Excision of lipodermatosclerotic tissue: an effective treatment for non-healing venous ulcers

In longstanding venous ulcers, the development of lipodermatosclerosis of the skin surrounding the ulcer is common. According to our clinical experience lipodermatosclerosis impairs the opportunities for the ulcer to heal. In this combined retrospective and prospective study the lipodermatosclerotic skin area was excised in 7 non-healing venous ulcers and then covered with split skin graft. All 7 legs had previously been treated with superficial venous surgery. Laser Doppler scanning of the ulcer area was performed pre- and postoperatively. Five of the 7 ulcers healed within 4 months and 1 healed within 9 months. Laser Doppler scanning showed increased blood flow in the lipodermatosclerotic skin area, which was decreased after the operation. This study indicates that excision of the lipodermatosclerotic skin area followed by split skin grafting can accomplish healing in non-healing venous leg ulcers that have failed to respond to previous superficial venous surgery.     

Kompressionsstrumpf zur Behandlung des venösen Ulcus cruris Eine effiziente Alternative zum Verband

Background and Objective. The aim of the study was to measure the pressure exerted on the skin with application of the specially designed UlcerCare^® compression stocking for treatment of chronic venous leg ulcers and simultaneously to objectify the improvement in venous function. Patients/Methods. Twenty patients with chronic venous insufficiency according to the CEAP Classification C_1–4 E_p A_S, A₁₄, A_p, P_R were examined. Static exerted pressure was measured while standing and the dynamic equivalent was measured during 10 repetitions of tip-toe exercise. The patients were wearing the standard stocking JOBST Medical LegWear UlcerCare^® (Beiersdorf AG, Hamburg, Germany). As a control for the effectiveness of the therapy on venous hemodynamics, the lower leg volume, calculated using optoelectronically-measured lower leg circumference and venous reflux, determined by strain gauge plethysmographically-measured venous refill time, were used. Results. Use of the compression stocking system UlcerCare^® resulted in a decreased lower leg volume. This decrease was on average 5.3%, corresponding to 106±78 ml (p<0.001). The calf and forefoot venous function parameters also improved. The venous refill time improved from 27.2±15.2 s to 45.0±27.4 s at the forefoot (p<0.003) and from 10.5±4.5 s to 19.4±10.9 s at the calf (p<0.002). The exerted pressure at the ankle while standing was 46.2±24.2 mmHg (resting pressure) and 48.5±27.2 mmHg during repetitive tip-toe exercises (mean exercise pressure). At the calf, the exerted pressure while standing was 40.7±26.9 mmHg (resting pressure) and during the repetitive tip-toe exercises it was 42.1±29.5 mmHg (mean exercise pressure). Conclusions. The exerted pressure of the UlcerCare^® compression stocking is equivalent to that of a class 3 medical compression stocking. This newly developed stocking diminishes venous reflux and reduces leg edema. These objectified effects suggest that the UlcerCare^® stocking is effective as compression therapy for venous ulcers.     

Surgical removal of ulcer and lipodermatosclerosis followed by split-skin grafting (shave therapy) yields good long-term results in "non-healing" venous leg ulcers

The purpose of this study was to evaluate the long-term effects of shave therapy in non-healing venous leg ulcers. Forty-one patients with 75 recalcitrant leg ulcers caused by primary deep vein incompetence or post-thrombotic syndrome were operated by shave therapy (removal of ulcer and surrounding lipodermatosclerosis with a Schink skin-grafting knife and covering of the wounds with meshed split-thickness skin grafts). After an average follow-up period of 2 years and 5 months all patients were evaluated for long-term results. The healing rate of ulcers classified as non-healing was 67% (50 of 75 ulcers). The healing rate was 76% for ulcers associated with primary deep vein incompetence and 58% for ulcers associated with post-thrombotic syndrome (p = 0.08). Even in cases with recurrence (33%) these ulcers were strikingly reduced by 80-90% of their original size. Hypaesthesia was noticed in 38% of the transplanted areas. In "non-healing" venous leg ulcers due to deep venous insufficiency shave therapy yields favourable long-term results. Because it is only a symptomatic treatment which does not reduce the pathological refluxes, continuous compression of the lower leg is important.     

Rund‐ oder Flachstrickversorgung in der Erhaltungstherapie beim Beinlymphödem? – Übersicht von Literatur und technischen Daten

To date, there have been no studies comparing flat‐knit and round‐knit compression garments for maintenance therapy of lymphedema of the leg. According to expert opinion, flat‐knit fabrics are generally recommended for this purpose. Given the differences in the clinical presentation of lymphedema in terms of disease stage and location as well as patient adherence, and, last but not least, for economic reasons, it seems questionable whether all patients with lymphedema of the leg actually do require flat‐knit compression garments. Considering technical aspects, published data and our own clinical experience, it seems reasonable that the choice of compression stockings be based on clinical findings and not on the diagnosis. Typical indications for flat‐knit garments include significant differences in leg circumference as well as deep skin folds and edema of the toes/forefoot. However, there are also patients with lymphedema who benefit from round‐knit fabrics with a high degree of stiffness. In any case, prior to maintenance therapy, it is essential to adequately decongest the legs using compression bandages and/or adaptive compression systems.     

Survey of registered nurses’ selection of compression systems for the treatment of venous leg ulcers in the UK

Background

Venous leg ulceration is common in older adults in the United Kingdom. The gold-standard treatment is compression therapy. There are several compression bandage and hosiery systems that can be prescribed or purchased, but it was unclear what types of compression systems are currently being used to treat venous leg ulceration within the UK. This online scoping survey of registered nurses sought to (1) to identify what compression systems are available across the UK, (2) how frequently these are in use and (3) if there are any restrictions on their use.

The pathogenesis of lipodermatosclerosis: facts, uncertainties and theories

Lipodermatosclerosis is the accepted term for describing induration of the skin and subcutaneous layers of the legs in patients with venous insufficiency. The pathogenic processes leading from venous insufficiency to lipodermatosclerosis are poorly understood. Based on their clinico-pathological studies of different subcutaneous indurative disorders, the authors suggest that lipodermatosclerosis exhibits similarities to eosinophilic fasciitis and other fasciitis panniculus syndromes. The theories of the pathogenesis of lipodermatosclerosis are reviewed and a unifying pathogenetic concept is proposed. The lipodermatosclerosis is best conceived as fasciitis paniculata reaction evolving in the calf of the patient with venous insufficiency.     

Acute lipodermatosclerosis: an open clinical trial of stanozolol in patients unable to sustain compression therapy

Acute lipodermatosclerosis (ALDS) is a painful counterpart of chronic lipodermatosclerosis (LDS) resulting from venous insufficiency. Severe pain is the leading symptom and many patients with ALDS are unable to tolerate compression therapy. We evaluated clinical efficacy of stanozolol (2 mg bid for 8 weeks) for the reduction of pain and dermal-thickness in 17 patients with ALDS. All patients had superficial venous insufficiency documented by duplex scans, and in all of them incompetent perforators were found under the area of ALDS. Mean pain scores prior to institution of stanozolol (7+/-2; range 4-10) lowered significantly at the end of the 8-week treatment (3+/-2; range 0-5, p<0.001). Dermal thickness was also significantly reduced (p<0.01) over the treatment period. Side effects were not noted. Stanozolol, given over 8 weeks, effectively and safely alleviates pain and reduces dermal thickness in patients with ALDS.     

The lived experience of recurrence prevention in patients with venous leg ulcers: An interpretative phenomenological study

Aim of the studyTo explore patient understanding of why they develop a venous leg ulcer and how they can prevent recurrence.MethodThe methodological framework of the hermeneutic phenomenological approach was used. Semi-structured interviews were conducted with seventeen participants living with a venous leg ulcer from May 2017 to November 2018. Data were analysed using Smith's interpretative hermeneutic analysis.ResultsThe results are categorised into three main themes: “Trauma due to accident” (initial venous leg ulcer) and “Prevention of ulcer recurrence” (compression); “Trauma due to compression therapy” (venous leg ulcer recurrence). The findings demonstrate active venous leg ulcers are often caused by acute incidents while carrying out an activity in people with underlying chronic venous insufficiency. After a complete healing, preventive measures, such a compression stockings are initiated by the patient or health care provider. Trauma due to adherence to compression stockings caused skin breakdown beneath compression that caused subsequent ulcer recurrence.ConclusionThis study contributes to understanding the lived experience of patients with venous leg ulcers who develop a venous leg ulcer and their understanding of how they can prevent recurrence. Patients with VLUs would benefit from early preventive strategies, such as such a compression stockings fitting and application, integrated into daily care plan of primary care and community settings.     

Increased expression of platelet-derived growth factor receptor alpha and beta and vascular endothelial growth factor in the skin of patients with chronic venous insufficiency

Abstract Growth factors produced by a variety of cells act as signalling peptides through specific cell surface receptor pathways. Functions such as cell proliferation, migration and differentiation have been assigned to each of them. Here, we report alterations of platelet-derived growth factor receptor alpha (PDGFR-α) and beta (PDGFR-β) and vascular endothelial growth factor (VEGF) expression patterns in the progressive clinical stages of chronic venous insufficiency (CVI). A total of 30 punch biopsies were taken from patients with CVI, and VEGF and PDGFR were detected by indirect immunofluorescence and immunoperoxidase techniques. PDGFR-α and PDGFR-β expression was strongly increased in endothelial cells of capillaries, pericapillary cells and connective tissue cells in the stroma of the skin of venous eczema and venous leg ulcer patients, and to a smaller extend in the dermis of those with lipodermatosclerosis. VEGF staining showed a similar expression pattern in the progressive CVI stages. However, staining of vessels in particular might simply reflect binding of VEGF, secreted by keratinocytes or fibroblasts, to its receptors. Growth factor and receptor expression in specimens from telangiectases and reticular veins, and from pigmented areas, resembled that of normal skin. We conclude that PDGFR-α, PDGFR-β and VEGF play an important role in mediating inflammation and epithelial hyperproliferation in venous eczema, inducing connective tissue sclerosis in lipodermatosclerosis, and causing the reduced reepithelialization tendency in venous ulcers. We speculate that endothelial proliferation with chronic venous hypertension might be mediated by these growth factors. Received: 1 April 1997     

Modulation of urokinase-type and tissue-type plasminogen activator occurs at an early stage of progressing stages of chronic venous insufficiency

Chronic venous insufficiency (CVI) progresses through a series of clinical stages, from healthy skin to poorly healing leg ulcers. The aim of this study was to analyse the distribution pattern and activity level of urokinase-type (uPA) and tissue-type plasminogen activators (tPA) in normal skin and in tissue biopsies of progressing stages of CVI, prior to and including venous ulceration. Biopsies 6 mm thick were taken from 14 healthy volunteers and 37 patients with 5 different stages of CVI: telangiectases; stasis dermatitis; hyperpigmentation; lipodermatosclerosis; and leg ulcer. Changes in the enzymatic activity and spatial localization of uPA and tPA during the progression of CVI were examined using in situ histological zymography. Normal skin and skin with telangiectases showed a punctate PA activity, consisting of both uPA and tPA activity. As CVI progressed, an increase in the distribution of uPA and a decrease in tPA activity was observed. The spatial localization of uPA was widespread within the dermis of biopsies from stasis dermatitis and lipodermatosclerosis and was associated in particular with the dermoepidermal junction. Hyperpigmented skin revealed a pattern of PA expression similar to that of healthy skin. However, leg ulcer specimens exhibited peak levels of uPA with little tPA. Furthermore, a plasminogen-independent protease activity that was not present in any of the earlier stages of CVI appeared. Our results indicate that there are profound changes in PA activity during the progression of CVI and that these changes begin early in CVI, for example, in stasis dermatitis. We hypothesize that the balance or imbalance of the PA activity in the later stages of CVI is an important pathogenic factor for the development of venous leg ulcer.     

Protein C and protein S plasma levels in patients with lipodermatosclerosis and venous ulceration

Lipodermatosclerosis of the lower extremity, with or without ulceration, is a common manifestation of severe venous disease and the result of sustained venous hypertension. The latter is generally a sequela of deep vein thrombosis. Factors that enhance clot formation or impair fibrinolysis contribute to the pathogenesis of venous disease. It is already established that faulty fibrinolysis may play a pathogenic role in patients with venous disease. We examined the possibility that patients with venous disease have abnormally low plasma levels of proteins C and S, two proteins whose deficiencies have been reported to cause an increased frequency of thromboembolic disease. Using immunologic and functional assays for plasma proteins C and S, we found that 4 (21%) of 19 patients with lipodermatosclerosis and leg ulcers had abnormally low levels of protein C or protein S. One of 7 patients with lipodermatosclerosis without ulceration had a profoundly depressed level of protein C and a history of cerebral stroke at a young age. Plasma levels of protein C were normal in five patients with arterial insufficiency severe enough to cause leg ulceration. We conclude that abnormally low plasma levels of proteins C and S may be found in patients with lipodermatosclerosis and venous ulceration. As with the abnormally low fibrinolytic activity in these patients, our findings indicate a possible propensity for increased thrombotic disease.     

An impressive therapeutic result of class III compression stockings in a patient with longstanding, extensive, combined leg ulcers

BACKGROUND: Only a few publications are available in the literature concerning the treatment of venous leg ulcers by means of medical compression stockings. SUBJECT: A 59-year-old female patient with longstanding, extensive bilateral leg ulcers due to venous insufficiency, arteriolosclerosis and secondary lymphoedema, was treated successfully by flat-knitted medical compression stockings of compression-class III. CONCLUSION: The great advantage of this treatment is the fact that it is comfortable and easy to carry out at home. Furthermore, the costs of compression therapy with medical compression stockings are only a fraction of those of conventional therapy by means of compressive non-elastic bandages. Once or twice weekly visits of the patient to the hospital are not necessary and less specialized dermatological nurses are needed.     

Acute lipodermatosclerosis in a pendulous abdomen

A 54-year-old female developed tender, hot, erythematous skin at the apex of a large pendulous abdomen at the same time as she became symptomatic with congestive cardiac failure secondary to respiratory failure. Clinically and histologically the changes in the abdominal-wall skin resembled lipodermatosclerosis, a condition normally seen in the legs secondary to chronic venous insufficiency.     

Erosive pustular dermatosis of the leg associated with compression bandaging and fungal infection

BACKGROUND: Erosive pustular dermatosis of the leg (EPDL) has been described in association with venous insufficiency and atrophy of the skin of the lower leg. Like erosive pustular dermatosis of the scalp, this disease has also been reported to be a non-infective condition. OBJECTIVES: To investigate the clinicopathological features and, where possible, the aetiology of clinical EPDL. METHODS: We identified a group of patients undergoing continuous compression bandaging for venous dermatitis of the legs and/or predominantly venous leg ulceration with clinical features described in patients with EPDL. They were investigated by skin biopsy, patch testing and microbiological tests for the presence of bacteria and fungi. RESULTS: Twenty-four of 400 (6%) patients were noted to have pustules on the leg(s). There was laboratory evidence of fungal infection in 13 of 24 patients (54%), with complete and sustained resolution of pustules after antifungal treatment. Pustulation in the other 11 patients (46%) was unresponsive to antibiotics for confirmed bacterial infection; some improvement was seen with potent topical corticosteroids but full clearance was achieved only after a switch from continuous four-layer compression bandaging to the use of intermittent long stretch compression. CONCLUSIONS: EPDL is a fairly common clinical picture seen in patients undergoing continuous compression bandaging. It may be produced by opportunistic, particularly fungal, infection. In almost half an infective aetiology cannot be demonstrated and a pyoderma gangrenosum-like process may be implicated.     

Lipodermatosclerosis

The most commonly recognized form of lipodermatosclerosis (LDS), chronic LDS presents with induration and hyperpigmentation of the skin involving the one or both of the lower legs in a characteristic “inverted champagne bottle” appearance. Associated with venous insufficiency, LDS is most common in middle aged women. In addition to chronic LDS, an acute form may also occur and is often misdiagnosed as cellulitis, inflammatory morphea, or erythema nodosum. The “acute” refers to the symptoms present that are exquisite pain. Treatment of LDS is based on the clinical presentation with compression therapy as the mainstay of treatment if tolerated. For acute LDS, patients often cannot tolerate compression therapy due to pain. We advise the use of fibrinolytic therapy, if available, until the patient can tolerate compression stockings.     

Once daily 300 mg aspirin with compression versus compression alone in patients with chronic venous leg ulcers (ASPiVLU): A randomised,double-blinded,multicentre, placebo-controlled,clinical trial

AimVenous leg ulcers are lower limb skin ulcers characterised by a cycle of healing and recurrence due to underlying chronic venous insufficiency. While compression improves healing outcomes, many ulcers do not heal. As a daily 300 mg oral dose of aspirin in conjunction with compression may improve healing outcomes, we investigated the effect of adjuvant aspirin on venous leg ulcer healing in participants already receiving compression.Materials and methodsWe conducted a prospective, randomised, double-blinded, placebo-controlled, clinical trial (known as ASPiVLU). Participants were recruited from six wound clinics in Australia. We screened 844 participants. Community-dwelling adult participants identified at six hospital outpatient clinics and clinically diagnosed with a venous leg ulcer present for 6+ weeks were eligible between April 13, 2015 to June 30, 2018. We randomised 40 participants (n = 19 aspirin, n = 21 placebo) and evaluated against the primary outcome. There were no dropouts. Ten serious adverse events in six participants were recorded. None were study related. The primary outcome measure was healing at 12 weeks based on blinded assessment.ResultsWe found no difference in the number of ulcers healed at 12 weeks between the intervention and control groups.ConclusionThis study could not detect whether or not aspirin affected VLU healing speed. This is likely because we recruited fewer participants than expected due to the high number of people with venous leg ulcers in Australia who were already taking Aspirin; future research should investigate other adjuvant therapies or different study designs.     

Fine structural deformation of the dermal capillary following immersion fixation procedure

The possibility of fine structural deformation related to skin biopsy and the subsequent immersion fixation procedure were investigated, because little attention has yet been focused on artifacts of the dermal microvasculature. Contraction of the material following biopsy removal was marked in skin regions with thin epidermis and resulted in capillary collapse. As the collapse of the vessels increased, lining cells became thicker and more rugged, endothelial fenestrations disappeared, and 10 nm filaments aggregated. Simultaneously, perivascular connective tissue material was separated from the dermal element in which the vessels were embedded and appeared as a homogenous areola around the endothelial tube. Basal lamina appeared folded and partially multilaminated around the vascular circumference, particularly in the venous segment of the microvasculature; these are considered to be the definite characteristics of dermal capillaries. In contrast to the skin regions with thin epidermis, the vessels in “well developed” dermal papillae did not collapse and bore close similarities to the perfused ones. The present study indicates that most of the so-called characteristics of dermal capillaries in biopsy skin is attributable to artifacts following the removal of the skin before fixation.     

Quantitative echographic analysis of photochemotherapy on systemic sclerosis skin

Systemic sclerosis (SSc) is a connective tissue disease of unknown etiology, in which development of fibrosis, vascular insufficiency and inflammatory processes are prominent in the skin as well as in other organs. We studied the effect of photochemotherapy with quantitative echography in SSc. Dermal echo intensity and dermal thickness was measured using high-frequency dermal echography before and after therapy. The dermal echo intensity after photochemotherapy (33.51±9.34) significantly increased than that before therapy (21.23±6.00) (P<0.01), while dermal thickness (1.20±0.20) significantly decreased than that before therapy (1.38±0.18) (P<0.05). Photochemotherapy was more likely to improve dermal edema, not fibrosis, because echo intensity after treatment was significantly elevated with that before treatment in patients with edema. Quantitative echographic analysis was concluded to be a reliable method in evaluating the change of skin edema in SSc.