Applied Evidence
How to do a 3-minute diabetic foot exam
This brief exam will help you to quickly detect major risks and prompt you to refer patients to appropriate specialists.
PRACTICE CHANGER
Consider adding simvastatin 40 mg/d to standard wound care and compression for patients with venous stasis ulcers.1
Strength of recommendation
B: Based on a high-quality randomized controlled trial (RCT).
Evangelista MT, Casintahan MF, Villafuerte LL. Simvastatin as a novel therapeutic agent for venous ulcers: a randomized, double-blind, placebo-controlled trial. Br J Dermatol. 2014;170:1151-1157.
Illustrative case
A 74-year-old woman with chronic lower extremity edema seeks treatment for a nonhealing venous stasis ulcer. For the past 9 months, she’s been wearing compression stockings and receiving intermittent home-based wound care, but nothing seems to help. She asks if there’s anything else she can try.
Venous stasis ulcers affect 1% of US adults and lead to substantial morbidity and more than $2 billion in annual health care expenditures.1,2 Edema management—generally limb elevation and compression therapy—has been the mainstay of therapy. Treatment can be lengthy, and ulcer recurrences are common.2,3
Statins have been found to help wound healing through their diverse physiologic (pleiotropic) effects. Evidence shows they can be beneficial for treating diabetic foot ulcers,4 pressure ulcers,5 and ulcerations associated with systemic sclerosis and Raynaud’s phenomenon.6 Evangelista et al1 investigated whether adding a statin to standard wound care and compression could improve venous stasis ulcer healing.
STUDY SUMMARY: Ulcers are more likely to close when a statin is added to standard care
This randomized, double-blind, placebo-controlled trial was performed at a large medical center in the Philippines. It was designed to assess the efficacy and safety of simvastatin 40 mg/d for venous ulcer healing when combined with standard treatment (compression therapy, limb elevation, and standard wound care).1
Researchers randomized 66 patients ages 41 to 71 who’d had one or more venous ulcers for at least 3 months to receive either simvastatin 40 mg/d (N=32) or an identical appearing placebo (N=34). Patients were excluded if they were pregnant, had an ulcer that was infected or >10 cm in diameter, or were taking any medication that could interact with a statin. Patients were stratified according to ulcer diameter (≤5 cm and >5 cm). There was no statistically significant difference between the 2 groups in the duration of venous ulceration (3.80 years in the placebo group vs 3.93 years in the simvastatin group) or incidence of diabetes (5% in the placebo group vs 3% in the simvastatin group).
The primary outcome was the proportion of patients whose ulcers completely healed at 10 weeks. Secondary outcomes were measures of the total surface area healed and healing time, and Dermatology Life Quality Index (DLQI) scores. Baseline ulcer diameter and surface area and DLQI scores were obtained prior to therapy. The same dermatologist, who was blinded to the patients’ assigned group, evaluated all patients every 2 weeks until wound closure or for a maximum of 10 weeks.
Overall, 90% of the patients who received simvastatin had complete ulcer closure at 10 weeks, compared with 34% of patients in the control group (relative risk [RR]=0.16; 95% confidence interval [CI], 0.05-0.47; number needed to treat [NNT]=2).
Among patients with ulcers ≤5 cm, 100% of the ulcers healed in the simvastatin group, compared to 50% in the control group (RR=0.10; 95% CI, 0.01-0.71; NNT=2). Perhaps more importantly, in patients with ulcers >5 cm, 67% of the ulcers in the simvastatin group had closure with a mean healing time of 9 weeks, whereas none of the ulcers of this size closed in the control group (RR=0.33; 95% CI, 0.12-0.84; NNT=1.5), and the mean healed area was significantly larger in patients who received simvastatin (28.9 cm2 vs 19.6 cm2; P=.03).
In addition, in the simvastatin group, healing times were significantly reduced (7.53±1.34 weeks vs 8.55±1.13 weeks) and quality of life (as evaluated by DLQI scoring) significantly improved compared to the control group.
Study dropouts (8%; 2 in the placebo group and 3 in the intervention group) were minimal. Using intention-to-treat analysis and worst-case scenarios for dropouts did not affect the primary outcome. There were no withdrawals for adverse reactions.
WHAT’S NEW: Statins offer significant benefits for treating venous stasis ulcers
This is the first human study to investigate the use of a statin in venous stasis ulcer healing. This intervention demonstrated significant improvements in healing rate and time, a very small NNT for benefit, and improved patient quality of life compared to placebo.
CAVEATS: Results were found in a carefully selected group of patients
Many wounds will heal with compression therapy alone, as occurred in this study, where 50% of ulcers ≤5 cm treated with standard therapy healed, albeit at a somewhat slower rate. Adding another medication to the regimen when these patients generally have multiple comorbidities should always prompt caution.