Management

Management of a patient with chronic venous leg ulcer will often be influenced by the patient’s comorbidity. Factors such as obesity, malnutrition, intravenous drug use and co-existing medical conditions will affect both prognosis and suitability for invasive venous surgery.

Initial assessment should address the following:

• patient’s mobility
• the availability of help at home, as many elderly patients find graduated compression hosiery difficult to put on
• conditions which require specific treatment
  • peripheral arterial disease: approximately 22% of patients with leg ulcer will have arterial disease
  • rheumatoid arthritis and systemic vasculitis: around 9% of patients with leg ulcer have rheumatoid arthritis
  • diabetes mellitus: approximately 5% of patients will have diabetes (1)

Aim of venous ulcer treatment is to control symptoms, promote healing of ulcers, and prevent recurrence (1).

Treatment of venous ulcer can be:

• conservative -
  • is the main treatment method used worldwide
    • methods include
      • strict bed rest and elevation of the affected leg - although effective this method is impractical for most patients
      • compression therapy
        • the most important step in the management of venous leg ulcers (in some instances patients with mixed vascular disease) and is the gold standard conservative approach
        • if applied correctly, 70% of ulcers can be healed within 3 months. Four-layer dressing promotes faster healing than short stretch bandaging (2)
        • different types of multi layer bandaging systems are available that are wrapped from the toes/foot to below the knee
      • wound dressing
        • there is no evidence that one type of dressing has specific benefit over another and a wide range of dressings and topical treatments are used (3)
• medication
  • pentoxifylline. This is recommended at a dose of 400 mg tds for the treatment of chronic venous ulcers. An ulcer is deemed chronic if it fails to respond to first-line treatment after four weeks. It should be given for six months.
  • aspirin; further research is needed concerning the benefit of aspirin as a Cochrane review could not find sufficient evidence to come to a conclusion about the risks and benefits of aspirin as an adjunct to compression bandaging (6)
  • antibiotics - in patients with chronic venous leg ulcers, systemic antibiotics should not be used unless there is evidence of clinical infection (4)
• surgical
  • debridement (one Cochrane review found only limited evidence to suggest that actively debriding a venous leg ulcer has a clinically significant impact on healing) (5)
  • surgery for venous insufficiency e.g. - ablation of the saphenous vein; interruption of the perforating veins with sub-fascial endoscopic surgery
  • skin grafting. Bilayer skin grafts are effective when combined with compression bandaging (7) and for complicated ulcers, artificial dermis combined with a thin skin graft has shown promising results. (8)

Overview of management: (1)

• all people with venous leg ulcers should be assessed for:
  • arterial insufficiency, by Doppler studies
  • oedema
  • venous eczema
  • signs of infection
• uncomplicated venous leg ulcer is managed by:
  • cleaning with tap water (or saline)
  • applying a simple low-adherent dressing o applying a 4-layer or 2-layer (for ambulant patients) compression bandage
• an infected venous leg ulcer is managed by:
  • cleaning the wound and taking a swab
  • applying a simple low-adherent dressing
  • prescription of an empirical course of antibiotics (flucloxacillin if not penicillin allergic)
• advise people about adopting a lifestyle that encourages healing and prevents recurrence of the ulcer
• when the ulcer has healed, people should be encouraged to wear class III compression stockings if they are not contraindicated and can be tolerated. This should be encouraged for a minimum of 5 years (although life long usage is preferable)
• if the ulcer fails to heal and complications have been excluded in secondary care, aim to improve the person's quality of life rather than heal the ulcer as healing of the ulcer may not be an achievable outcome
• management of associated conditions involves:
  • pain management with simple analgesia
  • encouraging leg elevation to reduce oedema
  • use of regular emollient plus a low-potency topical corticosteroid (after exclusion of cellulitis) for venous eczema
• exclude contact dermatitis related to dressings if skin rash worsens when applying dressings at any stage of treatment
• follow up an infected ulcer daily or every other day until the infection has resolved. Weekly to monthly reviews are then appropriate for uncomplicated venous ulcers until the ulcer heals
• during follow up look for possible complications related to the ulcer and treatment
• assess the impact that symptoms are having on the person's quality of life and look for risk factors and comorbidities which need treatment or referral.

Reference:

• 1. van Gent WB, Wilschut ED, Wittens C. Management of venous ulcer disease. BMJ. 2010;341:c6045.
• 2. O'Meara S, Cullum N, Nelson EA, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012 Nov 14
• 3. Norman G, Westby MJ, Rithalia AD, et al. Dressings and topical agents for treating venous leg ulcers. Cochrane Database Syst Rev. 2018 Jun 15;6(6)
• 4. O'Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014 Jan 10
• 5. Gethin G, Cowman S, Kolbach DN. Debridement for venous leg ulcers. Cochrane Database Syst Rev. 2015 Sep 14
• 6. de Oliveira Carvalho PE, Magolbo NG, De Aquino RF, et al. Oral aspirin for treating venous leg ulcers. Cochrane Database Syst Rev. 2016 Feb 18
• 7. Jones JE, Nelson EA, Al-Hity A. Skin grafting for venous leg ulcers. Cochrane Database Syst Rev. 2013 Jan 31
• 8. Canonico S, Campitiello F, Della Corte A, et al. The use of a dermal substitute and thin skin grafts in the cure of "complex" leg ulcers. Dermatol Surg. 2009 Feb.