AbstractBackgroundStasis dermatitis and pigmented purpuric dermatoses can both manifest as hyperpigmentation, petechiae and/or purpura on the lower extremities, posing a challenge for macroscopic differentiation. We investigated the histological differences in these two conditions.ObjectivesTo determine the histological characteristics of stasis dermatitis and pigmented purpuric dermatosis.MethodsSkin biopsy specimens were obtained from seven patients with stasis dermatitis, 15 with pigmented purpuric dermatosis, and three control patients. The samples were analysed for histological changes (hematoxylin‐eosin), melanin (silver nitrate), iron, elastic stain, and with an immunohistochemistry for melanocytes (Melan‐A).ResultsThe predominant histological features of stasis dermatitis were hemosiderin deposits, eosinophils and telangiectasias. Pigmented purpuric dermatosis was characterized by extensive erythrocyte extravasation, interface changes and spongiosis.ConclusionsThe distinct histological characteristics of stasis dermatitis and pigmented purpuric dermatosis can improve the diagnostic classification of these entities.

Kulac, Mustafa MD; Riggauer, Julia MD; Ramelet, Albert-Adrien MD; Bossart, Simon MD Author Information

BACKGROUND:Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES:To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS:An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS:Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION:Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Skin hyperpigmentation after sclerotherapy with polidocanol‐containing sclerosants is a common local side effect. Sclerotherapists should be familiar with factors that trigger hyperpigmentation after sclerotherapy with polidocanol‐containing sclerosants. A systematic literature review of works reporting hyperpigmentation after sclerotherapy for telangiectasias, reticular veins, side branches and truncal varices with polidocanol‐containing sclerosants was performed. Reported incidence rates, follow‐up periods and potentially triggering factors were assessed and analysed. The search yielded 1687 results; of these, 27 reports met the inclusion criteria. The incidence of hyperpigmentation seemed to increase with higher concentrations of polidocanol and was more evident after sclerotherapy for epifascial veins than for intrafascial truncal veins when the polidocanol concentration was more than 0.25%. Regarding sclerotherapy for telangiectasias and reticular veins, the incidence of hyperpigmentation ranged between 2% and 25% for polidocanol 0.25% (liquid and foam), between 12.5% and 67.9% for polidocanol 0.5% (liquid and foam) and between 13% and 73% for polidocanol 1% (liquid and foam). Regarding truncal veins, the incidence ranged from 7% to 45.8% for polidocanol 1% (liquid and foam), from 16% to 17% for polidocanol 2% (foam) and from 7.4% to 32.5% for polidocanol 3% (liquid and foam). Regarding the treatment of side branches, the incidence of hyperpigmentation ranged from 5.6% to 53% for both foam and liquid sclerotherapy. Regarding the duration of hyperpigmentation, there are few data describing reticular veins and telangiectasias. Hyperpigmentation persisting for more than 6 months has been reported to have an incidence of up to 7.5%. Hyperpigmentation persisting for more than 1 year after foam polidocanol 1%–3% treatment for truncal veins has an incidence ranging from 8.1% to 17.5%. Other factors such as higher volumes and compression therapy after treatment seem to have a minor influence. Data regarding hyperpigmentation after polidocanol‐related sclerotherapy are poor and should be improved by higher‐quality research.

Background: The skin hyperpigmentation index (SHI), a new objective method for measuring skin hyperpigmentation, needs validation. Objective: To gain evidence of the reliability and validity of the SHI. Methods: Fifteen raters were divided into 3 groups (5 dermatologists, 5 nondermatologist physicians, and 5 nonphysician clinicians). Each rated 5 pigmented mole lesions with mild-to-severe hyperpigmentation to determine intra- and interrater reliability. All raters photographed the lesions and rated them using the subjective Physician Global Assessment (PGA) score. The same photographs were then assessed based on automatic computer measurement software using the online SHI tool (https://shi.skinimageanalysis.com). Results: The SHI reliability was excellent for all intra- and interrater assessments, while most PGA assessments showed good intra- and interrater agreement. Between-group reliability was excellent for SHI, while moderate-to-good for PGA evaluations. Concordance between the SHI and PGA assessments was strong across all groups of assessors. Conclusion: There is evidence that the SHI is a reliable instrument for measuring skin hyperpigmentation, and can be used by nonexperienced clinicians.

Skin hyperpigmentation is of great concern to people who suffer from it. It may be endogenous (when the pigments are formed within the body) or exogenous (when the pigments are applied externally, for example tattoos). The main endogenous pigments are melanin (e.g. melanocytic nevi, lentigines) and hemosiderin (dermite ocre). The activation of melanocytes, due to pregnancy hormones, sunlight or local inflammations, causes an increase in the melanin production. Hemosiderin deposition can be caused by an increased hydrostatic pressure (such as during chronic venous insufficiency), vasculitis of small skin vessels or vessel destruction (resulting from sclerotherapy, postsurgical haematoma formation and skin-laser therapy).1, 2 In conclusion, this new automated digital imaging analysis offers new possibilities for further advances in objective clinical image analysis, by measuring the optical density proportional to the degree of hyperpigmentation. The disadvantage of only measuring the pigmentation score is that it can vary depending on skin type and photosetting. Therefore, the calculated SHI with reference image from the same patient with the same photosetting is necessary to make an objective measurement by reducing the possible confounding factors. Compared to other quantifying pigmentation grading systems, our method is examiner- and instrument-independent and can also be applied to different skin types due to the index calculation.5, 6 Therefore, the application of our new SHI facilitates an unbiased quantification of skin hyperpigmentation. It could help clinicians quantify the extent of hyperpigmentation, which may be useful in assessing the lesions correctly, planning appropriate therapies (such as topical and laser therapies) and following up on the efficacy of these therapies. The patient in this manuscript has given written informed consent to publication of her case details. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Skin hyperpigmentation in chronic venous insufficiency and as a side effect in vein treatments are of great importance for the affected individuals. There are only a few qualitatively limited methods that allow its quantification. Previous techniques to develop a reliable scientific approach to quantification have failed due to the lack of standardized conditions including differences in lighting, distances and equipment. A newly developed measuring method, the “skin hyperpigmentation index”, enables a fully automated and standardized quantification of skin hyperpigmentation with dermatoscopic images. The skin hyperpigmentation index defines the ratio of two scores, namely hyperpigmented skin of the affected area and normal sun protected skin from the same patient. This results in a range from 1 (no pigmentation) to 4 (maximum pigmentation). For a practical evaluation of the score, a free skin hyperpigmentation index calculator can be used online, which is accessible to all practitioners ( https://shi.skinimageanalysis.com/ ). The skin hyperpigmentation index is a fully automated method for the quantitative assessment of skin pigmentation which can easily be applied to any skin type with any type of hyperpigmentation. This allows a simple, fast, and standardized quantification of skin hyperpigmentation and is useful for monitoring the progress and planning of whitening therapy.

Subcutaneous Injection of Large Volumes of PolidocanolSclerotherapy is a standard treatment of varicose veins and telangiectasias. 1 Different sclerosing agents have been used, with sodium tetradecyl sulfate (STS) and polidocanol (POL) being the most frequent molecules.Both solutions are detergents and may be emulsified to produce foam, which will increase the potency over 2fold and decrease toxicity 4-fold.The risk of local complications after injection of POL seems relatively low.Cutaneous ulcerations have been reported between 0.2% and 1.2% of cases.The authors here report the case of a patient who was erroneously administered a high volume of POL as local anesthetic with no major and long-lasting complication.

Background: Chronic venous diseases are very common. Early symptoms such as a sensation of swelling and heaviness may occur without objectifiable findings, but are nevertheless perceived as bothersome. Progressive disease - marked by varicose veins and symptoms of chronic venous insufficiency - is associated with considerable impairment in quality of life.Methods: The present consensus recommendations are based on publications in Pubmed-listed journals as well as relevant international therapeutic guidelines on chronic venous diseases. Only conclusive randomized controlled trials ( RCTs) and review articles/meta-analyses were included.Results: Symptom-based treatment of chronic venous diseases is based on three therapeutic pillars with proven efficacy: invasive therapy, compression therapy, and oral pharmacological treatment. According to current therapeutic guidelines, invasive procedures aimed at restoring unimpaired venous blood flow as well as improving or eliminating pathological changes should be the first-line approach. If an invasive approach is infeasible or undesirable, or if symptoms persist following a therapeutic intervention, optimal use of symptom-based treatment options is recommended. Compression and pharmacological therapy may each be used as sole treatment or in combination. To guarantee maximum therapeutic success, individual treatment decisions should be made on a case-by-case basis.Conclusions: Chronic venous diseases should be treated on the basis of individual pathophysiological disturbances. Symptom-based treatment of chronic venous disorders encompasses invasive therapy, compression therapy, and oral pharmacological therapy. Considerations in choosing the appropriate treatment option should include both objective signs as well as subjective symptoms.

Objectives Anomalous intraosseous venous drainage is a rare and almost unknown entity; only 14 cases have been reported in the literature and 4 mentioned in textbooks. We report the characteristics of 35 further cases observed in 32 patients. Method After the presentation of two cases at the congress of the French Society of Phlebology in Paris (2013), 12 colleagues joined to present a large series of so-called bone perforators observed in their practice, all identified with at least a duplex investigation. Results Thirty-two patients suffering from varicose veins and/or skin changes (C2-C6) associated with a bone perforator of the tibia (with bilateral anomalies in three) are reported: 19 females and 13 males, average age 56.9. The majority of the affected legs were symptomatic (30/35). Bone perforator was an isolated finding in 27/35 legs. In three cases, the investigations revealed that the venous reflux in the bone originated from an incompetent posterior tibial vein. Conclusions We suggest the name of "bone perforators" for an anomalous tibial intraosseous venous drainage, feeding varicose veins, and in more advanced stages lipodermatosclerosis and leg ulcers. Most of them were successfully treated with surgery or sclerotherapy.

Members of EDF Guideline Committee: Prof. Dr. Werner Aberer, Graz (Austria) Prof. Dr. Martine Bagot, Créteil (France) Prof. Dr. Lasse Braathen, Bern (Switzerland) Prof. Dr. Sergio Chimenti, Rome (Italy) Prof. Dr. José Luis Diaz-Perez, Bilbao (Spain) Prof. Dr. Vladimir Hegyi, Bratislava (Slovak Republic) Prof. Dr. Lajos Kemény, Szeged (Hungary) Prof. Dr. Hans Christian Korting, Munich (Germany) Prof. Dr. Gillian Murphy, Dublin (Ireland) Prof. Dr. Martino Neumann, Rotterdam (The Netherlands) Prof. Dr. Tony Ormerod, Aberdeen (UK) Prof. Dr. Annamari Ranki, Helsinki (Finland) Prof. Dr. Nikolai Tsankov, Sofia (Bulgaria) Prof. Dr. Fenella Wojnarowska, Oxford (UK)

Members of EDF Guideline Committee: Prof. Dr. Werner Aberer, Graz (Austria) Prof. Dr. Martine Bagot, Cr eteil (France) Prof. Dr. Lasse Braathen, Bern (Switzerland) Prof. Dr. Sergio Chimenti, Rome (Italy) Prof. Dr. Jos e Luis Diaz-Perez, Bilbao (Spain) Prof. Dr. Vladimir Hegyi, Bratislava (Slovak Republic) Prof. Dr. Lajos Kem eny, Szeged (Hungary) Prof. Dr. Hans Christian Korting, Munich (Germany) Prof. Dr. Gillian Murphy, Dublin (Ireland) Prof. Dr. Martino Neumann, Rotterdam (The Netherlands) Prof. Dr. Tony Ormerod, Aberdeen (UK) Prof. Dr. Annamari Ranki, Helsinki (Finland) Prof. Dr. Nikolai Tsankov, Sofia (Bulgaria) Prof. Dr. Fenella Wojnarowska, Oxford (UK)

HINTERGRUND:Chronische Venenerkrankungen sind eine Volkskrankheit. Venöse Symptome wie Schwellungs- und Schweregefühl können bereits früh ohne sichtbaren Befund auftreten und werden als belastend erlebt. Ein Fortschreiten im Sinne einer objektivierbaren Varikose bzw. chronischen venösen Insuffizienz schränkt die Lebensqualität erheblich ein.METHODIK:Pubmed-gelistete Publikationen sowie relevante Leitlinien zur Therapie chronischer Venenkrankheiten bilden die Basis der vorliegenden Konsensusempfehlungen. Inkludiert in die Bewertung wurden ausschließlich aussagekräftige randomisierte Studien (RCT) und Übersichtsarbeiten (Reviews/Metaanalysen).ERGEBNISSE:Die symptomorientierte Behandlung chronischer Venenerkrankungen stützt sich auf drei Säulen mit nachgewiesener Wirksamkeit: invasive Therapie, Kompressionstherapie und orale medikamentöse Therapie. Gemäß Empfehlungen aktueller Leitlinien sollte zunächst eine Sanierung des venösen Gefäßbetts erwogen werden, um einen störungsfreien venösen Blutfluss wiederherzustellen und Symptome und pathologische Veränderungen zu beseitigen oder zu bessern. Ist ein invasiver Eingriff nicht möglich bzw. nicht erwünscht oder bestehen nach einem Eingriff noch Restsymptome, gilt es, die symptomatischen Therapieoptionen optimal auszuschöpfen. Kompressionstherapie und medikamentöse Therapie können allein oder in Kombination angewendet werden. Welche Strategie den größten Erfolg verspricht, ist individuell zu entscheiden.SCHLUSSFOLGERUNGEN:Chronische Venenerkrankungen sollten auf der Basis der individuellen pathophysiologischen Störung behandelt werden. Sie symptomorientierte Behandlung chronischer Venenerkrankungen fußt auf der invasiven Therapie, der Kompressionstherapie und der medikamentösen Therapie. Bei der Indikationsstellung sind objektive Symptome ebenso wie subjektive Beschwerden zu berücksichtigen.