Donning devices significantly improve the ability of elderly patients with CVI to don compression stockings successfully. However, there are differences in user-friendliness among the devices..

Background: Approximately 20% of leg ulcers remain unresponsive to the best conservative standard of care. So far, these patients could either receive conventional skin grafts or had to accept their intractable wound. Skin substitutes from cell culture may represent a promising alternative to heal a major part of these patients on a non-surgical, potentially more cost-effective basis. Objective: To systematically evaluate the first 68 patients treated in Switzerland (Swiss EpiDex® field trial 2004–2008). Methods: Retrospective study on EpiDex treatment of a complete consecutive series of 68 patients with chronic wounds (66 chronic leg ulcers, 2 sores) unresponsive to best conservative standard of care. The primary end point was complete wound closure within 9 months after transplantation, the secondary end points change of wound surface area, pain reduction and overall judgement by the patient. Adverse effects were infection, dermatitis and others. Calculation of treatment costs was made. Results: By the end of the study, 50/68 (74%) of patients had their wound completely healed [venous 29/37 (78%); mixed 7/9 (78%); others 14/22 (64%)]; 10/68 (15%) had the wound surface area reduced by >50%, and 8/68 (12%) did not respond to the EpiDex treatment. Wound pain disappeared completely in 78% and partially in 13%. Fifteen patients (22%) received antibiotics for wound infection, and 2 (3%) developed dermatitis (not related to the local therapy). Average treatment costs for venous ulcers amounted to EUR 5,357, compared to EUR 5,722–8,622 reimbursed according to the German DRG system (2010) for an in-patient skin graft. Conclusion: EpiDex may effectively heal up to three quarters of recalcitrant chronic leg ulcers. Thus, it represents an intermediate step to avoid costly in-patient split-skin mesh graft treatments. Patients remain mobilized, and a donor site is avoided. Large wound size or a necrotic wound bed limit the use of EpiDex. Otherwise, it offers the opportunity to avoid conventional skin grafts in a significant number of chronic leg ulcer patients.

A clinical model to examine the hypothesis that venous hypertension of the lower leg per se can cause lower leg stasis dermatitis is described. To prove this concept, we retrospectively studied a consecutive series of 38 patients with lower leg dermatitis who underwent phlebological examination at our consultation over a period of four years. Among those patients who had an insufficiency of the superficial veins only, without insufficiency of the deep veins, 22 had undergone patch testing to common allergens in phlebology. We found 10 patients with a stasis dermatitis of the lower leg and an incompetent great saphenous vein, six of whom had no detectable contact sensitization at all and another four exclusively to phlebologically irrelevant substances, e.g. nickel, cobalt, chromate or epoxid resin. All these 10 patients showed long saphenous vein incompetence from the groin to the medial aspect of the leg. All were operated by classical flush ligation and saphenectomy. Lower leg dermatitis healed in all 10 patients within 8-12 weeks and no recurrence was observed (1 year follow-up). These results support clinical experience that venous hypertension alone indeed can cause lower leg dermatitis.

Abstract. In the present study we were interested, if apoptosis plays a role in the surrounding skin of venous ulcers, where microcirculatory disorders were already observed. For this purpose laser Doppler flow and partial oxygen pressure were measured in 17 patients at the ulcer edge, the transitional area of the lower leg and the thigh. Subsequently biopsies were taken from the respective sites and subjected to terminal deoxynucleotidyl transferase labelling (TUNEL) and immunohistochemistry using antibodies to determine the protein expression of Fas, Fas-L, Bax, Bcl-2, p53 and c-Myc. Laser Doppler flow was increased and transcutaneous oxygen partial pressure was decreased, with significant differences at the ulcer edge and the lower leg compared to the thigh. The skin biopsies did not show any differences when labelling for apoptotic cells. Keratinocytes of basal and spinous layer stained with antibodies against Fas, Fas-L and Bax in all probes of the three sites. c-Myc and p53 were negative in all keratinocytes of the skin probes. However, staining with Bcl-2 was significantly decreased at the ulcer edge in comparison to the lower leg and the thigh (p=0.017). Our study revealed that a disturbed microcirculation does not increase the number of apoptotic cells at the ulcer edge in patients with venous disease. The reduced staining pattern with Bcl-2 at the ulcer edge seems not to result in higher susceptibility to apoptosis, but it remains to be proven whether it is involved in epidermal acanthosis.

We investigated in patients with chronic venous insufficiency (CVI) and after compression therapy the fluxmotion within characteristic frequency bands, which were described earlier by Bračič and Stefanovska (Bull. Math. Biol. 60 (1998), 919-935).Therefore, the frequency spectra of laser Doppler flux data of the 36 patient's legs were compared with 41 legs of healthy subjects. In addition, 14 patients with CVI wore a compression stocking (interface pressure: 25-32 mmHg) or compression bandages and were measured after 4 weeks therapy. Data were analyzed by means of a Wavelet packet transformation (a combination of the Daubechies filter of order 4 and the Haar filter).We found significant differences between the patients and the healthy subjects in the frequency intervals of myogenic 0.06-0.16 Hz, respiratory 0.16-0.6 Hz and heart activity 0.6-1.6 Hz (p < 0.05, Mann-Whitney U test). Furthermore, the main energy peak height in these frequency intervals increased with the severity of venous disease and was highest in patients with venous leg ulceration. Compression therapy had a significant influence in myogenic vessel activity, which has been proved by a positive frequency shift of 20% (p = 0.007, one-sided by the exact Wilcoxon test).In venous disease fluxmotion was increased. Compression therapy over a period of 4 weeks improved myogenic vessel activity.