Skin hyperpigmentation after sclerotherapy with polidocanol: A systematic review

Skin hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants is a common local side effect. Sclerotherapists should be familiar with factors that trigger hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants. A systematic literature review of works reporting hyperpigmentation after sclerotherapy for telangiectasias, reticular veins, side branches and truncal varices with polidocanol-containing sclerosants was performed. Reported incidence rates, follow-up periods and potentially triggering factors were assessed and analysed. The search yielded 1687 results; of these, 27 reports met the inclusion criteria. The incidence of hyperpigmentation seemed to increase with higher concentrations of polidocanol and was more evident after sclerotherapy for epifascial veins than for intrafascial truncal veins when the polidocanol concentration was more than 0.25%. Regarding sclerotherapy for telangiectasias and reticular veins, the incidence of hyperpigmentation ranged between 2% and 25% for polidocanol 0.25% (liquid and foam), between 12.5% and 67.9% for polidocanol 0.5% (liquid and foam) and between 13% and 73% for polidocanol 1% (liquid and foam). Regarding truncal veins, the incidence ranged from 7% to 45.8% for polidocanol 1% (liquid and foam), from 16% to 17% for polidocanol 2% (foam) and from 7.4% to 32.5% for polidocanol 3% (liquid and foam). Regarding the treatment of side branches, the incidence of hyperpigmentation ranged from 5.6% to 53% for both foam and liquid sclerotherapy. Regarding the duration of hyperpigmentation, there are few data describing reticular veins and telangiectasias. Hyperpigmentation persisting for more than 6 months has been reported to have an incidence of up to 7.5%. Hyperpigmentation persisting for more than 1 year after foam polidocanol 1%-3% treatment for truncal veins has an incidence ranging from 8.1% to 17.5%. Other factors such as higher volumes and compression therapy after treatment seem to have a minor influence. Data regarding hyperpigmentation after polidocanol-related sclerotherapy are poor and should be improved by higher-quality research.

Reliability Assessment and Validation of the Skin Hyperpigmentation Index Compared to the Physician Global Assessment Score

BACKGROUND

The skin hyperpigmentation index (SHI), a new objective method for measuring skin hyperpigmentation, needs validation.

OBJECTIVE

To gain evidence of the reliability and validity of the SHI.

METHODS

Fifteen raters were divided into 3 groups (5 dermatologists, 5 nondermatologist physicians, and 5 nonphysician clinicians). Each rated 5 pigmented mole lesions with mild-to-severe hyperpigmentation to determine intra- and interrater reliability. All raters photographed the lesions and rated them using the subjective Physician Global Assessment (PGA) score. The same photographs were then assessed based on automatic computer measurement software using the online SHI tool (https://shi.skinimageanalysis.com).

RESULTS

The SHI reliability was excellent for all intra- and interrater assessments, while most PGA assessments showed good intra- and interrater agreement. Between-group reliability was excellent for SHI, while moderate-to-good for PGA evaluations. Concordance between the SHI and PGA assessments was strong across all groups of assessors.

CONCLUSION

There is evidence that the SHI is a reliable instrument for measuring skin hyperpigmentation, and can be used by nonexperienced clinicians.

The skin hyperpigmentation index: An objective method of measuring the intensity of hyperpigmentation after sclerotherapy

Skin hyperpigmentation in chronic venous insufficiency and as a side effect in vein treatments are of great importance for the affected individuals. There are only a few qualitatively limited methods that allow its quantification. Previous techniques to develop a reliable scientific approach to quantification have failed due to the lack of standardized conditions including differences in lighting, distances and equipment. A newly developed measuring method, the "skin hyperpigmentation index", enables a fully automated and standardized quantification of skin hyperpigmentation with dermatoscopic images. The skin hyperpigmentation index defines the ratio of two scores, namely hyperpigmented skin of the affected area and normal sun protected skin from the same patient. This results in a range from 1 (no pigmentation) to 4 (maximum pigmentation). For a practical evaluation of the score, a free skin hyperpigmentation index calculator can be used online, which is accessible to all practitioners (https://shi.skinimageanalysis.com/). The skin hyperpigmentation index is a fully automated method for the quantitative assessment of skin pigmentation which can easily be applied to any skin type with any type of hyperpigmentation. This allows a simple, fast, and standardized quantification of skin hyperpigmentation and is useful for monitoring the progress and planning of whitening therapy.

Daflon 500 mg: Symptoms and Edema

Patients suffering from any class of the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification of chronic venous disease (CVD) may be symptomatic (C0s-C6s). Leg heaviness, discomfort, itching, cramps, pain, paresthesia, and edema (C3) are the most frequent manifestations of CVD and a major reason for medical consultation. Daflon 500 mg (micronized purified flavonoid fraction [MPFF]) is an effective treatment for symptoms and edema in CVD as demonstrated in several randomized controlled studies. A 2-month, double-blind study in 40 patients established the superiority of Daflon 500 mg over placebo with regard to symptoms and objective signs. This was confirmed in another double-blind, placebo-controlled trial (2 months’ treatment, 160 patients), and in the Reflux assEssment and quaLity of lIfe improvEment with micronized Flavonoids (RELIEF) study. The latter included 5,052 patients in 23 countries, using a visual analog scale for evaluating pain, leg heaviness, cramps, and a sensation of swelling. All symptoms showed significant and progressive improvement. The quality-of-life results (scores on the ChronIc Venous Insufficiency quality of life Questionnaire [CIVIQ]) paralleled those of symptoms. The decrease in the ankle and calf circumferences was significantly greater (p<0.001) in the group of patients treated with Daflon 500 mg in two studies, and correlated well with the improvement in the sensation of swelling (p<0.001). This was confirmed with more sophisticated measurement techniques as in the RELIEF study or in a trial assessing edema with an optoelectronic volumeter in 20 patients. A further double-blind, randomized, controlled study established a statistically significant difference in favor of Daflon 500 mg in comparison with diosmin, both on symptoms and edema. The therapeutic efficacy of Daflon 500 mg on CVD symptoms and edema has been demonstrated in double-blind, randomized, controlled studies. Further studies using a new approach may define the most precise and validated methodology for application in future research in phlebology.

Anomalous intraosseous venous drainage: Bone perforators?

Objectives Anomalous intraosseous venous drainage is a rare and almost unknown entity; only 14 cases have been reported in the literature and 4 mentioned in textbooks. We report the characteristics of 35 further cases observed in 32 patients. Method After the presentation of two cases at the congress of the French Society of Phlebology in Paris (2013), 12 colleagues joined to present a large series of so-called bone perforators observed in their practice, all identified with at least a duplex investigation. Results Thirty-two patients suffering from varicose veins and/or skin changes (C₂-C₆) associated with a bone perforator of the tibia (with bilateral anomalies in three) are reported: 19 females and 13 males, average age 56.9. The majority of the affected legs were symptomatic (30/35). Bone perforator was an isolated finding in 27/35 legs. In three cases, the investigations revealed that the venous reflux in the bone originated from an incompetent posterior tibial vein. Conclusions We suggest the name of "bone perforators" for an anomalous tibial intraosseous venous drainage, feeding varicose veins, and in more advanced stages lipodermatosclerosis and leg ulcers. Most of them were successfully treated with surgery or sclerotherapy.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Biologicals and fetal cell therapy for wound and scar management

Few biopharmaceutical preparations developed from biologicals are available for tissue regeneration and scar management. When developing biological treatments with cellular therapy, selection of cell types and establishment of consistent cell banks are crucial steps in whole-cell bioprocessing. Various cell types have been used in treatment of wounds to reduce scar to date including autolog and allogenic skin cells, platelets, placenta, and amniotic extracts. Experience with fetal cells show that they may provide an interesting cell choice due to facility of outscaling and known properties for wound healing without scar. Differential gene profiling has helped to point to potential indicators of repair which include cell adhesion, extracellular matrix, cytokines, growth factors, and development. Safety has been evidenced in Phase I and II clinical fetal cell use for burn and wound treatments with different cell delivery systems. We present herein that fetal cells present technical and therapeutic advantages compared to other cell types for effective cell-based therapy for wound and scar management.

Pharmacological treatment of primary chronic venous disease: rationale, results and unanswered questions

AIM

The aim of this article was first to review the complex pathophysiological mechanisms responsible for symptoms and signs of primary chronic venous disease (CVD) that allow the identification of targets for pharmacological treatment. The results of CVD treatment with venoactive drugs (VADs) were emphasised and presented in the form of recommendations. The last section raises key questions to be answered to improve protocols for good clinical trials and to draw up future guidelines on these agents.

METHODS

The literature has been reviewed here using PubMed and Embase.

RESULTS

Venous hypertension appears to underlie all clinical manifestations of primary CVD. Inflammation is key in wall remodelling, valve failure and subsequent venous hypertension. Changes in the haemodynamics of veins are transmitted to the microcirculation, resulting in capillary alteration leading to oedema, skin changes and eventually venous ulceration. Venous symptoms may be the result of interplays between pro-inflammatory mediators and nerve fibres located in the venous wall. Therefore, venous inflammation constitutes a promising therapeutic target for pharmacological intervention, and some available VADs could attenuate various elements of venous inflammation. Based on recent studies, reviews and guidelines, tentative recommendations for the use of VADs were proposed and strong recommendations were given to two of them (micronised purified flavonoid fraction and oxerutins).

CONCLUSION

VADs should be accorded a better role in the management of CVD. However, larger and more definitive clinical trials are needed to improve the existing recommendations.

Chronic wound healing by fetal cell therapy may be explained by differential gene profiling observed in fetal versus old skin cells

Engineering of fetal tissue has a high potential for the treatment of acute and chronic wounds of the skin in humans as these cells have high expansion capacity under simple culture conditions and one organ donation can produce Master Cell Banks which can fabricate over 900 million biological bandages (9 x 12cm). In a Phase 1 clinical safety study, cases are presented for the treatment of therapy resistant leg ulcers. All eight patients, representing 13 ulcers, tolerated multiple treatments with fetal biological bandages showing no negative secondary effects and repair processes similar to that seen in 3rd degree burns. Differential gene profiling using Affymetrix gene chips (analyzing 12,500 genes) were accomplished on these banked fetal dermal skin cells compared to banked dermal skin cells of an aged donor in order to point to potential indicators of wound healing. Families of genes involved in cell adhesion and extracellular matrix, cell cycle, cellular signaling, development and immune response show significant differences in regulation between banked fetal and those from banked old skin cells: with approximately 47.0% of genes over-expressed in fetal fibroblasts. It is perhaps these differences which contribute to efficient tissue repair seen in the clinic with fetal cell therapy.

Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study

BACKGROUND

The efficacy of wearing compression stockings on clinical vessel disappearance following sclerotherapy of telangiectasias and reticular veins has been a matter of debate for half a century.

OBJECTIVE

To determine the relative efficacy of compression following sclerotherapy and to determine its impact on general quality of life in a prospective randomized open-label trial.

METHODS

Female patients seeking treatment of telangiectasias and reticular veins and presenting comparable areas of telangiectasias on the lateral aspect of the thigh (C1AorSEPAS1PN) were randomized to wear medical compression stockings (23 to 32 mm Hg) daily for 3 weeks or no such treatment following a single session of standardized liquid sclerotherapy. Outcome was assessed by patient satisfaction analysis and quantitative evaluation of photographs taken from the lateral aspect of the thigh before and again at 52 days on the average after sclerotherapy by two blinded expert reviewers. Patients completed a quality of life questionnaire (SF-36) before treatment and again at the control.

RESULTS

Data of 96 of 100 randomized patients could be evaluated. Patient satisfaction with the outcome of treatment was similar in the two groups. Objective assessment of clinical vessel disappearance revealed a benefit of wearing stockings (P=.026) corresponding to a NNT (number needed to treat) of 4.7 patients to get a vessel disappearance score higher than 6. The interobserver agreement was very high (intraclass correlation coefficient=0.93). Compression was well tolerated with a low rate of discomfort claims (mean 17.5%). Micro-thrombi were rarely observed in either group, but still less prevalent in the compression group. The rate of pigmentation and matting was low and did not differ significantly between the two groups. Physical and mental quality of life scores in women seeking treatment of telangiectasias were similar to those of a healthy control population. Treatment had no impact on general quality of life.

CONCLUSION

Wearing compression stockings (23 to 32 mm Hg) for 3 weeks enhance the efficacy of sclerotherapy of leg telangiectasias by improving clinical vessel disappearance.

Veno-active drugs in the management of chronic venous disease. An international consensus statement: current medical position, prospective views and final resolution

BACKGROUND

Veno-active drugs (VAD) have effects on edema and symptoms related to chronic venous disease (CVD), especially so-called venous pain. VAD's effectiveness, although well established, is regularly debated.

OBJECTIVE

Our purpose was to select all randomized controlled trials (RCTs) and meta-analyses devoted to VAD and symptoms in CVD, to submit them to a group of international experts in CVD and to vote with secrete ballot to determine the level of efficacy of each drug, according to EBM (Evidence-Based Medicine) rules and critical analysis.

METHODS

Publications in any language devoted to VAD and venous symptoms were searched for in different databanks and submitted to the experts prior to the meeting.

RESULTS

83 papers were analyzed, including 72 RCTs or meta-analyses. Experts determined the level of EBM of each drug, according to the literature and personal experience, using 3 levels of recommendation, A, B and C (from large RCTs to non-randomized trials).

CONCLUSIONS

VAD are effective and may be applied in CVD when symptomatic, from C0s to C6s. However, etiological treatment of venous reflux and venous hypertension has always priority. In some cases VAD may replace compression and/or complement its effects. If respecting these prerequisites, VAD are safe and effective.

Exercise-induced purpura

Exercise-induced purpura (EIP) occurs on the lower legs after unusual or major muscular activity, as in marathon runners or as after long walks, especially in the mountains in hot weather. In leisure walkers, patients are otherwise healthy females. There is no relation with chronic venous disorder. Erythematous, urticarial or purpuric plaques arise on the lower leg, usually sparing the skin compressed by socks. Symptoms include itch, pain and a burning sensation. Histopathology demonstrates leukocytoclastic vasculitis. The lesions fade after some days, with frequent relapses at further muscular exercises and may be prevented in some cases by compression, intake of venoactive drugs and local application of steroids. EIP is not uncommon, even if very few descriptions have yet been published. It appears to be consecutive to venous stasis induced by an acute failure of the muscle pump of the calf and thermoregulation decompensation, after a prolonged and unusual exercise, such as running or walking in hot weather.

Single-blind, randomized study comparing chromated glycerin, polidocanol solution, and polidocanol foam for treatment of telangiectatic leg veins

BACKGROUND

A single-blind, randomized, comparative study was performed to evaluate the efficacy of pure chromated glycerin (CG), polidocanol (POL) 0.25% solution, and POL 0.25% foam (Monfreux technique) for treatment of telangiectasias and reticular leg veins.

OBJECTIVE

To determine the relative efficacy and safety of two sclerosing agents and foam.

METHOD

Of 150 randomized patients presenting comparable areas (lateral face of thigh) of telangiectasias and reticular leg veins, 147 could be evaluated by photographic assessment, patients' satisfaction score, and pain at injection sites. Internal and external agreement for the photographic assessment was good for two independent blinded experts.

RESULTS

CG cleared vessels significantly better than POL solution or foam (p<0.002). The patients' satisfaction score was also higher in the CG group, although the difference did not reach statistical significance. CG was significantly more painful at injection sites. Other side effects were very few, precluding any statistical comparison. Foam was associated with more side effects (microthrombi, matting) than CG or POL solution. Three patients treated with POL foam experienced a transient visual disturbance.

CONCLUSION

This study shows that CG is superior to POL solution and foam for sclerotherapy of leg telangiectasias.

The efficacy and safety of a coumarin-/troxerutin-combination (SB-LOT) in patients with chronic venous insufficiency: a double blind placebo-controlled randomised study

BACKGROUND

The objective was to evaluate the oedema-protective effect of a vasoactive drug (coumarin/troxerutin [SB-LOT]) plus compression stockings in patients suffering from chronic venous insufficiency after decongestion of the legs as recommended by the new guidelines.

PATIENTS AND METHODS

231 patients were randomly assigned medical compression stockings plus SB-LOT (90 mg coumarin and 540 mg troxerutin per day) or medical compression stockings plus placebo for the first 4 weeks and SB-LOT or placebo for the second 12 weeks of the study. The primary efficacy endpoint was the lower leg volume measured by well-established water plethysmometry.

RESULTS

226 patients were evaluated. After ceasing compression stockings, an edema protective effect was detected in the SB-LOT-group but not in the controls. Recurrence of leg volume increase was by 6.5 +/- 12.1 ml and by 36.7 +/- 12.1 ml in the SB-LOT and placebo group, respectively (p = 0.0402). The local complaint score and general aspects of quality of life were also superior for the SB-LOT-group (p = 0.0041). Significant differences were also observed with regard to clinical global impression and therapeutic effect. No serious adverse drug reaction or clinically relevant impairment of laboratory parameters occur.

CONCLUSION

This study confirms the oedema-protective effect of SB-LOT in chronic venous insufficiency and provides a treatment option for patients who discontinue compression after a short time.

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

High risk for hyperlipidemia and the metabolic syndrome after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne: a pharmacogenetic study

BACKGROUND

Administration of 13-cis retinoic acid (isotretinoin) for acne is occasionally accompanied by hyperlipidemia. It is not known why some persons develop this side effect.

OBJECTIVE

To determine whether isotretinoin triggers a familial susceptibility to hyperlipidemia and the metabolic syndrome.

DESIGN

Cross-sectional comparison.

SETTING

University hospital in Lausanne, Switzerland.

PARTICIPANTS

102 persons in whom triglyceride levels increased at least 1.0 mmol/L (> or =89 mg/dL) (hyperresponders) and 100 persons in whom triglyceride levels changed 0.1 mmol/L (< or =9 mg/dL) or less (nonresponders) during isotretinoin therapy for acne. Parents of 71 hyperresponders and 60 nonresponders were also evaluated.

MEASUREMENTS

Waist-to-hip ratio; fasting glucose, insulin, and lipid levels; and apoE genotype.

RESULTS

Hyperresponders and nonresponders had similar pretreatment body weight and plasma lipid levels. When reevaluated approximately 4 years after completion of isotretinoin therapy, hyperresponders were more likely to have hypertriglyceridemia (triglyceride level > 2.0 mmol/L [>177 mg/dL]; odds ratio [OR], 4.8 [95% CI, 1.6 to 13.8]), hypercholesterolemia (cholesterol level > 6.5 mmol/L [>252 mg/dL]; OR, 9.1 [CI, 1.9 to 43]), truncal obesity (waist-to-hip ratio > 0.90 [OR, 11.0 (CI, 2.0 to 59]), and hyperinsulinemia (insulin-glucose ratio > 7.2; OR, 3.0 [CI, 1.6 to 5.7]). In addition, more hyperresponders had at least one parent with hypertriglyceridemia (OR, 2.6 [CI, 1.2 to 5.7]) or a ratio of total to high-density lipoprotein cholesterol that exceeded 4.0 (OR, 3.5 [CI, 1.5 to 8.0]). Lipid response to isotretinoin was closely associated with the apoE gene.

CONCLUSION

Persons who develop hypertriglyceridemia during isotretinoin therapy for acne, as well as their parents, are at increased risk for future hyperlipidemia and the metabolic syndrome.

Removal of blue periocular lower eyelid veins by ambulatory phlebectomy

BACKGROUND

Prominent periocular veins, primarily of the lower eyelid, are a relatively frequent cosmetic problem. Reported treatment techniques have included electrosurgical, sclerotherapy, and longer-wavelength lasers.

OBJECTIVE

Ambulatory phlebectomy can be performed on reticular veins of the leg. This technique has been applied over the past few years to periocular reticular veins in order to observe the results and side effects.

METHODS

Using a hook specifically designed for reticular veins, we treated 10 patients who had larger reticular periocular eyelid veins. One or several punctures with an 18-gauge needle were made in the center of the targeted length of vein. The reticular vein was then gently dissected by undermining with the stem of the Ramelet phlebectomy hook.

RESULTS

All 10 patients tolerated the procedure well. In 8 of 10 patients there was complete elimination with a single procedure. Surprisingly, no significant hematoma was seen in any patient, although two patients had a small hematoma lasting less than 1 week. Two patients had only partial success, as a small segment of vein was difficult to extract. This was eliminated with a second phlebectomy performed 2 months later in both cases. Edema that is usually seen after sclerotherapy was not noted in any of these patients.

CONCLUSIONS

Ambulatory phlebectomy appears to be a safe and effective means of permanently eradicating periocular veins.

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.

Clinical benefits of Daflon 500 mg in the most severe stages of chronic venous insufficiency

Chronic venous insufficiency (CVI) affects a large number of people in Western countries, and is responsible for considerable inconvenience, discomfort, suffering, and costs. Micronized purified flavonoid fraction (MPFF, 450 mg diosmin plus 50 mg hesperidin-Daflon 500 mg) is a potent venotropic drug used in the treatment of venous insufficiency. Pharmacological and clinical studies demonstrated the comprehensive mode of action of Daflon 500 mg: it increases venous tone, it improves lymph drainage, and it protects the microcirculation. Clinical international, prospective, multicenter, randomized, controlled studies versus placebo studies documenting the effects of Daflon 500 mg in CVI at advanced stages with edema, skin changes, and venous leg ulcer are reviewed. In edema, one of the most frequent complaints of patients, Daflon 500 mg brings about a significant reduction in leg circumference, thanks to its capacity to inhibit inflammatory reactions and to decrease capillary hyperpermeability. The rationale for the use of Daflon 500 mg for treatment of skin disorders and venous leg ulcer is its action on the microcirculation-damaging processes. Regarding skin changes, Daflon 500 mg has been shown to improve venous trophic disorders, like gravitational (stasis) dermatitis, and dermatofibrosclerosis. In venous leg ulcer, Daflon 500 mg's clinical efficacy has been demonstrated in addition to standard treatment or versus standard treatment alone. Daflon 500 mg, thanks to its comprehensive mode of action on the veins, lymphatics, and microcirculation, is the method of choice not only in the early stages of CVI treatment, but also in the severe stages of this condition, in combination with compression treatment, sclerotherapy, and surgery if appropriate.

Homeopathic Arnica in postoperative haematomas: a double-blind study

OBJECTIVE

To determine whether homeopathic Arnica can reduce postoperative haematomas in venous surgery.

DESIGN

Randomized, prospective, multicentric, double-blind placebo-controlled trial.

PARTICIPANTS

130 consecutive patients undergoing saphenous stripping (204 legs), hospitalized in a clinic.

INTERVENTIONS

A homeopathic medicine (Arnica CH5) and an indistinguishable placebo, administered sublingually by a nurse the night before and immediately after the operation.

OUTCOME MEASURES

Clinical evaluation of haematomas 6 days postoperatively.

RESULTS

Groups were well matched (sex, age, history of bleeding or thrombosis, drug intake, previous intake of homeopathic drugs, type of operation and anaesthesia, operator). One drop-out has been replaced. No statistically significant difference in postoperative haematomas was found between the Arnica and placebo groups (p = 0.342). Subanalysis of all other items did not reveal any statistical difference either.

CONCLUSIONS

In this study, with this dosage, we did not observe any preventive effect of homeopathic Arnica CH5 on poststripping haematomas.

Teledermatoscopy in Switzerland: a preliminary evaluation

BACKGROUND

Since devices for digital epiluminescence microscopy and for telemedicine have become affordable, a critical evaluation of this new method has been needed.

OBJECTIVE

Our aim was a critical evaluation of teledermatoscopy under routine conditions in private practice.

METHODS

Pigmented skin lesions (PSLs) scheduled for excision were documented with a digital epiluminescence microscopy (DELM) system. Images were sent to the PSL consultation at the Department of Dermatology of the University Hospital Geneva, where a diagnosis was established. The histopathologic report including the initial diagnosis was sent afterward. Both approaches were compared concerning diagnostic accuracy.

RESULTS

Over a period of 6 months, 55 lesions on 51 patients have been included in this study. Picture quality was good or very good in more than 90%. Diagnostic accuracy of the teledermatoscopy approach was superior to that of the conventional approach for malignant melanocytic lesions.

CONCLUSION

We have shown the feasibility of a teledermatoscopic consultation. The gain of diagnostic accuracy in this teledermatoscopic approach, especially for malignant melanocytic lesions, suggests that patients might benefit directly from such a consultation at distance.

Pharmacologic aspects of a phlebotropic drug in CVI-associated edema

Several phlebotropic drugs, or edema-protecting drugs, are available, the most important of which are found in the gamma-benzopyrone family (flavonoids). gamma-Benzopyrones can be plant extracts, semisynthetic preparations, or synthetic preparations. This family is divided into two different groups: flavones and flavonols, and flavanes (flavanones). The flavone group contains various types of molecule and includes diosmin. Here we discuss the pharmacologic aspects in edema associated with chronic venous insufficiency (CVI) of one of the reference phlebotropic drugs, micronized purified flavonoid fraction (MPFF), a semisynthetic preparation from the diosmin group, which represents the latest improvement in flavonoid formulation. Before we detail the pharmacologic aspects, a brief summary of the pathophysiology of edema in CVI is necessary. Several factors are implicated: the veins, which create the conditions favorable to edema; the microcirculation, which is the site of fluid transfer into the interstitial tissue; and the lymphatics, which have a limited possibility to reduce edema. Major discoveries are currently being made in CVI and the microcirculation. Results of studies show that MPFF decreases capillary permeability and increases capillary resistance, which could partly be explained by inhibition of leukocyte activation, migration, and adhesion. This inhibition is linked to a significant decrease in plasma levels of endothelial adhesion molecules (VCAM-1 and ICAM-1) after MPFF treatment. Thus, the CVI-induced damage to the microcirculation is counteracted by MPFF. The lymphatic system is also improved by MPFF treatment. The lymphagogue activity of MPFF has been demonstrated in experimental animal models and confirmed by microlymphographic measurement in patients suffering from severe CVI. The pharmacologic activity of MPFF in lymphedema was observed in a study using an animal model of acute lymphedema and in a study in patients with upper limb lymphedema secondary to breast cancer treatment. All these findings point to the importance of acting on each factor involved in the formation and maintenance of edema. This pharmacologic activity is indeed reflected by the clinical efficacy on edema observed during treatment with MPFF.

Post-stripping sclerodermiform dermatitis

BACKGROUND

Cutaneous sclerosis, a process that results in hardening of the skin, is the hallmark of scleroderma and sclerodermoid disorders. Cutaneous sclerosis is usually classified as secondary or primary, depending on the presence or absence of underlying diseases. Primary cutaneous sclerosis is a feature of idiopathic inflammatory processes that are often associated with autoimmune disorders, whereas secondary cutaneous sclerosis arises in the context of many pathological processes of varying causes, including chronic graft-vs-host disease, defined metabolic or genetic disorders, and exposure to certain infectious organisms, drugs, or chemicals.

OBSERVATIONS

Three patients had localized cutaneous sclerosis overlying the site of a surgically removed (stripped) great saphenous vein. In all 3 patients, lesions were clinically characterized by multiple hypopigmented and indurated plaques distributed linearly along the path of the preexisting vein. Extensive history, physical examination, and diagnostic tests did not reveal known predisposing factors for cutaneous sclerosis.

CONCLUSIONS

Although the observed association of sclerodermiform dermatitis and venous stripping in these 3 patients does not imply a causal relationship, the absence of other identifiable predisposing factors and the striking linear distribution of the cutaneous lesions along the path of the preexisting vein are suggestive. This poststripping sclerodermiform dermatitis may be a rare late complication of saphenous vein stripping.

Complications of ambulatory phlebectomy

BACKGROUND

Ambulatory phlebectomy, as described by Muller, is a remarkable esthetic, effective, and cost-sparing technique for definitive removal of varicose veins. As this technique is becoming more and more popular, potential complications and incidents have to be recognized by all phlebologists.

OBJECTIVE

To review all possible complications after ambulatory phlebectomy and establish their frequency, relevance, treatment, and prevention.

METHODS

Extensive review of the European and American literature devoted to phlebectomy, with particular consideration of the complications, are discussed in comparison with the author's personal experience.

CONCLUSIONS

Notable adverse incidents after ambulatory phlebectomy are rare. Minor inconveniences are common, depending partially on surgical indications, operator's skill, and experience. Adequate training allows one to minimize untoward reactions. A great risk of ambulatory phlebectomy is the presumed facility of this surgical technique combined with its easy accessibility to poorly trained physicians in phlebology and dermatologic surgery.

Necrobiosis lipoidica and silicotic granulomas on Muller's phlebectomy scars

We report an unusual case of concomitant necrobiosis lipoidica and silicotic granulomas in scars of phlebectomies on the legs, suggestive of a Koebner phenomenon.