Nicholas A. Richmond

Evidence-based management of common chronic lower extremity ulcers

Chronic lower extremity ulcers are a significant burden on patients and health care systems worldwide. Although relatively common, these wounds can be difficult to treat and present a challenge to physicians. Treatment has often been based on anecdotal accounts; however, there is a growing emphasis on using evidence‐based conclusions to guide clinical decisions. In this review article, the standard of care and adjuvant therapies of venous leg ulcers and diabetic foot ulcers are presented from an evidence‐based perspective.

Epidermal Grafting Using a Novel Suction Blister–Harvesting System for the Treatment of Pyoderma Gangrenosum

Patient 1 A woman in her 40s without other significant medical history presented in 2013with an 8-month history of an exquisitely painful ulcer on thedistal left lateral leg. Shenoted that the lesionbeganas “a small red bump” that she believedtobean insectbite.Aphysician at another institutionperformedan incision anddrainage to treat a suspected abscess andprescribedoral antibiotics, but the lesiondeteriorated. Abiopsyperformed in 2012hadnonspecific results and Gram, acid-fast, and Fite stains were negative for organisms. Venous and arterial insufficiencywere excludedby lower limb duplexultrasound.She receivedadiagnosisofpyodermagangrenosum(PG)andwasprescribedprednisone60mgdailyandtopical clobetasol propionate ointment, 0.05%, to the wound edges. On referral,physicalexaminationrevealedasharplydemarcatedulcerwith purple undermined borders, consistent with the PG diagnosis. The prednisonedosagewas taperedbecauseof adverse effects, and cyclosporine 400 mg daily and weekly leg compression were initiated. Although the inflamed undermined borders improved, the wound failed to reduce in size after 2months of therapy (Figure 1).

US-National Institutes of Health-funded research for cutaneous wounds in 2012.

Chronic cutaneous wounds are a major burden on patients, healthcare providers, and the US healthcare system. This study, carried out in part by the Wound Healing Societys Government Regulatory Committee, aimed to evaluate the current state of National Institutes of Health funding of cutaneous wound healing–related research projects. National Institutes of Health Research Portfolio Online Reporting Tools Expenditures & Results system was used to identify wound healing projects funded by the National Institutes of Health in the 2012 fiscal year. Research projects focusing on cutaneous wound prevention/education, mechanisms, complications, treatment, or imaging/monitoring were included in the analysis. Ninety‐one projects were identified, totaling a collective funding of

Topical Timolol for Recalcitrant Wounds

29,798,991 and median funding of

The effect of ankle range of motion on venous ulcer healing rates

308,941. Thirteen institutes/centers from the National Institutes of Health were responsible for awarding funds; three of which (National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of General Medical Sciences, National Institute of Diabetes and Digestive and Kidney Diseases) accounted for 60.4% of the grant funding. The predominant funding mechanisms included R01 (48.3%), R43 (14.3%), and R21 (9.9%). New applications and pre‐existing applications accounted for 39.6 and 55.0% of the awarded grants, respectively. Grants awarded to investigators affiliated with universities accounted for 68.1% of grants and 25.3% were to investigators in the private sector. This analysis of current National Institutes of Health funding may facilitate more transparency of National Institutes of Health‐allocated research funds and serve as an impetus to procure additional support for the field of wound healing.

Topical and Biologic Therapies for Diabetic Foot Ulcers

Patient 1 A woman in her 80s with a history of venous insufficiency based on clinical presentation and vascular studies presentedwithmultiplepainfululcerationsonthebilateral ankles. She developed wounds in 1972 with subsequent trauma that led to repetitive skin breakdown.Her currentwounds began 1 year ago. The patient was initially treated with multilayered elastic compression bandages (Profore; Smith & Nephew), which were changed weekly, and various foam dressings (Allevyn; Smith & Nephew; Mepilex Ag; Molnlycke Health Care).When herwound failed to heal, adjuvant therapies, including serial applications of porcine small intestine submucosa (Oasis;HealthpointBiotherapeutics), bilayered living skin equivalent (Apligraf; Organogenesis) and an autologous splitthickness graft from the thighwere used but did not result in complete closure. After 6months, thewoundwas 3.2 cm2 and a β2-adrenergic receptor (B2AR) antagonist, topical timolol, 0.5% (Timoptic;AtonPharma),was instilled, 1dropevery2 cm of wound edge weekly, then covered with silicone foam and 3-layer compression. All wounds, including her target ulcer, were fully epithelialized after 8 weeks of treatment, and the patient was prescribed a compression apparatus (JuxtaCure; CircAid Medical Products) to prevent recurrence.

Primary nonadherence (failure to obtain prescribed medicines) among dermatology patients

Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose‐finding study of an allogeneic living cell bioformulation. Two hundred twenty‐seven patients were enrolled in four active treatment groups and one standard‐care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.

Educational interventions in venous leg ulcer patients

Chronic DFUs are a growing global health concern due to the implied high rates of morbidity and mortality. Standard-of-care modalities sometimes are not sufficient for some recalcitrant ulcers. The use of adjuvant topical therapies including advanced dressings and biologic therapies should be considered in patients whose DFU did not reduce in size after receiving standard care for a period of 4 weeks. These advanced treatments must be used in combination with standard care measures, including debridement, moist wound healing, offloading, and infection control.

Rapamycin for refractory discoid lupus erythematosus

intraepidermal neutrophilic dermatosis-type IgA pemphigus (IEN-type) and the remaining 8 had the subcorneal pustular dermatosis-type IgA pemphigus (SPD-type). The aim of this study focused the IgA pemphigus therapeutic approach, with a follow-up length from 1 to 12 years (mean 3.8 years). The following treatments were used: dapsone, colchicine, prednisone, acitretin, isotretinoin, tetracycline, sulfamethoxazole/trimethoprim, methotrexate, cyclosporine, adalimumab, sulfamethoxypyridazine, azathioprine, and PUVA. Dapsone was used as a first line therapy (25 to 125 mg/day) in 6 patients. One patient with IEN-type disease was in complete remission off therapy. Two patients with SPD-type disease had a partial response. Three of 9 patients had side effects (methemoglobinemia and hemolysis) of dapsone therapy, and withdrawal of medication was necessary. Another 2 of 9 patients showed no response to any of the proposed therapies. Five of 9 patients were treated with colchicine (0.5 to 2 g/day): 4 had no response and 1 was lost to follow-up. Four of 9 patients received prednisone (0.5 to 1.5 mg/kg/day): 3 had no response with medication withdrawal, and 1 patient stayed in partial remission on therapy. Two of 9 patients were treated with tetracycline (1 to 2 g/day): acute urticaria developed in 1 patient, and 1 showed no response to treatment. Two of 9 patients were unresponsive to treatment and so were treated with multiple drugs. The condition of 1 of these patients stabilized in partial remission with adalimumab 40 mg biweekly, and she is currently receiving 40 mg bimonthly, 1 year after treatment was initiated, without any side effect so far. This was the most recalcitrant IgA pemphigus case of our series, with the patient showing no response to 10 therapeutic options over 6 years. The other patient had a severe form of the disease and received acitretin 30 mg/day after undergoing a hysterectomy for postpartum hemorrhage. This patient had a very good response and no longer required frequent hospitalization. Although her case is classified as a partial remission on therapy, acitretin exerted a great impact on her quality of life. Five patients were in partial remission on therapy, 1 patient was lost to follow-up, and 2 patients died of unrelated causes. The only patient who had complete remission off therapy was the patient with IEN-type disease. A review of 49 patients of both subtypes of IgA pemphigus suggests that those with IEN-type showed a better response to treatment, in comparison to SPD-type. Our experience was limited to one IEN-type patient, and therefore we could not conclude that IENor SPD-type showed different responses to treatment. So far, there is no consensus on IgA pemphigus treatment. Our results confirmed the recalcitrant nature of IgA pemphigus in response to distinct therapies, indicating that further research focusing on therapeutic approaches for this group of IgA diseases is needed.

The Characterization of Indoor Tanning Facilities in Florida

To the Editor: Venous leg ulcers (VLUs) are the most common type of lower extremity ulceration, with an estimated prevalence of 2% of the US population. VLUs impose a physical and emotional toll on patients, as well as a significant societal burden, with an annual cost of