Keys To Treating Venous Leg Ulcerations
Venous leg ulcers are a severe outcome of chronic venous insufficiency, making it crucial to have an appropriate treatment plan. These authors highlight their three-pronged approach to treating venous leg ulcerations, emphasizing assessment of the ulcer, compression techniques and educating patients. Though the prevalence of venous leg ulcerations is still considered low, it is the refractory nature of this specific type of leg ulcer along with the inconsistency in treatment options that lead to the increased risk in the development and recurrence of venous leg ulcerations. Also referred to as stasis ulcers, venous leg ulcerations are the most severe and debilitating outcome of chronic venous insufficiency in the lower limb and account for 80 percent of lower limb ulcerations.1 We presume that the refractory nature of venous leg ulcers in particular could be closely related to the variable ways in which practitioners from diverse specialties, including podiatry, approach the assessment and therefore treatment of the venous leg ulcer. We will highlight our no-nonsense threefold approach to venous leg ulcerations: assess/address, compress, and educate. As podiatric physicians and lower extremity specialists, we play an integral role in the appropriate early assessment of venous leg ulcers, how best to treat ulcers at numerous stages of their development as well as the utilization of different methods of compression for short and long-term treatment. We hope to hone in on the practical aspects of addressing these ulcers within the scope of our specialty as well as the appropriate use of multidisciplinary consultation for best patient outcomes.
Assessing The Clinical Presentation And Using Ancillary Tests
A variety of underlying conditions play a role in the development of venous leg ulcerations but the most commonly accepted cause is the elevation of ambulatory venous pressure, also known as venous hypertension.1 In venous insufficiency, venous leg ulcerations typically present around the ankle. Even today, many practitioners may incorrectly diagnose an ulcer as “venous.” As treatment of the ulcer may vary depending on ulcer etiology, it is paramount to have an adequate understanding of the pathophysiology of venous leg ulcerations, and make a correct diagnosis before initiating treatment. Venous ulcers can exist in the presence of mixed arterial and venous pathology. It is important to differentiate between venous versus arterial origin as treatment of only the elevated venous pressure may not succeed if severe arterial disease is present.2 Regardless, moderate amounts of applied compression may be successful in healing venous leg ulcerations in patients with mild to moderate arterial insufficiency.3 On physical exam, one should rule out gross arterial disease by establishing that pedal pulses are present. However, note that oftentimes pedal pulses may be difficult to assess secondary to significant lymphedema. The ankle brachial index (ABI) should optimally be greater than 0.8. This is particularly important as compression therapy is generally contraindicated with an ABI of less than 0.7, which suggests a degree of vascular disease.4 In patients with diabetes or with an ABI greater than 1.0, a toe brachial index (TBI) of > 0.6 or a transcutaneous partial pressure of oxygen (TcPO2) of > 40 mmHg in the area of the ulcer may suggest adequate microvascular flow.
What You Should Know About Ancillary Testing
When assessing a true venous ulcer, one may perform several diagnostic tests. Though rarely used, venography helps to evaluate venous thrombosis. The most common test is a venous duplex scan. This will assess venous patency and reflux in the region of the ulcer. Color duplex ultrasound scanning, including both supine and standing positions to identify abnormal venous reflux and/or obstruction, is useful in providing anatomic and physiologic data, helping to confirm a venous etiology for the leg ulcer.5 Plethysmography determines changes in the volume and size of the extremities by measuring changes in blood volume. Practitioners should keep in mind that though a definitive diagnosis of venous disease is desirable, this is not always possible. When using various tests to document venous disease, clinicians should clearly communicate the necessary information to the test performer.
Recognizing The Classic Clinical Presentation Of A Venous Ulcer
Venous leg ulcerations may appear anywhere from the ankle to mid-calf level with the most common area being the medial aspect of the ankle proximal to the malleolus.7 Venous leg ulcers are irregular in shape. They may appear dry and crusted with slightly macerated borders. Venous leg ulcers usually have a shallow wound base covered with red granulation tissue, yellow slough or dark necrotic tissue depending on the acuity and bioburden of the wound. Clinically, a venous leg ulcer will often present in addition to lymphedema, supporting the causative venous hypertension theory. Pitting edema will be visible and skin typically appears hyperpigmented due to hemosiderin deposits in the tissue. The foot may also become cyanotic in the dependent position. It is essential to recognize these components of a typical venous leg ulceration in comparison to ulcers with arterial and/or lymphatic origins. Clinicians should conduct an ongoing and consistent documentation of wound history, recurrence and characteristics (location, size, base, exudates, condition of the surrounding skin, staging and pain) to monitor progress.
A Brief Look At Contributing Factors
As far as patient populations go, venous leg ulcerations typically result from some form of peripheral vascular disease. As previously stated, venous hypertension is a key contributing factor. Thus, patients with any disease that may precipitate lower extremity edema are at risk for venous ulcers.7 One should ascertain a thorough history on each patient, paying particular attention to any prior wounds and associated treatments. Physicians should present specific questions as to any history of thrombophlebitis or varicosities. Acutely, consider a traumatic inciting event as a factor if a patient does not meet other prerequisites for developing a venous leg ulcer. Practitioners should not hesitate to request consults and involve vascular surgeons, endocrinologists and/or internists to form a multidisciplinary care approach.
Addressing Key Components In Venous Leg Ulcer Treatment
Basic treatment goals for venous leg ulcerations include managing the underlying venous disease, controlling edema, and providing appropriate wound care. Patients should present on a regular basis for debridement and monitoring.8 One should apply a topical occlusive dressing to promote moist wound healing, proliferation of healthy granulation tissue and eventual re-epithelialization. There is a plethora of choices for topical treatment of venous leg ulcerations, and many dressings now combine wound bed preparation (debridement and/or antimicrobial activity) with moisture control.9 One may apply growth factors to the wound bed to improve the healing rate as needed. Limb elevation to allow gravity to drain fluid from the limb is essential, and physicians should communicate this to the patient. Compression bandages, layered compression dressings, elastic bandages and compression stockings should all be options to consider.10,11 One may also prescribe pneumatic compression devices for home use, especially for painful venous leg ulcerations. The intermittent pressure of pneumatic compression devices stimulates venous return and can be an option when patients do not tolerate constant compression.12
What About Adjuvant Modalities?
If wound healing does not occur in an appropriate timeframe, one may propose alternative treatments. These include bioengineered skin equivalents and substitutes. Also consider hyperbaric oxygen therapy to increase perfusion to a venous leg ulceration. Wounds will heal in an environment that is adequately oxygenated and hydrated.13 Many factors that increase sympathetic tone such as cold, stress or pain will all decrease tissue perfusion. Cigarette smoking also decreases tissue oxygen by peripheral vasoconstriction.14 For optimal tissue perfusion, minimize these aforementioned factors. Negative pressure wound therapy is another adjuvant treatment that helps remove fluid, assists in granulation tissue formation, and decreases wound size.
Pointers On Addressing Infection
Infection control is also essential to the treatment of venous leg ulcers. Infection plays various roles in the etiology, healing, operative repair and complications of venous ulcers. Necrotic tissue is laden with bacteria while devitalized tissue impairs the body’s ability to fight infection and serves as a medium for bacterial growth.15 As previously noted, patients should present on a regular basis for removal of all necrotic or devitalized tissue from the wound. Debridement can include any combination of sharp, enzymatic, mechanical, biological or autolytic methods. The practitioner may elect to obtain wound cultures to isolate suspected microbes. Subsequently, one may apply topical antibiotics to the venous leg ulcer as needed to assist in the healing process. Note that research has not shown systemically administered antibiotics to decrease bacterial levels effectively in granulating wounds. Accordingly, unless there is concomitant periwound cellulitis, a topical route is preferable.16,17
Addressing The Differential Diagnosis
When a wound is not responding to treatment, consider various differential diagnoses. Biopsy plays a major role in this situation. There is continuous debate amongst practitioners as to the exact amount of time to wait before performing a wound biopsy for histological diagnosis. In a clinical setting, persistent venous ulcers that show no signs of healing for three months or that do not respond appropriately to standard treatment after six weeks should have a biopsy.18 Practitioners should not hesitate to perform said biopsy sooner if suspicions are high. For example, excessive pain, discoloration and blue or purple borders surrounding a venous ulcer are usually atypical. Also consider as highly suspicious venous leg ulcers that progressively increase in size after debridement and/or despite treatment. Malignancy, vasculitis, collagen diseases and dermal manifestations of systemic diseases may all present as ulcers or precipitate ulcers on the lower extremity. Differential diagnoses include pyoderma gangrenosum, melanoma, squamous cell carcinoma, IgA monoclonal gammopathies, Wegener’s granulomatosis, cutaneous chronic granulomatous disease, and mycobacterial or fungal etiologies.19 Always take into account the presence of systemic diseases such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis, collagen vascular diseases, leukemia, or immunosuppression. Patients with homozygous, heterozygous or sickle cell trait hemoglobin can present with lower extremity ulcers resembling venous leg ulcerations.20 These patients should have a sickle cell prep and hemoglobin electrophoresis.
Understanding The Art Of Compression In VLU Treatment
Continued discussion still ensues amongst practitioners as to whether or not the use of compression therapy is effective and worthwhile. The most recent 2014 publication in the Journal of Vascular Surgery reviews the report from the 2013 meeting of the International Compression Club.21 This collaborative forum of medical experts and industry representatives provides its combined recommendations on the use of compression therapy in the treatment of chronic and acute vascular disease. It is important to note that though the International Compression Club has support through unrestricted educational industry grants, there is a clear delineation in that the only people eligible to participate in the planning process of the conference are the medical experts who are working together to present broad topics and products of all types and brands related to compression therapy. The primary goal of this group is to review the current state and knowledge of the various compression therapy modalities and identify the essential areas that need more comprehensive research. The types of compression highlighted in the study were inelastic short stretch compression, elastic long stretch compression, intermittent pneumatic compression, reusable multilayer bandages, Velcro wraps and a hybrid pneumatic compression. When the topic of compression comes up, many will refer to Laplace’s original formula for a curved surface of an inanimate object and apply the theory to the human leg, which is not as static.22 According to Laplace’s law, in the absence of variations in other factors, if the circumference of the leg increases, there is an inversely proportional decrease in pressure. In other words, under compression, the decreasing pressure gradient is guaranteed by normal leg morphology. This law was modified in order to approximately calculate the sub-bandage pressures of compression systems. One can extrapolate the resulting pressure by taking the number of layers of bandage applied as well as the width of the particular bandage. This is a close approximation of pressure on the leg but again is based on a theoretical mathematical equation that does not yet have the support of consistent and reproducible objective measures. The overall consensus is that research has proven the use of compression to be effective in treating venous leg ulcerations but there is a chasm of knowledge.21 Access/affordability and skill still exist and leave us with a great degree of variability in healing, which is both good and bad. The authors of the International Compression Club study reinforce that compression therapy is an art more so than a science and it can vary in its outcome depending on the skill of the practitioner applying the compression as well as the adherence and tolerance of the patient and diameter of the limb.21 The search for the ideal “intelligent” compression system would address the variables such as the interface pressure needed to counteract the hydrostatic pressure in the veins, providing low, tolerable pressure in the veins, when horizontal and high pressure are present in the vertical position. Longitudinal studies with the ability to obtain objective findings on accurate pressure measurements under compression garments are needed for consistency. More evidence based engineering of these compression dressings is also needed. Warriner and Wilcox studied twice weekly or at minimum weekly visits for compression and dressing changes in comparison to biweekly visits.23 They showed a significant difference in the time to heal a venous leg ulceration. Recurrence rates are reportedly as high as 70 percent.24 Therefore, one must address long-term maintenance even once an ulcer has closed and eventually healed. Always consider surgical options and further vascular intervention to address various underlying pathologies and discuss this with partnering healthcare providers. Advise patients to use compression stockings continuously. Most treatments for venous leg ulcerations do not eliminate the underlying increased ambulatory venous pressure. As such, a degree of compression is necessary in the long term to combat venous hypertension. Guide patients to embrace compression as a necessary preventative measure.25
The Importance Of Educating The Patient
The last piece of the triad is crucial. Education for the primary caretaker, partnering practitioners, and of course the patients themselves must play an important role in the treatment and prevention of venous leg ulcerations. On the practitioner side, ensuring that the etiology of the venous leg ulcerations is indeed venous in origin is essential. Fully understanding the role pressure on the limb plays in these recalcitrant wounds is imperative. One should guide patients in the initial stages of treatment. For example, one can manage the initial discomfort of a compressive bandage with pain medication as well as elevating the limb as much as physically possible. Even simple measures such as proper hygiene, nonirritating clothing, supportive shoe gear, and avoidance of prolonged standing cannot have enough emphasis. Having easy to understand pamphlets as well as instructional videos on the importance of prevention is also key in the educational piece of the puzzle. The time immediately following successful wound closure is the optimal time to fit patients for long-term compression hosiery as well as considering home pneumatic compression systems if warranted. In lieu of our current climate and access to healthcare with minimal benefits offered to support reimbursement of venous compression garments, the educational piece for our patients must start from the onset of their first visit. This will help maintain minimal risk for recurrence or development of a future venous leg ulcer.
Venous leg ulceration will continue to be a lower extremity condition that we will face daily in our everyday practices. Though mortality is not often closely associated with venous ulcerations, the extent to which it can impact an individual psychosocially as well as diminish his or her capacity to remain as a working member of society is high. The economic burden that venous leg ulcers pose in the form of healthcare dollars spent on treatment, recurrence and bandaging alone is enough to reinforce the importance of this timely and effective venous leg ulcerations triad: assess/address, compress, and educate. Dr. Zinszer is affiliated with the Dermatology Department in the Geisinger Health System in Danville, Pa. She is a Fellow of the American Professional Wound Care Association. Dr. Malhotra is a board-qualified foot and ankle surgeon with particular interests in wound care and sports medicine. She graduated from MedStar Washington Hospital Center Podiatric Residency program, affiliated with Georgetown University Medical Center in Washington, D.C. References 1. O’Meara S, Al-Kurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2008; (1):CD003557. 2. Trent JT, Falabella A, Eaglstein WH et al. Venous ulcers: pathophysiology and treatment options. Ostomy/Wound Manage. 2005;51(5):38–54. 3. Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg. 2012;55(1):122-128. 4. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. J Am Med Assoc. 2001;286(11):1317–24. 5. Coleridge-Smith P, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs: UIP consensus document: part I. Basic principles. Eur J Vasc Endovasc Surg. 2006;31(1):83-92. 6. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts, fourth edition. Mosby, St. Louis, 2011. 7. Mustoe T. Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy. Am J Surg. 2004;187(5A):65s–70s. 8. Davies CE, Turton G, Woolfrey G, et al. Exploring debridement options for chronic venous leg ulcers. Br J Nurs. 2005;14(7):393–7. 9. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev. 2003; 1:CD001177. 10. Wong IK, Andriessen A, Charles HE, et al. Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. J Eur Acad Dermatol Venereol. 2012;26(1):102-110. 11. Woo K, Cowie B. Understanding compression for venous leg ulcers. Nursing. 2013;43(1):66-68. 12. Nelson EA, Hillman A, Thomas K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2014; 5:CD001899. 13. Gottrup F. Oxygen in wound healing and infection. World J Surg. 2004;28(3):312–5. 14. Sorensen LT, Nielsen HB, Kharazini A, et al. Effect of smoking and abstention on oxidative burst and reactivity of neutrophils and monocytes. Surgery. 2004;136(5):1047–53. 15. Robson MC. Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am. 1997;77(3):637–50. 16. White RJ, Cooper R, Kingsley A. Wound colonization and infection: the role of topical antimicrobials. Br J Nurs. 2001;10(9):563–78. 17. Scotton MF, Miot HA, Abbade LP. Factors that influence healing of chronic venous leg ulcers: a retrospective cohort. An Bras Dermatol. 2014;89(3):414-22. 18. Snyder RJ, Stillman RM, Weiss SD. Epidermoid cancers that masquerade as venous ulcer disease. Ostomy/Wound Manage. 2003;49(4):63–6. 19. Chakrabarty A, Phillips T. Leg ulcers of unusual causes. Int J Low Extrem Wounds. 2003;21(4):207–16. 20. Karayalcin G, Rosner F, Kim KY, et al. Sickle cell anemia: clinical manifestations in 100 patients and review of the literature. Am J Med Sci. 1975;269(1):51–68. 21. Reyes AP, Partsch H, Mosti G et al. Report from the 2013 meeting of the International Compression Club on advances and challenges of compression therapy. J Vasc Surg: Venous and Lym Dis. 2014;1-8. 22. Thomas S. The production and measurement of sub-bandage pressure: Laplace’s Law revisited. J Wound Care. 2014:23(5):234-44. 23. Nelson EA, Harper DR, Prescott RJ et al. Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. J Vasc Surg. 2006;44(4):803-8. 24. Warriner RA, Wilcox JR. Influence of wound care center visit frequency on wound healing outcomes of diabetic foot and venous leg ulcers. Wound Healing Society, 2010. 25. Bainbridge P. Why don’t patients adhere to compression therapy? Br J Community Nurs. 2013; SupplS35-6:S38-40. For further reading, see “A Guide To Compression Dressings For Venous Ulcers” in the February 2012 issue of Podiatry Today or “Essential Insights On Treating Chronic Venous Stasis Ulcers” in the July 2012 issue.