Asha R. Patel

Venous ulcers: A reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function

Chronic venous insufficiency is a complex disease that can result in severe sequelae including venous ulceration. Though the exact progression from chronic venous insufficiency to venous ulcer remains unclear, the high cost and burden of this disease on patients and society is quite clear. Sustained ambulatory venous pressures or venous hypertension plays an integral role in the development of venous ulceration and involves the failure of the calf muscle pump system. Standard of care involves compression therapy to assist the calf muscle pump. However, several cofactors may contribute to or exacerbate this disease and understanding their impact may provide insight into new treatment modalities. Nerve involvement, which may result in neuropathic pain and muscle dysfunction, alterations in mobility and a decrease in range of motion may lead to gait alterations all affecting calf muscle pump function. In this paper, we analyze these cofactors and discuss possible treatment options to target them. Physicians treating this disease should be aware of the numerous factors involved in its development. Exploring new treatment options may 1 day lessen the burden and suffering caused by venous insufficiency.

Herpes simplex virus: A histopathologic study of the depth of herpetic wounds

Background  Herpes is a prevalent, infectious disease that can occur anywhere on the body; it is found primarily on the face and genitalia. Herpes simplex virus type 1 (HSV‐1) and herpes simplex virus type 2 (HSV‐2) are the DNA viruses that cause human herpes. Clinically, HSV‐1 and HSV‐2 infections produce lesions generally located on the mucocutaneous junctions of the face and genitalia. At times, vesicular lesions may ulcerate, leaving recalcitrant wounds that are challenging to treat. Until now, the basis of treatment has been related to the eradication of the viral infection. Little attention has focused on the consequence of the viral infection and the resulting wounds, specifically whether this represents an epidermal or dermal injury.

The isomorphic response in morphealike chronic graft-vs-host disease.

The isomorphic response of Koebner, also known as the Koebner phenomenon, is a well-recognized dermatologic manifestation first described in psoriasis. The isomorphic response occurs when a dermatologic disease develops at a site of normal-appearing skin that is injured in some manner.1 Chronic graft-versus-host disease (cGvHD) is a multisystem disorder that commonly affects the skin and may present with protean manifestations. Sclerotic cGvHD features are categorized as lichen sclerosus-like, morphea-like, or sclerosis involving the subcutaneous tissue and fascia.2 Morphea-like lesions of cGvHD are characterized by localized dyspigmented indurated plaques of skin thickening.

Treatment of herpes simplex virus infection: rationale for occlusion.

Orofacial herpes is a widespread benign malady that is also commonly known as herpes labialis or cold sores. Herpes of this type is generally caused by herpes simplex virus type 1 (HSV-1) and, to a lesser degree, herpes simplex virus type 2 (HSV-2), both of which are DNA viruses. The clinical presentation of herpetic lesions is normally located on mucocutaneous areas of the face and may eventually erode and ulcerate, leaving wounds that are known to be difficult to successfully treat. Focus of treatment has been related to treatment of the viral infection, and limited attention has focused on the resultant wounds. Clinical observation and recent histologic evaluation has demonstrated these wounds to extend through a disrupted cutaneous basement membrane into the dermis, suggesting that HSV is capable of causing partial-thickness wounds. This observation suggests a role for occlusion in the treatment of herpetic-induced partial-thickness wounds because occlusion is well recognized as the treatment of choice for other types of partial-thickness wounds.

Neuropathy and Gait Disturbances in Patients With Venous Disease: A Pilot Study

Methods. After institutional review board approval and informed consent, 10 patients with active noninfected venous ulcers or a history of such ulcers (CEAP [ClinicalEtiologic-Anatomic-Pathophysiologic] clinical classification 5 or 6) were recruited. No recruited patient had a history of neuropathy or predisposing conditions for neuropathy. Ten age-, sex-, and weight-matched control patients without diabetes or venous disease were also recruited from the same population. All patients had good arterial circulation and walked without assistance. A medical history was obtained and foot, leg, and ulcer examinations were performed on all patients. To evaluate symptoms of peripheral sensory neuropathy, the validated neuropathy symptom score (NSS) was determined. To measure quantitative objective neuropathic changes, we performed quantitative sensory testing of the feet using the validated neuropathy disability score (NDS). As part of the NDS, we used a 10-g monofilament to perform sensory testing of the feet at 6 sites. Vibration perception threshold testing was performed using a biothesiometer and a 128-Hz tuning fork. Temperature discrimination and Achilles reflex were also tested. Gait was analyzed by evaluating pedal pressures using the Novel Emed program and device (Novel Electronics Inc, Minneapolis, Minnesota), an electronic measurement system used to evaluate dynamic pressure distributions. This device uses calibrated capacitive sensors beneath a mat connected to a computer to analyze pedal pressures as subjects walk across the mat barefoot. Overall pressure for each patient was measured in kilopascals (kPa), as were localized pressures in 5 locations on each foot.

Clinical pearl: the evaluation of the surface area of small pigmented lesions

The ability to calculate the surface area of small pigmented lesions is an important assessment tool, especially if one is suspicious for malignancy. Calculation of the surface area can be an arduous task if one does not have a standard technique. This article is in regards to the inexpensive and relatively easy technique of calculating the surface area of small pigmented lesions. This technique is a unique method, not described in the literature before, and may be utilized by any dermatologist at any level of experience. Our method is presented because the calculation of small pigmented lesions is an important tool to utilize, especially in cases of skin carcinoma. This technique can also be modified to calculate the surface area of much larger lesions and therefore may have a broad clinical application in the field of dermatology and cutaneous surgery.