Management of Venous Ulcers

Ms C Martin

Definition Chronic Venous Ulcer

Open lesion between the knee and the ankle joint

Remains unhealed for at least

4 weeks

Occurs in the presence of venous disease

Assessment

Varicose veins

Haemosiderin

Lipodermatosclerosis

Atrophie blanche

Oedema

Dermatitis/eczema/Marjolin’s

Joint mobility – calf muscle pump

ArterialABPI over 0.8 - compression therapy is safe

with ABPI under 0.8 - should have referral and

cardiovascular risk factor modification

Assessment

Varicose veins

Haemosiderin

Lipodermatosclerosis

Atrophie blanche

Oedema

Dermatitis/eczema/Marjolin’s

Joint mobility – calf muscle pump

ArterialABPI over 0.8 - compression therapy is safe

with ABPI under 0.8 - should have referral and

cardiovascular risk factor modification

Assessment

Varicose veins

Haemosiderin

Lipodermatosclerosis

Atrophie blanche

Oedema

Dermatitis/eczema/Marjolin’s

Joint mobility – calf muscle pump

ArterialABPI over 0.8 - compression therapy is safe

with ABPI under 0.8 - should have referral and

cardiovascular risk factor modification

Assessment

Varicose veins

Haemosiderin

Lipodermatosclerosis

Atrophie blanche

Oedema

Dermatitis/eczema/Marjolin’s

Joint mobility – calf muscle pump

ArterialABPI over 0.8 - compression therapy is safe

with ABPI under 0.8 - should have referral and

cardiovascular risk factor modification

Investigations

Duplex - arterial and venous

Investigations

Duplex - arterial and venous

Bacteriology Swabs Only with clinical signs - cellulitis, pain, malodour, increased exudate. Colonisation does not delay healing

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting

Simple non-adherent dressings are recommended for ulcers.

Systematic review of 42 studies comparing - NA, alginate, hyrdocolloids, hydrogels, foams – no difference in healing when applied under multilayer bandages (ref 45).

NA UltraGranuflex DuoDerm

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting

Cochrane Review

Silver vs NA – no difference

Silver dressings not recommended in the routine treatment

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Systemic antibiotics should not be used unless there is evidence of clinical infection.

Placebo controlled studies suggest increased bacterial resistance with antibiotic usage.

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Aspirin insufficient evidence

Mesoglycan insufficient evidence

Zinc insufficient evidence

Pentoxifylline – 400mg tid should be considered improves healing interaction with NSAIDs

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Tap water vs sterile water

ManagementDressingsSilver Drugs Cleaning Debridement Larval TherapyManuka Honey CompressionStockingsSurgerySetting

• Use a scalpel

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting

Cochrane Review 19 trials – no benefit

Honey dressing are not recommended in the routine treatment of patients with venous leg ulcers.

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Compression

Cochrane review 7 RCTs comparing compression versus no compression – compression increases ulcer healing rates (Ref 51)

Caution ABPI < 0.8, DM, neuropathic

Compression LevelHighest that maintains compliance.

Reassess within 24-48hrs of application

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Multilayer Compression Layer Kit

Wound contact dressing (NA, Tubinet)Layer 1 subcompression wadding bandag (soffban)Layer 2 support bandageLayer 3 compression bandage (K-Plus) Layer 4 cohesive compressive bandage (Coban)

Light Compression 3 Layers Profore or K-Plus = 27 mmHG at the ankle

High Compression 4 Layers K-Plus + Coban = 40 mmHG at the ankle

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Below knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcers in patients where leg ulcer healing has been achieved.

Strongest compression which they can tolerate and apply (dexterity).

Compression should be worn indefinite during the day.

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Compression Class

British (1°) European(2°)

Class 1 14-17mmHg 18-21 mmHgClass 2 18-24 mmHg 23-32 mmHgClass 3 25-35 mmHg 34-46 mmHgClass 4 not available 49-70 mmHgClass 4(s) not available 60-90 mmHg

Brand Activa Medi (FP10)

Management

There is no difference in recurrence between class 3 versus class 2 stocking, however compliance is higher for class 2.

There is variation in the compression afforded between different brands of class 2 and 3 stockings.

DressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting

ManagementDressingsSilver Drugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting

Skin grafting

• – no evidence of benefit

• Bioengineered Products – single layer products – insufficient evidence of benefit

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting

Patients with chronic venous leg ulcers and superficial venous reflux should be considered for superficial venous surgery to prevent recurrence.

Surgery does not improve ulcer healing but does significantly reduce recurrence rates at 12 months.

ESCHAR study – Lancet 2004

ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting

Healing rates are significantly increased within a specialist leg ulcer care setting (Ref 51).

Costs are lower per leg healed within a specialist

clinic compared to costs within a non-specialist clinic.

Larger case load with specialist leg ulcer clinics are recommended as the optimal service for community treatment of venous leg ulcers.

Venous Ulcers – SIGN Summary

Recommended in routine care Not recommended in routine care

ABPI / duplex Silver

Tap water Larvae, Versajet

Simple skin care emollient Manuka honey, zinc

Simple non-adherent dressing Skin grafting

High compression 4 layer bandaging Hyperbaric/electromagnetic/Ultrasound

Pentoxifylline 400mg tid 6 months Antibiotics

B-K graduated compression stocking

Endovenous surgery

Community specialist leg ulcer clinics

Calf muscle exercise

Criteria for referral

Non-healing ulcer – no progress in 12 weeks

Suspicion of malignancy

ABPI < 0.8

Diabetes mellitus

Atypical ulcers

Vascular ulcer clinics

• Royal Surrey alternate weeks

• Farnham Hospital alternate weeks

• Aldershot Centre for health (weekly)

• Brants Bridge ulcer clinic (Bracknell)(weekly)

How to refer…

• Referral letter

• Fax: 01276 526516

• Vascular nurses: 01276 526302