Painful ulcerations: the sole clinical sign of mixed cryoglobulinaemia secondary to marginal zone lymphoma.

A man in his 70s with background vascular disease presented with 7 months of painful non-resolving lower leg ulcers with eschar and petechiae, left lower ear lobe ulceration and dusky inflammation of the right ear. He demonstrated good bilateral pedal pulses and no peripheral oedema. No lymphadenopathy was palpated.Biopsy suggested leucocytoclastic vasculitis on chronic stasis changes. Blood investigations showed elevated rheumatoid factor and mixed polyclonal IgG and monoclonal IgM cryoglobulins. He was diagnosed with mixed cryoglobulinaemia, and consequent conducted flow cytometry revealed CD5 +marginal zone lymphoma with elevated serum free light chains and kappa/lambda ratio.One-month following rituximab and chlorambucil therapy, the patient's pain had much improved, ear ulcers had healed and several leg ulcers had reduced in width and depth. The petechial eruption had also resolved.

Hand rejuvenation: Combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections.

Background The hands are an important aesthetic feature that can reveal aging through surface pigmentary changes, loss of skin thickness and ectatic dorsal hand veins. Techniques addressing these changes already exists but are not routinely combined for optimum results. Objective The combination techniques of dorsal hand veins sclerotherapy and sub-dermal filler injections are described. Methods The dorsal hand veins are treated with sclerotherapy (0.5% Sodium tetradecyl sulphate). This is then followed by subdermal injection of 0.75 mL-1.5 mL calcium hydroxylapatite (Radiesse, Merz) per hand, in conjunction with tumescent anaesthetic. The dorsal hands should be gently massaged for 2 min (per hand), twice a day for two days. If necessary, the procedure can be repeated after one month for further improvement. Results The techniques of sclerotherapy and filler injections complement each other well in hand rejuvenation. Calcium hydroxylapatite is safe and effective for hands and associated with high patient satisfaction. In suitable patients, the reduction in ectatic veins from sclerotherapy results in a longstanding improvement that complements volume restoration with fillers. Conclusion Aging hands with ectatic dorsal hand veins and skin atrophy/wrinkling not fully responsive to filler correction alone can further improve with the combination of sclerotherapy and filler injections.