Essential Insights On Treating Chronic Venous Stasis Ulcers

Start Page: 70
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Author(s): 
Nanjin J. Park, DPM, Latricia Allen, DPM, MPH, Guosheng Gu, MD, and Vickie R. Driver, DPM, MS, FACFAS

   In addition, one may consider treatments provided by vascular surgeons. These treatments include: injecting a sclerosing agent directly into veins; superficial and perforating vein ablation; deep vein reconstruction; and subfascial endoscopic perforator vein surgery combined with superficial vein ligation. If an ulcer is present, we recommend the aforementioned conservative treatments and adding local wound care to keep the wound site clean and non-infected. Therefore, cleansing the wound with each dressing change is important.

   Clinicians can determine the appropriate type of dressing for ulcers by the appearance of tissue type on the ulcer base (see “How To Select The Optimal Dressing For Venous Ulcers” at left).11

   Depending on the wound type and drainage amount, there are a plethora of dressings and therapies from which to choose. These include hydrogels, alginate dressings, collagen wound dressings, debriding agents such as Santyl (Healthpoint) and Accuzyme (Healthpoint), and antimicrobial dressings with silver- or cell-based therapies. Other options include platelet rich plasma (PRP), platelet-derived growth factor (PDGF), low frequency ultrasound therapy (MIST, Celleration) with composite dressings, negative pressure wound therapy (NPWT) and synthetic skin substitutes. All wound care therapy programs must include compression therapy to be more effective.

   There are many different types of composite/compression dressings. However, there is no international guideline for the proper application of compression treatments. In a 2007 article, the World Union of Wound Healing Societies proposed a management plan to assist clinical decision making in the use of compression therapy for venous leg ulcers.12 They explained the diagnosis of venous leg ulcers, treatment options and possible outcomes from the treatment (download “Key Considerations For Compression Therapy In The Treatment Of Venous Leg Ulcers” at http://podiatrytoday.com/files/PT_78.pdf ), which can initially guide the type of compression dressing one uses.

   In general, we apply multilayer compression wraps from the toes or foot to the area below the knee. Different types of compression layers on the market include four-layer bandages, double-layer tubular elastic bandages, compression stockings or short stretch compression.

   For clinical purposes, the level of compression dressing indicated depends on the patient’s comfort level, the amount of edema and the results of ABI testing. One should apply compression wraps with caution on the patient who has an ABI below 0.75. Never place compression wraps on a patient with an ABI lower than 0.5 or those who develop a sudden increase of edema on both lower extremities. These two clinical scenarios require consultation with a cardiologist or vascular surgeon for further evaluation for cardiac failure or arterial insufficiency.

   If the ABI is between 0.9 and 1.25, the patient can likely tolerate treatment with a four-layer compression or long stretch compression wrap. When the patient has an ABI between 0.75 and 0.9, we recommend single layer compression comprised of cast padding and Coban in spiral formation. However, the use of compression wrap remains dependent on the patient’s comfort level and degree of leg edema.

   We always recommend starting with single layer compression and gradually increasing the compression as the patient tolerates and as edema allows. In addition, the frequency of dressing changes depends on drainage volume. If patients have heavy exudate, they should change dressings more frequently. Dressing changes can initially occur daily and then gradually decrease to weekly changes depending on the degree of edema and amount of drainage. One can use steroids, either oral or topical, for short periods of time to help decrease exudate.

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