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

   The patient self treated his wounds at home for a couple of years. However, after not seeing any progress, he decided to see a physician at Boston Medical Center. The patient went to the vascular clinic for three years. During this time, he had venous reflux tests, which revealed incompetent superficial and deep venous systems on both legs. His ABI was 1.0 bilaterally. The patient was using a four-layer compression wrap and had multiple treatments of antibiotic therapy prior to our clinic consultation. Also, during treatment with the vascular team, the patient underwent a right saphenous ablation procedure on the right leg and had intraoperative debridement of the wound sites.

   On our initial visit, the patient admitted to smoking for 25 years. The physical examination revealed ulcers on the anterior surface of both legs. There was a 2 cm by 3 cm ulcer on the right leg and a 9.5 cm by 6 cm ulcer on the left leg. The ulcers were deep (approximately 3 to 5 mm) without exposed tendon or bone. The base of the ulcers was 80 percent fibrotic and 20 percent pink granulated tissue. There was no sign of infection and no odor, but there was mild edema. The surrounding periwound tissue had localized erythema, which was more from inflammation than infection.

   We debrided the ulcers to subcutaneous tissue. We provided standard of care treatment with the exception of soaking the ulcers for 15 minutes in a silver solution prior to using the compression wrap with PO antibiotics for 10 days.

   We also reinforced the necessity to quit smoking and educated the patient to elevate his leg above his heart any time he is resting.

   Originally, the patient’s ulcers had significant exudate so he came to our clinic three times a week for dressing changes. Then as the base of the wounds evolved into more red granulated tissue and exudate was under control, we reduced his dressing changes to twice per week. Once the base of the wounds filled with granulated tissue, we applied a skin substitute in conjunction with compression wrap after silver solution soaking.

   The right leg ulcer healed within two months and we prescribed 20 to 30 mmHg compression hose to control edema. The left leg ulcer is still open but diminished to 5 cm by 3 cm. The patient has cut down on smoking. He is committed to stopping smoking, elevating his leg at least one hour per day and wearing a compression stocking on the healed ulcer leg every day. He has not been using recreational drugs or pain medication for some time now.

Keys To Prevention And Patient Education

It is vital to individualize any treatment, based on the patient’s health, medical condition, psychological status and socioeconomic status as well as the patient’s physical ability to care for the wound. It is important to apply sufficient pressure to improve the chronic venous insufficiency during the treatment period. If needed, treatments should begin with antibiotics for infection or anti-platelet or anti-clotting medications to prevent a blood clot.

   Patients need to understand the treatment plan, the goals of treatment and how the patient and clinician are going to work together to achieve the stated goals. One needs to establish and maintain trust if the treatment is to be effective. It is important patients understand that venous leg ulcers often recur and that treatment is an ongoing process of preventing future ulcers and managing acute ulcerations.

   As healthcare providers, it is important to teach patients to monitor their wounds, check for complications often and maintain a daily self-care regimen. This regimen should include the following points.

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