Impact of psychiatric comorbidities in psoriasis, hidradenitis suppurativa and atopic dermatitis: The importance of a psychodermatological approach.

BACKGROUND: There is a strong interaction between the immunological and nervous system in the skin. Lesions that are physically disfiguring and chronically relapsing have a high impact on quality of life (QoL) and can result in the emergence of psychiatric disorders. The literature data confirm a higher prevalence of psychiatric disorders in patients with psoriasis, hidradenitis suppurativa (HS) and atopic dermatitis (AD), but such data are compromised by low-quality evidence due to methodological heterogeneity. OBJECTIVES: The primary aim was to analyse the prevalence of psychiatric comorbidities in a group of psoriasis, AD and HS patients compared with a control group. The secondary aims were to evaluate the impact of psychiatric comorbidities on the disease development, severity, flare-ups and QoL. METHODS: A total of 59 cases and 64 controls were included. RESULTS: Generalized anxiety disorder and depressive disorder with anxious distress were found to be risk factors for AD. Age, smoking and substance-related disorder showed a specific association with HS. Major depressive disorder showed a specific association with dermatology life quality index (DLQI) and all the above disease flare-ups. CONCLUSIONS: Atopic dermatitis, psoriasis and HS are associated with psychiatric disorders. A psychodermatological approach improves outcomes in terms of QoL, disease flare-ups and long-term management.

PG-TIME: A practical approach to the clinical management of pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis which may be rapidly progressive. Standard guidelines for local treatment are lacking. Through our experience, we suggested a local treatment algorithm based on the tissue, infection, moisture balance, and epithelization (TIME) concept. The clinical and histopathological features of 52 patients with PG, the duration, and the evolution of the lesions were retrospectively evaluated. Systemic therapies, local treatments, and standard wound treatments were reported. We observed ulcerative PG in the majority of the patients (82.6%), followed by the pustular form (9.6%), the peristomal type (3.8%), the vegetative form (1.9%), and the bullous type (1.9%). The lower leg was the most commonly area affected (90.4% of cases). Pathergy was reported in 15.3% of cases. The first-line treatment was the use of oral glucocorticosteroids (GCSs). We observed healing after 3 weeks of GCS in 17.3% of cases. In 25% of all cases, we obtained complete healing with long-term low doses (<0.5 mg/kg) of GCS in the range of 2 to 6 months. We used second-line treatments in 57.6% of patients. Local, systemic treatment, and correct wound management can be associated with better clinical results. We suggest a new local therapeutic algorithm in both the inflammatory and noninflammatory healing phases.

Biomodulation induced by fluorescent light energy versus standard of care in venous leg ulcers: a retrospective study.

OBJECTIVE: The recently completed EUREKA study confirmed the efficacy and safety profile of fluorescent light energy (FLE) in treating hard-to-heal wounds. To supplement the EUREKA prospective, observational, uncontrolled trial results, researchers selected one of the EUREKA clinical centres to conduct a retrospective analysis of matching wound care data for 46 venous leg ulcers (VLU) patients who had received standard wound care over a five-year period, compared with 10 EUREKA VLU subjects. METHOD: The study centre selected 46 patients with VLUs based on the matching criteria (wound age and size, patient's age and gender). They compared the healing rates of these matching VLUs with 10 VLU patients treated at the same centre during the EUREKA study. RESULTS: The EUREKA patients had larger and significantly older wounds (p<0.05) and significantly more risk factors (p<0.05) than the matching wounds. However, they had better outcomes (EUREKA: 40% versus matching group: 7% for full wound closure by 16 weeks). No wound breakdown was observed at 16 weeks in the EUREKA group, compared with 25% in the matching group. No EUREKA patient developed infections requiring antibiotics, compared with 37% in the matching group. EUREKA wounds had a mean relative wound area regression (RWAR) of 32% at week six and 50% at week 16, compared with -3% at week six and -6% at week 16 for the matching group. CONCLUSION: These findings show that the system based on FLE was well-tolerated and efficacious, with better clinical outcome results compared with the wounds analysed in this retrospective matching study and treated with standard of care alone.

The Association Between pH and Fluorescence as Noninvasive Diagnostic Tools in Chronic Wounds.

MolecuLight i:X is a noninvasive, portable device that captures images, measures wound areas, and allows the evaluation of the bacterial environment in real time. The aim of the study was to correlate the different fluorescence (light green, red, cyan) and dark red-purple-black color areas with average pH values in these areas and with average wound bed score (WBS). During a 4-week period, we enrolled 43 adult patients (23 females and 20 males) with clinically infected and uninfected chronic ulcers. In our study, the mean age was 68 years old. The etiologies were 21 venous ulcers, 3 arterial ulcers, 4 vasculitis, 7 pyoderma gangrenosum, 7 traumatic ulcers, and 1 neoplastic ulcer. The average area was 16.92 cm2 and the average WBS was 9.17. A total of 16 ulcers (37%) were positive for clinical signs and symptoms of infection and 27 ulcers were negative (63%). Thirty-six ulcers emitted a single fluorescence: cyan (n = 13), red (n = 1), light green (n = 14), and dark red-purple-black (n = 8). Six wounds showed a double fluorescence area: red and cyan (n = 1) and cyan and light green (n = 5). One ulcer emitted a triple fluorescence area: red, cyan, and light green. Overall in 43 ulcers, we found 43 fluorescence and 8 dark red-purple-black color. We found significant data between pH and fluorescence. pH values on wound bed confirm in a noninvasive way the correlation between fluorescence and bacterial burden. Moreover, MolecuLight i:X is able to detect objectively the bacterial proliferation, in contrast with pH which cannot distinguish different types of bacteria.

The Role of Autoflorescence Imaging Device in the Evaluation of Bacteria Burden Control.

MolecuLight i:X is a autofluorescence, portable device that allows an assessment of wound area, perimeter, width and length and an evaluation in real time of wound surface bacteria (>104 CFU/g). Primary objective of our study was to evaluate the reduction of bacterial load associated to 3 different therapeutic approaches: dressings and multicomponent bandages (Group1), sharp debridement, dressings and multicomponent bandages (Group 2), and 10 patients treated with zinc oxide bandage (Group 3). Secondary objective was NRS pain scale, Wound Bed Score (WBS) and Quality of Life (QoL) assessment. Despite the improvement of bacterial load, WBS, Qol and NRS was evident in all 3 groups, the analysis of our results demonstrates that the application of zinc oxide bandage, directly in contact with the wound bed and/or the perilesional skin, resulted in a higher improvement and a significant reduction of WBS and bacterial load. Fluorescence imaging can help the specialist in a more targeted assessment and management of infection. Sharp debridement and antiseptic dressings are classically used to reduced bacteria burden. Zinc oxide directly on the wound is an interesting cost-effective option to control different types of bacteria.

Palliative management of a recurrent destructive cutaneous squamous cell carcinoma of the scalp with brain exposure.

INTRODUCTION: Squamous cell carcinoma (SCC) is the second most prevalent malignant skin carcinoma. Bone infiltration is uncommon, and invasion of the dura mater and brain parenchyma is rare and possible only in the advanced stages of the disease. Treatment of advanced SCC is challenging and often requires the collaboration of a multidisciplinary team to provide local and systemic treatment. Management of advanced SCC of the scalp involving bones and meninges with brain exposure was described herein. CASE REPORT: An 85-year-old male presented with advanced SCC of the scalp. A vegetative and infiltrating neoplastic ulcer of the frontal and parietal regions with exposure of the brain and extensive meningeal and bone destruction was observed. Because of comorbidities and decisions made by the patient and his family, he did not undergo immunotherapy, radiotherapy, or other invasive treatments. The neoplastic tissue was covered by blood, fibrin, and bacterial colonization. The patient received palliative care in a wound healing clinic twice monthly for 1 year, and daily dressing changes were performed at home. Binding bacteria dressings, silver dressings, and absorbent dressings were used to control exudate and infection. Alginate was used to manage bleeding, and charcoal dressings were used to manage odor. The dressings were covered with gauze and bandage. Additionally, swabs were performed when signs of infection were present and targeted systemic antibiotic treatment administered. CONCLUSIONS: Squamous cell carcinoma rarely presents with a devastating and rapid evolution. In this case, the local approach was based on the TIME (tissue, inflammation/infection, moisture imbalance, epithelial edge advancement) concept, with special attention paid to the most significant features of neoplastic wounds (eg, pain, exudate, bleeding, odor). Despite the patient's serious conditions, he survived for a relatively long time.

Prognostic Indicators of Wound Healing in Atypical Wounds: A Case Series.

Healing rate is the most accurate method to predict healing; however, there are no data in atypical ulcers. We retrospectively analyzed clinical features, associated comorbidities, and therapies of 159 patients with atypical ulcers. In a subgroup of 59 patients, we analyzed the areas, perimeters, and the healing rate (mm/d) as prognostic indicators of wound healing. Atypical ulcers were more frequent among women (n = 98) with an average age of 76 years. Confirmed by biopsy, the etiologies were as follows: inflammatory diseases (38%), neoplastic ulcers (29%), vasculitis (21%), drug-induced ulcers (7%), and infectious ulcers (4%). Systemic therapies were applied based on the different etiologies. Wound bed preparation principles guided the local treatment. The average reduction of the area during the observation interval was 36%, while the average reduction in the perimeter was 41%. Overall, 51 ulcers showed a reduction in wound size and 8 ulcers showed an increase. Neoplastic ulcers were the group with the fastest healing rate, with an average speed of 0.24 mm/d. The slowest healing occurred in the inflammatory group with an average healing rate of 0.032 mm/d. The initial area and perimeters influenced wound healing; however, ulcer etiology and comorbidities significantly altered the healing rate.

Atypical ulcer arising on stasis dermatitis: achromic melanoma.

INTRODUCTION: Due to venous insufficiency, a vascular ulcer frequently occurs with the progression of stasis dermatitis. Achromic melanoma, a rare form of pigmentless melanoma frequently located on the sole of the foot, is often and easily confused with a typical wound. Diagnosis of ulcerated achromic melanoma is thus often delayed and associated with a poor prognosis. CASE REPORT: The authors report a very rare case of malignant melanoma in a 70-year-old female with stasis dermatitis. The painless ulcer was present for 1 year before the first visit. Upon clinical examination, a 2-cm diameter hypergranulating ulcer with irregular and pigmented borders was present. Dermoscopy revealed the presence of red globules, a gray-to-blue veil, irregular vessels, and the remains of a pigmented ridge pattern. Histological analysis showed infiltration of atypical melanocytes in the dermis, 2 mitoses, and ulceration. Diagnosis of melanoma was confirmed by positive MART-1 immunochemistry. After removal of the melanoma, the area was covered with an autologous skin graft excised from the inner thigh. In accordance with the guidelines, sentinel lymph node biopsy was performed, and the result was negative for lymph node involvement. A comprehensive clinical dermoscopic evaluation led to the correct diagnosis. CONCLUSIONS: The current case highlights the importance of evaluating a chronic, atypical, nonhealing ulcer clinically and dermoscopically as well as through a biopsy procedure.

5% Lidocaine Hydrochloride Cream for Wound Pain Relief: A Multicentre Observational Study.

BACKGROUND: Lidocaine hydrochloride is frequently used for management of painful wounds. This prospective, multicentre study examined the effects of 5% lidocaine cream on wound pain relief. MATERIAL AND METHODS: The study included 78 patients with painful wounds treated with 5% Lidocaine cream for two weeks in two Italian Hospitals. Patients' perception of pain was recorded by, using the 5-point Visual Rate Scale and the 11-point Numerical Pain Rating Scale. All medications and adverse events were evaluated in a daily diary. The primary outcome of the study was establishing the wound pain relief based on the results of 5-VRS and pain intensity based on the 11-NPRS testing from baseline to the end of treatment. Clinical aspects and adverse events were also collected. RESULTS: Seventy-eight patients had a median age of 67.5 years (range 18-96 years). 62.8% were women. The wounds included traumatic wounds (n = 39), venous ulcers (n = 25), post-surgical wounds (n = 6) pyoderma gangrenosum (n = 6), vasculitis (n = 1) and pressure ulcer (n = 1). The intensity of pain significantly decreased from the baseline level established at the beginning of treatment (mean score 6.7 - 1.90) - to the level at end of treatment (3.0 - 2.23-; p < 0.0001). 9 patients prematurely stopped the treatment for healing (n = 4), wound improvement (n = 2) and adverse events related to the treatment. (n = 3). 13 patients presented a total of 25 adverse events, 4 of them were related to the treatment. CONCLUSION: The treatment of painful wounds with 5% Lidocaine Cream for 14 days resulted in reduced pain intensity, and showed high safety and tolerability.

Blue light emission in the management of hard-to-heal wounds.

BACKGROUND: Blue light (400 and 450 nm) contributes to bringing the inflammatory phase under control, increases angiogenesis, stimulates the metabolism of all cellular processes, reduces scar formation, increases collagen production, and decreases the bacterial burden. METHODS: The aim of this study was to promote the healing process in 20 hard-to-heal wounds using a portable light-emitting diodes device that emits blue light (Emoled™). The primary endpoint of the study was to calculate in the three etiologic groups the reduction in wound size by the average delta area in square centimeters and as a percentage, and by the average healing rate (mm/days). The secondary endpoint was to assess the Wound Bed Score (WBS) and to assess patients' pain (Numerical Rating Scale, NRS). RESULTS: At week 4 the average healing rate was 0.098 mm/days for venous leg ulcers, 0.353 mm/days for traumatic ulcers, and 0.09 mm/days for vasculitis. Overall, 16 patients had a reduction in wound size, two patients were completely healed, and there was no improvement in two patients. At week 4, the average wound bed score had increased to 12.8 and average pain had decreased to 2.35. Almost all patients (N.=19) showed pain reduction, and all the patients increased wound bed score. CONCLUSIONS: The blue LED device is promising in terms of promoting wound healing, improving WBS and reducing pain in patients affected by long-term wounds that do not respond to standard treatment.

Local Management of Malignant and Unresectable Fungating Wounds: PEBO Assessment.

Malignant fungating wounds (MFWs) represent a major problem for public health. The most common symptoms associated with MFWs are pain, exudate, bleeding and odor. The aim of the study was to optimize the local management and dressing of MFWs. We developed a standardized 4- step approach to MFWs based on Pain, Exudate, Bleeding and Odor management in a case series of 24 patients: we call this the PEBO approach. We analyzed etiologies, localization, Quality of Life (QoL), pain and clinical signs and symptoms. We assessed the ulcers at baseline, after two weeks and after one month. In our study, most patients showed an improvement in the QoL using PEBO approach, although some experienced a deterioration in their general clinical conditions. Non-cytolesive cleansing, atraumatic dressings were applied to allow pain relief. Non-adherent dressings were combined with a secondary dressing in the case of exudate. Achieving hemostasis with dressing or medication is a priority in MFW management. Antibacterial dressings and odor absorbent dressings were used for odor absorption. Surgical debridement, adherent dressing and occlusive dressings were avoided. Dressing changes were programmed twice a week for four weeks. PEBO simplified the complex aspects of this type of ulcer, and could help physicians, nurses, and also the rest of the team, including the patients themselves and their family, in the multidisciplinary palliative care of MFWs.

Wound Dehiscence After Achilles Tendon Trauma and Repair: Treatment With Ultraportable Negative Pressure Wound Therapy and Compression Therapy.

INTRODUCTION: Achilles tendon rupture is a common injury requiring surgical repair. Re-ruptures, infections, delayed wound healing, and hematomas have been reported postoperatively. OBJECTIVE: This case series described the use of ultraportable negative pressure wound therapy (NPWT) and compression bandaging following postoperative dehiscence of Achilles tendon repair. MATERIALS AND METHODS: Retrospective records were reviewed to identify patients who underwent wound management for Achilles tendon dehiscence between January 2014 and January 2018. Patient demographics, wound size at first and last visit, number of visits, and previous treatment data were extracted. Wound management included wound irrigation, surgical debridement, and application of silver dressings, as needed. Therapy was transitioned to ultraportable NPWT with twice-weekly dressing changes. When possible, patients with an ankle-brachial index greater than 0.8 received multilayer, multicomponent compression. Treatment response was evaluated using a wound imaging system at 2-week to 4-week intervals for a total of 24 weeks. RESULTS: Nine male patients with a mean age of 69.7 years presented for care. One patient sustained injury during sports activities, and the other 8 patients sustained injuries resulting from household accidents. Six patients achieved complete wound closure. Three patients achieved a mean 90% wound closure. No adverse effects were observed during treatment with NPWT and compression therapy. CONCLUSIONS: In the current study, ultraportable NPWT and compression bandaging were found to be effective in the management of wounds with critical local vascularity. Larger, randomized controlled studies are necessary to fully assess the potential clinical benefit of NPWT and compression therapy in the management of postoperative wounds of the Achilles tendon.

Development of Methods for Recovering Endotoxins from Surfaces and from Air in Production Environment of Injectable Drugs.

The aim of this work is to develop and validate methods for quantifying endotoxins on surfaces and in the air of the manufacturing environment of injectable drugs, in order to use them to evaluate the quality of the process and the risk for the products processed therein. The method for recovering endotoxins from surfaces is a direct method that provides sampling surfaces by swabbing and extraction of endotoxins from the swabs with an appropriate diluent, while the method for airborne endotoxins provides an air-active sampling on a glass fiber filter and endotoxins extraction with an appropriate diluent.LAY ABSTRACT: Bacterial endotoxins are present in the environments devoted to the manufacturing of injectable drugs and could be a real risk for the quality and the safety of such drugs. So the quality control laboratories should have analytical methods to recover bacterial endotoxins from environmental samples. The aim of this publication is to show how we succeeded in developing and validating methods to quantify bacterial endotoxins on surfaces and in the air.