Changes in quality of life for patients with chronic venous insufficiency,present or healed leg ulcers

Background: Patients with chronic leg ulcers are handicapped in daily life, both by physical complaints and social problems. The aim of our study was not only to assess a possible impairment of quality of life (QOL) of leg ulcer patients but also to evaluate if there is a real improvement of QOL after healing of the ulcer. Patients with chronic venous insufficiency served as the control group. We further analyzed if there were significant differences in the response between patients who were and were not performing compression therapy. Patients and method: We interviewed three groups of patients (active venous leg ulcer, healed venous leg ulcer and patients with chronic venous insufficiency using the ?Freiburger Life Quality Assessment für Venenerkrankungen“ (FLQAv). Results: Physical problems, daily handicaps and social problems all increased with age. Contrary to our expectations, healing of a leg ulcer did not lead to a significant increase in QOL. Instead, patients with active ulcers did not regard their QOL as lower than those in the other groups. Compression therapy also did not impair QOL in the three groups. Conclusion: Even though ulcer healing is an admirable goal, it does not necessarily lead to an improved QOL, probably because of the numerous comorbidi‐ties in this patient group. Nonetheless, it is important to control problems associated directly with the wound to allow ulcer patients to participate actively in everyday life and minimize social problems.     

Differential diagnosis of leg ulcers

Over the last years the treatment of chronic leg ulcers has developed from a merely symptomatic to a differentiated therapy. Although more than 90% of the ulcers are of vascular origin, many other causes are possible. A survey of the various triggers of chronic ulcers of the lower limb is given. Vascular, hematological, neuropathic, infectious, malignant and chemico-physical causes are discussed. New findings regarding hemostatic defects as the basis of thrombophilia and ulcers are presented.     

OUTPATIENT TREATMENT OF CHRONIC VENOUS ULCERS IN A SPECIALIZED CLINIC

Chronic leg ulcers have many different causes and therefore need an accurate diagnosis in order to give the most effective treatment. A specialized clinic was set up in Fremantle Hospital in July 1988 with the aims of performing a thorough clinical and laboratory assessment to establish the cause of ulceration in every patient, and treating patients according to the cause of ulceration. Patients with arterial, neoplastic or dermatological conditions were treated as appropriate for their diagnosis and patients with other chronic ulcers were managed as outpatients where possible. Patients were seen between July 1988 and July 1989. Only 43% had purely venous ulcers, 32.6% had a venous component plus some other abnormality, and 5.2% were purely arterial. Using an outpatient treatment regimen, 67% of all ulcerated limbs and 73.7% of limbs with purely venous ulcers were healed within 6 months. Only 11 patients with venous ulceration (15 limbs) failed on this therapy and required admission during the observation period. The initial ulcer size was shown to influence the time to total healing of the limb. The healing rates achieved compare favourably with studies from other specialized centres and suggest that the majority of patients with chronic leg ulcers can be treated successfully using ambulatory outpatient dressing techniques.     

Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey

Background: The etiology of chronic leg ulcers is heterogenous and they exhibit quite different healing rates depending on the underlying cause. Although the prevalence and incidence of chronic leg ulcers appear to be increasing, data on these patients in Germany are lacking. Patients and Methods: Altogether 100 German wound care professionals were asked to complete a questionnaire regarding the diagnosis and etiology of their patients with chronic leg ulcers. Results: We received the data on 31,619 patients. In these patients, venous insufficiency was the dominating causative factor in 47.6 % and arterial insufficiency in 14.5 %, 17.6 % of ulcers were due to combined arterial and venous insufficiency. Rarer causes included vasculitis (5.1 %), exogenous factors (3.8 %), pyoderma gangrenosum (3.0 %), infection (1.4 %), neoplasia (1.1 %), calciphylaxis (1.1 %) and drug‐induced (1.1 %). The used diagnostic methods used varied widely between the medical and surgical specialties. Conclusions: Even though the results of our study cannot claim to be a representative overview, they demonstrate clearly that next to known etiologies, e. g. chronic venous insufficiency or peripheral arterial insufficiency, which are relevant in 79.7 % of all patients a multitude of other causes exist, which are responsible in 20.3 % of all patients for the development of chronic leg ulcers.     

Autologous suction blister grafting for chronic leg ulcers

Background Non‐healing leg ulcers represent a treatment problem. Objective Investigate grafting of autologous suction blister roofs as treatment. Methods Twenty‐nine chronic, non‐healing leg ulcers of various aetiologies in 18 inpatients were treated by autologous epidermal grafting using the roofs of suction blisters. Results 55% of ulcers completely healed 2 to 6 weeks after grafting. A 50–90% reduction in size was documented in 34% and no change was observed in 11% of ulcers. Twelve weeks after grafting, 89% of ulcers were healed completely. In most ulcers, we observed a stimulation of reepithelialization from the wound edge (‘edge effect’) and an accelerated formation of healthy granulation tissue. During a follow‐up period of 12 months, 90% of the ulcers remained healed. Conclusion Grafting of autologous suction blister roofs is an effective treatment option for non‐healing leg ulcers. The advantages of the method are its lack of pain, low costs and immediate availability.     

Is there an easier way to autograft skin in chronic leg ulcers? ‘Minced micrografts’, a new technique

Background Chronic venous leg ulcers represent an urgent and increasing problem for public health. The use of skin autografts results in a greater therapeutic success in healing chronic ulcers. Objective A simple method of skin autografting that could permit a wider use of skin grafts in outpatients is needed. A new technique allowing skin autografting in a simple one‐step process, without complex surgical procedures or expensive technical supplies, is presented. Methods A small, full‐thickness skin specimen taken from the patient is finely minced and spread on his leg ulcer bed allowing to cover a surface many times wider than the sample itself. Results This method induces faster re‐epithelization of chronic leg ulcers that failed to heal despite good conservative local therapy and give the possibility to repair very large ulcers with small fragments of skin. A clinical case is shown as an example out of 20 ulcers we recently treated. Conclusion Our preliminary report shows that this technique results in a greater therapeutic success (18 of 20 cases) in healing chronic leg ulcers, a common pathology that often affects outpatients treated for very long periods at home or in the Dermatologist's office. In our experience, this new and successful reparative possibility makes ‘mince grafting’ a recommendable procedure.     

Three‐dimensional documentation of wound healing: First results of a new objective method for measurement

Background: The objective assessment of wound healing is one essential parameter of quality assurance in a modern chronic wound management program. In the past assessment has been based exclusively on a two‐dimensional measurement of the wound surface with planimetry or digital photo documentation in combination with such measurements. An objective method for measuring the volume of chronic wounds has not yet been available. Patients and Methods: In cooperation with the company RSI, we linked digital photography, optical raster by means of digital scanner, and picture processing software (DigiSkin®) for an exact three‐dimensional image of chronic wounds. The generated point clouds allow the visual, computer‐assisted three‐dimensional quantification and can document the course of healing of chronic wounds. Results: In comparison to currently available systems, our new method makes possible the objective measurement of volume changes and wound healing course in chronic wounds.We demonstrate the utility of the system in reference to three patients with chronic venous leg ulcers. Conclusions: Using this new, objective three‐dimensional wound measurement system,it is possible to reliably quantify changes in wound healing for the first time. Future clinical studies have a new option for the gathering of data which will facilitate evidenced‐based conclusions.     

Contact allergy in chronic leg ulcers: results of a multicentre study carried out in 423 patients and proposal for an updated series of patch tests

Background:  There is a lack of prospective studies investigating contact sensitization in patients with chronic leg ulcers.
Objectives:  To determine the frequency of contact sensitization in patients with chronic leg ulcers using a special series of patch tests and to determine whether the number of sensitizations was correlated with the duration of the chronic leg ulcers.
Patients/methods:  Multicentre study carried out in patients with chronic leg ulcers; patch tests with the European baseline series and with an additional 34 individual allergens or mixes and 3 commercial products.
Results:  Of the 423 patients (301 women, 122 men, mean age 68.5 years) with chronic leg ulcers, 308 (73%) had at least one positive patch test with 3.65 positive patch tests per patient. The main allergens were Myroxylon pereirae (41%), fragrance mix I (26.5%), antiseptics (20%), and corticosteroids (8%). The number of positive tests per patient was not correlated with the cause of ulcer but was increased with the duration of the ulcer with a statistical difference between the group of the <1 year compared with the group >10 years duration.
Conclusions:  From this large prospective multicentre study, polysensitization is frequent in patients with chronic leg ulcers, increasing with the duration of the ulcer. We propose avoidance of topical antiseptics and ointments containing perfumes in patients with chronic leg ulcers and an updated patch test series for investigating these patients.     

A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks

Venous leg ulcers, which may take months to heal, account for 40-70% of all lower extremity chronic wounds. New treatment options for venous leg ulcers have recently been proposed, and therefore deciding which patients are candidates for these novel-and often expensive-treatments is an important task. Moreover, researchers conducting clinical trials often wish to enroll patients who are unlikely to heal in order to minimize sample sizes needed and research costs. Our purpose was to assess the use of percentage change in venous leg ulcer area over the first few weeks of treatment as a prognostic indicator of healing or non-healing at 24 weeks. We conducted a cohort study based on an existing data set from a multicentre randomized clinical trial that enrolled 104 patients. Wounds were measured using digital planimetry for 4 consecutive weeks following the inception of good wound care. Utilizing the Wilcoxon rank sum (Mann-Whitney) test, we found that percentage change in area over time distinguished between those who healed and those who failed to heal after 24 weeks of good wound care (P < 0.05). The rate of healing, or area healed per week, did not differentiate between those who healed at 24 weeks and those who did not, as all patients had similar rates of healing over the first 4 weeks of treatment. Percentage change in area from baseline to week 4 provided the best combination of positive and negative predictive values (68.2%, 74.7%) and the largest area under the receiver operating characteristic curve (0.75). Thus, percentage change in area over the first 4 weeks of treatment represents a practical and predictive measure of complete wound healing by 24 weeks.     

小腿溃疡449例病因分析

目的：明确下肢溃疡患者发病的主要原因。方法：对449例小腿溃疡住院患者的临床资料进行回顾性分析。结果：主要发病原因依次是外伤性感染（40.5%）、下肢静脉曲张（22.9%）和糖尿病（10.7%）。结论：外伤性感染、下肢静脉曲张和糖尿病是小腿溃疡患者发病的主要原因。     

Venous Leg Ulcer in a Sarcoidosis Patient: A Case Report

Venous leg ulcers, the most common form of leg ulcers, are relevant to the pathogenicity of pericapillary fibrin cuff. Sarcoidosis, a multiorgan granulomatous disease, causes fibrin deposition in tissues. We report a case of a 50-year-old man with venous leg ulcers coexisting with sarcoidosis. On the basis of the histologic findings, we propose the hypothesis that sarcoidosis patients are prone to the development of venous leg ulcers.     

Calf muscle pump impairment and delayed healing of venous leg ulcers: air plethysmographic findings

There is a need for a diagnostic tool to predict clinical outcome of venous leg ulcer patients, as the prognosis of healing based on clinical data alone has not appeared to be satisfactory. Air plethysmographic assessment of calf muscle pump was performed in the supine and upright position in 129 patients with active ulcers on their legs. All patients were managed in a specialized leg ulcer clinic. Results of air plethysmography were compared to clinical data and time of healing of ulcers. Muscle pump failure was found in 42.6% of extremities (supine position, 33.3%; upright, 22.5%; both, 12.4%). Patients with insufficient pump were older, and their ulcers were larger. Failure of pump was found more often in patients who began the treatment after long, unsuccessful, non-specialized care. Healing time of ulcers was prolonged in cases with insufficient pump. Regarding the subgroups with good clinical prognosis (patients with small ulcers or with a short history of ulceration), it was found that insufficiency of muscle pump correlated with delayed healing. It could be summarized that venous leg ulcers associated with calf muscle failure were larger, long-standing, and that their healing even after specialized treatment was delayed. Impaired muscle pump function revealed in plethysmographic examination can be a prognostic factor of delayed healing of leg ulcer. Ulcers with poor prognosis according to plethysmographic findings, and no quick recovery after standard management, should be considered for advanced therapies.     

Safety and efficiency of perilesional sclerotherapy in leg ulcer patients with postthrombotic syndrome and/or oral anticoagulation with phenprocoumon

Background: The positive effects of perilesional sclerotherapy for venous leg ulcers is well documented. Although many patients with venous leg ulcers require oral anticoagulation or have had a deep vein thrombosis, the effects of these factors on perilesional sclerotherapy are unknown. The aim of this study was to review effects of oral anticoagulation and/or postthrombotic syndrome on perilesional sclerotherapy. Patients and methods: 28 patients with venous leg ulcers were observed. 12/28 had a postthrombotic syndrome, 5/12 were on oral anticoagulants (phenprocoumon with INR 2‐3). During each treatment session, 1 ml sclerosing foam (1:5, polidocanol 2 %, method of Tessari) was injected.Treatment was continued until all extrafascial veins in the 15cm surrounding the ulcer were closed. Results: Closure of the perilesional veins was achieved in all patients with 2.5 ± 1.8 injections. In 10 of 28 patients (35.7 %),just one injection was needed.More injections were needed, both in patients with postthrombotic syndrome (3.3 ± 2.1 vs. 1.8 ± 1.3) and on anticoagulation with phenprocoumon (4.2 ± 1.2 vs. 2.1 ± 1.7). There were only two complications: an ascending phlebitis up to the accessory saphenous vein and a superficial erosion at an injection site which healed within 1 week. Conclusions: Perilesional sclerotherapy with foam is a safe and efficient therapy for patients with chronic venous leg ulcers even with postthrombotic syndrome and/ or ongoing anticoagulation.     

Use of high-resolution ultrasound to monitor the healing of leg ulcers: a prospective single-center study

Background: The quality and extent of leg ulcer healing in deeper skin layers remains poorly defined using standard visual inspection alone. High-resolution ultrasound (HR-US) offers a non-invasive, quantitative and objective assessment of dimensional and structural changes deep within the wound.
Methods: In a prospective, single-center study, healing of chronic, treatment-resistant leg ulcers was monitored by standard photography and HR-US.
Results: Twenty patients with 22 ulcers were enrolled. After study entry, treatment comprised continuation of conventional management ( n =4) or application of Apligraf^® ( n =17) or Thiersch ( n =1). All ulcers receiving a graft were classified as 'clinically healed' by visual inspection within a maximum of 5 weeks. With conventional management, closure required a period of several months in three out of four cases. After covering the ulcer with Apligraf^®, the skin reconditioned, resulting in fair skin color and a smooth skin surface in all but one case. HR-US images, however, revealed large subepidermal deficits of elastic and collagenous fibers at the time of 'clinical healing' in 14/18 engrafted ulcers, findings that are strongly indicative of a weakened skin scaffolding.
Conclusion: We suggest that the healing process for chronic ulcers can be monitored with both standard visual inspection (photography) and HR-US to allow early intervention.     

Light-activated nanofibre textiles exert antibacterial effects in the setting of chronic wound healing

The maintenance of an aseptic environment for chronic wounds is one of the most challenging tasks in the wound‐healing process. Furthermore, the emergence of antibiotic‐resistant bacterial strains is on the rise, rendering conventional treatments less effective. A new antibacterial material consisting of a polyurethane Tecophilic^? nanofibre textile (NT) that was prepared by electrospinning and doped by a tetraphenylporphyrin (TPP) photosensitizer activated by visible light was tested for use in wound beds and bandages. In vitro experiments were performed to assess the antibacterial activity of the textile against three bacterial strains. Furthermore, the new textile was tested in 162 patients with chronic leg ulcers. A complete inhibition of in vitro growth of the three tested bacterial strains was observed on the surface of NTs that had been illuminated with visible light and was clinically demonstrated in 89 patients with leg ulcers. The application of the textiles resulted in a 35% decrease in wound size, as assessed via computer‐aided wound tracing. Wound‐related pain, which was estimated using a visual analogue scale, was reduced by 71%. The results of this trial reveal that the photoinactivation of bacteria through the photosensitized generation of short‐lived, highly reactive singlet oxygen O₂(¹Δ_g) results in relatively superficial antibacterial effects in comparison with standard antiseptic treatment options. Thus, such treatment does not interfere with the normal healing process. This method therefore represents a suitable alternative to the use of topical antibiotics and antiseptics and demonstrates potentially broad applications in medicine.     

Optionen des Debridements in der Therapie chronischer Wunden

Debridement is defined as the removal of non‐vital tissue from wounds. In chronic wounds, debridement means the elimination of necrosis as well as the clearing away of wound dressings, foreign bodies, and other non‐vital substances. Sufficient debridement represents one basic prerequisite for a non‐delayed wound‐healing process. In addition to treating the causal factors for delayed wound healing, debridement should be the first step in an adequate phase‐adapted wound‐bed preparation for chronic wounds. This report aims to review the different options available in the execution of debridement in chronic wounds. The following therapeutic measures are available for the debridement of chronic wounds: surgery, maggot therapy, laser, ultrasound, hydrotherapy, wet‐to‐dry method, autolysis, proteolytic enzymes, osmotic or chemical debridement. There is no single correct debridement for all patients! Patients are individuals and therefore different methods of debridement may make sense. Which therapeutic option is chosen is determined by multiple factors. Moreover, depending on the wound milieu, the successive application of different methods can be useful.     

Successful treatment of a leg ulcer occurring in a rheumatoid arthritis patient under leflunomide therapy

Objective We report the case of a leg ulcer in a rheumatoid arthritis (RA) patient under treatment with leflunomide, discuss the influence of the drug on the aetiopathogenesis of the ulcer and describe its successful treatment. Case summary A 68‐year‐old woman with a 12‐year history of RA developed a leg ulcer after 4 months of leflunomide treatment. Other ulcerogenic factors were ruled out. There were some clinical hints for rheumatoid vasculitis. The ulcer was resistant to ambulant conservative phase adapted wound bed preparation and a split skin transplantation failed. After omission of leflunomide and washout procedure with cholestyramine a second split skin transplantation resulted in complete healing. Discussion Leflunomide inhibits the division of activated T cells and thus inhibits among others the production of proinflammatory cytokines and the adhesion of cells to the endothelium. These mechanisms may partly explain the possible influence of leflunomide on the perpetuation of the ulcer. Until now, occurrence of vasculitis and leg ulcers has been described in one case each for the novel immunomodulator leflunomide. No successful treatment of a leg ulcer under leflunomide has been described yet. Omission of leflunomide and a washout treatment in our case led to a complete healing. This may indicate a critical role of leflunomide in the maintenance of this slow healing ulcer. Conclusions An association between leflunomide intake, occurrence of leg ulcers in RA patients and delayed wound healing should be considered.     

A retrospective review of 20 hypertensive leg ulcers treated with mesh skin grafts

BACKGROUND: Few articles have been published about hypertensive leg ulcers and their surgical treatment. Since mid of the year 2000, it has been our policy to treat all hypertensive leg ulcers very early with mesh split-thickness skin grafts. The present series consists of 15 patients whose hypertensive leg ulcers, including five bilateral cases, were treated with 20 mesh grafts from 2000 to 2002. SUBJECTS AND METHODS: All patients, nine women and six men, had a long history of hypertension. The same surgical procedure was applied to all 15 patients: a complete mechanical debridement of all necrotic tissues, immediately followed by mesh skin grafting. RESULTS: Patients were discharged from the hospital after an average post-operative period of 16 days. Upon leaving the hospital, the patients had lesions completely healed in 14 of 20 cases. The graft take had been complete after an average period of 14 days. In six cases, one or two very small patches of skin graft had necrosed and complete healing required an additional period of 1 to 3 months. In all 20 cases, pain had disappeared within 1 week from surgery. DISCUSSION: All patients were on opioid therapy before surgery. With medical treatment only, hypertensive leg ulcers used to heal after a mean period of 15 months. After surgery, the average healing period was 2 weeks and opioids were stopped within 1 month after surgery. CONCLUSION: The review of the present series shows that early mesh grafting of hypertensive leg ulcers is beneficial, because healing is very quick and the pain will disappear quasi-instantly.     

Surrounding skin management in venous leg ulcers: A systematic review

ObjectivesChronic venous insufficiency may lead to the development of venous leg ulcers, the most common form of chronic wounds in the lower extremity. Key to venous leg ulcer care is the maintenance of healthy skin surrounding the ulcer, as failure to maintain skin integrity may influence the healing outcome. We thus reviewed the scientific literature looking for assessment and management instruments regarding this common but often neglected issue.MethodThe search included all studies published between 2000 and May 2019. Keywords used were: “peri-wound skin care”, “surrounding skin venous ulcers”, “surrounding skin management leg ulcers”, and “peri-lesional skin management”.ResultsManagement of moisture-balance with the selection of appropriate dressings is the most important target in surrounding-wound skin care. Moreover, contact dermatitis related to products and the dressings themselves is a neglected problem in patients with chronic leg ulcers which clinicians increasingly have to manage. The literature search revealed that there is an increasing interest in the use of noninvasive assessment tools in the field of wound care, and focusing on the surrounding-wound skin plays a role in assessing the potential of wound healing. Transepidermal water loss measurement (TEWL) and ultrasonography are two of the measurement techniques available.ConclusionThe integrity of the surrounding skin is necessary for wound healing, and appropriate management is needed to address this aspect which is part of an overall approach to treating wounds.     

Resolution of a leg ulcer after hysterectomy for huge uterine myoma

Venous ulcers are the most common type of leg ulcers, accounting for 80% to 90% of cases. We report a large, therapy-resistant ulcer present for three months on the right leg of a 44-year-old woman who also had a huge uterine myoma. Without any other treatment, the leg ulcer regressed spontaneously three months after a hysterectomy for the uterine myoma that had been demonstrated in a CT image to be compressing the right common iliac vein in the pelvis. Uterine myoma can become the cause of venous insufficiency of the leg, when it is big enough to disturb the blood circulation in the pelvis in individuals who have incompetent perforating veins.