Ultrasound Therapy for Lipodermatosclerosis

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.

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 (diona.damian@email.cs.nsw.gov.au).

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.