Essential Insights On Treating Chronic Venous Stasis Ulcers

Nanjin J. Park, DPM, Latricia Allen, DPM, MPH, Guosheng Gu, MD, and Vickie R. Driver, DPM, MS, FACFAS

Given the common and chronic nature of venous stasis ulcers, these authors offer salient diagnostic insights, keys to selecting appropriate wound care dressings and a guide to choosing optimal compression modalities. They also emphasize the importance of patient education in reducing the risk of recurrence.

As lower extremity specialists, we are not all trained or equipped to focus our attention on the treatment of venous leg ulcers. This is partly due to the integrated medical systems required to manage these patients with significant, complex medical comorbidities. Another possible factor is economic constraints imposed by inadequate reimbursement strategies that are “out of synchrony with government approved standards of care.”1

   However, the scope of the problem is greater than we may realize as primary chronic venous insufficiency is “widespread in the population.”2 Finlayson and co-workers recently noted that approximately 40 to 50 percent of the adult population has some degree of chronic venous insufficiency with 1 to 2 percent progressing on to ulceration.3

   Venous leg ulcers typically develop along the medial distal ankle, affecting over 2.5 million people per year in the United States with 70 to 90 percent becoming chronic and potentially very painful.4 Treatment requires an average of six to 12 months to heal completely and 70 percent recur within five years of closure.5 Recurrence is associated with loss of an estimated 2 million workdays and decreased quality of life.2 The cost for treating patients is burdensome with chronic venous ulcer treatment costing an estimated $3 billion per year in the U.S.6,7

   Podiatrists are in an ideal position to help address this clinical issue as part of the limb preservation effort. It is essential to understand the pathologic mechanisms causing the ulcers in order to develop the most evidence-based treatment plan. However, it is helpful to understand the challenges inherent in the lack of standardized diagnostic testing for chronic venous insufficiency. Likewise, it is critical to understand the factors that place patients at risk for progression to ulceration.2

   Recently, the National Guideline Clearinghouse accepted a content validated venous ulcer guideline developed by the Association for Advanced Wound Care (AAWC).1 This guideline represents a great step forward in support of our efforts to treat patients with chronic venous insufficiency. The AAWC venous leg ulcer guideline points out that there are multiple economic disincentives to providing optimal care.

   Due to the previous lack of a validated guideline, one issue is the inconsistent interpretation of federal regulations, which may lead to inconsistent reimbursement. The economic downturn, which has become as chronic as some of our patients’ venous leg ulcers, serves to put evidence-based practices even further out of reach for many.

   What can we do in our practice to help those who are not well insured and are not able to pay out of pocket for treatments that improve outcomes? Are we forced to watch our patients “settle” for what the guideline describes as “substandard care with gauze without compression that pushes them to associated pain, increased infection rates and protracted healing time”?1 For these patients, we can best spend our time by teaching the importance of the basics, such as compression, moist wound healing and elevation. We can also suggest lower priced materials such as Unna boots with cohesive wrap, which patients can change frequently with the aid of a family member.

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