J.D.D. Vuerstaek*, J.C.J.M. Veraart*, J. Wuite, H.A.M. Neumann†
* Department of Dermatologie, Academisch Ziekenhuis Maastricht
Department of dermatology, Atrium medisch centrum, Heerlen
Department of Dermatologie, Erasmus MC Rotterdam
Summary
We report a patient with a severe chronic ulcerated necrobiosis lipoidica (NL) who responded well to Vacuum Assisted Closure therapy (VAC®). The patient had suffered to persistent ulcerations localized in the atrophic NL lesion for a period of one year. Until now most treatments for ulcerated NLs show moderate success rates. Creating a sub-atmospheric pressure, the healing of atrophic NL lesions with ulceration could be supported.
In this case, the ulceration and the atrophic lesion healed completely after 46 days and have remained free of ulceration since 12 months.
Key words: ulcerated necrobiosis lipoidica, vacuum sealing, VAC®
Necrobiosis lipoïdica (NL) is a chronic granulomatous inflammatory skin disease, which results into a degeneration of collagen, associated with diabetes.1,2 The classic lesions are oval or irregular indurated plaques with central atrophy and sclerosis occurring over the front of the lower leg. About a third of patients suffering from NL show painful ulcerations of the involved atrophic skin, which are usually resistant to therapy (topical and intralesional injections of corticosteroids, surgical treatments, nicotinamide, antiplatelet and fibrinolytic agents, cyclosporin and topical tretinoin).3
In this case report, the results of the treatment by VAC® in a patient with ulcerating NL is described. Creating a sub-atmospheric pressure, the healing process of the ulcerated NL lesion could be supported. This kind of technique has so far never been publish in the treatment of ulcerated necrobiosis lipoidica lesions and seems to be successful.
Case report
A 24-year-old female diabetic patient (Insulin Dependent Diabetic Mellitus) presented with a history of atrophic, yellow-brown pretibial patches, approximately 15 x 20 cm localized on both lower legs (Figs. 1). In the centre of left lesion painfull ulcerations were present. A number of previous long-term treatment regimens with topical and oral corticosteroids, pentoxifylline, antiplatelet agents, surgical debridement and transplantation and topical therapy like: antiseptic substances, hydrogels, absorption and hydrocolloid foams combined with compression had been used. Nevertheless, the ulcerations persisted continuously for > 1 year.
The VAC® technique was used to reduce the degree of atrophy by stimulating the granulation tissue and supporting the transplants. During this therapy the patient was hospitalized until total wound closing.
The VAC® technique was performed as described before in the treatment of chronic leg ulcers.6 After a Polyurethane ether (PU) foam was trimmed to the appropriate size of the NL lesion, this foam was applied on the total NL lesion, the surface of the foam dressing was covered by an adhesive drape, extending 5 cm beyond the wound border, a continue sub-atmospheric pressure of 125 mmHg was applied to the wound. The proximal end of the evacuation tube leads to a collection canister localized on the VAC® pump. So, an open wound was now converted to a controlled closed wound. This therapy was monitored and changed twice a week.
Subsequently, biopt transplantation with post transplantation vacuum sealing using a Polyvinylalcohol (PVA) foam was performed, after the atrophic and ulcerated lesion was converted into a vitalized and granulated wound bed (Figs 2). When all punch grafts were attached well, local conventional therapy was continued until the wound was fully closed.
The chronic and atrophic NL wound bed was prepared to transplantation in 17 days. The patient reported by that time already less pain. Subsequently, post transplantation vacuum sealing was performed until the grafts adhered well (another extra 10 days). Thereafter, local therapy by conventional wound care techniques (hydrocolloid foam) combined with minor compression therapy was continued until wound closing. The ulcerated necrobiotic lesion was healed in 46 days. One year later, there was a marked reduction of skin atrophy with residual postinflammatory hyperpigmentation (Figs 3). No other episodes of ulceration were noted.
Discussion
Despite extensive investigation, the cause of NL is unknown. Whatever the pathogenesis is, the impairment of the microcirculation, the tissue necrosis and atrophy in NL lesions, explain the poor results of many treatments to ulcerated NL. Any therapy that would reduce all these tissue changes could be of potential benefit in decreasing the risk of ulceration.
The VAC® technique is an active, non-invasive wound care technique.5,6,8 The exact mechanisms to explain the effectiveness of this treatment are not known yet. In vitro research postulated some interrelated factors, devised in 3 subgroups: (1) Removing, (2) Improving, (3) Reducing.5-10
(1) The collection of the interstitial third-space fluid contains factors, which inhibits or suppresses mitosis the wound healing process. An active withdrawal of this fluid removes these inhibitory factors. The active withdrawal also results of course in removing of wound debris.5-10
(2) The collection of third space fluid mechanically comprises the micro-vascularisation and lymphatic system in chronic leg ulcers. Removing this fluid results in decompressing small blood vessels and restoring blood flow. 5-10
(3) It is known that successful wound healing correlates with bacterial counts of less than 100.000 organisms per gram of tissue. Bacterial counts of human wounds treated by VAC® techniques have demonstrated a significant decrease after 3-4 days usually until less than 1000 per gram of tissue. 5-10
Regarding the preceding discussion helps explain the therapeutic effect using the VAC® technique in necrobiotic ulcerations.
Summarised, ulceration is a major complication of NL. Any therapy that may decrease the risk of ulceration would be of value. By stimulating the microvasularisation, the granulation formation and epithelialisation, independent the pathogenesis, VAC® will improve the wound healing process of chronic ulcers. The results of this index case are encouraging and provide an advantageous alternative to standard methods.1-4
Despite the positive effects, this method needs more and further investigation. Further studies on the use of VAC® in ulcerative necrobiosis lipoidica, other ulcerative disorders and the recurrence risk are warranted.
References
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