Essential Insights On Treating Chronic Venous Stasis Ulcers

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

   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.

   Sometimes patients can wear Unna boots if their skin shows any type of dermatitis. Unna boots are rolled bandages that contain a combination of calamine lotion, glycerin, zinc oxide and gelatin. Calamine lotion can sometimes provide a soothing effect and it works well on the patient who has a burning sensation. However, the Unna boot itself does not provide any control of edema. Therefore, a compression wrap would still be required.

   It is important during treatment to consider the patient’s socioeconomic situation and possibly utilize a social worker to assist the patient in the frequent clinic visits that may be required. If a social worker is not available at the facility, arranging visits from the Visiting Nurse Associations of America may be another option. If nursing visits will be part of the treatment plan and follow-up, make sure dressing change orders are very clear and well communicated with the nurse. This plays an important role in treatment outcomes.

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