Key Insights On Treating Chronic Venous Ulcers

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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

A: Once one surgically debrides the wound, Dr. Mulder says xenografts or allografts may be very useful. He does note that the outcomes are “greatly dependent” on the patient’s tolerance of compression (preferably 30 to 40 mmHg) at all times. One must tell the patient that compression is for life, emphasizes Dr. Mulder.
   When using topical debridement agents, Dr. Mulder says these patients will need a compression modality that allows for removal of the compression on a daily basis. He says one may also use silver dressings in lightly colonized wounds.
Dr. Mulder adds that the choice of dressing is based on the amount of exudate, the status of the wound base and patient tolerance. As Dr. Mulder notes, it is usually fine to use anything that takes away excessive exudate, controls bacteria and is not painful. He says compression and addressing both micro- and macroedema are key factors in healing.
   “If you follow the basic wound care or debridement principles, the dressing is the least important factor,” explains Dr. Katz.
   If one is concerned about infection while the patient has compression on for a week, Dr. Katz suggests using a silver product for seven days under the compression. In most cases, Dr. Katz does not like having silver against the wound as it becomes an irritant and high silver concentrations may inhibit new cell growth. Dr. Katz notes that he uses Adaptic (Johnson and Johnson) and subsequently puts the silver dressing over the Adaptic.
   Dr. Katz says many patients will have heavily draining wounds. In these cases, he uses an alginate product and may change the compression twice weekly until the drainage slows.
   As far as topical dressings go, Dr. Suzuki says there is no good clinical evidence to show that one dressing heals faster than the others. Nonetheless, he prefers using soft silicone adhesive-based foam dressings such as Mepilex (Mölnlycke) as evidence has shown them to be less painful and less traumatic to the patients during the dressing removal. Dr. Suzuki will pay close attention to the amount of wound drainage, which determines the dressing components and how often the patient should change the dressing.

Dr. Katz is in private practice in Tampa, Fla. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Mulder is an Associate Professor of Surgery and Orthopedics at the Department of Surgery/Division of Trauma at the University of California-San Diego (UCSD). He is also the Director of the Wound Treatment and Research Center
at UCSD.

Dr. Suzuki is the Medical Director of Tower Wound Care Center at the CedarsSinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor of Tokyo Medical and Dental University in Tokyo, Japan. One can contact Dr. Suzuki at kazu88@gmail.com.

Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is the Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.

For further reading, see “How To Manage Venous Stasis Ulcers” in the May 2007 issue or “Treating Venous Stasis Ulcers In The Lower Extremity” in the October 2004 issue.

Also check out the archives at www.podiatrytoday.com.




References:

1. Ennis WJ, Borhani M, Meneses P. Re-establishing macro vascular flow and wound healing: beyond the vascular intervention. Vascular Disease Management 5(3):74-80, May 2008.
2. Falanga V, Sabolinski ML. A bilayered living skin construct (Apligraf®) accelerates complete closure of hard-to-heal venous ulcers. Wound Repair Regen 7(4):201-7, 1999.

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