Non-healing leg ulcer

12. 7. 2011

Casuistry – non-healing leg ulcer

Prim. MUDr. Helena Němcová, Anna Snopková, dermatology ambulance + welfare institution, KKN. a. s., Hospital in Sokolov

Ulcerus cruris as a chronic wound can be of various etiology, mostly venous or arterial, possibly of mixed etiology. Sometimes there is not possible to find a primary causation, what results in cases of non-healing leg ulcers, from which a patient suffers for many months or years. Despite of the entire examination effort and a therapy both general and local, whether standard treatment or treatment with modern dressings, repeated hospitalisations and nursery care, these ulcerations heal and recur repeatedly and sometimes they do not heal completely at all. This casuistry concerns a patient from this group, even if we, during continuous observations and examinations, have found other diseases worsening the ulcerations.

Casuistry Male patient: born in 1926. Family history: father died of injury consequence, mother died of old age, otherwise insignificant Personal history: varicose veins since youth, without inflammation, thrombosis and erysipelas. Injury in 1946 – burn of the right shinbone, healed with scar. Stopped smoking in 1976. Anaemia found during the years – Fe, acidum folicum substitution, limit hypertension – diuretics/ problematic treatment – the patient did not visit GP. Angiopathia hypertonica found in ophthalmology ward In 2006, during hospitalisation in dermatology ward, IgG paraproteinemia found – observed by haematologist, without therapy In 2009 – operation of cataract in ophthalmology ward

Current disease: The first ulceration appeared on the right shinbone in burn scar area in 1975, since then repeated recurs, use to be healed even 2–3 years. The patient has been in our ambulance care since 1994, the last ulceration before in 1990, healed in 1997. Now, since 2002 almost permanently ulcerations on the right shinbone with gradual extend, since 2006 on the left shinbone, too. Repeatedly hospitalised in dermatology ward – in 1996, 2002, 2003, 2006, 2007, 2009. In 6/2008 we noticed emerging blisters with a pellucid content around the defect on the right side. With regard to the localisation and the patient´s reluc­tance, the histological examination was not performed. Prednisone in 40 mg dose was administered – clinical summary Pemigoid bullosus. Since that time, gradual healing of the right ulceration, the ulceration on the left healed earlier (in the first half of 2009)

Examination: Repeated USG of lower limbs veins and arteries – without more significant pathology, repeated laboratory checks.

Course: The largest ulcerations extent was in 2006 – 2007 – on the right side the defect circumferently occupies almost the whole shinbone, width 15 – 22cm, repeatedly coated base, ulceration on the inner side of the shinbone 10×20 cm

Therapy: Generally – venotonics, diuretic, antianemics, vitamins, temporarily Nutridrink, Cubitan, analgesics, antiagregants, repeatedly antibiotics – according to smear and sensitiveness, cured repeatedly with antimycotics (for onychomycosis finding) Locally – standard therapy: Poultices, boric acid, Dermacyn, Prontosan, temporarily Persteril Unguent therapy: Boricum unguent 3% (with jecoris aselli oleum), borargent, rivanolum paste, flegmotom, Luzas´s paste. Modern dressing: Actisorb, Estex, Comfeel ulcer. dress., Traumastem Biodress. Physical therapy: bandages, lymphatic drainage (Lymfoven machine), bio-stimulating laser, bio-lamp, magnetotherapy The patient was treated during the hospitalisation, at first he treated himself at home, temporarily he used homecare and at most, especially in last years, he regularly visited our ambulance for rebandages, 3–4 times a week. The complete healing in the first half of 2009 – good effect of Compfeel ulcer.dress., gradual improvement on the right side after administration of total corticosteroid during finding the blisters in 6/2009. Currently keep-up dose of Prednisone 5–10 mg

Conclusion At the conclusion I would like to state the fact resulting from our casuistry – the long-term treatment, even outpatient, definitely pays off, due to the regular observations and repeated examinations and treating the patient with extend ulceration. It was also possible to find further factor with etiologic effect – in this case it was found and cured anaemia, hypertension, paraproteinemia and finally the localised form of Pemphigoid bullosus with an adequate treatment. This leads to a partial or complete healing of seemingly non-healing leg ulcers. It is necessary to emphasize careful and accurate nursery work and nurses´ observation of the patient and advising the doctor in case of new factors, the patient´s general state, nutrition, painfulness, any change of the wound character and in this particular case even the finding of the blisters emerging in the defect surroundings. Even if sometimes the treatment of the patients with leg ulcers seems to be „Sisyphean task”, every little progress and development towards the healing is a real success.