Intended for healthcare professionals

Rapid response to:

Clinical Review

Management of venous ulcer disease

BMJ 2010; 341 doi: (Published 12 November 2010) Cite this as: BMJ 2010;341:c6045

Rapid Response:

Management of venous ulcer disease

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.

10 January 2011
Pedro Redondo
Pedro lloret, Juan Cabrera
University Clinic of Navarra