these findings.
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Affiliation(s)
- Özlem Cinar Özdemir
- School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, Turkey
| | - Serkan Sevim
- School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, Turkey
| | - Elif Duygu
- School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, Turkey
| | - Alper Tuğral
- School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, Turkey
| | - Yesim Bakar
- School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, Turkey
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Abstract
For centuries, compression therapy has been utilized to treat venous disease. To date it remains the mainstay of therapy, particularly in more severe forms such as venous ulceration. In addition to mechanisms of benefit, we discuss the evidence behind compression therapy, particularly hosiery, in various forms of venous disease of the lower extremities. We review compression data for stand-alone therapy, post-intervention, as DVT prevention, post-thrombotic syndrome and venous ulcer disease. We also review the data comparing compression modalities as well as the use of compression in mixed arteriovenous disease.
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Affiliation(s)
- Robert R Attaran
- 1 Cardiovascular Medicine, Yale University, New Haven, Connecticut, USA
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