Efficacy and Safety of Pentoxifylline for Venous Leg Ulcers: An Updated Meta-Analysis

The venous leg ulcers are debilitating, painful, and often unresponsive to advanced dressing treatments, so drugs used locally and systematically are essential adjuvant therapy-pentoxifylline (PTX) whose anti-inflammatory effects may offer a promising avenue to treat venous leg ulcers. However, the current results are controversial. To further evaluate the efficacy and safety of PTX, we performed an updated meta-analysis of randomized placebo-controlled trials of PTX in the treatment of venous leg ulcers. We systematically searched multiple electronic databases PubMed, Web of Science, Embase, the Cochrane Library, the Cochrane Central Register of Controlled Trials, China Science and Technology Journal Database, WanFang Data, China National Knowledge Infrastructure, and the Chinese Biomedical Literature Database to identify eligible studies. Randomized clinical trials of pentoxifylline versus placebo treatment in patients with venous leg ulcers were considered for inclusion. The primary outcomes included ulcer healing rate and the incidence of adverse events after treatment. The secondary outcomes were the ulcer significant improvement (the ulcer size shrank by more than 60% after treatment) rate, mean duration of complete wound healing and changes in mean ulcer size. A meta-analysis and qualitative analysis were conducted to estimate endpoints. A total of 13 randomized clinical trials, including 921 individuals, were finally included. Compared with placebo, pentoxifylline significantly improved the ulcer healing rate (RR = 1.59, 95%CI 1.22 to 2.07, P < .001) and significant improvement rate (RR = 2.36, 95%CI 1.31 to 4.24, P = .004) while increased the incidence of gastrointestinal disturbances (RR = 2.29, 95%CI 1.04 to 5.03, P = .04) at the same time. Moreover, pentoxifylline also shortened mean duration of complete wound healing (P = .007) and shrank ulcer size (P = .02). Currently available evidence suggests that pentoxifylline could help venous leg ulcers heal more quickly and effectively. However, the evidence is insufficient to prove the results due to moderate-certainty evidence. Large-scale, well-designed randomized clinical trials are warranted.

The combination of hyaluronic acid and collagenase in the treatment of skin ulcers: an open, multicenter clinical study assessing safety and tolerability of Bionect Start®

OBJECTIVE

Several clinical studies have shown that hyaluronic acid collagenase is well-tolerated and very effective in managing chronic venous ulcers. The aim of the present study is to confirm the safety and tolerability of daily application in patients suffering from cutaneous ulcers of different etiologies. The efficacy of the treatment and its impact on patients' quality of life are also assessed.

PATIENTS AND METHODS

Patients with a clinical diagnosis of skin ulcer with devitalized/fibrinous/slough tissue that could delay the healing process were enrolled in the study. The hyaluronic acid/collagenase ointment was applied topically until wound closure or total debridement of non-viable tissue was achieved, however, with a limit of 30 days. Monitoring was performed weekly, either through outpatient visits or telephone surveys. Assessments included adverse events, local irritation reactions, pain at dressing changes, and wound bed status. Patients were also requested to complete a quality-of-life questionnaire.

RESULTS

The study involved 96 patients with a mean age of 71 years. The patients suffered mainly from traumatic (21.9%), venous (15.6%), or pressure ulcers (12.5%); in 26% of cases, ulcers had mixed etiology. In approximately 32% of patients, the ulcer had been present for more than 6 months, and 18.1% of subjects had previously undergone surgical wound debridement.

CONCLUSIONS

Daily application of hyaluronic acid-collagenase achieved the following results: i) absence of adverse events related to the use of the product; ii) significant reduction in the degree of localized irritation and pain at dressing changes; iii) significant support to wound bed preparation; iv) trend towards improvement in the quality of life and health status of the patients.

Cost-effectiveness analysis of intralesional and perilesional recombinant human epidermal growth factor vs hydrocolloid therapy in venous ulcer treatment in the Colombian context

OBJECTIVE

To perform a comparative analysis of health care expenses and outcomes in response to the question: What is the cost-effectiveness of intralesional and perilesional recombinant human epidermal growth factor (rhEGF) compared with hydrocolloid therapy in patients diagnosed with chronic venous insufficiency without infection in Colombia?

METHODS

A Markov model was used to determine cost effectiveness over a 5-year period, considering the perspective of the health system in Colombia. The study included patients aged >18 years diagnosed with chronic venous insufficiency and used clinical studies to calculate the probabilities of epithelialization, infection, recurrence, and mortality.

RESULTS

RhEGF is more expensive per unit than hydrocolloids, but it is proven to be effective at healing ulcers in 8 to 12 weeks, even in complex cases. Hydrocolloids, in contrast, typically require 29.5 weeks on average, and ≤46 weeks for complex cases. Despite the cost, rhEGF is more cost effective because it achieves results comparable with hydrocolloid therapy at a lower cost per additional quality-adjusted life-year.

CONCLUSIONS

Based on cost-effectiveness analysis, rhEGF is a superior alternative to hydrocolloids for treating venous ulcers in Colombia. Not only is it more affordable, but it also enhances patients' quality of life and streamlines the health care system's resource use.

Testing the feasibility of a co-designed intervention, comprising self-managed, home-based, exercise training with embedded behavioural support and compression therapy for people with venous leg ulcers receiving treatment at home (FISCU-II)

BACKGROUND

Venous leg ulcers (VLUs) heal slowly, are painful for patients and are costly for healthcare systems; they also affect patients' quality of life. Previous work suggests that supervised exercise training used in combination with compression therapy may offer clinical benefits. However, a large population of people with VLUs are unable to access such an intervention due to frailty and age.

OBJECTIVES

To assess the feasibility of 'FISCU Home' (a co-designed, 12-week home-based self-managed lifestyle programme based on exercise and behaviour support) as an adjunct therapy to compression in people with VLUs.

METHODS

Forty people with VLUs, receiving treatment at home, were recruited from community nursing and tissue viability teams, and via a newspaper advertisement. Participants were randomized 1 : 1 either to exercise with behaviour support (three times per week) plus compression therapy or compression only. The feasibility of the programme was assessed using progression criteria that included exercise attendance rate, loss to follow-up, patient preference(s) and adverse events (AEs). Baseline assessments were repeated at 12 weeks and 6 months. Secondary outcomes (i.e. ulcer recurrence, healing rate and healing time) were also documented at these intervals. Intervention and healthcare utilization costs were calculated.

RESULTS

The study recruitment rate was 65%, while 75% of the exercise group participants attended all scheduled exercise sessions. All participants completed compression therapy. No serious AEs or exercise-related AEs were reported. Median (interquartile range) ulcer healing time was shorter in the exercise group [29 (7-108) vs. 42 (6-116) weeks].

CONCLUSIONS

The feasibility and acceptability of both a home- and exercise-based lifestyle intervention in conjunction with compression therapy and the study procedures are supported.

Cost-effectiveness of ChloraSolv in treating hard-to-heal venous leg ulcers

OBJECTIVE

To estimate whether the topical, amino acid-buffered hypochlorite debriding gel ChloraSolv (RLS Global AB, Sweden) could potentially afford the UK's health services a cost-effective intervention for hard-to-heal venous leg ulcers (VLUs).

METHOD

A Markov model representing the management of hard-to-heal VLUs with ChloraSolv plus standard care (SC) or SC alone was populated with inputs from an indirect comparison of two propensity score-matched cohorts. The model estimated the relative cost-effectiveness of ChloraSolv in terms of the incremental cost per quality-adjusted life year (QALY) gained at 2021/2022 prices.

RESULTS

Addition of ChloraSolv to an SC protocol was found to increase the probability of healing by 36% (from 0.14 to 0.19) after 12 weeks, and by 79% (from 0.24 to 0.43) after 24 weeks. This led to a marginal increase in health-related quality of life. Treatment with ChloraSolv plus SC instead of SC alone reduced the total cost of wound management by 8% (£189 per VLU) at 12 weeks and by 18% (£796 per VLU) at 24 weeks. Use of ChloraSolv was estimated to improve health outcomes at reduced cost. Sensitivity analysis showed that use of ChloraSolv plus SC remained a cost-effective treatment with plausible variations in costs and effectiveness.

CONCLUSION

Within the limitations of the study, the addition of ChloraSolv to an SC protocol potentially affords a cost-effective treatment to the UK's health services for managing hard-to-heal VLUs.

Healing of Venous Leg Ulcers Influenced by Individual Aspects: Cluster Analysis in a Specialist Wound Management Clinic

INTRODUCTION/OBJECTIVE

Venous Leg Ulcers (VLU) present a challenging healing process. Attaining healing is a primary treatment objective, commonly pursued in Primary Health Care (PHC) or Specialist Wound Management Clinics. Our objective was to examine the association and interplay between sociodemographic, health, clinical, and care factors with the outcomes of VLU treatment in patients undergoing care at a Specialist Wound Management Clinic.

METHODS

Longitudinal, observational study took place in a center for the treatment of chronic injuries linked to PHC. The sociodemographic aspects, health status and habits, clinical and care aspects of patients with VLU were scrutinized over a 1-year period.

RESULTS

The sample comprised 103 participants, with some still under treatment (Treatment Group-TG/ n = 60) and others having achieved VLU healing (Healing Group-HG/ n = 43). An association between sociodemographic, health, clinical, and care factors and the healing outcome (HG) was identified. A moderate correlation was observed between factors predisposing to healing in the sociodemographic group and health habits. Notably, among sociodemographic factors, the older age group and improvements in health, particularly the reduced use of alcohol/smoking, appeared to exert the most significant influence on healing. Additionally, specialized service monitoring and the application of compression therapy were contributory factors.

CONCLUSIONS

These findings substantiate the hypothesis that sociodemographic, health, clinical, and care-related aspects are intertwined with VLU healing. Protective factors associated with healing interacted synergistically, fostering a positive outcome over one year of treatment.

Evaluation of factors affecting the healing process of venous ulcers: A 12-week longitudinal study

The process of healing venous ulcers is complex and influenced by many factors. By identifying the risk factors that influence a slower healing process, it is possible to predict impending delays and plan an individualised care plan. We analysed our database of patients with venous ulcers and identified clinical and demographic factors that delay the healing process. The research analysed the medical records of 754 patients with VLUs at Chronic Wound Treatment Unit of the University Hospital treated between 2001 and 2019. In study, the majority (64.3%) were women, the mean age was 65.7 years. The median duration of Chronic Venous Insufficiency was 24 years, 52% patients had had the disease >20 years, and 296 (39.3%) had experienced ulceration >12 months. Most of the patients (85.8%) had comorbidities, 84% were obese. At 12-week follow-up, 432 of the 754 ulcers had healed. Identified independent predictors of slower ulcer healing rates: wound area greater than 8.25 cm2 , location of the ulceration other than the medial ankle area, underlying disease >20 years, the presence of multiple comorbidities, depth of the ulcer, the presence of an unpleasant smell and alert pathogens. The presence of redness resulted in faster healing of VLUc. Many factors influence the healing process of venous ulceration. The results of the study can help in planning patient care and implementing appropriate early strategies to promote healing.

The Potential of Bacteriophage Therapy as an Alternative Treatment Approach for Antibiotic-Resistant Infections

OBJECTIVE

This study aimed to provide a comprehensive overview of the current state of the literature on the therapeutical application of bacteriophages.

METHODS

First, a bibliometric analysis was performed using the database Web of Science to determine annual number of publications and citations. Second, a systematic literature review was conducted on randomized-controlled trials (RCTs) of phage therapy in PubMed.

RESULTS

Over the past decade, the number of publications on bacteriophage therapy increased more than fourfold with 212 articles in 2011 and 739 in 2022. The systematic search in PubMed yielded 7 RCTs eligible for inclusion, reporting on a total of 418 participants. Identified indications in this study included bacterial diarrhea, urinary tract infections, infected burn wounds, chronic otitis, chronic venous leg ulcers, and chronic rhinosinusitis. In three studies, mild to moderate adverse events were reported in 10/195 participants (5.1%). Three of the studies reported a statistically significant difference in outcomes comparing phage therapy with standard of care or placebo.

CONCLUSION

Phage therapy has gained increasing interest over the years. RCTs on different indications suggest the safety of phage therapy; however, reasons why phage therapy is not yet well accepted are limitations in the study designs. For a successful translation into clinical practice researchers and clinicians should learn from the earlier experiences and consider issues such as the quality of phage preparation, sensitivity testing, titer and dosages, as well as access to the infection site and stability for standardized protocols and future trials.

Aetiological treatment of venous leg ulcers with compression therapy: real-life outcomes with two different procedures

OBJECTIVE

To evaluate the healing outcomes and costs associated with the aetiological management of venous leg ulcers (VLUs) treated with recommended multicomponent bandages (MCBs) and short-stretch bandages (SSBs).

METHOD

This observational study is a retrospective comparative study (Level 2b), based on the French administrative healthcare database (Système National des Données de Santé, SNDS). It includes patients treated from onset with reimbursed MCBs and SSBs for a VLU episode, between July 2018 and September 2020. Although other compression systems, such as long-stretch bandages, are commonly used for the treatment of VLUs, they are not recommended by health authorities in France and thus, were not considered for this study. A binomial regression model was performed to estimate the adjusted relative risk of wound closure rates at three months for each group, based on potential confounding factors including, notably, age, sex, key comorbidities, and wound dressing size. The mean healthcare cost was calculated for patients whose VLUs healed within the study period.

RESULTS

The reimbursement data (including prescribed compression systems and nursing care) of the 25,255 selected patients were analysed in the study. There were no significant differences between the MCBs and SSBs groups when considering patient characteristics. The healing rates after three months' treatment, were 42% and 35% (p<0.001) in the MCBs and SSBs groups, respectively. When adjusting the statistical model, the chance of healing at three months was still 12% higher with MCBs compared with SSBs (p<0.0001). The median healing time was estimated at 115 (interquartile range (IQR): 60-253) days in the MCB group versus 137 (IQR: 68-300) days in the SSBs group. The average treatment cost per patient with a healed ulcer was €2875±3647 in the MCB group and €3580±5575) in the SSBs group (p=0.0179), due to lower hospital stay and nursing costs in the MCB group. Differences in wound characteristics between the two groups cannot be totally excluded, due to the limited content of the database in terms of clinical data, but should have been addressed, to some extent, through the study selection criteria and the chosen regression model.

CONCLUSION

In this study, this SNDS analysis seemed to confirm that the healing outcomes achieved in real-life with MCBs were in line with those reported in clinical trials, and superior to SSBs, which reinforces the current position from the guidelines.

A simple index to predict healing in venous leg ulcers: a secondary analysis from four randomised controlled trials

OBJECTIVE

To investigate whether the use of a simple baseline measurement predicts venous leg ulcer healing at 12 and 24 weeks.

METHOD

This was a secondary analysis of a cohort of four randomised controlled trials (RCTs) of treatments adjuvant to compression. Self-reported ulcer duration, and measured ulcer length and width, to calculate estimated ulcer area, were used to obtain a Margolis index score. The score created three prognostic strata for likelihood to heal within 24 weeks, and the number of participants healed and time-to-healing were compared.

RESULTS

There were a total of 802 participants across the four RCTs-408 (50.9%) in two 12-week trials and 394 (49.1%) in two 24-week trials. The mean age of participants was 63.7±17.6 years, and 372 were female (46.4%). The Margolis index score at baseline was 0 for 320 participants (predicted normal healing); 1 for 334 participants; and 2 for 148 participants (both 1 and 2 predicted slow-to-heal). Overall, 248 (77.5%) of those participants who scored 0 at baseline healed within 24 weeks, compared with 182 (54.5%) of participants who scored 1, and 30 (20.3%) participants who scored 2. The median time-to-healing was 40 (24-62) days, 57 (35-100) days and 86.5 (56-151) days, respectively. The area under the receiver operating characteristic curve was 0.69 and 0.77, respectively, for the 12 and 24 week trials.

CONCLUSION

A simple baseline index identifies participants with normal or slow-to-heal wounds and could be used to demonstrate prognostic balance between treatment groups in trials. This approach could also be used in clinical practice to assist with managing expectations and for early identification of patients who may best benefit from adjuvant treatments.

Use of Intralesional and Perilesional Human Recombinant Epidermal Growth Factor (hrEGF) in the Local Treatment of Venous Ulcer - Review Article - Expert Recommendation

Venous Ulcers (VU) represent 60-80% of all leg ulcers and are the final stage of the disease secondary to venous hypertension or valve insufficiency. Conventional treatment that focuses on its etiological factors continues to be the gold standard; however, 30% of ulcers do not heal with this treatment; thus, it has been seen that the use of growth factor can be used as an adjuvant for this pathology. A literature review was carried out to evaluate the evidence from systematic reviews, meta-analyses, case studies, and quantitative studies that respond to the objective of this analysis review in the different databases with specific inclusion criteria with publications between 2002 and 2022, initially finding the topical application of the factor and later, more recently, the intralesional and perilesional application, the latter being an alternative treatment for this type of pathology and generating some recommendations for using the Factor.

Prospective study on the clinical and economic burden of venous leg ulcers in the tropics

OBJECTIVE

Venous leg ulcers (VLUs) are both chronic and recurrent. The treatment of such ulcers often require multiple outpatient visits and dressing changes. Several reports on the costs of treating such VLUs have been reported in the west. We prospectively evaluated the clinical and economic burden of VLUs in a population of Asian patients in the tropics.

METHODS

Patients from a prospective two-center study conducted at two tertiary hospitals in Singapore, as a part of the Wound Care Innovation in the Tropics program, between August 2018 and September 2021 were recruited. The patients were followed up for 12 weeks (visit 1 to visit 12), until index ulcer healing, death, or lost to follow-up (whichever came first). These patients were then followed up 12 weeks later to determine the longer term outcome of the wound (healed, recurrence, remained unhealed). The itemized costs derived from the medical service were retrieved from the relevant departments of the study sites. The patients' health-related quality of life was assessed at baseline and the last visit of the 12-week follow-up period (or until index ulcer healing), using the official Singapore version of the EuroQol five-dimension-5L questionnaire, which also includes a visual analog scale (EQ-VAS).

RESULTS

A total of 116 patients were enrolled; 63% were men, and the mean patient age was 64.7 years. Of the 116 patients, 85 (73%) had a healed ulcer at 24 weeks (mean duration to ulcer healing, 49 days), and 11 (12.9%) had experienced ulcer recurrence within the study period. Within the 6-month follow-up period, the mean direct healthcare cost per patient was USD$1998. The patients with healed ulcers had significantly lower costs per patient compared with those with unhealed ulcers (USD$1713 vs USD$2780). Regarding health-related quality of life, 71% of the patients had a lower quality of life at baseline, which had improved at 12 weeks of follow-up, with only 58% of the patients reported to have a lower quality of life. Also, the patients with healed ulcers scored higher for both utilities (societal preference weights) and EQ-VAS at follow-up (P < .001). In contrast, patients with unhealed ulcers only scored higher EQ-VAS at follow-up (P = .003).

CONCLUSIONS

The findings from this exploratory study provide information on the clinical, quality of life, and economic burden of VLUs in an Asian population and suggest the importance of healing VLUs to reduce the effects on patients. The present study provides data as a basis for economic evaluation as a consideration for the treatment of VLUs.

The co-design of an exercise-based, lifestyle intervention for people with venous leg ulcers; a self-care, expert-supported strategy for a chronic condition

Exercise is recommended as an adjunct treatment, alongside compression therapy to increase venous leg ulcer (VLU) wound healing times, however, there are no published programmes available that support patients to exercise at home on their own. To develop an exercise-based lifestyle intervention that is feasible and acceptable to people with VLUs, a participatory approach was utilised. Clinicians, researchers, and people living with VLUs collaborated in the design of "FISCU Home". Two focus groups and nine interviews were conducted with people living with a VLU. Tissue viability nurses provided clinical expertise. Data was analysed through thematic analysis. Ten key themes were identified and incorporated into FISCU Home: (I) a condition-specific flexible programme, (II) personal assessment and tailored exercises, (III) tapered individualised support, (IV) short lower-intensity sessions, (V) chair-based options, (VI) falls prevention, (VII) accessible resources, (VIII) functional, compact, self-managed exercises, (IX) a behaviour change strategy, and (X) education. FISCU Home has integrated patients' needs and preferences with evidence-based principles and theory to create an exercise-based lifestyle intervention for people with VLUs. FISCU Home could provide a mainstream adjunct therapy in wound care and support the movement towards self-management.

Application of StyleGAN Architecture for Generating Venous Leg Ulcer Images

Leg ulcers caused by impaired venous blood return are the most typical chronic wound form and have a significant negative impact on the lives of people living with these wounds. Thus, it is important to provide early assessment and appropriate treatment of the wounds to promote their healing in the normal trajectory. Gathering quality wound data is an important component of good clinical care, enabling monitoring of healing progress. This data can also be useful to train machine learning algorithms with a view to predicting healing. Unfortunately, a high volume of good-quality data is needed to create datasets of suitable volume from people with wounds. In order to improve the process of gathering venous leg ulcer (VLU) data we propose the generative adversarial network based on StyleGAN architecture to synthesize new images from original samples. We utilized a dataset that was manually collected as part of a longitudinal observational study of VLUs and successfully synthesized new samples. These synthesized samples were validated by two clinicians. In future work, we plan to further process these new samples to train a fully automated neural network for ulcer segmentation.

Relative cost-effectiveness of three compression bandages in treating newly diagnosed venous leg ulcers in the UK

OBJECTIVE

To assess the clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2, 3M, US) compared with a two-layer compression system (TLCS; KTwo, Urgo, France) and a cohesive inelastic bandage system (CIBR; Actico, L&R, Germany) in treating newly diagnosed venous leg ulcers (VLUs) in clinical practice, from the perspective of the UK's National Health Service (NHS).

METHOD

This was a modelling study based on a retrospective cohort analysis of the case records of patients with a newly diagnosed VLU randomly extracted from the The Health Improvement Network (THIN) database who were treated with TLCCB, TLCS or CIBR. No significant differences were detected between the groups. Nevertheless, analysis of covariance was performed to enable differences in patients' outcomes between the groups to be adjusted for any heterogeneity in baseline covariates. Clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over 12 months after starting treatment.

RESULTS

There were 250 patients in each group. Time from wound onset to starting compression was a mean of two months. The healing distribution of the TLCCB-treated patients was significantly different from that of the other two cohorts (p=0.003); the probability of healing at 12 months was 0.62, 0.51 and 0.49 in the TLCCB, TLCS and CIBR groups, respectively. Patients treated with TLCCB experienced better health-related quality of life (HRQoL) over 12 months (0.86 quality-adjusted life years (QALYs) per patient), compared with those treated with TLCS and CIBR (0.83 and 0.82 QALYs per patient, respectively). The 12-month NHS wound management cost was £3693, £4451 and £4399 per patient in the TLCCB, TLCS and CIBR groups, respectively.

CONCLUSION

Within the model's limitations, treating newly diagnosed VLUs with TLCCB instead of the other two compression systems appears to afford a more cost-effective use of NHS-funded resources in clinical practice, since it is expected to result in increased healing, better HRQoL and a lower wound management cost for the NHS.

Cost-Effectiveness of PHMB & betaine wound bed preparation compared with standard care in venous leg ulcers: A cost-utility analysis in the United Kingdom

BACKGROUND

Wounds cost £8.3 billion per year in the United Kingdom (UK) annually. Venous leg ulcers (VLUs) account for 15% of wounds and can be complicated to heal, increasing nurse visits and resource costs. Recent wound bed preparation consensus recommends wound cleansing and biofilm disrupting agents. However, inert cleansers such as tap water or saline are inexpensive, an evaluation of evidence is required to justify the higher upfront costs of treatment with active cleansers. We undertook a cost-effectiveness analysis of the use of a biofilm disrupting and cleansing solution and gel, Prontosan® Solution and Gel X, (PSGX) (B Braun Medical), as compared to the standard practice of using saline solution, for treating VLUs.

METHODS

A Markov model was parameterised to one-year costs and health-related quality of life consequences of treating chronic VLUs with PSGX versus saline solution. Costs are viewed from a UK healthcare payer perspective, include routine care and management of complications. A systematic literature search was performed to inform the clinical parameters of the economic model. Deterministic univariate sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were undertaken.

RESULTS

For PSGX an Incremental Net Monetary Benefit (INMB) of £1,129.65 to £1,042.39 per patient (with a Maximum Willingness to Pay of £30k and £20k per QALY respectively), of which cost savings are £867.87 and 0.0087 quality-adjusted life years (QALYs) gain per patient. PSA indicates a 99.3% probability of PSGX being cost-effective over saline.

CONCLUSIONS

PSGX for the treatment of VLUs is dominant compared with saline solution in the UK with expected cost-savings within a year and improved patient outcomes.

Effect of four-layer dressing on the microbiological profile of venous leg ulcer

OBJECTIVE

Venous leg ulcer (VLU) is a chronic disease and has periods of exacerbation and remission. Various bandage systems-single-layered, double-layered and multiple-layered with elastic and non-elastic components-have been developed. The requirement for sustained pressure brought about the introduction of the four-layer bandage. We studied the bacteriology of VLUs and the effect of four-layer bandages on their healing.

METHOD

Clinical details of all patients, with wound size measurement by gauze piece, wax paper and scale, were recorded. The wounds were initially debrided and photographic records of all patients were maintained. Patients were followed up every week, when the dressings and four-layer bandages were changed.

RESULTS

A total of 60 patients were recruited to the study with four patients having bilateral disease and so a total of 64 VLUs were evaluated. Of these, 60 (93.8%) healed completely, one (1.6%) healed partially and three (4.7%) did not heal. After excluding the four VLUs that did not fully heal, 10 (16.7%) had recurrence while 50 (83.3%) had no recurrence in the follow-up period, which lasted for one year. During the first visit (baseline), meticillin-resistant Staphylococcus aureus (MRSA) was isolated in 29 (45.31%) VLUs and Pseudomonas spp. in 20 (31.25%) VLUs. With subsequent dressing, the VLU size decreased and the culture of the VLU was sterile from the third culture onwards in 45 cases. There was a significant correlation (p<0.001) between VLU size and the number of dressings.

CONCLUSION

Compression therapy is the mainstay of treatment of VLU, with rapid healing and improvement in bacteriological profile. Compression in the range of 30-40mmHg is the most effective treatment for uncomplicated VLUs with adequate arterial competency.

[Low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) therapy for chronic venous leg ulcers, 10-year follow-up]

BACKGROUND

The treatment of leg ulcers is an enormous problem worldwide. Chronic venous ulceration affects 1% of the population and often has a protracted course. Recurrence rate is high, ranging up to 69% in the first year after healing.

OBJECTIVES

To determine whether topical application of low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) is safe in venous leg ulcer treatment, and whether it accelerates healing rates and reduces recurrence rates.

MATERIALS AND METHODS

Consecutive patients with chronic venous leg ulcers received topical treatment with low-dose rhu GM-CSF (10 µg/mL 0.9% sodium chloride solution; 1.0-2.3 µg rhu GM-CSF/cm²) in combination with treatment of venous insufficiency. All patients were previously treated with other topical wound remedies for several weeks (median 8 weeks) without success.

RESULTS

In 119 of 130 patients, the wounds healed completely (91.5%). No local or systemic adverse reactions were observed. The mean time to healing was 24 weeks (median 14 weeks). Median follow-up of the 119 patients with healed ulcers was 84 months. The recurrence rates were 5.2% after 1 year, 18.9% after 4 years and 32.0% after 10 years.

CONCLUSIONS

Topical low-dose rhu GM-CSF proved to be safe and highly effective. Healing rates were comparable to those reported in the ESCHAR study (Effects of Surgery and Compression on Healing And Recurrence in venous ulceration) and recurrence rates were the lowest reported in the literature. Topical therapy with rhu GM-CSF can be applied in an outpatient setting and does not require hospitalization.

Efficacy of a Self-managed Cooling Intervention for Pain and Physical Activity in Individuals With Recently Healed Chronic Venous Leg and Diabetic Foot Ulcers: A Randomized Controlled Trial

PURPOSE

This aim of this study was to evaluate the clinical efficacy of a self-managed cooling intervention in individuals with recently healed venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs) on pain reduction and physical activity improvement.

DESIGN

A 6-month longitudinal randomized controlled trial.

SUBJECTS AND SETTING

The sample comprised 140 individuals with previously healed VLU and DFU who received care in 3 outpatient wound centers in the Southeastern region of the United States. Participants were randomized to the MUSTCOOL or a placebo cooling patch intervention.

METHODS

The cooling and placebo interventions comprised cooling or cotton-filled patch application to recently healed skin for 30 minutes, 3 times weekly plus standard of care including compression and leg elevation (participants with VLU) or therapeutic footwear and hygiene (participants with DFU) over a 6-month period. Pain severity and intensity were measured with the Brief Pain Inventory and physical activity with the International Physical Activity Questionnaire, which assessed metabolic equivalent of tasks (METs) in minutes per week. Minutes in walking time per week were assessed with an accelerometer. Data were descriptively analyzed for difference changes in scores from baseline to 6 months post-intervention.

RESULTS

Data were analyzed for 81 participants randomized to cooling and placebo groups (VLUs, n = 26/29) and DFU (n = 12/16). Slight reductions in VLU pain severity (-0.5, -0.2) and interference (-0.4, -0.5) and minimal reductions in DFU pain severity (0, -0.1) and interference (0.4/0.1) were achieved. However, pain scores were low to moderate at baseline (mean 4, 0-10 with 10 worst pain possible) in both groups. For physical activity, the MET values showed low physical activity in both groups at baseline with slight improvements noted in VLU cooling and placebo groups (73/799) and DFU (1921/225), respectively. Walking time for the VLU groups improved by 1420/2523 minutes; the DFU groups improved 135/157 minutes, respectively. Findings for outcomes were not statistically significant within or between groups.

CONCLUSIONS

Application of the cooling pack compared to placebo was minimally efficacious in reducing posthealing pain and improving function in this posthealed ulcer population. However for pain, scores were initially low; thus outcomes on pain, while lower, were marginal.

TRIAL REGISTRATION

The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156), https://clinicaltrials.gov/ct2/show/NCT02626156 .

A Prospective Noninterventional Study of Type I Collagen Matrix Plus Polyhexamethylene Biguanide Antimicrobial for the Treatment of Venous Leg Ulcers: A Secondary Analysis

BACKGROUND

The RESPOND registry study was the first prospective noninterventional study evaluating the real-world effectiveness of a native type 1 collagen matrix plus polyhexamethylene biguanide antimicrobial (PCMP) barrier in nonhealing wounds.

PURPOSE

The objective of this secondary analysis was to describe the effects of PCMP in the subgroup of patients with venous leg ulcers (VLUs) in the RESPOND registry.

METHODS

RESPOND was a 28-site, prospective, noninterventional study for up to 32 weeks. All patients (N = 307) in RESPOND received PCMP. Eligibility criteria included patients being 18 years of age and older and having cutaneous wounds, not including third-degree burns. Kaplan-Meier methods analyzed the frequency and median time to wound closure.

RESULTS

For the cohort of PCMP-treated VLUs (n = 67), the mean baseline wound area was 20.07 cm2 and mean wound duration was 89 days. Wound closure frequencies were 33%, 42%, 45%, 53%, and 73% at weeks 8, 12, 16, 24, and 32, respectively. The median time to closure was 22 weeks. Incidences of achieving >60% reduction in baseline area and depth were 78% and 70%, respectively, with 87% showing a reduction of >75% in volume.

CONCLUSION

PCMP appears to be a valuable adjunct for treating venous leg ulcers.

Improving venous ulcer outcomes

Venous leg ulcers (VLUs) are caused by compromised flow of venous and lymphatic fluids from the lower leg toward the central circulatory system. They are one of the most common types of chronic wounds, affecting 3% to 5% of those 65 years of age and older.¹ Most VLUs heal within 12 weeks with sustained lower leg compression sufficient to reduce the edema associated with venous insufficiency.² Diagnosing and improving a patient's venous insufficiency and addressing concomitant arterial disease are key elements of VLU management.³ Surgical correction has been effective for superficial venous insufficiency.⁴ Various topical,⁵ physical,⁶ or systemic⁷ interventions have been studied as adjuncts to compression in efforts to further improve VLU outcomes, with mixed results. This month's Evidence Corner summarizes recent randomized clinical trials (RCTs) documenting healing effects of topical gauze dressings impregnated with hyaluronic acid (HA) or placebo cream⁸ as an adjunct to patient-appropriate compression or low-level laser radiation as an adjunct to clinically prescribed elastic compression, diet, leg elevation, exercise, and moisture-retentive, absorbent, or microbicidal dressings.⁸.

Efficacy and Safety of a Hyaluronic Acid-Containing Cream in the Treatment of Chronic, Venous, or Mixed-Origin Leg Ulcers: A Prospective, Multicenter Randomized Controlled Trial

INTRODUCTION

Topical applications of hyaluronic acid (HA)-containing formulations, based on the complex and vital role of HA in all stages of the wound-healing process, are routinely used with standard therapy to promote faster healing of chronic wounds. However, evidence to guide clinical decisions on the use of topical HA in the healing of vascular leg ulcers is limited.

OBJECTIVE

This study compared the efficacy and safety of topical application of a hyaluronic acid cream vs a neutral comparator (identical cream without HA) in treating subjects with chronic leg ulcers of vascular origin.

MATERIALS AND METHODS

This was a prospective, multicenter double-blind randomized controlled trial. One hundred sixty-eight subjects with chronic leg ulcers of venous or mixed (venous and arterial) origin were randomized to receive either topical applications of 0.2% HA cream or neutral comparator cream for a maximum of 20 weeks. The primary efficacy endpoint was complete ulcer healing (100% reepithelialization of the wound area centrally assessed at 20 weeks or before and confirmed 3 weeks later). In both groups, topical treatment was associated with standard therapy (ulcer cleansing and optimized compression).

RESULTS

The proportion of subjects with centrally assessed complete healing of the target ulcer that was confirmed 3 weeks later (primary efficacy endpoint) was substantially higher in the HA cream group (31.3%) than in the neutral cream group (14.8%; P =.009). Results in the full analysis, per protocol, and as assessed by the investigator were consistent with primary results. No significant difference in treatment effect was observed when subjects were stratified according to baseline ulcer size (≤20 cm2 or >20 cm2) regardless of topical treatment. Safety and tolerability were comparable between treatments.

CONCLUSIONS

Treatment of subjects with chronic leg ulcers of venous or mixed origin with HA cream is safe, well tolerated, and results in a higher rate of healing than a neutral comparator cream.

Antimicrobial resistance-is wound care prepared?

In an Essity-sponsored symposium, entitled 'Antimicrobial resistance-is wound care prepared?', four key opinion leaders discussed the difficult journey to managing antimicrobial resistance within wound care at the global and local levels, backed up by the latest research. Peter Bradley summarises the main points they presented at the EWMA 2020 Virtual Conference. This article offers an introduction to the symposium, Antimicrobial resistance-is wound care prepared?, held on 18 November 2020, as part of the EWMA 2020 Virtual Conference. There were four speakers. Claire Kilpatrick, Director, S3 Global and Consultant to the World Health Organization, spoke on 'Preventing infections and managing antibiotic use-tackling a crisis for the health of nations'. The topic of Karen Ousey, Professor of Skin Integrity, Director for the Institute of Skin Integrity and Infection Prevention, University of Huddersfield, was 'Antimicrobial stewardship in wound management-less words more action'. Finally, Hadar Lev-Tov, Assistant Professor, and Irena Pastar, Associate Professor, both of the Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, gave a talk on 'Silver-resistant bacteria in venous leg ulcers? First results of an exploratory study'.

Bacterial cellulose an effective material in the treatment of chronic venous ulcers of the lower limbs

Chronic venous ulcers (CVU) of the lower limbs (LL) are common and cause psychological changes and significant social impact, as they make the patient susceptible to pain, absence from work and social bonds. Some materials are suggested as dressings for the treatment of CVU, but they are expensive and are generally not available for use in public health services. To evaluate the efficacy of the treatment for lower limbs (LL) chronic venous ulcer (CVU) using bacterial cellulose (BC), gel and multi-perforated film associated. A randomized controlled clinical-intervention study was performed among participants with LL CVU, divided into two groups: experimental (EG), treated with BC wound dressing and control (CG), treated with a cellulose acetate mesh impregnated with essential fatty acids (Rayon®). The participants were followed for 180 days, evaluated according to the MEASURE methodology. Thirty-nine patients were treated, 20 from the EG and 19 from the CG. In both groups, the wound area decreased significantly (p < 0.001), the healing rate was similar to the CG. The mean number of dressing changes in the SG was 18.33 ± 11.78, while in the CG it was 55.24 ± 25.81, p < 0.001. The healing dressing of bacterial cellulose, gel and associated film, when stimulating the epithelization of the lesions, showed a significant reduction in the initial area, with a percentage of cure similar to the Rayon® coverage. In addition to requiring less direct manipulation of ulcers.

Efficacy and Safety of a Hyaluronic Acid-Containing Gauze Pad in the Treatment of Chronic Venous or Mixed-Origin Leg Ulcers: A Prospective, Multicenter, Randomized Controlled Trial

INTRODUCTION

Hyaluronic acid (HA)-containing formulations routinely are utilized along with standard therapy to promote faster healing of chronic wounds; evidence to guide clinical decisions on the use of topical HA in the healing of vascular leg ulcers is limited.

OBJECTIVE

This study compared the efficacy and safety of an HA-impregnated gauze pad with an identical gauze pad without HA in the treatment of chronic leg ulcers of vascular origin.

MATERIALS AND METHODS

A prospective, multicenter, multinational, parallel-group, randomized, double-blind, clinical study was conducted between June 13, 2017, and December 31, 2018. Adults with 1 or more chronic leg ulcers of venous or mixed origin between 2 months and 4 years' duration were eligible to participate. Participants were randomized to treatment consisting of standard care (ie, ulcer cleansing, debridement/anesthesia as necessary, and optimized compression) and either application of a gauze pad containing 0.05% HA or a neutral comparator once daily for a maximum of 20 weeks. The primary efficacy endpoint was complete ulcer healing (100% reepithelialization of the wound area centrally assessed by 1 independent and experienced assessor blinded with respect to the treatment applied, as shown on digital photographs taken under standardized conditions at or before 20 weeks and confirmed 3 weeks later). Secondary efficacy endpoints included the percentage of completely healed target ulcers, residual area of target ulcer relative to baseline, the condition of the periulcerous skin, the total amount of analgesics used, the incidence of infection at the ulcer site of the target ulcer, patient adherence to treatment, time to achieve complete healing as centrally assessed, and pain intensity as measured by a visual analog scale.

RESULTS

Among the 168 participants (82 in the HA gauze pad group and 86 in the neutral gauze pad group), 33 (39.8%) in the HA group experienced complete healing of the target ulcer, which was significantly higher than the neutral comparator group (15, 18.5%; P = .002). Results in the full analysis and per-protocol sets were consistent with the primary results; no significant difference was noted in outcomes when participants' wounds were stratified according to baseline ulcer size.

CONCLUSIONS

HA delivered in a gauze pad formulation could be a beneficial treatment for chronic leg ulcers of venous or mixed origin.

Treatment of Chronic Venous Ulcers With Heterologous Fibrin Sealant: A Phase I/II Clinical Trial

Background

Heterologous fibrin sealant (HFS) consists of a fibrinogen-rich cryoprecipitate extracted from Bubalus bubalis buffalo blood and a thrombin-like enzyme purified from Crotalus durissus terrificus snake venom. This study evaluated the safety and immunogenicity of HFS, estimated the best dose, and assessed its preliminary efficacy in the treatment of chronic venous ulcers (CVU).

Methods

A phase I/II non-randomized, single-arm clinical trial was performed on 31 participants, accounting for a total of 69 active CVUs. All ulcers were treated with HFS, essential fatty acid, and Unna boot for 12 weeks. The outcomes assessed were: (1) primary safety, immunogenicity analyses, and confirmation of the lowest safe dose; (2) secondary promising efficacy by analyzing the healing process. Immunogenicity was evaluated using the serum-neutralizing (IgM and IgG) and non-neutralizing (IgA and IgE) antibody techniques against the product. The immuno-detection of IgE class antibodies was assessed using dot-blot assay before and at the end of treatment. Positive samples on dot-blot assays were subsequently analyzed by western blotting to verify the results.

Results

No severe systemic adverse events related to the use of HFS were observed. Local adverse events potentially related to treatment include ulcer pain (52%), peri-ulcer maceration (16%), peri-ulcer pruritus (12%), critical colonization (8%), peri-ulcer eczema (4%), the opening of new ulcers (4%), and increased ulcerated area 4%). Neutralizing and non-neutralizing antibodies did not show significant deviations at any of the evaluated time points. Blot assays showed that all patients presented negative immunological reactions, either before or after treatment, with the thrombin-like enzyme component. In addition, two participants showed a positive immunological reaction to the cryoprecipitate component, while another two were positive before and during treatment. Regarding the secondary outcomes of preliminary efficacy, a total healing and significant reduction of the area was observed in 47.5 and 22%, respectively. A qualitative improvement was observed in the wound beds of unhealed ulcers.

Conclusions

The investigational HFS bioproduct proved to be safe and non-immunogenic with a good preliminary efficacy for the treatment of CVU, according to the protocol and doses proposed. A multicentric phase III clinical trial will be necessary to verify these findings.

Efficacy of Human Recombinant Epidermal Growth Factors vs Conventional Therapy for the Treatment of Chronic Venous Ulcers: A Retrospective Case Series

INTRODUCTION

Venous ulcers are the terminal phase of chronic venous insufficiency, the result of induced skin disorders and maintained by persistent venous hypertension. Affecting a large part of the adult population, they drain economic resources and greatly impact patient quality of life.

OBJECTIVE

The objective of this descriptive, retrospective case series was to determine the efficacy of recombinant human epidermal growth factor (rhEGF) plus compression therapy vs standard of care in 48 patients with active ulcers resulting from chronic venous insufficiency.

MATERIALS AND METHODS

In this descriptive, retrospective case series, 24 patients (mean age, 62.4 years) received rhEGF by intralesional and perilesional infiltration with compression therapy, and 24 patients (mean age, 69.4 years) received treatment with topical hydrocolloid gels and compression therapy. In 62.5% of patients, the ulcers were located in the internal malleoli. Ulcer progression time, ulcer size, Wollina score index, number of conventional cures, rhEGF vials used, and time to epithelialization were documented.

RESULTS

Epithelialization of the active ulcer was reached in 100% of intervened patients. In the 24 patients receiving rhEGF, 71% achieved wound closure in 8 weeks or less, and the remaining percentage achieved closure within 9 and 12 weeks. In the conventional therapy group, patients achieved closure in an average of 29.5 weeks, with a minimum of 13 weeks and a maximum of 46 weeks.

CONCLUSIONS

Although conventional therapy with the use of hydrocolloids and compression achieved adequate epithelialization of venous ulcers, the use of rhEGF significantly decreased healing time and could be a beneficial therapy to these patients who have few therapeutic options.

Skin Ulcers: Pharmacotherapy

Topical wound therapies have unclear benefits for patients with pressure ulcers, venous leg ulcers (VLUs), and arterial ulcers. There is slightly more evidence supporting the use of systemic therapies. Used with compression therapy or alone, oral pentoxifylline has been shown to be more effective than placebo or no therapy in improving and healing VLUs. (This is an off-label use of pentoxifylline.) To prevent bacterial resistance, most guidelines recommend use of antimicrobial dressings, antiseptics, and antibiotics only for patients with infected wounds. There is insufficient evidence to conclude that antiseptics or topical antibiotics improve or heal pressure ulcers and VLUs more effectively than nonmedicated dressings. Systemic antibiotics are used for patients with nonhealing wounds when the clinical infection is not improving with antiseptics or topical antibiotics. After the underlying cause of a chronic wound is addressed, pain management should start with topical drugs. When pain is not managed with topical drugs, systemic drugs should be considered. Opioids should be used only if the overall benefits outweigh the risks. Nutritional supplementation has not been clearly shown to prevent or manage chronic ulcers.

[Sucrose octasulfate-evidence in the treatment of chronic wounds]

Patients with chronic wounds should receive wound treatment in addition to causative therapy. In this context, the lack of adequate evidence for wound healing products has been repeatedly discussed. Using the example of TLC-sucrose octasulfate (TLC: technology lipido-colloid), the present review shows that there is significant data with good evidence and comparability in this area. One therapeutic approach to promote wound healing is the inhibition of matrix-metalloproteinases, for example by sucrose octasulfate. For wound products containing TLC-sucrose octasulfate, several sequential clinical studies have been conducted in recent years. The WHAT study was an open randomized controlled trial (RCT) with 117 patients with venous leg ulcers (VLU). The CHALLENGE study was a double-blind RCT with 187 patients with VLU. The SPID study was a pilot study with 33 patients with diabetic foot ulcers (DFU). The two prospective, multicenter clinical pilot studies NEREIDES and CASSIOPEE examined a total of 88 patients with VLU in different phases of healing. In the REALITY study, a pooled data analysis was performed on eight observational studies with 10,220 patients with chronic wounds of different genesis. In the double-blind, two-armed EXPLORER RCT, 240 patients with neuro-ischemic DFU were followed from first presentation until complete healing. In all studies, a significant promotion of wound healing could be shown by the use of wound healing products with TLC-sucrose octasulfate.

A Literature Review of Pharmacological Agents to Improve Venous Leg Ulcer Healing

Compression therapy is the gold standard treatment for venous leg ulcers (VLUs); however, with adjunctive pharmacological therapies and poor patient adherence using compressive dressings, clinicians are looking to find the advantage in treating VLUs. This literature review focuses on the efficacy of pharmacological agents, quality of life using agents in addition to compression therapy, and cost effectiveness to indicate the best outcomes for pharmacological treatment of VLUs. The following available venotonic, hemorheologic, and fibrinolytic agents were reviewed for oral management in treating VLUs: pentoxifylline, flavonoids (diosmin, hidrosmin, rutosides, and micronized purified flavonoid fraction, Vasculera), Red-Vine-Leaf-Extract AS 195, Ruscus, Ginkgo biloba, Centella asiatica, Pycnogenol (French maritime pine bark), escin/horse chestnut extract, nutritional supplements (ie, zinc and magnesium, glycosaminoglycans [sulodexide], mesoglycans), Axaven, cilostazol, fibrinolytic enhancers (stanozolol and defibrotide), calcium dobesilate, aspirin, antibiotics (antimicrobials, doxycycline, levamisole), diuretics, cinnarizine, naftazone, and benzarone. Venous leg ulcer pharmacological treatment options were searched in the English language from February 2020 to March 2020 using numerous databases and sites, such as PubMed. Drugs used adjunctively with compression therapy that facilitate healing in long-standing or large VLUs include micronized purified flavonoid fraction, pentoxifylline, sulodexide, and mesoglycan.

The Benefits of Micronized Purified Flavonoid Fraction (MPFF) Throughout the Progression of Chronic Venous Disease

At the 2019 European Venous Forum in Zurich Switzerland, a symposium entitled "State of the art: benefits of MPFF throughout CVD progression" was held to discuss the developing treatment strategies for patients at all stages of chronic venous disease (CVD). At the early stages of CVD, management should be focused on preventing disease progression through lifestyle changes and conservative treatment; treatment can also include venoactive drugs (VAD) such as micronized purified flavonoid fraction (MPFF; Daflon®), which is the most well-known and most widely prescribed VAD in Europe. As the disease progresses, patients who require interventional procedures (e.g., endovenous procedure or sclerotherapy) can also benefit from MPFF treatment in the recovery period after the procedure, as MPFF has been shown to reduce periprocedural pain and bleeding (hematoma), and to improve CVD symptoms during this period. Management of CVD in patients with venous leg ulcers (VLU) is the most challenging; in these patients, recommended adjunct therapies to be combined with standard compression therapy include VAD (MPFF) and non-VAD drugs (pentoxifylline and sulodexide) which have been shown to speed VLU healing in comparison with compression therapy alone.

Treatment with novel HYBENX® root canal cleanser suggests biofilms blocked healing of human wounds: case series

Pathogenic biofilms are considered a potential major obstacle to healing chronic wounds. The six-month evaluation period in this study assessed the effect of a single treatment of the HYBENX® (HYB) Root Canal Cleanser on chronic wounds, especially its ease of use, safety, potential for shortening duration of Inflammatory Phase, and promotion of granulation. HYB gel was applied to the wound bed and periwound skin for 10 seconds. Gel was removed by cotton gauze pads and low-pressure saline rinsing. Standard wound dressings based on wound etiology, location, and exudate characteristics were applied. Duration of these seven HYB-treated wound cases (two pressure ulcers, one surgical wound, four lower extremity ulcers-a venous reflux-associated calf ulcer, one diabetic foot ulcer, and two animal-induced wounds-brown recluse spider and bovine bite) ranged from 12 days to 10 years. Three cases had sinus tracts. After HYB application, sinus tract closure occurred at 7, 16, and 21 days. The 10-year recalcitrant wound from brown recluse spider bite healed in 97 days. Diabetic foot ulcer responded to HYB treatment plus additional strategies and healed in six months. These data support the hypotheses that pathogenic biofilm actively prevents the healing of chronic wounds, and biofilm can be disrupted with a single HYB treatment.

Efficacy and Safety of 4% Hibiscus rosa-sinensis Leaf Extract Ointment as an Adjunct Treatment to Compression Stockings on the Closure of Venous Leg Ulcers: A Pilot Study

INTRODUCTION

Venous leg ulcers (VLUs), the most common leg ulceration worldwide, are caused by venous hypertension due to venous reflux, the failure of the calf muscle to pump, and venous flow obstruction. They are associated with a reduced quality of life, particularly in relation to pain and physical function. Hibiscus rosa-sinensis is commonly employed because of its many medicinal properties, and studies have shown Hibiscus contains phytochemicals that have antimicrobial, antioxidant, and anti-inflammatory properties that promote wound healing.

OBJECTIVE

The authors evaluate the efficacy and safety of 4% gumamela leaf extract ointment in the closure of VLUs among patients seen in a dermatology outpatient department in the Philippines.

MATERIALS AND METHODS

The study included male or female patients with leg ulcers confirmed by duplex scan to be venous in origin and willing to have elastic compression therapy. Patients were instructed to clean the wound with normal saline solution and to apply the extract twice daily. The study was conducted for 12 weeks or until wound closure. Wounds were evaluated and photographed at baseline and every subsequent 2 weeks. Efficacy of therapy was evaluated based on ulcer area size using planimetry method at each visit. Safety was assessed using a 4-point grading system to monitor possible adverse reactions, namely pruritus, rash, burning, and urticaria.

RESULTS

Twelve patients were included in the study; 5 patients had an initial ulcer area of ⟩ 10 cm2 and 7 had an initial ulcer area of ≤ 10 cm2. By the end of the study, 10 patients (83.3%) achieved complete ulcer closure in ⟨ 12 weeks, 1 patient (8.3%) had a decrease in ulcer area ⟩ 50% by week 12, and 1 patient (8.3%) had ⟨ 50% decrease in ulcer area at the end of the study.

CONCLUSIONS

Data showed compression stockings with 4% gumamela leaf extract ointment application could close VLUs in ⟨ 12 weeks. Applied with compression stockings, the ointment shows potential use in VLU management.

Aspirin versus placebo for the treatment of venous leg ulcers-a phase II, pilot, randomised trial (AVURT)

BACKGROUND

Venous leg ulcers (VLUs) can take many months to heal and 25% fail to heal. The main treatment for venous leg ulcers is compression therapy and few additional therapies exist. Two previous trials indicated that low-dose aspirin may improve healing time, but these trials were insufficiently robust.

METHODS

A multi-centred, pilot, phase II, randomised, double blind, parallel-group, placebo-controlled, efficacy trial (RCT) was conducted to determine: if aspirin improves VLU healing time; the safety of aspirin in this population; treatment compliance; and the feasibility of recruitment to a phase III trial. We recruited patients from secondary care who were aged ≥ 18 years, had a chronic VLU and not regularly taking aspirin. Participants were randomly assigned (1:1) to receive 300 mg of daily aspirin or placebo in addition to standard care, which consisted of multi component compression therapy aiming to deliver 40 mmHg at the ankle where possible. The randomisation list was stratified by ulcer size (≤ 5 cm2 or > 5 cm2). The primary endpoint was time to ulcer healing, which was defined as 'complete epithelial healing in the absence of scab (eschar) with no dressing required'. Safety outcomes were assessed in all participants who received at least one dose of the study drug.

RESULTS

Twenty-seven patients were recruited from eight sites (target 100 patients). A short time-frame to recruit and a large number of patients failing to meet the eligibility criteria were the main barriers to recruitment. There was no evidence of a difference in time to healing of the reference ulcer following adjustment for log ulcer area and duration (hazard ratio 0.58, 95% confidence interval 0.18 to 1.85; p = 0.357). One expected serious adverse event related to aspirin was recorded. A number of options to improve recruitment were explored.

CONCLUSIONS

There was no evidence that aspirin was effective in expediting the healing of chronic VLUs. However, the analysis was underpowered due to the low number of participants recruited. The trial design would require substantial amendment in order to progress to a phase III (effectiveness) trial.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02333123. Registered on 5 November 2014.

Antibiogram in the biopsy of chronic venous ulcers related to sudden changes in the pain profile

INTRODUCTION

Chronic venous insufficiency (CVI) has an important impact on the public health system in particular due to the occurrence of chronic venous ulcers (UCV) and infections.

OBJECTIVE

To evaluate cultures of biopsies of chronic venous ulcers of patients who suffered an acute change in the intensity of pain of the lesion.

METHOD

Antibiograms of the cultures of chronic venous ulcer biopsies of patients who suffered an acute change in the lesion with significant pain for 24 hours were evaluated. All patients were treated between 2011 and 2015 in the Vascular Surgery Outpatient Clinic of the Medical School in São José do Rio Preto. Other causes of pain such as chronic arterial insufficiency and problems with the dressings were ruled out.

RESULTS

Positive cultures were detected in 34 of the 35 patients whose pain was resolved by antibiotic therapy.

CONCLUSION

Acute changes in the intensity of pain associated with chronic venous ulcers seem to be related to local infectious disease.

Sulodexide in venous disease

Sulodexide is a glycosaminoglycan extracted from porcine intestinal mucosa. The purpose of this review is to discuss sulodexide's complex pharmacological profile and its clinical applications for venous disease. Sulodexide has wide-ranging biological effects on the vascular system, including antithrombotic, profibrinolytic, anti-inflammatory, endothelial protective and vasoregulatory effects. Sulodexide has emerged as a potential therapeutic option for the management of chronic venous insufficiency, including venous ulceration, and the prevention of recurrent venous thromboembolism, with a low rate of major bleeding complications. Sulodexide's pleiotropic vascular effects may facilitate the management of common venous disorders.

Pathophysiological Mechanisms of Chronic Venous Disease and Implications for Venoactive Drug Therapy

Chronic venous disease (CVD) is a common pathology, with significant physical and psychological impacts for patients and high economic costs for national healthcare systems. Throughout the last decades, several risk factors for this condition have been identified, but only recently, have the roles of inflammation and endothelial dysfunction been properly assessed. Although still incompletely understood, current knowledge of the pathophysiological mechanisms of CVD reveals several potential targets and strategies for therapeutic intervention, some of which are addressable by currently available venoactive drugs. The roles of these drugs in the clinical improvement of venous tone and contractility, reduction of edema and inflammation, as well as in improved microcirculation and venous ulcer healing have been studied extensively, with favorable results reported in the literature. Here, we aim to review these pathophysiological mechanisms and their implications regarding currently available venoactive drug therapies.

Drug Treatment of Chronic Venous Insufficiency and Venous Ulceration: A Review

Treatment of venous insufficiency and venous ulceration has for many years relied on established principles of compression and limb elevation. Drug treatment has been of little benefit. In recent years, a better understanding of the pathological mechanisms underlying skin damage in venous disease has allowed more rational pharmacotherapeutic approaches to be made. This review examines these, with special reference to current theories of the cause of venous ulceration.

Healing of chronic venous ulcer with topical sevoflurane

The present study assesses the efficacy and safety of topical sevoflurane in chronic venous ulcers and its impact on analgesia and healing. This retrospective study included 30 patients older than 65 years with painful refractory chronic venous ulcers. Patients were treated with topical sevoflurane prior to the usual ulcer cleaning every 2 days for a period of 1 month. Treatment was initiated with a saline solution, followed by direct irrigation of 1 ml of liquid sevoflurane over the wound size, which was measured as cm2 . Sevoflurane had a fast, intense and long-lasting analgesic effect. Latency time ranged from 2 to 7 minutes (3·9 ± 1·5 minutes), and duration varied from 8 to 18 hours (12 ± 2·9). The mean ulcer size was 8·4 ± 9·7 cm2 . There was a progressive decrease in size in all patients, with a mean size of 4·2 ± 5·4 cm2 at the end of the study. There were no adverse systemic effects. Local adverse effects were mild and transient, including pruritus, erythema and heat. Topical sevoflurane is a new, efficient and safe therapeutic alternative in painful chronic venous ulcers, refractory to usual analgesic treatment. It can improve the ulcer-healing process that shortens the cicatrisation period.

Low dose aspirin as adjuvant treatment for venous leg ulceration: pragmatic, randomised, double blind, placebo controlled trial (Aspirin4VLU)

Objective To determine the effect of low dose aspirin on ulcer healing in patients with venous leg ulcers.Design Pragmatic, community based, parallel group, double blind, randomised controlled trial.Setting Five community nursing centres in New Zealand.Participants 251 adults with venous leg ulcers who could safely be treated with aspirin or placebo: 125 were randomised to aspirin and 126 to placebo.Interventions 150 mg oral aspirin daily or matching placebo for up to 24 weeks treatment, with compression therapy as standard background treatment.Main outcome measures The primary outcome was time to complete healing of the reference ulcer (largest ulcer if more than one ulcer was present). Secondary outcomes included proportion of participants healed, change in ulcer area, change in health related quality of life, and adverse events. Analysis was by intention to treat.Results The median number of days to healing of the reference ulcer was 77 in the aspirin group and 69 in the placebo group (hazard ratio 0.85, 95% confidence interval 0.64 to 1.13, P=0.25). The number of participants healed at the endpoint was 88 (70%) in the aspirin group and 101 (80%) in the placebo group (risk difference -9.8%, 95% confidence interval -20.4% to 0.9%, P=0.07). Estimated change in ulcer area was 4.1 cm² in the aspirin group and 4.8 cm² in the placebo group (mean difference -0.7 cm², 95% confidence interval -1.9 to 0.5 cm², P=0.25). 40 adverse events occurred among 29 participants in the aspirin group and 37 adverse events among 27 participants in the placebo group (incidence rate ratio 1.1, 95% confidence interval 0.7 to 1.7, P=0.71).Conclusion Our findings do not support the use of low dose aspirin as adjuvant treatment for venous leg ulcers.Trial registration ClinicalTrials.gov NCT02158806.

Are there clinical signs and symptoms of infection to indicate the presence of multidrug-resistant bacteria in venous ulcers?

The selection of topical and systemic therapies for the treatment of venous ulcers with signs of infection is challenging and should be accompanied by specific precautionary measures to protect against cross-contamination in the presence of multidrug-resistant microorganisms. However, there are still no clinical indicators for this situation, and confirmation of resistant strains occurs through culture and sensitivity, which can take up to 14 days. During this period, protective measures may no longer be taken, contributing to the spread of these pathogens. This study aimed to analyze the relationship between clinical signs and symptoms of infection in venous ulcers and the presence of antimicrobial-resistant Staphylococcus aureus and/or Pseudomonas spp. A cross-sectional study was developed including 69 patients with 98 venous ulcers. Clinical observation protocol was applied to detect infection indicators established by the European Wound Management Association and microbiological analysis of samples of the lesions. Fisher's exact test and χ² were used for analyses (P < 0.05). Two indicators of infection predominated (f >70%): discoloration of the opaque type and/or dark brick red and increased exudate volume; 31 (31.6%) ulcer samples showed positive culture for the bacteria studied. There was no relationship between signs and symptoms of infection and the presence of multidrug-resistant microorganisms. Taking into account the percentage of lesions with resistant strains, for safe care, contact precautionary measures should be implemented in the treatment rooms, in addition to standard precautions.

The role of Inadine in wound care: a consensus document

Iodine-based products are antibacterial. The small iodine molecular size is ideally suited to treat surface critical colonisation. Inadine is a 10% povidone iodine dressing with the equivalent of 1% available iodine that is easily extracted from the viscose backing by serum or exudate. The use of hydrophilic polyethylene glycol tulle dressing delivery vehicle allows the dressing to be easily removed by irrigation with potable water or saline. In this study, we developed a short online survey completed by 23 wound-care key opinion leaders from the nursing, medical and podiatry professions. A computerised modified Delphi technique was used to achieve 80% consensus on 11 statements related to the utility and everyday topical wound-care use of this product.

Enzymatic debridement: is HA-collagenase the right synergy? Randomized double-blind controlled clinical trial in venous leg ulcers

OBJECTIVE

The aim of this study is to evaluate the efficacy and safety of a new ointment containing Hyaluronic Acid and collagenase from non-pathogenic Vibrio alginolyticus.

PATIENTS AND METHODS

Double blind, multicenter, controlled clinical trial (no. ISRCTN71239043) conducted to demonstrate the superiority of Hyaluronic Acid-Collagenase applied once a day over placebo in mean reduction of devitalized/fibrinous/slough tissue after 15 days of treatment. 113 patients with venous ulcers were enrolled and randomized to receive active treatment therapy or vehicle preparation. Both arms also received compression therapy. Subjects were assessed at baseline and at 4 different clinical study visits up to a maximum of 30 days. Outcome measures included mean percentage debridement evaluated by digital planimetry, pain during change of dressing measured on a visual analogue scale and adverse event assessment for tolerance.

RESULTS

After 15 days the debridement rate in the active group was 67.5% compared to 59% in the placebo group (p = 0.0436). A significantly higher number of patients in the treatment group achieved 100% debridement by day 15 (p = 0.0025) than in the control group, and a higher percentage also demonstrated complete debridement at every other time point. Pain perception was similar in both groups with low levels during medication. No differences in tolerance were observed between groups.

CONCLUSIONS

Chronic venous ulcers treated with this novel compound of Hyaluronic Acid and collagenase resulted in a significantly higher debridement rate at Day 15 vs. the control group. Hyaluronic Acid-Collagenase was well tolerated and a low degree of pain was perceived during dressing change. The preparation of 0.2% of Hyaluronic acid-collagenase shows significant benefits in the management of chronic ulcers.

Maltodextrin/ascorbic acid stimulates wound closure by increasing collagen turnover and TGF-β1 expression in vitro and changing the stage of inflammation from chronic to acute in vivo

It has been reported that carbohydrates confer physicochemical properties to the wound environment that improves tissue repair. We evaluated in vitro and in vivo wound healing during maltodextrin/ascorbic acid treatment. In a fibroblast monolayer scratch assay, we demonstrated that maltodextrin/ascorbic acid stimulated monolayer repair by increasing collagen turnover coordinately with TGF-β1 expression (rising TGF-β1 and MMP-1 expression, as well as gelatinase activity, while TIMP-1 was diminished), similar to in vivo trends. On the other hand, we observed that venous leg ulcers treated with maltodextrin/ascorbic acid diminished microorganism population and improved wound repair during a 12 week period. When maltodextrin/ascorbic acid treatment was compared with zinc oxide, almost four fold wound closure was evidenced. Tissue architecture and granulation were improved after the carbohydrate treatment also, since patients that received maltodextrin/ascorbic acid showed lower type I collagen fiber levels and increased extracellular alkaline phosphatase activity and blood vessels than those treated with zinc oxide. We hypothesize that maltodextrin/ascorbic acid treatment stimulated tissue repair of chronic wounds by changing the stage of inflammation and modifying collagen turnover directly through fibroblast response.

[The treatment of elderly and senile patients with venous trophic ulcers and type 2 diabetes mellitus.]

The effectiveness of the inclusion of sulodexide in the pharmacotherapy of complex treatment of patients (n=52) elderly and senile with a combination of chronic diseases of the veins complicated by refractory trophic ulcers of the lower extremities, and type 2 diabetes mellitus was studied. Patients were randomly randomized in the 1st (n=26) and the 2nd (n=26) groups, the statistical differences between them in age (t1-2=0,2, p1-2=0,833), sex (χ21-2=0,008, p1-2=0,991), nosology (χ21-2=0,004, р1-2=0,993); the anamnesis of chronic diseases of veins (t1-2=0,14, p1-2=0,893); duration of trophic ulcers (t1-2=0,21, p1-2=0,827); planimetric parameters of trophic ulcers (t1-2=0,18, p1-2=0,865) were not recorded. Patients of the 1st group received treatment with sulodexide according to the standard schedule for 50 days. The primary outcome of the study is the complete closure of the trophic ulcer after 1 month. Secondary outcomes are epithelization after 2 months and dynamic planimetric indices within 12 months. The effectiveness of the use of sulodexide was assessed according to the VCSS scale, dynamic changes in the malleolar volume and changes in planimetric parameters. A statistically significant improvement in the overall VSCC score was observed in both the 1st (p=0,002) and the 2nd (p=0,0016) groups in all study outcomes. At the same time, a statistically significant improvement in the VSCC scores was more pronounced in the 1st group (p<0,05). After 2 and 6 months, a statistically significant decrease in the malleolar volume of the affected lower extremity was recorded both in the 1st (t=4,17, p=0,001) and in the 2nd (t=2,4, p=0,37) groups. Clinically and statistically significant decrease in malleolar volume was more pronounced in the 1st group (p<0,05). After 30 days, trophic ulcers were closed in 9 (34,6%) cases in the 1st group and in 5 (19,2%) patients in the 2nd group (p<0,05). On day 60 epithelization was achieved in 22 (84,6%) and 12 (46,1%) patients, respectively. The time of complete epithelization in patients of the 1st and the 2nd groups was 51,2±1,6 and 78,4±2,6 days (p<0,05). The conclusion is made that sulodexide is an effective and pathogenetically grounded pharmacological preparation for the treatment of patients of elderly and senile age with chronic clinical disease C6 of clinical class and type 2 diabetes mellitus.

Chronic Venous Insufficiency and the Therapeutic Effects of Daflon 500 mg

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.

Improvement of Microcirculation and Healing of Venous Hypertension and Ulcers With Crystacide ®: Evaluation With a Microcirculatory Model, Including Free Radicals, Laser Doppler Flux, and PO2/PCO2 Measurements

In 32 patients with chronic venous insufficiency and venous hypertension associated with ulcerations, the effects of the local application of a hydrogen peroxide cream (Crystacide) applied onto the skin was evaluated using a complex, proportional, microcirculatory model to assess and quantify venous microangiopathy after local treatment. A comparative group treated without Crystacide was included. Laser Doppler flowmetry was used to assess skin perfusion (flux and venoarteriolar response) in association with transcutaneous PO2 and PCO2 measurements. Local plasma free radicals were evaluated in the area surrounding the venous ulcer using the D-Roms test. Crystacide was applied around and on the ulcer for 10 days. Crystacide was more effective than the control treatments. PO2 was increased (improved, P < .05), and plasma free radicals, PCO2, and laser Doppler flowmetry were decreased (improving toward normal values, P < .05). Also, the ulcerated area was significantly smaller at 10 days in the Crystacide group in comparison with controls (P < .05). In the proportional microcirculatory model, all parameters indicated an important level of improvement significantly larger than in controls. In conclusion, in chronic venous insufficiency and venous ulcerations, local treatment with Crystacide (10 days) improves the microcirculation and decreases skin free radicals, thus improving healing.

Generalized rash follows ankle ulceration

After being treated for venous insufficiency and malleolus ulceration, this patient woke up covered in itchy, painful plaques. What was the connection between the 2?

Some Effects of a Topical Collagen-Based Matrix on the Microcirculation and Wound Healing in Patients With Chronic Venous Leg Ulcers: Preliminary Observations

Themicrocirculation of the wound bed is a key parameter for improving granulation tissue formation and, hence, wound healing. The aim of this study was to determine whether a wound dressing comprising collagen/oxidized regenerated cellulose has effects over a short term on wound healing. Wounds were evaluated using a clinical wound score; pain associated with wounds was measured using a visual analogue scale. Wound microcirculation was evaluated using a technique based on noncontact remission spectroscopy. A prospective trial was performed in 40 patients with chronic venous leg ulcers (mean age 74 years; range, 43-93 years; 25 females and 15 males). Patients in group A were treated with PROMOGRAN® Matrix (Johnson& Johnson, New Brunswick, NJ) combined with “good” ulcer care for 2 weeks. Control group B consisted of 10 patientswho received only good ulcer care. The authors measured a favorable clinical response in 76.9% (group A) versus 66.7% (group B). Themean reduction of ulcer area was statistically significant in group A (P < .05). The wound score improved in group A from 2.28 ± 1.24 (before treatment) increasing to 3.72 ± 1.57 (after 1 week; P < .00023) and 4.92 ± 1.68 (after 2 weeks; P < .000027). In group B, the score improved from 1.44 ± 1.33 (before treatment) to 3.22 ± 1.30 (after 1 week; P < .0077). The mean visual analogue pain score before treatment was 8.72 (group A) and 7.88 (group B) (ns,P > .05). After 1 week of treatment, the score dropped to 5.76 (group A) and 6.66 (group B). In the second week, group A patients had a mean pain score of 3.84 compared with the pain score before treatment (P < .05). After 1 week of treatment, in group A there was a decrease in remission spectroscopy, which is considered to reflect an improvement in microcirculation.

Sulodexide for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are common, chronic wounds caused by venous diseases, with a high recurrence rate and heavy disease burden. Compression therapy (bandages or stockings) is the first choice treatment for venous leg ulcers. However, when ulcers remain unhealed, medication can also be used with or without compression therapy. Sulodexide, a highly purified glycosaminoglycan (a naturally occurring molecule) has antithrombotic and profibrinolytic properties (it reduces the formation of blood clots) as well as anti-inflammatory effects. Sulodexide has been studied as a potential treatment for venous leg ulcers.

OBJECTIVES

To assess the efficacy and safety of sulodexide for treating venous leg ulcers.

SEARCH METHODS

In July 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Chinese Biomedical Literature Database (CBM); China National Knowledge Infrastructure Database (CNKI); Wan Fang and VIP. We also searched clinical trials registries to identify ongoing studies, as well as references listed in relevant publications. There were no restrictions based on date of publication, language or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving people with a diagnosis of venous leg ulcers which compared sulodexide with placebo or any other drug therapy (such as pentoxifylline, flavonoids, aspirin), with or without compression therapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The authors independently selected studies, extracted data and assessed risk of bias. We pooled data to present the risk ratio (RR) with 95% confidence interval (CI), or presented a narrative summary. We assessed overall evidence quality according to the GRADE approach.

MAIN RESULTS

We included four RCTs with a total of 463 participants (aged 42 years to 93 years); one report was only available as a published abstract.Meta-analysis of three RCTs suggests an increase in the proportion of ulcers completely healed with sulodexide as an adjuvant to local treatment (including wound care and compression therapy) compared with local treatment alone (rate of complete healing with sulodexide 49.4% compared with 29.8% with local treatment alone; RR 1.66; 95% CI 1.30 to 2.12). This evidence for sulodexide increasing the rate of complete healing is low quality due to risk of bias. It is unclear whether sulodexide is associated with any increase in adverse events (4.4% with sulodexide versus 3.1% with no sulodexide; RR 1.44; 95% CI 0.48 to 4.34). The evidence for adverse events is very low quality, downgraded twice for risk of bias and once for imprecision.

AUTHORS' CONCLUSIONS

Sulodexide may increase the healing of venous ulcers, when used alongside local wound care, however the evidence is only low quality and the conclusion is likely to be affected by new research. It is not clear whether sulodexide is associated with adverse effects. The standard dosage, route and frequency of sulodexide reported in the trials was unclear. Further rigorous, adequately powered RCTs examining the effects of sulodexide on healing, ulcer recurrence, quality of life and costs are necessary.