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EDITOR- The clinical review of Management of venous ulcer disease by van Gent et al is comprenhensive and clear, although some aspects deserve comment(1). We agree that venous hypertension is the underlying cause of venous ulceration. The authors postulate that compression is the mainstay of treatment, although surgery can help to promote healing. Compression therapy is associated with a protracted course of healing and multiple recurrences, while subfascial endoscopic perforator vein surgery reduces recurrence. They affirm that there are no data on ultrasound guided foam sclerotherapy efficacy in treating venous ulceration.

We have recently published a study of 116 patients with chronic venous ulcers treated with ultrasound-guided injection of polidocanol microfoam (UIPM)(2). To reduce venous hypertension UIPM was used to selectively sclerose sources of incompetence. At 6-months?follow-up, treatment with UIPM achieved complete healing in 83% of patients with median time to healing of 2.7 months. In comparison with the patients treated with allogeneic cultured human skin equivalent of a previously reported series,(3) we obtained a highly significant advantage for our overall results (X2 test, P<.001). Recent studies have reported similar healing rates with the use of foam sclerotherapy in smaller series(4).

Skin closure rapidly occurs when venous hypertension is decreased. The ablation of superficial and perforator vein incompetence provides clinical and hemodynamic improvement in patients with chronic venous ulcers. Subfascial endoscopic perforator surgery has become the surgical technique of choice for perforator ablation, although this approach cannot be adopted in all cases. Small interconnected collaterals between the perforators and the skin frequently convey the venous hypertension to the skin area, and surgical procedures are inherently unable to treat these vessels. However UIPM is able to close these small interconnected collateral veins (5). UIPM of superficial and perforating incompetent veins is a well-tolerated and effective outpatient procedure. This technique may become a first-line treatment in the management of leg venous ulcers.

Pedro Redondo, Dermatologist

Pedro Lloret, Dermatologist
Department of Dermatology, University Clinic, Medical School, University of Navarra, 31080 Pamplona, Spain.

Juan Cabrera, Vascular Surgeon Vascular Surgery Clinic, Granada, Spain

1.- van Gent WB, Wilschut ED, Wittens C. Management of venous ulcer disease BMJ 2010; 341: 1092-6.

2.- Cabrera J, Redondo P, Becerra A, et al. Ultrasound-guided injection of polidocanol microfoam in the management of venous leg ulcers. Arch Dermatol 2004; 140: 667-73.

3.- Falanga V, Margolis D, Alvarez O, et al, and the Human Skin Equivalent Investigators Group. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Arch Dermatol 1998; 134: 293-300.

4.- Darvall KA, Bate GR, Adam DJ, Silcerman SH, Bradbury AW. Ultrasound-guided foam sclerotherapy for the treatment of chronic venous ulceration: a preliminary study. Eur J Vasc Surg 2009;38:764-9.

5.- Cheng UL, Shortell CK, Bergan JJ. Foam treatment of venous leg ulcers: a continuining experience. In: Venous ulcers (Bergan JJ et Shortell CK eds). Burlington, MA, USA: Elsevier Inc. 2007; 227-242.

Competing interests: Dr J. Cabrera have a financial interest in the commercial development of the patented microfoam (BTG International Limited). Provensis Ltd, a subsidiary of BTG, has developed the patented microfoam concept into a pharmaceutical product, Varisolve, which is currently used in clinical trials in Europe and the United States.

Pedro Redondo, Dermatologist

Pedro lloret, Juan Cabrera

University Clinic of Navarra

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24 November 2010

Venous leg ulceration is a chronic condition with consequences to the individual that reach beyond the breached squamous epithelium. Patients with venous ulceration may experience significant pain, depression, sleep disturbance and disability (1). The review by Wijnand Bert van Gent and colleagues evinces a description of the pathology and medical treatment of venous ulcers but it is surprising coy about the effect on the patients wellbeing and what to do about it.

Pain is a significant problem in a large minority of patients with venous ulcers (2). Dressing changes can be especially painful and a number of strategies have been tried to prevent this. Some patients experience continuous severe pain in between dressing changes which makes life very difficult for them and their carers. Doctors in the 21st century understand that the management of chronic conditions isn't just about the pathology and biology of disease it is also about the managing pain, disability and suffering which Wijnand Bert van Gent and colleagues seem to have chosen to ignore.

1. Hamer C. Patients' perceptions of chronic leg ulcers. J Wound Care 1994; 3: 99-101 2. Noonan L, Burge SM. Venous leg ulcers: is pain a problem? Phlebology 1998; 3: 14-9

Competing interests: None declared

Ivan L Marples, Consultant in Pain Medicine

Lothian Health Board

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Dear Editor,

May I flag up an important omission in the otherwise useful article by van Gent & co-authors? As the authors point out (1), venous ulcers are common and consume huge health resources. However, under the heading of 'surgical management' they refer only to techniques for the long-term relief of the venous hypertension which underlies the origin of the ulcer.

But if we are to tackle costs, we need to shorten the time when the ulcer is being actively dressed, which is when resource needs are at their most intensive. In this context the authors fail to mention the proven technique of tangential shaving and skin grafting (2,3) which can dramatically shorten this time and produce full healing within 7-10 days.

It is a simple but demanding process which removes pain, the need for regular wound care and the potential for infection. It does not of course relieve the tendency for ulceration but allows care to focus on vascular support by the wearing of graduated compression stockings which can cost as little as ten pounds ($16, E12) per pair.

Yours sincerely,

Peter Mahaffey FRCS

1)van Gent,W et al, BMJ 2010 341 1092-6

2)Schmeller, W et al J Am Acad Derm 1998 39 232-8

3)Quaba,AA et al J Plast Recon Aesth Surg 1987 40 68-72

Competing interests: None declared

Peter J Mahaffey, consultant plastic surgeon

bedford hospital nhs trust

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A perhaps forgotten treatment for ulcus cruris was first used over 70 years ago by the German doctor who "discovered" the usefulness of a natural substance called carbo coffeae. His name was August Heisler.

He found many uses for this substance which is derived from the coffee bean, made into extremely fine powder. Similar but much superior in action to animal charcoal, it "cleans" up and it drastically increases local circulation.

Dusted on to inflamed tonsils, he would often eliminate the need for other intervention as the tonsils would become fiery red and soon return to a normal status. Similar action was observed with all kinds of intestinal problems, the carbo would simply do a wonderful job of housecleaning.

I have witnessed countless venous ulcers reluctant to heal yield to the application of carbo, no other assistance (eg massage) was necessary. A toe (diabetic dry gangrene) scheduled for amputation with the appearance of a "goner" was restored within 2 days by this substance.

For decades the German company MADAUS sold this, it is still available through WELEDA I believe.

Such a simple, harmless, inexpensive and highly rewarding treatment.

The technique for ulcus cruris venosum is as follows: Clean the wound with hydrogen peroxide. Flush with saline solution. When dry, apply carbo powder and finish with Varihesive bandage (Made by Convatec).

The success rate is about 90 %.

Competing interests: None declared

Dr. Herbert H. Nehrlich, Semi-retired

Private Practice

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The three continental authors have given us a quite excellent review of venous ulcer disease. Giving credit to another continental scource,Denmark,I would make a plea for more active physiotherapy as part of the management.

Bisgaard,himself,as part of his regimen,used sessions of deep massage around the ulcer with a suitable emollient cream. This reduced the oedema and encouraged the ingrowth of new bloodvessels. It also benefitted the patients by their association with an active physiotherapist.

Active massage was used by Falconer at the Western General in Edinburgh, by Buchan at Bangour and myself in Hartlepool between 1948 and 1984. I wonder if this is historical and has the practice and usage of massage in Physiotherapy changed?

Competing interests: None declared

Gordon H McNaught, retired surgeon

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