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ZusammenfassungDie Kompressionstherapie ist seit mehreren Hunderten von Jahren ein wesentlicher Bestandteil der konservativen Therapie bei Menschen mit chronischen Wunden und Ödemen der unteren Extremitäten. Die dann eingeleitete Therapie kann in die Phasen der Entstauung, Erhaltung und Prävention unterteilt werden. Die Auswahl der jeweiligen Kompressionsversorgung orientiert sich u. a. an den Therapiephasen, dem klinischen Stadium und Symptomen, den Bedürfnissen Betroffener und deren körperlichen Fähigkeiten. Für die Kompressionstherapie steht heute eine Vielzahl an unterschiedlichen Materialien und Methoden zur Verfügung. Daher gestaltet es sich zunehmend schwieriger, einen Überblick über diese Behandlungsoptionen zu behalten, zumal die verwendete Nomenklatur der Hersteller oft nicht einheitlich ist. In dieser Übersichtsarbeit werden daher die aktuell im deutschsprachigen Raum verfügbaren Materialien und Methoden zur Kompressionstherapie mit ihren Einsatzmöglichkeiten erläutert. Zudem wird eine einheitliche Nomenklatur vorgeschlagen, auf deren Basis eine sachgerechte Dokumentation und Kommunikation aller an der Versorgung von Menschen mit Kompressionstherapie Beteiligten gewährleistet ist.

ZusammenfassungChronische Wunden sind ein komplexes Symptom verschiedener Grunderkrankungen. Sie können bspw. vaskulärer, metabolischer oder immunologischer Genese sein. Auch wenn die Therapie dieser Grunderkrankungen im Vordergrund steht und zielführend ist, so beeinflussen diese Wunden die Lebensqualität der einzelnen Patienten oder Patientinnen stark. Zur Lokaltherapie chronischer Wunden steht ein breites Portfolio an Möglichkeiten zur Verfügung. Anders als in anderen Bereichen der Medizin ist die Evidenz für die verschiedenen Lokaltherapeutika meist gering. Deshalb rücken Experten-Empfehlungen und Leitlinien an ihre Stelle, die sinnvolle Behandlungspfade aufzeigen. Die wichtigsten Fragestellungen in der täglichen Praxis betreffen die Wahl und Effektivität der Wundspülung und des Wunddebridements, das Exsudatmanagement, den Einsatz von antimikrobiellen Wirkstoffen in Lösungen und Wundauflagen, die Unterdruck-Wundtherapie (NPWT) und die Indikationsstellung zur Kompressionstherapie. Trotz des Mangels an Evidenz folgt die Behandlung chronischer Wunde einigen grundlegenden Prinzipien, die im folgenden Artikel inklusive der dazugehörigen Behandlungsempfehlungen dargestellt werden.

Introduction La superiorite en termes de cicatrisation et le rapport cout-efficacite des pansements TLC-NOSF dans la prise en charge locale des plaies chroniques ont ete demontres dans des etudes controlees randomisees de haut niveau [1] , [2] . Cette etude observationnelle visait a evaluer l’efficacite et l’innocuite des pansements TLC-NOSF avec des fibres poly-absorbantes sur une population de patients non selectionnes, en conditions de vie reelles. Nous rapportons les resultats obtenus pour les patients presentant un ulcere vasculaire. Methodes Une etude observationnelle prospective multicentrique avec deux formats de pansements poly-absorbants TLC-NOSF a ete menee en Allemagne entre juillet 2017 et decembre 2018. Les principaux resultats comprenaient le taux de cicatrisation des plaies, l’evaluation clinique de la progression de la cicatrisation, la reduction relative de la surface de la plaie et la tolerance et l’acceptabilite des pansements. Resultats Quatre cent quatre-vingt-quatre patients presentant un ulcere vasculaire (353 d’etiologie veineuse, 45 d’etiologie arterielle et 86 d’etiologie mixte) ont ete traites avec les pansements etudies dans 114 centres pour une duree moyenne de 58 ± 34 jours. Lors de la derniere visite, 47,1 % des plaies avaient cicatrise, avec une reduction relative de la surface de la plaie de 97,3 % (mediane). Des resultats similaires ont ete rapportes quel qu’ait ete le stade cicatriciel (detersion ou granulation) en debut de traitement. L’analyse en sous-groupe selon l’anciennete de la plaie montre que plus le traitement TLC-NOSF est initie tot, meilleurs sont les resultats cicatriciels. Les pansements ont ete tres bien toleres et acceptes. Conclusions Ces resultats sont concordants avec ceux des essais controles randomises publies menes avec des pansements TLC-NOSF. Ils completent les preuves relatives a l’efficacite en termes de cicatrisation et au bon profil d’innocuite de ces pansements, notamment chez des populations non selectionnees traitees en pratique courante, et quelles que soient les caracteristiques des plaies et des patients.

Incontinence-associated dermatitis (IAD) describes damage to the skin caused by repeated and prolonged contact with urine and/or feces. Patients of all ages can be affected; the diagnosis is preferably used in adults and adolescents. The predilection sites are perineal, perianal, the inner thighs and the convex areas of the buttocks. Increased moisture on the skin surface, increased pH, occlusion, feces digestive enzymes and repeated skin cleansing procedures are pathophysiologically relevant factors. Typical clinical signs of IAD are erythema, erosions, excoriations and pain. Diagnosis is often difficult because there are many relevant differential diagnoses, some of which may occur together with an IAD. In particular, pressure ulcer, contact dermatitis and intertrigo need to be differentiated and treated. Effective strategies of prevention and therapy of IAD are continence management, the use of efficient, absorbent products as well as consistent skin protection and care. IAD is a skin disease that is often not or incorrectly diagnosed. It should be treated as early as possible, together with the causative factors such a fecal and/or urinary incontinence, as otherwise it can lead to an unnecessarily long duration and severity of the symptoms.

SummaryPyoderma gangrenosum (PG) is a rarely diagnosed neutrophilic skin disorder that still remains a diagnosis of exclusion. Therefore, the diagnosis has to be done in the synopsis of typical clinical findings, patient’s history and exclusion of relevant differential diagnoses. There are numerous references to relevant comorbidities from the metabolic syndrome, rheumatoid arthritis and inflammatory bowel diseases. Of particular importance is the potential association of PG with (haematologic) neoplasms. Treatment of PG includes topical and systemic immuno-modulating or immuno-suppressant therapies. Most important are for topical as well as systemic treatments are glucocorticoids. All other treatments represent an off-label-use. Especially Cyclosporine and TNF-α-inhibitors demonstrated very good and promising clinical results. Accompanying modern moist wound-therapy concepts avoiding painful dressings and an analgesic therapy are recommended.

Pressure ulcers comprise serious skin and tissue damage. The correct diagnosis and classification into different categories is often difficult in daily practice.What procedure can be recommended to correctly diagnose and classify pressure ulcers in practice?The society Initiative Chronische Wunden (ICW) e. V. established a group of experts who developed practical recommendations for the diagnosis and classification of pressure ulcers based on the current literature and their own expertise.Pressure ulcers should only be diagnosed if skin and/or tissue damage is most likely due to prolonged pressure or pressure associated with shear forces. A complete anamnesis must be performed to detect periods of previous prolonged immobility. Pressure ulcers are usually located at typical predilection sites. For category I and "suspected deep tissue damage" the tissue damage occurs under (initially) intact skin. However, the diagnosis is uncertain and the classification should be made later. The category II pressure ulcer is usually an exclusion diagnosis. The categories III and IV are pressure ulcers in the proper sense. As long as the distinction between category III and IV is not possible, the lower category should be coded.Currently, a relevant classification should be used uniformly for the respective setting. In accordance with the clinical picture, a most suitable diagnosis is to be made. It does not matter which classification system is used. The future WHO ICD-11 version will allow better classification of pressure ulcers.

With a prevalence of approximately 3 % worldwide, psoriasis is one of the most frequent chronic inflammatory skin diseases. Patients with moderate to severe psoriasis are treated guideline-conform with immunomodulatory or immunosuppressive agents. According to current guidelines physicians should be vigilant about the vaccination status of immunosuppressed patients.The aim of the study was to serologically objectify the tetanus vaccination status in systemically treated patients with moderate to severe psoriasis in Germany.Within the context of this retrospective study the concentration of immunoglobulin G antibodies against Clostridium tetani was determined in 101 patients with systemic immunosuppression suffering from psoriasis.In a total of 27.7% (n = 28; 11 male, 17 female) of the patients, insufficient immunoglobulin G antibody concentrations were detected, corresponding to a higher risk of an infection with C. tetani. Group subanalyses indicated an insufficient tetanus protection especially in patients ≥65 years old (50%).The tetanus immune status of psoriasis patients was shown to be comparable with the general population. The results of our investigation underline that people suffering from psoriasis have to be tested for tetanus protection and if necessary, vaccinations have to be renewed.

For effective compression therapy in patients with venous leg ulcers, sufficient pressure is essential. In everyday life, it is often the patients themselves who apply the compression bandages. Many of these patients have restriction in their movement and had been rarely trained adequately. Hence, there was the question of how efficient are the autonomously applied compression bandages of those patients.In all, 100 consecutive patients with venous leg ulcer were asked to apply compression bandages on their own leg. We documented both the achieved compression and formal criteria of correct performance.A total of 59 women and 41 men with an average age of 70.3 years were included in the study. Overall 43 patients were not able to apply a compression bandage because of physical limitations. The measured pressure values in the remaining 57 patients ranged between 6 and 93 mm Hg (mean 28.3 mm Hg). Eleven patients reached the prescribed effective compression pressure. Of these, formal errors were found in 6 patients, so that only 5 patients had correctly applied the compression bandages.Our data show that most patients with venous leg ulcers are not able to apply effective compression therapy with short-stretch bandages to themselves. Multilayer systems, adaptive compression bandages, and ulcer stocking systems today are possibly easier and more effective therapy options. Alternatively short-stretch bandages could be applied by trained persons but only under the control with pressure measuring probes.

Bakterien konnen bei Patienten mit chronischem Ulcus cruris sowohl in der Genese als auch als Komplikation von erheblicher Bedeutung sein. Am haufigsten wird bei mindestens 50 % der Patienten Staphylococcus aureus nachgewiesen; am zweithaufigsten wird mit steigender Tendenz Pseudomonas aeruginosa gefunden. Eine zunehmende Bedeutung gewinnen Problemkeime wie Methicillin-resistente Stapylococcus aureus (MRSA) oder multiresistente gramnegative Erreger (MRGN). Fur den Erregernachweis reichen meist bakteriologische Abstriche der Wundoberflache beispielsweise entsprechend der Technik des „Essener Kreisels“. In der uberwiegenden Zahl der Patienten mit chronischem Ulcus cruris liegt eine unkritische bakterielle Kolonisation vor, sodass keine systemische Antibiotikatherapie notwendig ist. Fur Patienten mit erhohtem Infektionsrisiko sowie fur Wunden mit lokalen Infektionszeichen sind Antiseptika mit Polihexanid oder Octenidin meist erste Wahl.

Chronic wounds are of high socio-economic importance. Accurate and efficient treatment includes the use of outcomes measures in clinical care and in research. To date, consented standards for documentation of chronic wounds, agreements on interpretation of wound outcomes and harmonisation about standardised goal setting in wound treatment are lacking. Objective (1) To establish a national German consensus group for the definition of standards in outcomes measurement of chronic wounds, (2) to agree on recommendations for practice and research based on a continuous decision process, including implementation of the standards. Methods The national consensus group includes delegates from the German scientific medical societies involved in health care for chronic wounds, the national boards on nursing, and the chairs of regional wound networks. Moreover, the roof organisations of the German health insurances, the German ministry of health and further single wound experts were invited. The consensus work is based on a structured decision process. Results The consensus group consists of 58 representatives and co-representatives of 26 societies and organisations. Since 2012, in the regular bi-annual meetings a Delphi-based workflow has been followed starting with standards for documentation and outcomes measurement in patients with leg ulcers. Additionally, web-based decision processes are conducted and the results are presented for finalisation in the face-to-face meetings. The following application areas of particular interests were defined: clinical routine, health services research, clinical research, and health economics. In the meantime, 245 single decisions have been approved. Conclusions Based on a national joint process involving medical societies, nursing groups, German sickness funds and health politics, a continuous decision process on standards for outcomes measurement and interpretation could be established. The Delphi based decision processes showed high levels of participations, thus providing a valid and robust set of standards. First results are in process of approval by the societies.

Standards in the assessment and documentation of disease processes are the basis of guideline-based care. For the treatment of chronic wounds, especially leg ulcers, no approved parameters are available.Against this background, our aim was to develop standards for the documentation of leg ulcer in routine care. This article presents the recommendations for the classification and characteristics of the variables.The development of the documentation standard was based on a systematic literature research and was performed in a Delphi-based consensus process. The national consensus process included meetings as well as web-based questionnaires. The Consensus Group is coordinated by the German Center for Health Services Research in Dermatology (CVderm).The documentation standards and their variables for leg ulcer routine care were developed in seven meetings of the consensus group. The consensus group consists of 38 delegates of wound care societies, health insurances, wound networks and associations.For each variable, recommended in routine care, a distinct response scheme (defined set of variable characteristics) was defined. As a next step, a structured implementation process is required, which was part of the resolutions of the consensus group.

Standards for basic documentation and the course of treatment increase quality assurance and efficiency in health care. To date, no standards for the treatment of patients with leg ulcers are available in Germany.The aim of the study was to develop standards under routine conditions in the documentation of patients with leg ulcers. This article shows the recommended variables of a "standard dataset" and a "minimum dataset".Consensus building among experts from 38 scientific societies, professional associations, insurance and supply networks (n = 68 experts) took place. After conducting a systematic international literature research, available standards were reviewed and supplemented with our own considerations of the expert group. From 2012-2015 standards for documentation were defined in multistage online visits and personal meetings.A consensus was achieved for 18 variables for the minimum dataset and 48 variables for the standard dataset in a total of seven meetings and nine online Delphi visits. The datasets involve patient baseline data, data on the general health status, wound characteristics, diagnostic and therapeutic interventions, patient reported outcomes, nutrition, and education status.Based on a multistage continuous decision-making process, a standard in the measurement of events in routine care in patients with a leg ulcer was developed.

Chronic wounds often manifest as ulcers on the lower legs. The main causes of chronic leg ulcers are chronic venous insufficiency and/or peripheral arterial occlusive disease in approximately 80% of all patients. However, there are also numerous other potentially relevant factors which can cause or almost impede the healing of chronic leg ulcers. Therefore, disease such as vasculitis, livedo vasculopathy, pyoderma gangrenosum, necrobiosis lipoidica, Martorell hypertensive leg ulcer, calciphylaxis, infectious diseases, neoplasms, drugs, cutaneous artefacts and genetic defects are exemplarily presented. The successful therapy of patients with chronic leg ulcers is only possible on the basis of an adequate diagnosis. Therapeutic options include conservative, surgical and interventional treatment options. In particular the consequent implementation of compression therapy is of very great importance in the therapy of most patients with chronic leg ulcers and edema. However, a permanent effective treatment always requires a causally oriented therapy, which usually needs an interdisciplinary and interprofessional approach.

More than 1 million people in Germany suffer from leg ulcers. The diagnosis leg ulcer summarizes many different etiologies. The therapy of leg ulcers is an interdisciplinary and interprofessional challenge. Early identification of the cause of the leg ulcer and initiation of a causal therapy are essential for healing.The aim of this study was to investigate the initial manifestation age of patients with causally associated leg ulcers. Afterwards we calculated the most common etiologies according to decade.A prospective database at the University Hospital Essen, dermatological wound care center, was used to identify patients with chronic leg ulcers between 2002 and 2014. Clinical data of 1000 patients with chronic leg ulcers were analyzed in this monocentric study.A total of 29 different etiologies were differentiated. Approximately 70% of etiologies were of vascular origin, while 30% were rare causes. The count of different etiologies showed significant differences related to the onset and the occurrence in individual decades of life. In particular, nonvascular etiologies such as pyoderma gangrenosum or necrobiosis lipoidica are relatively more common in younger patients than in the aged.Based on the findings of our study, it is possible to limit the underlying etiology on the basis of the age of first manifestation of the leg ulcer in order to make targeted diagnostics more effective. Thus, this information can help to optimize scarce time resources in daily practice and improve the prediction probability of leg ulcers.

Compression therapy, together with modern moist wound treatment, is the basis for a successful conservative treatment of patients with chronic leg ulcers. In clinical practice, it is often the patients themselves who apply compression therapies. Many of the mostly elderly patients, however, are not able to reach their legs and feet due to movement restrictions, such as arthritis, arthrosis and even obesity. An adequate compression therapy also requires extensive experience and regular training. In practice only the minority of patients can perform bandaging well and therefore this should not be recommended. Self-management with do-it-yourself medical devices will become more and more important in the future. In addition to the psychological factors, cost aspects and demographic change, an expected lack of qualified nursing staff due to the number of elderly patients who are potentially in need of care means that self-management is becoming increasingly more important. For the essentially important compression therapy of patients with chronic leg ulcers, there already exist various therapy options. The needs, preferences and abilities of the patients concerned can be considered when selecting the appropriate system. Particularly for the self-management of compression therapy, adaptive compression bandages are suitable for patients with leg ulcers during the initial decompression phase and ulcer stocking systems in the subsequent maintenance phase.

Compression therapy is the basis for successful treatment in most patients with venous leg ulcers. Concerning compression therapy, the initial phase of decongestion and the following phase of maintenance should be differentiated. While in the maintenance phase (ulcer) stocking systems are now frequently recommended, in the decongestion phase compression bandages are mostly still used, which however are often inappropriately applied. In German-speaking countries, compression therapy with short-stretch bandages has a long tradition. However, their correct application requires good training and monitoring, which is often lacking in daily practice. Less error-prone treatment alternatives are multicomponent systems, some of which have an optical marker for the control of the correct subbandage pressure. In another new type of compression system, which is called adaptive or wrap bandages, the compression pressure can be adjusted using a Velcro fastener. Accompanying intermittent pneumatic compression therapy can also be used in the decongestion phase. Thus, there are now several different treatment options that can be used for the decongestion phase in patients with venous leg ulcers. Often bandages with short-stretch materials are very prone to errors and should in most cases be replaced by other compression systems today. The patient's preference, need, and capability should be considered when selecting the appropriate system for the individual patient.

Compression therapy is well-tried treatment with only few side effects for most patients with leg ulcers and/or edema. Despite the very long tradition in German-speaking countries and good evidence for compression therapy in different indications, recent scientific findings indicate that the current situation in Germany is unsatisfactory. Today, compression therapy can be performed with very different materials and systems. In addition to the traditional bandaging with Unna Boot, short-stretch, long-stretch, or multicomponent bandage systems, medical compression ulcer stockings are available. Other very effective but far less common alternatives are velcro wrap systems. When planning compression therapy, it is also important to consider donning devices with the patient. In addition to compression therapy, intermittent pneumatic compression therapy can be used. Through these various treatment options, it is now possible to develop an individually accepted, geared to the needs of the patients, and functional therapy strategy for nearly all patients with leg ulcers.

In Western developed countries a growing incidence of patients with chronic wounds has been described. The underlying etiopathologically relevant causes are manifold and thus interdisciplinary diagnostics and causal therapy are the basis for a good and successful wound treatment. Later a modern, moisten, and phase adapted wound therapy should be initiated as a part of a complex therapeutic concept. Beside modern wound-dressings which could be divided in for example passive, interactive and active dressings there exists an increasing amount of innovative therapeutic options. For instance negative pressure therapies, treatments with ultrasound, hydrotherapies or biosurgery could be used. Moreover beside the well known growth factors there are some hopeful procedures with first clinical results for future wound healing strategies available like TNF-α inhibitors, stem cells or bone marrow derived cells. Therefore the employment of a modern wound therapy together with causally orientated treatment of the underlying causes is helpful to ensure a long-term complete healing of chronic wounds.

Although the positive effects of negative pressure-therapy in wound-healing has been well known for several decades, the first paper on the now widely used vacuum systems was published ten years ago. Since then vacuum-therapy has been widely used in patients with"hard-to-heal" wounds, including dermatologic patients. Although there is still a lack of relevant comparative prospective controlled clinical trials, vacuum-therapy seems to accelerate the healing process in chronic wounds in both the granulation and epithelialization phases. Therefore, following debridement, vacuum-therapy can be considered as the therapy of choice for many patients with chronic wounds.

ZusammenfassungDie Dokumentation chronischer Wunden wird aktuell von unterschiedlichen Berufsgruppen mit z. T. erheblichen Wissensunterschieden durchgeführt. Das Ziel unserer Untersuchung war es, die Beurteilung von 12 verschiedenen Bildern von Ulcera crurum durch fünf unterschiedlich vorgebildete Untersuchergruppen zu vergleichen. Material und Methoden: Die Probanden der Untersuchergruppen Experten, Ärzte, ambulante Pflegedienste, stationäre Pflege und Laien sollten alle relevanten Parameter der Wundbeurteilung einschätzen. Als objektive Referenz kam ein neu entwickeltes und von uns erstmalig klinisch eingesetztes digitales kolorimetrisches Wunddokumentationssystem zum Einsatz. Die Ergebnisse unserer Untersuchung belegen, dass die Beurteilung verschiedener Parameter der Wundheilung durch unterschiedlich vorgebildete Untersucher mit erheblichen Unterschieden erfolgt. Insgesamt fand sich eine unerwartet hohe Abweichung der digital berechneten Werte im Vergleich zu den von den Untersuchergruppen geschätzten, mit Abweichungen von teilweise über 100% bei der Wundoberfläche sowie den einzelnen Wundbestandteilen. Als erfahrungsabhängige Parameter zeigten sich hingegen Länge, Breite, Oberfläche, Infektion sowie das Wundstadium. Schlussfolgerung: Eine suffiziente, reliable und adäquate Wunddokumentation ist ohne technische Hilfsmittel (z. B. digitale Fotodokumentation) unmöglich.

In the last years increasing of numbers dermatologic patients with chronic wounds and problem bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) have been reported. Even though it is still unclear if bacterial contamination with MRSA independently interferes with wound healing, both the logistic and therapeutic consequences of identifying MRSA are considerable for the patient and the treatment facility. In this review the practical consequences and the therapy options associated with the identification of MRSA in patients with chronic wounds are considered.

The incidence of chronic wounds is increasing in developed Western countries. There are many causes for chronic or non-healing wounds. A multidisciplinary diagnostic approach and attention to underlying disorders are essential. A modern, moist, and phase adapted wound therapy is also essential. Modern wound dressings include activated charcoal, alginates, hyaluronic acid, hydrofibers, hydrogels, hydrocolloids, impregnated gauze, collagen, moist methods, proteolytic enzymes, foams, semipermeable membranes and silver dressings. Because of the lack of comparative investigations the phase-adapted use of wound dressings is still empiric. Application of modern wound dressings may help to create an optimized wound milieu and accelerate healing. Treatment of the underlying causes is an absolute requirement for long-term complete healing.

Non-Surgical Therapy of Basalcell Carcinoma of the Head-Neck Region. Basal cell carcinoma is a semi-malignant epithelial skin tumour with a locally destructive growth pattern but a very low tendency to metastases. Basal cell carcinoma represent the most frequent malignant cutaneous tumour worldwide in white population with a lifetime risk of 30% and still increasing incidence. Lifetime cumulative UV-exposure, as well as frequent sunburns are the most common exogeneous risk factors, others are ionising radiation, exposure to chemical carcinogens, genetic predisposition, and chronic immunosuppression. Basal cell carcinoma are predominantly located in the central region of the face. The characteristic clinical feature is a single nodule with multiple teleangiectasia, as well as an irregular shaped ulceration with and elevated border. The very rarely observed occurrence of metastases seems to be a result of insufficient therapy or a metatypic basal cell carcinoma type. Therapy of first choice of basal cell carcinoma is the complete, micrographically controlled excision. In addition, radiotherapy, topical immunotherapy with Imiquimod or photodynamic therapy may be considered as therapeutic altematives in selected cases.

Die Kalziphylaxie ist eine potentiell lebensbedrohliche Erkrankung, die als Komplikation bei bis zu 4% der Patienten mit terminaler Niereninsuffizienz und sekundärem Hyperparathyreodismus auftritt. Die Kardinalsymptome der Kalziphylaxie sind schmerzhafte livide Erytheme, die als Folge von Kalkablagerungen in den kleineren und mittleren Arterien des subkutanen Fettgewebes sekundär exulcerieren. Die Mortalität der Erkrankung beträgt 87% hervorgerufen durch Wundinfektion und Sepsis. Wir berichten über eine 59-jährige Patientin mit dialysepflichtiger terminaler Niereninsuffizienz und normwertigem Kalzium-Phosphatprodukt, bei der als seltene Ursache für Ulcera crurum eine Kalziphylaxie diagnostiziert werden konnte. Trotz frühzeitiger Intervention in Form einer Parathyreoidektomie und temporärer vollständiger Abheilung der Ulcerationen konnte mittelfristig ein letaler Verlauf der Kalziphylaxie nicht verhindert werden.

In den letzten Jahren wurde haufiger uber den effektiven Einsatz verschiedener proteolytischer Enzyme in der Konditionierung chronischer Wunden berichtet. Proteolytische Enzyme in der Konditionierung chronischer Wunden ermoglichen eine weitestgehend schmerzfreie und selektive Nekrosektomie. Auch werden zahlreiche positive Effekte auf die Ausbildung einer rascheren Granulation und Epithelisation diskutiert. Somit konnte es durch die Wundgrundkonditionierung mit proteolytischen Enzymen zu einer Beschleunigung der Abheilung chronischer Wunden kommen. Trotz zahlreicher interessanter Teilaspekte sind diese Daten im Sinne einer evidenzbasierten Medizin noch nicht endgultig zu beurteilen. Fur viele chronische Wunden stellt das enzymatische Debridement insbesondere in der ambulanten Therapie und ggf. in Kombination mit mechanischer Wundsauberung heute eine Methode der 1. Wahl dar.

Wound networks are structured collaborations between various professions and medical disciplines in the field of treatment of patients with chronic wounds. In view of the complex chronic courses of such wounds with many relevant underlying diseases, comorbidities and a multitude of possible therapy options, the evidence-based structured treatment of patients with wound problems is of particular importance. However, this treatment is very heterogeneous and often uncoordinated.This article describes a stocktaking of the active regional wound networks in Germany with characterization of their structures, activities and objectives.A nationwide survey was carried out targeting wound specialists and wound societies as well as already established wound networks for which an updating was carried out. All identified networks were issued with a standardized questionnaire about the size of the network, extent of regional coverage, participating medical disciplines and professional groups and activities. In addition to the preformulated questions, free text information was also encouraged.A total of 35 wound networks could be identified. The majority of networks consisted of representatives of hospitals as well as physicians in private practice and nursing personnel. The most frequently represented medical disciplines were vascular surgeons (74%), general physicians (63%), diabetologists (60%), general surgeons (60%) and dermatologists (57%). The most frequent activities were informal meetings on further education (77%), exchange of experiences and second opinions (both 71%) and consultation on patient treatment (69%). Selective contracts were only implemented in very few cases.The wound networks established in Germany on self-initiatives represent strong interdisciplinary and interprofessional-oriented specialist platforms with a high potential for structured and efficient treatment. Incentives for systematic utilization of these structures in the course of improvements in quality and remuneration of treatment of patients with chronic wounds would be desirable.

Due to the increasing problem of antibiotic resistance in gram-negative pathogens, the Commission for Hospital Hygiene and Infection Prevention (KRINKO) decided to establish a new clinically oriented definition of multi-resistance. Gram-negative pathogens with a multidrug-resistance (MRGN) are divided into those with resistance to three (3MRGN) or four (4MRGN) antibiotic groups.In this multicenter study which was done in ten dermatological wound clinics, the bacteriological swabs from up to 100 patients with chronic leg ulcers per center were analyzed according to the current classification KRINKO and evaluated.Overall, the results of 970 patients (553 women, 417 men) could be evaluated. We found 681 gram-positive and 1155 gram-negative bacteria. Pseudomonas aeruginosa was with a detection-rate of 31.1% the most frequent gram-negative pathogen, followed by Proteus mirabilis with 13.7% and various enterobacteria with 28.6%. According to the current KRINKO classification,eight patients with 4MRGN and 34 patients with 3MRGN could be identified.Our results demonstrate the current spectrum of bacteria in patients with chronic leg ulcers with a variety of gram-negative pathogens, some of which are classified as multi-drug resistant. As a clinical consequence some of the patients require individualized preventive measures and therapy.

Die chronische Hyperglykamie und andere damit verbundene Storungen des metabolischen Stoffwechsels bei Diabetes mellitus fuhren uber einen langeren Zeitraum zu spezifischen Folgeerkrankungen und Symptomen. Auf typische Symptome wie auch auf die Klassifikation und die Diagnostik, wird in diesem Kapitel eingegangen. Die Diagnosestellung eines Pradiabetes geschieht uber einen oralen Glukosetoleranztest. Zur Diagnostik eines manifesten Diabetes mellitus gibt es verschiedene Verfahren, die kurz vorgestellt werden. Weiterhin wird das geriatrische Assessment mit moglichen Testverfahren erlautert. Haufig auftretende geriatrische Syndrome, wie z.B. Sturze, Frakturen, und Begleit- und Folgeerkrankungen finden in diesem Kapitel ausfuhrlich Platz, u.a. Arterielle Hypertonie, Herzinsuffizienz, Schlaganfall, diabetische Nephropathie oder das Diabetische Fussyndrom.

The importance of bacteria in the treatment of patients with chronic wounds has been a focus of attention in recent years. A bacteriological swab taken from the wound in a Essen rotary technique is usually adequate for the diagnosis. The current detection rate of bacteria in patients with chronic leg ulcers in Germany is about 50 % for Staphylococcus aureus, 30 % for Pseudomonas aeruginosa and Enterobacteriaceae and approximately 10 % for MRSA. Most of these patients have a clinically unimportant bacterial colonization, so that systemic administration of antibiotics usually is not required. For wound cleansing only sterile solutions such as Ringer's or physiological saline solution should be used. If tap water is used, then the use of sterile filters is strongly recommended. In patients with increased risk of infection, a critical colonization or local signs of infection, modern wound antiseptics using polyhexanide or octenidine are available. The use of systemic antibiotics should be strictly limited to patients with systemic signs of infections.

The toxin Panton-Valentine leukocidin (PVL) produced by S. aureus is known as a virulence factor that leads to severe infections of skin and soft tissue. However the effect of PVL on wound healing is not known yet. Therefore we examined the detection rate of PVL in patients with chronic wounds.The study included 100 patients with chronic wounds of the lower limb. We determined in all S. aureus isolates the presence of the PVL gene using a PCR technique.Altogether 94% of the patients had a leg ulcer, while 6% had a foot ulcer; 65% were women. PVL was found in two patients. One of the strains was methicillin-resistant (MRSA) and the other was methicillin-sensitive (MSSA).In our investigation there was detection rate for PVL of 2% of all S. aureus isolates in patients with chronic wounds of the lower extremities. Although the role of PVL as a virulence factor of S. aureus in wound healing remains unclear, the detection of PVL should be taken as a cause for a consequent topical antimicrobial wound therapy because of the increased risk of serious infections.

Routine care of non-healing acute and chronic wounds often comprises either cleaning or debridement. Consequently, debridement is a basic necessity to induce the functional process of tissue repair, which makes it a central medical intervention in the management of acute and chronic, non-healing wounds.

A 50-year-old women had suffered from recurrent and extremely painful ulcerations of both legs and the back of her feet for about 3 weeks. The clinical examination showed multiple hemorrhagic and bizarre configured ulcerations with a surrounding livid-erythematous discoloration, hyperpigmentation and extensive atrophie blanche.Neither instrument-based nor serological tests revealed specific pathological findings. Histological results from the border area of the ulceration confirmed the diagnosis of livedoid vasculopathy.A systemic treatment with low-molecular-weight heparin was initiated, resulting in a rapid pain reduction and complete healing of the ulcerations after some weeks of therapy.This case report demonstrates that unusual entities like livedoid vasculopathy should be considered as rare causes for recurrent leg ulcers because different underlying etiologies need different specific treatment strategies. Until now treatment for patients with livedoid vasculopathy has not been standardized but anticoagulative therapy with low-molecular-weight heparin is considered to be one treatment of first choice.

Necrobiosis lipoidica is a rare inflammatory granulomatous skin disease of unknown etiology which is associated with diabetes mellitus in about 60 % of the patients. In up to 30 % of these patients extremely painful and often hard-to-heal ulcerations occur in the course of the disease. We present a new therapeutic option using adalimumab to treat refractory ulcerated necrobiosis lipoidica non diabeticorum. The clinical efficacy of adalimumab probably reflects an immunomodulatory effect through the specific TNF-α inhibition which is one central aspect of the underlying inflammation. Thus, adalimumab could represent promising new treatment option, especially for patients with otherwise therapy-refractory ulcerated necrobiosis lipoidica.

A 71-year-old patient presented with very painful ulcers after uterus-resection with the da Vinci® Surgical System 3 months before. The anamnesis revealed that in the past 10 months similar wounds had appeared after osteosynthesis of a humerus fracture and after breast biopsy. The patient had been unsuccessfully treated with different antibiotics and wound dressings for several months for a suspected superinfected, postoperative disturbed wound healing. None of the wounds became smaller or healed completely. After exclusion of relevant differential diagnoses pyoderma gangrenosum (PG) could be diagnosed and systemic immunosuppressive therapy was initiated. The pain improved rapidly and complete wound healing was achieved. Pyoderma gangrenosum is a rarely diagnosed autoimmune disease which often occurs after physical trauma such as surgical interventions. Because a correct diagnose is usually made late it is important to be aware of this disease to treat it early and correctly.