Pinch grafting of chronic leg ulcers: a retrospective analysis of 104 patients with 169 ulcers.

OBJECTIVE: To compare healing rates of inpatients and outpatients with chronic leg ulcers treated with pinch grafting and to define which of these patients would benefit most from the therapy. METHOD: This retrospective analysis reports the healing rates of 104 patients with 169 ulcers treated with pinch grafting during 1997-2007 at the Department of Dermatology, Tampere University Hospital. RESULTS: These relate to 17 outpatients with 18 pinch-grafted ulcers and 95 inpatients with 151 ulcers. Nine ulcers (50%) in the outpatient and 95 (62.9%) in the inpatient group healed completely. Median healing times were five and eight weeks for the outpatient and inpatient groups respectively. For the sample as a whole, 61.5% of the ulcers healed. CONCLUSION: This retrospective study found that pinch grafting is an efficient method of treating chronic leg ulcers, with an overall healing rate over 60%. Patients who complied with compression therapy were most likely to benefit from this therapy.

Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility.

OBJECTIVE: To assess whether a difference in venous reflux pattern, ulcer size or duration, regular medications or the daily use of walking aids can predict the healing of a chronic venous leg ulcer (VLU). METHOD: In this prospective, randomised, single-centre study, 110 consecutive patients with chronic leg ulcers were assessed. Ninety-nine patients met the inclusion criteria and a controlled, conservative 3-month treatment period was initiated, in which 90 patients were managed with standardised local treatment combined with compression therapy. In this group, 62 VLUs healed within 12 weeks and 28 were still open after 12 weeks. The study group consisted of 22 patients with non-healed ulcers and a control group (n=28), which was selected randomly from the healers. In both groups, venous reflux profiles were assessed using colour-flow duplex imaging. RESULTS: The study and control groups did not differ in smoking habits, age, gender or daily oral medications. On average, the healing wounds were 5cm² before starting controlled treatment (range 1-80cm²) and had been open for 7 months (range 2-48 months); the non-healing wounds were on average 11.2cm² (range 1-31cm²) and had been open for 26 months (range 8-106 months). Venous disease severity scores were similar for both groups (12.6 vs. 13.4). Five patients (18%) with healed ulcers regularly used walking aids, the use of which was more frequent (36%) among non-healers (p<0.001). Venous reflux profiles differed significantly between the groups, with isolated superficial reflux noted in 64% of healers, compared with 36% of non-healers. In addition, isolated deep reflux was found in 14% of the healers, compared with 41% of non-healers (p=0.0002). The rate of popliteal reflux was significantly higher in non-healers (59% versus 21%; p=0.0004). CONCLUSION: Long duration of a chronic venous ulcer may predict a poor outcome. The presence of deep venous reflux, especially in the popliteal vein, is typically found in those legs with non-healed ulcers. .

Vasoactive intestinal polypeptide (VIP)-like immunoreactivity in the nerves of human axillary sweat glands.

The cholinergic innervation of the human axillary sweat glands of hyperhidrotic patients was demonstrated by using the specific Karnovsky-Roots thiocholine method. The cholinergic innervation pattern was compared with the immunohistochemically demonstrated vasoactive intestinal polypeptide (VIP)-like activity at light and electron microscopic levels. The innervation patterns were identical in the light microscopic serial sections. In the electron microscope sections, VIP-like immunoreactivity was localized to the nerve terminals containing large, dense-cored vesicles 100-140 nm in size. No synapses were found, however positively stained nerve terminals were located immediately outside the basement membrane but close to the glandular secretory and myoepithelial cells, blood vessels, and occasionally the mast cells. Our results suggest the coexistence of the two neurotransmitters, acetylcholine and VIP, in the same nerves innervating both eccrine and apocrine sweat glands in human axillae.

Expression of diazepam-binding inhibitor peptide in human skin: an immunohistochemical and ultrastructural study.

Human diazepam binding inhibitor (DBI) was originally isolated from the brain and subsequently found to be present in several peripheral tissues. The various physiologic effects recently attributed to DBI include acting as an endogenous ligand for the central and peripheral (mitochondrial) benzodiazepine receptors. The present work provides, for the first time, evidence of DBI immunoreactivity in skin. DBI immunoreactivity was found in the epidermis, in the eccrine sweat and in sebaceous glands. Ultrastructurally, DBI was distributed throughout the cytoplasm. Although the physiologic role of DBI in skin is unknown, our results indicate that DBI may serve as an endogenous ligand for mitochondrial benzodiazepine receptors. Its activity could be related to the regulation of lipid and cholesterol synthesis in keratinocytes and sebaceous glands and to the secretion of sweat in sweat glands.

Evidence for gamma-melanocyte stimulating hormone containing nerves and neutrophilic granulocytes in the human skin by indirect immunofluorescence.

gamma-melanocyte stimulating hormone (gamma-MSH)-like immunoreactivity has been found by indirect immunofluorescence in nerve fibers and terminals as well as in neutrophilic granulocytes of normal human skin. A preferential localization to sensory nerves was seen; abundant nerve fibers displaying gamma-MSH immunoreactivity were observed as free nerve endings in the basal layer of the epidermis and in the upper dermis, close to the Merkel cells, in Meissner's corpuscles, around the external root sheath of the lower part of the hair follicles, and in nerve bundles of the deeper parts of the dermis. Very few fibers were seen to be associated with sweat glands and most blood vessels, although arterioles were densely innervated. Thus, gamma-MSH should be considered for possible role as a sensory or axon-reflex chemical messenger. Furthermore, the presence of gamma-MSH in neutrophilic granulocytes raises the possibility that gamma-MSH may play a role in the genesis of post-inflammatory hyperpigmentation, nevi, and melanomas.

Location of androgen receptor in human skin.

The distribution of androgen receptor (AR) in human skin was studied by an immunohistochemical method using a polyclonal antibody against the human AR. Skin samples of preputial skin and male and female nongenital skin were examined. The possible correlation of AR location to acne was studied in skin biopsies from skin areas affected or unaffected by acne. In preputial skin, AR was expressed in epidermal cells as well as in fibroblasts, smooth muscle cells, and endothelial cells of blood vessels in the dermal area. AR was found located also in the flat fibroblast-like cells of Pacinian corpuscles. In nongenital skin, AR was also expressed in the basal cells and glandular cells of sebaceous glands, in the outer root sheath of hair follicles, and in eccrine sweat glands. The presence of AR in different cell types in the skin reflects the numerous direct effects androgens may have on this target tissue. The distribution of AR was similar in male and female skin.

Immunohistochemical evidence for the presence of somatostatin-containing sensory nerve fibres in the human skin.

Somatostatin-like immunoreactivity has been found to occur in nerve terminals and fibres of the normal human skin using immunohistochemistry. The immunoreactivity seemed predominantly to be associated with sensory nerves. Thus, nerve fibres displaying weak or moderately strong somatostatin immunofluorescence were observed as free nerve endings of the epidermis and as nerve fibres in the dermis. The immunoreactive nerves were found in low numbers in skin from arm, back and chest, however, only single fibres were seen in sensory specialized areas, such as fingertips. Very few fibres were found close to e.g. blood vessels and sweat glands. Somatostatin, generally believed to be a strongly inhibitory substance, should also be considered when examining the role of different sensory chemical messenger candidates in the human skin.

Electron microscopic study on the innervation of the human axillary sweat glands.

The innervation of human axillary sweat glands was studied at electron microscopic level. Nerve endings with many small agranular vesicles and few large dense-cored vesicles were found outside the basement membrane of the secretory coils. These nerve endings can be classified as cholinergic. This result confirms the previous knowledge that axillary sweat glands are innervated by sympathetic cholinergic nerves.

The effect of sympathetic denervation with 6-hydroxydopamine on the ventral prostate of the rat.

The effect of chemical sympathectomy with 6-hydroxydopamine (6-OHDA) on the ventral prostate of the rat was studied. A dose of 50 mg/kg i.v., which was repeated after 1 week, was effective enough to produce total disappearance of sympathetic nerves. Reappearance of nerve fibres was evident 2 weeks after treatment. Dilation of prostatic alveoli was noted 1 week after denervation. It is concluded that the absence of normal sympathetic innervation prevents the emptying of the rat prostate.

Adequate blood flow is essential for reinnervation in neurovascular skin flaps.

The effect of arterial and venous ischaemia on reinnervation of skin flaps after transsection and resuture of the epigastric nerve was investigated in rat groin flaps. The results were compared with those in corresponding flaps with adequate blood flow. Arterial or venous ischaemia was induced by ligation of the epigastric artery or vein. The reinnervation of the flaps was studied after a 20-week healing period using specific antisera for calcitonin gene-related peptide (CGRP) in sensory nerves, and neuropeptide Y (NPY) in adrenergic nerves. Arterial ischaemia clearly and significantly hampered reinnervation. Venous ischaemia was even more harmful and practically no regenerated nerves were detected in the flaps. We conclude that adequate blood flow is critical for sensory and adrenergic reinnervation in skin flaps.

Immunocytochemical demonstration of gamma-melanocyte stimulating hormone-like immunoreactivity in human neutrophilic granulocytes.

Using the indirect immunohistochemical approach the occurrence of gamma-melanocyte stimulating hormone (MSH)-like immunoreactivity in neutrophilic granulocytes is described.

Nerve endings in the human prostate.

The ultrastructure of nerve endings in the human prostate was studied using glutaraldehyde-OsO4 and KMnO4 fixation. The nerve endings were classified into three categories according to the size of the vesicles and the contents of the synaptic profiles. In addition to the conventional adrenergic and cholinergic axons, a third type of axon profile containing a predominance of large granular vesicles was constantly found. Synaptic contacts were found only on smooth muscle cells. No epithelial innervation could be demonstrated. The functions and possible transmitters of the various types of axon terminals are discussed.

Innervation of the ventral prostate of the rat.

The autonomic innervation of the rat ventral prostate was studied in an attempt to evaluate the role of innervation in the normal function of the gland. Specific histochemical methods for both catecholamines (the formaldehyde-induced fluorescence method, FIF) and acetylcholinesterases (the Gomori-Koelle thiocholine method) were used. The neuro-effector contacts were studied by electron microscopy using both 3% glutaraldehyde and 3% potassium permanganate (KMnO4) as fixatives. It was found that the rat ventral prostate receives dual autonomic innervation. Adrenergic fibers, which formed the majority of the nerves, were often seen in close contact with the smooth muscle cells around both the prostatic alveoli and secretory ducts. The non-adrenergic nerve fibers, which were fewer in number, did not form such intimate contacts with the muscle cells. No direct synapses with epithelial cells were detected.

Autonomic innervation of the human prostate.

The autonomic innervation of the human prostate has been studied using both light and fluorescence microscopic techniques. A dense network of both adrenergic and acetylcholinesterase-positive nerves innervates the smooth muscle around the ducts and acini of the prostate. No direct innervation of the acinar epithelium can be observed. The role of the innervation in both normal and pathologic states is discussed.

Calcitonin gene-related peptide immunoreactivity in prurigo nodularis: a comparative study with neurodermatitis circumscripta.

Eight patients with intensely pruritic lesions of chronic idiopathic prurigo nodularis and three patients with neurodermatitis circumscripta were investigated using the indirect immunofluorescence method. Results showed similarities in epidermal hyperplasia but not in nerve proliferation and neuropeptide immunoreactivity. Increased numbers of calcitonin gene-related peptide (CGRP) and substance P immunoreactive nerve fibre bundles were detected in specimens taken from prurigo nodularis lesions, but no increased immunoreactivity could be seen in specimens taken from patients having neurodermatitis circumscripta compared to normal skin. The neuropeptides, CGRP and substance P, may be responsible for the intense itching of prurigo nodularis lesions.