Managing Venous Ulcers In The Lower Extremity
Given the potentially serious nature of venous ulcers in the lower extremity, our expert panelists take a closer look at key risk factors and share their treatment approaches to this condition. Drawing from their experience, they also discuss topical treatments, the use of bioengineered skin substitutes and surgical procedures. Q: What risk factors predispose patients to the development of lower extremity venous ulcers? A: Mark Hirko, MD, and Lawrence Karlock, DPM, agree that risks include prior deep venous thromboses (DVT), morbid obesity, lower extremity trauma and chronic venous hypertension, which can lead to perforator vein incompetence. Allen Holloway, MD, agrees and emphasizes that venous hypertension is the primary factor associated with the development of venous ulcers. He notes this may be secondary to previous DVT, either deep, superficial or perforator vein incompetence or severe edema from the dependent position. According to Dr. Hirko, other less common risk factors include changes in the progesterone-estrogen ratio, pregnancy, increased intraabdominal pressure and chronic phlebitis leading to venous hypertension. Q: What is your traditional treatment protocol in managing these ulcers? A: After an in-depth patient history and physical exam, Drs. Hirko and Holloway will proceed with a venous duplex study of the lower extremities and, based upon the severity and/or location of the ulceration, include compression as a first-line treatment. Drs. Holloway and Karlock agree that compression is the most important aspect of treating venous ulcers. Simple forms of compression include an elastic bandage (ACE) wrap or a compression stocking, according to Dr. Holloway. However, he says simple compression may not be practical in heavily draining wounds. In these cases, Dr. Holloway will employ an Unna’s boot or a multilayer compression bandage. He emphasizes that these modalities, which are commonly changed weekly, provide compression and absorb drainage. When treating serious, chronic cases with extensive lower extremity ulcerations and/or necrotic skin, Dr. Hirko combines judicious debridement with compression. He says the compression could include ace wraps with skin moisturizers, the traditional Unna’s boot and the newer multilayer compression boots. Drs. Holloway and Karlock emphasize the importance of elevating the involved legs as much as possible in order to decrease the venous hypertension and edema. In severe cases, Dr. Holloway says using a venous compression pump can be a useful adjunct. When healing has occurred, Drs. Karlock and Holloway advocate the use of compression stockings in order to prevent recurrence. Q: What topical products do you prefer to use for these ulcers? A: When drying is a problem in smaller ulcers, Dr. Holloway says he frequently uses a calcium alginate or newer silver-containing dressing, and applies a vaseline gauze dressing over it in order to keep the wound moist and protect the surrounding skin. If the wound has extensive moisture, bordering on maceration, Dr. Hirko considers using sheets of Kaltostat. He says this seaweed-based agent helps dry the wound, remove excessive fluid and provides a moist hydrogel layer in the same setting. Dr. Karlock agrees, adding that he prefers using Aquacel or Kaltostat on highly draining venous wounds. When using these modalities, Dr. Karlock notes that he will first apply an Adaptic dressing, directly to the wound. If the wound has extensive contamination, Dr. Hirko recommends using an iodine-based gel such as Iodosorb. If the wound is somewhat dry and nearly healed, he says using hydrogel-type wound products is appropriate. When extensive chemical debridement is called for, Dr. Hirko says he will use Accuzyme. When it comes to irritated, dry skin or a necrotic ulceration, Dr. Hirko says you can perform gentle debridement with a combination of Santyl and Polysporin powder. Q: Do you see any role for bioengineered skin substitutes in the treatment of these ulcers? A: When using bioengineered skin substitutes, Dr. Holloway says one should ensure meticulous preparation of the wound bed with excellent underlying tissue. Dr. Hirko concurs. If the ulcerations are chronic, clean, free of bacterial contamination and the patient has no suitable harvest sites for split thickness skin graft, Dr.