Bioderma Congress Reports EWMA 2025

Speaker: Marion Delannoy (France)

Old patients do not want to feel alone and be in pain. The elderly are at higher risk of side effects of medication, and it is essential to know when to stop. Wound care will mainly include pressure ulcers, malignant ulcers and peripheral arterial disease.

The number 1 enemy for patients is pain. For nociceptive pain, both short acting and extended-release opioids are effective. Regarding neuropathic pain, gabapentinoids (gabapentin> pregabalin) or tricyclic antidepressants (amitriptyline) should be prescribed. Moreover, non-pharmacological approaches should be considered (occupational therapy, psychology).

Enemy number 2 is anxiety, both acute and chronic. In addition to benzodiazepines, antidepressants should be considered chronic anxiety. Psychological support and involvement of relatives is also helpful.

To control malodor, cinnamon dressings or cat litter in the room are good alternatives.

The key points on palliative wound care for the elderly are:

• Palliative care does not mean end of life
• The top priority should always be zero pain
• The objective in wound care should be “avoiding worsening”
• Underuse and misuse of medication should be avoided
• Believe in teamwork
• Listen to the patient
• Think outside the box, be creative
• Do not forget the patient´s family

Speaker: Emma Candas (France)

Patients with dementia need a specific kind of care. Dementia represents a constant challenge in our daily clinical practice. In the context of dementia, behavioral disorders may produce or worsen wounds. The caregiver should keep a watchful eye on prevention, which is essential. A balance should be found between protecting and respecting the patient.

Distracting strategies during dressing changes, such as giving the patient a piece of bread to have in his hand, may be useful.

Moreover, when you cannot stop the movement, you can change the dress while walking.

Be creative.

Speaker: Hester Colboc (France)

When a bone is found in a wound bed, it can be either the patient´s bone (normal or pathological) or ectopic calcifications (metastatic or dystrophic). 

The author focused on the frequent dystrophic calcifications, as she performed a single center retrospective study that was published in 2022 in the Journal of the Gerontological Society of America, with the clinical description, morphology, and chemical characterization of calcified leg ulcers in older patients. 143 patients were included, 10(7%) with calcified leg ulcers. Calcified and non-calcified ulcers were compared (structural and chemical analysis) though scanning electron microscopy and infra-red spectroscopy/ X-ray fluorescence. It was found that calcified leg ulcers in older patients are characterized by the presence of dystrophic calcifications within the ulcer bed. Clinically, these ulcers are often associated with chronic venous insufficiency and are more likely to be colonized by bacteria such as Pseudomonas aeruginosa. They typically exhibit a prolonged healing course and may be accompanied by hypercalcemia. Morphologically, the calcifications in these ulcers are composed of calcium-phosphate apatite and are often associated with the presence of zinc. The calcified deposits can be identified using field-emission scanning electron microscopy, which reveals lacunar spheres and intermingled fibrils consistent with bacterial and biofilm imprints. These findings suggest an involvement of microorganisms and an inflammatory process in the formation of dystrophic calcifications

Histopathologic ally, these calcifications can be confirmed using various staining techniques such as hematoxylin-eosin, van Kossa, and are typically found in the subcutaneous tissue and can be associated with necrosis and chronic inflammation.

Regarding treatment of these calcifications, if possible, they should be excised to promote healing. However, dystrophic calcifications represent a therapeutic challenge in these patients as they involve a big area in several cases.

Speaker: Tanja Planinšek Ručigaj (Slovenia)

Different cases were presented to explain the challenges on diagnosis and treatment of patients with Martorell leg ulcer. 

The diagnosis of Martorell ulcer is primarily clinical, with a focus on the patient's medical history of hypertension and the characteristic appearance of the ulcerations. The lesions are usually well-defined, with irregular edges and a necrotic base, often accompanied by erythema and edema. It is important to differentiate Martorell ulcer from other conditions, such as venous ulcers and pyoderma gangrenosum, through clinical assessment and, if needed, skin biopsy.

Management of Martorell leg ulcer requires a multifaceted approach, addressing the underlying hypertension, if it exists. Regarding conservative standard care often involves blood pressure control, wound care and infection prevention.

In the presented cases it was shown the strategy with hydrogel and alginate for promoting debridement of necrotic plaques and the benefits of the use of sodium thiosulfate, an agent with antioxidant and anti-inflammatory properties. Sodium thiosulfate has been shown to improve wound healing by promoting collagen formation and reducing the inflammatory response in chronic ulcers.

Sodium thiosulfate is typically administered topically or via systemic routes. Topical applications have been found to decrease pain and accelerate healing by reducing oxidative stress in the affected tissue. Systemic administration may be considered in severe cases, although further studies are needed to establish optimal dosing and treatment protocols.

Speaker: Jesse Karppinen (Helsinki)

Acute necrotic wounds normally develop fast, and the treatment plan depends on etiopathologies.

The first question assessing necrosis in a wound could be: Has the necrotic tissue an intact contact with the surrounding tissue?

• Yes, necrosis is dry: it can be maintained, as physiological dressing.
• No, it is liquefaction of the necrosis: It may be invaded by bacteria, so debridement should be considered.

Regarding diagnosis, firstly, typical causes should be ruled out. A compulsory question would be: Are we in front of a typical wound? Is it due to arterial insufficiency? diabetes? pressure? infection? Or, on the contrary, is it an atypical etiology? Has it a weird location? Preceding livedo? Pathergy? Are there vesicles, bullae or pustules? We should study the patient as a whole. Ask for comorbidities, immunosuppression, medicines, travels, risk behaviors.

Before grabbing a knife, stop, listen, ask the patient, look, touch, make a diagnostic suspicion and start a treatment plan.

Speaker: Alessandra Michelucci (Italy)

The management of Pyoderma Gangrenosum, Acne, and Hidradenitis Suppurativa (PASH) syndrome is complex and often requires a multimodal approach. The primary treatment modalities include the use of biologics, corticosteroids, and antibiotics. A case of a challenging PASH syndrome was shared, highlighting the important impact on quality of life.

An algorithm of combined dermatologist approach for this disease was shared.

Regarding local treatment, it will depend on the activity of the disease:

• Active HS: corticosteroids, clindamycin, antimicrobial dressings, absorbent dressings, perilesional skin management.
• Active PG: corticosteroids, enzymatic debridement, absorbent dressings, non-adherent dressings.

Considering systemic management, for active lesions it is recommended biological therapy (anti-TNF alfa, anti-IL-23-17, anti-IL-1 drugs) + immunosuppressive drugs (corticosteroids, cyclosporine) + antibiotics (doxycycline, dapsone). Antibiotics, particularly those with anti-inflammatory properties, can be beneficial. Targeted antibiotic therapy has been reported to induce remission in refractory cases of PASH syndrome. 

In some cases, addressing underlying conditions or comorbidities can lead to improvement in PASH syndrome. 

Overall, the management of PASH syndrome should be individualized, considering the severity of the disease, patient comorbidities, and response to previous treatments. Further research is needed to establish standardized treatment guidelines for this rare condition.

It highlighted the need for a multidisciplinary approach involving pain specialists, nutritionist, psychologist, infectious disease specialist, gastroenterologist, rheumatologist, surgeon.

Speaker: Elena Conde (Spain)

Punch grafting is a simple and efficient technique that can be performed on an outpatient basis, to promote epithelialization.

The presentation focused on the cases in which punch grafting is particularly indicated, starting by underlining that this technique does not require an optimal wound bed and that, in addition to favoring wound closure, it will have a rapid analgesic effect. The spacing of dressing changes and the importance of avoiding cleaning to avoid damaging the epithelialization-promoting microenvironment were emphasized.

Punch grafting will be indicated to promote epithelialization of a wound once its etiological treatment has been initiated. However, in palliative cases, such as arterial ulcers that cannot be revascularized or are not candidates for amputation, it may be an alternative, especially for pain reduction.

Cases in which punch grafting is particularly indicated, as an early treatment, are ulcers due to arteriolosclerosis, the “so-called” mixed ulcer (predominantly venous leg ulcer with some degree of arteriopathy), stagnant venous leg ulcers, atrophied blanche, recurrent venous leg ulcers, ulcers with exposed tendon that are not candidates for flap, atypical ulcers such as pyoderma gangrenosum or vasculitis that no longer show signs of inflammation.

To promote graft attachment in undermined wound beds, with a suboptimal wound bed or on tendon, the use of negative pressure therapy is recommended. This therapy is also recommended when grafting wounds in locations other than the leg, such as the abdomen.

It may be needed to repeat the procedure several times until complete epithelialization is achieved. Even if there is no graft attachment to the wound bed, it will be beneficial as growth factors and cells will be released.

Speaker: Iulia Negulet (Romania)

In pyoderma gangrenosum, early diagnosis is essential to avoid unnecessary antibiotics and deleterious surgical procedures. Moreover, multidisciplinary approach gets the best outcomes.

Two controversial issues were addressed during the talk:

• The decision to prescribe prophylactic immunosuppressive treatment before surgery in a patient with a history of pyoderma gangrenosum (PG): PG is known for its pathergy phenomenon, where minor trauma, including surgical procedures, can trigger new lesions or exacerbate existing ones.

Several case reports and reviews support the use of prophylactic corticosteroids to mitigate this risk. While there is no consensus on optimal perioperative management, prophylactic corticosteroids are often used to prevent postoperative disease progression. The optimal prophylactic dosage has not been studied.

• The timing of discontinuation of immunosuppression after complete epithelialization of pyoderma gangrenosum: Although there is no consensus on the duration of treatment; to avoid the precipitation of a sudden PG flare, steroids/cyclosporine might be slowly tapered over months under close monitoring.

Speakers: Joachim Dissemond (Germany) and Valentina Dini (Italy)

It is hypothesized that the effect of compression therapy on microcirculation, venous and lymphatic drainage and inflammation is what would justify its indication in different inflammatory dermatological pathologies. In fact, by preventing capillary hypertension and consequently reducing inflammatory mediators, compression therapy can help treat and prevent cutaneous complications secondary to edema. 

Although there are very few publications in the literature on compression therapy for inflammatory dermatoses of the legs, there are numerous experts’ recommendations on its use in different inflammatory pathologies.

In daily clinical practice we observe that some of the generalized inflammatory dermatoses are much more persistent and pronounced in the legs than in other anatomical regions. For example, psoriasis plaques are often particularly refractory to treatment compared to other affected areas of the body. Although the cause is unclear, it has been hypothesized that inflammation leads to an increased tendency to edema, so that the resolution of the inflammatory reaction would be slowed down by venous stasis. However, the benefit of compression therapy has not been proven.

About vasculitis, compression therapy may improve the therapeutic response and reduction of systemic immunosuppression.

Regarding livedoid vasculopathy, given the thrombotic occlusion of cutaneous vessels that occur, in addition to promoting healing, it could also prevent recurrence, based on expert recommendations. On pyoderma gangrenosum, despite a few studies, experts agree that patients benefit from compression therapy because of its anti-inflammatory action. It may reduce pain and produce odor relief and promote corticosteroids tapering. Continuous counseling and adherence are essential, and starting with low presence will increase adherence. We should start compression therapy before skin inflammation starts.

Expert recommendations also include compression therapy in necrobiosis lipoidica, and cases have been published on its benefit in other pathologies, such as erythema nodosum.

How much pressure is recommended by experts in these skin conditions? Often 20 mmHg is sufficient for edema reduction and, as it is less painful, it may increase adherence.

Two review articles with the title “Compression therapy in Dermatology “(in English and Spanish) have just been published.

In the discussion it was commented that some inflammatory skin diseases, such as bullous pemphigoid, can appear on the altered local environment phlebolymphedema. The pathogenesis may involve factors such as slow lymphatic circulation, increased capillary permeability, and localized antibody deposition, although the exact mechanism remains unclear.

Speakers: Elena Conde (Spain) and Julian-Dario Rembe (Germany)

Cleansing is considered a fundamental step in wound management to remove debris, bacteria, and other contaminants that can impede healing and increase the risk of infection. Even if there is some debate regarding the optimal cleansing solutions and techniques, the consensus is that cleansing is essential for all types of wounds to promote healing and prevent infection. However, is this recommendation evidence-based or a mere ritual?

Elena Conde, that has just published a paper on rituals in wound healing in the International Wound Journal, argued that wounds that are progressing well may not need to be cleaned and debrided at dressing changes, and wound dressing changes should be spaced out to not alter the pro- healing microenvironment. Moreover, scabs are part of physiological epithelialization, not dirt, and should be maintained if no signs of infection exist, to protect the new epidermis. In addition to this, slough includes not only denaturalized tissue, but also viable proteins, and there is no evidence in leg ulcers to support debridement to accelerate wound healing. Excessive cleansing and debridement may alter the wound healing process.

On the other hand, Dario argued that cleansing and debridement was essential in the presence of necrotic tissue and biofilm and the so called “wound hygiene” should be considered the first step in wound care to prevent infection and promote healing.

Both presenters agreed on the need to adapt the management strategy to each patient. Adequate etiological treatment is key and, especially in venous leg ulcers, may be sufficient to promote wound healing, regardless of local treatment. They also agreed on the need to have more research comparing different cleansers and cleansing techniques so that their use in clinical practice may be more controlled and homogenized.

The conclusion of the debate is that a clinical trial should be done including both speakers' centers to define the real benefit of wound cleansing.