Fibrinolytic abnormalities in two different cutaneous manifestations of venous disease

Chronic venous insufficiency: Part 1 Pathophysiology and Clinical features

Chronic venous disease (CVD) is a commonly encountered disease in dermatology out-patient department and if untreated, may progress to chronic leg ulcer causing serious morbidity to the patient. Also, it affects the quality of life of the affected patient and contributes to the loss of work productivity. The range of clinical manifestations is myriad, ranging from asymptomatic varicose veins and pigmentation to ulceration and scarring. The awareness of spectrum of clinical presentations is required to identify, diagnose and manage CVD. Long standing cases may develop ankle joint stiffness, significant fibrosis causing fixed flexion deformity, periostitis and even, Marjolin's ulcer. Increased venous hypertension, thought to result from incompetent valve and failure of calf muscle pump, is central to the pathophysiology of the development of CVD. Tissue edema, hypoxia and subsequent fibrosis are major immediate contributing factors responsible for the clinical manifestations of CVD. Localized, chronic inflammation is now increasingly being recognized as a key player, directly responsible for stasis dermatitis and hypercoagulable state. The complete ramifications of persistent inflammation in CVD is yet to be understood and serious systemic morbidities like arterial and cardiac disease are increasingly been recognized in association with CVD.

Dermal Changes in the Lower Leg Skin of Patients With Venous Hypertension

Patients with chronic venous disease may develop characteristic changes in the skin of the lower limb known as lipodermatosclerosis (LDS). The affected skin becomes indurated and pigmented and often ulcerates. The degree of induration associated with LDS correlates directly with ulcer formation and leads to a subsequent delayed rate of healing. However, there is limited information regarding the cellular and molecular events that lead from venous dysfunction to LDS development. This article reviews the current knowledge of the clinical progression of chronic venous disease, summarizing the histological findings from these authors’ laboratory and other studies on LDS, and offers possible mechanisms to explain the fibrotic changes associated with this condition.

Does inflammation have a role in the pathogenesis of venous ulcers? A critical review of the evidence

Chronic venous disease, a disorder involving venous return from the legs, is a growing epidemic in the developed world. Numerous studies have been conducted in the past two decades in an attempt to elucidate its underlying pathophysiology. Many theories have been proposed to address the profound inflammatory dysregulation, with the majority focusing on fibrin trap, inflammatory trap, cytokines, growth factors, and matrix metalloproteinases. Although many of these theories have obtained great momentum, much of the data are contradictory. Moreover, many treatments built on these theories have claimed overwhelming success despite insufficient evidence. At the same time, there are few reviews that critically analyze and evaluate these data. Therefore, in this paper, we will provide summaries of the background data and evolution of these theories and examine their supporting evidence.

Dermatologic Complications of Chronic Venous Disease: Medical Management and Beyond

Patients with venous insufficiency commonly develop complications which can result in significant morbidity and occasional mortality. Venous leg ulcers, the most prevalent type of lower extremity ulcer, are the most frequent sequela of venous insufficiency and negatively affect quality of life for the patient. Most have focused on venous ulceration, but other complications may arise including dermatitis, atrophie blanche, lipodermatosclerosis, and malignancy. Contact dermatitis is a common complication seen in the treatment of venous disease. Patients with venous insufficiency have a disrupted epidermal barrier, making them more susceptible than the general population to contact sensitization and subsequent dermatitis. Venous dermatitis is often the first manifestation of venous insufficiency and needs to be addressed promptly. Atrophie blanche, an end point of a variety of conditions, appears as atrophic plaques of ivory white skin with telangiectasias. Lipodermatosclerosis is an indurated plaque in the medial malleolus which can, at times, be quite tender and painful. Malignant degeneration is a rare but important complication of venous disease since tumors which develop in the setting of an ulcer tend to be more aggressive. Pain is a feature of venous disease often overlooked and commonly undertreated. Finally, psychosocial issues such as anxiety and depression are more common in patients with venous disease and should be adequately addressed. Recognizing these complications of chronic venous insufficiency is important as early intervention is the key to preventing unnecessary patient suffering and discomfort.

Lipodermatosclerosis: review of cases evaluated at Mayo Clinic

BACKGROUND

Lipodermatosclerosis describes bound-down, sclerotic skin involving the lower extremities.

OBJECTIVE

Our purpose was to describe the demographic and clinical features of patients with lipodermatosclerosis.

METHODS

This was a retrospective study of patients presenting to Mayo Clinic between 1976 and 1998 with a diagnosis of lipodermatosclerosis.

RESULTS

Of 97 patients, 84 (87%) were women. Mean age was 62 years (range, 25-88 years). Mean body mass index was 34.3 (range, 17.8-71.5). Clinical signs were bilateral involvement in 44 patients (45%), induration localized to a discrete plaque in 49 (51%), erythema in 69 (71%), hyperpigmentation in 57 (59%), ulceration in 13 (13%), concomitant edema in 69 (71%), and varicosities in 55 (57%). Vascular studies performed on 72 patients showed abnormalities in 49: deep venous incompetence in 33 (67%), calf muscle pump abnormality in 19 (39%), abnormal pulsatility in 10 (20%), and obstruction in 1 (2%).

CONCLUSION

Lipodermatosclerosis was associated with female sex, middle age, high body mass index, and venous abnormalities.

Chronic venous insufficiency and venous leg ulceration

Venous ulcers are the most common form of leg ulcers. Venous disease has a significant impact on quality of life and work productivity. In addition, the costs associated with the long-term care of these chronic wounds are substantial. Although the exact pathogenic steps leading from venous hypertension to venous ulceration remain unclear, several hypotheses have been developed to explain the development of venous ulceration. A better understanding of the current pathophysiology of venous ulceration has led to the development of new approaches in its management. New types of wound dressings, topical and systemic therapeutic agents, surgical modalities, bioengineered tissue, matrix materials, and growth factors are all novel therapeutic options that may be used in addition to the "gold standard," compression therapy, for venous ulcers. This review discusses current aspects of the epidemiology, pathophysiology, clinical presentation, diagnostic assessment, and current therapeutic options for chronic venous insufficiency and venous ulceration. (J Am Acad Dermatol 2001;44:401-21.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the 3 main types of lower extremity ulcers and should improve their understanding of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic assessment, and current therapies for chronic venous insufficiency and venous ulcers.

Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997)

This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.

Activated protein C resistance and anticardiolipin antibodies in patients with venous leg ulcers

BACKGROUND

Hypercoagulable states, which include the presence of anticardiolipin antibodies (ACAs), have been associated with skin ulceration. Resistance to activated protein C (APC), resulting from the factor V Leiden mutation, is a common risk factor for venous thrombosis. Its prevalence among patients with venous leg ulcers is not known.

OBJECTIVE

Our purpose was to determine the prevalence of factor V Leiden and ACA in patients with venous leg ulceration.

METHODS

Twenty-nine consecutive patients with venous leg ulcers were studied. Resistance to APC was first determined by functional assay based on the partial thromboplastin time. Patients with an abnormally low APC ratio were then subjected to molecular analysis for confirmation of factor V Leiden. Measurements of ACA were performed by enzyme-linked immunosorbent assay.

RESULTS

APC resistance was detected in 11 of 26 patients. However, only 2 of these 11 patients (7.7% overall) were found to be heterozygous for the factor V Leiden mutation. ACA was present in neither patient with the Leiden mutation but was found in 6 of 21 patients tested (29% overall).

CONCLUSION

The factor V Leiden mutation, unlike ACA, may not be more prevalent in patients with venous leg ulcers than in the general population. Our results emphasize the importance of molecular analysis for factor V Leiden in patients with APC resistance.