[Necrotic leg ulcers after topical application of chlormethine]. / Ulcères de jambe nécrotiques après application locale de chlorméthine.

BACKGROUND: Topical chlormethine has been widely used in the early stages of mycosis fungoides for many years. Cutaneous reactions (skin irritation and itch) are the most frequent adverse effects. Herein we report a rare side effect: severe necrotic leg ulcers. PATIENTS AND METHODS: An 82-year-old woman with a history of high blood pressure developed hyperalgesic necrotic ulcers on the lower limbs following local trauma one month after initiation of topical chlormethine (Valchlor®) to treat mycosis fungoides. Aetiological examination showed moderate peripheral arterial disease which, while constituting an aggravating factor, did not account fully for these skin ulcers. Moreover, drug-induced ulcer was suspected on account of the chronology. Dermal corticoids and topical treatment were prescribed in place of chlormethine and led to a favourable outcome. CONCLUSION: Incrimination of chlormethine was based on the chronological and semiological criteria. This is the first published case of leg ulceration induced by Valchlor®.

[Frequency of contact sensitization to modern dressings used to treat chronic leg ulcer]. / Fréquence des sensibilisations de contact aux pansements modernes utilisés sur les ulcères de jambe.

INTRODUCTION: Allergic contact dermatitis around chronic leg ulcers (CLU) is a common complication in patients presenting CLU and prolongs healing times. The aim of this study was to describe the rate of sensitization to modern dressings (MD) used in these patients and to assess whether there is a relation between the number of sensitizations and ulcer type, the time from onset of the ulcer, and patient age and gender. PATIENTS AND METHODS: We conducted a retrospective study at Reims University Hospital between 2010 and 2014 that included all patients with CLU of vascular etiology surrounded by eczematous lesions, and who had one of the patch-tests in the following 3 series: European baseline±leg ulcers±corticosteroids. RESULTS: Among the 73 patients included, 43 % were polysensitized. Thirty-three patients (45 %) were sensitized to MD (38 % to hydrocolloids, 18 % to hydrogels, 7 % to hydrocellular dressings, 7 % to hydrofiber dressings, 5 % to contact layers and 3 % to alginates). Median age and sex did not differ between "polysensitized" patients and "non-polysensitized" patients (P=0.84 and P=0.25, respectively). Polysensitization was more frequent among patients presenting ulcers for more than 5 years (P=0.032). CONCLUSION: Practically half of all patients presenting CLU with surrounding contact dermatitis had sensitization to modern dressings (mostly hydrocolloids and hydrogels). The rate of sensitization increased with the length of presence of CLU.

[Retrospective study of hypertensive leg ulcers at Reims University Hospital: Epidemiological, clinical, disease progression data, effects of vitamin K antagonists]. / Étude rétrospective des angiodermites nécrotiques au CHU de Reims : données épidémiologiques, cliniques, évolutives et rôle des antivitamine K.

BACKGROUND: Hypertensive leg ulcers (HLU) are a form of necrotic leg ulcer. Their physiopathology is not well known and in these patients, no venous or arterial insufficiency is detected. The primary objective of this study was to evaluate the association between HLU severity and the presence or absence of concomitant vitamin K antagonist (VKA) medication. We furthermore aimed to describe the epidemiology of this entity and the prevalence of thrombophilia factors in this population. PATIENTS AND METHODS: This was a retrospective study in 54 patients hospitalized in the dermatology department of Reims University Hospital between 01/01/2007 and 31/12/2013: 23 patients were included in the "without VKA" group, and 30 were included in the "with VKA" group. Clinical and laboratory data were collected. RESULTS: The average HLU surface was higher in the "with VKA" group i.e. 35.00cm2 (min: 3.0; max: 220.0) versus 23.00cm2 (min: 5.0; max: 300.0) (P=0.05). No significant difference was found in terms of time to healing, mean hospitalization duration, HLU treatment by skin grafting, or time to recurrence after healing. Mean patient age was 74.2±9.3 years; 100% of patients had arterial hypertension, 50.9% had diabetes, and 20.8% were active smokers. Abnormal but non-significant values for thrombophilia factors were observed. CONCLUSION: Our study shows no obvious differences between patients with HLU with or without VKA medication. A prospective, comparative study is necessary to further evaluate this hypothesis, with particular emphasis on routine thrombophilia factor analysis.

[Leg ulcers in sickle cell disease: A retrospective study of 40 cases]. / Ulcères de jambe au cours de la drépanocytose: étude rétrospective de 40 cas.

BACKGROUND: In Africa, studies primarily devoted to chronic leg ulcer due to sickle cell disease are rare. The objectives of the study were to determine the epidemiology, diagnosis and progression of chronic leg ulcers in sickle cell disease. PATIENTS AND METHODS: A 5-year multicentre, retrospective study was conducted in three university hospitals in Dakar. We included all patients with chronic leg ulcers occurring in a setting of sickle cell disease. RESULTS: We identified 40 cases of chronic leg ulcers associated with sickle cell disease, representing 3.4% of the current population of sickle cell patients in our institutions. The average patient age was 25.9 years and the sex ratio was 2.33. Chronic leg ulcer was the presenting feature enabling diagnosis of sickle cell disease in one third of the cases. The average time to consultation from onset was 5.4 years. Pain was reported in 22 cases (48%). Ulcers were isolated in 76% and multiple in 24% of cases. The most common site was the medial malleolus (39%). A CBC allowed identification of anaemia in 35 cases. Haemoglobin electrophoresis was performed and homozygous sickle cell SS disease was identified in 39 cases and heterozygous SC disease in 1 case. Local treatments included physiologic serum, topical antibiotics and skin grafting. Systemic treatment included supplementation with folic acid in all patients, blood transfusion in 16 cases, vasodilators in 11 cases and antibiotics in 25 cases. The outcome was favourable in 61.8% of cases. DISCUSSION: In Dakar, sickle cell disease is a common cause of chronic leg ulcer and is frequently revealed by chronic leg ulcer.

[Cellular therapy and leg ulcers: Future approaches]. / Thérapie cellulaire et ulcères de jambe : l'avenir ?

The prevalence of leg ulcers, which are most commonly caused by venous insufficiency, is high in Europe. Current treatments are fairly unsatisfactory, with long healing times in many cases, as well as a high risk of relapse. Over the last 15 years, improved understanding of the cellular and molecular mechanisms at work in delayed wound healing has contributed to the development of cellular therapy in this field. The use of keratinocytes or cultured fibroblasts, whether autogenic or allogenic, has been of little value in terms of either healing times or rates of complete healing. For the moment, there are very few allogenic skin substitutes available; they are expensive and have been insufficiently studied in the indication of leg ulcers. Pluripotent mesenchymal adult stem cells have proved capable of accelerating wound healing in animal models and their study in chronic wounds in humans is currently awaited.

[When to ask for a skin biopsy in a patient with leg ulcer? Retrospective study of 143 consecutive biopsies]. / Quand poser l'indication d'une biopsie cutanée chez un patient porteur d'ulcère de jambe ? Étude rétrospective sur 143 biopsies consécutives.

OBJECTIVE: A vascular cause is found in around 85% of leg ulcer patients, but non-vascular causes are also observed. Their diagnosis is based on a set of clinical arguments and skin biopsy with histological analysis. The aim of this study was to analyze the results of these biopsies and to find common criteria for ulcers whose skin biopsies had led to the diagnosis of a non-vascular ulcer. MATERIAL AND METHOD: A retrospective study was carried out on the analysis of 143 skin biopsies of leg ulcers. The reasons for the biopsy were mainly atypical clinical signs and/or the lack of improvement in care after 6 months, as advocated by the French health authorities. RESULTS: The skin biopsies led to a diagnosis of non-vascular ulcer in 4.9% of cases (7/143), including skin cancer (n=5, 3.5%), cutaneous leishmaniasis (n=1, 0.7%) and Pyoderma gangrenosum (n=1, 0.7%). The univariate statistical analysis revealed that an elevated rim and abnormal excessive granulation tissue were significantly more frequently found in these ulcers. All patients with a positive skin biopsy had associated vascular involvement. CONCLUSION: This study found a 5% rate of non-vascular causes of ulcers, mainly skin cancer. Elevated rims and abnormal excessive granulation tissue were the unusual features most commonly found in these ulcers. All patients whose skin biopsy revealed a non-vascular cause had associated vascular involvement. This information confirms the need to perform a skin biopsy, even in the presence of a vascular disease.

[When to worry about before a vascular chronic leg ulcer?]. / Quand s'inquiéter devant un ulcère de jambe d'origine vasculaire ?

Leg ulcers are a chronic condition. Healing can be long for venous ulcers and the risk of complications is significant. Infection is the most severe complication and can occur in the form of easily diagnosed acute bacterial dermohypodermitis that generally responds well to antibiotic treatment if given at an appropriate dose or in the form of localized infection that is more difficult to diagnosis. Indeed, no consensus has been reached in the literature on the clinical criteria to retain for the diagnosis of localized infection. Similarly, the most appropriate treatment remains to be established. Local care would be a logical starting point, followed by systemic antibiotics if this approach is unsuccessful. Individual conditions also should be taken into consideration (immunodepression, severe arteriopathy warranting more rapid use of systemic antibiotics). The second most frequent complication is an allergic reaction to a topical agent used for wound care. The rate of sensitivization in patients with leg ulcers is high (60 %), although the rate is declining with modern dressings. No product can be considered perfectly safe for these polysensitized patients. Dermocorticoid therapy can be very effective. Allergology tests are needed. Certain leg ulcers require special care from diagnosis. An arterial origin must be suspected for deep, or necrotic ulcers. Arterial supply must be explored rapidly, followed by a revascularization procedure when necessary. Highly painful superficial extensive necrotic ulcers due to necrotic angiodermitis require hospital care for skin grafts that will control the antiodermitis and provide pain. Carcinoma should be suspected in cases of leg ulcers with an atypical localization exhibiting excessive budding. A biopsy is mandatory for leg ulcers with an unusual course (absence of healing despite well-conducted care).

[Compression therapy: Choosing the right option for leg ulcers in 2016]. / Quelle compression veineuse utiliser en 2016 pour un ulcère de jambe ?

Compression therapy is a mandatory treatment of leg ulcers whether the goal is cure (stage C6 in the international classification for chronic venous disease) or prevention of recurrence (stage C5). Different indications for compression therapy were proposed by the French Superior Health Authority (HAS) in 2010, but new studies have modified attitudes since that time. Considering the very large number of options available, the many co-morbid conditions observed in these patients, as well as patient age and available assistance, it is important to adapt to the variable clinical and social situations encountered. One must keep in mind that a well-controlled treatment should improve trophic disorders and patient comfort. A poorly-adapted treatment with little or even deleterious effect will be abandoned by the patient.

[Skillful care for chronic vascular wounds]. / Quels « petits ¼ gestes infirmiers rendent de grands services en cas de plaies chroniques d'origine vasculaire ?

In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology.

[Leg ulcers: Should general practitioners hospitalize their patients?]. / Ulcères de jambe: une expertise hospitalière est-elle souhaitable?

OBJECTIVES: Determine whether general practitioners have sufficient expertise in the field of leg ulcers. METHOD: A cross-sectional survey was conducted among 179 general practitioners working in the region Île-de-France to evaluate the implementation of leg ulcer guidelines issued by the Superior Health Authority (HAS) in 2006. Participating physicians were either internship supervisors or practitioners in Paris' 14th district. RESULTS: The first hundred usable answers (response rate 65%) came from 71 internship supervisors and 29 practitioners of Paris' 14th district. Only 40% of the physicians were aware of the guidelines, with no significant difference noted between the two groups. 9/10 practitioners examined less than 10 patients with leg ulcers per year. Physical examinations were done according to the guidelines and a venous Doppler was prescribed in two thirds of the cases. The ankle-brachial pressure index (ABPI) essential to diagnose lower limb arteriopathy was measured for only 10% of the patients. In accordance with the guidelines, compression was by far (73%) considered as the main treatment as compared to dressing (37%), but compression therapy was well prescribed in only one-third of the cases. Despite poor prognosis criteria (characteristic and time course), referral for a specialized opinion was rare. CONCLUSION: Even if they were not always aware of the detailed guidelines, the practitioners applied the main recommendations. Nevertheless, practices could be improved by measuring the ABPI, searching for a diagnosis of arteriopathy, and better prescription of compression therapy. General practitioners should refer patients with leg ulcers to a specialized hospital unit.

[Necrotic leg ulcer revealing vasculitis induced by vitamin K antagonists]. / Ulcère de jambe nécrotique révélant une vasculite induite par les antivitamines K.

UNLABELLED: Vitamin K antagonists are widely used in thromboembolic diseases. Hemorrhagic complications related to drug overdose represent their main side effect. We report a rare side effect, a severe and unexpected type of skin vasculitis - necrotic leg ulcer - induced by vitamin K antagonist. CASE REPORT: A 63-year-old female with a history of diabetes developed hyperalgesic necrotic ulcerations on the lower limbs one month after starting an acenocoumarol-based treatment for ischemic heart disease. Histological examination revealed lymphocytic vasculitis with fibrinoid necrosis. Etiological explorations searching for vasculitis were negative. In the absence of a precise etiology, drug-induced ulcer was suspected. Low molecular weight heparin was prescribed to replace acenocoumarol. The lesions slowly resolved with topical treatment. DISCUSSION: The chronological criteria and the negativity of etiological explorations allowed the diagnosis of vitamin K antagonist-induced necrotic skin ulcer. Clinicians should be aware of this rare complication induced by oral anticoagulants because of its practical therapeutic implications. This is the first case of necrotic leg ulcer induced by acenocoumarol corresponding histologically to necrotising lymphocytic vasculitis.

[Ankle and foot ulcerations in a diabetic patient revealing cutaneous leishmaniasis]. / Des ulcérations de cheville et du pied chez un diabétique révélant une leishmaniose cutanée.

INTRODUCTION: Cutaneous leishmaniasis is a parasitic disease that typically manifests as a typical crusted ulcer called the oriental sore. Its localization on the lower limbs can be mistaken for a leg ulcer. CASE REPORT: An 81-year-old male, native of Algeria, with type 2 diabetes, arterial hypertension and arteriopathy developed a chronic ulceration of the right ankle and foot compatible with the diagnosis of infectious diabetic foot. Non-improvement with antibiotics, local treatment and rest, and the absence of any hemodynamic arteriopathy led to skin biopsies. Polymerase chain reaction performed on biopsy samples for parasitological investigations yielded the diagnosis of cutaneous leishmaniasis due to Leishmania major. Complete healing was obtained with topical care alone, the patient having declined an etiological treatment. DISCUSSION: Cutaneous leishmaniasis is one of the rare infectious etiologies of chronic leg ulcers. Several therapeutic options, including abstention, can be proposed.

[Compression and venous leg ulcer: observational study in general medicine]. / Compression et ulcère veineux en pratique de ville: une étude observationnelle en médecine générale.

INTRODUCTION: Multi-component compression, inelastic, short stretched or coated strips bandages, and class 4 stockings have been recommended since 2010 by the French Superior Health Authority as first- and second-line treatment for venous leg ulcers. OBJECTIVES: Assess the prescribing habits and knowledge of general practitioners about compression therapy and determine factors predictive of prescriptions consistent with recommendations. METHODS: Evaluation study of professional practices conducted during a six-week period. A questionnaire was sent to 210 general practitioners asking them to report their prescribing practices and the last prescription written for a patient with venous ulcers. RESULTS: The response rate was 36.2% (76 responses). For the last patient seen, long stretched bands were prescribed by 50.8% of responders, stockings by 40% and multi-component compression by 7.7%. Stockings were class 2 for 87.7% of the prescriptions. Knowledge of short stretched bands and multi-component compression was reported by 45.8% and 38.9% of general practitioners respectively. Guidelines were followed by 10.8% of the physicians. No factor related to the general practitioner (age, sex, modalities of exercise, experience and education), to the patients (age, sex, under-nutrition, autonomy) or to the leg ulcer (size, exudates, course, complexity of care), was associated with compliance or not with the guidelines. General practitioner training enabled a non-significant improvement of prescriptions (14.3% vs 4%, P=0.24). CONCLUSION: Compliance with the guidelines for compression therapy is insufficient in general medicine. Better training and knowledge of modalities for compression therapy could be useful to improve prescription practices and encourage use of multi-component compression and short stretched bandages, known to be more effective and better tolerated.

Compression therapy in 100 consecutive patients with venous leg ulcers.

OBJECTIVE: To evaluate compression therapy for venous leg ulcers in terms of adherence, acceptability, quality, and effectiveness. DESIGN OF STUDY: Prospective observational cohort study. SETTING: Vascular diseases outpatient clinic in Paris, France. SUBJECTS: One hundred consecutive patients with active or healed leg ulcers and chronic lower limb venous insufficiency stage C5 or C6 in the CEAP classification scheme. INTERVENTIONS: Compression systems applied in a community-based practice. MAIN OUTCOME MEASURES: A standardized form was used to collect: (1) data on patient adherence; (2) objective criteria evaluating the quality, effectiveness, and correct application of compression systems and; (3) patient education and perceptions about their compression therapy. RESULTS: Patient adherence with compression therapy was high (89%), even though it was often a source of discomfort. Only 10% of patients signaled no discomfort. Drawbacks reported by patients were excessive warmth (29%), pruritus (33%), unacceptably high cost (48%), and moderate to considerable difficulty putting on footwear (64%). In the 11% of patients who did not wear their compression system, reasons for nonadherence were inadequate comprehension of expected benefits (45.5%), pain related to compression (36.4%), difficulty applying the compression system (27.3%), and difficulty putting on footwear (27.3%). Application was correct in 51.7% of adherent patients; errors in the remaining patients included slippage, failure of the bandage to extend to just under the knee (55.8%), a tourniquet effect (21%), failure of bandaging starting at the base of the toes (37.2%), and failure to cover the heel (53.5%). Full edema control was achieved in 51.7% of adherent patients. Compression was adequate overall (worn, correctly applied, and effective) in 49% of adherent patients. The most common reasons for lack of effectiveness were inadequate pressure and errors in application. Lack of awareness of potential benefits and wearing modalities of compression therapy was noted in 56% of patients. CONCLUSION: Patients, nurses, and physicians have inadequate knowledge of the modalities of compression therapy and as a result they are not well respected. Educational programs are needed.