2023-05-18 10:00:04
Chronic wounds represent an increasing medical and economic problem worldwide. The majority of these wounds manifest as diabetic foot syndrome, decubitus, wounds from peripheral arterial occlusive disease or leg ulcers. In Germany, the medical costs of patients with chronic leg ulcers are 9,500 euros per patient and year, whereby a reliable diagnosis can have a major impact on the costs. What is still unclear, however, is what significance do comorbidities (e.g. the metabolic syndrome) and cofactors (e.g. body size) have on the course of chronic leg ulcers? Finja Jockenhöfer, assistant doctor, and Prof. Dr. medical Joachim Dissemond, both in the clinic and polyclinic for dermatology, venereology and allergology at the University Hospital Essen. In their multi-centre study, they not only examined the genesis, but also the comorbidities and cofactors of 1,000 patients with chronic leg ulcers from ten dermatological wound centers.
The results
Venous leg ulcers were the most common cause with 51.3%, followed by mixed leg leg ulcers with 12.9% and arteriolar leg ulcers with 11.0%. Other diagnoses were vasculitis in 4.5%, trauma in 3.2%, pyoderma gangrenosum in 2.8%, lymphedema in 1.7%, neoplasia in 1.0% and postoperative wound healing disorders in 0.6% of the patients: Inside. In 11.0% of the patients, the exact genesis could not be determined [Abb. 1]. Of the 513 patients with a venous leg ulcer, 239 (46.7%) had a thrombosis and/or a postthrombotic syndrome.
Abb. 1: Genesis of chronic leg ulcers nationwide.
It should be mentioned that only dermatological wound centers were included in this study. This could have led to the patient population examined representing a negative selection of patients, since uncomplicated wounds can more often be successfully treated by general practitioners, for example. In addition, a subject-specific preselection of patients takes place in Germany. Venous diseases are often treated by dermatologists with phlebological training, while arterial diseases are more likely to be diagnosed and treated by angiologists or vascular surgeons.
The distribution of the comorbidities is just as heterogeneous as the genesis. Current estimates by the Institute for Workplace Health Promotion (BGF) of the General Local Health Insurance Fund (AOK) state that 20 million people in Germany are affected by a metabolic syndrome. Of the patients examined, 70.5% had manifest hypertension, 27.2% had glucose tolerance disorders in the form of type 2 diabetes mellitus and 24.4% (n = 738) had hyperlipidemia. Overall, 45.2% (n = 746) had a BMI ≥ 30 and were therefore (according to WHO) obese. In addition, there were different combinations of risk constellations in this population, which were therefore compatible with a total of 18.4% of the patients with a metabolic syndrome [Tab. 1].
Metabolic Syndrome | Genesis | |||
absolut | % | absolut | % | |
Venous leg ulcer | 84 | 45,7 | 513 | 16,4 |
Mixed leg ulcer | 33 | 17,9 | 129 | 25,6 |
Arterial leg ulcer | 27 | 14,7 | 110 | 24,5 |
Not clear | 23 | 12,5 | 110 | 20,9 |
Vasculitis | 5 | 2,7 | 38 | 13,2 |
Post-traumatic leg ulcers | 4 | 2,2 | 32 | 12,5 |
lymphedema | 3 | 1,6 | 17 | 17,6 |
Pyoderma gangraenosum | 2 | 1,1 | 28 | 7,1 |
Post OP | 2 | 1,1 | 6 | 33,3 |
Neoplasms | 1 | 0,5 | 10 | 10,0 |
In total | 184 | 100 | 1.000 | 100 |
Tab. 1: Metabolic syndrome related to the genesis of chronic leg ulcers.
The patients with vascular origin most frequently had hypertension, for example 88.4% of mixed leg ulcers, 84.2% of vasculitis, 73.6% of arterial leg ulcers and 66.2% of venous leg ulcers. This association could be due to the pathological interaction of degenerated venous, atherosclerotic arterial and inflammatory damaged vessels due to permanent hypertension.
Obesity was found in 45.2% of the patients. This was found particularly often with 91.6% in the presence of lymphedema, followed with 53.8% with pyoderma gangrenosum. The causal connection between lymphoedema and obesity can be explained, among other things, by the obvious lack of exercise. For patients with pyoderma gangrenosum, it was currently discussed that obesity is a relevant cofactor of inflammation in 32.6%. These data are comparable to the results shown here. Impaired glucose tolerance in type 2 diabetes mellitus plays a major role in patients with ulcus cruris arteriosum (46.4%) and mixtum (37.2%). Hyperlipidemia was also present in more than a third of the patients with arterial (34.9%) and mixed (33.7%) ulcers. Here, too, atherosclerotic remodeling of the vessels, favored by the comorbidities associated with hyperglucosemia and hyperlipidemia, could provide an explanation.
The complete risk constellation of the metabolic syndrome showed the clearest prevalence in patients with vascular wounds. Arterial (24.5%), mixed (25.6%), and venous (16.4%) ulcers accounted for about a quarter of these diagnoses. Overall, it can be seen that the comorbidities, the manifestation of which is in the arterial vascular system, occur more frequently in patients with a leg ulcer and mixed leg ulcer.
In addition to comorbidities, there are other factors that influence wound healing. It was shown that PAOD (p = 0.022), also combined with CVI (p = 0.001), was diagnosed more frequently with increasing age. This can be explained by progressive atherosclerosis with increasing age. The correlation was the opposite for lymphedema (p = 0.01) or pyoderma gangrenosum
(p=0.001). These diagnoses were made more frequently the younger the patients were. A CVI correlated significantly positively (p = 0.002) with the duration of existence, which in turn with age, which is associated with an increased incidence of CVI. Pyoderma gangrenosum, on the other hand, correlated significantly negatively (p = 0.039) with the duration of its existence, which reflects the course of a relapsing, rapidly occurring and usually extremely painful disease with a very high level of suffering.
Conclusion
In addition to the genesis of patients with chronic leg ulcers, the multi-centre study was able to show that there are specific correlations between comorbidities and cofactors. Since it has been shown again and again in recent years that these factors can be negative predictors of wound healing, appropriate diagnostics and, if necessary, therapy should be integrated into an individual overall concept, for example in the form of structured treatment programs for the patient.
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