Correlation between durometer readings and 20 MHz ultrasound images of chronic lipodermatosclerosis Valentina Dini MD, PhD, Valeria Cacioppo MD, Battistino Paggi RN, Salvatore Panduri MD, Michela Macchia RN, Marco Romanelli MD, PhD Wound Healing Research Unit Department of Dermatology University of Pisa Introduction Chronic LDS is characterized by hyperpigmentation, induration and depression of LDS and it is usually restricted to medial leg but can be widespread, we do not know the reason for this localization, although this anatomic location is reported to have less direct venous drainage. The LDS imparts to the leg an appearance of an invereted bottle of Champagne. This is caused by fibrosis and sclerosis of the dermis and subcutaneous tissue (Kirsner RS et al J Am Acad Dermatol 1993) (Fig.1) Fig.1 Leg with LDS Ulcers often develop and recur within LDS, and a high degree of skin induration has been associated with poor ulcer healing. (Nemeth AJ, Eaglstein WH, Falanga V. J Am Acad Dermatol 1989; 20:186-90) (Fig.2) Fig.2 Leg with LDS and ulcer non healing Falanga et al have assessed skin hardness in LDS with a clinical skin severity score (Tab.1) adapted from studies of patients with systemic sclerosis. With these criteria, they reported that ulcers surrounded by severe LDS rarely heal. In order to obtain an objective measurements Romanelli and Falanga have proposed an instrumental evaluation by a durometer (Graph.1). They have found that durometer readings were higher in patients whose affected skin was judged blindly to be more indurated. 0Normal 1Minimal 2Moderate 3Maximal Tab.1 Clinical Score Nemeth AJ, Eaglstein WH,FalangaV J Am Acad Dermatol 1989;20: Graf.1 Instrumental Evaluation: Durometer Romanelli M J Am Acad Dermatol 1995;32: Durometer readings decrease as one measured from the superior edge of the ulcer to the knee. The presence of edema did not influence durometer measurements (Le Blanc N, Falabella A, Murata H, Hasan A, Weiss E, Falanga V Durometer Measurements of Skin Induration in Venous Disease. Dermatol Surg 1997;23: ), but the authors used a clinical assesment of edema. Aim To correlate the high frequency ultrasound measurement of edema to durometer skin hardness measurement in patients with or without chronic lipodermatosclerosis. The purpose of this comparison is to understand whether the durometer readings are influenced by the edema by means of 20 MHz ultrasound evaluation. Materials and Method We studied 30 patients with venous 20 MHz ultrasound scanner insufficiency divided in four groups (Tab ) Inclusion criteria: Patients with Venous insufficiency with or without LDS (confirmed by Color Doppler assessment) Exclusion criteria: Patients who present scleroderma (systemic and localized), clinical signs of skin atrophy, clinical signs of skin infection/inflammation, thrombotic disease, lymphedema and heart failure Fig.3 Dermascan® Cortex Technology, Hadsund Denmark Objective assessment of Edema (Fig.3) and skin hardness (Fig.4) Fig. 4 Ultrasound image of patient with venous insufficiency without edema Fig. 5 Ultrasound image of edema in a patient with venous insufficiency Fig. 4 Durometer model 1700, Rex Gauge Co, Inc, Glenview, Ill In leg edema the dermal echogenicity is significantly lower than control skin. In patients with venous insufficiency and lipodermatosclerosis the edema is confined mostly in the upper dermis (Gniadecka M J Am Acad Dermatol July 1996) Results: Patients Skin Hardnes s Edema Area (mm 3 ) Total intensity % Intensity within range % BA3810,686,24,56 BG6214,737,715,71 NG5113,456,25,17 DLB5117,897,195,52 LV4511,138,066,2 NL4910,798,655,53 KL628,118,735,65 LM4712,437,865,22 Tab.2 Group 1 LDS and Edema Patients Skin Hardness (durometer readings) G.E.60 T. A.59 N.M.35 V.M.A.50 G.G.40 M.E.36 B. E.40 B. F.60 Patients Skin Hardness DPC 29 DMF22 GD21 SR21 CP22 GG25 NV22 Pazients Skin Hardness AreaTotal intensity Intensity range SP2110,945,485,09 CV2011,147,645,64 MI226,5310,246,73 PN2310,798,655,53 TG CR CF Tab.3 Group 2 LDS without EdemaTab.4 Group 3 No Edema No LDS Tab.5 Group 3 Edema No LDS P > 0,1 Looking at patients with LDS if you compare the group with edema to the group with out edema, durometer is able to detect the skin hardness without a statistically significant difference (Graph.2) Conclusions : 20 MHz ultrasound scanning is able to detect interstitial fluid without clinical signs of edema at different skin depth 20 MHz ultrasound assessment of edema has shown that durometer readings are not influenced by the presence of interstitial fluid Durometer is a valid device to assess skin hardness. This cheap and portable device could be useful to detect patients at major risk of ulcer development. Graph. 2 Results of the assessment