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Biofilm in chronic wounds is associated with delayed healing and ineffective local treatment. The purpose of this study was to investigate the in vitro anti-biofilm activity of two commonly used antimicrobials, povidone-iodine (PVP-I) and polyhexamethylene biguanide (PHMB). The rate of anti-biofilm activity of PVP-I, PHMB, and phosphate-buffered saline (negative control) was assessed on monomicrobial biofilms of varying maturity and composition. Antimicrobial efficacy was determined by counting colony-forming units (CFU). Live/dead cell staining and time-lapse confocal microscopy were also performed. Both PVP-I and PHMB demonstrated robust in vitro anti-biofilm activity against all tested biofilms; however, PVP-I had a more rapid action versus PHMB against methicillin-resistant Staphylococcus aureus (MRSA) biofilms, as determined by both CFU counts and microscopy. PVP-I completely eradicated Pseudomonas aeruginosa biofilms of 3- and 5-day maturity (in ≤0.5 h) and 7-day maturity (in ≤3 h), while PHMB only partially depleted cell density, with no complete biofilm eradication even after 24 h. In conclusion, PVP-I had a similar in vitro anti-biofilm activity to PHMB against biofilms of varying microbial compositions and maturity, and in some cases demonstrated more potent and rapid activity versus PHMB. PVP-I may be particularly effective in treating MRSA biofilms. However, further high-quality clinical research on the efficacy of antimicrobials is required.

Despite progress in the prevention of pressure injuries (PIs), they remain a challenging public health problem because of their frequency and morbidity. Protection of the skin by multilayer silicone foam dressings may be an adjuvant measure to prevent PIs in high-risk patients. Despite the available clinical data and published recommendations on this measure, caregivers face difficulties in identifying patients who would benefit from this adjuvant measure. The objective of this work was to define the profiles of high-risk patients who would benefit optimally from this measure in combination with basic preventive procedures. This consensual expert opinion was drawn up using two methods: the Nominal Group Technique with eight medical and paramedical experts, and the Delphi process with 16 experts. The bases for this expert consensual opinion were a formal search and analysis of the published literature regarding evidence on the prevention of PIs using multilayer silicone foam dressings. The consensual expert opinion reported here addresses five proposals mostly intended to define patients who would benefit from the use of a multilayer silicone foam dressing (≥4 layers) to prevent PIs (sacrum and heels).

The term dermatoporosis (DP) is used to describe the clinical signs and functional consequences of age-related extreme skin fragility. It is associated with potentially severe complications, including deep dissecting hematomas and extended skin lacerations. No studies have evaluated the prevalence and risk factors of DP in adults aged 75 and older.The aim of our study was to assess the prevalence, complications, and risk factors of DP in a cohort of older patients hospitalized in a rehabilitation center. A case-control, single-center study was conducted between September and October 2020 in our rehabilitation ward, Rothschild Hospital, Paris, France. A senior dermatologist and a resident in geriatric medicine performed a systematic dermatological examination. The presence of DP, its stage, its location, and complications were collected, as were demographical data, comorbidities, past sun exposure, skin phototype, treatments, and biological data.A total of 101 patients (62 women, median age 86 years [extreme values 75-104]) were included. The overall prevalence of DP was 27%. Stage 1 was the most frequent. DP was mainly located on the upper limbs. Ten (37%) patients had a DP complication: eight (30%) skin lacerations and two (7%) deep dissecting hematomas. Multivariate analysis revealed a significant association between DP and age (odds ratio [OR] 5.82, 95% confidence interval [CI] 1.67-24.92, p = 0.009), smoking (OR 8.67, 95% CI 2.59-34.85, p = 0.001), recreational sun exposure (OR 4.23, 95% CI 1.30-15.21, p = 0.02), and anticoagulant therapy (OR 4.53, 95% CI 1.32-17.26, p = 0.02).Our study is the first to analyze the prevalence and risk factors of DP in older adults in rehabilitation. Frequency of DP makes it relevant for the geriatrician and should be described more to prevent potential severe complications. A multicentric study, with inpatients and outpatients, could evaluate the prevalence of DP in a more representative older adult population.

Chronic wounds, including leg ulcers, constitute an important medical problem among older patients. Dystrophic calcifications (DC) are associated with a variety of disorders, including leg ulcers. The aim of this study was to report the clinical and biological characteristics of older patients with DC in leg ulcers and to determine the morphology and chemical composition of these calcifications. We conducted a prospective monocentric study in our Geriatric-Wound and Healing ward, Rothschild Hospital, Paris, from January 2018 to December 2019. Patients with leg ulcers were screened for DC by palpation. Patients’ clinical, biological, and radiological findings were collected. DC morphology was analyzed using field-emission scanning electron microscopy and chemical composition was analyzed using µFourier transform infra-red spectroscopy and X-ray Fluorescence. Ten (7%) of the 143 patients hospitalized for leg ulcers presented DC. Older patients with DC were more likely to have leg ulcers with venous insufficiency (p = .015), colonized by Pseudomonas aeruginosa (p = .026), with a longer healing evolution (p = .0072) and hypercalcemia (p = .041). Five DC were extracted from ulcers: 2 presented 500 nm lacunar spheres and intermingled fibrils of about 10 nm in diameter, consistent with bacterial and biofilm imprints. DC were always composed of calcium–phosphate apatite and associated to the presence of zinc. Our analyses were consistent with the involvement of microorganisms and inflammatory process in DC formation. Early management of venous insufficiency, treatment of chronic bacterial colonization and use of calcium-solubilizing drugs seem to be rational strategies for calcified leg ulcer management in older patients.

Afin d’elaborer une nouvelle grille de suivi des soins des orifices des fiches transcutanees des fixateurs externes (FE) et des halos crâniens (HC), 34 fiches de cinq patients portant un FE ou un HC ont ete evaluees, utilisant une nouvelle grille integrant la classification de Lee-Smith. Malgre l’augmentation du nombre des soins, douze orifices etaient infectes a la 6e semaine. Avec cette nouvelle grille, nous pouvons ameliorer la qualite de recueil de signes cutanes autour des orifices des fiches.

Pour toute plaie, l’existence de fibrine ou de necrose est un obstacle a la formation du tissu de granulation et cree un environnement propice a la proliferation bacterienne. Aussi, une detersion mecanique, effectuee au lit du malade (par un medecin ou un infirmier) ou chirurgicale, realisee au bloc operatoire, s’impose le plus souvent ; elle est completee par une detersion autolytique faisant appel a des pansements techniques. Parmi les nombreux pansements modernes concus sur le principe de la cicatrisation en milieu humide, certains sont plus adaptes a la phase detersive. Tous ne sont pas disponibles et rembourses en France en 2019. Etat des lieux.

Biofilms play a major role in delaying chronic wounds from healing. A wound infiltrated with biofilm, or “critically colonised” wound, may become clinically infected if the number of microbes exceeds a critical level. Chronic wound biofilms represent a significant treatment challenge by demonstrating recalcitrance towards antimicrobial agents. However, a “window of opportunity” may exist after wound debridement when biofilms are more susceptible to topical antiseptics. Here, we discuss the role of antiseptics in the management of chronic wounds and biofilm, focusing on povidone‐iodine (PVP‐I) in comparison with two commonly used antiseptics: polyhexanide (PHMB) and silver. This article is based on the literature reviewed during a focus group meeting on antiseptics in wound care and biofilm management, and on a PubMed search conducted in March 2020. Compared with PHMB and silver, PVP‐I has a broader spectrum of antimicrobial activity, potent antibiofilm efficacy, no acquired bacterial resistance or cross‐resistance, low cytotoxicity, good tolerability, and an ability to promote wound healing. PVP‐I represents a viable therapeutic option in wound care and biofilm management, with the potential to treat biofilm‐infiltrated, critically colonised wounds. We propose a practical algorithm to guide the management of chronic, non‐healing wounds due to critical colonisation or biofilm, using PVP‐I.

Despite the aging of the population, little attention is paid to the development of specific care protocols appropriate to the skin and even less to the scars in the elderly. The purpose of this chapter is to highlight common clinical problems with scar and scarring in older adults and provide appropriate advices on protocols for managing them. The literature review was carried out to look for the evidence-based elements, but, if the subject of scars is sometimes found, the elements relating specifically to scars in old age are nonexistent. Unsurprisingly, practices vary widely and are carried out according to habit rather than science. Based on our clinical experience of dermatologist and geriatrician and some literature data, some pathways for future research on scars in elderly are proposed.

Les proprietes antibacteriennes et anti-inflammatoires de l’argent sont connues depuis l’Antiquite. Toutefois, les applications qui en decoulent, notamment dans la prise en charge des plaies, restent controversees. Ainsi, les ulceres de jambe constituent a ce jour la seule indication pour laquelle les pansements a base d’argent sont actuellement rembourses en France. Au vu des donnees cliniques rapportees dans la litterature, celle-ci est justifiee quand leur indication est bien posee ; leur rapport benefice/risque semble bien plus favorable que generalement percu dans le debat scientifique actuel. En dehors de l’effet antimicrobien, son utilisation selective (adaptee a l’etat de la plaie) et temporaire (limitee dans le temps) ameliore sur le plan cicatriciel les plaies qui justifient de leur prescription. Etat des lieux des recommandations.

L’utilisation de la therapie par pression negative est recommandee en geriatrie comme en soins palliatifs. Il existe un certain nombre de restrictions a son utilisation en pratique, mais l’acces a ces technologies est possible a l’hopital, en service de geriatrie, comme en ambulatoire, aussi bien dans les etablissements d’hebergement pour personnes âgees dependantes qu’au lit du patient, grâce a l’hospitalisation a domicile. Les TPN ambulatoires et les nouvelles TPN avec instillation et mousse a trous sont indiquees pour accelerer la fermeture des plaies y compris chez les personnes âgees. Les TPN standard, TPN portables non motorisees et pansements TPN restent dans certains cas accessibles aussi aux patients en fin de vie de facon palliative.

Background In institutional care, oral liquid pharmaceutical products are widely prescribed for older patients, especially for those with swallowing disorders. As medicines acceptability is a key factor for compliance in the older population, this study investigated the acceptability of oral liquid pharmaceutical products in this targeted population. Methods An observational, multicenter, prospective study was conducted in eight geriatric hospitals and eight nursing homes in France. Observers reported several behaviours/events describing the many aspects of acceptability for various pharmaceutical products’ uses in patients aged 65 and older. Acceptability scores of oral liquid pharmaceutical products were obtained using an acceptability reference framework (CAST - ClinSearch Acceptability Score Test®): a 3D-map summarizing the different users’ behaviors, with two clusters defining the positively and negatively accepted profiles materialized by the green and red zones, respectively. Results Among 1288 patients included in the core study and supporting the acceptability reference framework, 340 assessments were related to the administration of an oral liquid pharmaceutical product. The mean age of these patients was 87 (Range [66-104y]; SD = 6.7), 68% were women and 16% had swallowing disorders. Globally, the oral liquid pharmaceutical products were classified as “positively accepted,” the barycenter of the 340 assessments, along with the entire confidence ellipses surrounding it, were positioned on the green zone of the map. Sub-populations presenting a different acceptability profile have also been identified. For patients with swallowing disorders, the oral liquid pharmaceutical products were classified as “negatively accepted,” the barycenter of the 53 assessments along with 87% of its confidence ellipses were associated with this profile. A gender difference was observed for unflavored oral liquids. In women, they were classified “negatively accepted,” the barycenter of the 68 assessments with 75% of its confidence ellipses were located in the red zone, while they were classified “positively accepted” in men. Conclusion This study showed that oral liquid pharmaceutical products are a suboptimal alternative to solid oral dosage forms in patients with swallowing disorders. To ensure an optimal acceptability, prescribers should also consider the presence of a taste-masker in these oral liquids. As highlighted herein, palatability remains crucial in older populations, especially for women.

La prevention de la survenue de cicatrices pathologiques est un element important a connaitre des soignants prenant en charge des plaies. En effet, un certain nombre de propositions doivent etre faites afin de minimiser l’impact de la blessure ou de la chirurgie au-dela de la prise en charge de la plaie : application de strips sur la cicatrice pendant trois mois, utilisation d’emollients, protection solaire. Ce sont les silicones qui semblent presenter la solution de premiere intention qui a fait l’objet du plus grand nombre d’etudes en prevention des cicatrices pathologique sur terrain a risque. Enfin, en cas de cicatrice hypertrophique ou cheloide, des traitements par injection de corticoides, ou plus recemment de 5-fluorouracile (5-FU), ou par cryotherapie sont proposes seuls ou en association avec d’autres techniques.

La biopsie des plaies, en particulier des plaies chroniques, est un acte frequemment realise par un dermatologue ou un chirurgien a la phase de diagnostic de la plaie ou a l’occasion de survenue de complications (infection, lesion periulcereuse, retard de cicatrisation, suspicion de cancerisation). Les medecins non dermatologues peuvent pratiquer ce geste a condition d’en maitriser la technique. Les infirmiers doivent pouvoir expliquer au patient son deroulement et savoir le rassurer si necessaire. Lorsqu’une biopsie osseuse doit etre realisee, celle-ci est effectuee par un chirurgien au bloc operatoire.

Ces recommandations formalisees d’experts ont ete elaborees par la Societe francaise de medecine d’urgence, avec la collaboration de la Societe francaise et francophone des plaies et cicatrisations, la Societe francaise de chirurgie plastique, reconstructrice et esthetique, et le soutien de la Societe francaise de pathologie infectieuse de langue francaise et du Groupe francophone de reanimation et urgences pediatriques. Leur but est de delivrer des messages clefs sur l’un des motifs les plus frequents de prise en charge en structures d’urgence (SU). Il existe peu de consensus relatifs a la prise en charge et a la regulation des plaies en pre-hospitalier comme a l’hopital. Le precedent referentiel national datait de 2005 et necessitait une actualisation. Le principal enjeu en urgence est d’abord d’evaluer le risque vital d’une plaie, puis son devenir fonctionnel et esthetique. Le soin se positionne en support a la cicatrisation naturelle. Le lavage abondant a l’eau controlee est la premiere etape primordiale a enseigner des le plus jeune âge aux populations. Une couverture humide entre les differentes etapes de prise en charge ainsi que l’application d’un protocole d’anesthesie locale anticipee favorise une evaluation et ne detersion mecanique en SU de qualite gage d’une bonne cicatrisation. Il n’existe pas de justification a l’utilisation des antiseptiques en dehors des plaies difficilement accessibles au lavage. La maitrise du risque de contamination exogene d’une plaie est un objectif constant et majeur lors les soins. La notion de delai de fermeture d’une plaie en urgence n’a des lors plus d’interet et il n’existe plus d’indication a une antibiotherapie locale. Une evaluation initiale pertinente ainsi qu’une surveillance du risque infectieux regional ou general implique parfois une antibiotherapie generale, un avis d’un specialiste ou un suivi a la sortie de la SU. Ce referentiel traite de la prise en charge des plaies aigues en SU, y compris sur plaie chronique. Seront exclues les suites de soins, les complications, les plaies chroniques, les brulures ainsi que les lesions survenues dans un contexte nucleaire, radiologique, biologique ou chimique.

L’arteriopathie obliterante des membres inferieurs diagnostiquee par l’index de pression systolique (IPS) est frequente chez les plus de 75 ans. La plethysmographie de type Dopplex® ABility a montre un gain de temps et serait moins operateur dependant que la methode de reference pour la mesure de l’IPS. L’objectif de l’etude etait de verifier la correlation du Dopplex® ABility avec la technique doppler chez les plus de 75 ans hospitalises. Au final, la plethysmographie par Dopplex® ABility ne concorde pas avec le doppler pour la mesure de l’IPS chez les plus de 75 ans hospitalises. Une mesure par photoplethysmographie a l’orteil deja utilisee chez les diabetiques pourrait etre une solution chez les sujets âges.

Objective: In patients with reduced mobility, specialised pressure-relieving supports (mattresses, beds and cushions) are widely used to reduce or relieve the interface pressure between the skin and support surfaces to prevent incidence of pressure ulcers (PUs). The primary objective of these two observational studies was to assess the incidence of PUs in patients at high risk of PUs, seated in a wheelchair using a single- or multi-compartment air cushion. The level of patient satisfaction with the comfort and the views of the care team that used the air cushions were considered as secondary objectives. Method: The PRESCAROH project was two prospective observational studies conducted in patients free of PUs at baseline and at high risk of PUs (Braden score ≤13 or ≤16 for people with spinal cord injury). Patients had to spend more than eight hours a day in a wheelchair and use either a single-compartment air cushion (patient without asymmetry of support) for the first study or a multi-compartment air cushion (patient with asymmetry of support) for the second study. The primary end point was the percentage of patients in whom a PU (sacrum and/or ischium) developed over a 35-day period. The analysis was performed on the full-analysis set (FAS) of patients included with at least a second assessment. Results: We recruited 152 patients, 78 seated on a single-compartment air cushion (SiCAC group) and 74 on a multi-compartment air cushion (MuCAC group), in the two independent studies. All patients were included in the FAS (n=152). Most patients had spinal cord injuries. The average time spent sitting was 10.2 (standard deviation (SD): 2.3) hours a day in the SiCAC group and 9.1 (SD: 1.9) hours a day in the MuCAC group. In the SiCAC group, 6.4% (5/78) of patients dropped out of the study (one patient because of pulmonary infection and four patients for cushion installation problems). In the MuCAC group, 8.1% (6/74) of patients dropped out of the study (three patients because of adverse events not related to cushions, two for onset of PU, one for cushion-related problem). Over the study period of 35 days, 2.6% (2/78) [95% confidence interval (CI): 0.3–9.0%] of patients in the SiCAC group and 4.0% (3/74) [95%CI: 0.8–11.4%] in the MuCAC group developed a PU. Conclusion: These two observational studies showed that in patients at high risk of PUs and seated for more than eight hours a day in a wheelchair, the use of a single-compartment or multi-compartment air cushion with telescopic cells was associated with a low incidence of PUs.

L’hematome dissequant est un decollement sous-cutane profond avec collection de sang constituee rapidement et sous pression entre la peau et le fascia des muscles. Les hematomes dissequants sont frequents mais peu rapportes dans la litterature medicale ou chirurgicale. Aucune etude de prevalence n’est disponible a ce jour. Ils surviennent en general apres un traumatisme mineur chez des personnes âgees sous anticoagulants (AVK le plus souvent) ou antiagregants plaquettaires. Classique complication de la dermatoporose, le probleme de leur prise en charge se pose frequemment aux urgences ou dans les services de geriatrie.

Un certain nombre de complications immediates (saignement, douleur, malaise), rapides (saignement, douleur, infection, retard de cicatrisation, dermatoses autour de la zone de prise de greffe, prurit, necrose) ou retardees (cicatrices pathologiques, alopecie, cancerisation) sont en rapport direct avec le geste de prise de greffe, dʼautres sont des dermatoses survenant sur les sites donneurs de greffe, rapidement ou parfois tres a distance du geste chirurgical (pyoderma gangrenosum, pustulose erosive, pemphigoide). Quel quʼen soit le type, ces complications sont rares mais doivent etre connues afin dʼadapter le traitement.

Avec une population vieillissante, les praticiens sont de plus en plus souvent confrontes aux problemes de cicatrisation chez le patient âge comportant des specificites. L’objectif de cet article est d’aborder dans un premier temps, le vieillissement cutane et ses consequences sur la cicatrisation, puis les troubles de la cicatrisation consecutive au vieillissement cutane et enfin les comorbidites frequentes dans cette population pouvant entrainer des troubles de la cicatrisation. Du fait de ces specificites, la cicatrisation chez le sujet âge est souvent complexe, et doit etre pluridisciplinaire pour permettre une prise en charge optimum.

Objective: To assess the efficacy, safety and acceptability of a new TLC-NOSF dressing with poly-absorbent fibres in the management of exuding leg ulcers, at the different stages of healing. Method: This work presents the results of two prospective, multicentric clinical studies: NEREIDES and CASSIOPEE. Patients with a non-infected, moderate-to-strongly exudating leg ulcer of venous or mixed origin, were treated with the dressing and an appropriate compression system for 12 weeks. The wounds included in NEREIDES had to be in debridement stage, and those in CASSIOPEE at granulation stage. In both studies, the primary outcome was the relative wound area reduction (RWAR) at week 12. Main secondary outcomes included healing rate, time-to-reach wound closure, adverse events and acceptability of the dressing by patients and health professionals. Results: There were 37 patients included in NEREIDES and 51 in CASSIOPEE. The two cohorts presented similar patient and wound characteristics, except from the percentage of sloughy tissue on wound bed at baseline (median: 75% NEREIDES and 30% CASSIOPEE). At week 12, the RWAR (60% NEREIDES and 81% CASSIOPEE), wound closure rates (18% NEREIDES and 20% CASSIOPEE) and mean times-to-reach wound closure (58±27 days NEREIDES and 55±23 days CASSIOPEE) supported the beneficial outcomes of the treatment in both cohorts. In patients with a wound duration ≤6 months, the wound area reduction reached 85% in NEREIDES and 81% in CASSIOPEE, highlighting the importance to initiate adequate treatment as soon as possible. The nature and frequency of the local adverse events were similar in both studies and consistent with the good safety profiles of the poly-absorbent fibres and of the TLC-NOSF dressings. The acceptability of the dressing (easy to apply, conformable and non-adherent to the wound bed at removal, with no pain or bleeding at removal) has been judged ‘very good’ or ‘good’ at each stage of the healing process, by both nursing staff and patients. Conclusion: These clinical results establish the new TLC-NOSF dressing with poly-absorbent fibres (UrgoStart Plus, Laboratoires Urgo) as an effective, safe and simple treatment for the local management of leg ulcers, at the different stages of healing and until wound closure.

Actinic keratosis and squamous cell carcinoma in the elderly. The increase in life expectancy and the change in the habits of the population with respect to UV exposure have led to an increase in the incidence of actinic keratosis (AK) and squamous cell carcinoma (SCC). There is no specific recommendation for the "frail" elderly, but they would not differ much from the recommendations of the younger subjects. AK are common: 1 in 3 men and 1 in 5 women after 70 years. In the absence of treatment, the AK can evolve towards a SCC, justifying the interest of a systematic and early management of the AK by cryotherapy (liquid nitrogen), dynamic phototherapy, cream containing 5-fluorouracil (5(FU), imiquimod or ingenuous mebutate. Incidence of SCC is also important in the elderly and especially in mans. It can be localized on skin or mucosa. There are forms of SCC in situ or Bowen disease, cutaneous or mucosal, accessible to cryotherapy, 5-FU, imiquimod or dynamic phototherapy as an alternative to surgery. The SCC presents a mainly local evolutionary risk, with involvement of adjacent noble organs, but also regional, with significant risk of lymph node metastases, and visceral (lungs, liver in particular). The treatment must be supervised by a multidisciplinary team. If the patient has cognitive disorders, the presence of the "person of trust" is possible. At best the presence of a geriatrician or onco-geriatrician is recommended. Most often active treatment will be considered and surgical excision is the standard treatment. If general anesthesia is required, the limitation may be at this time of management because of significant co-morbidities. For inoperable SCC radiotherapy and radiochemotherapy are sometimes proposed. Metastatic SCC is complex in elderly patients because chemotherapy is poorly tolerated.Kératose actinique et carcinomes épidermoïdes du sujet âgé. L’augmentation de l’espérance de vie et la modification des habitudes de la population vis-à-vis de l’exposition aux rayons ultraviolets ont conduit à l’augmentation d’incidence des kératoses actiniques et des carcinomes épidermoïdes cutanés. Il n’existe pas de recommandation spécifique pour le sujet très âgé « fragile » mais elles ne différeraient pas beaucoup des recommandations concertant les sujets plus jeunes. Les kératoses actiniques sont fréquentes : 1 homme sur 3 et 1 femme sur 5 après 70 ans. En l’absence de traitement, les kératoses actiniques peuvent évoluer vers un carcinome épidermoïde, justifiant l’intérêt d’une prise en charge systématique et précoce des kératoses actiniques par cryothérapie (azote liquide), photothérapie dynamique, crème à base de 5-fluoro-uracile (5-FU), imiquimod ou mébutate d’ingénol. Le carcinome épidermoïde cutané est à risque de métastase, son incidence est également importante chez le sujet âgé et surtout chez l’homme. Il peut être de localisation cutanée ou muqueuse. Il existe des formes de carcinome épidermoïde in situ ou maladie de Bowen cutanée ou muqueuse accessibles à la cryothérapie, au 5-FU, à l’imiquimod ou à la photothérapie dynamique en alternative à la chirurgie. Le carcinome épidermoïde a un risque évolutif principalement local, avec atteinte des organes nobles adjacents, mais également régional, avec un risque non négligeable de métastases ganglionnaires et viscérales (poumons, foie en particulier). La prise en charge doit être encadrée par une réunion de concertation pluridisciplinaire, en présence éventuellement de la personne de confiance si le patient a des troubles cognitifs ; au mieux, la présence d’un gériatre ou oncogériatre est recommandée lors de cette réunion. Le plus souvent, un traitement actif est envisagé, et l’exérèse chirurgicale est le traitement de référence. Si une anesthésie générale est requise, des comorbidités importantes peuvent être une limitation à un geste chirurgical. Pour les carcinomes épidermoïdes inopérables, la radiothérapie externe, la curiethérapie et la radiochimiothérapie sont parfois proposées. Les carcinomes épidermoïdes métastatiques sont de traitement complexe chez le sujet âgé car les chimiothérapies sont mal supportées.

Objective: The primary objective was to assess the incidence of pressure ulcer (PU) in patients at high risk of PU and lying between 15–20 hours per day on an alternating-pressure mattress overlay (APMO). Secondary objectives were the patient's satisfaction with the comfort of the APMO, patient acceptance of its sound level, and the care team's assessment of its use and the moisture level. Method: This prospective observational study was conducted in three rehabilitation centres and two nursing homes between June 2016 and March 2017. To be included, patients should not have PU at baseline and present a high risk of PU (Braden score between 10–15). The primary endpoint was the percentage of patients in whom a PU developed over a 35-day period. Results: A total of 83 patients were included in the study. Neurological disease was responsible for the reduced mobility of 44 (53.7%) patients, 10 patients (12.0%) dropped out (one patient for a serious adverse event (femoral neck fracture) considered not to be related to the APMO, four patients for adverse events, two of which were considered to be related to APMO and five for other reasons, including, in one case, discomfort with the APMO. These patients were considered in the analysis. Over the study period, 1.2% (1/83) (95% confidence interval (CI): 0.03 to 6.53) of patients developed a PU. Patient satisfaction with the comfort of the APMO, patient acceptance of its sound level, and the care team's assessment of its use were considered satisfying for most patients. Conclusion: Based on the findings of this study of a low incidence of PU in participating patients, the use of an AMPO is recommended in high-risk patients lying for between 15–20 hours a day.

International audience; PurposeMedicine acceptability, which is of the utmost importance for vulnerable patients’ adherence, is driven by both user and product characteristics. Herein, a novel multivariate approach integrating the many aspects of acceptability is used to discriminate positively and negatively accepted medicines in the older population.MethodsAn observational study was carried out in eight hospitals and eight nursing homes to collect a large set of real-life data on medicines uses in older patients (≥65 years). Mapping and clustering explored these multiple observational measures and summarised the main information into an intelligible reference framework. Resampling statistics were used to validate the model’s reliability.ResultsA three-dimensional map and two clusters defining acceptability profiles, as positive or negative, emerged from the 1079 evaluations. Factors of interest (medicines, user features…) were positioned on the map at the barycentre of their evaluations and assigned to an acceptability profile. Focusing on patients’ ability to swallow, we have highlighted the tool’s efficacy in demonstrating the impact of user features on medicine acceptability.ConclusionsThis multivariate approach provides a relevant judgement criterion for this multi-dimensional concept. Facilitating the choice of the most appropriate dosage form to achieve optimal acceptability in a targeted population, this tool is of real potential to improve clinical decisions.

International audience; Flammacerium is a topical treatment composed of silver sulfadiazine and cerium nitrate initially used in burns. The objective was to assess the effectiveness of silver sulfadiazine and cerium nitrate on ischemic necrosis wounds of the lower limb as an alternative to amputation for a period of 12 weeks. Patients were prospectively randomized to receive silver sulfadiazine and cerium nitrate or standard care. Patients included adults with an ischemic wound of the lower limb, with necrosis covering over at least 50%. Critical ischemia limb was confirmed by an ankle-brachial index \textless0.7 or \textgreater1.3 with radiological confirmation. Patient demographic data, amputations procedures, wound area, Visual Analogue Scale pain rating, clinical infection, and adverse events were recorded. Fifty patients, 34 males and 16 females, were recruited between January 2010 and April 2014, 25 in each group. The mean age was 75.14 years (\textpm11.64). Nine amputations (36%) occurred in each group. Amputation-free survival was superior in the active treatment group versus the standard group (169 393 days, 95% confidence interval = 134.926-203.861, vs 169 393 days, 95% confidence interval = 134.926-203.861). It was not statistically significant (log-rank, P = .958). Wound area reduction between both groups was not statistically different ( P = .651). Less adverse events of the lower limb occurred in the active treatment group ( P = .001). Our study showed that silver sulfadiazine and cerium nitrate is not inferior to standardized care on ischemic necrotic wounds of the lower extremity. Further studies are still needed to confirm its effectiveness.

Objective: We recently showed the superiority of a matrix metalloproteinase (MMP) modulating dressing (foam impregnated with NOSF, nano-oligosaccharide factor) compared with a lipidocolloid matrix (TLC) control dressing in median wound area reduction (WAR). Here we report the results from the same study assessing the performance and safety of TLC-NOSF in the local management of venous leg ulcers (VLUs) or mixed leg ulcers and determining its impact on the patient's health-related quality of life (HRQoL). Method: A superiority randomised double-blind controlled trial was conducted on patients presenting with a non-infected leg ulcer (VLUs or mixed leg ulcers) of predominantly venous origin (ABPI >0.8), with a surface area ranging from 5 to 50cm2 and a duration of 6 to 36 months. Patients were randomly allocated to either the TLC-NOSF matrix foam (UrgoStart) dressing group or to the neutral TLC foam dressing group (UrgoTul Absorb). All received appropriate compression therapy and the wounds were assessed blindly (clinical examination, wound area tracing and photographic record) every 2 weeks for a period of 8 weeks, or until complete closure. A secondary endpoint, described here, was the patient's HRQoL, documented by the patient, through the EuroQol 5D tool (EQ-5D) questionnaire and visual analogue scale (VAS). Results: In total, 187 patients were randomised to either the TLC-NOSF group (n=94) or the control dressing group (n=93). The two groups were well balanced at baseline with regard to wound and patient characteristics. In the HRQoL questionnaire (EQ-5D), the pain/discomfort and anxiety/depression dimensions were significantly improved in the TLC-NOSF group versus the control one (pain/discomfort: 1.53±0.53 versus 1.74±0.65; p=0.022, and anxiety/depression: 1.35±0.53 versus 1.54±0.60, p=0.037). The VAS score was better in the test group compared with the control group (72.1±17.5 versus 67.3±18.7, respectively), without reaching significance (p=0.072). Acceptability and tolerance of the two products were similar in both groups. Conclusion: The double-blind clinical trial has demonstrated that the TLC-NOSF matrix dressing promotes faster healing of VLUs and mixed leg ulcers and significantly reduces the pain/discomfort and anxiety/depression experienced by the patients. These results suggest that acceleration of VLU healing could improve the HRQoL of the patients and reduced the emotional and social burden of these chronic wounds.

Objective: A number of randomised controlled trials (RCT) have compared control groups with TLC-NOSF dressings (UrgoStart) on chronic wounds. Our aim was to determine whether the clinical trials' results translate into routine management of such wounds, by pooling the data from real-life observational studies. Method: Observational studies, conducted in France and Germany, evaluating current practices in patients suffering from non-selected chronic wounds treated with a TLC-NOSF dressing were identified. Demographic data, baseline description of wounds and description of their evolution during treatment were extracted and combined. We used two main indicators of clinical outcomes to measure the impact of the TLC-NOSF dressing on this population: time to wound closure and time to 50% reduction of the Pressure Ulcer Scale for Healing (PUSH) score. Results: In total, data from 10,220 patients were included, with 7903 leg ulcers (LUs), 1306 diabetic foot ulcers (DFUs) and 1011 pressure ulcers (PUs). The overall closure rate was 30.8 % [95 % confidence interval (CI): 29.9–31.7 %]. While the country, patient age, and number of wounds were identified as independent prognosis factors of healing, the most significant were wound duration and baseline area. The delay in initiating TLC-NOSF dressings treatment was also found to be significant. Overall the average time to complete closure was 112.5 days [95%CI: 105.8–119.3] for LUs, 98.1 days [95 %CI: 88.8–107.5] for DFUs and 119.5 days [95%CI: 94.6–144.3] for PUs. Based on a subgroup analysis of the French cohort, time to closure is substantially shorter for wounds treated with the TLC-NOSF dressing as a first-line intervention compared with those where it has been prescribed as a second-line intervention. Conclusion: Compared with available data on time to complete closure of chronic wounds managed by ‘standard’ care, the data from this pooled data analysis showed healing time is reduced, which is consistent with the results of RCTs on TLC-NOSF. That these data are in agreement with those from the RCTs is testimony to their generalisability and important for routine practice. This indicates that using TLC-NOSF dressings in routine wound management can reduce the healing time of LUs, DFUs and PUs. These data also suggest that the earlier the decision to use this dressing, the shorter the time to closure, whatever the severity and the nature of these chronic wounds.

SummaryHypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities.An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes.The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

Negative-pressure wound therapy (NPWT) was developed in the early 1990s and reported in 1997 by Argenta and Morykwas. Ignored at first, this technique progressively came to be considered as an outstanding advancement in reconstructive surgery. Several randomized controlled studies produced evidence for the effect of NPWT on promotion of granulation tissue formation and prevention of tissue damage and amputation. However, no important longitudinal study has yet produced clinical and economic data on the consequences of integrating NPWT into practice in multiple institutions. This prospective, comparative longitudinal study of NPWT as a clinical-practice innovation was conducted in 1,126 patients between March 2006 and June 2009 in 30 university and nonuniversity public and private hospitals in France. NPWT was proposed in a nonrandomized fashion for various clinical indications, and the patients were divided into two groups, one using NPWT, the second using standard care. Efficacy criteria were spontaneous closure, closure after surgical coverage using skin grafts or flaps, or achievement of 40% wound area regression. The results, observed in a pragmatic but not randomized study, are suggestive of a favorable impact of NPWT in multiple clinical situations. The significance of differences between surgical patients who underwent NPWT and those who did not was unclear, as NPWT had already been adopted by most of the surgical wards.

Objective: To evaluate the performance (efficacy, safety and acceptability) of a new micro-adherent absorbent dressing (UrgoClean®) compared with a hydrofiber dressing (Aquacel®) in the local management of venous leg ulcers, in their debridement stage. Method: A non-inferiority European randomised controlled clinical trial (RCT) was conducted in 37 centres, on patients presenting with venous or predominantly venous, mixed aetiology leg ulcers at their sloughy stage (with more than 70% of the wound bed covered with slough at baseline). Patients were followed over a 6-week period and assessed weekly. The primary judgement criteria was the relative regression of the wound surface area after the 6-week treatment period. Secondary endpoints were the relative reduction of sloughy tissue and the percentage of patients presenting with a debrided wound. Results: Altogether, 159 patients were randomised to either UrgoClean (test group; n=83) or Aquacel (control group; n=76) dressings. Regarding the wound healing process predictive factors (wound area, duration, ABPI value, recurrence), at baseline, the two groups were well balanced, for both wound and patient characteristics. Compression therapy was administered to both groups and after a median 42-day treatment period, the percentage of relative reduction of the wound surface area was very similar (-36.9% vs -35.4% in the UrgoClean and control groups, respectively). When considering the secondary criteria at week 6, the relative reduction of sloughy tissue was significantly higher in the UrgoClean group than in the control group (-65.3% vs -42,6%; p=0.013). The percentage of debrided wounds was also significantly higher in the test group (52.5% vs 35.1%; p=0.033). Conclusion: This ‘EARTH’ RCT confirmed that the UrgoClean dressing has similar efficacy and safety compared to Aquacel. However, UrgoClean also showed better autolytic properties than the control group in the management of venous leg ulcers at the sloughy stage. The new UrgoClean dressing therefore represents a promising therapeutic option within the current range of autolytic dressings available. Declaration of interest: This study was sponsored by a grant from the pharmaceutical company Laboratoires Urgo. S. Bohbot and O. Tacca are employees of Laboratoires Urgo. S. Meaume, J. Dissemond and G. Perceau have received monetary compensation as presenters for Laboratoires Urgo. Data management and statistical analyses were conducted independently by Vertical (Paris, France).

Between 5% and 10% of cancer patients develop malignant wounds. Cancer wounds can occur as a clinical entity, especially over the breast, with the development of painful, spreading cancer invasions of the skin. Marjolin's ulcers develop in open wounds after a long period, and form rare malignancies arising from previously traumatised, chronically inflamed, or scarred skin. Marjolin's ulcer is associated with malignant transformation of chronic ulcers, sinus tracts, and burn scars. Squamous cell carcinoma may be linked to a wide variety of medical and surgical clinical situations, such as chronic ulcers, sinuses, chronic osteomyelitis, radiotherapy, burn scars, chronic pressure ulcers, as well as cystostomy sites, and Fournier's gangrene scars. Melanomas, lymphomas, and other cancers can also be observed. Basal cell carcinoma is more frequently observed in ulcers associated with venous insufficiency. According to some reports, the ulcer should have existed for at least 3 years to evoke a diagnosis of degenerescence as opposed ulcerated tumour. Epidermoid carcinomas represent between 0.21% and 0.34% of cancers that develop over leg ulcers, but large series are still lacking. The current lack of epidemiological data could be rectified by more frequent evocation of the diagnosis and a policy of systematic biopsy of chronically open wounds.

Philippe Humbert,1 Brigitte Dréno,2 Jean Krutmann,3 Thomas Anton Luger,4 Raoul Triller,5 Sylvie Meaume,6 Sophie Seité71Research and Studies Centre on the Integument (CERT), Clinical Investigation Centre (CIC BT506), Department of Dermatology, Besançon University Hospital, University of Franche-Comté, Besançon, France; 2Department of Dermato-Cancerology, Nantes University Hospital, Nantes, France; 3IUF-Leibniz Research Institute for Environmental Medicine, Heinrich-Heine-University, Düsseldorf, Germany; 4Department of Dermatology, University of Münster, Münster, Germany; 5International Centre of Dermatology, Hertford British Hospital, Levallois, France; 6Geriatric Service, Wounds and Healing, Rothschild Hôspital, Paris, France; 7La Roche-Posay Dermatological Laboratories, Asnières, FranceAbstract: The increasingly aged population worldwide means more people are living with chronic diseases, reduced autonomy, and taking various medications. Health professionals should take these into consideration when managing dermatological problems in elderly patients. Accordingly, current research is investigating the dermatological problems associated with the loss of cutaneous function with age. As cell renewal slows, the physical and chemical barrier function declines, cutaneous permeability increases, and the skin becomes increasingly vulnerable to external factors. In geriatric dermatology, the consequences of cutaneous aging lead to xerosis, skin folding, moisture-associated skin damage, and impaired wound healing. These problems pose significant challenges for both the elderly and their carers. Most often, nurses manage skin care in the elderly. However, until recently, little attention has been paid to developing appropriate, evidence-based, skincare protocols. The objective of this paper is to highlight common clinical problems with aging skin and provide some appropriate advice on cosmetic protocols for managing them. A review of the literature from 2004 to 2014 using PubMed was performed by a working group of six European dermatologists with clinical and research experience in dermatology. Basic topical therapy can restore and protect skin barrier function, which relieves problems associated with xerosis, prevents aggravating moisture-associated skin damage, and enhances quality of life. In conclusion, the authors provide physicians with practical recommendations to assist them in implementing basic skin care for the elderly in an integrated care approach.Keywords: elderly, skin, cosmetic management