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