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Such is their prevalence in the population that community nurses are very likely to encounter unfamiliar dermatological problems during their practice, many of which will have been self-treated for some time before professional help is sought. This article reports a case of a rare congenital condition called Flegel's disease, which leads to the presence of small horny papules on the skin, predominantly on the legs. In this case, the papules had deteriorated and were causing wider problems.

Background: Leg ulcers affect up to 1 per cent of people at some time in their life. Management includes care of the ulcer using dressings and treatment of underlying medical problems such as malnutrition, lack of minerals, vitamins, poor blood supply or infection., Objectives: To assess the effectiveness of oral zinc in healing arterial or venous leg ulcers., Search Strategy: Searches of 19 databases, hand searching of journals and conference proceedings from 1948 onwards, and examination of bibliographies. The company manufacturing zinc sulphate tablets was asked for references to relevant trials., Selection Criteria: Randomised controlled trials comparing oral zinc sulphate with placebo or no treatment in patients with arterial or venous leg ulcers. There was no restriction on date or language. The main outcome measure used was complete healing of the ulcers. Trials were eligible for inclusion if they measured ulcer healing objectively, by time to complete healing, proportion of ulcers healed during the study, or healing rates of ulcers., Data Collection and Analysis: All data extraction and assessment of trial quality were done by both authors independently., Main Results: There were six eligible trials. All are small and serum zinc was measured at baseline or during the trial in 4 trials. Overall there is no evidence of a beneficial effect of treatment with zinc sulphate on the number of ulcers healed at the end of the trials. There is some evidence that oral zinc might have a beneficial effect on healing of venous ulcers in people with a 'low' serum zinc level at baseline., Reviewer's Conclusions: Overall, oral zinc sulphate does not appear to aid healing of leg ulcers, although it might be beneficial in those with venous leg ulcers and low serum zinc. Further research is needed to ascertain the serum zinc concentration below which treatment with zinc might be beneficial, and the dose required. [This abstract was prepared centrally]

Topical zinc is widely used in wound treatment although the beneficial effect of zinc has only been documented in zinc-deficient patients who were given zinc orally. The main purpose of this study was to investigate the effect of topically applied zinc on leg ulcer healing and examine its effect on some mechanisms in wound healing using standardized animal models. Additionally, absorption of zinc into wounds and intact skin treated topically with zinc was studied. In a double-blind trial involving 37 leg ulcer patients with low serum zinc levels, topical zinc oxide promoted cleansing and re-epithelialization. Infections and deteriorations of ulcers were less common in zinc oxide treated patients. Re-epithelialization, an important mechanism in the closure of leg ulcers, was enhanced with zinc oxide applied topically on partial-thickness wounds in pigs with normal zinc status. Zinc sulfate at three different concentrations did not, however, result in this beneficial effect on the resurfacing of wounds. The inflammatory reaction was diminished in zinc treated wounds except when a high zinc sulfate concentration was applied. Bacterial growth and concomitant diseases such as diabetes can complicate wound healing. In normal rats, bacterial growth in full-thickness wounds was reduced with topical zinc oxide but not in hyperglycemic diabetic rats. The anti-bacterial mechanism of zinc oxide seemed to be more indirect and to be mediated via local defense systems rather than being directly toxic to the bacteria. Healing of 21-day-old skin incisions was impaired in zinc deficiency, as measured by a significantly decreased wound breaking strength in zinc-deficient rats compared with that of pair-fed controls. The decreased breaking strength did not seem to be due to differences in collagen concentration of the wounds. Zinc oxide was slowly but continuously solubilized when applied on open wounds in rats. On the other hand, with zinc sulfate, the zinc concentrations, either locally or systemically, did not maintain a constant level for the 48-hour post-operative treatment period as they did with zinc oxide. Zinc absorption in and through normal human forearm skin was demonstrated after treatment with a zinc oxide medicated occlusive dressing by increased zinc levels in epidermis, interstitial fluid and dermis compared with the non-zinc control dressing. In conclusion, topical zinc may stimulate leg ulcer healing by enhancing re-epithelialization, decreasing inflammation and bacterial growth. When zinc is applied on wounds it not only corrects a local zinc deficit but also acts pharmacologically.(ABSTRACT TRUNCATED AT 400 WORDS)

Two occlusive dressings--one zinc oxide medicated (Mezinc) and one hydrocolloid (Duoderm)--were compared in a prospective, randomized trial over a period of 8 weeks to determine their healing ability and effect on pain for venous and arterial leg ulcers. All patients were patch-tested before the study and colophony allergy was an exclusion criterion. Of the 43 outpatients included, 31 completed the trial and 6 patients randomized to each treatment group were withdrawn. The initial ulcer areas decreased after 8 weeks of treatment with Mezinc by 64% and by 48% after treatment with Duoderm. Ulcer pain was relieved in 50% of the patients--with a similar analgesic effect for the two dressings. Mezinc treatment was discontinued in 2 cases due to sensitization to colophony (one ingredient of Mezinc) which indicated a risk of contact allergy to colophony due to Mezinc treatment. 1103 consecutive eczema patients were patch-tested on the back with Mezinc and colophony 20% in petrolatum simultaneously. It was found that 42 (4%) of the patients showed allergic skin reactions to colophony and 19 (2%) to Mezinc. Both dressings were well tolerated by leg ulcer patients and there appeared to be no major differences in the efficacy of the two occlusive dressings.

The effect of oral zinc on the healing of chronic venous leg ulcers has been investigated in 91 hospitalized patients aged approximately 70 years. The patients were divided into three groups: group A consisted of patients with serum zinc concentrations in the upper normal range (Zn greater than or equal to 1.0 mg/l) who received no zinc therapy. Groups B and C consisted of patients with serum zinc concentrations in the lower normal range (Zn less than 1.0 mg/l) who received either 3 daily doses of 220 mg zinc sulphate (group B) or placebo (group C). In group B, a marked increase in serum zinc concentration occured within one month (from 0.9 to 1.25 mg/L). In group A, serum zinc levels decreased slightly during the observation period of three months (from 1.1 to 1.0 mg/l) while a slight rise was seen in group C (from 0.9 to 1.0 mg/l). The healing rate of the ulcers in group A was not superior to that in group C. Zinc substitution in the low zinc group B did not improve healing as compared to placebo-treated low zinc group C. A favourable effect of oral zinc on wound healing in patients with initially low serum zinc concentrations could not be demonstrated. Initial ulcer areas were significantly smaller in patients with higher serum zinc levels than in patients with lower serum zinc levels. Low serum zinc levels appear to be a consequence of insufficient nutrition, an observation which may indicate a correlation between nutritional deficiency and ulcer area. The healing rate did not depend significantly upon age, sex, weight or cause. It was, however, accelerated in the case of larger ulcers.

We performed a randomized, double-blind study of the efficacy of locally applied zinc oxide on the healing of leg ulcers. Thirty-seven geriatric patients, nineteen with arterial and eighteen with venous leg ulcers, were treated either with a gauze compress medicated with zinc oxide (400 micrograms ZnO/cm2) or with an identical compress without zinc oxide. The treatment was assessed from ulcer size measurements and the presence or absence of granulation and ulcer debridement over a period of 8 weeks. The zinc-treated patients (83% success rate) responded significantly better (P less than 0.05) than the placebo-treated patients (42% success rate). The results suggest that healing of leg ulcers is improved after the addition of zinc oxide to the local regimen.

Four stressed surgical patients who had different diseases are presented. They had dermatitis associated with low serum zinc levels but were not on total parenteral nutrition. The range of serum zinc varied between 25 and 56 mu/dl when first seen. All but one had hypoalbuminemia and anemia; one patient had diarrhea. When measured, other microelements were normal. These patients were thought to have zinc deficiency and all their symptoms responded favorably to oral zinc and nutritional support. A highlight of previous reported cases of zinc deficiency is presented along with a brief review of the subject. Acute stress including major operations will decrease the serum zinc level temporarily. Zinc deficiency may be the result of chronic zinc depletion caused by other conditions. Chronic leg ulcers are associated with low serum zinc levels and might precipitate zinc selectively. A zinc supplement will help in the healing of these ulcers and wounds in general. The possibility of an interrelationship of zinc and other microelements is raised but is not clear.

Three hundred thirty-nine of 400 chronic cutaneous ulcers in 264 patients (including some with multiple or bilateral ulcers of both) were healed with silver-zinc-allantoinate creamed (AZAC 1%). Some of the patients treated had failed to respond to medicated wrappings, saline dressings, and various other therapeutic agents, including antibiotics. In one week of treatment with AZAC 1%, bacterial counts were reduced on the average from approximately 2 X 10(7) to 2 X 10(5) (99%). Silver-zinc-allantoinate cream also demonstrated a wide spectrum of antimicrobial activity. It did not give rise to resistance by the infecting organisms, was nonallergenic, debrided necrotic tissue, and stimulated healthy granulation. Treatment was well tolerated, side effects being limited to a burning sensation in three patients. Most patients cared for themselves at home with minimal interference in their usual daily activities.

28 Gambian children and adolescents with acute tropical leg ulcers entered a double blind trial of oral zinc supplements as an adjunct to standard treatment. Analysis of the area healing of the ulcers resulted in a mathematical expression which showed that for each subject re-epithelialization reduced the ulcer radius at a constant healing rate (k). k was derived from the equation At = pi X (r - k X t)2, where At = residual ulcer area at time "t", r = initial ulcer radius and t = time from start of treatment. In the zinc treated group k was 0.55 +/- 0.39 mm/day, and 0.51 +/- 0.25 mm/day in the placebo group. The initial low plasma zinc of 6.5 +/- 1.9 mumol/L in the ulcerated subjects was not significantly lower than that of 7.5 +/- 3.6 mumol/L in the nonulcerated controls. Oral zinc supplements significantly elevated plasma zinc concentrations by 5.8 +/- 4.8 mumol/L compared to the placebo group's change of 0.4 +/- 2.0 mumol/L (p less than 0.001). Plasma alkaline phosphatase activities and fatty acid profiles did not change with zinc supplementation. Thus unequivocal clinical and biochemical evidence of zinc deficiency in these ulcerated subjects was not established, despite changes in plasma zinc. This study does not indicate any role for zinc supplementation in the management of acute tropical ulcers.

The toxicity of oral zinc was investigated in patients hospitalized for chronic leg ulcers. Untoward effects were monitored by reference to clinical tolerance, hematological, hepatic and renal parameters, and serum concentrations of copper and iron. The investigation was conducted by comparing two groups of patients who initially did not differ significantly with regard to ulcer area, hemoglobin, leukocytes, copper, iron and zinc. Both groups had serum zinc concentrations in the lower normal range. One group was treated with 3 daily doses of 220 mg oral zinc sulfate and the other with placebo, and hence, untoward effects of zinc should have become manifest in the zinc-treated group. This was not the case. Therefore, oral zinc appears to be well tolerated clinically and does not cause hematological, renal or hepatic toxicity. In view of the increasing interest in and range of indications for zinc, particularly in conditions associated with cellular immunological hyporeactivity, this finding is a prerequisite for the institution of clinical zinc therapy.