title: The use of immunosuppressive agents in the management of recalcitrant lower limb ulcers.
abstract: OBJECTIVE
  Lower limb ulcers that are resistant to standard forms of treatment place a significant burden on both patients and health services. There is no widely agreed definition of a recalcitrant ulcer but failure to heal following 6-12 months of focused treatment would identify a small group of patients with highly resistant ulceration. We describe a series of patients with recalcitrant ulceration for which immunosuppressive agents have been used.
  
  
  METHODS
  This is a case series of 13 patients who underwent immunomodulation therapy for lower limb ulcers at a tertiary referral university hospital. Regimens of immunomodulation used mainly ciclosporin and/or cyclophosphamide, with concurrent antibiotic therapy. Case notes and computer systems were analysed by two reviewers. A patient was deemed to have a success if their ulcer fully healed while on immunomodulation therapy.
  
  
  RESULTS
  Over a period of eight years, from 2004-2012, 13 patients underwent immunomodulation therapy. Among these patients there were 18 ulcerated limbs. Ulcer healing occurred in 10 limbs out of 18 (55.6%) and full healing occurred in six patients (46.2%). Ulcers were present for a median of five years (range 2-40 years), with a median diameter of 7.5 cm (range 4-18 cm) before treatment.
  
  
  CONCLUSIONS
  Treatment of truly recalcitrant ulceration can be very frustrating for both the patient and physician, with poor success from more standard forms of treatment. We report experience with immunomodulation therapy that suggests there may be benefit from using this treatment in a subset of patients with this debilitating disease.
authors.affiliation: Clinical Research Fellow, Royal Liverpool University Hospital; UK.
authors.forename: A
authors.initials: A
authors.lastname: Millen
authors.forename: J
authors.initials: J
authors.lastname: Coulston
authors.forename: J
authors.initials: J
authors.lastname: Brennan
authors.forename: T
authors.initials: T
authors.lastname: Kennedy
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002908:Chronic Disease; D003520:Cyclophosphamide / Q000627:therapeutic use; D016572:Cyclosporine / Q000627:therapeutic use; D005260:Female; D006785:Hospitals, University; D006801:Humans; D056747:Immunomodulation; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007871:Leg Ulcer / Q000188:drug therapy* / Q000209:etiology; D035002:Lower Extremity / Q000293:injuries; D008297:Male; D008875:Middle Aged; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000150:complications; D014945:Wound Healing
chemical_list: D000900:Anti-Bacterial Agents; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D003520:Cyclophosphamide
keywords: immunomodulation; leg ulcer; vasculitis