Leg ulcers in childhood: A multicenter study in France

BACKGROUND

Leg ulcers in adults are a major public health concern. Their incidence increases with age and many causes have been identified, predominantly associated with vascular diseases. Leg ulcers in children and teenagers are less frequent. The aim of our study was to identify the causes of leg ulcers in children and teenagers, and to evaluate their management.

METHODS

This retrospective multicenter study was conducted by members of the Angio-dermatology Group of the French Society of Dermatology and of the French Society of Pediatric Dermatology. Data from children and teenagers (< 18 years), seen between 2008 and 2020 in 12 French hospitals for chronic leg ulcer (disease course>4 weeks), were included.

RESULTS

We included 27 patients, aged from 2.3 to 17.0 years. The most frequent causes of leg ulcer were: general diseases (n=9: pyoderma gangrenosum, dermatomyositis, interferonopathy, sickle cell disease, prolidase deficiency, scleroderma, Ehlers-Danlos syndrome), vasculopathies (n=8: hemangioma, capillary malformation, arteriovenous malformation), trauma (n=4: bedsores, pressure ulcers under plaster cast), infectious diseases (n=4: pyoderma, tuberculosis, Buruli ulcer) and neuropathies (n=2). Comorbidities (59.3%) and chronic treatments (18.5%) identified as risk factors for delayed healing were frequent. The average time to healing was 9.1 months.

DISCUSSION

Leg ulcers are less frequent in children and teenagers than in adults and their causes differ from those in adults. Comorbidities associated with delayed healing must be identified and managed. Children and teenagers tend to heal faster than adults, but a multidisciplinary management approach is necessary.

International validation of the Bullous Pemphigoid Disease Area Index severity score and calculation of cut-off values for defining mild, moderate and severe types of bullous pemphigoid

BACKGROUND

The Bullous Pemphigoid Disease Area Index (BPDAI) score has been proposed to provide an objective measure of bullous pemphigoid (BP) activity.

OBJECTIVES

The objective of this study was to calculate BPDAI cut-off values defining mild, moderate and severe BP. We also aimed to assess the interrater reliability and correlation with the number of daily new blisters, and anti-BP180 and anti-BP230 antibodies.

METHODS

Severity scores were recorded by two blinded investigators. Anti-BP180 and anti-BP230 antibodies were measured using an enzyme-linked immunosorbent assay (ELISA). Cut-off values defining mild, moderate and severe subgroups were calculated based on the 25th and 75th percentiles of the BPDAI score.

RESULTS

In total, 285 patients with BP were enrolled from 50 dermatology departments in Europe. Median BPDAI activity was 37·5 points (range 0-164). Cut-off values corresponding to the first and third quartiles of the BPDAI score were 20 and 57, respectively; thus, these values were used to define mild (≤ 19), moderate (≥ 20 and ≤ 56) and severe (≥ 57) BP. The median BPDAI score for patients with ≤ 10 daily new blisters was 26 [interquartile range (IQR) 17-45], and for patients with > 10 daily new blisters the median score was 55 (IQR 39-82). The BPDAI intraclass correlation coefficient measured at baseline was 0·97 and remained higher than 0·90 up to month 6. The improvement in the BPDAI score was correlated with the absolute decrease in anti-BP180 ELISA value (Spearman's rank r = 0·34, P < 0·004), but not with anti-BP230 antibodies (r = 0·17, P = 0·15).

CONCLUSIONS

This study suggests cut-off values of 20-57 for BPDAI to distinguish mild, moderate and severe BP, and confirms that it is a robust tool to assess BP severity precisely.

Clinical and haemodynamic risk factors associated with discrepancies in lower limb length with capillary malformations: data from the national paediatric French cohort CONAPE

BACKGROUND

Genetics discoveries have allowed for a better understanding of capillary malformations (CMs) associated with overgrowth syndrome. However, molecular analyses are still not easy to perform or interpret. Other analytical methods are needed.

OBJECTIVES

To identify clinical and haemodynamic factors associated with leg length discrepancy (LLD) in children with CMs of the lower limbs.

METHODS

Data were obtained from the multicentre French national cohort CONAPE (COhorte Nationale d'enfants atteints d'Angiome Plan de membrE inférieur), from children aged 2-12 years old with CMs of the lower limbs. Clinical characteristics were prospectively collected. Haemodynamic factors were measured by an sonographer who calculated the arterial blood flow (ABF) in both lower limbs. An ABF difference ≥ 50% between the two lower limbs was considered relevant. LLD ≥ 2% was determined by the same radiologist on centralized radiographs.

RESULTS

We analysed data at baseline for 96 children. The mean ± SD age was 5·6 ± 3·1 years; 49 (51%) were male; and 14 (15%) showed LLD. In total, 32 patients (33%) had venous anomalies, 13 (14%) lymphatic anomalies and in one child a diagnosis of Parkes Weber syndrome was made. Only an increased circumference above the knee was more frequent with than without LLD (43% vs. 13%, P = 0·02). In all, 10/79 patients (13%) showed a difference in ABF ≥ 50%: four had LLD. The frequency of differences in ABF ≥ 50% was greater with than without LLD [33% (n = 4/12) vs. 9% (n = 6/67), P = 0·04].

CONCLUSIONS

ABF measured by Duplex ultrasonography is a simple, low-cost and noninvasive complementary examination for help in detecting LLD, with a difference of ≥ 50% possibly associated.

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.

Cutaneous events during treatment of chronic inflammatory joint disorders with anti-tumour necrosis factor alpha: a cross-sectional study

BACKGROUND

Anti-tumour necrosis factors (anti-TNF) are more and more used, but the rate of skin adverse events is not known.

OBJECTIVE

The aim was to assess the number of skin infections and other dermatoses in patients treated with anti-TNFalpha.

PATIENTS AND METHODS

One hundred eighty-seven patients suffering from rheumatoid arthritis or ankylosing spondylitis underwent a dermatological exam. Patients with anti-TNF were compared with those without this treatment in a prospective transversal study.

RESULTS

Among them, 59 patients were treated with anti-TNFalpha and steroids were prescribed in 100 cases. There was no difference in the prevalence of skin infections or eczema or tumours. Skin drug reactions were observed in six patients. Infections by dermatophytes appear very frequent, approaching 70% in both groups.

CONCLUSIONS

This study shows that skin infections (or other skin diseases) are not more frequent in these patients. No differences were observed in infections (bacterial fungal, parasital or viral), tumours, psoriasis or the manifestations of atopic dermatitis. Nonetheless, a long-term survey might be interesting, especially about skin tumours.

Grains de milium diffus chez un nourrisson révélateurs d’un syndrome de Bazex, Dupré et Christol

BACKGROUND

We report two cases of Bazex-Dupré-Christol syndrome in a father and daughter with divergent clinical pictures at two different ages.

PATIENTS AND METHODS

A 6-month-old infant was seen with her parents for profuse milia which had appeared when she was 2 months old and persisted ever since. The remainder of the dermatological examination and the psychomotor development tests were normal. Dermatological examination of the father showed atrophic cutaneous lesions with follicular punctuated depressions (like "ice-pick marks") on the back of the hands and the forearms. He also presented diffuse hypotrichosis and hypohydrosis. In addition, he had a history of basal cell carcinoma with surgery before the age of 35 years. Finally, questioning revealed the existence of numerous similar cases in the family. In view of all these factors, a diagnosis of Bazex-Dupré-Christol syndrome was made.

DISCUSSION

Bazex-Dupré-Christol syndrome is a genodermatosis with X-linked dominant inheritance. Diagnosis is based on association of follicular atrophoderma, congenital hypotrichosis, hypohydrosis and early basal cell carcinoma. Other than fragile skin and cosmetic blemishes, these tumors are the only complication of the disease and require regular dermatological surveillance and solar protection. Common initial signs of the disease are abnormally profuse milia in neonates that tend to persist throughout childhood. Several differential diagnoses may be evoked.

Multiple cutaneous squamous cell carcinomas arising in a patient with generalized morphea

Association of cutaneous scleroderma and squamous cell carcinoma (SCC) has been reported in a few cases. We report a new case of multiple SCC which occurred in sclerotic patches on the leg. The role of factors explaining this association is discussed as immunosuppression or ulcerations.

[Venous ulcer on the hand due to a treatment-related arteriovenous fistula]

BACKGROUND

An arteriovenous fistula of the arm for hemodialysis needs to last long and provide easy access for puncture.

CASE-REPORT

A 50 year-old woman, with type 2 diabetes complicated by chronic renal failure, presented with an ulcer on the dorsum of the right hand that had developed over the past year. Humeral artery to basilica vein, side-to-side, arteriovenous fistula in the right arm was created in 1996. In 1999, she received a renal transplant. In 2002, she developed a deep ulcer on the dorsum of the right hand that progressed over one year, without improvement good local treatment. Doppler echography and a fistulography revealed proximal stenosis of the basilica vein, and a less restricted distal stenosis before the shunt. A venous ulcer on the dorsum of the hand due excessive venous pressure in the draining area.

DISCUSSION

The complications of arteriovenous fistulas can be severe. Arterial stenosis is frequent and is the consequence of intimal hypertrophy. Chronic ischemia symptoms can be observed, but the hemodynamic loss is usually asymptomatic. When clinical signs are noisy emergency surgery is required. Venous stenosis is responsible for ischemia through venous overload, leading to edema of the arm, and rarely to venous-ulcer type trophic disorders as seen in this patient. Screening for stenosis on the vascular vein network must be systematic before creating an arteriovenous fistula.

Étude prospective multicentrique 1991-2001 de la batterie standard des photopatch-tests de la Société Française de Photodermatologie

INTRODUCTION

To develop a standard panel of photopatch tests, the French Society of Photodermatology conducted a prospective study from 1991 to 2001 on the frequency of photoallergens encountered in France and on the relevance of the choice of the various photoallergens.

PATIENTS AND METHODS

Thirteen photobiology centers participated in the study from 1991 to 1995, and ten centers from 1995 to 2001. A set of 3 samples of photopatch tests was applied on any patient suspected of photoallergy. On Day 2, two sets were irradiated with ultraviolet A (UVA) and total spectrum (DEM 0.75); with the third set being used as control. Readings were made on D3 and D4.

RESULTS

Two thousand sixty-seven patients were tested. Eight hundred fifty-six, i.e., 41% exhibited one or several positive tests. In the majority of cases it was a photoallergy (39.7 to 60% of cases) and eczema (29.5 to 45.6%). Photoaggravation was infrequent (7.9 to 10.3%). Cases of phototoxicity were rare. Sesquiterpenic lactones constantly provoked photoallergy, with 12 cases in 10 years. Although phenothiazines were the most photosensitizing allergens up until 1995, they were then overridden by ketoprofen in 1996 with 107 cases of UVA photosensitive reactions (75 cases) and total spectrum (32 cases). These were followed closely by sun screens, benzophenone (notably Eusolex 4360 with 54 pertinent cases of photoallergy) and dibenzoylmethane (with 31 cases due to Eusolex 8020). UVB filters were all potentially photosensitizing but to a lesser degree from 1 to 5 cases).

DISCUSSION

Our results differ from those of Anglo-Saxon teams in the appearance of a new photoallergen, ketoprofen, which provoked numerous photosensitivities in both UVA and UVB. This justifies the systematic addition of this substance in our prospective set. Photoallergy was relatively rare, with around 100 cases reported within 10 years. Total spectrum irradiation of the photopatch tests revealed photoallergies that would not have been found with UVA alone.

CONCLUSION

Study of photopatch tests has permitted the uniformization of the methodology in France, an overview of the frequency of the photoallergens tested and the development of a new standard set.

[What is the value of non-immunosuppressor therapy in the treatment of atopic dermatitis?]

INTRODUCTION

Atopic dermatitis (AD) is a frequent dermatosis in infants and children, the management of which combines measures of prevention and medical treatment.

METHODS

The efficacy of the various treatments available requires rigorous assessment. Our analysis of the literature used the "Pubmed" data bank. More specifically, we studied the interest of antihistamines, antibiotics, antifungals, essential fatty acids and probiotics during AD in children.

RESULTS

Concerning antihistamines, only the anti-h1 have been assessed during AD and their efficacy appears modest in the papers published. The interest of antibiotics and antiseptics, in the absence of documented surinfection, is marginal. The management of herpes virus viral infections during AD essentially relies on acyclovir. The interest raised by essential fatty acid supplementation in atopic patients has not been confirmed in papers published on the subject. Although the role of probiotics in the prevention and treatment of AD is attractive, intellectually, it has not been validated in large cohort studies.

CONCLUSION

In the light of this study, many supplementary treatments with topical corticosteroids during AD do not resist "evidence-based" clinical trials. However, the individual benefits of some of these treatments should not be ruled out.