Compression Therapy in Dermatology. / Terapia compresiva en Dermatología.

The benefit of lower limb compression therapy is not limited to chronic venous insufficiency or/and lymphoedema. Thanks to its anti-edema and anti-inflammatory effects, compression therapy is considered a beneficial adjuvant therapy to treat atypical wounds, inflammatory dermatoses, cellulitis, and traumatic wounds in the absence of contraindications. Strict contraindications are limited to severe peripheral arterial disease and decompensated heart failure. The variability of commercially available compression materials and systems, such as short-stretch bandages, multi-component systems, zinc oxide bandages, medical adaptive compression systems, ulcer compression stockings or medical compression stockings, facilitates the adaptation of compression therapy to the individual needs of each patient. Compared to venous leg ulcers, low pressures of 20mmHg are often sufficient to treat dermatological disorders, with higher patient tolerance and compliance.

[Is compression therapy contraindicated for lower leg erysipelas? : Results of a retrospective analysis]. / Ist die Kompressionstherapie bei Erysipel des Unterschenkels kontraindiziert? : Resultate einer retrospektiven Analyse.

In many medical expert recommendations and guidelines, the use of compression therapy for acute erysipelas is designated as a contraindication. Due to the sometimes massive oedema, compression therapy is nevertheless used in some clinics. This led to the question whether compression therapy for erysipelas of the lower leg actually leads to complications due to the acute infection and thus represents a contraindication. For the period 01 January 2018 to 30 June 2019, the records of 56 inpatients with acute erysipelas of the lower leg who received compression therapy in addition to systemic antibiotic therapy were retrospectively evaluated. The duration of inpatient treatment, the infection parameters determined as part of the ward routine and any complications that occurred were evaluated. While treated as inpatients the blood parameters for infection clearly dropped. Compression therapy was started on admission day in 92.9% of patients and continued until discharge. None of the patients showed an increase in fever or clinical signs of sepsis during the hospital stay. In this retrospective analysis it could be shown for the first time that compression therapy does not cause a clinical worsening or trigger a septic clinical picture in patients with acute erysipelas. Therefore, the authors consider the declaration of acute erysipelas as contraindication for compression therapy as not justified.

[Incontinence-associated dermatitis: a position paper]. / Inkontinenzassoziierte Dermatitis: ein Positionspapier.

Incontinence-associated dermatitis (IAD) describes damage to the skin caused by repeated and prolonged contact with urine and/or feces. Patients of all ages can be affected; the diagnosis is preferably used in adults and adolescents. The predilection sites are perineal, perianal, the inner thighs and the convex areas of the buttocks. Increased moisture on the skin surface, increased pH, occlusion, feces digestive enzymes and repeated skin cleansing procedures are pathophysiologically relevant factors. Typical clinical signs of IAD are erythema, erosions, excoriations and pain. Diagnosis is often difficult because there are many relevant differential diagnoses, some of which may occur together with an IAD. In particular, pressure ulcer, contact dermatitis and intertrigo need to be differentiated and treated. Effective strategies of prevention and therapy of IAD are continence management, the use of efficient, absorbent products as well as consistent skin protection and care. IAD is a skin disease that is often not or incorrectly diagnosed. It should be treated as early as possible, together with the causative factors such a fecal and/or urinary incontinence, as otherwise it can lead to an unnecessarily long duration and severity of the symptoms.

The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum.

BACKGROUND: The lack of objective diagnostic criteria renders pyoderma gangrenosum (PG) a diagnosis of exclusion. The diagnostic approaches proposed to date have not been systematically evaluated. Thus, PG remains a challenging and frequently misdiagnosed disorder. OBJECTIVES: To develop and assess a comprehensive, yet clinically practicable, sensitive diagnostic scoring system for PG. METHODS: Clinical history and images of a total of 60 participants with previously confirmed PG located on the lower extremity and a control cohort of 50 patients with venous leg ulcers were retrospectively evaluated by expert teams at two tertiary dermatological centres specializing in wound care using a newly developed diagnostic scoring system composed of 10 criteria. RESULTS: The three major diagnostic criteria are rapidly progressing disease, assessment of relevant differential diagnoses and a reddish-violaceous wound border (prevalent in 98% of patients with PG). Minor criteria (evident in 61-95% of patients with PG) include amelioration by immunosuppressant drugs, characteristically irregular shape of ulceration, extreme pain > 4/10 on a visual analogue scale and localization of lesion at the site of the trauma. Three additional criteria (observed in up to 60% of patients with PG) encompass suppurative inflammation in histopathology, undermined wound borders and systemic disease associated. A total score value of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers. The initial letters of the above-listed criteria form the acronym PARACELSUS. CONCLUSIONS: The PARACELSUS score represents a novel, easily implementable, effective and sensitive diagnostic tool for PG.

[Quality of self-applied compression bandages in patients with chronic venous ulcers : Results of a prospective clinical study]. / Qualität von selbst angelegten Kompressionsverbänden bei Patienten mit chronischem Ulcus cruris venosum : Resultate einer prospektiven klinischen Studie.

BACKGROUND: For effective compression therapy in patients with venous leg ulcers, sufficient pressure is essential. In everyday life, it is often the patients themselves who apply the compression bandages. Many of these patients have restriction in their movement and had been rarely trained adequately. Hence, there was the question of how efficient are the autonomously applied compression bandages of those patients. PATIENTS AND METHODS: In all, 100 consecutive patients with venous leg ulcer were asked to apply compression bandages on their own leg. We documented both the achieved compression and formal criteria of correct performance. RESULTS: A total of 59 women and 41 men with an average age of 70.3 years were included in the study. Overall 43 patients were not able to apply a compression bandage because of physical limitations. The measured pressure values in the remaining 57 patients ranged between 6 and 93 mm Hg (mean 28.3 mm Hg). Eleven patients reached the prescribed effective compression pressure. Of these, formal errors were found in 6 patients, so that only 5 patients had correctly applied the compression bandages. CONCLUSION: Our data show that most patients with venous leg ulcers are not able to apply effective compression therapy with short-stretch bandages to themselves. Multilayer systems, adaptive compression bandages, and ulcer stocking systems today are possibly easier and more effective therapy options. Alternatively short-stretch bandages could be applied by trained persons but only under the control with pressure measuring probes.

[Recognition and correct classification of pressure ulcers: a position paper]. / Dekubitus erkennen und richtig klassifizieren: ein Positionspapier.

BACKGROUND: Pressure ulcers comprise serious skin and tissue damage. The correct diagnosis and classification into different categories is often difficult in daily practice. QUESTION: What procedure can be recommended to correctly diagnose and classify pressure ulcers in practice? MATERIALS AND METHODS: The society Initiative Chronische Wunden (ICW) e. V. established a group of experts who developed practical recommendations for the diagnosis and classification of pressure ulcers based on the current literature and their own expertise. RESULTS: Pressure ulcers should only be diagnosed if skin and/or tissue damage is most likely due to prolonged pressure or pressure associated with shear forces. A complete anamnesis must be performed to detect periods of previous prolonged immobility. Pressure ulcers are usually located at typical predilection sites. For category I and "suspected deep tissue damage" the tissue damage occurs under (initially) intact skin. However, the diagnosis is uncertain and the classification should be made later. The category II pressure ulcer is usually an exclusion diagnosis. The categories III and IV are pressure ulcers in the proper sense. As long as the distinction between category III and IV is not possible, the lower category should be coded. CONCLUSIONS: Currently, a relevant classification should be used uniformly for the respective setting. In accordance with the clinical picture, a most suitable diagnosis is to be made. It does not matter which classification system is used. The future WHO ICD-11 version will allow better classification of pressure ulcers.

[Insufficient tetanus vaccination protection in psoriasis and systemic immunosuppression : Results of a retrospective investigation of 101 patients]. / Unzureichender Tetanusimpfschutz bei Psoriasis und systemischer Immunsuppression : Ergebnisse einer retrospektiven Untersuchung an 101 Patienten.

BACKGROUND: With a prevalence of approximately 3 % worldwide, psoriasis is one of the most frequent chronic inflammatory skin diseases. Patients with moderate to severe psoriasis are treated guideline-conform with immunomodulatory or immunosuppressive agents. According to current guidelines physicians should be vigilant about the vaccination status of immunosuppressed patients. OBJECTIVE: The aim of the study was to serologically objectify the tetanus vaccination status in systemically treated patients with moderate to severe psoriasis in Germany. MATERIAL AND METHODS: Within the context of this retrospective study the concentration of immunoglobulin G antibodies against Clostridium tetani was determined in 101 patients with systemic immunosuppression suffering from psoriasis. RESULTS: In a total of 27.7% (n = 28; 11 male, 17 female) of the patients, insufficient immunoglobulin G antibody concentrations were detected, corresponding to a higher risk of an infection with C. tetani. Group subanalyses indicated an insufficient tetanus protection especially in patients ≥65 years old (50%). CONCLUSION: The tetanus immune status of psoriasis patients was shown to be comparable with the general population. The results of our investigation underline that people suffering from psoriasis have to be tested for tetanus protection and if necessary, vaccinations have to be renewed.

[Compression therapy of chronic leg ulcers : Practical aspects]. / Kompressionstherapie des chronischen Ulcus cruris : Praxisrelevante Aspekte.

Compression therapy, together with modern moist wound treatment, is the basis for a successful conservative treatment of patients with chronic leg ulcers. In clinical practice, it is often the patients themselves who apply compression therapies. Many of the mostly elderly patients, however, are not able to reach their legs and feet due to movement restrictions, such as arthritis, arthrosis and even obesity. An adequate compression therapy also requires extensive experience and regular training. In practice only the minority of patients can perform bandaging well and therefore this should not be recommended. Self-management with do-it-yourself medical devices will become more and more important in the future. In addition to the psychological factors, cost aspects and demographic change, an expected lack of qualified nursing staff due to the number of elderly patients who are potentially in need of care means that self-management is becoming increasingly more important. For the essentially important compression therapy of patients with chronic leg ulcers, there already exist various therapy options. The needs, preferences and abilities of the patients concerned can be considered when selecting the appropriate system. Particularly for the self-management of compression therapy, adaptive compression bandages are suitable for patients with leg ulcers during the initial decompression phase and ulcer stocking systems in the subsequent maintenance phase.

Analysis of the German DRG data for livedoid vasculopathy and calciphylaxis.

BACKGROUND: Livedoid vasculopathy and calciphylaxis are rare skin disorders. Large cohorts of patients have been missing so far for detailed analysis. PATIENTS AND METHODS: Data from diagnosis-related groups (DRGs) of hospitalized cases of livedoid vasculopathy (ntotal = 1357) and calciphylaxis (ntotal = 699) were analysed for the years 2008-2013 concerning sex, age and frequency of diagnosis. To avoid deviations to non-relevant secondary diagnosis and due to changes in ICD-10 indices, we selected the two most recent available years 2013 and 2014 for evaluation of the accompanying diagnoses for both, livedoid vasculopathy (n = 519) and calciphylaxis (n = 324). Those were additionally evaluated as possible comorbidity. RESULTS: The male-female ratio for livedoid vasculopathy was 2.1:1. Patients older than 45 years comprehended 74.7% of all patients with peaks between the ages of 45-50 and 70-75. Livedoid vasculopathy patients suffered from cardiovascular and renal diseases. Coding of coagulation disorders was found rarely in our analysis. For calciphylaxis, we calculated a male-female ratio of 1.7:1. Most of the patients were at an age between 65 and 80 years. Diagnosis at an age under 35 years was rare. In general, most calciphylaxis patients showed end-stage renal disease with need of dialysis and presented with the resulting complications. CONCLUSIONS: Our data analysis shows relevant comorbidity and cofactors of these rare diseases like livedoid vasculopathy and calciphylaxis in Germany by a large number of cases.

Diagnosis and treatment of chronic wounds: current standards of Germany's Initiative for Chronic Wounds e. V.

The diagnosis and treatment of patients with chronic wounds is an enormous challenge in various disciplines of medicine. These very complex processes usually involve several experts of different medical specialties with varying educational backgrounds. A necessary basis for consistent communication and documentation is the use of unambiguous nomenclature. Therefore, the board of the German wound association, Initiative for Chronic Wounds (ICW) e.V., has started to define various terms and procedures. An easy to remember algorithm, in the form of the ABCDE rule, has been developed for the structured diagnosis of chronic wounds. The successful therapy of chronic wounds is then based on the causal treatment of the underlying, pathophysiological relevant diseases. M.O.I.S.T. a concept which helps health professionals in the systematic approach to the local treatment of patients with chronic wounds, in conforming to the most up-to-date scientific knowledge. By using consistent definitions and standards in wound care, it is possible to optimise current diagnostic and treatment strategies as well as to make them more easily understandable.

[Chronic leg ulcers]. / Chronisches Ulcus cruris.

Chronic wounds often manifest as ulcers on the lower legs. The main causes of chronic leg ulcers are chronic venous insufficiency and/or peripheral arterial occlusive disease in approximately 80% of all patients. However, there are also numerous other potentially relevant factors which can cause or almost impede the healing of chronic leg ulcers. Therefore, disease such as vasculitis, livedo vasculopathy, pyoderma gangrenosum, necrobiosis lipoidica, Martorell hypertensive leg ulcer, calciphylaxis, infectious diseases, neoplasms, drugs, cutaneous artefacts and genetic defects are exemplarily presented. The successful therapy of patients with chronic leg ulcers is only possible on the basis of an adequate diagnosis. Therapeutic options include conservative, surgical and interventional treatment options. In particular the consequent implementation of compression therapy is of very great importance in the therapy of most patients with chronic leg ulcers and edema. However, a permanent effective treatment always requires a causally oriented therapy, which usually needs an interdisciplinary and interprofessional approach.

[First manifestation of leg ulcers : Analysis of data from 1000 patients]. / Erstmanifestation eines Ulcus cruris : Analyse der Daten von 1000 Patienten.

BACKGROUND: More than 1 million people in Germany suffer from leg ulcers. The diagnosis leg ulcer summarizes many different etiologies. The therapy of leg ulcers is an interdisciplinary and interprofessional challenge. Early identification of the cause of the leg ulcer and initiation of a causal therapy are essential for healing. OBJECTIVES: The aim of this study was to investigate the initial manifestation age of patients with causally associated leg ulcers. Afterwards we calculated the most common etiologies according to decade. PATIENTS AND METHODS: A prospective database at the University Hospital Essen, dermatological wound care center, was used to identify patients with chronic leg ulcers between 2002 and 2014. Clinical data of 1000 patients with chronic leg ulcers were analyzed in this monocentric study. RESULTS: A total of 29 different etiologies were differentiated. Approximately 70% of etiologies were of vascular origin, while 30% were rare causes. The count of different etiologies showed significant differences related to the onset and the occurrence in individual decades of life. In particular, nonvascular etiologies such as pyoderma gangrenosum or necrobiosis lipoidica are relatively more common in younger patients than in the aged. CONCLUSION: Based on the findings of our study, it is possible to limit the underlying etiology on the basis of the age of first manifestation of the leg ulcer in order to make targeted diagnostics more effective. Thus, this information can help to optimize scarce time resources in daily practice and improve the prediction probability of leg ulcers.

[German national consensus on wound documentation of leg ulcer : Part 1: Routine care - standard dataset and minimum dataset]. / Nationaler Konsensus zu Wunddokumentation beim Ulcus cruris : Teil 1: Routineversorgung ­ "Standard-Dataset" und "Minimum-Dataset".

BACKGROUND: Standards for basic documentation and the course of treatment increase quality assurance and efficiency in health care. To date, no standards for the treatment of patients with leg ulcers are available in Germany. OBJECTIVES: The aim of the study was to develop standards under routine conditions in the documentation of patients with leg ulcers. This article shows the recommended variables of a "standard dataset" and a "minimum dataset". MATERIALS AND METHODS: Consensus building among experts from 38 scientific societies, professional associations, insurance and supply networks (n = 68 experts) took place. After conducting a systematic international literature research, available standards were reviewed and supplemented with our own considerations of the expert group. From 2012-2015 standards for documentation were defined in multistage online visits and personal meetings. RESULTS: A consensus was achieved for 18 variables for the minimum dataset and 48 variables for the standard dataset in a total of seven meetings and nine online Delphi visits. The datasets involve patient baseline data, data on the general health status, wound characteristics, diagnostic and therapeutic interventions, patient reported outcomes, nutrition, and education status. DISCUSSION: Based on a multistage continuous decision-making process, a standard in the measurement of events in routine care in patients with a leg ulcer was developed.

[German national consensus on wound documentation of leg ulcer : Part 2: Routine care - classification of variable characteristics]. / Nationaler Konsensus zur Wunddokumentation beim Ulcus cruris : Teil 2: Routineversorgung ­ Klassifikation der Variablenausprägungen.

BACKGROUND: Standards in the assessment and documentation of disease processes are the basis of guideline-based care. For the treatment of chronic wounds, especially leg ulcers, no approved parameters are available. OBJECTIVES: Against this background, our aim was to develop standards for the documentation of leg ulcer in routine care. This article presents the recommendations for the classification and characteristics of the variables. MATERIALS AND METHODS: The development of the documentation standard was based on a systematic literature research and was performed in a Delphi-based consensus process. The national consensus process included meetings as well as web-based questionnaires. The Consensus Group is coordinated by the German Center for Health Services Research in Dermatology (CVderm). RESULTS: The documentation standards and their variables for leg ulcer routine care were developed in seven meetings of the consensus group. The consensus group consists of 38 delegates of wound care societies, health insurances, wound networks and associations. DISCUSSION: For each variable, recommended in routine care, a distinct response scheme (defined set of variable characteristics) was defined. As a next step, a structured implementation process is required, which was part of the resolutions of the consensus group.

[Prophylaxis of Recurrent Venous Leg Ulcer]. / Rezidivprophylaxe des Ulcus cruris venosum.

Venous leg ulcer (VLU) counts among the most common chronic wounds in Europe. Treatment is lengthy, cumbersome and costly, and there is a high rate of recurrence. This review shows the measures that should be offered to every patient with healed VLU to permanently prevent recurrence. To prevent VLU in case of varicose veins, the progression of chronic venous insufficiency (CVI) has to be stopped. There is convincing evidence that the effective treatment of varicose veins reduces the recurrence rate in patients with VLU. In patients with post-thrombotic syndrome (PTS), further thrombosis should be prevented through targeted prophylaxis of new thromboembolic events. The benefit of endovascular revascularization on the VLU recurrence rate in patients with post-thrombotic damage in the pelvic veins has not been proven in clinical studies. On the other hand, it has been clearly demonstrated in several studies that compression therapy is the basic procedure for the prevention of recurrent VLU in patients with varicose veins or PTS, regardless of whether other measures have been implemented or not. Good adherence in patients with compression therapy is more important than choosing the highest possible compression class. Future efforts for patients with VLU must aim to provide therapists with tools and treatment strategies to guide their patients and to increase patients' acceptance and understanding of the importance of self-management, in particular regarding compression therapy for the prevention of recurrent VLU.

Photoacoustic imaging of real-time oxygen changes in chronic leg ulcers after topical application of a haemoglobin spray: a pilot study.

OBJECTIVE: To use a non-invasive measurement of oxygen saturation in chronic leg ulcers after the application of a topical haemoglobin spray to investigate if photoacoustic tomography is able to measure the oxygen saturation and if the stimulated oxygen increase can be demonstrated. METHOD: We measured the oxygen saturation of the ulcer tissue in five patients with chronic leg ulcers before application and 5 and 20 minutes after application of the haemoglobin spray, using photoacoustic tomography as a new method to assess oxygenation in real-time. RESULTS: The average oxygen saturation showed a significant increase from 56.4% before to 69% (p=0.042) after 5 minutes and 78.8% (p=0.043) 20 minutes after the topical haemoglobin application. CONCLUSION: The oxygenation status of chronic, hard-to-heal wounds is gaining increasing interest in modern wound therapy. Topical haemoglobin spray is a new and effective method to increase the oxygenation in the ulcer tissue, but until now the link between clinical results and the mode of action was unclear. We were able to show for the first time that the use of a topical haemoglobin spray leads to an increase in oxygen saturation in vivo using photoacoustic tomography. DECLARATION OF INTEREST: Joachim Dissemond received financial support from the company SastoMed for several scientific projects as well as for lectures and as an advisor. The haemoglobin spray was provided by SastoMed GmbH (Georgsmarienhütte, Germany).

[Compression therapy in leg ulcers]. / Kompressionstherapie des Ulcus cruris.

Compression therapy is well-tried treatment with only few side effects for most patients with leg ulcers and/or edema. Despite the very long tradition in German-speaking countries and good evidence for compression therapy in different indications, recent scientific findings indicate that the current situation in Germany is unsatisfactory. Today, compression therapy can be performed with very different materials and systems. In addition to the traditional bandaging with Unna Boot, short-stretch, long-stretch, or multicomponent bandage systems, medical compression ulcer stockings are available. Other very effective but far less common alternatives are velcro wrap systems. When planning compression therapy, it is also important to consider donning devices with the patient. In addition to compression therapy, intermittent pneumatic compression therapy can be used. Through these various treatment options, it is now possible to develop an individually accepted, geared to the needs of the patients, and functional therapy strategy for nearly all patients with leg ulcers.