This digest summarises recent key papers published in the areas of pressure ulcers, skin integrity, venous leg ulcers and diabetic foot ulcers.

Leg Ulcers
1 Identification of patient characteristics and comorbidities associated with Pyoderma gangrenosum

• Pyoderma gangrenosum (PG) is a rare, painful ulcerating disease associated with a variety of comorbidities
• This study involved a detailed, retrospective evaluation of the clinical presentation, demographics, and therapeutic modalities used in 103 adult patients with a diagnosis of pyoderma gangrenosum (PG)
• The leg was the most frequent site for PG (77.7%) while the trunk was reported in 11.7%, peristomal site in 8.7%, the upper extremities in 8.7%, and the head and neck in 7.8%
• The data supports that PG is associated with female predominance, inflammatory bowel disease, haematological disorders, hepatitis, major depression, and a significant mortality rate (16%)
• While the authors state that a cohort of 103 is relatively small in comparison to studies of more common diseases, PG is a rare disease and this is possibly the largest published PG case series.

Binus AM , Qureshi AA, Li VW, Winterfield LS, Pyoderma gangrenosum: a retrospective review of patient characteristics,omorbidities, and therapy in 103 patients. Br J Dermatol 2011 doi: 10.1111/j.1365-2133.2011.10565.x. [Epub ahead of print]

Skin integrity
2 International consensus on the prevention and management of skin tears

• This international consensus document on the prevention and management of skin tears was based on a two-day roundtable discussion involving 13 key opinion leaders
• A three-phase modified Delphi Method was used to reach consensus on a skin tear definition and 12 statements are proposed within the document
• The document asserts that skin tears are perceived to be common wounds and occur more frequently than pressure ulcers
• A collaborative multidisciplinary approach should be utilised for skin tear prevention and management
• The statements presented describe in detail the measures that should be taken to prevent and manage skin tears
• Statement 9 describes the evidence-based wound care principles which should guide treatment
• The concluding statement identifies that further research is needed in order to determine best practice in skin tear prediction, prevention and assessment.

LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care 2011; Sep : 24(9 Suppl): 2-15.

Pressure Ulcers
3 Improving understanding of the role of friction forces and pressure forces in pressure ulcer aetiology and classification

• This study was undertaken to explore the empirical relationships between friction forces and category II pressure ulcers and between pressure forces and categories III and IV pressure ulcers
• Methods involved a secondary analysis of data collected from 161 hospitals in Germany and 28,299 adult hospital patients using Chi-square Automatic Interaction Detection (CHAID) analysis
• Results indicate, that there is a strong relationship between frictional forces and superficial skin lesions and between pressure and deeper categories III and IV pressure ulcers
• The authors conclude that because superficial ulcers seem to be primarily caused by frictional forces they are therefore excluded by definition from the current European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP ) pressure ulcer definition and classification
• Importantly these findings have implications for the interventions used for pressure ulcer prevention.

Lahmann NA, Kottner , J Relation between pressure, friction and pressure ulcer categories: A secondary data analysis of hospital patients using CHAID methods. Int J Nurs Stud, 2011 in press.


Diabetic foot ulcers
4 Identifying the 'at-risk' foot in clinical practice

• This study was undertaken to identify which individual risk factors were most accurate at predicting foot ulceration, and whether an integrated system, rather than individual criteria, is a better screening tool
• Data regarding foot and general diabetes indicators were recorded on the regional diabetes electronic register. Follow-up data on foot ulceration were taken from the same register, along with multidisciplinary foot clinic, community and podiatry paper records. Data were linked to assess which risk factors best predicted future foot ulceration
• A total of 3719 people (44% female; mean age, 59±15 years) had foot risk scores recorded: 851 (22.9%) were insensitive to monofilaments; 629 (17.2%) had both pulses absent; 184 (4.9%) had a previous ulcer
• Using multivariate analysis, the strongest predictors of foot ulceration were: previous ulcer, insulin treatment, insensitivity to monofilaments, structural abnormality, proteinuria and retinopathy
• The sensitivity (and specificity) of predicting foot ulceration was 52% (99%) for previous ulcer, 61% (81%) for insensitivity to monofilaments, 75% (89%) for 'high-risk' on an integrated score, and 91% (61%) for a combination of high and
• moderate risk
• It was concluded that integrated foot risk scores are more sensitive than individual criteria in predicting foot ulceration and are likely to be more efficient screening tools.

Leese GP, Cochrane L, Mackie AD et al. Measuring the accuracy of different ways to identify the 'at-risk' foot in routine clinical practice. Diabet Med 2011; 28: 747-54.


5 Importance of limb preservation in people with diabetes

• This retrospective study aimed to determine outcomes in people with diabetes undergoing proximal forefoot/midfoot (PF/M) amputations
• Records extracted from a limb-salvage database were split into two groups: 88 people (92 limbs)
• in the PF/M amputation group (Group 1); 25
• people in the below-knee amputation group
• (Group 2)
• At two years in Group 1, 80% were still alive, 73% of limbs remained intact and 64% were ambulatory; in Group 2, 52% had died and 64% of survivors were ambulating with a prosthetic limb
• It was concluded that aggressive efforts at limb salvage with PF/M amputation procedures should be considered prior to higher level amputation.

Evans KK, Attinger CE, Al-Attar A et al. The importance of limb preservation in the diabetic population. J Diabetes Complications 2011; 25: 227-31.