Non-surgical treatment for arterial leg ulcers: a narrative review.

OBJECTIVES: Arterial leg ulcers (ALUs) pose a considerable burden on patients and health services. The cornerstone of treatment is revascularisation; however, this is not always possible and does not necessarily guarantee ulcer healing. Alternative treatment options are therefore also important. This narrative review aims to summarise the evidence available for non-surgical treatment of ALUs, including topical therapy, pharmacological agents, therapeutic angiogenesis and devices. METHODS: A literature search was performed in November 2020 to identify studies reporting data on the non-surgical management of ALUs. Prospective randomised controlled trials (RCTs), controlled clinical trials and meta-analyses that investigated conservative or medical interventions on patients with intractable ALUs, and which provided quantitative data on ulcer healing were included. Following screening, studies that met the inclusion criteria underwent a data extraction process and findings were synthesised and categorised narratively. RESULTS: In total, 14 controlled trials were selected for inclusion and analysed based on experimental protocol and outcome measures. CONCLUSION: There is some evidence available for the use of short-term systemic prostanoids, ultrasound therapy and pneumatic compression. There are limitations to these options including side effects, patient tolerance due to pain and availability in clinical practice. Further research is needed to improve treatment options for this complex group.

The use of vascularised muscle flaps for treatment or prevention of wound complications following arterial surgery in the groin.

Wound complications following arterial surgery in the groin are relatively common and can result in significant morbidity and mortality. Vascularised muscle flaps (VMF) may be used as an adjunct to aid healing, either to manage complications or prophylactically. This series describes 46 patients who received sartorius or gracilis muscle flaps, of which 70% were performed as a salvage procedure to treat complications ranging from wound breakdown to vascular graft infection. The remaining 30% were performed at the time of the arterial surgery in patients with risk factors such as re-do surgery or immunosuppression. The peri-operative mortality rate was 9% and the major amputation rate was 26%, reflecting the complexity of patients that require intervention. Overall, 85% achieved successful healing in the groin without the need for further treatment following VMF. Only one case of flap necrosis occurred. Wound healing complications occurred more commonly after sartorius muscle flaps. The gracilis muscle offers a bulkier mass and greater mobility and so may be preferable, particularly for larger groin defects. This series has shown that VMF offer a safe and reliable option for selected cases to achieve wound healing in the groin in patients with often significant co-morbidities.

Pressure ulcers in patients receiving palliative care: A systematic review.

BACKGROUND: Pressure ulcers are associated with significant morbidity and mortality as well as high cost to the health service. Although often linked with inadequate care, in some patients, they may be unavoidable. AIM: This systematic review aims to quantify the prevalence and incidence of pressure ulcers in patients receiving palliative care and identify the risk factors for pressure ulcer development in these patients as well as the temporal relationship between pressure ulcer development and death. DESIGN: The systematic review is registered in the PROSPERO database (CRD42017078211) and conducted in accordance with the 'PRISMA' pro forma. Articles were reviewed by two independent authors. DATA SOURCES: MEDLINE (1946-22 September 2017), EMBASE (1996-22 September 2017), CINAHL (1937-22 September 2017) and Cochrane Library databases were searched. In all, 1037 articles were identified and 12 selected for analysis based on pre-defined inclusion and exclusion criteria. RESULTS: Overall pressure ulcer prevalence and incidence were found to be 12.4% and 11.7%, respectively. The most frequently identified risk factors were decreased mobility, increased age, high Waterlow score and long duration of stay. CONCLUSION: The prevalence of pressure ulcers is higher in patients receiving palliative care than the general population. While this should not be an excuse for poor care, it does not necessarily mean that inadequate care has been provided. Skin failure, as with other organ failures, may be an inevitable part of the dying process for some patients.

An unusual presentation of a common condition: Allergic contact dermatitis.

Allergic contact dermatitis commonly affects patients with chronic venous leg ulcers and can contribute to impaired wound healing. Many allergens have been identified, and despite the use of advanced dressings, the incidence of allergy has remained high. We discuss an unusual presentation of allergic contact dermatitis in a patient with a chronic wound. The patient's history was consistent with a recurrent venous leg ulcer, but on this occasion, the wound continued to deteriorate despite optimal treatment. This prompted further investigation, which included patch testing. Although the clinical features were not suggestive of allergy, the patch test was positive for several allergens, including Atrauman® dressings, which the patient was using at the time. This case highlights the importance of regular reassessment and accurate diagnosis for the management of chronic wounds. It also demonstrates that allergic contact dermatitis can contribute to delayed wound healing without causing the classical clinical features of inflammation of the surrounding skin, and even hypoallergenic, non-adherent dressings can be sensitising.