[Compression therapy: Choosing the right option for leg ulcers in 2016]

Compression therapy is a mandatory treatment of leg ulcers whether the goal is cure (stage C6 in the international classification for chronic venous disease) or prevention of recurrence (stage C5). Different indications for compression therapy were proposed by the French Superior Health Authority (HAS) in 2010, but new studies have modified attitudes since that time. Considering the very large number of options available, the many co-morbid conditions observed in these patients, as well as patient age and available assistance, it is important to adapt to the variable clinical and social situations encountered. One must keep in mind that a well-controlled treatment should improve trophic disorders and patient comfort. A poorly-adapted treatment with little or even deleterious effect will be abandoned by the patient.

Prognostic factors associated with healing of venous leg ulcers: a multicentre, prospective, cohort study

BACKGROUND

Some prognostic markers of venous leg ulcer (VLU) healing have been evaluated, mostly in retrospective studies.

OBJECTIVES

To identify which clinical characteristics, among those known as possible prognostic factors of VLU healing, and which VLU-associated sociodemographic and psychological factors, are associated with complete healing at week 24 (W24).

METHODS

A prospective, multicentre, cohort study was conducted in 22 French dermatology departments between September 2003 and December 2007. The end point was comparison between healed and nonhealed VLUs at W24, for patient clinical and biological characteristics; psychological, cognitive and social assessments; affected leg inclusion characteristics; venous insufficiency treatment and percentage of initial wound area reduction during follow-up.

RESULTS

In total, 104 VLUs in 104 patients were included; 94 were analysed. The mean VLU area and duration were 36.8 ± 55.5 cm2 and 24.8 ± 45.7 months, respectively. At W24, 41/94 VLUs were healed. Univariate analysis significantly associated complete healing with superficial venous surgery (P = 0.001), adherence to compression therapy at W4 (P = 0.03) and W24 (P = 0.01), ankle-joint ankylosis (P = 0.01) and mean percentage of VLU area reduction at W4 (P = 0.04). Multivariate analysis retained superficial venous surgery during follow-up [odds ratio (OR) 8.4, 95% confidence interval (CI) 1.9-48.2] and percentage reduction of the VLU area at W4 (OR 1.6, 95% CI 1.0-2.14) as being independently associated with healing.

CONCLUSIONS

These results indicate that complete healing of long-standing, large VLUs is independently associated with ablation of the incompetent superficial vein and percentage of wound area reduction after the first 4 weeks of treatment.

[Risk factors of serious bleeding among ambulatory patients taking antivitamin K aged 75 and over]

The benefits of anti-vitamin K (AVK) drugs have been acknowledged in several indications. Such indications increasing with increasing age, AVK prescriptions also increases with age. At the same time, conditions involving significant bleeding are common in this elderly population. It is thus essential to recognize the determining factors. This study included all patients taking AVK drugs aged 75 years and older who sought emergency care at the Cochin Hospital from January to December 2011 for significant bleeding. These patients were compared with a cohort of patients aged 75 years or older who were taking AVK drugs and who were admitted to the same unit during the same time period for other reasons. The case-control comparison included demographic data, comorbidity factors, multiple medications, emergency measured INR, and CHA2DS2VASC level. The hemorrhagic risk was evaluated by HEMORR2HAGES and HAS-BLED. A total of 34 patients were studied and compared with 70 case-controls. The Charlson comorbidity index was higher in patients than case-controls (P<0.05), with a much higher hemorrhagic risk for scores ≥ 9 (OR=2.5; P<0.05). Multiple medication was also more predominant in patients (P<0.05). The risk of serious hemorrhage was also higher when the hemorrhagic scores were high, especially for HEMORR2HAGES (P<0.0001) and HAS-BLED (P<0.001). The risk of serious hemorrhage in elderly outpatients taking AVK drugs is related to their higher comorbidity and hemorrhagic levels which need to be evaluated before starting or stopping AVK treatment.

Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers--a randomized controlled trial

Background

Stringent control of proteolytic activity represents a major therapeutic approach for wound-bed preparation.

Objectives

We tested whether a protease-modulating polyacrylate- (PA-) containing hydrogel resulted in a more efficient wound-bed preparation of venous leg ulcers when compared to an amorphous hydrogel without known protease-modulating properties.

Methods

Patients were randomized to the polyacrylate-based hydrogel (n = 34) or to an amorphous hydrogel (n = 41). Wound beds were evaluated by three blinded experts using photographs taken on days 0, 7 and 14.

Results

After 14 days of treatment there was an absolute decrease in fibrin and necrotic tissue of 37.6 ± 29.9 percentage points in the PA-based hydrogel group and by 16.8 ± 23.0 percentage points in the amorphous hydrogel group. The absolute increase in the proportion of ulcer area covered by granulation tissue was 36.0 ± 27.4 percentage points in the PA-based hydrogel group and 14.5 ± 22.0 percentage points in the control group. The differences between the groups were significant (decrease in fibrin and necrotic tissue P = 0.004 and increase in granulation tissue P = 0.0005, respectively).

Conclusion

In particular, long-standing wounds profited from the treatment with the PA-based hydrogel. These data suggest that PA-based hydrogel dressings can stimulate normalization of the wound environment, particularly in hard-to-heal ulcers.

[Radiation arteritis- and radiodermitis-induced leg ulcer: surgical revascularization]

A forty-four-year old man was hospitalized for diagnosis and treatment of a left leg ulcer which did not heal despite good compliance with a three-month medical regimen. Twenty years before he had undergone surgical curettage and radiotherapy (81 gy) for an osteosarcoma of the upper third of the left tibia. He was considered completely cured with regular findings. On examination he had a 5 X 7 cm deep ulcer with raised margins and no signs of infection, localized on the radiodermatitis on the medial aspect of his left leg. Arterial examination confirmed the left arteriopathy with absence of distal pulses; the Ankle Brachial Pressure Index was 0.69 and the foot TcPO2 27 mmHg. Arteriography confirmed the localized left lesions with three distal popliteal and proximal arterial occlusions, all other arteries being strictly normal. Arterial and dermatological radiation leg ulcer was retained as the etiological diagnosis. As the ulcer was very painful, extensive and limited walking distance, surgical revascularisation was undertaken because endoluminal revascularization was impossible. A femoroperoneal saphenous bypass was performed with surgical incisions beyond the radiodermatitis area. Two months after a split skin graft, the ulcer was considered healed and the patency of the by-pass confirmed on duplex examination. This is the first case report of a successful distal by-pass performed for radiation arteritis and ulcer healing. Long-term follow up should be reported.

[Nutritional status assessment of patients with leg ulcers]

INTRODUCTION

Nutritional deficiencies may delay the wound healing process. The aim of this study was to evaluate the prevalence of protein malnutrition in patients presenting with a leg ulcers and to determine which clinical data can predict malnutrition on population.

PATIENTS AND METHODS

This prospective survey included community patients, hospitalized in rehabilitation care unit for treatment of a leg ulcer unhealed for at least 3 months. Clinical, anthropometric and biological data were collected on admission.

RESULTS

Sixty-six patients, mean age 72.9 +/- 16.3 years, were included. Fifty-three p. 100 presented wound surfaces over 30 cm(2); 59 p. 100 of the ulcers had lasted for more than one year; 62 p. 100 of the ulcers were venous. 48.5 p. 100 of the patients exhibited protein malnutrition defined by biological criteria, associated with an inflammatory syndrome in 66 p. 100. Anemia and an inflammatory syndrome were present in respectively 59 and 58 p. 100 of the patients. Neither anthropometric measurements nor nutritional intake or wound characteristics significantly differenced between patients with malnutrition or not. Hypoalbuminemia was significantly more frequent and severe in patients aged over 70.

DISCUSSION

Protein malnutrition prevalence is very high in patients with leg ulcers, particularly in the elderly. Since nutritional interview or clinical data failed to predict protein malnutrition, systematic biological assessment is justified in all patients with leg ulcers.

Methicillin-resistant Staphylococcus aureus. Nosocomial acquisition and carrier state in a wound care center

OBJECTIVE

To assess methicillin-resistant Staphylococcus aureus (MRSA) nosocomial acquisition and carrier state in a wound care center.

DESIGN AND SETTING

The results of an intervention to control MRSA were compared with those of historical controls at the wound care center of university-based Hôpital Broussais, Paris, France.

PATIENTS

Patients admitted for specific care of chronic ulcers and surgical wounds.

MAIN OUTCOME MEASURES

Incidence rates of MRSA carriers and acquisition in wounds.

RESULTS

Of 88 patients admitted during a 3-month preintervention period in 1993, 18 (21%) were MRSA carriers. Of 334 patients admitted in 1994 and 395 in 1996, 65 (19.5%) and 81 (20.5%) were MRSA carriers, respectively (P=.80). In 1993, 6 (9%) of 70 patients without MRSA acquired MRSA wound infections; the corresponding numbers were 6 (2.2%) of 269 in 1994 and 3 (0.9%) of 314 in 1996. Despite that the number of MRSA carriers remained stable at admission to the wound care center, the rate of MRSA infections in wounds per 100 noncarriers decreased significantly between the preintervention period and subsequent years: 1994 (P=.02) and 1996 (P=.002).

CONCLUSIONS

Although our results are limited by the use of historical controls, they showed that simple infection control measures, such as the use of soap and water and barrier precautions associated with staff education, seemed to significantly reduce MRSA infection rates in patients with chronic skin breaks.

Leg ulcers and hydroxyurea: forty-one cases

BACKGROUND

Hydroxyurea is an antitumor agent used to treat chronic myeloproliferative disorders. Leg ulcerations have been reported in patients undergoing long-term hydroxyurea therapy for myeloproliferative diseases. To better define this dermatological adverse effect of hydroxyurea therapy and to try to understand the pathophysiological process of this disease, we collected medical information for such patients in a multicenter retrospective study.

OBSERVATIONS

Forty-one patients (mean age, 67 years) developed leg ulcerations while undergoing hydroxyurea therapy (mean therapy duration, 5 years). The sex ratio was 1, and there was no underlying vascular disease. Hematologic abnormalities were identified. Complete recovery from the ulcerations occurred quickly after withdrawal of treatment in 33 (80%) of the cases.

CONCLUSIONS

This longest-reported series of patients confirms the role of hydroxyurea therapy in the onset of leg ulcerations. Healing or improvement requires cessation of treatment. Cutaneous atrophy and impaired wound healing may explain the relationship between hydroxyurea and leg ulcers. In addition, the megaloblastic erythrocytes resulting from the presence of hydroxyurea may circulate poorly through the capillary network. A prospective study in hematologic centers would be valuable.

EMLA cream as a topical anesthetic for the repeated mechanical debridement of venous leg ulcers: a double-blind, placebo-controlled study

BACKGROUND

A granulating surface is important for skin grafting and healing of leg ulcers. Mechanical debridement to remove necrotic tissue often must be stopped before completion because of pain.

OBJECTIVE

Our purpose was to assess the effect of EMLA cream on the number of debridements required to obtain a clean ulcer and on pain during debridement and to determine its safety after repeated doses.

METHODS

In this randomized double-blind, placebo-controlled study, 69 patients with venous leg ulcers received cream before debridement until a clean ulcer was obtained (or a maximum of 15 debridements).

RESULTS

EMLA decreased the median number of debridements required for a clean ulcer (EMLA 11.5, placebo >15; P = .019) and decreased pain by 50% (P = .003). Plasma levels of lidocaine, prilocaine, and their main metabolites were low without any apparent accumulation.

CONCLUSION

EMLA produces effective pain relief for the debridement of leg ulcers and shortens the time to a clean ulcer.

Benefit of a 2-month treatment with a micronized, purified flavonoidic fraction on venous ulcer healing. A randomized, double-blind, controlled versus placebo trial

OBJECTIVE

To assess the efficacy of a micronized purified flavonoid fraction (Daflon 500 mg = Dios) in venous leg ulcer healing, in addition to compression therapy and standardized local care.

DESIGN

Double-blind, multicentre, randomized, parallel groups, controlled versus placebo trial; stratification according to ulcer size.

SUBJECTS

107 patients, with venous ulcer of the leg for at least 3 months, and accepting bandaging therapy.

RESULTS

105 patients (Dios = 53, placebo = 52) were available for an intention to treat (ITT) analysis. Age (mean +/- SD, 71+/-11 years), gender (M = 33, F = 74) and ulcer size were evenly distributed among both groups. 99 patients completed the protocol (Dios = 51, placebo = 48). Among the 91 patients with ulcer size < or = 100 cm (Dios = 44, placebo = 47), a significantly higher number of patients had complete ulcer healing at 2 months in the Dios group (n = 14) in comparison to the placebo group (n = 6) after ITT analysis (32 vs. 13%, p = 0.028) and after per protocol analysis (32 vs. 14%, p = 0.048), and a shorter time duration of healing (p = 0.037). Among the 14 patients with ulcer size > 10 cm (Dios = 9, placebo = 5), no ulcer healed.

CONCLUSION

This study showed that a 2-month course of purified micronized flavonoid fraction (2 tablets/day), in addition to conventional treatment, is of benefit in patients by accelerating complete healing of venous leg ulcers which are < or = 10 cm in diameter.

Efficacy of Daflon 500 mg in venous leg ulcer healing: a double-blind, randomized, controlled versus placebo trial in 107 patients

The objective of this study was to evaluate the efficacy of Daflon 500 mg (Dios)* in venous ulcers. A multicenter, double-blind, randomized, controlled versus placebo (Plac) trial was conducted, with stratification according to the size of ulcer (< or = 10 cm and > 10 cm). The protocol called for a two-month treatment with Dios (one tablet = 450 mg micronized purified Diosmin) or a placebo, two tablets/day, in addition to compression therapy. Evaluations were performed every fifteen days, from D0 to D60. The primary endpoint, in accordance with Alexander House group requirements were: percentage of patients with complete ulcer healing, ie, comparison between Dios and Plac group at D60, and comparison of survival curves in each group between D0 and D60 (log rank test). Secondary endpoints included ulcer surface area assessed by computerized planimetric measurements, qualitative evaluation of ulcers, and symptoms. The patients were 105 men and women ranging in age from eighteen to eighty-five years, with standard compression stocking, who were undergoing standardized local care of ulcer and had no significant arterial disease (ankle/arm systolic pressure index > 0.8). Fifty-three patients received Dios, and 52 received Plac. The 2 groups were well matched for age (m +/- 1 SD = seventy-one +/- eleven years), gender, ulcer size, and associated disorders. Among patients with ulcer size < or = 10 cm (Dios = 44, Plac = 47) a significantly larger number of patients had a complete ulcer healing at two months in the Dios group (n = 14) in comparison with the Plac group (n = 6) (32% vs 13%, P = 0.028) with a significantly shorter time duration of healing (P = 0.037). No difference was shown for the secondary criteria, except for sensation of heavy legs (P = 0.039) and a less atonic aspect of ulcer (P = 0.030) in favor of Dios. Among the 14 patients with ulcer size > 10 cm (Dios = 9, Plac = 5), subjected to a descriptive analysis only, no ulcer healed. This study showed that a two-month course of Daflon 500 mg at a daily dose of two tablets, in addition to conventional treatment, is of benefit in patients with venous ulcer < or = 10 cm by accelerating complete healing.

[Diagnostic pitfalls of cutaneous complications of chronic venous insufficiency]

Cutaneous lesions of the lower limbs are not always of venous origin. Only careful examination of the skin and of the leg can detect other causes. Such examination is important not only for understanding the pathophysiological origin but especially for treatment decision. Certain possible causes should be routinely sought such as arterial abnormalities and cutaneous vasculitis. Some ulcerations from the onset have an atypical appearance, such as necrotic angiodermatitis and pyoderma gangrenosum. Rarer causes (tumoural, haematologic, infectious or congenital) should be considered in case of resistance to usual treatments for severe venous insufficiency.

Hypothenar hammer syndrome: seventeen cases with long-term follow-up

Hypothenar hammer syndrome is a rare and often incorrectly diagnosed form of secondary Raynaud's phenomenon in workers who use their hand as a hammer. We report 17 documented cases with long-term follow-up after diagnosis made on the basis of arteriography. Clinical findings include male sex, unilaterality, sudden onset, and severe Raynaud's phenomenon. Angiography indicated that the 17 patients had either ulnar thrombosis or ulnar aneurysm; most of them also had embolic occlusions of the digital arteries. Main pathologic findings were thrombosis on the intima and fibrosis in the media. We adopted a surgical procedure consisting of resection with end-to-end reconstruction for patent aneurysms to avoid downstream emboli and more conservative treatment when the ulnar artery was thrombosed. No patient required digital amputation and all except one improved and were able to live and work normally with only a moderate disability, consisting of Raynaud's phenomenon during the cold season only.

[Multiple arterial lesions in von Recklinghausen's disease. A case]

Arterial lesions are thought to be rare in neurofibromatosis. In the case reported here full vascular exploration demonstrated diffuse lesions of the aorta, splenic artery, renal arteries, left internal carotid artery, right common iliac artery and arteries of the legs. This underlines the usefulness of thorough angiographic exploration when arterioplasty is envisaged in a patient with neurofibromatosis. Microscopic examination of an arterial biopsy specimen showed fibrodysplasia of the media associated with hyperplasia of the periarterial nerves, thus confirming that the lesions involved tissues of both mesodermal and neuroectodermal origins.

Fine structural capillary changes and basal lamina thickening in scleroderma (progressive systemic sclerosis) and Raynaud's disease

Capillary abnormalities were found by electron microscopy in labial salivary gland biopsies obtained from 20 patients with progressive systemic sclerosis (PSS). They consisted of marked thickening and multilayering of basal lamina, degenerative and adaptative endothelial cell changes, alterations of pericytes and perivascular mononuclear cell infiltration. There was no correlationship between the intensity of the capillary abnormalities and the duration of the disease. In 12 patients with Raynaud's disease (RD) such changes were not found. Thus capillaries displayed normal-looking ultrastructural appearances. Mean capillary basal lamina width was consistently thicker in the PSS group than in the RD group (p less than 0.001). These observations are consistent with the hypothesis that the primary event in PSS occurs in the microvessels. It is suggested that labial salivary gland biopsy may be helpful for early recognition of PSS among subjects with Raynaud's syndrome.