Leg ulcers part 2 - management - Issue 20 (July 2005)

Issue 20 July 2005

On this page

  1. General points
  2. Introduction
  3. Wound Management
  4. Pain Management
  5. Patient Education and Involvement
  6. Arterial Ulcers
  7. Venous Ulcers
  8. Reduced Compression
  9. Skin Graft
  10. Slow to Heal Ulcers
  11. Recurrence
  12. Venous surgery
  13. References:

General points

  • Comprehensive assessment is the key to successful management of leg ulcers
  • High compression bandaging is the recommended treatment for venous ulcers
  • Arterial ulcers require referral to a vascular specialist
  • All non-improving wounds of 4 weeks or more duration require wound bed preparation with TIME
  • Tissue management
  • Inflammation and infection
  • Moisture balance
  • Epithelialisation
  • Pain management may be required.

Introduction

The key to successful management of leg ulcers is comprehensive assessment and an holistic approach, often in a multidisciplinary setting. The cause of many ulcers is multifactorial and it is important to address medical, surgical, psychological and socioeconomic factors as well as correcting any underlying arterial or venous disease. This is the second ACC Review on leg ulcers and summarises best practice on the management of leg ulcers.1, 2

Wound Management

Wounds of 4 weeks or more duration, without improvement, require wound bed preparation involving TIME.3

T – tissue management. Remove necrotic or sloughy tissue by sharp debridement or autolytic wound dressings.

I – inflammation and infection. A bacterial burden of 106 or more per gram of tissue seriously impairs healing. Consider systemic antibiotics only if ulcer is clinically cellulitic; avoid topical antibiotics.

M – moisture balance. Maintain an optimum moisture level with correct dressings. Chronic wound fluid can block cellular proliferation and angiogenesis. Ulcers do not require the same level of moisture as acute wounds, but should not dry out.

E – epithelialisation. Chronic wounds are often hypoxic as a result of cellular inactivity. TIME will help to correct this.

Clean wounds with tap water or warm saline and use products with minimal additives and/or preservatives.

Pain Management

Ulcer pain assessment and management is important.4 Advise patients that pain levels may rise initially.5 Pain management strategies include non-adherent wound dressings; regular analgesia (e.g. paracetamol); management of oedema, inflammation and infection; and patient education on exercise/rest/elevation. Poorly controlled ulcer pain, or pain that is separate from the ulcer itself requires specialist input.

Patient Education and Involvement

Involving patients in their ulcer care can improve treatment compliance. Walking to activate the calf muscle pump can benefit patients with venous ulcers by reducing venous hypertension and swelling. Elevating the affected limb above the heart level when resting is also effective, except for patients with arterial ulcers as this may increase pain.

Rates of healing and adherence to therapy may be affected by psychosocial factors such as depression, social isolation and stress. Measures to address these may be necessary.5

Arterial Ulcers

Consider referral to a vascular specialist for patients with an Ankle Brachial Pulse Index (ABPI) of <0.8. For patients with an ABPI of <0.6 vascular specialist assessment is mandatory.1 Compression therapy is not recommended in the presence of significant arterial disease. Treatment could include vascular and endovascular surgery to improve arterial inflow to the affected limb. Control of cardiovascular risk factors such as smoking, diabetes, hypertension and hyperlipidemia are essential components of management.

Venous Ulcers

High compression therapy is the recommended treatment for all patients with uncomplicated venous ulcers. Correctly applied high compression elastic or inelastic multi-layer systems are more effective than single layer or low compression bandaging.6

Selection of elastic or inelastic compression bandaging should take into account patient mobility and the type of arterial and/or venous impairment. Consider also skin condition, presence of neuropathy or cardiac failure.2

Effective bandaging requires achieving adequate and graduated compression. All compression bandages must have an underlayer of protective padding, particularly to protect the tibial crest and malleoli. Ankle measurements should be taken and extra padding applied for ankles under 18 cm. More tension (stretch) is required for ankles over 25 cm.

Effective and safe bandaging is a skilled task and should only be undertaken by trained staff.

Reduced Compression

Reduced compression may be effective in selected patients with an ABPI between 0.6 and 0.8 and clinically venous ulcers. Patients with venous ulcers can develop arterial disease as they age, but may still be able to have low compression applied. Careful patient selection and close monitoring is required. Only patients who can detect increasing pain and remove the bandages themselves should be trialled on reduced compression.

Skin Graft

Skin grafts may assist ulcer healing. For arterial ulcers, this would occur usually after revascularisation of the limb, and for venous ulcers once the ulcer is clean and granulating well.

Slow to Heal Ulcers

A complete reassessment is recommended for patients with slow to heal ulcers. There may be contact sensitivity, infection or possible malignancy. Biopsy should be considered where the diagnosis is in doubt.

Recurrence

Compression stockings

Correctly fitted graduated Class 3 stockings are more effective at reducing recurrence than Class 2, but Class 2 are better tolerated.1 The type of stocking selected should take into account the cost to the patient, the ability of the patient to apply and tolerate stockings, and patient access to regular reassessment of vascular status. All patients with healed uncomplicated venous ulcers should wear long term compression stockings.

Drug therapy

Drug therapy has not been shown to reduce the recurrence of venous ulcers.

Venous surgery

Superficial venous surgery can be justified for patients with isolated superficial venous incompetence, and in some patients with mixed superficial and deep venous incompetence.7, 8 Surgery has not been shown to be of benefit for deep venous incompetence.

References:

  1. 1. New Zealand Guideline Group. Care of people with chronic leg ulcers, an explicit evidence-based guideline. 1999.
  2. 2. Moffat C, Thomas S. (eds). Understanding compression therapy - European Wound Management Association Position Document.London. Medical Education Partnerships Ltd;2003.
  3. 3. Moffat C. (ed) Wound bed preparation in practice - European wound management association position document.London. Medical Education Partnerships Ltd;2004.
  4. 4. Kunimoto B, Cooling M,et al. Bestpractices for the prevention and treatment of venous leg ulcers. Ostomy Wound Management. 2001; 47(2):34-50.
  5. 5. Moffat C. Compression Therapy. Journal of Community Nursing.2000; 14 (12): 26,29-30,32.
  6. 6. Simon D, Dix F, McCollum CN. Management of venous leg ulcers. BMJ. 2004; 328: 1358 - 1362.
  7. 7. Scriven JM et al. Role of saphenous vein surgery in the treatment of venous ulceration. Br J Surg. 1998; 85 (6): 781-4.
  8. 8. Bello M et al. Role of Superficial venous surgery in the treatment of venous ulceration. Br J Surg. 1999; 86 (6): 755-9.

©ACC Provider Development Unit, 2005