ORLANDO – , Hadar Lev-Tov, MD, said at the ODAC Dermatology, Aesthetic & Surgery Conference.
At the meeting, Dr. Lev-Tov, associate professor of dermatology at the University of Miami, reviewed some of the latest developments in several conditions involving wound care.
Dr. Hadar Lev-Tov
Pyoderma gangrenosum (PG): In this condition, pustules or nodules become large ulcerations, and one-third of patients with PG have pathergy, exaggerated skin injury after a mild trauma such as a bump or a bruise.
“You want to look at the clues in the history because 20% of these patients had histories of PG elsewhere,” Dr. Lev-Tov said. “Ask them about other ulcers, maybe they had some wound dehiscence history.”
Criteria have been developed to help with the diagnosis of ulcerative PG, which includes one major criterion, a biopsy of the ulcer edge showing neutrophilic infiltrate, along with minor criteria, including exclusion of an infection, pathergy, and a history of inflammatory bowel disease or inflammatory arthritis.
“This is no longer a diagnosis of exclusion,” Dr. Lev-Tov said.
Cyclosporine and oral steroids have been found to work well, but it typically takes many months before healing occurs. Tacrolimus or topical steroids can work as well, but healing also takes a fairly long time with those medications, Dr. Lev-Tov said.
The tumor necrosis factor (TNF) blocker infliximab is another option. He had a patient who was referred to him who had been treated with cyclosporine for 3 years for PG on his feet, even though it had not been effective. Dr. Lev-Tov tried infliximab, and the wounds finally cleared, he said.
Apremilast, a phosphodiesterase 4 (PDE4)-inhibitor, is another option for treating PG, he said. “Anecdotally, I used apremilast on three patients with recurrent PG for long-term suppression, with success,” he noted.
Epidermal grafting using suction and heat is an approach that might deserve further exploration for PG, Dr. Lev-Tov suggested. With this procedure, described in an article in 2014, heat and suction are used to induce blistering to separate and remove the epidermis from the dermis at the dermal-epidermal junction, creating an epidermal graft is placed over the wound to promote healing. Patients with PG who are immunosuppressed but demonstrate pathergy do not tend to experience pathergy when epidermal skin grafting is performed, he said.
The heat-suction procedure is simple, painless, and scarless, but better controlled data on this approach are needed, he said.
Corona phlebectatica: This disease involving abnormally dilated veins near the ankle has received formal recognition as a sign of venous insufficiency, in a 2020 update of a classification system for describing patients with chronic venous disorders, Dr. Lev-Tov said.
“We knew about it for years, but now there’s some data that can actually predict the severity of disease,” and, he said, it is now a part of the diagnostic criteria for venous insufficiency .
Venous leg ulcers: These often painful sores on the inside of the leg typically take more than a month to heal. A systematic review of placebo-controlled studies of pentoxifylline as a treatment for venous leg ulcers, published in 2021, supports its use for healing venous leg ulcers, Dr. Lev-Tov said. “It improved the healing rate and increased what [the researchers] called ‘significant improvement,’ ” a category they created to account for the varying methods across the studies, he said.
Topical beta-blockers can improve epithelialization and fibroblast migration in wound healing, he said. A study on topical timolol for various wounds found that a 0.5% formulation of topical timolol, with one drop applied per square centimeter as frequently as possible, was effective in healing. But the healing process was prolonged – a median of 90 days, said Dr. Lev-Tov, one of the study authors.
“When you start this, I don’t want you to expect the wound to heal tomorrow,” he said. “You’ve got to educate your patient.”
Dr. Lev-Tov reports relevant financial relationships with Abbvie, Novartis, Pfizer and other companies.