Lipodermatosclerosis (LDS) consists of lower-leg inflammation and woody induration in patients with chronic venous or lymphatic hypertension.1 Acute LDS may be painful and is frequently misdiagnosed as cellulitis. While compression stockings1 may be helpful, therapeutic options are limited. Ultrasound treatment of LDS was reported once more than 25 years ago2; we now report 16 legs treated with this technique.
After we received approval from Sydney South West Area Health Service and Sydney University Ethics Committees, all patients provided written informed consent.
We used 3-MHz continuous ultrasound (US3M; TGS Electronics Pty Ltd, New Gisborne, Australia) thrice weekly for 4 to 8 weeks, commencing at 0.7 W/cm2 (5 minutes per 50-cm2 area) and increased to 1 to 1.5 W/cm2 for 8 minutes. All patients were instructed to wear grade 2 compression stockings (30-40 mm Hg). For patients treated later in the series, a durometer (Rex Gauge Company, Buffalo Grove, Illinois) was used to measure skin hardness,3 and a reflectance erythema meter (DiaStron, Hampshire, England) measured redness.4 Measures were taken in triplicate at treated and adjacent “background” skin sites.
We treated 10 women and 1 man (mean age, 61 years; age range, 46-79 years) with LDS present for an average of 5 years (range of disease duration, 3 months to 21 years). Since 5 patients had bilateral disease, 16 legs were treated (2 acute and 14 acute-on-chronic LDS). Ten patients (14 legs) were overweight or obese (mean body mass index, calculated as weight in kilograms divided by height in meters squared, 31; range, 23-39); 5 legs had previous venous thrombosis; 7 legs were of diabetic patients; and 10 legs had demonstrated venous incompetence. Given the risks of infection and nonhealing in these compromised legs with classic LDS, biopsies were not routinely performed. Five patients regularly wore compression stockings at enrollment (8 legs); 4 refused to wear stockings (5 legs); and only 2 commenced wearing stockings during their ultrasound treatment (3 legs).
Four legs were treated for 4 weeks and 12 for 8 weeks. Of the 13 legs with durometer measures, 10 showed reduced hardness (mean reduction in hardness, 60%) (Figure, A). Erythema was reduced by 46% in 7 of the 9 legs with erythema indices (Figure, B). In 2 patients without measurements, all treated areas subjectively improved in tenderness, erythema, and hardness. Overall, in all but 3 cases the LDS substantially improved or resolved, and in many cases pain and tenderness were markedly reduced within 2 weeks. Of the 3 patients who showed no substantial improvement, 1 had severe venous incompetence in each treated leg, and 2 refused to wear stockings. No adverse effects occurred.
Substantial reduction from baseline in durometer and erythema meter readings was observed with a decrease in skin hardness (A) and erythema (B), respectively. Mean (SEM) hardness at baseline, 4 weeks, and 8 weeks was 14.0 (1.3), 11.8 (2.4), and 5.7 (2.2) units, respectively, while the mean (SEM) erythema index at these respective time points was 61.0 (8.9), 42.6 (8.6), and 36.5 (11.3). The readings at 8 weeks showed significant improvement by 2-tailed t test compared with baseline readings. *P < .01. †P < .05.
In our patients with LDS, many for a long duration, ultrasound treatment significantly reduced hardness and erythema and rapidly alleviated symptoms. These results are unlikely due to compression alone: all but 2 of our patients were either already using compression stockings at presentation (without improvement) or refused to wear stockings.
The mechanisms of ultrasound therapy's effects on LDS are unclear but might reflect the known immunomodulatory and anti-inflammatory effects of infrared radiation,5 which also upregulates collagen-degrading matrix metalloproteinase 1.6 Ultrasound therapy might thus help to reverse both the fibrotic and inflammatory changes of LDS. Ultrasound equipment is readily available through physiotherapy departments, where it is routinely used to treat soft-tissue injuries. It is portable and relatively inexpensive, and this simple, safe treatment may offer substantial improvement for an otherwise painful and refractory condition.
Correspondence: Dr Damian, Dermatology Department, GH3, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia (email@example.com).
Author Contributions:Study concept and design: Damian and Gupta. Acquisition of data: Damian, Yiasemides, and Armour. Analysis and interpretation of data: Damian. Drafting of the manuscript: Damian and Yiasemides. Critical revision of the manuscript for important intellectual content: Damian, Yiasemides, Gupta, and Armour. Statistical analysis: Damian. Administrative, technical, and material support: Damian, Yiasemides, Gupta, and Armour. Study supervision: Damian.
Financial Disclosure: None reported.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Dermatology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 3
Customize your page view by dragging & repositioning the boxes below.
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.