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Gary C, Gautier V, Lazareth I, Bagot M, Asgari R, Priollet P. [Necrotic leg ulcers after topical application of chlormethine]. Ann Dermatol Venereol 2019; 146:226-231. [PMID: 30704945 DOI: 10.1016/j.annder.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/18/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Topical chlormethine has been widely used in the early stages of mycosis fungoides for many years. Cutaneous reactions (skin irritation and itch) are the most frequent adverse effects. Herein we report a rare side effect: severe necrotic leg ulcers. PATIENTS AND METHODS An 82-year-old woman with a history of high blood pressure developed hyperalgesic necrotic ulcers on the lower limbs following local trauma one month after initiation of topical chlormethine (Valchlor®) to treat mycosis fungoides. Aetiological examination showed moderate peripheral arterial disease which, while constituting an aggravating factor, did not account fully for these skin ulcers. Moreover, drug-induced ulcer was suspected on account of the chronology. Dermal corticoids and topical treatment were prescribed in place of chlormethine and led to a favourable outcome. CONCLUSION Incrimination of chlormethine was based on the chronological and semiological criteria. This is the first published case of leg ulceration induced by Valchlor®.
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Affiliation(s)
- C Gary
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - V Gautier
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - M Bagot
- Service de dermatologie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - R Asgari
- Centre régional de pharmacovigilance, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
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Garval E, Plee J, Lesage C, Grange-Prunier A, Bernard P, Perceau G. [Frequency of contact sensitization to modern dressings used to treat chronic leg ulcer]. Ann Dermatol Venereol 2018; 145:339-346. [PMID: 29673752 DOI: 10.1016/j.annder.2018.01.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 09/03/2017] [Accepted: 01/15/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Allergic contact dermatitis around chronic leg ulcers (CLU) is a common complication in patients presenting CLU and prolongs healing times. The aim of this study was to describe the rate of sensitization to modern dressings (MD) used in these patients and to assess whether there is a relation between the number of sensitizations and ulcer type, the time from onset of the ulcer, and patient age and gender. PATIENTS AND METHODS We conducted a retrospective study at Reims University Hospital between 2010 and 2014 that included all patients with CLU of vascular etiology surrounded by eczematous lesions, and who had one of the patch-tests in the following 3 series: European baseline±leg ulcers±corticosteroids. RESULTS Among the 73 patients included, 43 % were polysensitized. Thirty-three patients (45 %) were sensitized to MD (38 % to hydrocolloids, 18 % to hydrogels, 7 % to hydrocellular dressings, 7 % to hydrofiber dressings, 5 % to contact layers and 3 % to alginates). Median age and sex did not differ between "polysensitized" patients and "non-polysensitized" patients (P=0.84 and P=0.25, respectively). Polysensitization was more frequent among patients presenting ulcers for more than 5 years (P=0.032). CONCLUSION Practically half of all patients presenting CLU with surrounding contact dermatitis had sensitization to modern dressings (mostly hydrocolloids and hydrogels). The rate of sensitization increased with the length of presence of CLU.
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Affiliation(s)
- E Garval
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France.
| | - J Plee
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France
| | - C Lesage
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France
| | - A Grange-Prunier
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France
| | - P Bernard
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France
| | - G Perceau
- Service de dermatologie, CHU, avenue du Général-Koenig, 51100 Reims, France
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Stansal A, Khayat K, Duchatelle V, Tella E, Gautier V, Sfeir D, Attal R, Lazareth I, Priollet P. [When to ask for a skin biopsy in a patient with leg ulcer? Retrospective study of 143 consecutive biopsies]. J Med Vasc 2018; 43:4-9. [PMID: 29425540 DOI: 10.1016/j.jdmv.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE A vascular cause is found in around 85% of leg ulcer patients, but non-vascular causes are also observed. Their diagnosis is based on a set of clinical arguments and skin biopsy with histological analysis. The aim of this study was to analyze the results of these biopsies and to find common criteria for ulcers whose skin biopsies had led to the diagnosis of a non-vascular ulcer. MATERIAL AND METHOD A retrospective study was carried out on the analysis of 143 skin biopsies of leg ulcers. The reasons for the biopsy were mainly atypical clinical signs and/or the lack of improvement in care after 6 months, as advocated by the French health authorities. RESULTS The skin biopsies led to a diagnosis of non-vascular ulcer in 4.9% of cases (7/143), including skin cancer (n=5, 3.5%), cutaneous leishmaniasis (n=1, 0.7%) and Pyoderma gangrenosum (n=1, 0.7%). The univariate statistical analysis revealed that an elevated rim and abnormal excessive granulation tissue were significantly more frequently found in these ulcers. All patients with a positive skin biopsy had associated vascular involvement. CONCLUSION This study found a 5% rate of non-vascular causes of ulcers, mainly skin cancer. Elevated rims and abnormal excessive granulation tissue were the unusual features most commonly found in these ulcers. All patients whose skin biopsy revealed a non-vascular cause had associated vascular involvement. This information confirms the need to perform a skin biopsy, even in the presence of a vascular disease.
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Abstract
Leg ulcers are a chronic condition. Healing can be long for venous ulcers and the risk of complications is significant. Infection is the most severe complication and can occur in the form of easily diagnosed acute bacterial dermohypodermitis that generally responds well to antibiotic treatment if given at an appropriate dose or in the form of localized infection that is more difficult to diagnosis. Indeed, no consensus has been reached in the literature on the clinical criteria to retain for the diagnosis of localized infection. Similarly, the most appropriate treatment remains to be established. Local care would be a logical starting point, followed by systemic antibiotics if this approach is unsuccessful. Individual conditions also should be taken into consideration (immunodepression, severe arteriopathy warranting more rapid use of systemic antibiotics). The second most frequent complication is an allergic reaction to a topical agent used for wound care. The rate of sensitivization in patients with leg ulcers is high (60 %), although the rate is declining with modern dressings. No product can be considered perfectly safe for these polysensitized patients. Dermocorticoid therapy can be very effective. Allergology tests are needed. Certain leg ulcers require special care from diagnosis. An arterial origin must be suspected for deep, or necrotic ulcers. Arterial supply must be explored rapidly, followed by a revascularization procedure when necessary. Highly painful superficial extensive necrotic ulcers due to necrotic angiodermitis require hospital care for skin grafts that will control the antiodermitis and provide pain. Carcinoma should be suspected in cases of leg ulcers with an atypical localization exhibiting excessive budding. A biopsy is mandatory for leg ulcers with an unusual course (absence of healing despite well-conducted care).
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Affiliation(s)
- I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Senet P, Monfort JB, Debure C. [Compression therapy: Choosing the right option for leg ulcers in 2016]. ACTA ACUST UNITED AC 2016; 41:347-50. [PMID: 27596567 DOI: 10.1016/j.jmv.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
Compression therapy is a mandatory treatment of leg ulcers whether the goal is cure (stage C6 in the international classification for chronic venous disease) or prevention of recurrence (stage C5). Different indications for compression therapy were proposed by the French Superior Health Authority (HAS) in 2010, but new studies have modified attitudes since that time. Considering the very large number of options available, the many co-morbid conditions observed in these patients, as well as patient age and available assistance, it is important to adapt to the variable clinical and social situations encountered. One must keep in mind that a well-controlled treatment should improve trophic disorders and patient comfort. A poorly-adapted treatment with little or even deleterious effect will be abandoned by the patient.
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Affiliation(s)
- P Senet
- UF de dermatologie et médecine vasculaire, service de dermatologie, hôpital Tenon, 4, rue de la Chine, 75970 Paris cedex 20, France.
| | - J-B Monfort
- Service de rééducation vasculaire, hôpital Corentin-Celton, 4, parvis Corenton-Celton, 92133 Issy-les-Moulineaux cedex, France
| | - C Debure
- Service de rééducation vasculaire, hôpital Corentin-Celton, 4, parvis Corenton-Celton, 92133 Issy-les-Moulineaux cedex, France
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Goullet de Rugy C, Lazareth I, You C, Stansal A, Priollet P. [Skillful care for chronic vascular wounds]. ACTA ACUST UNITED AC 2016; 41:335-46. [PMID: 27594570 DOI: 10.1016/j.jmv.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
Abstract
In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology.
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Affiliation(s)
- C Goullet de Rugy
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 750674 Paris cedex 14, France.
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 750674 Paris cedex 14, France.
| | - C You
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 750674 Paris cedex 14, France
| | - A Stansal
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 750674 Paris cedex 14, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 750674 Paris cedex 14, France
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Sfeir D, Lazareth I, Stansal A, Ghaffari P, Michon Pasturel U, Bonhomme S, Priollet P. [Leg ulcers: Should general practitioners hospitalize their patients?]. ACTA ACUST UNITED AC 2016; 41:18-25. [PMID: 26809200 DOI: 10.1016/j.jmv.2015.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 11/28/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Determine whether general practitioners have sufficient expertise in the field of leg ulcers. METHOD A cross-sectional survey was conducted among 179 general practitioners working in the region Île-de-France to evaluate the implementation of leg ulcer guidelines issued by the Superior Health Authority (HAS) in 2006. Participating physicians were either internship supervisors or practitioners in Paris' 14th district. RESULTS The first hundred usable answers (response rate 65%) came from 71 internship supervisors and 29 practitioners of Paris' 14th district. Only 40% of the physicians were aware of the guidelines, with no significant difference noted between the two groups. 9/10 practitioners examined less than 10 patients with leg ulcers per year. Physical examinations were done according to the guidelines and a venous Doppler was prescribed in two thirds of the cases. The ankle-brachial pressure index (ABPI) essential to diagnose lower limb arteriopathy was measured for only 10% of the patients. In accordance with the guidelines, compression was by far (73%) considered as the main treatment as compared to dressing (37%), but compression therapy was well prescribed in only one-third of the cases. Despite poor prognosis criteria (characteristic and time course), referral for a specialized opinion was rare. CONCLUSION Even if they were not always aware of the detailed guidelines, the practitioners applied the main recommendations. Nevertheless, practices could be improved by measuring the ABPI, searching for a diagnosis of arteriopathy, and better prescription of compression therapy. General practitioners should refer patients with leg ulcers to a specialized hospital unit.
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Affiliation(s)
- D Sfeir
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
| | - I Lazareth
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - A Stansal
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - P Ghaffari
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - U Michon Pasturel
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - S Bonhomme
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - P Priollet
- Service de médecine vasculaire, institut de la cicatrisation Jean-Paul-Belmondo, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
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Chabli H, Hocar O, Akhdari N, Amal S, Hakkou M, Hamdaoui A. [Necrotic leg ulcer revealing vasculitis induced by vitamin K antagonists]. ACTA ACUST UNITED AC 2015; 40:402-5. [PMID: 26548536 DOI: 10.1016/j.jmv.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/20/2015] [Indexed: 11/28/2022]
Abstract
UNLABELLED Vitamin K antagonists are widely used in thromboembolic diseases. Hemorrhagic complications related to drug overdose represent their main side effect. We report a rare side effect, a severe and unexpected type of skin vasculitis - necrotic leg ulcer - induced by vitamin K antagonist. CASE REPORT A 63-year-old female with a history of diabetes developed hyperalgesic necrotic ulcerations on the lower limbs one month after starting an acenocoumarol-based treatment for ischemic heart disease. Histological examination revealed lymphocytic vasculitis with fibrinoid necrosis. Etiological explorations searching for vasculitis were negative. In the absence of a precise etiology, drug-induced ulcer was suspected. Low molecular weight heparin was prescribed to replace acenocoumarol. The lesions slowly resolved with topical treatment. DISCUSSION The chronological criteria and the negativity of etiological explorations allowed the diagnosis of vitamin K antagonist-induced necrotic skin ulcer. Clinicians should be aware of this rare complication induced by oral anticoagulants because of its practical therapeutic implications. This is the first case of necrotic leg ulcer induced by acenocoumarol corresponding histologically to necrotising lymphocytic vasculitis.
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Affiliation(s)
- H Chabli
- Service de dermatologie et de vénéréologie, hôpital Arrazi, CHU Mohammed VI, Marrakech, Maroc.
| | - O Hocar
- Service de dermatologie et de vénéréologie, hôpital Arrazi, CHU Mohammed VI, Marrakech, Maroc
| | - N Akhdari
- Service de dermatologie et de vénéréologie, hôpital Arrazi, CHU Mohammed VI, Marrakech, Maroc
| | - S Amal
- Service de dermatologie et de vénéréologie, hôpital Arrazi, CHU Mohammed VI, Marrakech, Maroc
| | - M Hakkou
- Laboratoire ZOHOR d'anatomie et cytologie pathologiques, Marrakech, Maroc
| | - A Hamdaoui
- Laboratoire ZOHOR d'anatomie et cytologie pathologiques, Marrakech, Maroc
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Niclot J, Stansal A, Lazareth I, Galloula A, Duchatelle V, Laurent-Bellue A, Priollet P. [Ankle and foot ulcerations in a diabetic patient revealing cutaneous leishmaniasis]. ACTA ACUST UNITED AC 2014; 39:430-3. [PMID: 25201090 DOI: 10.1016/j.jmv.2014.07.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Cutaneous leishmaniasis is a parasitic disease that typically manifests as a typical crusted ulcer called the oriental sore. Its localization on the lower limbs can be mistaken for a leg ulcer. CASE REPORT An 81-year-old male, native of Algeria, with type 2 diabetes, arterial hypertension and arteriopathy developed a chronic ulceration of the right ankle and foot compatible with the diagnosis of infectious diabetic foot. Non-improvement with antibiotics, local treatment and rest, and the absence of any hemodynamic arteriopathy led to skin biopsies. Polymerase chain reaction performed on biopsy samples for parasitological investigations yielded the diagnosis of cutaneous leishmaniasis due to Leishmania major. Complete healing was obtained with topical care alone, the patient having declined an etiological treatment. DISCUSSION Cutaneous leishmaniasis is one of the rare infectious etiologies of chronic leg ulcers. Several therapeutic options, including abstention, can be proposed.
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Affiliation(s)
- J Niclot
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - A Stansal
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - A Galloula
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - V Duchatelle
- Service d'anatomopathologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - A Laurent-Bellue
- Service d'anatomopathologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
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