Successful methods of treating leg ulcers. The tried and true, plus the novel and new

Role of Vascular Ultrasound in Cases of Lower Limb Hyperpigmentation

Background

Hyperpigmentation remains an important finding in cases of venous insufficiency and peripheral arterial disease (PAD) among the vascular causes.

Aims

This study aimed at finding the presence of arterial and/or venous insufficiency in patients of lower leg hyperpigmentation by using vascular ultrasound (US).

Materials and Methods

Fifty patients of lower leg pigmentation were included in the study. The detailed history, general physical examination, and laboratory investigations were done. Color Doppler ultrasonography was performed to check for venous insufficiency/PADs. Qualitative variables were correlated using chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.

Results

The mean age of the patients was 44.32 ± 14.16 years. Four patterns of skin changes were seen - reticulate macular, diffuse macular, lipodermatosclerosis and ulcer. Thirty-five (70%) patients had no visible varicose vein while 15 (30%) had visible varicose vein. In patients with visible varicose vein, color Doppler showed signs of venous insufficiency in all patients, but in cases of no visible varicose vein, color Doppler showed signs of venous insufficiency in 19 (54.28%) patients and showed no signs of venous insufficiency in others (P = 0.78). Only 1 (2%) patient showed atherosclerotic changes in both anterior tibial arteries.

Conclusion

All patients with lower leg pigmentation with or without visible varicose vein should undergo vascular US to rule out any venous insufficiency.

Leg Ulcers and Pain: A Review

Leg ulcers are a common health problem. Ulcers of any etiology including venous ulcers may be very painful, but until recently, health professionals have not been good at recognizing or managing this type of pain. It is important to clarify the type, severity, and frequency of pain and to anticipate pain at dressing changes. The measurement of pain by the use of pain scales is very useful, particularly in assessing the efficacy of an intervention. Neuropathic pain and unusually painful ulcerations are discussed in this article.

An overview of technologies related to care for venous leg ulcers

Venous leg ulcers remain a major problem in the United States, with spending reaching more than $1 billion annually. Current treatment options for this condition center around the use of compression therapy delivered by bandages, medical-grade stockings, or pneumatic compression devices. While these forms of therapy can produce dramatic improvements, cost and patient compliance remain an issue. In parallel with this need, wearable, wireless health monitoring systems have recently emerged as a low-cost solution for management of chronic health conditions. To this end, researchers at the Center for Robotics and Intelligent Machines (North Carolina State University) and the Carolon Company (Rural Hall, NC) have proposed an integrated sensing and therapeutic compression module. This article will review technologies related to the design of such a device, as well as provide direction for future research.

Risk assessment of the application of a plasma jet in dermatology

Regardless of the fact that several highly efficient antiseptics are commercially available, the antiseptic treatment of chronic wounds remains a problem. In the past, electrical plasma discharges have been frequently used in biometrical science for disinfection and sterilization of material surfaces. Plasma systems usually have a temperature of several hundred degrees. Recently, it was reported that "cold" plasma can be applied onto living tissue. In in vitro studies on cell culture, it could be demonstrated that this new plasma possesses excellent antiseptic properties. We perform a risk assessment concerning the in vivo application of a "cold" plasma jet on patients and volunteers. Two potential risk factors, UV radiation and temperature, are evaluated. We show that the UV radiation of the plasma in the used system is an order of magnitude lower than the minimal erythema dose, necessary to produce sunburn on the skin in vivo. Additionally, thermal damage of the tissue by the plasma can be excluded. The results of the risk assessment stimulate the in vivo application of the investigated plasma jet in the treatment of chronic wounds.

Tumor necrosis factor-alfa in nonhealing venous leg ulcers

BACKGROUND

Venous leg ulcers are responsible for more than half of all lower extremity ulcerations, affecting more than one million Americans annually. Studies have demonstrated alterations in levels of proinflammatory cytokines in patients with chronic wounds, including tumor necrosis factor-alfa (TNFalpha), which may be implicated in wound chronicity.

OBJECTIVE

To test the hypothesis that recalcitrant venous leg ulcers have increased local tissue TNFalpha as compared to normal skin.

METHODS

Five patients with nonhealing healing chronic venous leg ulcers were recruited. Two 4-mm punch biopsy specimens were obtained: one from the wound margin and one from noninvolved, non-sun exposed normal skin on the flexor aspect of the forearm. Tissue samples were processed using fixed with formalin stained by immunohistochemistry for TNFalpha. Qualitative and quantitative comparisons were made for the presence of TNFalpha receptor in all tissue samples, specifically comparing the presence of TNFalpha in nonhealing venous leg ulcer samples versus normal skin.

RESULTS

The overall staining score for nonhealing venous leg ulcers was significantly higher compared to respective normal skin samples (P = .01). In addition, immunostaining for TNFalpha was significantly less in the two nonhealing venous leg ulcers that were present for the shortest duration compared to the other ulcers of longer duration (P = .048).

LIMITATIONS

The small sample size may mitigate the clinical implications of findings.

CONCLUSIONS

Increased levels of TNFalpha in nonhealing venous leg ulcers, especially those of longer duration, implies that excessive inflammation may be causal in wound chronicity and suggests potential therapeutic alternatives.

A gene signature of nonhealing venous ulcers: potential diagnostic markers

BACKGROUND

Venous leg ulcers are responsible for more than half of all lower extremity ulcerations. Significant interest has been focused on understanding the physiologic basis on which patients fail to heal with standard therapy.

OBJECTIVE

This study uses complementary DNA microarray analysis of tissue samples from healing and nonhealing venous leg ulcers to identify the genetic expression profiles from these dichotomous populations.

METHODS

Ulcer size and chronicity, factors that have been identified as prognostic indicators for healing, were used to distribute venous leg ulcers as healing versus nonhealing. Punch biopsy samples were obtained from the wound edge and wound bed of all venous leg ulcers. The top 15 genes with differential expression greater than 2-fold between the two populations of wounds (P < .05) were reported.

RESULTS

Significant differences were demonstrated in the expression of a diverse collection of genes, with particular differences demonstrated by genes coding for structural epidermal proteins, genes associated with hyperproliferation and tissue injury, and transcription factors.

LIMITATIONS

Small sample size may mitigate potential clinical implications of findings.

CONCLUSIONS

The genetic expression profiles displayed here may have implications for the development of novel therapies for chronic venous leg ulcers, and may also serve as prognostic indicators for wound healing.

Efficacy of concentrated autologous platelet-derived growth factors in chronic lower-extremity wounds

The efficacy of concentrated autologous platelet-derived growth factors in the healing and closure of chronic lower-extremity wounds was evaluated in 24 patients with 33 lower-extremity wounds treated previously for at least 6 months using traditional methods. Surgical wound debridement was performed to convert chronic ulcers into acute wounds. Concentrated autologous platelet-derived growth factors and thrombin were applied to the wound bases and protected with a nonadhering compression dressing that remained intact for 7 days. Wounds were evaluated and the concentrate was reapplied every 2 weeks. Wound closure and complete epithelialization was achieved in 20 wounds. Seventy-five percent or greater wound closure was obtained in three wounds, 50% to 74% closure in three wounds, and 25% to 49% closure in two wounds. Five wounds displayed no improvement. Mean time to complete closure was 11.15 weeks. The application of concentrated autologous platelet-derived growth factors and thrombin resulted in substantial wound healing and wound-diameter reduction. This technique constitutes a safe and effective treatment option and avoids lengthy treatment periods that increase the potential for infection.

Treatment of Venous Ulcers

Underlying the pathogenesis of venous ulceration is venous hypertension. Therefore, the use of multilayered compression therapy is the gold standard in the treatment of a venous ulcer. As treatment progresses, an important determinant of response is wound assessment, which should be performed on initial visit and subsequently thereafter. Among the methods to assess improvement are digital photography and planimetry, which are objective methods to measure response to treatment and rate of wound healing. Lack of improvement over a 2- to 4-week period is predictive of eventual lack of response to therapy and suggests the need for adjunctive methods to achieve success, such as oral pentoxifylline, tissue-engineered skin, or skin grafting.

Clinical and economic impact of Apligraf for the treatment of nonhealing venous leg ulcers

BACKGROUND

Controlled studies have shown that Apligraf(R) (Organogenesis Inc., Canton, USA) is more economical and more effective at healing venous leg ulcers (VLUs) than compression therapy alone. However, the clinical and economic impact of Apligraf on healing VLUs in clinical practice has not been fully examined.

METHODS

A medical chart review was conducted of patients who were treated with Apligraf for one or more nonhealing VLUs over a 2-year period at the Henry Ford Hospital. Following Apligraf treatment, patients were followed for up to 9 months. Primary clinical outcome measures were mean change in baseline ulcer size (cm2) per week and percent reduction in baseline ulcer size at final study visit. Economic evaluation of Apligraf treatment was based on VLU-related medical care costs (US$) in relation to ulcer size (cm2) changes before and after Apligraf therapy.

RESULTS

Thirteen patients with 21 chronic VLUs were treated with Apligraf. All had at least one comorbidity, most commonly hypertension (38%). Twelve patients were known to have had a prior history of VLU. At baseline, mean ulcer duration was 23.9 months and median ulcer size was 13.5 cm2; for the 6 months preceding Apligraf treatment, in which patients received conventional compression therapy, mean ulcer size increased +0.72 cm2 per week. During the Apligraf post-treatment study period, mean ulcer size decreased by -2.37 cm2 per week. At final clinic visit, ulcers exhibited an average 60.5% reduction in baseline size; 21 ulcers (n = 13) showed 75% or greater reduction in size, compared with baseline. Economic data were available for five patients; among these individuals ulcer-related medical costs per unit change in ulcer size were lower following Apligraf treatment relative to such costs with conventional compression therapy applied during the Apligraf pretreatment period.

CONCLUSIONS

In a clinical practice setting, Apligraf is more effective and more economical at healing VLUs than conventional therapy alone.

Venous leg ulcers

In 1837, Piorry, a French professor of medicine stated, "It is rather difficult to understand why the investigation of veins has been passed over almost in silence, while such a great diagnostic value has been attached to the investigation of arteries." Even today, our understanding of venous disease pales in comparison to our understanding of arterial disease. This is despite the fact that millions of Americans are afflicted with chronic venous insufficiency and hundreds of thousands suffer from debilitating lower extremity venous ulcers. A better understanding of the pathophysiology of venous disease is necessary to provide appropriate and efficient medical care for patients suffering from lower extremity venous ulcerations.

Design and development of novel bandages for compression therapy

During the past few years there have been increasing concerns relating to the performance of bandages, especially their pressure distribution properties for the treatment of venous leg ulcers. This is because compression therapy is a complex system and requires two or multi-layer bandages, and the performance properties of each layer differs from other layers. The widely accepted sustained graduated compression mainly depends on the uniform pressure distribution of different layers of bandages, in which textile fibres and bandage structures play a major role. This article examines how the fibres, fibre blends and structures influence the absorption and pressure distribution properties of bandages. It is hoped that the research findings will help medical professionals, especially nurses, to gain an insight into the development of bandages. A total of 12 padding bandages have been produced using various fibres and fibre blends. A new technique that would facilitate good resilience and cushioning properties, higher and more uniform pressure distribution and enhanced water absorption and retention was adopted during the production. It has been found that the properties of developed padding bandages, which include uniform pressure distribution around the leg, are superior to existing commercial bandages and possess a number of additional properties required to meet the criteria stipulated for an ideal padding bandage. Results have indicated that none of the mostly used commercial padding bandages provide the required uniform pressure distribution around the limb.

Healing of venous ulcers of long duration with a bilayered living skin substitute: results from a general surgery and dermatology department

BACKGROUND

A laboratory-grown bilayered living skin substitute (LSS) has been shown to accelerate the healing of venous ulcers. However, issues related to optimal wound bed preparation prior to the application of LSS have not been addressed.

OBJECTIVE

When combined with standard compression therapy and near elimination of wound exudate, bioengineered skin can achieve complete closure of venous ulcers which have been present for more than a year and which are difficult to heal.

METHODS

In the general surgery (center A) and dermatology (center B) departments at two separate medical centers, LSS was used to treat venous ulcers of more than 1 year's duration and which had been unresponsive to conventional therapy. Wound bed preparation at both centers had as common goals the removal of necrotic tissue, optimal formation of granulation tissue, and elimination of wound exudate.

RESULTS

There was great comparability between the two centers in the patients being treated, wound size and duration, and number of LSS applications. Both centers achieved a frequency of complete wound closure of greater than 70% within 6 months.

CONCLUSION

At two separate clinical and specialty sites having a common goal of optimal wound preparation, treatment with LSS was associated with a high rate of complete closure of hard to heal venous ulcers.

Chronic venous insufficiency and venous leg ulceration

Venous ulcers are the most common form of leg ulcers. Venous disease has a significant impact on quality of life and work productivity. In addition, the costs associated with the long-term care of these chronic wounds are substantial. Although the exact pathogenic steps leading from venous hypertension to venous ulceration remain unclear, several hypotheses have been developed to explain the development of venous ulceration. A better understanding of the current pathophysiology of venous ulceration has led to the development of new approaches in its management. New types of wound dressings, topical and systemic therapeutic agents, surgical modalities, bioengineered tissue, matrix materials, and growth factors are all novel therapeutic options that may be used in addition to the "gold standard," compression therapy, for venous ulcers. This review discusses current aspects of the epidemiology, pathophysiology, clinical presentation, diagnostic assessment, and current therapeutic options for chronic venous insufficiency and venous ulceration. (J Am Acad Dermatol 2001;44:401-21.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the 3 main types of lower extremity ulcers and should improve their understanding of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic assessment, and current therapies for chronic venous insufficiency and venous ulcers.

Management of leg ulcers

Leg ulcer is a leading cause of morbidity among older subjects, especially women in the Western world. About 400 years BC, Hippocrates wrote, "In case of an ulcer, it is not expedient to stand, especially if the ulcer be situated on the leg". Hippocrates himself had a leg ulcer. The best treatment of any leg ulcer depends upon the accurate diagnosis and the underlying aetiology. The majority of leg ulcers are due to venous disease and/or arterial disease, but the treatment of the underlying cause is far more important than the choice of dressing. The aetiology, pathogenesis, treatment, and the future trends in the management of the leg ulcers are discussed in this review.