[Chronic wounds of the lower limbs: a guide for non-specialists]. / Plaies chroniques des membres inférieurs : un guide pour le non-spécialiste.

Chronic lower-extremity ulcers are a growing public health problem, resulting in significant costs for society and patients, and having a significant impact on the quality of life of patients and informal caregivers. As general practitioners are often solicited early on, the acquisition of basic knowledge regarding wound care management is therefore essential to initiate local care, to make an early diagnosis and identify emergencies and patients that need a referral. The CASE and TIMERS frameworks enable a holistic assessment of the patient and the wound, to propose a treatment of the wound based on its etiology combined with appropriate local wound care. This framework allows also to identify atypical, severe, or recalcitrant wounds requiring specialized advice.

Les plaies chroniques des membres inférieurs sont un problème grandissant de santé publique, occasionnant des dépenses conséquentes et entraînant une répercussion non négligeable sur la qualité de vie des patients et de leurs proches aidants. Les médecins de premier recours étant le plus souvent les premiers intervenants, l'acquisition d'un socle commun de connaissances est donc essentielle pour la bonne prise en soin initiale des plaies chroniques, obtenir un diagnostic précoce et identifier les urgences et les patients à référer. L'approche selon les principes CASE et TIMERS permet une évaluation holistique du patient et de sa plaie, et de proposer un traitement étiologique associé à des soins locaux adaptés. Celle-ci permet également d'identifier les plaies atypiques, sévères ou récalcitrantes, nécessitant un avis spécialisé.

Leg ulcers are indicators of systemic dysfunction in individuals with sickle cell disease.

Leg ulcers in individuals living with Sickle Cell Disease are evidence of systemic dysfunction. Data from a U.S. study link leg ulcers to wider pulse pressure and markers of chronic hemolysis, inflammation, renal, and liver dysfunction.

Occlusive cutaneous vasculopathies as cause of chronic ulcers.

The term occluding vasculopathies covers a large number of different conditions. These often manifest as skin ulcers. Occluding vasculopathies should be considered in the differential diagnosis of leg ulcers. The term "occlusive vasculopathies" encompasses pathophysiologically related entities that share structural or thrombotic obliteration of small cutaneous vessels. In this article, we will focus on livedoid vasculopathy with and without antiphospholipid syndrome and calciphylaxis with differentiation from hypertonic leg ulcer as the most relevant differential diagnoses of leg ulcer. The term also includes vascular occlusion, for example due to oxalate or cholesterol embolism, and septic vasculopathy. This often leads to acral ulceration and is therefore not a differential diagnosis with classic leg ulcers. It will not be discussed in this article. Occlusive vasculopathy may be suspected in the presence of the typical livedo racemosa or (non-inflammatory) retiform purpura as a sign of reduced cutaneous perfusion in the wound area. Inflammatory dermatoses, especially vasculitides, must be differentiated. This is achieved by histopathological evaluation of a tissue sample of sufficient size and depth taken at the appropriate time. In addition, specific laboratory parameters, particularly coagulation parameters, can support the diagnosis.

Diagnosing and Managing Venous Stasis Disease and Leg Ulcers.

Venous insufficiency is a common medical condition that affects many individuals, especially those with advanced age. Chronic venous insufficiency can lead to secondary cutaneous changes that most commonly present as stasis dermatitis but can progress to more serious venous ulcers. Although venous ulcers are the most common cause of lower extremity ulcers, the differential diagnosis of leg ulcers is broad. This article will discuss clinical clues to help guide patient workup and will review basic clinical evaluation and management of common leg ulcers.

Exploring the Association between Hemochromatosis and Lower-Limb Venous Disease.

OBJECTIVE: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. METHODS: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. RESULTS: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. CONCLUSIONS: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

"SCULP" study: The benefits of skin graft pellets on the pain of sickle cell leg ulcers (SCLU).

BACKGROUND: Leg ulcers associated with major sickle cell disease (SCLU) are a chronic, painful complication, often treated by autologous skin graft. The analgesic effect of skin grafting in SCLU is poorly studied. The aim of this study was to evaluate the effect of skin grafting on the pain and healing of SCLU. METHODS: Patients hospitalized for SCLU skin grafting were included in a retrospective and prospective observational cohort, between 2019 and 2023: 53 autologous pinch grafts were performed on a total of 35 SCLUs in 25 sickle cell patients. The primary endpoint was the evaluation of the analgesic effect of the skin graft, measured by visual analog scale (VAS) and weekly cumulative analgesic consumption between day (D)0, D7 and D30. Wound healing was assessed by variation in wound areas between D0 and D30. RESULTS: Twenty-five patients with a median age range of 45.5years old were included, 68% were men, SS genotype was present in 96% of the cases. At D7, a significant decrease in VAS and consumption of analgesics of all classes was observed. At D30, only a significant decrease in VAS and consumption of mild opioids was present, as well as a significant reduction in wound surface area compared with D0. CONCLUSION: Pinch grafts have a significant early analgesic effect in the management of patients with SCLU, and significantly notice reduction of wound surface area within one month.

The evolution of leg ulcer guidelines and recommendations.

BACKGROUND: Clinical guidelines aim to consolidate and incorporate the latest evidence and opinion to improve patient outcomes and reduce variations in practice. AIMS AND METHODS: This article will examine the evolution of clinical guidelines and recommendations in leg ulcer assessment and management, from the seminal Royal College of Nursing clinical guideline (1998) to the current Leg Ulcer Recommendations from the National Wound Care Strategy Program (2023). The evolving definitions of leg ulcers will be discussed, as well as the multidisciplinary approach needed to manage the underlying aetiology of this condition. FINDINGS AND CONCLUSION: A national appetite for improving leg ulcer assessment and treatment, is being informed by clinical guidelines and recommendations. The cornerstones of assessment and management remain constant, although some fundamental elements around ankle brachial pressure index ranges, historically used to aid diagnosis of leg ulcer aetiology, have been omitted in the recent recommendations.

Sclerotherapy and its complications: a literature review and a case report.

Hard-to-heal or recurrent leg ulcers can have multiple aetiologies. One of these is incompetent veins. The main focus of this article is to discuss the common treatment for venous leg ulcers with the use of sclerotherapy. This simple surgical procedure obliterates smaller veins and telangiectasia. Veins with larger diameters (varicosities) can be treated with ablation therapy. The intent of sclerosis or ablation therapy is to destroy the incompetent veins and allow the collateral circulation to improve venous return, decreasing venous hypertension, which then enhances skin closure, wound healing and the resolution of the ulcer.

Development of a localization-based algorithm for the prediction of leg ulcer etiology.

BACKGROUND: Diagnostic work-up of leg ulcers is time- and cost-intensive. This study aimed at evaluating ulcer location as a diagnostic criterium and providing a diagnostic algorithm to facilitate differential diagnosis. PATIENTS AND METHODS: The study consisted of 277 patients with lower leg ulcers. The following five groups were defined: Venous leg ulcer, arterial ulcers, mixed ulcer, arteriolosclerosis, and vasculitis. Using computational surface rendering, predilection sites of different ulcer types were evaluated. The results were integrated in a multinomial logistic regression model to calculate the likelihood of a specific diagnosis depending on location, age, bilateral involvement, and ulcer count. Additionally, neural network image analysis was performed. RESULTS: The majority of venous ulcers extended to the medial malleolar region. Arterial ulcers were most frequently located on the dorsal aspect of the forefoot. Arteriolosclerotic ulcers were distinctly localized at the middle third of the lower leg. Vasculitic ulcers appeared to be randomly distributed and were markedly smaller, multilocular and bilateral. The multinomial logistic regression model showed an overall satisfactory performance with an estimated accuracy of 0.68 on unseen data. CONCLUSIONS: The presented algorithm based on ulcer location may serve as a basic tool to narrow down potential diagnoses and guide further diagnostic work-up.

Lower-Extremity Vascular Ulcers: Assessment and Approaches to Management.

Healing of skin wounds of the lower extremities can be complicated by concomitant vascular disease. Dysfunction of the arterial, venous, and/or lymphatic systems can compromise the healing of skin ulcers of the legs, creating a burden for patients from painful, draining wounds and placing patients at risk for infection, amputation, and even death. Insights into vascular pathophysiology and an understanding of the processes of wound healing permit an evidence-based approach to patients with vascular leg ulcers. Clinical trials have demonstrated opportunities to improve the care of patients with vascular leg ulcers, thereby reducing morbidity and mortality and easing patients' burdens.

Association of haemolysis markers, blood viscosity and microcirculation function with organ damage in sickle cell disease in sub-Saharan Africa (the BIOCADRE study).

Sickle cell anaemia (SCA) is a monogenic disease with a highly variable clinical course. We aimed to investigate associations between microvascular function, haemolysis markers, blood viscosity and various types of SCA-related organ damage in a multicentric sub-Saharan African cohort of patients with SCA. In a cross-sectional study, we selected seven groups of adult patients with SS phenotype in Dakar and Bamako based on the following complications: leg ulcer, priapism, osteonecrosis, retinopathy, high tricuspid regurgitant jet velocity (TRV), macro-albuminuria or none. Clinical assessment, echocardiography, peripheral arterial tonometry, laboratory tests and blood viscosity measurement were performed. We explored statistical associations between the biological parameters and the six studied complications. Among 235 patients, 58 had high TRV, 46 osteonecrosis, 43 priapism, 33 leg ulcers, 31 retinopathy and 22 macroalbuminuria, whereas 36 had none of these complications. Multiple correspondence analysis revealed no cluster of complications. Lactate dehydrogenase levels were associated with high TRV, and blood viscosity was associated with retinopathy and the absence of macroalbuminuria. Despite extensive phenotyping of patients, no specific pattern of SCA-related complications was identified. New biomarkers are needed to predict SCA clinical expression to adapt patient management, especially in Africa, where healthcare resources are scarce.

The effectiveness of adalimumab as an add-on therapy in two cases with leg ulcers in Behçet's disease resistant to conventional immunosuppressive therapy alone and a review of the literature.

The current report presents two cases with leg ulcers related to Behçet's disease (BD) resistant to conventional immunosuppressive therapy (CIST) but successfully treated with adalimumab (ADA). BD, which can affect vessels of any size and type, is a systemic vasculitis. In the vascular system, veins are the most predominantly affected blood vessels, with deep vein thrombosis and recurrent superficial vein thrombophlebitis being the most common vascular signs of the disease in the lower extremities. Leg ulcers, commonly associated with vasculitis or deep vein thrombosis, are rare in patients with BD. Conventional immunosuppressive therapy is very critical to prevent relapses and diminish the risk of post-thrombotic syndrome. In patients with BD-associated venous thrombosis (deep vein thrombosis or superficial vein thrombophlebitis) resistant to these treatments, tumour necrosis factor-α inhibitors can be used alone or in combination with traditional disease-modifying antirheumatic drugs. In view of such information, add-on adalimumab treatment was considered appropriate for both patients. Response to this intervention was highly satisfying for the patients at the end of the 6-month treatment. Nonetheless, it warrants further studies directly evaluating the efficacy of tumour necrosis factor-α inhibitors alone in leg ulcers in BD.

Skin Cancer Associated With Chronic Leg Ulcers in the Population of Olmsted County, Minnesota.

Malignant skin tumors in the setting of chronic leg ulcers (CLUs) are often underdiagnosed which may contribute to treatment delay and poor outcomes. The aims of our study were to determine the incidence and clinical characteristics of skin cancers in leg ulcers in the Olmsted County population from 1995 to 2020. We used the Rochester Epidemiology Project (a collaboration between health care providers) infrastructure to describe this epidemiology, allowing "population-based" research. Electronic medical records of adult patients with International Classification of Diseases diagnosis codes for leg ulcers and skin cancers on the legs were queried. Thirty-seven individuals with skin cancers in nonhealing ulcers were identified. The cumulative incidence of skin cancer over the 25-year period was 37:7864 (0.47%). The overall incidence rate was 470 per 100,000 patients. Eleven (29.7%) men and 26 (70.3%) women were identified with mean age of 77 years. History of venous insufficiency was present in 30 (81.1%) patients and diabetes in 13 (35.1%) patients. Clinical characteristics of CLU with skin cancer included abnormal granulation tissue in 36 (94.7%) and irregular borders in 35 (94.6%) cases. Skin cancers among CLUs included 17 (41.5%) basal cell carcinomas, 17 (41.5%) squamous cell carcinomas, 2 (4.9%) melanomas, 2 (4.9%) porocarcinomas, 1 (2.4%) basosquamous cell carcinoma, and 1 (2.4%) eccrine adenocarcinoma. The apparent association between chronic wounds and subsequent biopsy-proven skin cancer of the same site was primarily observed in elderly patients; malignant transformation of wounds favored basal cell carcinoma and squamous cell carcinoma. This retrospective cohort study further characterizes the association between skin cancers and chronic leg wounds.

The role of venous intervention for the treatment of patients with venous leg ulceration.

More than 1 million people are estimated to have lower limb venous ulceration in the UK. Such wounds are predominantly caused by sustained venous hypertension, as a result of chronic venous insufficiency, often due to venous valve incompetence or an impaired calf muscle pump. Compression therapy is key to venous leg ulcer management and the majority of nurses are aware of the importance of starting patients on compression therapy as early as possible. However, there appears to be a lack of awareness of the importance of venous assessment and that more patients could benefit from endovenous correction of superficial venous incompetence.

What Is the Role of Allergic Contact Dermatitis in Patients with Lower Leg Ulcers?

GENERAL PURPOSE: To analyze the relationship between contact dermatitis and delayed wound healing, discuss the diagnosis and treatment of lower leg contact dermatitis, and provide an algorithm for the patient with a red leg and delayed wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Describe the nature of contact dermatitis.2. Distinguish between allergic and irritant contact dermatitis and the other major differential diagnoses of delayed wound healing in this clinical scenario.3. Outline the steps in the diagnosis of allergic contact dermatitis and irritant contact dermatitis and identify common haptens responsible for allergic contact dermatitis in patients with venous leg ulcers.4. Apply the algorithm for delayed wound healing on a background of lower leg dermatitis.

Lower leg ulcers are a common clinical presentation to wound care clinics. They are often associated with the presence of dermatitis on the periwound skin, which can be a factor in delayed wound healing. Correctly diagnosing the underlying etiology is critical to reversing the breakdown in the skin barrier function. The author discusses allergic contact dermatitis as an etiology and describes the most common allergens, fragrances, and preservatives identified from a limited literature review. Patch testing is the criterion standard for the diagnosis of allergic contact dermatitis and is the most appropriate means of identifying causative allergens. An algorithm for the identification and treatment of lower leg dermatitis is provided to simplify the process.