Birgit Heinig

Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment

Acne inversa (AI) is a disabilitating chronic inflammatory disease with major negative impact on quality of life and significant co-morbidities. This is an important link to insights into immune dysfunction, which stimulated therapeutic approaches like tumor necrosis-α inhibitor therapy. This new off-label drug treatment is particularly beneficial when used in combination with wide excision of inflamed skin and subcutaneous tissue. Retinoids have been reported to be helpful in secondary prevention. The standard of therapy in advanced cases is surgery with wide excisions and healing by secondary intention. This treatment results in significant reduction of complaints and achieves satisfactory body contouring.

Therapeutic Ultrasound in Lower Extremity Wound Management

In medical practice, ultrasound (US) is used for diagnosis and therapy. High-frequency (1-4 MHz) and low-frequency (20-120 KHz) therapeutic US are relevant to wound healing. The heating effects of high-frequency US are important, whereas the mechanical effects of low-frequency US must be considered. The physiological effects of low-frequency US include metabolic enhancement, perfusion, wound cleansing, and the acceleration of wound granulation. The therapeutic efficacy of US depends on dose (W/cm 2 time)and dosage (frequency of application, series). At adequate doses, high-frequency and low-frequency therapeutic US induce in vitro cell proliferation; protein synthesis; and the production of cytokines by fibroblasts, osteoblasts, and monocytes. The mechanical effects of low-frequency US cause transient cavitation in wound surfaces for soft and smooth wound cleaning, ulcer debridement, and the stimulation of granulation. These effects can be determined in clinical studies, though the quality of the studies done so far and of the evidence of the usefulness of US is poor. Nevertheless, high-frequency and low-frequency US may be reasonable options in the management of chronic wounds.

Management of Severe Anogenital Acne Inversa (Hidradenitis Suppurativa)

BACKGROUND Severe anogenital acne inversa (AI) is a debilitating chronic inflammatory disease with a major negative effect on quality of life. OBJECTIVES To evaluate the role of surgery in the treatment of severe anogenital AI. METHODS We analyzed the records of patients with anogenital AI from 2000 to 2010. Assessment was done using the Hidradenitis Suppurativa Lesion, Area, and Severity Index (HS‐LASI), pain visual analogue scale, physician global assessment (PhGA), and patient global assessment (PaGA). Comorbidities and adverse events were analyzed. RESULTS Sixty‐seven patients with a Hurley score of 3 were identified. Mean follow‐up was 56.9 ± 41.3 months. A number of comorbidities were observed. After surgery, mean pain scores decreased from 6.3 ± 1.5 to 0.8 ± 0.7, PhGA improved from 6.8 ± 1.2 to 0.9 ± 0.6, PaGA improved from 7.3 ± 1.2 to 1.1 ± 0.5, and HS‐LASI decreased from 41.8 ± 21.3 to 2.4 ± 2.8. Adverse reactions were seen in 10.4%. The total relapse rate was 6% (5 patients) with only one case with healing by secondary intention (2% of 49 patients). CONCLUSIONS Surgery is the cornerstone of treatment for advanced AI. Healing by secondary intention results in significant reduction of complaints and achieves satisfying body contouring.

Transdermal CO2 Application in Chronic Wounds

Chronic wounds are a challenge to treatment. In this retrospective study, the effect of transdermal CO2 application on wound healing in chronic ulcers was investigated and compared to the effect of CO2 on acute surgical wounds. Eightysix patients (52 females and 34 males) with chronic wounds of different origin except arterial occlusive disease were included. In addition, 17 patients (5 females, 12 males) with wide excision wounds after surgical therapy of acne inversa were considered. The indication for CO2 application was a wound at risk for infection. Treatment was performed with a Carboflow® device once daily for 30 to 60minutes. Therewas clinical evidence of improvement of granulation and reductionof discharge and malodor within 1 week of treatment in both chronic and acute wounds. Only 9 patients, all diabetics, needed an additional systemic antibiosis. The treatment was well tolerated. No adverse effects have been noted. Transdermal CO2 application is a useful method to reduce the risk of infection and improve wound healing in both chronic and certain acute wounds. Systematic prospective trials are needed.

Treatment of elderly patients with advanced lipedema: a combination of laser-assisted liposuction, medial thigh lift, and lower partial abdominoplasty

Background Lipedema is a rare female disorder with a characteristic distribution of adipose tissue hypertrophy on the extremities, with pain and bruising. In advanced stages, reduction of adipose tissue is the only available effective treatment. In elderly patients with advanced lipedema, correction of increased skin laxity has to be considered for an optimal outcome. Methods We report on a tailored combined approach to improve advanced lipedema in elderly females with multiple comorbidities. Microcannular laser-assisted liposuction of the upper legs and knees is performed under tumescent anesthesia. Medial thigh lift and partial lower abdominoplasty with minimal undermining are used to correct skin laxity and prevent intertrigo. Postsurgical care with nonelastic flat knitted compression garments and manual lymph drainage are used. Results We report on three women aged 55–77 years with advanced lipedema of the legs and multiple comorbidities. Using this step-by-step approach, a short operation time and early mobilization were possible. Minor adverse effects were temporary methemoglobinemia after tumescent anesthesia and postsurgical pain. No severe adverse effects were seen. Patient satisfaction was high. Conclusion A tailored approach may be useful in advanced lipedema and is applicable even in elderly patients with multiple comorbidities.

Classification of vascular disorders in the skin and selected data on new evaluation and treatment

Cutaneous vascular disorders are common. They include arteries, veins, and lymphatic vessels, or a mixture of them. In this review, we discuss classification, new developments in understanding and treatment of vascular diseases. We focus on infantile hemangiomas and drug therapy, vasculitides with new vasculitic syndromes, yellow nail syndrome and localized lymphatic malformations. Benign cutaneous vascular lesions may be a sign of severe internal diseases. In many cases multidisciplinary treatment is important. The dermatologist can often act as a pilot for these patients.

Effects of low-frequency ultrasound on microcirculation in venous leg ulcers.

Background: Therapeutic low-frequency ultrasound (US) has been used for many years to improve wound healing in chronic wounds like venous leg ulcers. No human data are available for the possible effects of single US applications on microcirculation and their frequency-dependency. Aims: To investigated the role of therapeutic low-frequency US on microcirculation of venous leg ulcers in vivo. Patients and Methods: This is a pilot study on an inpatient basis. We use a newly developed low-frequency continuous-wave US-equipment composed of a US transducer based on piezo-fiber composites that allow the change of frequency. In this study, we apply US of 34 kHz, 53.5 kHz, and 75 kHz respectively. Twelve patients with chronic venous leg ulcers are analyzed. As an adjunct to good ulcer care, therapeutic US is applied, non-contacting, once a day, in a subaqual position for 10 minutes. Microcirculation is assessed in the ulcers adjacent to skin before US-therapy, immediately after the treatment and 30 minutes later. We use a micro-light guide spectrophotometer (O2C, LEA Medizintechnik GmbH, Gieίen, Germany) for calculation of blood flow velocity, hemoglobin oxygen saturation (SCO2) and relative hemoglobin concentration (rHb) in 2 and 8 mm depth. Contact-free remission spectroscopy (SkinREM3, Color Control Chemnitz GmbH, Chemnitz, Germany) allows contact free measurements in the VIS-NIR range of the spectrum (400 ± 1600 nm). Results: It is seen that therapeutic US is well tolerated. One patient dropped out from a treatment series since he developed erysipelas responding to standard antibiotic. Effects were seen at 34 kHz only. The SO2 values increased after single US application. The values for rHb were higher in the superficial layer of the wound bed (depth 2 mm) compared to deeper parts (8 mm depth). US treatment did not result in significant changes of rHb and blood cell velocity. The data obtained by remission spectroscopy disclose an increase of oxygenized hemoglobin. Conclusions: The major findings are that continuous-wave low-frequency US of 34 kHz, but not, 53.5 kHz or 75 kHz, has a temporary stimulatory effect on microcirculation mainly due to an improved oxygenation. Further studies with treatment series are necessary.

Madelung’s Disease – Case Series and Treatment by Tumescent Liposuction or Lipectomy

Madelung disease is a disfiguring disorder belonging to the heterogeneous group of lipomatosis. The aetiology is not well understood, but alcohol consumption has been regarded as of importance. The reported incidence is about 1 in 25,000 inhabitants. We reviewed our files of the last ten years and identified eight adult patients with an equal gender distribution. Their age was between 60 and 85 years of life. Comorbidities are frequent. Clinical presentation may vary. Surgical treatment is reported and discussed. Both cold steel surgery and tumescent liposuction have their place in treatment.

The Use of Biophysical Technologies in Chronic Wound Management

Wound healing is a complex biological response of cells and tissues. In this chapter we will focus on physical therapies used to support the debridement, local perfusion, bacterial growth control, granulation and epithelialization of wounds, in particular of chronic wounds like leg ulcers or pressure ulcers, and the diabetic foot syndrome. Therapeutic ultrasound does not only improve debridement but microcirculation and granulation. More recently, shock waves have been used in topical wound therapy as well. Topical negative pressure has been investigated in acute and chronic full-thickness wounds. The method can also be used to ensure skin transplant take. Infrared light has been used to control colonization of chronic wounds among other effects. The role of light an lasers is increasing, with low-level laser treatment more commonly used in practice. Among the electrotherapies both inductively and conductively coupled methods will be discussed. Biological effects can be generated using either direct current, alternating current or pulsed current. Although physical therapies have a longer tradition in wound treatment, the level of evidence often is low and larger placebo controlled or comparative trials are the exception. Our current understanding of the role of physical therapy in wound management is the adjuvant use of such techniques in individualized treatment protocols.

Surgery in Congential Lymphedema: A Follow-Up of 50 Years

Surgical methods have been widely used in the past to treat patients with congential lymphedema. There are only scant data in recent literature about the long-term outcome of these mostly historical methods. On the other hand, the subject is not only of interest to those concerned with the history of medicine but also may raise a couple of questions about treating such patients today. The authors report on a 77-year-old female patient with congential lymphedema with a 50-year follow-up after lymphedema resection and focus on practical problems of bandaging today.