S2k guideline lipedema.

This S2k guideline was developed on the initiative and under the German Society of Phlebology and Lymphology (DGPL) leadership. The guideline aims to optimize the diagnosis and treatment of lipedema. It is intended to bring together the different approaches of the respective professional groups in a consensus-based manner and thus offer a basic concept for the best possible treatment of patients with lipedema. Sixty recommendations were formulated and agreed on in diagnostics, conservative and surgical treatment options, psychosocial factors and self-management. The guideline is intended to reflect the current scientific knowledge and be widely used for diagnosis and treatment recommendations for patients with lipedema. In particular, the guideline comments on diagnostic criteria, differential diagnoses, and coinciding clinical pictures, their influence on diagnosis and treatment, sensible treatment measures, and self-management options. The lipedema guideline summarizes the current national and international evidence and the German expert consensus and derives recommendations for the best treatment for patients with lipedema. The recommendations in the guideline are intended as an orientation aid in the sense of action and decision-making corridors from which deviations are possible in justified cases.

External valvuloplasty of the saphenofemoral junction in insufficient great saphenous veins - six weeks results of a prospective multicentre trial.

Background: Varicosis of the great saphenous vein (GSV) is a common disease. Most of the therapeutic concepts attempt to remove or destroy the truncal vein. However, the absence of the GSV could be harmful for further treatments of artherosclerotic disease as the GSV is often used as bypass graft in lower extremity or coronary artery revascularisations. External valvuloplasty (EV) is one of the vein-sparing treatment options. The aim of this clinical study was to describe the outcome, safety and complications of this procedure in a prospective multicentre trial. Patients and methods: The function of the terminal and preterminal valve was restored by external valvuloplasty. Furthermore, multiple phlebectomies of tributaries were performed. Patients were reinvestigated six weeks after surgery. Primary endpoint was the function of the external valvuloplasty measured by diameter of the GSV and the prevalence of reflux in the GSV. The eligibility of the vein as a potential bypass graft was noticed. CEAP class and VCSS scores were analysed. Results: A total of 359 patients were included in the study. After six weeks 297 patients could be reinvestigated. The function of the external valvuloplasty was sufficient in 284 patients (95.6%). Treatment failed in 8 patients (2.6%) due to an occlusion or junctional reflux despite valvuloplasty. The GSV was estimated as suitable as a bypass graft in 261 patients (87.8%). Reflux at the saphenofemoral junction was significantly reduced after treatment and the diameter of the GSV near the saphenofemoral junction significantly decreased from 4.4 mm to 3.8 mm (p < 0.05). The VCSS was significantly reduced from 4.6 preoperatively to 2.6 postoperatively. Conclusions: External repair of the great saphenous vein can reduce venous symptoms and may preserve the great saphenous vein as a bypass graft. Nevertheless, this treatment option is only suitable for a limited number of patients.

Safety of a compression stocking for patients with chronic venous insufficiency (CVI) and peripheral artery disease (PAD).

BACKGROUND: With increasing age, it is increasingly common for patients to develop both chronic venous insufficiency (CVI) and peripheral artery disease (PAD). While there are special compression bandage systems commercially available for individuals thus affected, appropriate compression stockings have previously not been available. In the present study, we investigated the safety and effectiveness of a type of compression stocking specifically designed for this patient group (VenoTrain® angioflow, Bauerfeind Germany, German compression class 1 with high stiffness). PATIENTS AND METHODS: In a prospective case series, we included patients with both CVI (C3-C5 disease according to CEAP classification) and PAD (ankle-brachial index of < 0.9 and > 0.5; absolute ankle systolic pressure of > 60 mmHg). Primary outcome measures consisted of 1) safety in terms of PAD, as determined by measuring acral pressure using acral photoplethysmography (APPG), and 2) effectiveness in terms of CVI symptoms, as assessed by using a suitable questionnaire (VVSymQ). RESULTS: Fifty patients were evaluated (mean age: 67.1; mean ankle-brachial index: 0.75 ± 0.77). Fifteen patients had stage IIa PAD (according to Fontaine); 15, stage IIb; the remainder, stage I disease. Thirty-one patients had stage C3 CVI (according to CEAP classification); 16 patients, stage C4; and three patients, stage C5 disease. Immediately after donning the medical compression stocking, systolic arterial pressure in the big toe increased significantly (from 83.3 mmHg ± 27.6 mmHg to 90.8 mmHg ± 24.1 mmHg) (p = 0.026). The VVSymQ score dropped significantly from 5.0 ± 4.95 points to 1.4 ± 2.26 points (p < 0.001), thus reflecting an improvement in CVI symptoms. CONCLUSIONS: The compression stocking tested herein is safe for individuals with an ankle brachial index ≥ 0.5. Skin damage was not observed.

Round-knit or flat-knit compression garments for maintenance therapy of lymphedema of the leg? - Review of the literature and technical data.

To date, there have been no studies comparing flat-knit and round-knit compression garments for maintenance therapy of lymphedema of the leg. According to expert opinion, flat-knit fabrics are generally recommended for this purpose. Given the differences in the clinical presentation of lymphedema in terms of disease stage and location as well as patient adherence, and, last but not least, for economic reasons, it seems questionable whether all patients with lymphedema of the leg actually do require flat-knit compression garments. Considering technical aspects, published data and our own clinical experience, it seems reasonable that the choice of compression stockings be based on clinical findings and not on the diagnosis. Typical indications for flat-knit garments include significant differences in leg circumference as well as deep skin folds and edema of the toes/forefoot. However, there are also patients with lymphedema who benefit from round-knit fabrics with a high degree of stiffness. In any case, prior to maintenance therapy, it is essential to adequately decongest the legs using compression bandages and/or adaptive compression systems.

Systemic therapies for leg ulcers.

Successful management of patients with leg ulcers requires identification of the underlying etiology, with subsequent initiation of causal treatment, if feasible. Supplementary measures of first choice include stage-adjusted wound treatment, usually combined with compression therapy. The significance of systemic drugs has been the subject of controversial debate, depending on the underlying cause of the condition. The present review article is therefore meant to highlight current aspects of systemic drug therapies for the treatment of leg ulcers associated with chronic venous insufficiency, peripheral arterial disease, livedoid vasculopathy, vasculitis, necrobiosis lipoidica, calciphylaxis and pyoderma gangrenosum. In summary, the majority of therapeutic options presented herein are used off-label. While systemic drugs are promising options for the more common types of wounds such as venous, mixed or arterial leg ulcers, they do not represent the current standard of treatment. By contrast, systemic agents play a key role in the management of many of the other disorders presented herein. These agents primarily include immunomodulatory and rheological drugs used to expedite wound healing.

S1 Guidelines - Dermatoses associated with dermal lymphostasis.

The objective of the present S1 guidelines is to present current knowledge about dermatologically relevant diseases associated with localized dermal lymphostasis, thus facilitating their early detection, diagnostic workup, and targeted treatment. Whenever possible, treatment should be based on stage-appropriate and clearly defined algorithms. The numerous issues regarding differential diagnosis and treatment clinicians are confronted with in everyday clinical practice seem to warrant the publication of up-to-date guidelines. These guidelines focus on patients of all age groups and genders exhibiting skin lesions caused by dermal lymphostasis. Specific recommendations are provided with respect to the diagnosis and differential diagnosis of the various clinical manifestations. In this context, comorbid skin diseases such as atopic dermatitis, psoriasis, hidradenitis suppurativa, urticaria, and contact dermatitis will be highlighted, including their treatment and associated specific risks. Several other relevant current guidelines are referenced as regards the distinction from and treatment of common cofactors and comorbid conditions.

S1-Leitlinie - Dermatosen bei dermaler Lymphostase.

Das Ziel dieser S1-Leitlinie ist es, aktuelles Wissen über dermatologisch relevante Krankheitsbilder bei lokal begrenzter dermaler Lymphostase an allen Lokalisationen des Hautorgans zu vermitteln, um diese frühzeitig zu erkennen, diagnostisch zu sichern und gezielt zu behandeln. Wann immer möglich, sollte diese Therapie anhand klar definierter Algorithmen stadiengerecht erfolgen. Die im klinischen Alltag häufig auftauchenden differenzialdiagnostischen und therapeutischen Fragen lassen eine aktuelle Leitlinie notwendig erscheinen. Diese Leitlinie fokussiert auf Patienten jeglichen Alters und Geschlechts mit Hautveränderungen, die im kausalen Zusammenhang mit dermaler Lymphostase stehen. In konkreten Handlungsempfehlungen werden die Diagnostik und Differenzialdiagnostik der verschiedenen Manifestationsformen bei gleichzeitig auftretender dermatologischer Komorbidität wie beispielsweise atopische Dermatitis, Psoriasis vulgaris, Acne inversa, Urtikaria, Kontaktekzeme sowie ihre Therapien unter Berücksichtigung besonderer Risiken veranschaulicht. Für die Abgrenzung und Behandlung häufiger therapierelevanter Kofaktoren und Komorbidität wird auf mehrere andere hierfür relevante aktuelle Leitlinien verwiesen.

Impact of Gram-negative bacteria on the treatment of venous leg ulcers.

Gram-negative germs with and without multi-resistance are garnering more and more importance. The aim of this study was to investigate the frequency and rate of resistance against antibiotics and to clarify the impact of Gram-negative bacteria, especially with high rates of resistance, for the treatment of venous leg ulcers. This is a retrospective, monocentric, non-randomised open study. Included were all data within 1 year of bacterial swabs of venous leg ulcers. We performed summarization, pooling, and descriptive analysis for frequencies and crossover. We analysed 679 swabs of 285 patients with venous leg ulcers. The mean patient age was 69.78 years. There were 76.1% Gram-positive and 58.2% Gram-negative germs detected; 56.5% of the swabs showed multi-resistance. Gram-negative bacteria were associated with more pain. Exacerbation and relevant aggravation of wounds that led to stationary treatment occurred more frequently. With polihexanid treatment, we saw less Gram-negative flora. This study showed an immediate impact of Gram-negative germs on the patient's pain, the risk for aggravation, and the choice of treatment. Further studies for prophylaxis and treatment of Gram-negative germs in venous leg ulcer therapy are needed.

S1 guidelines: Lipedema.

The present, revised guidelines on lipedema were developed under the auspices of and funded by the German Society of Phlebology (DGP). The recommendations are based on a systematic literature search and the consensus of eight medical societies and working groups. The guidelines contain recommendations with respect to diagnosis and management of lipedema. The diagnosis is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if - despite thorough conservative treatment - symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction.

S1-Leitlinie Lipödem.

Die vorliegende überarbeitete Leitlinie zum Lipödem wurde unter der Federführung der Deutschen Gesellschaft für Phlebologie (DGP) erstellt und finanziert. Die Inhalte beruhen auf einer systematischen Literaturrecherche und dem Konsens von acht medizinischen Fachgesellschaften und Berufsverbänden. Die Leitlinie beinhaltet Empfehlungen zu Diagnostik und Therapie des Lipödems. Die Diagnose ist dabei auf der Basis von Anamnese und klinischem Befund zu stellen. Charakteristisch ist eine umschriebene, symmetrisch lokalisierte Vermehrung des Unterhautfettgewebes an den Extremitäten mit deutlicher Disproportion zum Stamm. Zusätzlich finden sich Ödeme, Hämatomneigung und eine gesteigerte Schmerzhaftigkeit der betroffenen Körperabschnitte. Weitere apparative Untersuchungen sind bisher besonderen Fragestellungen vorbehalten. Die Erkrankung ist chronisch progredient mit individuell unterschiedlichem und nicht vorhersehbarem Verlauf. Die Therapie besteht aus vier Säulen, die individuell kombiniert und an das aktuelle Beschwerdebild angepasst werden sollten: komplexe physikalische Entstauungstherapie (manuelle Lymphdrainage, Kompressionstherapie, Bewegungstherapie, Hautpflege), Liposuktion und plastisch-chirurgische Interventionen, Ernährung und körperliche Aktivität sowie ggf. additive Psychotherapie. Operative Maßnahmen sind insbesondere dann angezeigt, wenn trotz konsequent durchgeführter konservativer Therapie noch Beschwerden bestehen bzw. eine Progredienz des Befundes und/oder der Beschwerden auftritt. Eine begleitend zum Lipödem bestehende morbide Adipositas sollte vor einer Liposuktion therapeutisch angegangen werden.

Pressure profiles of sport compression stockings.

BACKGROUND: While sport compression stockings (SCS) have become increasingly popular, there is no regulatory norm as exists for medical compression stockings (MCS). The objective of this pilot study was to compare five SCS with respect to their pressure profiles ex vivo and in vivo, and in relation to German standards for MCS (RAL norm). PATIENTS AND METHODS: In vivo (10 competitive athletes; standardized procedure using the Kikuhime pressure monitor) and ex vivo (tested at the Hohenstein Institute) pressure profiles were tested for the following products: CEP Running Progressive Socks, Falke Running Energizing, Sigvaris Performance, X-Socks Speed Metal Energizer, and 2XU Compression Race Socks. RESULTS: Ex vivo ankle pressures of CEP (25.6 mmHg) and 2XU (23.2 mmHg) corresponded to class 2 MCS; that of Sigvaris (20.8 mmHg), to class 1 MCS. The remaining SCS achieved lower pressure values. The pressure gradients showed marked differences, and did not meet MCS standards. Average in vivo pressures were higher for 2XU, CEP, and Sigvaris than for Falke and X-Socks. However, in vivo values for all SCS were below those of class 1 MCS. None of the SCS showed the decreasing pressure gradient (from distal to proximal) required for MCS. CONCLUSIONS: In vivo and ex vivo pressure profiles of all SCS examined showed marked heterogeneity, and did not meet MCS standards. Consequently, the clinical and practical effects of SCS cannot be compared, either. It would therefore be desirable to establish a classification that allows for the categorization and comparison of various SCS as well as their selection based on individual preferences and needs (high vs. low pressure, progressive vs. degressive profile).

Das Druckprofil von Sportkompressionsstrümpfen.

HINTERGRUND: Zunehmend werden Sportkompressionsstrümpfe (SKS) eingesetzt, doch fehlt eine Norm in Analogie zu medizinischen Kompressionsstrümpfen (MKS). Ziel dieser Pilotstudie war der Vergleich der Druckprofile von fünf SKS ex vivo und in vivo miteinander sowie mit MKS-Normen. PATIENTEN UND METHODIK: CEP Running-Progressive-Socks, Falke Running--Energizing, Sigvaris Performance, X-Socks Speed-Metal-Energizer und 2XU Compression--Race-Socks wurden an zehn Leistungssportlern (standardisiert in vivo, Kikuhime--Sensor) sowie im Hohenstein Institut (ex vivo) hinsichtlich ihres Druckprofils getestet. ERGEBNISSE: Die Ex-vivo-Messungen im Fesselbereich von CEP (25,6 mmHg) und 2XU (23,2 mmHg) entsprachen der deutschen MKS-Klasse 2, von Sigvaris-SKS (20,8 mmHg) der deutschen MKS-Klasse 1. Die übrigen SKS lagen darunter. Die ermittelten Druckprofile differierten stark und entsprachen nicht der MKS-Norm. Die In-vivo-Messungen zeigten für drei SKS (2XU, CEP, Sigvaris) durchschnittlich einen höheren Anpressdruck als die SKS von Falke und X-Socks. Alle SKS lagen in vivo jedoch unter der deutschen MKS-Klasse 1. Kein SKS bot den für MKS geforderten Druckabfall vom Messpunkt B nach D. SCHLUSSFOLGERUNGEN: Die in vivo und ex vivo ermittelten SKS-Druckprofile zeigten heterogene Ergebnisse und folgten kaum den MKS-Anforderungen. Entsprechend sind auch die klinisch-praktischen Effekte von SKS nicht vergleichbar. Wünschenswert wäre eine SKS-Klassifikation, die erlaubt, Produkte einzuordnen, zu vergleichen und nach konkreten Vorlieben und Bedürfnissen (hoher vs. geringer Druck, progressiver vs. degressiver Gradient) auszuwählen.

Occlusion rate, venous symptoms and patient satisfaction after radiofrequency-induced thermotherapy (RFITT®): are there differences between the great and the small saphenous veins?

BACKGROUND: Previous studies on the therapy of insufficient saphenous veins mainly compare different treatment methods. Only a few investigate differences of a specific treatment option between the great (GSV) and the small saphenous vein (SSV). The aim of this study was to evaluate the efficacy, clinical improvement and patient satisfaction after radiofrequency-induced thermotherapy (RFITT®) with regard to the treated vein. PATIENTS AND METHODS: We included 65 patients (40 women, 25 men; mean age 54.75 years) who were treated with RFITT® for incompetent saphenous veins (n = 83: 62 GSV, 21 SSV). Occlusion rates were determined by duplex-sonography. Additionally, we performed a prospective analysis of venous symptoms and signs by means of a standardized questionnaire and of patient satisfaction using a semi-quantitative rating (1 = very good, 6 = insufficient). RESULTS: The GSV group showed a significantly greater reduction of venous symptoms in comparison to the SSV group (p = 0.005) despite no significant differences in long term occlusion rates (mean time after operation: 22 months) of 90 % in the GSV group and 81.8 % in the SSV group (p = 0.598). Following the procedure, detailed analysis revealed significantly more swelling (p = 0.022), feeling of heavy legs (p = 0.002) and nightly calf cramps (p = 0.001) in the SSV group. Additionally, RFITT® led to a significant improvement in patient satisfaction in the GSV group (from 1.93 at day 1 - 3 to 1.41 after 6 - 12 months, p = 0.009) but not in the SSV group (from 2.29 to 2.07, p = 0.43). CONCLUSIONS: With regard to the improvement of venous symptoms and patient satisfaction, the benefit of RFITT® is greater for patients with incompetent GSV compared to those with incompetent SSV.

Squamous cell carcinomas in chronic venous leg ulcers. Data of the German Marjolin Registry and review.

BACKGROUND: Secondary squamous cell carcinoma (SCC) is a rare complication of chronic venous leg ulcers. So far, little is known about its pathophysiology and clinical behavior. Initiated by the working group "Wound Healing" (AGW) of the German Society of Dermatology (DDG), it is the objective of the current Marjolin registry to collect cases of SCC arising in venous ulcers, in order to evaluate diagnostic characteristics. PATIENTS AND METHODS: All members of the AGW received questionnaires inquiring about basic patient data, ulcer characteristics, and therapy conducted. RESULTS: From 2010 to 2013, 30 patients (20 women, 10 men) from six tertiary wound care centers were registered. Mean age was 76.17 years. The average duration of venous leg ulcers prior to SCC diagnosis was 15.93 years. Suspicious wound characteristics primarily included: pain (n = 3), therapy resistance (n = 27), and fetor (n = 12) as well as clinical appearance (n = 10) with atypical morphology, nodular wound bed, and hypergranulation. CONCLUSIONS: Atypical morphology or changes in appearance as well as therapy resistance despite optimal care (6-12 weeks) should prompt physicians to take spindle-shaped, if necessary multiple and serial, biopsies. Primary risk factors for malignant transformation include patient age and ulcer duration.

A novel epidermal growth factor--containing wound dressing for the treatment of hard-to-heal venous leg ulcers.

OBJECTIVE: To evaluate the efficacy, tolerability, and safety of a novel wound dressing containing epidermal growth factor (EGF) in a collagen-gel matrix on hard-to-heal venous leg ulcers. PATIENTS AND METHODS: The authors included 33 hard-to-heal venous leg ulcers found on 31 patients. The EGF-containing dressing was applied 3 times while best practice conservative wound treatment was continued. Patients were followed up with after 1, 2, and 3 months to evaluate (a) the wound size, (b) the ease of application and dissolution of the dressing, and (c) the wound dressing by means of a scale ranging from 1 to 5 (1 = best, 5 = worst). RESULTS: The protocol was completed by 25 of 31 patients. The reasons for discontinuation were wound infection, pain, and lost to follow-up (n = 2 each, respectively). After 3 months, the average wound surface was significantly reduced (from 33.69 cm to 18.94 cm, P = .023). On a scale from 0 to 100, the wound dressing was evaluated as very easy to apply and highly dissolvable (mean value of 97.14 and 98.11, respectively; 100 = very easy to apply or 100% dissolution). The dressing was generally well tolerated and scored a mean overall rating of 2.16 by healthcare specialists and 2.40 by patients. CONCLUSION: The authors' results demonstrate that the novel EGF-containing wound dressing was generally well tolerated and safe. Combined with the significant wound surface reduction, it can be regarded as an adequate novel treatment option for patients with hard-to-heal venous leg ulcers.

Foam sclerotherapy with enoxaparin prophylaxis in high-risk patients with postthrombotic syndrome.

BACKGROUND: According to the current guidelines for sclerotherapy hypercoagulability and thrombophilia with or without deep venous thrombosis are seen as relative contraindication for this treatment. But often such patients have an indication for a sclerotherapy. Recommendations for additional anticoagulation for sclerotherapy are missing. PATIENTS AND METHODS: In this retrospective analysis (2009 - 2010), 54 patients with deep venous thrombosis and/or pulmonal embolism in their medical history that had had foam-sclerotherapy of truncal or tributary veins with polidocanol 0.5 - 3 % without prior anticoagulation therapy were included. In addition to compression treatment (23 - 32 mmHg) for 3 weeks patients were treated with enoxaparin 40 mg once a day for 3 days after sclerotherapy. Clinical and duplex controls were conducted before every treatment and 2 - 3 weeks after the last injection. RESULTS: Sclerotherapy was done on one (30/54) or on both (24/54) legs. In 2/54 legs a truncal vein and in all patients tributaries were treated. The volume per treatment session averaged 3.3 ml foam (2 - 6 ml). The patients had undergone an average of 4.9 treatments (1 - 11); altogether 262 sessions. There were no cases of deep venous thrombosis or symptomatic pulmonary embolism. In 7/262 treatments (2.7 %) symptomatic localized phlebitis occurred and in 2/262 (0.8 %) patients an ascending phlebitis beyond the sclerotherapy region was observed. CONCLUSIONS: Based on current data, foam sclerotherapy can be regarded as safe in patients with anamnestic thromboembolism when co-treated with compression therapy (23 - 32 mmHg) and enoxaparin 40 mg once per day for 3 days post sclerotherapy. The current study is the first with a standardized regime. In view of the limitations of this study there should be further randomized controlled trials.

Thick legs - not always lipedema.

Due to its increased presence in the press and on television, the diagnosis of lipedema is on the way to becoming a trendy diagnosis for those with thick legs. Despite this, one must recognize that lipedema is a very rare disease. It is characterized by disproportional obesity of the extremities, especially in the region of the hip and the legs, hematoma development after minimal trauma, and increased pressure-induced or spontaneous pain. Aids for making the correct diagnosis are (duplex) sonography, the waist-hip index or the waist-height index and lymphoscintigraphy. Important differential diagnoses are constitutional variability of the legs, lipohypertrophy in obesity, edema in immobility, edema in chronic venous insufficiency and rheumatic diseases. The symptom-based therapy of lipedema consists of conservative (compression, manual lymphatic drainage, exercise) and surgical treatments (liposuction). Until now there is no curative therapy. Obesity is an important risk factor for the severity and prognosis of lipedema. Further studies for a better understanding of the pathogenesis of lipedema and in the end possible curative treatments are urgently needed.