Management of venous ulcer disease

Nutrients with Antioxidant Properties and Their Effects on Lower-Limb Ulcers: A Systematic Review

Chronic lower-limb ulcers (LLUs) are ulcers that fail to proceed through an orderly and timely process to produce anatomic and functional integrity. LLUs reduce the quality of life of affected individuals and are a public health problem. The treatment options include medications or surgery. Nutrition therapy is an important adjunct to improve the clinical picture and healing of LLUs. Considering that nutrients with antioxidant properties can improve the process of tissue healing, this systematic review aimed to evaluate the efficacy of antioxidant nutrient supplementation in the treatment of LLUs through randomized clinical trials. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses and the Cochrane Handbook for Systematic Reviews of Interventions. The guiding question was-can antioxidant nutrients help in the treatment of chronic LLUs? In total, 1184 articles were found when searching for antioxidant nutrients associated with the most common causes of LLUs. Fourteen articles were included in this review after removing duplicates, studies with topical and/or venous use of antioxidants, and articles published in other languages, except English. Omega-3 fatty acids, magnesium, zinc, vitamins A, C, D, and resveratrol along with probiotics positively improved the ulcer healing. These effects were more significant when there was initially a deficiency of the respective supplemented nutrients. Therefore, correcting and maintaining an adequate nutritional status can improve ulcer healing and contribute to the clinical treatment of patients with LLUs.

Reconstruction of Foot and Ankle Defects: A Prospective Analysis of Functional and Aesthetic Outcomes

INTRODUCTION

Reconstruction of foot and ankle defects requires selecting an appropriate durable and aesthetically appealing option. From the different options, the procedure's choice depends on the defect's size, location, and donor area's availability. Patients' main goal is to have an acceptable biomechanical outcome.

MATERIALS AND METHODS

In this prospective study, we have included patients who had undergone reconstruction of the ankle and foot defects between January 2019 and June 2021. Patient demographics, location and size of the defect, different procedures, complications, sensory recovery, ankle hindfoot score, and satisfaction score were recorded.

RESULTS

50 patients with foot and ankle defects were enrolled in this study. All flaps survived except one free anterolateral thigh flap. Five locoregional flaps developed minor complications, and all skin grafts healed well. The Ankle Hindfoot Score outcome has no significant relation with the anatomical location of the defects and the reconstructive procedure. All patients reconstructed using random local flap and with free flap were satisfied with the aesthetic outcome.

CONCLUSIONS

Because of limited soft tissue, local flap availability is restricted to small defects. Satisfaction rates are high in local and free flaps and are best suited for reconstructing the weight-bearing part of the foot. Bulky flaps should be avoided over the dorsum and ankle region.

Characteristics of venous leg ulcer patients at a tertiary wound care center

OBJECTIVE

The objective of this study was to assess patient, wound, care, and reflux characteristics of venous leg ulcers (VLUs) to update and improve knowledge of disease etiology, identify barriers to healing, and improve treatment.

METHODS

Patients diagnosed with VLUs treated at the Stanford Advanced Wound Care Center between 2018 and 2019 were identified from the Healogics iHeal database. We identified 327 VLU entries, of which 133 were patients who had multiple or recurring wounds. An additional 27 patients were labeled as misdiagnosis, resulting in a final patient sample of 167. Patient demographics, wound, care, and ultrasound data for these patients were extracted from the Stanford electronic medical records regarding characteristics. The initial data analysis suggested possible differences in VLU characteristics depending on patient age and body mass index (BMI), which was then further analyzed.

RESULTS

Of the 167 VLU patients assessed, 53.9% were male and 46.1% were female. The mean age was 74.7 years, and the average BMI was 30.2 kg/m2, including 41.1% of patients with a BMI over 30 kg/m2. Approximately 50% of wounds were presented in multiples, had cellulitis, or were recurring, and 39.5% were caused by trauma. Most common venous reflux patterns on duplex ultrasound examination were below-knee great saphenous vein reflux and calf perforator reflux, which was identified in 37.7% and 29.3% of the patients, respectively. Axial great saphenous vein reflux was detected in 14.4% of patients. When looking at the patient sample under 60 years of age, 67.7% were male, 61.3% presented with venous skin changes, and 51.6% had diabetes. In the patients older than 60, only 51.9% were male, 37.6% presented with venous skin changes, and 31.6% had diabetes. BMI was greater in the patients under age 60, with an average of 39.2 kg/m2, compared with 28.2 kg/m2 in those above 60. Of the patients with a BMI ≥30 kg/m2, 64.3% had multiple wounds, 61.4% had recurring wounds, and 56.5% had venous skin changes. In contrast, in patients with BMI <30 kg/m2, 47.4% had multiple wounds, 39.2% had recurring wounds, and 32.0% had venous skin changes.

CONCLUSIONS

VLU pathology appears to differ depending on patient demographics and characteristics. Different drivers may influence disease cause, progression, and prognosis, making a standard approach to VLUs difficult. Our findings suggest that identifying different subtypes of VLUs and adapting an algorithm of care with a personalized treatment may help optimize management of these patients.

Clinical validation of a smartphone application for automated wound measurement in patients with venous leg ulcers

Chronic wounds are associated with significant clinical, economic and quality-of-life burden. Despite the variety of wound imaging systems available in the market for wound assessment and surveillance, few are clinically validated among patients of Asian ethnicity. We aimed to clinically validate the accuracy of a smartphone wound application (Tissue Analytics [TA], Net Health Systems Inc, Florida, USA), versus conventional wound measurements (visual approximation and paper rulers), in patients of Asian ethnicity with venous leg ulcers (VLU). A prospective cohort study of patients presenting with VLU to a specialist wound nurse clinic over a 5-week duration was conducted. Each patient received seven wound measurements: one by a trained wound nurse clinician, and three separate wound measurements using TA on each of the iOS and Android operating systems. Inter-rater and intra-rater reliability between clinical and TA-based measurements were analysed using intra-class correlation statistics, with values of <0.5, 0.5 to 0.75, 0.75 to 0.9, and >0.9 indicating poor, moderate, good and excellent reliability, respectively. 82 patients (51% males), with a mean age at 65.8 years, completed the 5-week study duration. 25 (30%) had underlying diabetes mellitus. Chinese, Malay and Indian ethnicity comprised 68%, 12% and 11%, respectively. The VLU healed in 26 (32%) of patients within the study period. In total, 358 wound episodes with 2334 wound images were analysed. Inter-rater reliability for length, width and area between wound nurse measurements and TA application measurements was good (range 0.799-0.919, P < 0.001). Separate measurements of intra-rater reliability for length, width and area within the iOS or Android systems were excellent (range 0.967-0.985 and range 0.977-0.984 respectively, P < 0.001). Inter-rater reliability between TA used on the iOS and Android systems was also excellent (0.987-0.989, P < 0.001). Tissue Analytics, a smartphone wound application, is a useful adjunct for wound assessment and surveillance in VLU patients of Asian ethnicity.

Efficiency of endovenous laser and glue ablation methods in comparison with conventional surgery for the treatment of venous ulcers

Introduction

In this study, we aimed to investigate the efficiency of endovenous laser and glue ablation techniques and compared the results with conventional surgical stripping.

Patients and Methods

Between January 2005 and January 2020, among 3133 consecutive patients with superficial venous reflux disease receiving treatment at our institution, there were 112 consecutive patients with active venous ulcers. Patients were divided into 3 groups as receiving conventional open surgical treatment (Group 1, n: 70), endovenous glue ablation (Group 2, n: 20), and endovenous laser ablation (Group 3, n: 22). Comorbidity factors, duration and size of the ulcers, deep, perforating, and small saphenous vein disease detected with detailed Doppler ultrasonography, and duration for healing and recurrence were investigated.

Results

The age, gender, comorbidities, smoking, history of previous treatment, diameter of the small saphenous vein, number of refluxing perforating veins, size of the ulcer, and ulcer recurrence ratio were not significantly different between groups. There were 7 patients with bilateral disease and in total 119 legs were intervened. Mean durations for complete ulcer healing were significantly lower in Group 1 (53.28 ± 22.1 days) than Group 2 (73.7 ± 39.6 days); however, it did not differ significantly between Group 1 and Group 3 (62.59 ± 19.65 days), and Group 2 and Group 3 ( p: 0.26). Ulcers recurred in 23 patients (33%) in stripping group at a mean follow up of 14.42 ± 4.6 months, in 7 patients (35%) in glue ablation group at a mean follow up of 11.97 ± 2.94 months, and in 5 patients (23%) in laser ablation group at a mean follow up of 12.66 ± 3.48 months ( p > 0.05 for all). Increased body mass index, co-existence of chronic venous insufficiency, active cigarette smoking, non-compliance with physician advises and exercise and compression stockings, and depth of the ulcers were correlated with recurrence.

Conclusion

The rationelle beyond treatment of the venous ulcers and prevention of recurrence relies on relief of the venous hypertension by interventional methods and/or compression therapy. None of the methods is superior over the others. Healing in short term without further recurrence may be achieved with successful intervention as well as good patient compliance.

Decreased mobility, lack of social support, haemosiderosis and use of antidepressant medications may predict recurrent venous leg ulcers within 12 months of healing: A prospective longitudinal study

AIM

To identify clinical, medical and psychosocial predictors of venous leg ulcer recurrence within 12 months of healing.

METHODS

A multi-site study was conducted in Australia in community and hospital outpatient settings. Adults with venous leg ulcers were recruited within 4 weeks of healing and data were collected on preventative treatments and health, medical, clinical and psychosocial factors. Follow-up data on recurrences were collected every 3 months until ulcer recurrence, or until 12 months after healing pending which occurred first. Factors associated with time to recurrence were analysed using a Cox proportional hazards regression model.

DESIGN

Secondary data analysis of a multi-site, prospective longitudinal study to validate a risk assessment tool for recurrence.

RESULTS

A sample of 143 participants was recruited (51% male, M^age = 73 years, SD 13.6). Almost half (49.6%) had an ulcer recurrence within 12 months, with a mean time to ulcer recurrence of 37 weeks (SE 1.63, 95% CI 33.7-40.1). Factors measured at the time of healing that were significant independent predictors of recurrence were: prescribed antidepressant medications (p = .035), presence of haemosiderosis (p = .006), decreased mobility (longer sitting times) (p = .007) and lower social support scale scores (p = .002). Participants who wore compression systems providing 20 mmHg or higher for at least 5 days/week were less likely to recur, although not reaching statistical significance (p = .06).

CONCLUSION

Results provide evidence that antidepressant medications, haemosiderosis, decreased mobility and lack of social support are risk factors associated with ulcer recurrence; therefore, these variables are modifiable and could guide early intervention.

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.

Evaluation of the introduction of the one-stop clinic and dedicated nurses for the ulcer cruris venosum care in the east of the Netherlands

Objective

In the Ziekenhuisgroep Twente Hospital, nurses from two community care organizations were trained to visit patients at home and provide adequate ulcer care. Furthermore, the one-stop clinic was introduced to set a diagnosis and treatment plan at the first visit in the hospital. The purpose of this study was to (a) evaluate if there is a difference in time to wound healing for patients with UCV treated by dedicated nurses compared to treatment by nurses in the Dermatology outpatient clinic and (b) determine if the one-stop clinic setting would lead to a difference in time to wound healing compared to the standard way of care.

Methods

In this retrospective cohort study, all files of patients with an ulcer in the Dermatology department of ZGT between 1 June 2010 and 1 June 2015 were studied.

Results

Out of a total of 385 new patients with an ulcer, 97 cases were included. Patients who were treated by dedicated nurses were significantly older ( p = 0.002) and had larger wounds ( p = 0.008). Age was not significantly related to time for wound closure (HR 0.99; 95% CI: 0.97–1.01, p = 0.226). After adjustment for confounders, there was no significant difference in time to wound closure between dedicated nurses (2.2 months (1.4–3.0)) versus hospital care (2.3 months (2.1–2.6)) (HR 1.01; 95% CI: 0.61–1.67, p = 0.961). The one-stop clinic led to a statistically shorter time to closure of the wound (1.8 versus 2.7 standard way of care, p = 0.007).

Conclusions

Time to wound closure is not statistically different between patients treated by dedicated nurses compared to hospital care when adjusted for the effects of the one-stop clinic. The one-stop clinic gives a significant better chance for faster time to wound closure controlled for both groups.

Biological Mechanisms of Chronic Wound and Diabetic Foot Healing: The Role of Collagen

The treatment of chronic wounds is a continuously developing research focus. The problems of excessive mechanical forces, infection, inflammation, reduced production of growth factors, and lack of collagen will affect the results of treatment. The purpose of this study was to analysse the elements that lead to long-term non-healing of chronic wounds and trophic ulcers, including diabetic foot syndrome, by determining the optimal treatment algorithm. The paper presents an analysis of the world literature on the etiopathogenesis and principles of chronic wound treatment in diabetic foot syndrome. The epidemiology of chronic wounds of different genesis is presented. The issues of physiological and metabolic disorders in chronic ulcers affecting the process of wound healing are discussed. Particular attention is paid to collagen, which is a protein that forms the basis of connective tissue; collagen ensures the strength and elasticity of the skin, which confirms the importance of its role not only in aesthetics but also in the process of wound healing. Different types of collagen and their roles in the mechanisms of chronic wound healing in diabetic foot syndrome are described. The results of clinical studies evaluating the effectiveness of medical products and preparations, consisting of collagen with preserved (native collagen) and fractionated structures, in treating chronic wounds of diabetic foot syndrome are analysed. It has been shown that the use of native collagen preparations is a promising treatment for chronic ulcers and wounds, including diabetic foot syndrome, which makes it possible to increase the effectiveness of treatment and reduce the economic costs of managing these patients.

Autogenously derived regenerative cell therapy for venous leg ulcers

Introduction

Venous leg ulcers (VLUs), which arise from chronic venous insufficiency in the lower limbs, are a major cause of morbidity and significantly negatively impact patients’ health-related quality of life. Treatment of venous ulcers can be either conservative or surgical. Despite appropriate treatment, VLUs can be resistant to healing. Clinical results of treatment of venous foot ulcers with adipose-derived autologous stem cells, which did not improve despite the surgical treatment of the underlying venous pathology in the following case series, are reported.

Material and methods

Between April 2015 and January 2016, a total of 31 patients who had undergone surgery for underlying venous pathology but the venous ulcer had not healed were included in the study. The mean venous ulcer size was 3.6–6.2 cm (range: 2 to 8 cm by 3 to 9 cm). All patients were treated with adipose-derived autologous stem cells prepared using the MyStem Regenerative Adipose-Derived Stem Cell Purification Kit (MyStem LLC, USA). The ulcer diameter was measured and recorded in the third, sixth and twelfth months. The follow-up time was 12 months after ulcer healing.

Results

Eighteen ulcers demonstrated complete healing at the 12^th month. Thirteen ulcers exhibited serious contraction and epithelialization even though the ulcer was not completely closed. At the 12^th month, the ulcer size was reduced by 96.00 ±1.74% in these patients. The reduction in the ulcer area based on the month analyzed was significant (p = 0.001; p < 0.01). After the ulcers healed, the patients were followed for recurrence for one year. Recurrent ulcers were observed at the treated sites in 3 of 31 patients (9%). No adverse events, such as infection, inflammation, or tissue reactions, were observed.

Conclusions

Application of cell therapy in venous leg ulcer is currently used exclusively in patients not responding to the standard treatment. Autogenously derived regenerative cell therapy for VLUs can be considered as an additional treatment to primary surgical therapy.

Local warming therapy for treating chronic wounds: A systematic review

BACKGROUND

Several studies suggest that local warming therapy (LWT) may help to treat chronic wounds, such as pressure ulcers, venous ulcers, arterial ulcers, and diabetic foot ulcers. However, evidence supporting the efficacy of this treatment is still incomplete. This study aimed to assess the effects of LWT in treating chronic wounds.

METHODS

For this review, we searched the Cochrane Wounds Specialized Register (March 6, 2017); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2017 issue 3); Ovid MEDLINE (1946 to March 6, 2017); Ovid Embase (1974 to March 6, 2017); EBSCO CINAHL (1982 to March 6, 2017); Chinese Biomedical Literature Database (1980 to March 20, 2017); China National Knowledge Infrastructure (1980 to March 20, 2017); VIP Information (1980 to March 20, 2017) (Chinese Database); and Wanfang Data (1980 to March 20, 2017). We did not apply date or language restrictions. Published or unpublished randomized controlled trials (RCTs) analyzing the effects of LWT in the treatment of chronic wounds (pressure ulcers, venous ulcers, arterial ulcers, and diabetic foot ulcers) were screened and selected. Two review authors independently conducted study selection, we planned that 2 review authors would also assess risk of bias and extract study data.

RESULTS

No studies (RCTs) met the inclusion criteria for this review. Thus, it was impossible to undertake a meta-analysis or a narrative description of studies.

CONCLUSIONS

The effects of LWT for treating chronic wounds are unclear because we did not identify any studies that met the inclusion criteria for this review. Quality improvement for LWT trials is urgently needed.

Extracorporeal shockwave therapy for the treatment of chronic wound of lower extremity: current perspective and systematic review

The purpose of this study was to provide an up-to-date review for the accurate estimation of the efficacy of extracorporeal shock wave therapy (ESWT) on the healing of chronic wounds on the lower extremity (CWLE). A systematic review of 10 databases for clinical trials about ESWT in the management of CWLE published between 2000 and 2016 was performed. A total of 11 studies with 925 patients were found. Expert therapists assessed the methodological qualities of the selected studies using the Physiotherapy Evidence Database (PEDro) scale and categorised each study according to Sackett's levels of evidence. Eight studies were categorised as level II; two studies were categorised as level III and one study was categorised as level V. In conclusion, this review demonstrated mild to moderate evidence to support the use of ESWT as an adjuvant therapy with a standardised wound care programme. However, it is difficult to draw firm conclusions about the efficacy of ESWT. So, future researches with high methodological quality are required to assess the efficacy and cost-effectiveness of this relatively new physical therapy application.

A single-arm trial indirect comparison investigation: a proof-of-concept method to predict venous leg ulcer healing time for a new acellular synthetic matrix matched to standard care control

To compare data on time to healing from two separate cohorts: one treated with a new acellular synthetic matrix plus standard care (SC) and one matched from four large UK pragmatic, randomised controlled trials [venous leg ulcer (VLU) evidence network]. We introduce a new proof-of-concept strategy to a VLU clinical evidence network, propensity score matching and sensitivity analysis to predict the feasibility of the new acellular synthetic matrix plus SC for success in future randomised, controlled clinical trials. Prospective data on chronic VLUs from a safety and effectiveness study on an acellular synthetic matrix conducted in one wound centre in the UK (17 patients) and three wound centres in Australia (36 patients) were compared retrospectively to propensity score-matched data from patients with comparable leg ulcer disease aetiology, age, baseline ulcer area, ulcer duration, multi-layer compression bandaging and majority of care completed in specialist wound centres (average of 1 visit per week), with the outcome measures at comparable follow-up periods from patients enrolled in four prospective, multicentre, pragmatic, randomised studies of venous ulcers in the UK (the comparison group; VLU evidence network). Analysis using Kaplan-Meier survival curves showed a mean healing time of 73·1 days for ASM plus SC (ASM) treated ulcers in comparison with 83·5 days for comparison group ulcers treated with SC alone (Log rank test, χ2 5·779, P = 0·016) within 12 weeks. Sensitivity analysis indicates that an unobserved covariate would have to change the odds of healing for SC by a factor of 1·1 to impact the baseline results. Results from this study predict a significant effect on healing time when using a new ASM as an adjunct to SC in the treatment of non-healing venous ulcers in the UK, but results are sensitive to unobserved covariates that may be important in healing time comparison.

Mesenchymal stem cell in venous leg ulcer: An intoxicating therapy

Venous leg ulcers (VLU) are a prevalent and reoccurring type of complicated wound, turning as a considerable public healthcare issue, with critical social and economic concern. There are both medical and surgical therapies to treat venous leg ulcers; however, a cure does not yet exist. Mesenchymal stem cells (MSC) are capable and proved of accelerating wound healing in vivo and their study with human chronic wounds is currently awaited. MSCs are a promising source of adult progenitor cells for cellular therapy and have been demonstrated to differentiate into various mesenchymal cell lineages. They have a crucial and integral role in native wound healing by regulating immune response and inflammation. Improved understanding of the cellular and molecular mechanisms at work in delayed wound healing compels to the development of cellular therapy in VLU. This review focuses on the current treatment option of VLU and further emphasizing the role of MSCs in accelerating the healing process. With further understanding of the mechanism of action of these cells in wound improvement and, the involvement of cytokines can also be revealed that could be used for the therapeutic purpose for VLU healing. Clinical uses of MSCs have been started already, and induced MSCs are surely a promising tool or compelling therapy for VLU.

A Double-Blind, Placebo-Controlled Randomized Evaluation of the Effect of Low-Level Laser Therapy on Venous Leg Ulcers

This study aimed to determine the effect of low-level laser therapy (LLLT) on chronic venous leg ulcers (VLUs). A double-blinded prospective randomized controlled trial was conducted to compare incidence of complete wound closure, ulcer size and pain reduction in patients randomized to 24 treatments of placebo or LLLT (635 nm) over 12 weeks. Patients presented with a 6-week history of VLUs ranging in size from 5 to 20 cm2. Venous origin was confirmed by Doppler ultrasound and an ankle brachial index of 0.8 or greater. Of 24 patients, 23% of the test group (n = 13) and 18% of placebo group (n = 11) achieved complete wound closure. At 12 weeks, patients in test and placebo groups had a mean surface area reduction of 6.26 cm2 ( P < .0001) and 6.72 cm2 ( P < .005), respectively, and a mean pain score decrease of 43.54 points ( P < .0001) and 25.73 points ( P = .002) respectively. Differences between groups was not statistically significant for wound closure ( P = 1.0) or ulcer size ( P = .80). Mean ulcer pain was significantly reduced from initiation of treatment compared with 4 weeks’ follow-up after 12 weeks with LLLT ( P < .01). Within the limitations of the study, LLLT may not have early effects as an adjunctive therapy to wound healing of VLUs, but LLLT may have delayed effects on VLU healing and associated pain, which requires further study.

Effect of Pycnogenol on the Healing of Venous Ulcers

BACKGROUND

Venous ulcers are common complications of chronic venous insufficiency that result in severe physical and mental suffering to patients. The oral administration of diosmin/hesperidin has been used as adjuvant therapy in the treatment of chronic venous insufficiency. The purpose of this study was to evaluate and compare the effect of pycnogenol and diosmin/hesperidin on the healing of venous ulcers.

METHODS

This longitudinal, prospective, randomized clinical trial was conducted with 30 adult patients with venous ulcers from a vascular surgery outpatient clinic of a university hospital. The patients were randomly allocated to 2 groups: Group 1 (n = 15) was treated with pycnogenol (50 mg orally, 3 times daily) and Group 2 (n = 15) was treated with diosmin/hesperidin (450/50 mg orally, twice daily). They were assessed every 15 days for 90 days. During follow-up visits, photo-documentation was obtained and the ulcer area and circumference of the affected limb were measured. Friedman's test and Mann-Whitney test were used to compare ulcer areas and circumference of affected limbs between and within groups at different time points. The level of significance was set at 5% (P < 0.05) for all tests.

RESULTS

Both the pycnogenol and diosmin/hesperidin treatments had a similar effect on the healing of venous ulcers and led to a significant decrease in the circumference of affected limbs (P < 0.0001).

CONCLUSION

The results suggest that pycnogenol has an adjuvant effect on the healing of venous ulcers, similar to diosmin/hesperidin.

Successful Treatment of Chronic Venous Ulcers With a 1,320-nm Endovenous Laser Combined With Other Minimally Invasive Venous Procedures

BACKGROUND

Venous ulcers are very common with few curative treatment options.

OBJECTIVE

To report the closure rate and clinical characteristics of active venous ulcers in a vein clinic using endovenous laser ablation (EVLA) with a 1,320-nm laser.

METHODS AND MATERIALS

A prospective database was kept consisting of patients with an active venous ulcer at the time of consultation in a single-practitioner academic vein clinic from March 2007 to May 2014. A database was maintained and charts were reviewed with attention to the length of time the patient reported having the ulcer, procedures performed, and time to ulcer healing.

RESULTS

Thirty-one patients were identified at consultation with venous ulceration. One patient's ulcer was healed with conservative medical management before receiving treatment. The remaining 30 patients were treated with a combination of EVLA of the great and/or short saphenous veins, foam sclerotherapy of insufficient varicose and reticular veins, and phlebectomy as appropriate. Two patients were lost to follow up after partial treatment. Ulcer healing occurred in more than 93% (27/29) of patients with a median healing time of 55 days from the time of first treatment. The median follow-up time after treatment was 448 days.

CONCLUSION

Endovenous laser ablation with a 1,320-nm laser in combination with foam sclerotherapy and phlebectomy as appropriate is effective treatment of chronic venous ulcers and should be considered as a treatment option for patients with C6 venous insufficiency. To the authors' knowledge, this is the largest, prospective series of chronic venous ulcers treated with EVLA. Further randomized controlled studies are needed to confirm these findings.

Prevenção de recidiva de úlcera varicosa: um estudo de coorte

Resumo Objetivo Determinar a taxa de recidiva de úlcera varicosa, e verificar a associação entre recidiva e medidas de prevenção adotadas. Métodos Estudo de coorte com 50 pacientes maiores de 18 anos com úlcera varicosa pós-cicatrização acompanhados durante 10 anos. A recidiva foi avaliada por meio de inspeção direta durante a avaliação clínica, e as medidas de prevenção usadas foram informadas pelo paciente. Utilizou-se o teste qui quadrado de Pearson, sendo significante p-value ≤0,05. Resultados A recidiva de úlcera varicosa foi de 62,2%, a maioria em mulheres, seguida por idosos, analfabetos e aposentados. Mostrou-se medida eficaz na prevenção de recidivas o seguinte conjunto: uso da meia de compressão, repouso e aplicar creme hidratante. Conclusão A taxa de recidiva de úlcera varicosa foi elevada e as principais medidas de prevenção aplicadas em conjunto foram usar meia de compressão, repousar e aplicar creme hidratante.

Meta-analytic approaches to determine gender differences for delayed healing in venous leg ulcers

Objective The aim of this analysis was to perform a meta-analysis evaluating gender difference of delayed healing risk in patients with venous leg ulcers. Methods We searched the PubMed and Web of Knowledge from their inception to 4 July 2015. The meta-analysis of pooled odds ratio and 95% confidence interval for venous leg ulcers healing risk were calculated. Results Twelve studies with 4453 patients were included in the meta-analysis. The pooled odds ratio for healing rate stratified by gender was 1.055 (95% CI 0.955-1.165; Z = 1.05, p = 0.292) by fix-effects model. The Begg's test (z = 2.67, p = 0.007), the Egger's test (t = 4.00, p = 0.003), and asymmetric funnel plot suggested there was significant publication bias. Subgroup analysis showed the pooled odds ratios were 1.048 (95% CI 0.945-1.162; Z = 0.88, p = 0.376) in prospective studies and 1.439 (95% CI 0.757-2.736; Z = 1.11, p = 0.266) in retrospective studies. Sensitivity analyses by only pooled adjusted odds ratios showed the pooled odds ratio was 1.049 (95% CI 0.946-1.163; Z = 0.91, p = 0.365), which indicated the results of meta-analysis were robust. Meta-regression analysis showed the healing rate odds ratio stratified by gender was not related with healing rate (t = 0.73, p = 0.484). Conclusion Our meta-analysis indicates that no gender difference existed for delayed healing in venous leg ulcers. Our results may be also useful in developing a risk score for failure of venous leg ulcers to heal.

Effectiveness of papain gel in venous ulcer treatment: randomized clinical trial

OBJECTIVE:

to assess the effectiveness of 2% papain gel compared to 2% carboxymethyl cellulose in the treatment of chronic venous ulcer patients.

METHOD:

randomized controlled clinical trial with 12-week follow-up. The sample consisted of 18 volunteers and 28 venous ulcers. In the trial group, 2% papain gel was used and, in the control group, 2% carboxymethyl cellulose gel.

RESULTS:

the trial group showed a significant reduction in the lesion area, especially between the fifth and twelfth week of treatment, with two healed ulcers and a considerable increase in the amount of epithelial tissue in the wound bed.

CONCLUSION:

2% papain gel demonstrated greater effectiveness in the reduction of the lesion area, but was similar to 2% carboxymethyl cellulose gel regarding the reduction in the amount of exudate and devitalized tissue. Multicenter research is suggested to evidence the effectiveness of 2% papain gel in the healing of venous ulcers. UTN number: U1111-1157-2998

Venous ulcers of the lower extremity: Definition, epidemiology, and economic and social burdens

Venous ulcer is a common vascular condition affecting 1% of the population, and a prevalence that increases with age. Venous ulcer is defined by the American Venous Forum as "a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing." The economic and social burden of this condition is significant to both the affected individual and the health care system. The recurrent nature of venous ulcers underscore the need for treatment of the underlying pathophysiology, that is, ambulatory venous hypertension produced by venous valve reflux alone or in conjunction with venous obstruction.

Chronic Venous Insufficiency

Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.

Prognostic factors associated with healing of venous leg ulcers: a multicentre, prospective, cohort study

BACKGROUND

Some prognostic markers of venous leg ulcer (VLU) healing have been evaluated, mostly in retrospective studies.

OBJECTIVES

To identify which clinical characteristics, among those known as possible prognostic factors of VLU healing, and which VLU-associated sociodemographic and psychological factors, are associated with complete healing at week 24 (W24).

METHODS

A prospective, multicentre, cohort study was conducted in 22 French dermatology departments between September 2003 and December 2007. The end point was comparison between healed and nonhealed VLUs at W24, for patient clinical and biological characteristics; psychological, cognitive and social assessments; affected leg inclusion characteristics; venous insufficiency treatment and percentage of initial wound area reduction during follow-up.

RESULTS

In total, 104 VLUs in 104 patients were included; 94 were analysed. The mean VLU area and duration were 36.8 ± 55.5 cm2 and 24.8 ± 45.7 months, respectively. At W24, 41/94 VLUs were healed. Univariate analysis significantly associated complete healing with superficial venous surgery (P = 0.001), adherence to compression therapy at W4 (P = 0.03) and W24 (P = 0.01), ankle-joint ankylosis (P = 0.01) and mean percentage of VLU area reduction at W4 (P = 0.04). Multivariate analysis retained superficial venous surgery during follow-up [odds ratio (OR) 8.4, 95% confidence interval (CI) 1.9-48.2] and percentage reduction of the VLU area at W4 (OR 1.6, 95% CI 1.0-2.14) as being independently associated with healing.

CONCLUSIONS

These results indicate that complete healing of long-standing, large VLUs is independently associated with ablation of the incompetent superficial vein and percentage of wound area reduction after the first 4 weeks of treatment.

A comparative clinical study on five types of compression therapy in patients with venous leg ulcers

The aim of this study was to compare five types of compression therapy in venous leg ulcers (intermittent pneumatic vs. stockings vs. multi layer vs. two layer short stretch bandages vs. Unna boots). Primary study endpoints were analysis of changes of the total ulcer surface area, volume and linear dimensions inside observed groups. The secondary end points were comparisons between all groups the number of completely healed wounds (ulcer healing rates), Gilman index and percentage change of ulcer surface area. In total, 147 patients with unilateral venous leg ulcers were included to this study. Participants were randomly allocated to the groups: A, B, C, D and E. After two months the healing rate was the highest in group A (intermittent pneumatic compression) - 57.14%, 16/28 patients, B (ulcer stocking system) - 56.66%, 17/30 patients and C (multi layer short stretch bandage) - 58.62%, 17/29 patients. Significantly much worse rate found in group D (two layer short stretch bandages) - only 16.66%, 5/30 patients and E (Unna boots) - 20%, 6/30 patients. The analysis of changes of the percentage of Gilman index and wound total surface area confirmed that intermittent pneumatic compression, stockings and multi layer bandages are the most efficient. The two layer short - stretch bandages and Unna boots appeared again much less effective.

Influence of perforating vein surgery in patients with venous ulceration

Objectives

The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration.

Methods

This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed.

Results

Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure ( p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure.

Conclusion

In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.

Clinical unity and community empowerment: the use of smartphone technology to empower community management of chronic venous ulcers through the support of a tertiary unit

BACKGROUND

Chronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics.

OBJECTIVE

We propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety.

METHODS

Bespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion.

RESULTS

From October to December 2011 eight patients (61-83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system.

CONCLUSIONS

With an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds.

Chronic venous leg ulcer treatment: future research needs

The prevalence and costs of chronic venous ulcer care in the US are increasing. The Johns Hopkins University Evidence-Based Practice Center recently completed a systematic review of the comparative effectiveness of advanced wound dressings, antibiotics, and surgical management of chronic venous ulcers. Of 10,066 citations identified in the literature search, only 66 (0.06%) met our liberal inclusion criteria for providing evidence on the effectiveness of interventions for chronic venous ulcers. Based on review of those studies, members of our team and a panel of informed stakeholders identified important research gaps and methodological deficiencies and prioritized specific future research needs. Based on that review, we provide the results of our assessment of future research needs for chronic venous ulcer care. Advanced wound dressings were considered to have the highest priority for future research, followed by venous surgery and antibiotics. An imperative from our assessment is that future research evaluating interventions for chronic venous ulcers meet quality standards. In a time of increasing cost pressure, the wound care community needs to develop high-quality evidence to justify the use of present and future therapeutic modalities.

Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management

Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.

RCT to evaluate a hyaluronic acid containing gauze pad in leg ulcers of venous or mixed aetiology

OBJECTIVE

To investigate the efficacy and safety of an hyaluronic acid (HA)-impregnated gauze pad compared with a hydrocolloid (HC) dressing, in patients with leg ulcer of venous or mixed aetiology.

METHOD

A 56-day blind-observer, randomised, multicentre, controlled, non-inferiority trial. Patients were randomised to receive either an HA gauze pad (ialuset gauze pad) or an HC dressing (DuoDERM E).The primary endpoint was the difference between the groups regarding the percentages of patients achieving a reduction of at least 40% of the initial wound surface after 56 days of treatment (visit 5). Secondary endpoints included reduction of wound area, aspect of the wound (percentage of necrotic,fibrinous or granulation tissue), rate of complete ulcer healing, pain intensity, and clinical status of the peri-ulcerous skin.

RESULTS

In total, 170 patients were included and analysed in the intention-to-treat (ITT) population; 27 patients presented at least one major protocol deviation and were excluded from the per-protocol (PP) population.Therefore, 143 patients constituted the PP population (n=72 and n=71 in the HA gauze pad group and HC dressing group, respectively).At day 56, the confidence interval of the difference between the two groups for the percentage of patients with a reduction of at least 40% of the target ulcer initial surface was [-0.128; 0.164] with a lower limit above the non-inferiority threshold (-0.15). Peri-ulcerous skin was significantly less impaired in the HA gauze pad group for oedema at day 56 (p = 0.04), purpura at day 14 (p = 0.009) and for maceration at day 14 (p = 0.003). Other secondary endpoints were not significantly different between the two groups. Overall, both treatments were well tolerated and adverse events were comparable between the two groups regarding their pattern, frequency, likely relationship to treatment and severity which was mostly mild (grade I) or moderate (grade 2). These results were confirmed in the overall ITT population.

CONCLUSION

These data support the non-inferiority of the HA gauze pad compared with HC for the primary endpoint.The significant differences in favour of HA gauze pad regarding peri-ulcerous skin changes (oedema, purpura and maceration) may suggest a trend for HA gauze pad to have a better acceptability than the reference HC dressing.

DECLARATION OF INTEREST

This study was sponsored by Laboratoires Genévrier. Authors received honoraria for their contributions to the study, but have no other conflicts of interests to declare.

Venous ulcers of the lower limb: Where do we stand?

Venous ulcers are the most common ulcers of the lower limb. It has a high morbidity and results in economic strain both at a personal and at a state level. Chronic venous hypertension either due to primary or secondary venous disease with perforator paucity, destruction or incompetence resulting in reflux is the underlying pathology, but inflammatory reactions mediated through leucocytes, platelet adhesion, formation of pericapillary fibrin cuff, growth factors and macromolecules trapped in tissue result in tissue hypoxia, cell death and ulceration. Duplex scan with colour flow is the most useful investigation for venous disease supplying information about patency, reflux, effects of proximal and distal compression, Valsalva maneuver and effects of muscle contraction. Most venous disease can be managed conservatively by leg elevation and compression bandaging. Drugs of proven benefit in venous disease are pentoxifylline and aspirin, but they work best in conjunction with compression therapy. Once ulceration is chronic or the patient does not respond to or cannot maintain conservative regime, surgical intervention treating the underlying venous hypertension and cover for the ulcer is necessary. The different modalities like sclerotherapy, ligation and stripping of superficial varicose veins, endoscopic subfascial perforator ligation, endovenous laser or radiofrequency ablation have similar long-term results, although short-term recovery is best with radiofrequency and foam sclerotherapy. For deep venous reflux, surgical modalities include repair of incompetent venous valves or transplant or transposition of a competent vein segment with normal valves to replace a post-thrombotic destroyed portion of the deep vein.

Efficacy and safety of a gauze pad containing hyaluronic acid in treatment of leg ulcers of venous or mixed origin: a double-blind, randomised, controlled trial

Topical hyaluronic acid (HA) is routinely used in the local treatment of chronic wounds, but few data have been reported to date. A 60-day double-blind, randomised, controlled superiority trial was designed to investigate the efficacy and safety of a gauze pad containing HA in local treatment of venous leg ulcers, compared with its neutral vehicle. The primary endpoint was the percentage of wound size reduction after 45 days. Totally 89 patients were included. At day 45, the percentage of ulcer surface reduction was significantly greater in the HA group (73 ± 4·6%) versus neutral vehicle group (46 ± 9·6%) (P = 0·011). The number of healed ulcers was significantly higher in the HA group at day 45 (31·1% versus 9·3% respectively) and day 60 (37·8% versus 16·3% respectively; P < 0·05). At day 30, pain intensity based on visual analogue scale was significantly lower in the HA group (12·4 mm ± 2·6 versus 22·8 mm ± 3·8; P = 0·026). Tolerance of both treatments was comparable in the two groups. HA gauze pad, in local treatment of venous leg ulcers, was significantly more effective than the neutral vehicle on wound size reduction, healed ulcers rate and pain management with a good safety profile.

Obesity and the skin

Obesity is a serious global health problem, perhaps the biggest public health issue of our times. Excess body weight may be a factor in carcinogenesis in general, as well as contributing to the pathogenesis of metabolic, cardiovascular and musculoskeletal disorders. Obesity also has many cutaneous features, which form the basis for this review article. Many of these clinical entities are common to the majority of obese patients, e.g. striae distensae, plantar hyperkeratosis and an increased risk of skin infections. However, it may also be associated with poor wound healing, malignant melanoma and an increased risk of inflammatory dermatoses, such as psoriasis, as well as some rarer disorders. Therapeutic interventions for obesity, whether over-the-counter, prescription medicines or surgical interventions, are increasingly commonplace. All of these treatment modalities potentially have dermatological side-effects too.