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Ad ances in de ma ology and ene eology Ac a De ma o-Vene eologica
SHORT COMMUNICATION
Ac a De m Vene eol 2017; 97: 653–654
This is an open access a icle unde he CC BY-NC license. www.medicaljou nals.se/ac a
Jou nal Compila ion © 2017 Ac a De ma o-Vene eologica.
doi: 10.2340/00015555-2608
653
Foo and leg ulce s a e a common diso de . I has been
es ima ed ha 0.12–1.1% o he popula ion ha e ulce a-
ion o his kind (1). Vasculi ic ulce s ha e been epo ed
o accoun o 5–15% o all leg ulce s (2–4). The diag-
nosis o asculi ic ulce is a challenge, howe e , as he
diagnos ic his ological ea u es a e de ec able only in
ecen skin lesions no olde han 48 h (5). Cu aneous
small essel asculi is gene ally a ec s blood essels
in he supe icial de mis. Vasculi is o he medium o
la ge essels occu s deepe in he de mis o e en in
subcu aneous issue (6). Thus, a skin biopsy om an
adequa e dep h is c ucial o he co ec diagnosis o
asculi ic ulce . In addi ion o a his ological assessmen
o he skin sample, he accu a e diagnosis o asculi ic
skin ulce equi es he exclusion o sys emic asculi is
(5, 7, 8).
Vasculi ic ulce s a e ypically pain ul and o en equi e
a long pe iod o ea men . The ulce may heal and he
pa ien may eco e in a ew weeks. Howe e , in he
mos di icul cases he ulce a ion may con inue o yea s
and se e al elapses may occu (9, 10). Since he e a e
only limi ed da a on he epidemiology o cu aneous as-
culi ic ulce s, his s udy e alua ed he incidence o his
disease in Pi kanmaa Coun y, Finland, o e he pe iod
1980–2010.
PATIENTS AND METHODS
This e ospec i e s udy was based on a coho o pa ien s aged
a leas 17 yea s who we e ea ed o cu aneous asculi ic ulce s
a he Depa men o De ma ology, Tampe e Uni e si y Hospi al,
in 1980–2010. They we e all li ing in Pi kanmaa Coun y a he
ime. The ea men o de ma ological pa ien s om he coun y
has been cen alized in he Uni e si y Hospi al. Popula ion da a
o Pi kanmaa Coun y we e ob ained om he Finnish Popula ion
Regis e Cen e. The o al popula ion aged a leas 17 yea s in he
dis ic se ed by Tampe e Uni e si y Hospi al was 316,505 in
1980 and 395,300 in 2010.
Pa ien da a we e e ie ed om he Tampe e Uni e si y Hospi-
al pa ien da a sys em using In e na ional Classi ica ion o Disease
(ICD) codes. The case his o ies o a o al o 1,327 pa ien s we e
e alua ed. Pa ien s wi h cu aneous symp oms associa ed wi h sys-
emic asculi is we e excluded. Da a om his ological and di ec
immuno luo escence examina ions o he pa ien ’s skin biopsy
we e eco ded, as s a ed in he de ma opa hologis ’s epo . The e-
sul s o assays o an ineu ophil cy oplasmic an ibodies (ANCA),
c yoglobulins and phospholipid an ibodies we e eco ded. Ulce
was de ined as asculi ic ulce i he de ma opa hologis had s a-
ed ha his ological c i e ia o cu aneous asculi ic ulce we e
ul illed, o i was s a ed in he case his o y ha he diagnosis o
asculi ic ulce had been made based on ypical clinical indings.
App o al om he e hics commi ee was no conside ed obliga o y,
because he s udy was based on case eco ds, and due pe mission
was ob ained o eading hese.
The da a we e analysed s a is ically using STATA 13.1 and SPSS
so wa e (SPSS 19.0 Inc. Chigaco, IL, USA). Annual incidences
o asculi ic ulce s we e calcula ed using Poisson eg ession
analysis (11). Incidence a e a ios wi h 95% con idence in e als
(CI) we e calcula ed o assess annual a ia ions in he incidence
o asculi ic ulce s.
RESULTS
A o al o 191 pa ien s (age ange 18–95 yea s, median
age 66 (SD 17.1) yea s, 73 men) p esen ing o he i s
ime and ecei ing ea men o cu aneous asculi ic
ulce a he Depa men o De ma ology om Janua y
1980 o Decembe 2010 we e iden i ied. A skin biopsy
o his ological examina ion had been ob ained om
143 o he 191 pa ien s (74.9%) and om 162 (84.8%)
o analysis by di ec immuno luo escence assay (DIF).
Al oge he , 126 pa ien s (66.0%) had his ologically con-
i med leukocy oclas ic asculi is (G oup 1, Table I) and
he emaining 65 pa ien s had been diagnosed on clinical
indings wi hou his ological con i ma ion (G oup 2).
DIF was diagnos ic in 86 o 191 pa ien s (45.0%). The
incidence o asculi ic ulce s in hese g oups was asses-
sed sepa a ely.
Nine een pa ien s es ed posi i e o pe inuclea an i-
neu ophil cy oplasmic an ibodies (P-ANCA) and 2
o cy oplasmic an i-neu ophil cy oplasmic an ibodies
(C-ANCA), all wi hou any speci ic de ini ion. The i -
es we e low in all he pa ien s who es ed posi i e o
c yoglobulins (n = 2) o phospholipid an ibodies (n = 8)
and he clinical signi icance o hese emained unce ain.
The incidence o leukocy oclas ic asculi ic ulce s
among all he pa ien s in 2010 was 45.5/10
6
pe son yea s
Inc eased Incidence o Cu aneous Vasculi ic Ulce s: 30-yea Resul s om a Popula ion-based
Re ospec i e S udy
Teija KIMPIMÄKI
1
, Rii a HUOTARI-ORAVA
2
, Jaakko ANTONEN
3
and Annikki VAALASTI
1
1
Depa men o De ma ology and Alle gology, Tampe e Uni e si y Hospi al, PO Box 2000, FIN-33521 Tampe e,
2
Uni e si y o Tampe e and
Fimlab Labo a o ies, and ³Depa men o In e nal Medicine, Tampe e Uni e si y Hospi al, Tampe e, Finland. E-mail: [email p o ec ed]
Accep ed Jan 12, 2017; Epub ahead o p in Jan 17, 2017
Table I. His opa hological indings in 191 pa ien s wi h cu aneous
asculi ic ulce s
All pa ien s
(n = 191)
G oup 1
(n = 126)
G oup 2
(n = 65)
His ology (n = 143)
Vasculi is 97 97 0
Nega i e 46 27 19
No a ailable 48 2 46
Immuno luo escence (n = 162)
Posi i e 86 86 0
Nega i e 76 27 49
No a ailable 29 13 16
G oup 1: Pa ien s wi h his ologically con i med leukocy oclas ic asculi is. G oup
2: Pa ien s whose diagnosis was based on clinical indings only.
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(30.4/10
6
pe son yea s o G oup 1 and 39.5/10
6
pe son
yea s o G oup 2). The incidence o cu aneous ascu-
li ic ulce s inc eased o e he pe iod 1980–2010. The
incidence a e a io (IRR) was 1.07 (95% CI 1.05–1.09,
p < 0.001) among all he pa ien s. In G oup 1 he IRR
was 1.06 (95% CI 1.04–1.09, p < 0.001), and in G oup 2
IRR was 1.09 (95% CI 1.06–1.13).
The mean age o he o al popula ion had inc eased
om 44.8 yea s in 1980–1990 o 47.6 yea s in 2001–
2010, bu ha o he asculi ic ulce pa ien s was signi-
ican ly highe (mean 66.1 yea s; CI 62.8–69.4 yea s) in
2001–2010 han in ei he 1980–1990 (mean 50.7 yea s;
CI 42.3–59.2 yea s) o 1991–2000 (mean 62.3 yea s; CI
58.7–65.8 yea s; p < 0.001).
DISCUSSION
This epo shows ha he annual incidence o cu aneous
leukocy oclas ic asculi ic ulce s among he adul po-
pula ion o Pi kanmaa Coun y, Finland, in 2010 was
45.5/10
6
. The IRR was 1.07 o e he pe iod 1980–2010,
ep esen ing a 7% annual inc ease in he incidence o
asculi ic ulce s. The incidence o his ologically con i -
med leukocy oclas ic asculi is was simila ly inc eased
(IRR 1.06) eaching a le el o 30.4/10
6
. Ou inding o
an inc ease in he incidence o cu aneous asculi is is
suppo ed by he ecen obse a ion o a compa able
incidence a e o biopsy-p o en cu aneous small essel
asculi is o 21/10
6
pe son yea s in a e ospec i e popu-
la ion-based s udy pe o med in Minneso a, USA (12).
We also ound ha he mean age o pa ien s diagnosed
as ha ing asculi ic ulce s inc eased mo e s eeply o e
he in e al 1980–2010 han did he mean age o he o al
popula ion conce ned (15.4 yea s s. 2.8 yea s). Ageing
o he popula ion may, howe e , somewha explain he
inc eased incidence o asculi ic ulce s du ing he las
h ee decades. The e may also be o he ac o s, e.g. medi-
ca ion o in ec ions, ha could no be e alua ed eliably
in his e ospec i e s udy.
The e a e some limi a ions a ached o his wo k.
Ce ain clinical da a may be incomple e, as he ma e ial
was collec ed e ospec i ely. On he o he hand, he ob-
se a ion pe iod was qui e long, as he da a co e ed he
in e al om 1980 o 2010. In common wi h i s names
and de ini ions, he diagnos ic c i e ia o asculi ic ulce
ha e al e ed o e he pe iod 1980–2010, and his may
ha e in luenced he incidence a es in he epo s co e-
ing he pe iod be o e 1994, pa icula ly hose epo ed
be o e 1994, when cu aneous leukocy oclas ic asculi is
was de ined as isola ed cu aneous leukocy oclas ic angii-
is wi hou sys emic asculi is o glome uloneph i is
(13). The e o e, cases o asculi ic ulce wi h sys emic
disease may ha e been included in he p e ious epo s
conce ning he incidence o cu aneous leukocy oclas ic
asculi is be o e 1994, and i s ac ual incidence may
ha e been lowe han was epo ed p io o ha da e.
The ope a ional en i onmen , ne e heless, emained
he same be ween 1980 and 2010, as did he hospi al
dis ic ’s e e al policy.
In conclusion, hese esul s indica e ha cu aneous
asculi ic ulce s a e mo e common in Pi kanmaa Coun y,
Finland, nowadays han hey we e p e iously. We sug-
ges ha ageing o he popula ion is he main eason o
his, bu p ospec i e s udies would be needed in o de o
examine he ae iology and pa hogenesis o his disease
sys ema ically, wi h he ul ima e objec i e o p e en ing
new cases.
ACKNOWLEDGEMENTS
The au ho s a e g a e ul o Heini Huh ala, MA, o he skil ul
s a is ical analyses.
The au ho s decla e no con lic s o in e es .
REFERENCES
1. G aham ID, Ha ison MB, Nelson EA, Lo ime K, Fishe A. P e-
alence o lowe -limb ulce a ion: sys ema ic e iew o p e-
alence s udies. Ad Skin Wound Ca e 2003; 16: 305–316.
2. Kö be A, Klode J, Al-Benna S, Wax C, Schadendo D, S ein-
s aesse L, e al. E iology o ch onic leg ulce s in 31,619
pa ien s in Ge many analyzed by an expe su ey. J D sch
De ma ol Ges 2011; 9: 116–121.
3. Pannie F, Rabe E. Di e en ial diagnosis o leg ulce s. Phle-
bology 2013; 28 Suppl 1: 55–60.
4. Bi sch M, Lau sen I, Engel A-M, Ch is iansen M, Olesen La sen
S, I e sen L, e al. Epidemiology o ch onic wound pa ien s
and ela ion o se um le els o mannan-binding lec in. Ac a
De m Vene eol 2009; 89: 607–611.
5. Sais G, Vidalle A, Jucglà A, Se i je O, Condom E, Pey i J.
P ognos ic ac o s in leukocy oclas ic asculi is. A ch De -
ma ol 1998; 134: 309–315.
6. S one JH, Nousa i HC. “Essen ial” cu aneous asculi is: wha
e e y heuma ologis should know abou asculi is o he
skin. Cu Opin Rheuma ol 2001; 13: 23–34.
7. Ca lson JA, Ca alie e LF, G an -Kels JM. Cu aneous ascu-
li is: diagnosis and managemen . Clin De ma ol 2006; 24:
414–429.
8. Jenne e JC, Falk RJ. Pa hologic classi ica ion o asculi is.
Pa hol Case Re 2007; 12: 179–185.
9. Ca lson JA, Ng BT, Chen K-R. Cu aneous asculi is upda e:
Diagnos ic c i e ia, classi ica ion, epidemiology, e iology,
pa hogenesis, e alua ion and p ognosis. Am J De ma opa hol
2005; 27: 504–528.
10. Ma zano AV, Vezzoli P, Be i E. Skin in ol emen in cu aneous
and sys emic asculi is. Au oimm Re 2013; 12: 467–476.
11. Ki kwood BR, S e ne JAC. Poisson eg ession. In: Medical
S a is ics, 2nd edn. Ox o d: Blackwell Publishing L d, 2003:
p. 249–262.
12. A o a A, We e DA, Gonzalez-San iago TM, Da is MDP, Lohse
CM. Incidence o leukocy oclas ic asculi is, 1996 o 2010:
a popula ion-based s udy in Olms ed coun y, Minneso a.
Mayo Clin P oc 2014.
13. Jenne e JC, Falk RJ, And assy K, Bacon PA, Chu g J, G oss
WL, e al. Nomencla u e o sys emic asculi ides. A h i is
Rheum 1994; 37: 187–192.