Acta Dermato-Venereologica Issue No. 97-5 97-5CompleteContent | Page 26

SHORT COMMUNICATION 653

Advances in dermatology and venereology Acta Dermato-Venereologica

Increased Incidence of Cutaneous Vasculitic Ulcers : 30-year Results from a Population-based Retrospective Study

Teija KIMPIMÄKI 1 , Riitta HUOTARI-ORAVA 2 , Jaakko ANTONEN 3 and Annikki VAALASTI 1

1

Department of Dermatology and Allergology , Tampere University Hospital , PO Box 2000 , FIN-33521 Tampere , 2 University of Tampere and Fimlab Laboratories , and ³ Department of Internal Medicine , Tampere University Hospital , Tampere , Finland . E-mail : teija . kimpimaki @ elisanet . fi Accepted Jan 12 , 2017 ; Epub ahead of print Jan 17 , 2017

Foot and leg ulcers are a common disorder . It has been estimated that 0.12 – 1.1 % of the population have ulceration of this kind ( 1 ). Vasculitic ulcers have been reported to account for 5 – 15 % of all leg ulcers ( 2 – 4 ). The diagnosis of vasculitic ulcer is a challenge , however , as the diagnostic histological features are detectable only in recent skin lesions not older than 48 h ( 5 ). Cutaneous small vessel vasculitis generally affects blood vessels in the superficial dermis . Vasculitis of the medium or large vessels occurs deeper in the dermis or even in subcutaneous tissue ( 6 ). Thus , a skin biopsy from an adequate depth is crucial for the correct diagnosis of vasculitic ulcer . In addition to a histological assessment of the skin sample , the accurate diagnosis of vasculitic skin ulcer requires the exclusion of systemic vasculitis ( 5 , 7 , 8 ).

Vasculitic ulcers are typically painful and often require a long period of treatment . The ulcer may heal and the patient may recover in a few weeks . However , in the most difficult cases the ulceration may continue for years and several relapses may occur ( 9 , 10 ). Since there are only limited data on the epidemiology of cutaneous vasculitic ulcers , this study evaluated the incidence of this disease in Pirkanmaa County , Finland , over the period 1980 – 2010 .

PATIENTS AND METHODS

This retrospective study was based on a cohort of patients aged at least 17 years who were treated for cutaneous vasculitic ulcers at the Department of Dermatology , Tampere University Hospital , in 1980 – 2010 . They were all living in Pirkanmaa County at the time . The treatment of dermatological patients from the county has been centralized in the University Hospital . Population data for Pirkanmaa County were obtained from the Finnish Population Register Centre . The total population aged at least 17 years in the district served by Tampere University Hospital was 316,505 in 1980 and 395,300 in 2010 .

Patient data were retrieved from the Tampere University Hospital patient data system using International Classification of Disease ( ICD ) codes . The case histories of a total of 1,327 patients were evaluated . Patients with cutaneous symptoms associated with systemic vasculitis were excluded . Data from histological and direct immunofluorescence examinations of the patient ’ s skin biopsy were recorded , as stated in the dermatopathologist ’ s report . The results of assays for antineutrophil cytoplasmic antibodies ( ANCA ), cryoglobulins and phospholipid antibodies were recorded . Ulcer was defined as vasculitic ulcer if the dermatopathologist had stated that histological criteria for cutaneous vasculitic ulcer were fulfilled , or it was stated in the case history that the diagnosis of vasculitic ulcer had been made based on typical clinical findings .

Approval from the ethics committee was not considered obligatory , because the study was based on case records , and due permission was obtained for reading these .

The data were analysed statistically using STATA 13.1 and SPSS software ( SPSS 19.0 Inc . Chigaco , IL , USA ). Annual incidences of vasculitic ulcers were calculated using Poisson regression analysis ( 11 ). Incidence rate ratios with 95 % confidence intervals ( CI ) were calculated to assess annual variations in the incidence of vasculitic ulcers .

RESULTS

A total of 191 patients ( age range 18 – 95 years , median age 66 ( SD 17.1 ) years , 73 men ) presenting for the first time and receiving treatment for cutaneous vasculitic ulcer at the Department of Dermatology from January 1980 to December 2010 were identified . A skin biopsy for histological examination had been obtained from 143 of the 191 patients ( 74.9 %) and from 162 ( 84.8 %) for analysis by direct immunofluorescence assay ( DIF ). Altogether , 126 patients ( 66.0 %) had histologically confirmed leukocytoclastic vasculitis ( Group 1 , Table I ) and the remaining 65 patients had been diagnosed on clinical findings without histological confirmation ( Group 2 ). DIF was diagnostic in 86 of 191 patients ( 45.0 %). The incidence of vasculitic ulcers in these groups was assessed separately .

Nineteen patients tested positive for perinuclear antineutrophil cytoplasmic antibodies ( P-ANCA ) and 2 for cytoplasmic anti-neutrophil cytoplasmic antibodies ( C-ANCA ), all without any specific definition . The titres were low in all the patients who tested positive for cryoglobulins ( n = 2 ) or phospholipid antibodies ( n = 8 ) and the clinical significance of these remained uncertain .

The incidence of leukocytoclastic vasculitic ulcers among all the patients in 2010 was 45.5 / 10 6 person years

Table I . Histopathological findings in 191 patients with cutaneous vasculitic ulcers

All patients ( n = 191 )

Group 1 ( n = 126 )

Group 2 ( n = 65 )

Group 1 : Patients with histologically confirmed leukocytoclastic vasculitis . Group 2 : Patients whose diagnosis was based on clinical findings only .

This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2608 Acta Derm Venereol 2017 ; 97 : 653 – 654