Use of topical corticosteroids on chronic leg ulcers

Hofman, D.; Moore, Keith; PhD, RN Diane M. Cooper; Eagle, Michelle; Cooper, Suzane C.

doi:10.12968/jowc.2007.16.5.27047

Cited by 38 publications

(39 citation statements)

References 6 publications

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“…Among many agonists, glucocorticoids have been shown to promote antiinflammatory macrophage populations (70). Interestingly, treatment of CVUs with topical corticosteroids was of benefit for 79% of the patients in terms of healing (71). It remains to be seen whether the favorable outcome following short-term topical application of corticosteroids in fact results in a switch from proinflammatory macrophages to macrophage populations with antiinflammatory properties.…”

Section: Discussionmentioning

confidence: 99%

An unrestrained proinflammatory M1 macrophage population induced by iron impairs wound healing in humans and mice

Sindrilaru¹,

Peters²,

Wieschalka³

et al. 2011

J. Clin. Invest.

951

790

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Uncontrolled macrophage activation is now considered to be a critical event in the pathogenesis of chronic inflammatory diseases such as atherosclerosis, multiple sclerosis, and chronic venous leg ulcers. However, it is still unclear which environmental cues induce persistent activation of macrophages in vivo and how macrophage-derived effector molecules maintain chronic inflammation and affect resident fibroblasts essential for tissue homeostasis and repair. We used a complementary approach studying human subjects with chronic venous leg ulcers, a model disease for macrophage-driven chronic inflammation, while establishing a mouse model closely reflecting its pathogenesis. Here, we have shown that iron overloading of macrophages -as was found to occur in human chronic venous leg ulcers and the mouse model -induced a macrophage population in situ with an unrestrained proinflammatory M1 activation state. Via enhanced TNF-α and hydroxyl radical release, this macrophage population perpetuated inflammation and induced a p16 INK4a -dependent senescence program in resident fibroblasts, eventually leading to impaired wound healing. This study provides insight into the role of what we believe to be a previously undescribed iron-induced macrophage population in vivo. Targeting this population may hold promise for the development of novel therapies for chronic inflammatory diseases such as chronic venous leg ulcers.

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Section: Discussionmentioning

confidence: 99%

An unrestrained proinflammatory M1 macrophage population induced by iron impairs wound healing in humans and mice

Sindrilaru¹,

Peters²,

Wieschalka³

et al. 2011

J. Clin. Invest.

951

790

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“…[327][328][329][330] One RCT of nail matrix ablation described hypergranulation as an adverse effect of hydrogel. 331 Otherwise, individual case reports and uncontrolled case series were identified [332][333][334] Computer-generated block randomisation with stratification according to ulcer size and treatment centre; allocation concealment not described; methods of outcome assessment not reported (but unlikely to be blind); analysis was by intention to treat Full reports screened for inclusion (n = 91)…”

Section: Measures Of Treatment Effectmentioning

confidence: 99%

Wounds research for patient benefit: a 5-year programme of research

Cullum

Buckley

Dumville

et al. 2016

Programme Grants Appl Res

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BackgroundComplex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.ObjectivesTo (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.MethodsTo meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.ResultsFrom the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.ConclusionsComplex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…Excessive pain has been used as an indication for commencing topical steroid therapy previously. 19 Inflammatory products (such as tumour necrosis factor, and interleukins 1B and 6) stimulate nocioception and reduce pain threshold levels. 27 We suggest that the reduction in pain seen is a direct response of the reduction in inflammation.…”

Section: Resultsmentioning

confidence: 99%

“…30 The advantage of a combined preparation is that an antimicrobial theoretically reduces the risk of infection developing in an ulcer, which is potentially locally immunosuppressed by the topical steroids. 19 Its antimicrobial effect may reduce the bioburden in the wound bed, thereby reducing inflammation. 8 Furthermore, oxytetracycline may also play an anti-inflammatory role in addition to its antimicrobial action.…”

Section: Resultsmentioning

confidence: 99%

“…Case series exist of the successful use of topical corticosteroids for excessive granulation tissue following dermatological surgery but they are few and far between, and topical steroids have not become commonplace in general wound care. 18,19 In this article we review our unit's experience with Trimovate ® (GlaxoSmithKline, Uxbridge, UK), a topical agent containing a steroid, antibiotic and antifungal (clobetasone butyrate 0.05%, oxytetracycline 3%, nystatin 100,000 units/g) in a variety of chronic wounds. This agent was used on wounds displaying excessive and abnormal inflammatory features despite receiving best clinical wound care.…”

Section: Bosanquet Rangaraj Richards Riddell Saravolac Hardingmentioning

confidence: 99%

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Topical steroids for chronic wounds displaying abnormal inflammation

Nikkhah

Dheansa

Bosanquet

et al. 2013

annals

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INTRODUCTION Chronic, non-healing wounds are often characterised by an excessive, and detrimental, inflammatory response. We review our experience of using a combined topical steroid, antibiotic and antifungal preparation in the treatment of chronic wounds displaying abnormal and excessive inflammation. METHODS A retrospective review was undertaken of all patients being treated with a topical preparation containing a steroid (clobetasone butyrate 0.05%), antibiotic and antifungal at a tertiary wound healing centre over a ten-year period. Patients were selected as the primary treating physician felt the wounds were displaying excessive inflammation. Healing rates were calculated for before and during this treatment period for each patient. Changes in symptom burden (pain, odour and exudate levels) following topical application were also calculated. RESULTS Overall, 34 ulcers were identified from 25 individual patients (mean age: 65 years, range: 37-97 years) and 331 clinic visits were analysed, spanning a total time of 14,670 days (7,721 days 'before treatment' time, 6,949 days 'during treatment' time). Following treatment, 24 ulcers demonstrated faster rates of healing, 3 ulcers showed no significant change in healing rates and 7 were healing more slowly (p=0.0006). Treatment generally reduced the burden of pain and exudate, without affecting odour. CONCLUSIONS In normal wound healing, inflammation represents a transient but essential phase of tissue repair. In selected cases, direct application of a steroid containing agent has been shown to improve healing rates, presumably by curtailing this phase. Further evaluation is required to establish the role of preparations containing topical steroids without antimicrobials in the management of chronic wounds.

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Use of topical corticosteroids on chronic leg ulcers

Cited by 38 publications

References 6 publications

An unrestrained proinflammatory M1 macrophage population induced by iron impairs wound healing in humans and mice

An unrestrained proinflammatory M1 macrophage population induced by iron impairs wound healing in humans and mice

Wounds research for patient benefit: a 5-year programme of research

Topical steroids for chronic wounds displaying abnormal inflammation

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