Dengue is endemic in the U.S. territories of American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands.The safety and effectiveness of the vaccine was determined in three randomized, placebo-controlled studies involving approximately 35,000 individuals in dengue-endemic areas, including Puerto Rico, Latin America and the Asia Pacific region. The vaccine was determined to be approximately 76 percent effective in preventing symptomatic, laboratory-confirmed dengue disease in individuals 9 through 16 years of age who previously had laboratory-confirmed dengue disease. Dengvaxia has already been approved in 19 countries and the European Union.Dengvaxia is not approved in the U.S. for use in individuals not previously infected by any dengue virus serotype or for whom this information is unknown.Dengvaxia is a live, attenuated vaccine that is administered as three separate injections, with the initial dose followed by two additional shots given six and twelve months later.The U.S. Food and Drug Administration (FDA) granted the application for Dengvaxia priority review designation and a tropical disease priority review voucher. The approval of Dengvaxia was granted to Sanofi Pasteur. CYD-TDV (Dengvaxia)
CYD-TDV, sold under the brand name Dengvaxia and made by Sanofi Pasteur, is a live attenuated tetravalent chimeric vaccine made using recombinant DNA technology by replacing the PrM (pre-membrane) and E (envelope) structural genes of the yellow fever attenuated 17D strain vaccine with those from the four dengue serotypes.
Rare causes of skin ulcers include pyoderma gangraenosum, lesions caused by Crohns disease or ulcerative colitis, granulomatosis with polyangiitis, morbus Behçet and infections that are usually seen in those who are immunocompromised, for example ecthyma gangraenosum. It is important to consider such causes if the skin ulcerations dont show improvement with antibiotic treatments and when other systemic symptoms are present. It is advised not to use surgical procedures on ulcerations caused by Behçet or pyoderma gangraenosum since those diseases usually exhibit pathergy. Diagnosis
Grading
Wagners grading of ulcer follows:

Management
Investigations
Some of the investigations done for ulcer are:: 19 
Study of discharging fluid: Culture and sensitivity
Edge biopsy: Edge contains multiplying cells
Radiograph of affected area to look for periostitis or osteomyelitis
Fine needle aspiration cytology (FNAC) of lymph node
Chest X-ray and Mantoux test in suspected tuberculous ulcer

Treatment
Skin ulcers may take a very long time to heal. Treatment is typically to avoid the ulcer getting infected, remove any excess discharge, maintain a moist wound environment, control the edema, and ease pain caused by nerve and tissue damage. Topical antibiotics are normally used to prevent the ulcer getting infected, and the wound or ulcer is usually kept clear of dead tissue through surgical debridement. Commonly, as a part of the treatment, patients are advised to change their lifestyle if possible and to change their diet. Improving the circulation is important in treating skin ulcers, and patients are consequently usually recommended to exercise, stop smoking, and lose weight. In recent years, advances have been made in accelerating healing of chronic wounds and ulcers.