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The socioeconomic significance of chronic venous leg ulcers is considerable due to the high number of patients, the costs of diagnosis and therapy, the deterioration in quality of life, and the loss of working capacity during the disease. This is further increased by a progressive course and an increased tendency to recurrence. Taking these facts into account, surgical treatment options are of particular importance, especially in otherwise therapy-refractory courses. For this purpose, an extensive spectrum of surgical and new, partly not yet finally evaluated, invasive techniques are now available. Venous surgery and endovenous closure techniques are suitable for eliminating primary or secondary varicosis as a causal therapy for venous leg ulcers. Shave therapy is the method of choice in the presence of dermatolipo(fascio)sclerosis. Current long-term results show good results with cure rates of 70-80%. In individual cases, surgical techniques involving fascia cruris (faciotomy, fasciotomy) can also be used. Recurrence ulcers can often be successfully treated by repeated shave therapy, optionally with simultaneous vacuum-assisted dressing techniques or by a fasciotomy. In addition, local invasive techniques such as autologous fat tissue transplantation or autologous platelet-rich plasma can be used to promote wound healing. Thus, both surgically invasive local therapy and advanced surgery of the causes of chronic venous leg ulcers play a key role in the overall therapy concept.

Purpose: Chronic leg ulcers can be a challenge to treat and long-term therapy a significant cost factor in western public health budgets. Objective wound assessment assays enabling selection of appropriate wound therapy regimes would be desirable. Oxygenation status in ulcer tissue has obtained increased attention as a relevant factor in wound healing. To increase oxygenation in wounds, a topical hemoglobin spray was developed. Although favorable results have been noted, the link between clinical efficacy and the mode of action has not been demonstrated. The aims were to determine if changes in tissue oxygenation can be measured after topical application of hemoglobin on chronic wounds and to evaluate the findings in terms of therapy strategies., Procedures: Photoacoustic imaging was used to measure the local oxygen saturation (StO 2 ) in leg ulcers before and after hemoglobin spray treatment. Sclerosis of the leg ulcers was histopathologically graded and the change in wound size was documented in a follow-up examination., Results: Measuring 49 patients, an increase in StO 2 after topical hemoglobin application from on average 66.1 to 71 % (p = 0.017) after 20 min was observed. Depending on the increase in StO 2 (>10 % or <10 %) patients were stratified into a Responder and a Non-Responder group. Wound size significantly decreased in the Responder Group (p = 0.001), while no significant difference in the Non-Responder group (p = 0.950) was noted., Conclusion: Our findings suggest that the likelihood of wound healing under conservative therapy can be predicted by measuring changes in StO 2 after topical hemoglobin application. This assay may reduce treatment time and costs by avoiding ineffective conservative long-term therapy., Trial Registration: German Clinical Trials Register: DRKS00005993.

Background: Necrobiosis lipoidica (NL) is a rare granulomatous inflammatory skin disease of unknown pathophysiology. Its potential association with diabetes mellitus is well known. Other relevant cofactors and comorbidities are subject to controversial debate., Patients and Methods: DRG (diagnosis-related groups) data of all inpatients with a coded primary or secondary diagnosis of NL treated at German hospitals in 2012 were evaluated., Results: Data of 262 inpatient cases with the primary or secondary diagnosis of NL were analyzed. Women (63.4%; n = 166) were nearly twice as frequently affected as men (36.2%; n = 96). Most NL patients (14.8%) were in the age group between 50 and 55 years. Among comorbidities included in the metabolic syndrome complex, diabetes mellitus was the most common (34.4%; IDDM 20.6%, NIDDM 13.8%), while essential hypertension was observed in 9.2%, obesity in 4.6%, chronic heart failure in 4.1%, and dyslipidemias in 2.3% of cases. Leg ulcers were diagnosed in 7.3% of individuals; other venous disorders, in 5.7%., Conclusions: Our data analysis describes one of the largest compilations of patient cases with the diagnosis of NL worldwide. Besides the well-known association with diabetes mellitus, there are numerous other potentially relevant cofactors and comorbidities that should be considered in the diagnosis and management of NL patients., (© 2016 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.)

Background and Objectives: Chronic wounds are colonized by many different bacteria., Patients and Methods: We analyzed microbiological swabs from chronic leg ulcers from 2012/2013 and matched the results with those from 2002/2003 and 2007/2008 from the same institution., Results: Results from 100 patients from our specialized wound care center were evaluated retrospectively. The etiologies were broadly variable with chronic venous insufficiency being the most common. As the most common bacterium Staphylococcus aureus was found in 53% of patients; 9% of patients were positive for methicillin-resistant S. aureus (MRSA). Pseudomonas aeruginosa was detected in 25% of patients. Different fecal bacteria and Enterobacteriaceae were found in 49% of the patients; 11% of the swabs were sterile. The detection rate for S. aureus has regressed by 17.1% over the past decade and in the case of MRSA by 12.5%. In contrast, colonization with gram-negative bacteria species significantly increased by 11.7%. This tendency was also seen in 2007/2008, but with a higher count of P. aeruginosa., Conclusion: Although S. aureus is still the most frequently detected bacterium in our wound care center, there has been a shift in the bacterial spectrum from gram-positive towards gram-negative bacteria over the last decade., (© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.)

Most chronic wounds are colonised with different microorganisms, especially problematic bacteria like methicillin-resistant Staphylococcus aureus (MRSA), which represent an increasing therapeutic challenge in the modern wound therapy regimen. Therefore, it is essential to specify the bacteria in wounds for an individual-specific treatment. In most patients, an exemplary bacterial swab is taken from the centre of the wound surface. This so-called Levine technique is propagated currently as the gold standard. The aim of our clinical investigation was to compare the results of different swab techniques to the new established Essen Rotary. In this monocentric prospective investigation, 50 patients with chronic leg ulcers were examined consecutively. The results of our clinical study show that bacteria are heterogeneously spread on wound surfaces. The analysis of the semiquantitative measured results showed that the Essen Rotary could detect significant more bacteria with a total amount of 111 bacteria (P = 0·049) compared to usual swab techniques. Considerably, only the Essen Rotary identified five compared to three MRSA-patients detected by other techniques. The Essen Rotary is an efficient, economic and uncomplicated modification of bacteriological swab techniques which detects significant more bacteria compared to other conventional swab techniques. Therefore, the Essen Rotary may become the new gold standard in routinely taken bacteriological swabs especially for MRSA screenings in patients with chronic leg ulcers., (© 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: In almost every chronic wound different bacteria species can be detected., Patients and Methods: Retrospective, multicenter evaluation of bacterial swab results from 2010 and 2011 in patients with chronic leg ulcer treated in 10 dermatologic wound care centers from 5 regions in Germany., Results: Data of 970 patients were analyzed. Staphylococcus aureus was detected in 47.6 % of the patients, 8.6% of these were methicillin-resistant (MRSA). Pseudomonas aeruginosa was found in 31.1 %, enterobacteria in 28.6 % and Proteus mirabilis in 13.7 % of the patients. The regional comparison showed a significant south-north gradient for S. aureus, P. aeruginosa, and enterobacteria. Moreover, a highly significant west-east gradient for MRSA was found with detection rates of 13.5 % in the west to 4.0 % in the east. Furthermore, nationally there was a significant negative correlation between S. aureus and P. aeruginosa or P. mirabilis, respectively, as well as a positive correlation of P. aeruginosa with respect to wound size and duration. In addition to climatic and therapeutic conditions, different regional health care structures are discussed as potentially relevant reasons for these significantly different regional detection rates., Conclusions: Our data show the regional variability of the spectrum of currently detected bacteria in patients with chronic leg ulcers in Germany., (© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin.)

Background: There have been reports indicating seasonal differences in the onset of chronic leg ulcers. The reasons for such seasonal fluctuations are not well understood. Therefore we decided to examine the seasonal incidence of chronic leg ulcers in our patient population, caused by chronic venous insufficiency (CVI) or mixed arterial and venous disorders, for any correlation with climatic factors., Methods: We retrospectively analysed the data of 183 patients with chronic leg ulcers, evaluated the monthly and seasonal onset of the leg ulcers and investigated correlations between the incidence and climatic factors., Results: The onset of chronic leg ulcers showed significant seasonal fluctuations with a decrease in summer and an increase in autumn-winter. The ulcer onset in the cold months, autumn and winter, was significantly higher (P = 0.026) compared with spring and summer. Furthermore, in the bivariate correlation analysis of the variables temperature and ulcer onset, there was a statistically significant negative correlation between temperature and new ulcer onset. The colder the temperature was, the higher was the new ulcer onset with a correlation coefficient of -0.613 (P = 0.034)., Conclusion: The onset of chronic leg ulcers caused by CVI and mixed arterial and venous disorders in our patient population showed significant seasonal variations and demonstrated an inverse relationship to temperature. In summary, climatic factors appear to play an important role in the onset of chronic leg ulcers. Climatic factors may therefore need consideration in future clinical investigations and in the development of prophylactic therapeutic strategies., (© 2011 The Authors. Journal of the European Academy of Dermatology and Venereology © 2011 European Academy of Dermatology and Venereology.)

Background: The approach to patients with chronic leg ulcers should include not only an accurate diagnosis with appropriate therapy fort he underlying disease, but also the development of effective analgesia. To assess the analgesic effect of topical morphine, we developed a new morphine gel with polihexanide as a preservative for the local pain treatment., Patients and Methods: We have studied 30 patients with painful chronic leg ulcers with an average age of 66 years. The respective pain intensity was assessed 24 hours after application of the morphine hydrogel and objectified with a visual analogue scale (VAS) ranged from 0 to 10., Results: All investigated patients had a pain intensity of at least 4 points before the topical application of the morphine gel; the average pain intensity was 7.8. After application of the morphine gel, a significant reduction of the average pain intensity was observed, with an average pain intensity of 4.5., Conclusion: These first clinical results with the new morphine gel suggest that at least fort he first 24 hours it combines the advantages of a moist wound healing and a local pain treatment. This new development is certainly a promising therapeutic alternative for pain treatment in patients with chronic leg ulcers.

Background: The etiology of chronic leg ulcers is heterogenous and they exhibit quite different healing rates depending on the underlying cause. Although the prevalence and incidence of chronic leg ulcers appear to be increasing, data on these patients in Germany are lacking., Patients and Methods: Altogether 100 German wound care professionals were asked to complete a questionnaire regarding the diagnosis and etiology of their patients with chronic leg ulcers., Results: We received the data on 31,619 patients. In these patients, venous insufficiency was the dominating causative factor in 47.6 % and arterial insufficiency in 14.5 %, 17.6 % of ulcers were due to combined arterial and venous insufficiency. Rarer causes included vasculitis (5.1 %), exogenous factors (3.8 %), pyoderma gangrenosum (3.0 %), infection (1.4 %), neoplasia (1.1 %), calciphylaxis (1.1 %) and drug-induced (1.1 %). The used diagnostic methods used varied widely between the medical and surgical specialties., Conclusions: Even though the results of our study cannot claim to be a representative overview, they demonstrate clearly that next to known etiologies, e. g. chronic venous insufficiency or peripheral arterial insufficiency, which are relevant in 79.7 % of all patients a multitude of other causes exist, which are responsible in 20.3 % of all patients for the development of chronic leg ulcers., (© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin.)

Background: In nearly every chronic wound different bacteria species can be detected. Nevertheless, the presence of such microorganisms is not necessarily obligatory associated with a delayed wound healing. But from this initially unproblematic colonization an infection up to a sepsis can arise in some patients. The aim of our clinical investigation was to analyse the spectrum of microbial colonization of patients with a chronic leg ulcer in our specialized dermatological outpatient wound clinic, and to compare them with the results of comparable data already collected 5 years ago., Objectives: In our retrospective investigation the results of bacteriological swabs were documented in 100 patients with a total of 107 chronic leg ulcers. All patients visited the specialized wound outpatient clinic, Department of Dermatology, University of Essen in Germany., Methods: A total of 60 patients were female, 40 were male. The mean age was 65 years. Altogether a total of 191 bacterial isolates and 25 different bacterial species could be identified., Results: The most often detected species were Staphylococcus aureus (n = 60), Pseudomonas aeruginosa (n = 36) as well as Proteus mirabilis (n = 17). In 10 patients (10%) we identified a colonization with methicillin resistant S. aureus (MRSA). Merely in 6 patients the taken swabs were sterile. Five years ago a comparable investigation was already carried out in our wound outpatient clinic. At that time we could detect in particular more frequent MRSA (21.5% vs. 10%) and rarely P. aeruginosa (24.1% vs. 33.6%)., Conclusion: The results of our investigation demonstrate the current spectrum of the bacterial colonization in patients with chronic leg ulcers in a university dermatological wound centre in comparison to the last 5 years. In our institution we were able to demonstrate a shift of the detected bacterial species from gram-positive in direction to gram-negative germs. Beside the already known problems with MRSA, in future therapeutic strategies in patients with chronic leg ulcers the increasing amount of gram-negative bacteria and especially of P. aeruginosa should considered.

Calciphylaxis is a potentially life-threatening disease that occurs up to 4% of patients with chronic terminal renal failure and secondary hyperparathyroidism. Clinical symptoms are painful skin erythema and ischemic necrosis as a result of calcification of the small and medium-sized arteries of the subcutaneous tissues. The mortality of the disease is as high as 87% mainly due to sepsis from superinfection. We report on a 59-year-old patient with chronic renal failure and normal calcium-phosphate-product with leg ulcers as a rare manifestation of a calciphylaxis. In spite of an early parathyroidectomy and a temporary complete wound-healing the death because of calciphylaxis could not be prevented.