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BACKGROUND: Long-term results following liposuction in patients with lipoedema are available only for an average period of 4 years. OBJECTIVE: To find out whether the improvement of complaints persists for a further 4 years. METHODS: In a single-centre study, 85 patients with lipoedema had already been examined after 4 years. A mail questionnaire - often in combination with clinical controls - was repeated after another 4 years (8 years after liposuction). RESULTS: Compared with the results after 4 years, the improvement in spontaneous pain, sensitivity to pressure, oedema, bruising and restriction of movement persisted. The same held true for patient self-assessment of cosmetic appearance, quality of life and overall impairment. Eight years after surgery, the reduction in the amount of conservative treatment (combined decongestive therapy, compression garments) was similar to that observed 4 years earlier. CONCLUSION: These results demonstrate for the first time the long-lasting positive effects of liposuction in patients with lipoedema.

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BACKGROUND: Lipoedema is a painful disease in women with circumscribed increased subcutaneous fatty tissue, oedema, pain and bruising. Whereas conservative methods with combined decongestive therapy (manual lymphatic drainage, compression garments) have been well established over the past 50years, surgical therapy with tumescent liposuction has only been used for about 10years and long-term results are unknown. OBJECTIVES: To determine the efficacy of liposuction concerning appearance (body shape) and associated complaints after a long-term period. METHODS: A total of 164 patients who had undergone conservative therapy over a period of years, were treated by liposuction under tumescent local anaesthesia with vibrating microcannulas. In a monocentric study, 112 could be re-evaluated with a standardized questionnaire after a mean of 3years and 8months (range 1year and 1month to 7years and 4months) following the initial surgery and a mean of 2years and 11months (8months to 6years and 10months) following the last surgery. RESULTS: All patients showed a distinct reduction of subcutaneous fatty tissue (average 9846mL per person) with improvement of shape and normalization of body proportions. Additionally, they reported either a marked improvement or a complete disappearance of spontaneous pain, sensitivity to pressure, oedema, bruising, restriction of movement and cosmetic impairment, resulting in a tremendous increase in quality of life; all these complaints were reduced significantly (P<0·001). Patients with lipoedema stage II and III showed better improvement compared with patients with stage I. Physical decongestive therapy could be either omitted (22·4% of cases) or continued to a much lower degree. No serious complications (wound infection rate 1·4%, bleeding rate 0·3%) were observed following surgery. CONCLUSIONS: Tumescent liposuction is a highly effective treatment for lipoedema with good morphological and functional long-term results.

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BACKGROUND: In chronic venous insufficiency (CVI) III typical changes of skin, subcutaneous tissue, fascia and muscle can be found. It was believed, that the thickening of the fascia is irreversible and it has been postulated that the degeneration of muscles is causative for the persistence of recalcitrant leg ulcers. PATIENTS AND METHODS: By computed tomography (CT) and magnetic resonance imaging (MRI) 8 patients with therapy resistant venous ulcers were examined. Changes of fascia and muscles were determined preoperatively and 12 months after successful shave therapy. RESULTS: By CT a thinning of the preoperatively thickened fascia could be demonstrated in all patients one year after surgery. Before shave therapy MRI showed that the fascia was not only thickened and blurred, but also had fluid accumulations perifascial. 12 months after therapy the fascia was thinner and sharply demarcated. The fluid was either absent or distinctively reduced. Referring to the thickness of fascia an average decrease of 0.084 cm (0.03-0.17 cm) was observed. Before surgery the muscles showed a fatty degeneration as a sign of atrophy; with CT and MRI no changes could be demonstrated after one year in all patients. CONCLUSION: The results after one year demonstrate for the first time, that the changes of the fascia in CVI III are reversible and that there is no direct correlation between the degeneration of muscles and the persistence of venous leg ulcers.

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Autologous fat grafting is a standard method for soft tissue augmentation. The method is commonly used for volume restoration of the ageing face. Furthermore, atrophic scars, lipodystrophy and scleroderma en coup de sabre can be treated. Following liposuction, the harvested fat can be reinjected immediately or stored at minus 28 degrees C for at least 2 years. In most cases, several injections at 3 to 4 months intervals are needed for good long-term effects. The procedure is used world-wide with good results and a minimum of side effects.

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BACKGROUND: Activated protein C (APC) resistance is the most frequently diagnosed heritable thrombophilic defect predisposing to thrombosis. OBJECTIVES: To determine the prevalence of APC resistance due to factor V Leiden mutation in patients with leg ulcers. METHODS: Within a 2-year-period 100 consecutive patients with leg ulcers were examined for factor V Leiden mutation. RESULTS: APC resistance due to factor V Leiden mutation was detected in 19 of 53 patients (36%) with post-thrombotic leg ulcers and in three of 47 patients (6%) with ulcers caused by primary varicosis. In a healthy control group APC resistance due to factor V Leiden mutation was found in five of 96 (5%) volunteers. CONCLUSIONS: In view of this high prevalence of APC resistance of 36%, which has never previously been reported, patients with post-thrombotic leg ulcers should be investigated for APC resistance.

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BACKGROUND: Following an epidemiological study on skin diseases in 5780 pupils from 13 schools in rural western Kenya in 1993, a dermatology project within the primary health care system was established in 1994 by the German non-government organization (NGO) 'Doctors in Aid of Children with Skin Diseases in Africa'. Within this project trained community health workers carried out regular visits to schools and nurseries and treated children with hydrocortisone acetate 1% cream for dermatitis, gentian violet 1% solution for bacterial skin infections, Whitfield's ointment for dermatophytoses and benzylbenzoate emulsion 25% for scabies. OBJECTIVES: To assess the impact of this intervention. METHODS: In 1999, after a 5-year period, 4961 pupils from the same 13 schools were re-examined and the prevalence rates were compared. RESULTS: Non-infective dermatitis had a prevalence of 1.7% in 1993 as well as in 1999; among the communicable diseases bacterial infections declined from 12.7% to 11.3% (not significant), fungal infections rose from 10.1% to 13.9% (P < 0.05) and arthropod infections (mainly scabies) remained at similar levels of 8.3% in 1993 and 8.0% in 1999. A distinctive reduction could only be found for tropical ulcers (0.1% in 1999 compared with 1.2% in 1993). CONCLUSIONS: The prevalence of dermatoses in children in rural Africa does not only depend on treatment schemes within the primary health care system, but on the socio-economic conditions available.

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The purpose of this study was to evaluate the long-term effects of shave therapy in non-healing venous leg ulcers. Forty-one patients with 75 recalcitrant leg ulcers caused by primary deep vein incompetence or post-thrombotic syndrome were operated by shave therapy (removal of ulcer and surrounding lipodermatosclerosis with a Schink skin-grafting knife and covering of the wounds with meshed split-thickness skin grafts). After an average follow-up period of 2 years and 5 months all patients were evaluated for long-term results. The healing rate of ulcers classified as non-healing was 67% (50 of 75 ulcers). The healing rate was 76% for ulcers associated with primary deep vein incompetence and 58% for ulcers associated with post-thrombotic syndrome (p = 0.08). Even in cases with recurrence (33%) these ulcers were strikingly reduced by 80-90% of their original size. Hypaesthesia was noticed in 38% of the transplanted areas. In "non-healing" venous leg ulcers due to deep venous insufficiency shave therapy yields favourable long-term results. Because it is only a symptomatic treatment which does not reduce the pathological refluxes, continuous compression of the lower leg is important.

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BACKGROUND AND OBJECTIVE: APC resistance (Factor V Leiden mutation) is the most often diagnosed hereditary thrombolytic defect. Data about the prevalence in patients with leg ulcers, especially postthrombosis, are limited of this defect. PATIENTS/METHODS: APC resistance was determined in 100 patients with venous leg ulcers. 53 patients had ulcers caused by postthrombotic syndrome and 47 patients ulcers associated with primary varicosities. A control group of 96 healthy volunteers was also studied. RESULTS: 19 of 53 patients (36%) with postthrombotic ulcers and 3 of 47 patients (6%) with varicosity-related ulcers had APC resistance. In the control group APC resistance was detected in 5 of 96 volunteers (5%). CONCLUSIONS: APC resistance should be considered as a risk factor for the development of venous leg ulcers.

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BACKGROUND AND OBJECTIVE: In spite of the importance of skin diseases in Africa south of the Sahara, dermatology is insufficiently represented within the established primary health care systems. Aim of this study was to find out whether an integrated dermatology project could reduce the prevalence of dermatoses. PATIENTS/METHODS: Since 1994 trained community health workers have carried out regular weekly visits to schools and nurseries in 10 communities in rural western Kenya. Epidemiological studies were done in 13 schools in 4 communities involving 5780 and 4961 pupils one year before (1993) and 5 years (1999) following the introduction of the dermatology project. RESULTS: Within this period the prevalence of bacterial skin infections fell from 12.7% to 11.3% (n.s.). Mycoses rose from 10.1% to 13.9% (p < 0.05), while arthropod infections (mainly scabies) remained unchanged with a prevalence of 8.3% in 1993 and 8.0% in 1999 (n.s.). Dermatitis also showed no changes (1.7% in both years). CONCLUSIONS: The prevalence of infective dermatoses depends not only on medical treatment but also far more on socio-economic factors.

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In fibrotic skin of lipodermatosclerosis a substantial increase of the cross-link hydroxylysylpyridinoline is observed. Hydroxylysylpyridinoline is a typical cross-link of skeletal tissue and is thought to play a major part in the hardening of sclerotic tissue. We investigated whether the increase in hydroxylysylpyridinoline is due to overhydroxylation of lysyl residues in the collagen molecule, which may also be associated with an increase of glycosylated hydroxylysine residues. Furthermore, we determined whether the collagen fibrils in lipodermatosclerosis showed a decrease of the diameter in the tissue as well as in vitro after fibrillogenesis of pepsin-solubilized collagens. Isolated alpha-chains of pepsin solubilized collagen I showed an increase in lysyl hydroxylation (hyl/(hyl + lys)) as compared with normal control [alpha1(I): lipodermatosclerosis 0.18 +/- 0.01; control 0.12 +/- 0.01; alpha2(I): lipodermatosclerosis 0.36 +/- 0.02; control 0. 25 +/- 0.03, p < 0.001]. Furthermore, the content of enzymatic glycosylated hydroxlysine residues increased. This increase is associated with a decrease of fibril diameter of both tissue and fibrils formed in vitro of pepsin-solubilized collagens. In the same pool of collagens an increase in collagen III content was observed as compared with controls (lipodermatosclerosis 14.5% +/- 1.6, control 10.3% +/- 1.6, p < 0.001). Our results showed that the overhydroxylation of lysyl residues, which is required for the generation of hydroxylysylpyridinoline, is not only restricted to the telopeptides but also affects the helical part of the molecule. This process is further associated with an increase of glycosylated hydroxylysyl residues. These changes along with the increase in collagen III content seem to be responsible for the observed alteration in the architecture of collagen fibrils in sclerotic skin.

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Changes in skin thickness and echodensity during the spontaneous menstrual cycle, in women taking hormonal contraceptives and pregnant women were investigated by high-frequency (20 MHz) ultrasound. Women with a spontaneous ovulatory menstrual cycle (group I), women taking one-phase contraceptives (group II), women taking three-phase contraceptives (group III) and pregnant women (group IV) were measured at the following locations: proximal and distal forearm and lower leg on both sides. The skin was investigated during three phases of the menstrual cycle: days 2-4 (phase A), days 12-14 (phase B) and days 20-22 (phase C). Oestradiol and progesterone levels were determined at each phase. The pregnant women were investigated 2 weeks prepartal and 6 weeks after delivery. Group I showed a statistically significant increase in the skin thickness from phase A to phase B, but not from phase B to phase C. Group II showed no significant changes in skin thickness, whereas the skin thickness increased from phase A to phase B in group III. In group IV, the skin was significantly thicker prepartal than after delivery. The measured echodensity showed a negative correlation with skin thickness in group III and in pregnant women. We were able to demonstrate that the status of female sex hormones influences the thickness of the skin. These results can be explained by hormone-induced water retention in the skin. Sonography at 20 MHz is able to quantify these effects, which should be considered when performing ultrasound measurement in women.

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A patient with a complete agenesis of the inferior vena cava is presented. In this rare anomaly the blood of the pelvic veins is drained through the dilated venae lumbales, vena azygos and vena hemiazygos into the superior vena cava. The malformation was detected within the scope diagnostics of deep vein thrombosis. The diagnosis was made by sonography, computed tomography and magnetic resonance angiography.

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BACKGROUND: Leg ulcers in deep venous insufficiency, especially the postthrombotic type, are often resistant to therapy. OBJECTIVE: The purpose of this study was to evaluate short-term and long-term effects of shave therapy in persistent or recurrent venous ulcers. METHODS: From January 1994 to October 1997, 80 patients with 105 chronic leg ulcers were treated by shave therapy. This method involved removing ulcers together with the surrounding lipodermatosclerosis and covering the wounds with meshed split-skin graft. Fifty-nine patients with 76 ulcers were examined after 3 months for assessment of short-term results. The first 18 patients with 26 ulcers from the years 1994 and 1995 were evaluated for long-term results. RESULTS: The short-term healing rate after 3 months in 59 patients was 79%. Of 8 patients from 1995 (follow-up period, 1 year and 8 months), 7 patients had complete healing and 1 patient had a small ulcer. Of 10 patients from 1994 (average follow-up period, 2 years and 8 months), 8 patients had complete healing and 2 patients showed small superficial ulcerations within the transplanted areas. From these results, a long-term healing rate of 88% was calculated in 18 patients. Two of the 3 patients with recurrences had stopped compression therapy after good short-term results. CONCLUSION: For patients with recalcitrant leg ulcers in deep venous insufficiency and/or postthrombosis, shave therapy is a simple, quick, and effective surgical method with favorable short-term and long-term results.

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BACKGROUND: Epidemiologic data concerning skin diseases in many rural areas in sub-Saharan Africa are not available. Little is known about the effect of regular treatment schedules by paramedical staff (especially community health workers) in the primary healthcare system on the severity and prevalence of dermatoses. METHODS: 5780 school and pre-school children from 13 primary schools in four sublocations in rural western Kenya (Kisumu District) were examined for dermatoses by the author, together with community health workers in 1993. On-the-spot training and weekend seminars about important and common dermatoses were also given. In 1994 a dermatology program was started within the primary healthcare system. Twelve trained community health workers carried out regular school visits once a week and diagnosed and treated pupils with dermatoses. Treatment was performed with gentian violet 1% solution for bacterial skin infections, Whitfield's ointment for dermatophytoses, benzylbenzoate emulsion 25% for scabies, and hydrocortisone acetate 1% cream for eczemas. All schools were visited again in 1995 to evaluate the long-term effects of the program. RESULTS: In 1993, the prevalence rate for dermatoses was 32.4%. Most of the skin diseases found were of infective origin (27.1% were caused by bacteria, 21.6% by fungi, and 17.6% by arthropods, mainly scabies mites). Dermatitis accounted for 3.5%. In 1995, the prevalence of dermatoses declined to 29.6% (p<0.05), and this reduction was most strongly observed for tropical ulcers and tinea capitis. Additionally, there was an improvement in the extent and severity of skin diseases. CONCLUSIONS: This study defines, for the first time, the number and extent of skin diseases in children in rural Kisumu District; most dermatoses were of infective origin. The study demonstrates that community health workers in the primary healthcare system are capable of dealing successfully with the most common dermatoses in children following a short training period.

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BACKGROUND: In patients with chronic venous insufficiency erythematous areas in indurated skin (hypodermitis) and non erythematous areas of lipodermatosclerosis were examined. METHODS: In 13 patients with venous ulcers a total of 32 localizations in more or less erythematous and indurated ulcer edges were measured. The amount of erythema was taken as an indicator for the extent of hypodermitis. The parameters examined were erythema (a-value), skin temperature (t), laser Doppler flow (LDF), transcutaneous (tcpO2) and intracutaneous oxygen tension (icpO2). According to the amount of erythema the different localizations were separated into two groups: areas with a-values lower than 14,2 were classified as lipodermatosclerosis without or with little erythema, are-as with a-values higher than 14,2 were classified as areas of lipodermatosclerosis with extensive erythema. Identical measurements were also performed in healthy looking skin below the knee. RESULTS: Skin temperature and LDF were higher in areas with much erythema compared to those with little or no erythema. TcpO2, measured with an electrode temperature of 44 degrees C, was lower in areas with inflammation; tcpO2-values at 37 degrees C and icpO2-values showed no differences in ulcer edges with different amounts of inflammation. CONCLUSION: The results show differences of microcirculation between areas of lipodermatosclerosis with and without hypodermitis. These differences did not influence the actual tissue oxygenation in deeper parts in the dermis.

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In a survey of 5780 children from 13 schools in rural Kisumu District (western Kenya) in 1993, a prevalence rate of dermatophytomycoses of 10.1% was found. Three-quarters of the affected children suffered from tinea capitis (prevalence rate 7.8%), caused by Microsporum audouinii var. langeronii, Trichophyton violaceum and Microsporum canis. In 1994, a dermatology programme within the primary health care system was started. Twelve community health workers (CHWs), trained in diagnosis and treatment of the most common skin diseases, carried out regular school visits once a week. All dermatophytomycoses, dry forms of tinea capitis included, were treated locally with Whitfield's ointment. In 1995 the prevalence rate of fungal skin infections in the same schools was found to be 9.3%; the difference to 1993 was not significant. Only tinea capitis, with a prevalence rate of 5.8%, showed a significant reduction (P < 0.05). Altogether, a distinctive improvement regarding the extent and the severity of dermatophytomycoses could be noticed. In the cultures from tinea capitis, Microsporum canis was not found to be present. Trained community health workers are capable of the diagnosis and treatment of fungal skin infections of children in rural areas, which leads to a reduction in the prevalence of tinea capitis.

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