Eccrine syringofibroadenoma in a patient with a burn scar ulcer

A 72-year-old woman with a burn scar on the calves of both legs developed an ulcer on her right heel, surrounded by multiple verrucous nodules and plaques. She had experienced similar verrucous lesions on both legs in the burn scar areas. Although the clinical diagnosis was Marjolin's ulcer, histologically the ulcer region showed thick fibrous tissue without any atypical epithelial cells. The verrucous lesions were consistent with the diagnosis of eccrine syringofibroadenoma (ESFA). Moreover, an ESFA-like growth pattern was seen in the elevated margin of the ulcer. Our findings suggest that these lesions developed as a result of reactive eccrine duct hyperplasia followed by skin tissue remodelling.     

Lower extremity ulcer image segmentation of visual and near‐infrared imagery

Background/purpose: We propose an automatic ulcer segmentation system with a simple manual correction possibility. In addition to visual color information, we use near‐infrared (NIR) images because NIR can penetrate deeper into tissue than visual light. The system is able to measure the surface area of a lower extremity ulcer segmented at its different stages and constructs corresponding healing curves over time. This knowledge is useful in monitoring lower extremity ulcers and helps clinicians select the most efficient therapy. Methods: Eighteen lower extremity ulcers and one ulcer on the back were examined from 17 patients. The patients were elderly individuals residing in the long‐term care department of the Vaasa city hospital. One of the patients (P14) had been diagnosed with diabetes. The inclusion criteria for patients were an ulcer with a suitable size for the imaging device and the free will to volunteer. We developed a four‐band spectral digital camera to image the reflectance of the skin. We use the spectral image pixels, in visual light and NIR, in analysis of lower extremity ulcers. For segmentation, the support vector classifier was found to be the best one. The segmentation system is designed to analyze three main ulcer tissue classes: black/necrotic, yellow/fibrous and red/granulation tissue. Results: The experiments conducted confirm the feasibility of our approach. In most cases, the computed healing curves correspond to those made manually. The maximum error rate of ulcer area measurement for red/granulation tissue is 33% for 20 cases. This corresponds to the results published in the literature. The black/necrotic tissue may be located deeper under the skin surface; hence, the ulcer boundaries are not well defined, allowing only a rough estimate, yielding a maximum error of 44% for the three cases analyzed. For yellow/fibrous tissue, we had only one image in our database, whose error value is 23%. Conclusion: We propose a new imaging system for segmentation and measurement of different kinds of ulcers. This system is useful in practice for analysis and measurement of ulcer surface areas and observation of their change over time, which helps clinicians in the treatment of ulcers.     

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.     

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.     

The biomechanics of heel ulcers

Heel ulcers are common, dangerous and costly, but their etiology is poorly understood and no biomechanical studies were conducted to explore it. This paper describes a biomechanical investigation of heel ulcers using a theoretical model that characterizes the internal mechanical loading at the soft tissues of a supported heel. The study is aimed first at identifying some heel-ulcer-specific risk factors pointed out by the biomechanical theory, and second, at demonstrating the kind of support that biomechanical theory and computer modeling can offer in the conduct of clinical studies in the pressure ulcer field. The modeling demonstrated that atypical foot anatomies characterized by heavy-weight foot, sharp posterior calcaneus and thin soft tissue padding are theoretically more prone to heel ulcers. Diabetes and edema at the feet were also predicted to impose risks for heel ulcers, which agrees very well with clinical observations. This paper therefore demonstrated that a biomechanical theory can be used to explain and interpret clinical and epidemiological findings related to heel ulcers.     

糖尿病足溃疡创面的综合治疗

目的探讨促进糖尿病足溃疡创面愈合,降低致残率的方法。方法对糖尿病足溃疡患者,在内科治疗稳定病情的基础上,采用以创面清创换药,改善局部血运和促进局部组织生长,或采用手术的方法治疗。结果52例糖尿病足溃疡创面,除1例因溃疡坏疽创面较深大合并骨髓炎行截肢治疗,其余均顺利修复。随访,出现溃疡复发或有新的皮肤溃疡者8.5%,疗效满意率91.5%。结论在全身治疗稳定病情的基础上,积极进行创面处理和手术的综合治疗是促进糖尿病足溃疡创面早期愈合,缩短病程和降低致残率切实可行的方法。重视糖尿病足患者溃疡愈合出院后的康复指导工作至关重要。     

Predisposing factors for recurrent skin ulcers in leprosy

This study was designed to determine the factors associated with recurrence of leprosy ulcers. Between April and August 1992, 55 consecutive leprosy patients admitted with skin ulcers were studied. Factors predisposing to recurrence, e.g. patient's age, disease duration, ulcer site, ulcer depth and physical deformity (taking into account neuromuscular and skeletal damage) were evaluated. Ulcer recurrence occurred in 40/55 (75%) patients. Recurrent ulceration was associated with location in the lower extremity (P = 0.02), where recurrences were more common in the midfoot and heel (P = 0.01). Recurrence was also associated with severity of physical deformity (P = 0.01), which increased the odds of recurrent ulceration by 4.2 times (95% confidence interval, 1.01-18.3). The severity of physical deformity itself was associated with the age of the patient (P = 0.04) and the disease duration (P = 0.02). In conclusion, there is a need to focus on identification of risk factors for recurrent leprosy ulceration. Targeted prevention strategies would be required if morbidity associated with recurrent skin ulceration is to be avoided.     

Utilization of living bilayered cell therapy (Apligraf) for heel ulcers

Among lower extremity chronic wounds, heel ulcers present one of the greatest challenges to the wound care provider. The potential for these ulcers to progress to osteomyelitis of the calcaneus is well known. The concept of "what to take off the wound" is a known clinical axiom; however, extensive debridement or surgical reconstruction including a partial calcanectomy can significantly impair the patient's ambulation, balance, and overall functional mobility. Critical to the wound healing process is the need to replace damaged cells. The use of cellular therapy to achieve wound closure has added to the armamentarium of the wound care specialist. Among several commercially available advanced wound products, the Food and Drug Administration has approved only 1 living bilayered cell therapy (Apligraf) for use with standard therapy in the treatment of venous ulcers, as well as for full-thickness neuropathic diabetic foot ulcers. Apligraf has the capability to express multiple growth factors found in normal skin, thus potentially providing a biologically active matrix in the wound. This case review summarizes the use of living bilayered cell therapy in 10 heel ulcerations. The use of Apligraf with appropriate pressure offloading resulted in effective wound closure, leading to an alternative care plan for patients with heel ulcers.     

The cuticular purse string suture: a modified purse string suture for the partial closure of round postoperative wounds

BACKGROUND: The purse string suture can be used to provide primary closure for small skin defects or as a partial closure for larger round wounds. The size of the defect is reduced secondary to the tension placed on the suture, which uniformly advances the skin from the entire periphery of the wound. METHODS: We reviewed retrospectively the features of 98 consecutive patients for whom a total of 100 cuticular purse string sutures were used to partially close their postoperative surgical defects. The location and types of the tumors removed were also summarized. RESULTS: Postoperative wounds were created following Mohs' micrographic excision of nonmelanoma skin cancer (basal cell carcinoma, 44; squamous cell carcinoma, 25), wide local excision of melanoma (29), or conservative excision of benign cutaneous neoplasms (two). The incidence of purse string suture for partial closure of each tumor was 4.1% for basal cell carcinoma, 7.3% for squamous cell carcinoma, and 46.3% for melanoma. The tumors were equally distributed on the trunk, head and neck, and extremities; however, purse string closures for basal cell carcinomas were more frequent on the trunk, head, and neck, relative to squamous cell carcinomas and melanomas, which were more common on the extremities. Concurrent medical problems and/or the use of an agent with anticoagulant or antiplatelet effects were noted in more than 50% of patients. Absorbable material of thicker diameter was most frequently used for the suture, and the postoperative wound area decreased by 6-90% (mean, 60%) following purse string partial closure. The suture was usually removed after 3-4 weeks. Postoperative complications occurred in six patients: allergic contact dermatitis in two, wound infection in two, exuberant granulation tissue in one, and hypertrophic scar in one. All of the wounds healed completely with either a round or linear scar. CONCLUSION: The cuticular purse string suture is a rapid and simple procedure that provides complete or partial closure of round skin defects and excellent long-term cosmetic and functional results. This closure provides uniform tension to the wound, enhances hemostasis at the tissue edge, and significantly decreases the size of the defect. Partial wound closure with the purse string suture may be advantageous following the local excision of melanoma, either as definitive surgical wound management or as a temporary partial wound closure prior to subsequent complete repair of the surgical defect. The purse string suture is also useful following nonmelanoma skin cancer removal in patients who insist on maintaining an active lifestyle in the immediate postoperative period, who are receiving one or more systemic anticoagulant and/or antiplatelet agents, and who have large surgical wounds that would require either a skin graft or a local cutaneous flap in order to close the postoperative defect.     

Nicorandil-induced leg ulceration without mucosal involvement

We report a case of leg ulceration occurring in a patient without mucosal ulcers, in whom nicorandil appeared to be the main aetiological factor. Having failed to heal on compression therapy, the ulcer rapidly improved and healed after the discontinuation of nicorandil. Most cases of nicorandil-induced ulcers reported in the literature develop on mucosal surfaces, including oral, vulval, perianal and peristomal ulcers. There are rare reports of cutaneous ulceration attributable to nicorandil, occurring concurrently with mucosal ulcers. To our knowledge, this is the first case of nicorandil-induced leg ulceration affecting the skin without mucosal involvement.     

The mechanism of persistent undermining of a sacral pressure ulcer: Experimental analyses using a deformable model and examination of skin mobility over different anatomical locations

Undermining is an important issue in the treatment and care of deep pressure ulcers. The frequency of the undermining over different bony prominences varies. In particular, deep pressure ulcers over the sacrum exhibit undermining more frequently than those occurring over the heel. Although shear force has been suggested as a critical factor in undermining, the exact mechanism remains unclear due to ethical and technical reasons in clinical practice. To clarify this issue, a deformable model was constructed to recreate the physical and morphological properties of a pressure ulcer with persistent undermining. The model was constructed using urethane to recreate the physical properties of a pressure ulcer. To examine the clinical relevance of the model, mechanical properties of the skin and the model were measured using a durometer. The model was further mounted onto a phantom that was laid on a bed. Backrest elevation of the bed induced deformities in the urethane model, suggesting a mechanism of persistent undermining of the sacral pressure ulcer. Moreover, a simple palpation examination in elderly volunteers revealed that the skin over the sacrum was more mobile than the skin over the heel. Therefore, persistent undermining is likely caused by specific external forces and the characteristic skin mobility of the sacral region. These two different factors explain the frequent undermining that occurs in sacral pressure ulcers.     

Cultured allogeneic skin cells are effective in the treatment of chronic diabetic leg and foot ulcers.

Diabetic ulcers on the lower extremities present a difficult treatment problem, and some ulcers respond poorly to conventional topical and cast treatment. The purpose of this study was to assess the effect of cultured allogeneic keratinocyte epithelium and fibroblast-gelatin sponge on the healing of chronic, refractory diabetic leg and foot ulcers. Non-diabetic chronic leg ulcers were treated for comparison. This open study comprised 22 patients with type I or type II diabetes and 16 patients with leg or ankle ulcers of different aetiologies. A total of 26 diabetic and 25 non-diabetic ulcers were treated mainly with keratinocyte epithelium and/or fibroblast-gelatin sponge once weekly until complete healing or until no further healing could be observed despite several repeated treatments. The duration of diabetic ulcers was 10.3+/-15.8 (mean+/-SD) months and the size 3.1+/-6.6 cm2. The diabetic ulcers were located in the heel (7), toe (7), sole (5), leg (6) and Achilles (1). The mean duration of non-diabetic ulcers was 6.8+/-6.0 months and the size 10.5+/-11.8 cm2. A total of 12+/-11 skin cell transplantations were performed for the diabetic ulcers. All but 1 diabetic ulcer healed during the study. The time for 50% reduction in ulcer area was 32+/-32 days, but 99+/-110 days were needed for complete ulcer closure. The longer the ulcer had existed the longer was the healing time. Heel ulcers showed significantly slower healing response than leg, sole and toe ulcers. Preliminary results suggest that both keratinocytes and fibroblasts are equally effective in the healing process. The time required for healing of the diabetic ulcers did not differ markedly from that of the non-diabetic ulcers. The results suggest that cultured allogeneic skin cells used once weekly are effective in the treatment of recalcitrant diabetic ulcers.     

The diabetic foot

Diabetic foot problems are common throughout the world, resulting in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures assist in identifying the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with irremovable casting, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patients' adherence to the effectiveness of pressure relief.     

Nested graft for chronic ulcer in scar tissue after heroin extravasation in a drug addict

IntroductionNested graft is a surgical technique that allows to manage difficult-to-treat medical conditions such as chronic cutaneous ulcers, thanks to the high efficacy it has in reverting the fibroblasts senescence. Because of its peculiar regenerative property, nested graft is a surgical technique suitable also for the treatment of cutaneous ulcers developing on fibrotic scar tissue.Case reportWe reported the case of a 45-year-old man, drug-addict, with a large ulcer on the back of the right forearm in the context of scar fibrotic tissue. This lesion resulted from a previous heroin extravasation treated with a dermo-epidermal skin graft, that was accidentally scratched away by mechanical trauma. After several therapeutic failures with topical medications, we decided to treat the ulcer performing a skin graft using the nested graft technique. No adverse events were reported by the patient during or after the surgery. At the clinical evaluation performed three years later the wound was completely healed.ConclusionsNested graft represents a safe and easy-to-use technique that can be successfully used to treat ulcers on scar tissue, ensuring the achievement and the long-term maintenance of optimal resistance and aesthetic results.     

Association of verrucous skin lesions and skin ulcers on the feet in patients with diabetic neuropathy

We report the simultaneous or chronological association of verrucous skin lesions and diabetic ulcers on the feet of three diabetic patients. All three patients had poor diabetic control and were suffering from complications such as neuropathy, retinopathy and nephropathy at the time of presentation. In patient 1, verrucous skin lesions on the feet in diabetic neuropathy (VSLDN) and a diabetic skin ulcer developed simultaneously. In patient 2, VSLDN preceded the development of diabetic ulcers, while in patient 3, diabetic ulcers preceded VSLDN. These associations suggest that VSLDN and diabetic ulcers are closely related in their aetiology and pathogenesis. Strategies for the treatment and prevention of VSLDN should include multiple treatment modalities combined with foot care as proposed by the international working group on the diabetic foot.     

Autologous full-thickness skin substitute for healing chronic wounds

BACKGROUND: Chronic wounds represent a major problem to our society. Therefore, advanced wound-healing strategies for the treatment of these wounds are expanding into the field of tissue engineering. OBJECTIVES: To develop a novel tissue-engineered, autologous, full-thickness skin substitute of entirely human origin and to determine its ability to heal chronic wounds. METHODS: Skin substitutes (fully differentiated epidermis on fibroblast-populated human dermis) were constructed from 3-mm punch biopsies isolated from patients to be treated. Acellular allodermis was used as a dermal matrix. After a prior 5-day vacuum-assisted closure therapy to prepare the wound bed, skin substitutes were applied in a simple one-step surgical procedure to 19 long-standing recalcitrant leg ulcers (14 patients; ulcer duration 0.5-50 years). RESULTS: The success rate in culturing biopsies was 97%. The skin substitute visibly resembled an autograft. Eleven of the 19 ulcers (size 1-10 cm2) healed within 8 weeks after a single application of the skin substitute. The other eight larger (60-150 cm2) and/or complicated ulcers healed completely (n = 5) or continued to decrease substantially in size (n = 3) after the 8-week follow-up period. Wound healing occurred by direct take of the skin substitute (n = 12) and/or stimulation of granulation tissue/epithelialization (n = 7). Skin substitutes were very well tolerated and pain relief was immediate after application. CONCLUSIONS: Application of this novel skin substitute provides a promising new therapy for healing chronic wounds resistant to conventional therapies.     

A case of chromomycosis in a nonendemic region

A 43-year-old miner of the Donetsk coal fields is described, who developed in a month after a microinjury of the skin of the thoracic left side an intumescence and skin reddening. Later an agglomeration of nodules formed there with small ulcers regularly appearing, that did not heal for a long time. Histologic and bacteriologic analysis confirmed chromomycosis. The disease focus was resected. No recurrences were recorded in the following 8 months. This observation points to a wider prevalence of chromomycosis in a nonendemic area, the European part of the USSR, than it is reported in literature.     

Hepatocyte growth factor; expression, concentration and biological activity in chronic leg ulcers

BACKGROUND: Hepatocyte growth factor (HGF) is a multifunctional cytokine that is involved in recovery process after organ injuries. OBJECTIVE: We studied HGF and the membrane bound receptor, c-met locally in patients who suffered from chronic leg ulcers (> or =1 year) caused by venous insufficiency. METHODS: Skin biopsies from the edge of the ulcers were taken from patients (n=13) and studied by immunohistochemical staining for detection of HGF and c-met. Skin biopsies from healthy volunteers (n=10) were used as the control material. Ulcer secretion from chronic ulcers (n=11) was examined for the presence of HGF by ELISA and the concentration of HGF was compared with acute ulcers in healthy controls (n=10) and in patients operated for a non-invasive breast cancer (n=12). RESULTS: We observed that c-met expression in the ulcer area increased significantly in chronic ulcers compared to controls (p=0.005). Concentration of ulcer-HGF in the patients with chronic ulcer was significantly higher than acute ulcers (p<0.01). The biological activity of HGF in ulcer secret was assessed in-vitro in transferred, mouse skin epithelial cell monolayer. Enhanced migration and morphologic changes were seen after adding ulcer secret from acute ulcers (> 1 ng/mL) that was inhibited by anti-HGF antibodies. No biological activity was observed by adding ulcer secret from chronic ulcers irrespective HGF concentration. CONCLUSION: We conclude that in chronic skin ulcers decreased biological activity of endogenous HGF and overexpression of c-met is seen which might explain fibrosis and delayed recovery. Administration of exogenous active HGF might contribute to accelerated healing in these patients.     

Nicorandil-induced cutaneous ulceration on a pacemaker implantation wound

BACKGROUND: Nicorandil is a potassium-channel activator used to prevent angina. While mucosal ulceration is a well-known adverse effect of this drug, skin ulcers have been described only rarely, and always in association with mucosal ulcers. PATIENTS AND METHODS: An 86-year-old woman presented ulceration on a pacemaker implantation scar despite complete initial wound healing. Nicorandil had been initiated three months earlier. None of the usual causes of ulceration of a pacemaker scar were seen. Complete and permanent wound-healing was achieved 12 days after discontinuation of nicorandil. DISCUSSION: This is the first reported case of cutaneous ulceration on a vulnerable area of skin ascribable to high-dose nicorandil.     

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.